Stomatology Edu Journal 1/2014
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S T O M A T O L O G Y E D U J O U R N A L<br />
VOLUME 1 ISSUE 1 SPRING <strong>2014</strong><br />
A WORLD OF EDUCATIONAL RESOURCES FOR EACH PRACTICE
Volume 1, Issue 1,<br />
Pages 1-76, Spring, <strong>2014</strong><br />
CEO<br />
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Alexandra MĂNĂILĂ<br />
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Andreea BANEA<br />
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Copyright © <strong>2014</strong><br />
MEDIA SYSTEMS COMMUNICATION<br />
The author rights for all the published articles<br />
and photographs are owned exclusively by<br />
Media Systems Communication S.R.L.<br />
Partial and total reproduction, under any form,<br />
printed or electronic, or the distribution<br />
of published materials can only be done<br />
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Media Systems Communication S.R.L.<br />
ISSN 2360 – 2406<br />
ISSN – L 2360 – 2406<br />
All the original content published is the sole<br />
responsibility of the authors.<br />
All the interviewed persons are responsible<br />
for their declaration and the advertisers are<br />
responsible for the information included in<br />
their commercials.<br />
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EDITORIAL<br />
WHY PEER REVIEW?<br />
Jean-François Roulet<br />
CONTINUING MEDICAL EDUCATION PROGRAM – A PROFESSIONAL<br />
ESTIMATE IN DENTISTRY PRACTICE.<br />
Rolf Ewers<br />
PLEA FOR A HOLISTIC APPROACH IN STOMATOLOGY.<br />
Vasile Astărăstoae<br />
WHY A NEW JOURNAL?<br />
Marian-Vladimir Constantinescu<br />
FDI EASTERN EUROPE CONTINUING EDUCATION PROGRAMME<br />
PREVENTION FOR THE ELDERLY PATIENTS.<br />
Alexandre Mersel<br />
CARIOLOGY<br />
REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE<br />
MATERIALS IN THE STEPWISE EXCAVATION TECHNIQUE.<br />
Sorin Andrian, Gianina Iovan, Simona Stoleriu, Claudiu Topoliceanu, Andrei Georgescu<br />
ORTHODONTICS<br />
NONEXTRACTION METHODS FOR CREATING SPACE IN ORTHODONTIC<br />
THERAPY.<br />
Mariana Păcurar, Ana Maria Jurcă, Doru Roman, Eugen Bud, Irina Nicoleta Zetu, Ioana Vâţă<br />
PERIODONTICS<br />
SALIVARY AND SERUM ENZYMES AS DIAGNOSTIC BIOMARKERS IN<br />
PATIENTS WITH PERIODONTAL DISEASE.<br />
Daniela Miricescu, Alexandra Totan, Bogdan Calenic, Brânduşa Mocanu, Maria Greabu<br />
OCCLUSION<br />
ETIOLOGICAL CONSIDERATION IN BRUXISM.<br />
Cristiana Ileana Croitoru, Iulia Roxana Marinescu, Emma Cristina Drăghici,<br />
Sanda Mihaela Popescu, Monica Scrieciu, Veronica Mercuţ<br />
OROFACIAL PAIN<br />
HEADACHE – AN INTERDISCIPLINARY PROBLEM. ASPECTS OF DENTAL<br />
FUNCTIONAL DIAGNOSTICS AND THERAPY<br />
Georg B. Meyer, Olaf Bernhardt, Arnd Küppers<br />
OVERDENTURE<br />
FUNCTIONAL EVALUATION OF IMPLANT SUPPORTED PROSTHESES.<br />
Gianluca Martino Tartaglia, Chiarella Sforza<br />
GERODONTOLOGY<br />
FACTORS AFFECTING RECENT DENTAL SERVICES UTILIZATION BY AN<br />
URBAN OLDER POPULATION IN ATHENS.<br />
Vasilia Petraki, Philippos Thomopoulos, Anastassia E. Kossioni<br />
ORAL IMPLANTOLOGY<br />
AN IMPLANT SUPPORTED MAXILLARY FIXED PROSTHESIS WITH A<br />
SUBSTRUCTURE/SUPRASTRUCTURE DESIGN: A CLINICAL CASE.<br />
Joanna Kempler<br />
ORAL REHABILITATION<br />
COMORBITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE<br />
SANODENTAPRIM PROGRAMME.<br />
Aranka Ileaa, Dan Buhățel, Minodora Moga, Claudia Feurdean, Anca Ionel, Arin Sava,<br />
Ondine Lucaciu, Adina Sârbu, Radu Septimiu Câmpian<br />
BOOKS REVIEW<br />
AUTHOR’S GUIDELINES
J<br />
Edited by<br />
Jean-François Roulet, DDS, PhD, Prof hc Rolf Ewers, MD, DMD, PhD Marian-Vladimir Constantinescu, DDS, PhD<br />
EDITORIAL BOARD<br />
Editors-in-Chief<br />
Jean-François Roulet<br />
DDS, PhD, Prof hc<br />
Professor<br />
Department of Restorative Dental Science,<br />
College of Dentistry<br />
University of Florida<br />
Gainesville, FL, USA<br />
Rolf Ewers<br />
MD, DMD, PhD<br />
Professor and Chairman em.<br />
University Hospital for Cranio<br />
Maxillofacial and Oral Surgery<br />
Medical University of Vienna<br />
Vienna, Austria<br />
Marian-Vladimir Constantinescu<br />
DDS, PhD<br />
Professor<br />
Department of Prosthetic Dentistry<br />
“Carol Davila” University<br />
of Medicine and Pharmacy<br />
Bucharest, Romania<br />
David C. Watts<br />
BSc, PhD, DSc, FRSC, FInstP,<br />
FADM, FSB<br />
Professor<br />
Department of Biomaterials Science<br />
School of Dentistry &<br />
Photon Science Institute<br />
University of Manchester<br />
Manchester M13 9PL,<br />
United Kingdom<br />
Senior Editors<br />
Bruce R. Donoff<br />
DMD, MD<br />
Professor of Oral and<br />
Maxillofacial Surgery<br />
Department of Oral<br />
and Maxillofacial Surgery<br />
Dean, Harvard School<br />
of Dental Medicine<br />
Harvard University<br />
Boston, MA, USA<br />
Ecaterina Ionescu<br />
DDS, PhD<br />
Professor<br />
Discipline of Orthodontics<br />
and Dento - Facial Orthopedics<br />
Faculty of Dental Medicine<br />
Vice-Rector, “Carol Davila”<br />
University<br />
of Medicine and Pharmacy<br />
Bucharest, Romania<br />
Associate Editors-in-Chief<br />
Poul Erik Petersen, DDS, Dr Odont, BA, MSc<br />
(Sociology), WHO Senior Consultant<br />
Professor, Department for Global Oral Health<br />
and Community Dentistry School of Dentistry<br />
University of Copenhagen<br />
Copenhagen K, Denmark<br />
Lakshman Samaranayake, DSc(hc)<br />
DDS(Glas), DSRCSE(hon),<br />
FRCPath(UK), FRACDS(hon)<br />
Professor and Head of School<br />
University of Queensland<br />
Brisbane, Australia<br />
Luigi M Gallo, dipl. El.-Ing. ETH<br />
Professor and Chairman<br />
University of Zurich<br />
CH-Zurich, Switzerland<br />
Veronica Mercuţ, DMD, PhD<br />
Professor Prosthetics Department<br />
Dean, Faculty of Dental Medicine<br />
University of Medicine and Pharmacy Craiova,<br />
Dolj, Romania<br />
Radu Septimiu Câmpian, DMD, MD<br />
Professor and Head Oral Rehabilitation<br />
Oral Health and Management of Dental Office<br />
Department<br />
Dean, Faculty of Dentistry<br />
“Iuliu Hațieganu” University of Medicine and<br />
Pharmacy, Cluj-Napoca, Romania<br />
Ion Lupan, DMD, MD<br />
Profesor OMF pediatric surgery<br />
Pedodontics & Orthodontics<br />
Dean, Faculty of <strong>Stomatology</strong><br />
State Medical and Pharmaceutical University<br />
“N. Testemitanu”, Chişinău, Moldova<br />
Associate Editors<br />
Rafael Benoliel, BDS<br />
Professor, Department of Diagnostic Sciences<br />
Associate Dean for Research<br />
Rutgers School of Dental Medicine The State<br />
University of New Jersey Newark, NJ, USA<br />
Dana Cristina Bodnar, DDS, PhD<br />
Assistant Professor<br />
Discipline of Restaurative<br />
Odontotherapy<br />
Vice-Dean, Faculty of Dental Medicine<br />
“Carol Davila” University of Medicine and<br />
Pharmacy, Bucharest, Romania<br />
Associate Editors Board<br />
Cristina Maria Borțun, DDS, PhD<br />
Professor<br />
Discipline Prosthetic Technology<br />
and Dental Materials<br />
Dean, Faculty of Dental Medicine<br />
“Victor Babeș” University of Medicine<br />
and Pharmacy, Timișoara, Romania<br />
Alexandru Bucur, DDS, MD, PhD<br />
Professor<br />
Discipline Oral - Maxillofacial Surgery<br />
Dean, Faculty of Dental Medicine<br />
“Carol Davila” University<br />
of Medicine and Pharmacy<br />
Bucharest, Romania<br />
Asja Celebic, DDS, MSc, PhD<br />
Professor<br />
Department of Prosthodontics<br />
School of Dental Medicine<br />
University of Zagreb, Zagreb, Croatia<br />
Ingrīda Čēma, DDS<br />
Professor<br />
Department of Oral Pathology<br />
Dean, Faculty of Dental Medicine<br />
Riga Stradins University, Riga, Latvia<br />
Daniel Edelhoff, CDT, DMD, PhD<br />
Professor<br />
Department of Prosthodontics<br />
Dental School Ludwig-Maximilians-University<br />
Munich, Germany<br />
Norina Consuela Forna, DDS, PhD<br />
Professor<br />
Department Clinics and<br />
Therapy of Partial Reduced Interrelated<br />
Edentation<br />
Dean, Faculty of Dental Medicine<br />
“Gr. T. Popa” University of Medicine<br />
and Pharmacy, Jassy, Romania<br />
Roland Frankenberger, DMD, PhD<br />
FICD, FADM, FPFA, Hon Prof<br />
Professor and Chairman<br />
Department of Operative<br />
Dentistry and Endodontics<br />
Dean, Dental School, University of Marburg<br />
Marburg, Germany<br />
Klaus Gotfredsen, DDS, PhD, Dr Odont<br />
Professor<br />
Department of Oral Rehabilitation<br />
Faculty of Health Science<br />
University of Copenhagen<br />
København, Denmark<br />
Galip Gürel, DDS, MSc<br />
Professor<br />
Dentis Dental Clinic<br />
Istanbul, Turkiye<br />
Anastassia E Kossioni, DDS, PhD<br />
Assistant Professor<br />
Department of Prosthodontics<br />
Athens Dental School University of Athens<br />
Athens, Greece<br />
Amid I Ismail, BDS, MPH, MBA, Dr PH<br />
Professor<br />
Department of Restorative Dentistry<br />
Dean, Maurice H. Kornberg School<br />
of Dentistry Temple University<br />
Philadelphia, PA, USA<br />
Armelle Maniere-Ezvan, DDS, PhD<br />
Professor<br />
Department of Orthodontics<br />
Dean, Faculty of Odontology<br />
Nice Sophia-Antipolis University<br />
Nice, France<br />
Domenico Massironi, DDS, PhD<br />
Professor<br />
MSC Massironi Study Club<br />
Melegnano Milano, Italy<br />
Noshir R. Mehta, DMD, MDS, MS<br />
Professor and Chair Department<br />
of General Dentistry<br />
Associate Dean of Global Relations<br />
School of Dental Medicine, Boston,<br />
MA Tufts University<br />
Boston, MA, USA<br />
Alexandre Mersel, DDS, PhD<br />
Professor<br />
Director FDI Eastern Europe<br />
Jerusalem, Israel<br />
Georg B. Meyer, DMD, PhD, Dr hc<br />
Professor and Chairman<br />
Zentrums für Zahn-, Mund- und<br />
Kieferheilkunde<br />
Ernst-Moritz-Arndt Universität<br />
Greifswald, Germany<br />
Takahiro Ono, DDS, PhD<br />
Associate Professor<br />
Department of Prosthodontics and Oral<br />
Rehabilitation<br />
Graduate School of Dentistry<br />
Osaka University<br />
Osaka, Japan
Jean-Daniel Orthlieb, DDS, PhD<br />
Professor and Chairman<br />
Department of Dental Anatomy &<br />
Occlusodontology<br />
Vice-Dean, Faculty of Odontology<br />
Aix Marseille University<br />
Marseille, France<br />
Mariana Păcurar, DDS, PhD<br />
Professor Discipline of Orthodontics<br />
and Dento - Facial Orthopedics<br />
Dean, Faculty of Dental Medicine<br />
University of Medicine and Pharmacy<br />
Târgu Mureș, Romania<br />
Gabriela Pițigoi-Aron, DDS, PhD<br />
Professor<br />
Department of Integrated Reconstructive<br />
Dental Sciences<br />
Arthur A. Dugoni School of Dentistry<br />
University of the Pacific<br />
San Francisco, CA, USA<br />
George E. Romanos, DDS, DMD, PhD<br />
Professor Department of Periodontology/<br />
Implant Dentistry<br />
Associate Dean, SUNY Stony Brook School<br />
of Dental Medicine<br />
Stony Brook University<br />
Stony Brook, NY, USA<br />
Mugurel C. Rusu, MD, PhD<br />
Associate Professor<br />
Faculty of Dental Medicine<br />
“Carol Davila” University of Medicine and<br />
Pharmacy<br />
Bucharest, Romania<br />
Anton Sculean, DMD, Dr hc, MS<br />
Professor and Chairman<br />
Department of Periodontology<br />
University of Bern<br />
Bern, Switzerland<br />
Chiarella Sforza, MD, PhD<br />
Professor<br />
Department of Biomedical Sciences for Health<br />
Faculty of Medicine<br />
University of Milan, Milano, Italy<br />
Roman Šmucler, MD, PhD<br />
Associate Professor<br />
Department of Maxillofacial Surgery<br />
First Faculty of Medicine and<br />
General University Hospital<br />
Charles University<br />
Prague, Czech Republic<br />
Sorin Uram-Țuculescu, DDS, PhD<br />
Assistant Professor<br />
Department of Prosthodontics<br />
School of Dentistry<br />
Virginia Commonwealth University<br />
Richmond, VA, USA<br />
David Wray, MD (Honours), BDS, MB ChB, FDS<br />
RCPS (Glasgow)<br />
FDS RCS (Edinburgh), F Med Sci<br />
Professor Emeritus, Professor and Chairman<br />
Department of Oral Medicine<br />
Dean, Dubai School of Dental Medicine<br />
Dubai, United Arab Emirates<br />
Emeritus Editors-in-Chief<br />
Emeritus Editors-in-Chief<br />
Birte Melsen, DDS, Dr Odont<br />
Professor Aarhus University, Aarhus, Denmark<br />
Prathip Phantumvanit, DDS, MS, FRCDT<br />
Professor Thammasat University,<br />
Bangkok, Thailand<br />
Rudolf Slavicek, MD, DMD<br />
Professor Medical University of Vienna<br />
Vienna, Austria<br />
Julian B. Woelfel, DDS, FACD, FICD<br />
Professor The Ohio State University, Columbus, USA<br />
Editors<br />
Editors<br />
Marcus Oliver Ahlers, DDS, PD<br />
Hamburg University Eppendorf<br />
Hamburg, Germany<br />
Orlando Alves Da Silva, MD, PhD<br />
Professor Universitary Hospital of Santa Maria<br />
Lisbon, Portugal<br />
Sorin Andrian, DDS, PhD<br />
Professor “Gr. T. Popa” University of Medicine<br />
and Pharmacy, Jassy, Romania<br />
Wilson Martins Aragão, DDS, PhD<br />
Professor Catholic University of Rio De Janeiro<br />
Rio De Janeiro, Brasil<br />
Vasile Astărăstoae, MD, PhD<br />
Professor, Rector, “Gr. T. Popa” University of<br />
Medicine and Pharmacy, Jassy, Romania<br />
Emanuel Adrian Bratu, DDS, MD, PhD<br />
Professor “Victor Babeș”<br />
University of Medicine and<br />
Pharmacy, Timișoara, Romania<br />
Nardi Caspi, DMD, MD<br />
Associate Professor Hebrew University<br />
HadassaH Jerusalem, Jerusalem, Israel<br />
Arnaldo Castellucci, DDS, PhD<br />
Professor Florence, Italy<br />
Romeo Călărașu, MD, PhD<br />
Professor “Carol Davila” University of Medicine<br />
and Pharmacy Bucharest, Romania<br />
Rayleigh Ping-Ying Chiang, MD, MMS<br />
Taipei Veterans General Hospital<br />
Taipei, Taiwan<br />
Paulo G. Coelho, DDS, PhD<br />
Associate Professor Biomaterials<br />
and Biomimetics Department<br />
New York University, USA<br />
New York, NY, USA<br />
Robert A. Convissar, DDS, FAGD<br />
New York Hospital Medical Center of Queens<br />
New York, NY, USA<br />
Antonino Marco Cuccia, DDS, PhD<br />
Professor University of Palermo<br />
Palermo, Italy<br />
Ioan Dănilă, DDS, PhD<br />
Professor “Gr. T. Popa” University of Medicine<br />
and Pharmacy, Jassy, Romania<br />
Yuri Dekhtyar, Eng, Dr phys<br />
Professor<br />
Riga Technical University, Riga, Latvia<br />
Mohamed Sherine El-Attar, DDS, PhD<br />
Professor Pharos Alexandria<br />
University<br />
Alexandria, Egypt<br />
Paul B. Feinmann, DDS, PhD<br />
Professor Canton of Geneva,<br />
Switzerland<br />
Claudia Maria de Felicio, MD, PhD<br />
Professor Universidade De São Paulo (USP)<br />
Ribeirão Preto, Brazil<br />
Luis J. Fujimoto, DDS, PhD<br />
Associate Professor<br />
New York University, New York, USA<br />
Adi A. Garfunkel, DDS, PhD<br />
Professor Hebrew University Hadassah<br />
Jerusalem, Jerusalem, Israel<br />
Daniela Aparecida Godoi Gonçalves, DDS, PhD<br />
Assistant Professor UNESP - Univ Est<br />
Paulista, Araraquara, Brazil<br />
Maria Greabu, MD, PhD<br />
Professor “Carol Davila” University of Medicine<br />
and Pharmacy<br />
Bucharest, Romania<br />
Martin D Gross, BDS, LDS, RCS, MSc<br />
Associate Professor Tel Aviv University<br />
Tel Aviv, Israel<br />
Emilian Hutu, DDS, PhD<br />
Professor “Carol Davila” University of Medicine<br />
and Pharmacy, Bucharest, Romania<br />
Joannis Katsoulis, DMD, PhD, MAS<br />
Associate Professor University of Bern<br />
Bern, Switzerland<br />
Joanna Kempler, DDS, PhD<br />
Associate Professor University of Maryland<br />
Baltimore, MD, USA<br />
Robert L. Ibsen, DDS, OD<br />
Santa Maria, CA, USA<br />
Werner Lill, DDS, PD<br />
Austrian Society of Periodontology (OEGP)<br />
Vienna, Austria<br />
Tomas Linkevičius, DDS, PhD<br />
Associate Professor Vilnius University<br />
Vilnius, Lithuania<br />
Mauro Marincola, DDS, PhD<br />
Professor State University of Cartagena<br />
Cartagena, Colombia<br />
Nicoleta Măru, MD, PhD<br />
Associate Professor “Carol Davila” University of<br />
Medicine and Pharmacy<br />
Bucharest, Romania<br />
Rodolfo Miralles, MD, PhD<br />
Professor University of Chile, Santiago, Chile<br />
Annalisa Monaco, DDS, PhD<br />
Professor University of L’Aquila DA<br />
L’Aquila, Italy<br />
Marian Neguț, MD, PhD<br />
Professor “Carol Davila” University of Medicine<br />
and Pharmacy, Bucharest, Romania<br />
Mutlu Özcan, DDS, PhD<br />
Professor University of Zurich<br />
Zurich, Switzerland<br />
Ion Pătrașcu, DDS, PhD<br />
Professor “Carol Davila” University of Medicine<br />
and Pharmacy, Bucharest, Romania<br />
Letizia Perillo, DDS, PhD<br />
Professor Seconda Università degli Studi di<br />
Napoli (SUN), Napoly, Italy<br />
Sever Popa, DDS, PhD<br />
Professor “Iuliu Hațieganu” University<br />
of Medicine and Pharmacy<br />
Cluj-Napoca, Romania<br />
Sanda Mihaela Popescu, DDS, PhD<br />
Associate Professor University of Medicine and<br />
Pharmacy, Craiova, Romania<br />
Sorin Claudiu Popșor, DDS, PhD<br />
Professor University of Medicine and Pharmacy<br />
Tg. Mureș, Romania<br />
Xiaohui Rausch-Fan, DDS, PhD<br />
Professor Bernhard-Gottlieb-University<br />
Vienna, Austria<br />
Mihaela Răescu,<br />
DDS, PhD<br />
Professor Associate “Titu Maiorescu” University<br />
Bucharest, Romania<br />
Lucien Reclaru, Eng, PhD<br />
Professor Px Holding SA<br />
La Chaux De Fonds, Switzerland<br />
Matjaz Rode, DDS, PhD<br />
Professor University of Ljubljana<br />
Ljubljana, Slovenia<br />
Stephen F. Rosenstiel, BDS, MSD<br />
Professor Emeritus The Ohio State University<br />
Columbus, OH, USA<br />
Mare Saag, DDS, PhD<br />
Professor University of Tartu, Tartu, Estonia<br />
Martina Schmid-Schwap, DDS, PhD<br />
Associate Professor Bernhard-Gottlieb University<br />
Vienna, Austria<br />
Gregor Slavicek, DDS, PhD<br />
Steinbeis University<br />
Berlin, Germany<br />
Marius Steigmann, DDS, PhD<br />
Associate Professor Steigmann<br />
Implant Institute Neckargemund, Germany<br />
Jon B Suzuki, DDS, PhD<br />
Professor Temple University<br />
Philadelphia, PA, USA<br />
Gianluca Martino Tartaglia, DDS, PhD<br />
Associate Professor University of Milan<br />
Milano, Italy<br />
Mihai C. Teodorescu, MD, PhD<br />
Associate Professor University of Wisconsin<br />
Hospitals and Clinics Madison, WI, USA<br />
Douglas A. Terry, DDS, PhD<br />
Professor Esthetics Institute of<br />
Esthetic & Restorative Dentistry, Houston, TX, USA<br />
Bernard Touati, DDS, PhD<br />
Professor Paris V University, Paris, France<br />
Jacques Vanobbergen, DDS, PhD<br />
Professor Gent University, Gent, Belgium<br />
Irina Nicoleta Zetu, DDS, PhD<br />
Associate Professor “Gr. T. Popa” University<br />
of Medicine and Pharmacy, Jassy, Romania<br />
Reviewers-in-Chief<br />
Stephen F. Rosenstiel, BDS, MSD<br />
Professor Emeritus<br />
The Ohio State University<br />
Columbus, OH, USA<br />
Mihaela Rodica Păuna, DDS, PhD<br />
Professor<br />
“Carol Davila” University of Medicine and<br />
Pharmacy, Bucharest, Romania<br />
Sheldon Dov Sydney, DDS, FICD<br />
Associate Professor<br />
University of Maryland Baltimore,<br />
Maryland, USA, World Editor, International<br />
College of Dentists<br />
Reviewers<br />
Petr Bartak, Prague, Czech Republic<br />
Gabriela Băncescu, Bucharest, Romania<br />
Bogdan Calenic, Bucharest, Romania<br />
Cristian Niky Cumpătă, Bucharest, Romania<br />
Barbara Janssens, Gent, Belgium<br />
Hercules Karkazis, Athens, Greece<br />
John Kois, Seattle, WA, USA<br />
Henriette Lerner, Baden-Baden, Germany<br />
Cinel Maliţa, Bucharest, Romania<br />
Marina Meleșcanu-Imre, Bucharest, Romania<br />
Joel Motta Junior, Manaus, AM, Brazil<br />
Hazem Mourad, Qassim, Saudi Arabia<br />
Paula Perlea, Bucharest, Romania<br />
Nikola Petricevic, Zagreb, Croatia<br />
Laurențiu Popa, Dallas, TX, USA<br />
Robert Sabiniu Şerban, Bucharest, Romania<br />
Elina Teodorescu, Bucharest, Romania<br />
Luc De Visschere, Gent, Belgium<br />
Maciej Zarow, Krakow, Poland<br />
English Language Editor-in-Chief<br />
Roxana-Cristina Petcu, Phil, PhD<br />
Associate Professor,<br />
Faculty of Foreign Languages, University<br />
of Bucharest, Bucharest, Romania<br />
English Language Editors<br />
Valeria Clucerescu, Biol.<br />
Cristina Alina Huidiu, LIS<br />
Niculina Smaranda Ion, Phil.<br />
Honorary Statistical Adviser<br />
Radu Burlacu, PhD, Bucharest, Romania<br />
Editorial Book Reviewer<br />
Florin Eugen Constantinescu<br />
Bucharest, Romania<br />
Project Editor<br />
Valentin Rădoi, MD<br />
Faculty of Medicine "Carol Davila" University of<br />
Medicine and Pharmacy, Bucharest, Romania
Editorial<br />
Why Peer Review?<br />
Jean-Francois Roulet<br />
DDS, PhD, Prof hc<br />
Professor<br />
University of Florida, Gainesville, FL, USA<br />
Dear Readers,<br />
As dentists we are part of the medical community. We are the experts in everything related to the health of<br />
the oral cavity and its surroundings. Therefore ethical guidelines require us to deliver treatment or provide<br />
advice of the highest quality for the benefit of our patients. This sounds great; however it includes an inherent<br />
conflict: how to define quality. This is very difficult in medicine and dentistry. Quality may be divided into<br />
process quality (in simple terms: do the right thing) and outcome quality (in simple terms: do it right). Both<br />
need definitions, what is good or bad; and this is where the problem sits.<br />
Once upon a time our teachers were setting the requirement for what is considered good quality, often based<br />
on their opinion, and we students had to comply. These days things got more complicated. We need to base our<br />
definitions on facts or results based on experiments. For dental care and medicine the ultimate measurement<br />
of good quality is the survival of the restoration or the patient after an intervention or therapy. “Evidence<br />
based” is the magic word here. However we cannot base all our doing only on results of clinical studies, as we<br />
would postpone good treatment options to our patients for years. Therefore we need to accept lower evidence<br />
levels such as in vitro studies as well, to make up our mind.<br />
In the age of the internet information is available instantaneously and globally, which is a very good thing. The<br />
back side of this is the information overload and the black side is that the average user cannot distinguish<br />
anymore which information is relevant or true, or which information is pure claim or just intended to motivate<br />
the target reader to use it, or to use the product described. This is where peer review becomes important.<br />
Anders Linde, the Editor of the European <strong>Journal</strong> of Oral Sciences once stated: “Nothing is scientifically<br />
shown or proven before it has been published in a scientific journal with a peer review system, so one<br />
can critically judge what was done, how it was done and evaluate how solid it is.” The application of<br />
this by an editorial team means that a group of experts in the field (the peers) will have very carefully<br />
looked at every document which is finally published. They will check if the information provided is new,<br />
if the formatting is correct, if the language is used correctly, if the methods used make sense and are<br />
free of bias. Statisticians will look at the results to make sure that the outcome is really a function of the<br />
experimental variables. The experts will also ask themselves “Does it make sense?” and will critically<br />
look at results which may significantly differ from other similar tests. Finally, the editorial team will<br />
make sure that the conclusions drawn are strictly related to the outcome of the experiments. If there<br />
are questions, which is almost always the case, then the authors are challenged to address them. These<br />
are a few facts that make the difference between a non peer reviewed publication and a peer reviewed<br />
publication. Of course during the review process some manuscripts get rejected. These are the ones that<br />
do not fulfill the quality requirements or do not survive the critical review because of incurable flaws<br />
(mostly in the methodology). Notwithstanding, the main objective of the review process is to improve<br />
the quality of the manuscript, so you, readers, can trust the information provided.<br />
So, in order to be credible, there is no alternative to peer review!<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).edit.1
Continuing Medical <strong>Edu</strong>cation<br />
Program – a professional<br />
estimate in dentistry practice<br />
Rolf Ewers<br />
MD, DMD, PhD<br />
Professor and Chairman em.<br />
Medical University of Vienna, Vienna, Austria<br />
Prof. Dr. Constantinescu has asked me to serve as an Editor in Chief for the <strong>Stomatology</strong> <strong>Edu</strong> <strong>Journal</strong><br />
(Stoma <strong>Edu</strong> J) and consequently to be in charge with the editors for Western and Central Europe. I am<br />
very happy to accept this and I am looking forward to do so.<br />
As Prof. Constantinescu pointed out this new dental journal will serve as a new information tool for<br />
dentists and doctors to treat patients better with the up to date knowledge which they will get in all our<br />
specialty fields by reading the peer-reviewed articles.<br />
I am convinced that the questionnaire at the end of each article will help the reader to really concentrate<br />
on the subject he is reading, controlling his understanding and last but not least getting points for the<br />
Continuing Medical <strong>Edu</strong>cation Program.<br />
I am very happy that I will have the opportunity to work together with Professor Jean-François Roulet<br />
from University of Florida and Professor Stephen F. Rosenstiel, from Ohio State University.<br />
I am sure that with the help and enthusiasm of Prof. Constantinescu we will achieve together with all<br />
the other editors an excellent journal for the benefit of all.<br />
How Prof. Constantinescu says: Stoma <strong>Edu</strong> J will be indeed a world of educational resources for<br />
each practice.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).edit.2<br />
Editorial
Editorial<br />
Plea for a holistic<br />
approach in stomatology<br />
Vasile Astărăstoae<br />
MD, PhD, Licensed in Law<br />
Professor<br />
Rector, “Gr.T.Popa” University of Medicine and Pharmacy, Jassy, Romania<br />
President of the Romanian College of Physicians<br />
The ethos of the medical profession derives from its tradition. Since the first medical acts, the approach<br />
of this profession was anthropological and holistic. This is why, during its evolution, medicine has<br />
evolved combining two tendencies: asklepian (knowing) and the samaritan one (feeling compassion<br />
for your patient). In the contemporary age, new forces have begun acting: financers influencing health<br />
systems while being preoccupied by the rationalization of resources, the importance given to evidence<br />
based medicine, guidelines and protocols, subspecialties, the fragmentation of medical care, an excess<br />
of technology which removes the human touch (the patient becomes a subject not a person) and, last<br />
but not least, the influence of t he commercial market which i s r un by p harmaceutical companies.<br />
Slowly, medicine has become institutionalized and instrumentalized, affecting n ot only t he classic<br />
doctor-patient relationship but also the performances related to protecting people's health.<br />
Among the many branches of medicine, dental medicine (stomatology) emerged as a specialty. One of<br />
the many perceptions related to it is that it is a standalone specialty and that only the technical aspects<br />
need to be considered. In other words, the stomatologist needs only to be an exquisite technician<br />
(professionist) for the dental and buco-maxillary apparatuses.<br />
This approach is not only wrong, but also dangerous for the future of stomatology. It is wrong because<br />
contemporary medicine is turning back to a holistic approach and parts of a whole cannot be treated<br />
if we do not take into account the interactions between these parts and the whole. Dangerous because<br />
those who work in this domain might be considered technicians in the future and not what they are,<br />
doctors.<br />
This is why a source for doctors and researchers was needed, one that could show that the medical<br />
aspects are well kept in stomatology. This source will be the journal you are reading. This is why a<br />
forensic pathologist happily and gratefully accepts to be a part of this beneficial project for all<br />
the specialties and doctors out there.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).edit.3
Why a new journal?<br />
Marian-Vladimir Constantinescu<br />
DDS, PhD<br />
Professor<br />
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania<br />
<strong>Stomatology</strong>.edu is a new biannual dental journal whose main purpose is to inform researchers,<br />
educators, graduates, postgraduates and practitioners about the latest trends in the field, which<br />
followed, would bring immediate and lasting benefits to the patients; and about opinions of the most<br />
authorized specialists on what is best in current practice, for the good of both, patient and dentist.<br />
<strong>Stomatology</strong>.edu is a peer-reviewed, open access European dental journal to be database indexed,<br />
meant to contribute to the development and completion of the medical training of practitioners from<br />
Romania, Republic of Moldova and other Central and Eastern Europe countries for, as Dr. Greene<br />
Vardiman Black stated: “the professional man has no right to be other than a continual student”.<br />
To get points under the Continual Medical <strong>Edu</strong>cation Program, at the end of each article there is a<br />
questionnaire.<br />
The authors will approach such dental practice topics, as: Dental Anatomy, Anesthesiology, Cariology,<br />
Community Dentistry, Dentoalveolar Surgery, Oral and Maxillofacial Surgery, Oral and Dental<br />
Diagnosis, Endodontics, Cosmetic Dentistry, Dental Ergonomics, Dental Hygiene, Dental Laser,<br />
Dental Materials, Dental Microscopy, Dental Photography, Dental Public Health, Dental Radiology,<br />
Gerodontology, Oral Implantology, Oral Microbiology, Oral Pathology, Oro-Dental Management,<br />
Oro-Dental Prevention, Occlusion and TMJ, Orofacial Pain, Orthodontics and Dento-Facial Orthopedics,<br />
Pedodontics, Periodontology, Posturology, Prosthetic Dentistry, Computerized Dental Prosthetics,<br />
Minimally Invasive Dentistry, Dental Technology and Emergencies at the Dentist’s.<br />
We underline the high professional status of editorial team members and the exceptional importance<br />
in the field of Editors-in-Chief: Professor Rolf Ewers from Medical University of Vi enna; Professor<br />
Jean-François Roulet from University of F lorida (Editor-in-Chief of three I SI quoted j ournals) and<br />
Reviewer-in-Chief, Professor Stephen F. Rosenstiel, from O hio State University (Editor-in-Chief of<br />
<strong>Journal</strong> of Prosthetic Dentistry) accepting to share their expertise with us.<br />
By national and international scientific contribution of editors and of peer review experts we hope for<br />
a clear improvement of the medical care quality through better and more effective treatments applied<br />
by professionals in Romania, Republic of Moldova and Central and Eastern Europe, thus proving that<br />
<strong>Stomatology</strong>.edu <strong>Journal</strong> is indeed a world of educational resources for each practice.<br />
SO HELP US, GOD!<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).edit.4<br />
Editorial
FDI Eastern Europe Continuing <strong>Edu</strong>cation Programme<br />
Prevention for the<br />
Elderly Patients<br />
Prof. Alexandre<br />
Mersel<br />
Senior Research Fellow<br />
Department of<br />
Community Dentistry<br />
Hadassah, Faculty of Dental<br />
Medicine Jerusalem<br />
Regional Director FDI<br />
Continuing <strong>Edu</strong>cation<br />
Programme<br />
The aging of the elderly population is a dramatic<br />
demographic fact.<br />
One of the most important challenges of the<br />
dental profession in the coming years will be in<br />
providing oral care to geriatric patients.<br />
The new trend is that the elderly will have more<br />
retained teeth and that their expectation will be<br />
greater. On the other hand the increase of their<br />
life–span will increasingly affect their medical<br />
status, therefore the profession has to develop an<br />
adapted prevention management and treatment<br />
strategy.<br />
The main field of action will be:<br />
Prevention of the Dental caries<br />
A special preventive protocol and a conservative<br />
approach is necessary in order to achieve a maximum<br />
of teeth when aging “20 teeth for the eighties”.<br />
Oral cancer<br />
Oral cancer has a high morbidity and mortality<br />
rate. The 5-year survival rate is 75% for local lesions<br />
but only 17% for those with distant metastasis.<br />
Oral cancer constitutes 13-16 % of all cancers,<br />
therefore early detection, and preventive attitudes<br />
and actions are compulsory. The profession must<br />
start with an education program both for the<br />
practitioner and the patients.<br />
Salivary hypo function<br />
With aging a great decrease of the saliva flow is<br />
noted. Aside from the normal gland hypo function<br />
more than 700 medications are known to cause<br />
dry mouth. Bad taste, bad breath and more root<br />
caries are the direct consequences. Prevention<br />
and control of the salivary pH is indicated.<br />
Periodontal Prevention<br />
With the loss of periodontal attachments, bad<br />
habits (smoking), poor conservative restoration<br />
and poor prosthodontic rehabilitation, the elderly<br />
are often subject to chronic periodontal diseases.<br />
This situation will finally lead to the loss of<br />
their teeth, in a way that step by step they will be<br />
edentulous.<br />
Edentulism is now recognized by the WHO as<br />
a real disability. Special attention should be taken<br />
in order to provide a large preventive treatment<br />
including, of course, the education and motivation<br />
of these patients.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.1<br />
Alexandre Mersel<br />
Senior Research Fellow Department of Community Dentistry Hadassah<br />
Faculty of Dental Medicine Jerusalem<br />
Regional Director FDI Continuing <strong>Edu</strong>cation Programme<br />
CV<br />
Prof. Alexandre Mersel is a Professor at the Faculty of Dental<br />
Medicine in Jerusalem, having worked in research for over 30 years<br />
He has published 87 scientific articles and 3 chapters in academic<br />
textbooks. He is also a Senior Research Fellow at the Department<br />
of Community Dentistry Hadassah, a Member of the <strong>Edu</strong>cation<br />
Committee of the FDI, the Regional Director for the FDI Continuing<br />
<strong>Edu</strong>cation Program and a Member in the Editorial board of several<br />
International <strong>Journal</strong>s. Among his past accomplishments we<br />
mention the City of Paris Silver<br />
Medal (1986), the fact that he was a Consultant on the Prime<br />
Minister’s commission of Public Health (1982) and Co-founder and<br />
vice-President of the International Association<br />
of Gerodontology (1985- 1986).<br />
10 Stoma.eduJ (<strong>2014</strong>) 1 (1)
11
cariology<br />
Cite this article:<br />
Andrian S, Iovan G,<br />
Georgescu A.<br />
Remineralisation<br />
of affected dentine by<br />
different bioactive<br />
materials in the stepwise<br />
excavation tehnique.<br />
Stoma <strong>Edu</strong> J. <strong>2014</strong>;<br />
1(1):12-17.<br />
REMINERALISATION OF AFFECTED<br />
DENTINE BY DIFFERENT BIOACTIVE<br />
MATERIALS IN THE STEPWISE<br />
EXCAVATION TECHNIQUE<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.2<br />
Sorin Andrian a *,<br />
Gianina Iovan b ,<br />
Simona Stoleriu c ,<br />
Claudiu Topoliceanu d ,<br />
Andrei Georgescu e<br />
Department of Odontology, Periodontology<br />
and Fixed Prosthodontics, Faculty of Dental<br />
Medicine, „Gr.T.Popa” University of Medicine<br />
and Pharmacy, Jassy, Romania<br />
a. DDS, PhD, Professor<br />
b. DDS, PhD, Associate Professor<br />
c. DDS, PhD, Lecturer<br />
d. DDS, PhD student, Assistant Professor<br />
e. DDS, PhD, Assistant Professor<br />
Abstract<br />
Introduction. The aim of this study was to assess dentine remineralisation<br />
and the possibility to maintain the pulp vitality using several bioactive<br />
materials applied in the „stepwise” excavation technique after the carious<br />
dentine was removed using the CarisolvTM system (Sävedalen, Sweden).<br />
Methodology. The study was performed on 25 patients with a high caries<br />
risk, between 18-34 years old. 30 posterior teeth with acute dental caries<br />
were treated using the „stepwise” excavation technique. The patients were<br />
divided in three study groups, according to the type of bioactive materials:<br />
group 1 (10 acute dental caries) - Ca(OH) 2 liner (Dycal, DeTreyDentsply)<br />
and zinc-oxyde-eugenol (Caryosan, Spofa Dental); group 2 (10 acute dental<br />
caries) - zinc-oxyde-eugenol (Caryosan, Spofa Dental); group 3 (10 acute<br />
dental caries) - Ca(OH) 2 liner (Dycal, DeTreyDentsply) and glassionomer<br />
cement (Ketac Molar Easymix, 3M ESPE). After 6 months the changes<br />
of color and consistency of dentine were assessed using both clinical<br />
examination and radiographs, and pulp vitality was tested.<br />
Results. In study group 1, the dental vitality was maintained in 100% percent<br />
of the cases. In study group 2, a case of chronic pulpitis was recorded. In this<br />
study group, the dental vitality was maintained in 90% cases. In study group<br />
3 a case of pulp necrosis associated with a periapical lesion was recorded.<br />
This study group also presented therapeutical success in 90% cases.<br />
Conclusion. The „stepwise” technique used after the removal of infected<br />
dentine with the CarysolvTM system provided remineralisation of affected<br />
dentine in 70-80% percent of the patients and maintained the pulp vitality in<br />
90%-100% cases.<br />
Key words: acute dental caries, „stepwise” excavation technique,<br />
CarisolvTM, remineralisation, dentine.<br />
Received: 27 November 2013<br />
Accepted: 11 December 2013<br />
*Corresponding author:<br />
Professor Sorin Andrian, DDS, PhD<br />
Department of Odontology, Periodontology and<br />
Fixed Prosthodontics,<br />
Faculty of Dental Medicine, „Gr.T.Popa” University of<br />
Medicine and Pharmacy, Jassy, Romania<br />
16 Universitatii Str., RO-700115, Jassy, Romania.<br />
Tel/Fax: +40232301618<br />
e-mail: sorinandrian@yahoo.com<br />
Introduction<br />
Acute dental caries, characterized by deep demineralization and high risk of pulp involvement,<br />
require a progressive therapeutical approach more adequate in maintaining pulp vitality. The<br />
therapy of acute dental caries, using the „stepwise” excavation technique, requires the monitoring<br />
of pulp-dentine response to the materials applied for pulp capping. The traditional evaluation<br />
uses clinical examination, recording of the changes of dentine color and consistency during<br />
therapy. The neodentinogenesis and remineralisation reactions represent an important part<br />
of the pulp-dentin protection system, blocking the invasion of bacteria and their co-products.<br />
There are two layers of altered dentine with different characteristics: the layer of infected<br />
dentine which is heavily contaminated and the layer of affected dentine with a lower degree<br />
of bacterial contamination. The infected dentine is soft and yellow and it is characterized by<br />
extensive breakdown of the organic matrix. This layer should be removed as its remineralisation<br />
potential is lost. The affected layer consists of dentine with medium consistency and some<br />
degree of elasticity. In many cases of acute dental caries it is difficult to clearly differentiate<br />
the limit between the two layers. Since most of the recent data recommend the maintenance<br />
12 Stoma.eduJ (<strong>2014</strong>) 1 (1)
REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE<br />
MATERIALS IN STEPWISE - EXCAVATION TECHNIQUE<br />
Table 1. Results regarding the changes of dentine color in the three groups<br />
(in accordance with the different bioactive materials used)<br />
Group 1/<br />
Ca(OH) 2<br />
+ZOE<br />
Group 2/<br />
ZOE<br />
Group 3/ Ca(OH) 2<br />
+<br />
glassionomer cement<br />
Dark-brown 50% 30% 30%<br />
Brown-yellow 30% 40% 50%<br />
Unchanged (yellow) 20% 30% 20%<br />
Table 2. Mann Whitney statistical test results when comparing the color changes of the remineralized<br />
dentine after 6 months; Group 1-Ca(OH) 2+ZOE; Group 2-ZOE; Group 3-Ca(OH) 2+glassionomer cement<br />
Group 1 Group 2 Group 3<br />
Group 1 - 0.397 0.516<br />
Group 2 0.397 - 0.776<br />
Group 3 0.516 0.776 -<br />
of the affected dentine, the „stepwise” excavation<br />
technique is focused on its preservation and<br />
remineralisation (1-7). For the asymptomatic cases<br />
where the pulp exposure seems possible during<br />
the treatment, the „stepwise” excavation technique<br />
is the most recommended therapeutical approach.<br />
The practical application of this technique presents<br />
considerable variations. The acceptable consistency<br />
of remaining dentine can vary from soft to hard, while<br />
color can vary from yellow to brown. There are also<br />
different opinions regarding the optimal moment for<br />
the removal of carious dentine.<br />
Acute caries is characterized by periods of intense<br />
activity of the pulp tissue alternating with periods<br />
of pulp inactivity. Despite the scientific data that<br />
highlight the possibility to preserve affected dentine<br />
in deep dental caries, most practitioners continue<br />
to apply basic surgical principles. Most practitioners<br />
are also focused on the complete removal of carious<br />
dentine even with the risk of pulp exposure (3).<br />
Also, for the treatment of temporary teeth, most<br />
dentists perform pulpotomy instead of the stepwise<br />
technique. However many researchers are focused<br />
on finding efficient therapeutical procedures aimed<br />
at stimulating the defensive pulp-dentine complex<br />
processes (6,7). There are different recommendations<br />
regarding the bioactive materials used in the<br />
„stepwise” excavation technique (calcium hydroxidebased<br />
products, zinc-oxyde-eugenol, glassionomer<br />
cements). The intervals between treatment stages<br />
can also vary, from 4 to 8 weeks or from 2 to 6 months<br />
(1-5).<br />
During the last decades new methods have been<br />
developed for removal of carious dentine in an<br />
attempt to increase the efficacy, speed and patient<br />
comfort. In the absence of a clear macroscopic or<br />
microscopic delimitation between necrotic dentine<br />
and affected dentine (that can be remineralized), the<br />
use of the chemo-mechanical technique based on<br />
the CarisolvTM system was proposed.<br />
The aim of study was to assess the capacity of the<br />
mentioned bioactive materials to stimulate dentine<br />
remineralisation and to preserve pulp tissue vitality,<br />
following the removal of carious dentine with the<br />
CarisolvTM system.<br />
Methods<br />
The study included 25 patients with ages between<br />
18-34 years, having 30 posterior teeth affected by<br />
acute dental caries and high caries risk. The presence<br />
of systemic diseases was an exclusion criteria. The<br />
patients were informed about the structure and<br />
objectives of study and informed consent was<br />
obtained. The ethics Committee of the „Gr.T.Popa”<br />
University of Medicine and Pharmacy gave its<br />
approval for this study.<br />
The removal of carious dentine was performed<br />
with the CarisolvTM system (Sävedalen, Sweden) by<br />
a single practitioner. The CarisolvTM gel was applied<br />
on the carious dentine surface. The Carisolv gel was<br />
applied to cover the carious dentine from the lesion.<br />
After 30 seconds, the gel in the carious lesion was<br />
agitated using the excavators. The moist material<br />
was removed. A new layer of gel was applied and<br />
the procedure continued after waiting 30 seconds.<br />
The removal of the carious dentine was considered<br />
completed when the surface of the dentine had<br />
leather consistency.<br />
The treatment was performed using the „stepwise<br />
excavation” approach. Depending on the bioactive<br />
materials, three study groups were formed: group<br />
1 (10 acute dental caries) - calcium-hydroxide liner<br />
13
cariology<br />
Table 3. Results regarding the changes of dentine consistency (in accordance with different bioactive materials)<br />
Group 1/<br />
Ca(OH) 2+ZOE<br />
Group 2/<br />
ZOE<br />
Group 3/ Ca(OH) 2 +<br />
glassionomer cement<br />
Hard 50% 40% 30%<br />
Leather 40% 40% 50%<br />
Soft 10% 20% 20%<br />
Table 4. Mann Whitney statistical test results when comparing the consistency changes of the dentine after<br />
6 months; Group 1-Ca(OH) 2+ZOE; Group 2-ZOE; Group 3-Ca(OH) 2+glassionomer cement<br />
Group 1 Group 2 Group 3<br />
Group 1 - 0.565 0.344<br />
Group 2 0.565 - 0.744<br />
Group 3 0.344 0.744 -<br />
(Dycal, DeTreyDentsply) and zinc-oxyde-eugenol<br />
(Caryosan, Spofa Dental); group 2 (10 acute dental<br />
caries) zinc-oxyde-eugenol (Caryosan, Spofa Dental);<br />
group 3 (10 acute dental caries) - calcium-hydroxide<br />
liner (Dycal, DeTreyDentsply) and glassionomer cement<br />
(Ketac Molar Easymix, 3M ESPE). The assessment of<br />
the affected dentine was performed using two criteria:<br />
the color (yellow, brown-yellow, dark-brown) and<br />
the consistency (soft, leather, hard) immediately after<br />
completing the excavation procedure and 6 months<br />
later. The presence of dentine remineralisation was also<br />
assessed on the radiographic images. The vitality tests,<br />
assessing the vitality of pulp tissue, were performed<br />
using an electric pulp test device (Digitest, Parkell Inc,<br />
USA). Statistical analyzes of the results were performed<br />
using the Mann Whitney test with a significance level<br />
p0.05) (table 2).<br />
Table 3 presents the results regarding the<br />
consistency changes (Leksell indices) after 6 months.<br />
Study group 1 (Ca(OH) 2 + zinc-oxyde-eugenol)<br />
included 50% cases with hard dentine (total<br />
remineralisation), 40% cases with leather consistency<br />
(partial remineralisation) and only 10% cases with<br />
soft dentine (absent remineralisation). Study group<br />
2 (zinc-oxyde-eugenol) included 40% cases with<br />
hard dentine (total remineralisation), 40% cases with<br />
leather consistency (partial remineralisation) and<br />
20% cases with soft dentine (absent remineralisation).<br />
Study group 3 (Ca(OH) 2 + glassionomer cement)<br />
included 30% cases with hard dentine (total<br />
remineralisation), 50% cases with leather consistency<br />
(partial remineralisation) and 20% cases with soft<br />
dentine (absent remineralisation).<br />
No significant statistical differences were obtained<br />
when comparing consistency changes of the dentine<br />
after 6 month in groups 1, 2 and 3 (p>0.05) (table 4)<br />
An analysis of the radiographic images showed<br />
that in the study group 1 (Ca(OH) 2 + zinc-oxydeeugenol)<br />
dentine remineralisation was present in 90%<br />
of the cases. In this study group, the remineralisation<br />
processes were absent in 10% of the cases. This was<br />
the lowest percent of failure from all the study groups.<br />
In study group 2 (zinc-oxyde-eugenol) dentinal<br />
remineralisation was present in 80% of the cases.<br />
In study group 3 (Ca(OH) 2 + glassionomer cement)<br />
dentinal remineralisation was present in 80% of the<br />
cases. In Figure 1 is presented the radiographic<br />
aspect of demineralised dentine in deep acute<br />
carious lesion at 46 tooth. Figure 2 presents<br />
the radiographic aspect after 6 months of pulp<br />
capping with Ca(OH)2 and ZOE. It can be seen the<br />
area of dentinal remineralisation associated with<br />
neodentinogenesis and retraction of pulp beneath<br />
the mesial horn (Figure 2).<br />
Pulp tissue vitality was preserved in 100% of the<br />
cases in the study group, 6 months after indirect pulp<br />
14 Stoma.eduJ (<strong>2014</strong>) 1 (1)
REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE<br />
MATERIALS IN STEPWISE - EXCAVATION TECHNIQUE<br />
Figure 1. Demineralised dentine in contact with<br />
mesial pulp horn (arrow). Acute dental caries<br />
(tooth 46)<br />
capping with Ca(OH) 2 and zinc-oxyde-eugenol. For<br />
teeth undergoing pulp capping with zinc-oxydeeugenol,<br />
one case of chronic pulpitis was recorded.<br />
This study group presented 90% therapeutical<br />
success, regarding the preservation of pulp tissue<br />
vitality. For teeth undergoing pulp capping with<br />
Ca(OH) 2 and glassionomer cement, one case of pulp<br />
necrosis associated with chronic apical periodontitis<br />
was recorded. For this study group, the failure rate<br />
was 10%.<br />
Discussion<br />
Preserving and remineralizing affected dentine<br />
minimizes the risk of pulp exposure during the<br />
treatment of acute caries. This approach usually<br />
requires materials which seal the cavity and medicate<br />
the dentine-pulp complex, allowing the preservation<br />
of the pulp vitality and apposition of tertiary dentin.<br />
These two aspects prove the importance of the<br />
temporary restorations in the treatment of acute<br />
dental caries.<br />
Remineralisation is not a simple precipitation,<br />
but also a result of complex biochemical<br />
mechanisms initiated by the pulp tissue. The dentine<br />
remineralisation is also performed by odontoblasts<br />
through the transfer of mineral salts from the systemic<br />
circulation to the mineralization area. In the cases<br />
where the remineralisation processes are stimulated<br />
by glassionomer cements, the essential elements<br />
are represented by fluoride, calcium and strontium.<br />
Some glassionomer cements contain a high percent<br />
of calcium ions and a low percent of strontium ions,<br />
while others contain a high percent of strontium<br />
ions. The calcium ions have a major influence in<br />
the remineralisation of the affected dentine, while<br />
strontium ions have an important antibacterial effect<br />
and also stimulate the remineralisation processes.<br />
Fluoride ions and strontium ions can penetrate the<br />
demineralized dentine and become components<br />
of apatite crystals (8). For a short time, glassionomer<br />
Figure 2. The remineralised dentine,<br />
neodentinogenesis and the retraction of mesial<br />
pulp horn (arrow), following indirect pulp capping<br />
with Ca(OH) 2 and ZOE (tooth 46)<br />
cements also release aluminum ions that increase<br />
the enamel resistance to acidic attack. Our results<br />
regarding the reactions of the pulp-dentine complex,<br />
are similar with the results of several studies and<br />
support the widespread use of the „stepwise”<br />
excavation technique. Some authors recommend<br />
the association between Ca(OH) 2 liners and zincoxyde-eugenol<br />
for at least 3 months, with a 80%-90%<br />
success rate, following the environment alcalinisation<br />
and odontoblast stimulation by eugenol (1). The<br />
calcium ions released by Ca(OH) 2-based liners<br />
influence both passive and active remineralisation<br />
by the activation of enzymes associated with the<br />
remineralisation processes. Some studies have<br />
reported preservation of the pulp vitality in teeth with<br />
dentine remineralisation and neodentinogenesis,<br />
in 100% of cases, at an interval of 3-6 months (2).<br />
In this study, the researchers demonstrated that<br />
Ca(OH) 2-based liners associated with zinc-oxydeeugenol<br />
initiate neodentinogenesis and dentine<br />
remineralisation in 82,5% of the cases after 8-24<br />
weeks. For the cases treated by indirect pulp capping<br />
with zinc-oxyde-eugenol, the authors reported a<br />
94% success rate after the removal of temporary<br />
restoration (1). Similar success rates were recorded<br />
in the „stepwise” excavation technique using the<br />
association of Ca(OH) 2-based liners with zinc-oxydeeugenol<br />
or glassionomer cements (9). Other studies<br />
reported a 100% success rate after a 6-12 months<br />
interval, following the „stepwise” technique in acute<br />
dental caries (10). Results of some studies proved<br />
the association between dentinal remineralisation<br />
and a massive decrease of bacterial concentration<br />
in carious dentine, after 6 months of „stepwise”<br />
therapy with zinc-oxyde-eugenol (11). Similar studies<br />
proved the dentine remineralisation following the<br />
penetration of dentinal tubules by fluoride and<br />
strontium ions (12,13).<br />
Some authors sustain that the use of the “stepwise”<br />
excavation technique in deep dental caries plays a<br />
15
cariology<br />
primary role in protecting the pulp-dentine complex<br />
(14). When using this technique, the practitioner can<br />
arrest the acute progression of the carious lesion,<br />
by modifying the cariogenic environment. The soft<br />
demineralized dentine is changing in most cases,<br />
into a dentine with increased consistency and brownyellow<br />
or dark-brown appearance. The efficiency<br />
of the „stepwise” excavation technique was also<br />
assessed after 6-12 months by other authors (15).<br />
The clinical changes of demineralized dentine<br />
were associated with a high reduction of bacterial<br />
contamination. After 6 months, in 90% of the cases<br />
the consistency of demineralized dentine increased,<br />
while in 20% of the cases there was a complete<br />
sterilization of demineralized dentine. Using a<br />
standardized scale of consistency and color changes,<br />
some authors found the remineralisation of dentine<br />
in 94% of the cases after 2-19 months following the<br />
„stepwise” excavation technique (16). The clinical<br />
and radiographical changes of the demineralized<br />
dentine, following indirect pulp capping with<br />
Ca(OH) 2 and zinc-oxyde-eugenol, after an interval of<br />
6-7 months, were assessed by different authors (4).<br />
The affected dentine became hard dentine in 80%<br />
of the treated teeth, while 16,67% of teeth presented<br />
demineralized dentine with medium consistency.<br />
In the same study, only 3,3% cases were associated<br />
with total absence of remineralisation processes.<br />
The „stepwise” excavation technique is included<br />
in the category of new operatory treatment<br />
options for dental caries, but some authors claim<br />
potential failures in the long-term follow up of the<br />
treated teeth (17). Performing a critical review of<br />
23 studies focused on this technique, the authors<br />
sustain the use of this technique on a large scale<br />
for the treatment of deep acute dental caries. A<br />
similar critical review of such studies concluded<br />
that the „stepwise” excavation technique presents<br />
positive results in the long-term, regarding the<br />
vitality preservation of the pulp-dentine complex<br />
(18).<br />
Conclusion<br />
1. The remineralisation of the affected dentine<br />
from acute carious lesions performed with zincoxide-eugenol<br />
or with calcium-hydroxide liner and<br />
glassionomer cement in „stepwise” excavation<br />
technique was present in 80% of the cases.<br />
2. After 6 months, 90% of the acute carious lesions<br />
treated with calcium-hydroxide liner and zinc-oxideeugenol<br />
in the „stepwise” excavation technique<br />
presented dentine remineralisation.<br />
3. The „stepwise” excavation technique is an<br />
efficient approach in the treatment of acute dental<br />
caries maintaining pulp vitality in 90-100% of the<br />
cases.<br />
Bibliography<br />
1. Oliveira EF, Carminatti G, Fontanella V, Maltz M.The<br />
monitoring of deep caries lesions after incomplete dentine<br />
caries removal: results after 14-18 months. Clin Oral<br />
Investig. 2006;10(2):134-139.<br />
2. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after<br />
stepwise versus direct complete excavation of deep carious<br />
lesions in young posterior permanent teeth. Endod Dent<br />
Traumatol. 1996;12(4):192-196<br />
3. Ricketts D. Management of the deep carious lesion and the<br />
vital pulp dentine complex. Br Dent J. 2001;191(11):606-<br />
610.<br />
4. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep<br />
caries lesions after incomplete dentine caries removal:40-<br />
month follow-up study. Caries Res. 2007;41(6):493–496<br />
5. Duque C, Negrini TD, Sacono NT, Spolidorio DM, de<br />
Souza Costa CA, Hebling J. Clinical and microbiological<br />
performance of resin-modified glass-ionomer liners after<br />
incomplete dentine caries removal. Clin Oral Investig.<br />
2009;13 (4):465-471<br />
6. Manton D. Partial caries removal may have advantages<br />
but limited evidence on restoration survival. Evid Based<br />
Dent. 2013;14(3):74-75<br />
7. Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE.<br />
Operative caries management in adults and children. Br<br />
Dent J. 2001;191(11):606-610.<br />
8. Studervant CM. The art and science of operative dentistry.<br />
3rd ed. St Louis:Mosby,1995<br />
9. Goldberg M, Six N, Decup F. Bioactive molecules and the<br />
future of pulp therapy. Am J Dent. 2003;16(1):66–76.<br />
10. Iovan Gianina. Diagnosis and Management of Patients<br />
with High Caries Activity. Apollonia Press, 2002<br />
11. Banerjee A, Kidd EAM, Watson TF. In vitro evaluation<br />
of five alternative methods of carious dentine excavation.<br />
Caries Res. 2000;34 (2):144-150.<br />
12. Banerjee A, Kidd EAM, Watson T F. Scanning electron<br />
microscopic observations of human dentine after mechanical<br />
caries excavation. J Dent. 2000;28 (3):179-186.<br />
13. Braut A, Kollar EEEJ, Mina M. Analysis of the odontogenic<br />
and osteogenic potentials of dental pulp in vivo using a Col1a1-<br />
2.3-GFPtransgene. Int J Dev Biol. 2003;47 (4):281-292.<br />
14. Banerjee A., Watson T, Kidd E.A.M. Carious dentine excavation<br />
using Carisolv gei:a quantitative, autofluorescence assess¬ment<br />
using scanning microscopy. Caries Res. 1999;33(4):313<br />
15. Carneiro F.C, Teixeira F, Guimaraes L, Dias K, Naclanovsky<br />
P. Clinical comparison between chemo-mechanical and hand<br />
instruments caries removal. J Dent Res. 2000;79 (5):295<br />
16. Fure S, Lingstrom P, Birkhed D. Evaluation of Carisolv(TM)<br />
for the Chemo-Mechanical Removal of Primary Root Caries.<br />
Caries Res. 2000;34(3):275-280.<br />
17. Love RM, Jenkinson HF. Invasion of dentinal tubules by<br />
oral bacteria. Crit Rev Oral Biol Med. 2002;13(2):171-183.<br />
18. Perdigäo J, Cardoso PEC, Lopes M, Moura SK, Geraldeli<br />
S, Cardoso. JMS. Effect of carisolv on the hybrid layer. J.<br />
Dent. Res. 2000;79 (1 suppl):537<br />
16 Stoma.eduJ (<strong>2014</strong>) 1 (1)
orthodontics<br />
Cite this article:<br />
Pacurar M, Jurca AM,<br />
Roman D, Bud E,<br />
Zetu I, Vata I.<br />
Nonextraction methods<br />
for creating space in<br />
orthodontic therapy.<br />
Stoma <strong>Edu</strong> J. <strong>2014</strong>;<br />
1(1):18-21.<br />
NONEXTRACTION METHODS<br />
FOR CREATING SPACE<br />
IN ORTHODONTIC THERAPY<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.3<br />
Mariana Păcurar 1a ,<br />
Ana Maria Jurcă 1c ,<br />
Doru Roman 1b *,<br />
Eugen Bud 1c ,<br />
Irina Nicoleta Zetu 2b ,<br />
Ioana Vâţă 2c<br />
1. Orthodontic Department, Faculty of Dentistry,<br />
University of Medicine and Pharmacy of<br />
Târgu-Mureş, Târgu-Mureş, Romania<br />
2. Orthodontic Department, Faculty of Dentistry,<br />
„Gr.T.Popa” University of Medicine and<br />
Pharmacy, Jassy, Romania<br />
a. DDS, PhD, Professor,<br />
Dean of Faculty of Dentistry<br />
b. DDS, PhD, Lecturer<br />
c. DDS, Assistant Professor<br />
Abstract<br />
Introduction: Molar distalization is an alternative treatment method in dento-maxillary<br />
anomalies, to avoid extraction especially in low angle cases. The orthodontic literature<br />
indicates that upper molar distalization is a tipping movement, combined with mesiobuccal<br />
rotation and buccally-crown torque. The aim of the study was to analyze the advantages<br />
to create space during upper first molar distalization movement, by using different<br />
devices. We used this method in skeletal Angle Class II, dental Class II/2 malocclusion with<br />
crowding and low profile.<br />
Methodology: The study consisted of a retrospective statistical analysis on 435 patients<br />
aged 11-13 years treated with fixed appliances (straight wire technique), between 2009-<br />
2012. The patients were divided in two groups: group A (83) who worn distalization<br />
devices and group B (352) who did not. Group B was divided in: B1 (278) with other<br />
nonextraction appliances and B2 (74) with extraction during orthodontic treatment.<br />
Results: Upper molar distalization was successful in 45% of the cases, the values of the space<br />
being: 2,13- 2,33 mm, by tipping movement. Bodily distal upper molar movement was<br />
successfully obtained only when the rotational axis is at infinite and the compressive stress<br />
is homogeneously distributed in the periodontal ligament. The success rate depended on:<br />
eruption of the second molar, overjet and overbite size.<br />
Conclusions:<br />
1. Molar distalization is a challenge in orthodontic treatment and is indicated for Angle<br />
Class II, crowding and low angle (extraction makes the profile worse).<br />
2. Molar distalization depends on the position of the second molar and this technique is<br />
not singular, but associated with multibracket appliance .<br />
Key words: distalization, second molar, class II, extraction, fixed appliances.<br />
Introduction<br />
Modern orthodontic therapy attempts, whenever possible, a nonextraction treatment,<br />
with convenient means for the patient, which would allow current activities and it would not<br />
affect facial harmony (1).<br />
In this context, molar distalization is an useful treatment method in obtaining arcade space,<br />
especially in anomalies Angle Class II/2 with accentuated retrognatic profile and hipodivergent<br />
growth pattern, cases where extraction would obviously create aesthetic facial damage (2) .<br />
The authors propose in this paper an assessment of the molar distalization method in comparison<br />
with other nonextraction therapy methods (expansion, frontal protrusion and stripping).<br />
Received: 19 November 2013<br />
Accepted: 11 March <strong>2014</strong><br />
* Corresponding author:<br />
Lecturer Doru Roman, DDS, PhD<br />
Orthodontic Department, Faculty of Dentistry,<br />
University of Medicine and Pharmacy of Târgu-<br />
Mureş, Târgu-Mureş, Romania.<br />
38 Gh. Marinescu Str., RO-540139,<br />
Târgu-Mureş, Romania.<br />
Tel/Fax: +40265210407. e-mail:<br />
tudorroman2000@ yahoo.com<br />
Methods<br />
We conducted a retrospective statistical study on a sample of 435 patients, aged between<br />
11-13 years, who were treated at the Orthodontic Department of the Faculty of Dentistry in<br />
Târgu Mureș in the period 2009-2012, for various malocclusions.<br />
The initial sample was divided into two subgroups: group A - 83 patients average age<br />
11,25 with upper or lower molar distalization. The following parameters were evaluated:<br />
- duration of treatment;<br />
- type of distalization;<br />
- type of used appliance;<br />
- obtained results.<br />
18 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Nonextraction methods for space regane in orthodontic therapy<br />
Figure 1. Cases distributrion<br />
Figure 2. Correlation betwen owerjet and distalization<br />
Figure 3. Correlation between<br />
owerbite and distalization<br />
Figure 4. Correlation between molar<br />
distalization and anomalies<br />
Group B - represented by the rest of the<br />
patients, average age 12,15 were divided in<br />
two subgroups: B1 – cases of permanent teeth<br />
extractions and B2 - nonextraction cases, treated<br />
with other methods than distalization.<br />
Results<br />
The distribution of cases by gender demonstrated<br />
a predominance of female patients, representing<br />
64% of the studied group (Figure 1).<br />
Analysis of cases depending on the type<br />
of anomaly revealed a higher frequency of<br />
Angle Class I malocclusion (56,09%), Class II<br />
represented by 35% of which 20,69% Class<br />
II/1, and 14,71% Class II/2, and Angle Class III<br />
malocclusion represented only 8,51% of the<br />
studied group (Table 1).<br />
Table 1. The distribution of anomalies<br />
Angle Class No. cases %<br />
Angle Class I anomalies 244 56.09%<br />
Angle Class II/1 anomalies 90 20.69%<br />
Angle Class II/2 anomalies 64 14.71%<br />
Angle Class III anomalies 37 8.51%<br />
Total 435<br />
In group A, represented by patients with molar<br />
distalization, the distribution on the arches was the<br />
following: the upper jaw 11,26%, lower jaw 4,83%<br />
and bimaxilarry: 2.99% of cases (Table 2).<br />
Table 2. The distribution of arches<br />
No. cases %<br />
Molar distalization 83 19.08%<br />
Upper arch 49 11.26%<br />
Lower arch 21 4.83%<br />
Upper and lower 13 2.99%<br />
Total 166<br />
The distribution of cases from subgroup B 2<br />
includes:<br />
- upper expansion plate 34%;<br />
- lower expansion plate 8%;<br />
- maxillary disjunction (rapid palatal expander) 4%;<br />
- functional therapy 2,5%;<br />
- class II elastics 37%;<br />
- lee-way-space maintenance 1,5%;<br />
- stripping (interproximal reduction) 13%.<br />
Correlational analysis of the type of extractional/<br />
nonextractional treatment related to overjet<br />
shows that: for overjet values between 0-2 mm,<br />
19
orthodontics<br />
the most frequent therapy is nonextractional<br />
(other than distalization) in 60% of cases, followed<br />
by dental extraction in 28% of cases and molar<br />
distalization in 12% of cases. The frequency with<br />
which distalization was used decreases with the<br />
growth of overjet value (Figure 2) .<br />
Correlational analysis of the type of<br />
extractional/nonextractional treatment related<br />
to overbite shows that in open bite cases the<br />
extraction treatment is more frequent and in<br />
deep bite cases the most frequent treatment is<br />
nonextraction. (expander or stripping), followed<br />
by distalization cases (Figure 3).<br />
Our study showed an increased incidence<br />
of therapy with molar distalization in Class II/2<br />
anomalies (28,13%), followed by Angle class I<br />
(11,07%) and class II/1 (4,44%) (Figure 4).<br />
Regarding the type of dentition, we found<br />
that the difference in the incidence of upper<br />
molar distalization is not significant, between<br />
permanent (10,81%) and mixed dentition<br />
(11,57%), as opposed to the lower jaw, with a<br />
frequency of 7,02% in the mixed dentition and<br />
2,16% in the permanent dentition (Figure 5).<br />
A major issue in this kind of therapy is the<br />
timing of treatment initiation. In group A the<br />
mean age of the patients was 11,25 years and in<br />
group B the mean age was 12,15 years.<br />
The highest chances of molar distalization<br />
success are when the second molar has not yet<br />
erupted.<br />
Discussion<br />
The updated data from the literature indicates<br />
that during molar distalization we obtain a distal<br />
tipping and less corporal displacement because<br />
the force application point is at a distance from<br />
the resistance center of the tooth (3,4). For<br />
bodily movement, the moment/force ratio at the<br />
molar centre of resistance must be zero, so it is<br />
necessary to reduce the moment on the molar<br />
bond using a counterbalancing couple (CBC)<br />
with effects in the vertical plane (5,6).<br />
Figure 5. Correlation between type of<br />
dentition and molar distalization<br />
In the orthodontic field it is better to have<br />
dental movement by translation (7).<br />
But during distalization we obtain a distal<br />
tipping, is important to follow the maintenance<br />
of initial molar angulation, adding to the initial<br />
coronal tipping a root distal tipping (8).<br />
Molar distalization is not a single orthodontic<br />
therapy, but has to be followed by fixed<br />
orthodontic treatment, which uses the obtained<br />
space for aligning the tooth and for overjet<br />
correction.<br />
Most authors recommend that distalization<br />
appliances should be inserted on an oral part of<br />
the arch in order to be nearer to the resistance<br />
centre.<br />
The other possibilities to have a translation<br />
movement during distalization is to put an extraoral<br />
force (9).<br />
Conclusions<br />
Molar distalization is a challenge in orthodontic<br />
treatment and is indicated for Angle II Class,<br />
crowding and low angle (extraction makes the<br />
profile worse).<br />
The rate of success in molar distalization is<br />
less than that in other nonextraction methods<br />
and sometimes this method is followed by<br />
extraction.<br />
Bibliography<br />
1. Proffit WR. Biomechanics and mechanics. Contemporary<br />
Orthodontics 3rd ed. St Louis: Mosby Inc; 2000:298-305.<br />
2. Baccetti T, Franchi L, Kim LH. Effect of timing on the outcomes<br />
of 1-phase nonextraction therapy of Class II malocclusion. Am J<br />
Orthod Dentofacial Orthop. 2009;136(4):501-509.<br />
3. Antonarakis GS, Kiliaridis S. Maxillary molar distalization with<br />
noncompliance intramaxillary appliances in Class II malocclusion.<br />
A systematic review. Angle Orthod 2008, 78(6):1133-1140.<br />
4. Escobar SA, Tellez PA, Moncada CA, Villegas CA, Latorre CM, Oberti G.<br />
Distalization of maxillary molars with the bone supported pendulum. A<br />
clinical study. Am J Orthod Dentofacial Orthop 2007;131(4):545-549.<br />
5. Henneman S, Von den Hoff JW, Maltha J.C. Mechanobiology of<br />
tooth movement. Eur J Orthod. 2008;30(3):299-306.<br />
6. Kinzinger GSM, Fritz UB, Sander FG, Diedrich PR. Efficiency of a<br />
pendulum appliance for molar distalization related to second and<br />
third molar eruption stage. Am J Orthod Dentofacial Orthop 2004;<br />
125 (1):8-23.<br />
7. Birte M. Biological reaction of alveolar bone to orthodontic tooth<br />
movement. The Angle Ortodontist. 1999;69(2):151-158.<br />
8. Papadopoulos MA, Mavropoulos A, Karamouzos A. Cephalometric<br />
changes following simultaneous first and second maxillary molar<br />
distalization. J Orofac Orthop 2004;65 (2):123-136.<br />
9. Klontz H. The Extraction/nonextraction dilemma – the Class II<br />
solution. The Tweed Profile. 2006;5:25-30.<br />
10. Korkmaz S, Fulya I, Ferdi A, Tülin A. Unilateral molar distalization<br />
with a modified slider. Eur J Orthod. 2006;28(4):361-365.<br />
20 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Periodontics<br />
Cite this article:<br />
Miricescu D, Totan A,<br />
Calenic B, Mocanu B,<br />
Greabu M. Salivary and<br />
serum enzymes as<br />
diagnostic biomarkers in<br />
patients with periodontal<br />
disease. Stoma <strong>Edu</strong> J.<br />
<strong>2014</strong>; 1(1):22-27.<br />
Salivary and serum enzymes as<br />
diagnostic biomarkers in patients<br />
with periodontal disease<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.4<br />
Daniela Miricescu 1a ,<br />
Alexandra Totan 1b ,<br />
Bogdan Calenic 1c ,<br />
Brânduşa Mocanu 2c ,<br />
Maria Greabu 1d *<br />
1. Department of Biochemistry, Faculty of Dental<br />
Medicine, "Carol Davila" University of Medicine<br />
and Pharmacy, Bucharest, Romania<br />
2. Department of Periodontology, Faculty of<br />
Dental Medicine, "Carol Davila" University of<br />
Medicine and Pharmacy, Bucharest, Romania<br />
a. PhD, Teaching Assistant<br />
b. PhD, Lecturer<br />
c. DDs, PhD, Teaching Assistant<br />
d. PhD, Professor, Head of Department<br />
Abstract<br />
Introduction: Periodontitis is a common oral affection characterized by inflammation,<br />
connective tissue breakdown and, finally, alveolar bone loss. One feature of the<br />
inflammatory process is the release of enzymes from different oral tissues. The general<br />
aim of the present study was to detect salivary and serum enzyme levels in patients with<br />
periodontitis.<br />
Methodology: We included 20 patients with chronic periodontitis and 20 controls.<br />
Unstimulated whole saliva and serum was used to detect the enzymes employing<br />
the kinetic method and an automatic analyzer. Patients and healthy controls were<br />
investigated for plaque index (PI), bleeding index (GI) and probing depth (PD)<br />
(p
Salivary and serum enzymes as diagnostic biomarkers at patients with periodontal disease<br />
Table 1. Clinical parameters for periodontal disease<br />
Variable<br />
Patients<br />
(n=20)<br />
Controls<br />
(n=20)<br />
p value<br />
PI (%) 48±0.21 19±0.60
Periodontics<br />
Table 2. Salivary levels<br />
Parameters Patients Controls p value<br />
LDH U/mg proteins 102,89±96 179,06
Salivary and serum enzymes as diagnostic biomarkers at patients with periodontal disease<br />
oral cavity, analyzing biomarkers in saliva may<br />
provide a thorough overview of the periodontal<br />
status compared with GCF. Studies show that<br />
different results are due primarily to different<br />
processing methods for the saliva. Therefore the<br />
study design requires careful standardization in<br />
the collection and processing of saliva. Numerous<br />
studies show that there is a direct relationship<br />
between periodontal complications and many<br />
systemic diseases such as cardiovascular disease,<br />
metabolic syndrome or diabetes (16-20). Another<br />
aim of the present study was to test the hypothesis<br />
that periodontal disease can influence general<br />
health by analyzing enzymatic levels. In the serum of<br />
patients with periodontal disease we have obtained<br />
a series of changes in the enzymatic activity of ALP,<br />
LDH, GGT and AST in patients with periodontal<br />
disease when compared with the control group.<br />
ALP is present especially in bones and the liver,<br />
duodenum and kidney. Increased levels of this<br />
enzyme have been recorded in skeletal damage<br />
associated with osteoblastic reaction and cholestasis<br />
(21, 22). Our overall results show that the serum levels<br />
of the enzyme in patients with periodontal disease<br />
are statistically increased when compared to the<br />
control group. Previous studies show an association<br />
between periodontal disease and osteoporosis,<br />
especially in postmenopausal women (23,24). Our<br />
group of patients with periodontal disease included<br />
15 females with the average age of over 50 years<br />
so they present higher risk of osteoporosis. LDH is<br />
present especially in the muscle, liver, myocardium,<br />
kidney and erythrocytes. Marked increase of the enzyme<br />
activity of LDH is found in myocardial infarction, toxic<br />
liver damage or testicular cancer. Moderate increments<br />
of LDH were also found in muscle disease, hemolysis<br />
and malignant lymphoma (22,25). In our experiments,<br />
LDH was increased but the increase was not statistically<br />
significant. This increase in LDH levels may be a warning<br />
sign even if it was not a statistically significant value.<br />
Beck and colleagues have postulated a connection<br />
between periodontal disease and atherosclerosis. As<br />
such, people suffering from periodontal disease may be<br />
at increased risk of atherosclerosis (26). GGT is present<br />
in the kidney, pancreas and liver. Significant increases<br />
of GGT activity have been recorded in cholestasis,<br />
alcoholism and hepatic tumors. Moderate increases<br />
were observed for chronic hepatitis and pancreatitis<br />
(22). In our experiments, GGT levels were statistically<br />
increased in the serum from patients with periodontal<br />
disease versus the healthy subjects. AST is a widespread<br />
enzyme, mainly localized in the liver, myocardium or<br />
muscle, but also present in small amounts in the lungs,<br />
kidneys, pancreas and erythrocytes. Marked increments<br />
of AST are present in myocardial infarction, acute<br />
hepatitis or toxic liver damage. Moderate increases<br />
are observed in patients with chronic hepatitis and<br />
infectious mononucleosis (22,27). The enzymatic<br />
activity of AST was increased (p>0.05) in the serum of<br />
patients with periodontal disease versus the healthy<br />
group.<br />
Conclusion<br />
The salivary and serum enzymes detected in our<br />
study can be useful in the monitoring of patients<br />
with periodontal disease.<br />
Acknowledgements<br />
This study was supported by the Sectorial<br />
Operational Programme Human Programme<br />
Human Resources Development (SOP HRD),<br />
financed from the European Social Fund and by<br />
the Romanian Government under the contract<br />
number POSDRU/6/1.5/S/S17.<br />
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6. Dabra S, China K, Kaushik A: Salivary enzymes as diagnostic<br />
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10. Totan A, Greabu M, Totan C, Spinu T: Salivary aspartate<br />
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11. Yan F: Alkaline phosphatise level in gingival crevicular<br />
fluid of periodontities before and after periodontal treatment.<br />
Chung Hua Kou Chiang Hseuch Tsa Chin 1995, 30(4):204-206,<br />
255-256.<br />
12. Agawal S, Chandra CS, Piesco NP, Langkamp HH, Bowen L,<br />
Baran C: Regulation of periodontal ligament cell functions by<br />
interleukin-1 beta. Infect Immun 1998, 66(3):932-937.<br />
13. Zappacosta B, Manni A, Persichilli S, Boari A, Scribano D,<br />
Minucci A, Raffaelli L, Giardina B, De Sole P: Salivary thiols and<br />
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14. Atici K, Yamalik N, Eratalay K, Etikan I: Analysis of gingival<br />
crevicular fluid intracytoplasmic enzyme activity in patients<br />
with adult periodontitis and rapidly progressive periodontitis.<br />
A logitudinbal study model with periodontal treatment. J<br />
Periodontol 1998, 69(10):1155-1163.<br />
15. Battino M, Greabu M, Totan A, Bullon P, Tovaru S, Mohora M,<br />
Didilescu A, Parlatescu I, Spinu T, Totan C: Oxidative stress markers<br />
in oral lichen planus. Biofactors 2008, 33(4):301-310.<br />
16. Esen C, Alkan BA, Kırnap M, Akgül O, Işıkoğlu S, Erel O:<br />
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oxidant status and oxidative stress index. J Periodontol 2012,<br />
83(6):773-779.<br />
17. Bullon P, Cordero MD, Quiles JL, Ramirez-Tortosa Mdel C,<br />
Gonzalez-Alonso A, Alfonsi S, García-Marín R, de Miguel M,<br />
Battino M: Autophagy in periodontitis patients and gingival<br />
fibroblasts: unraveling the link between chronic diseases and<br />
inflammation. BMC Med 2012, 17;10:122.<br />
18. Bullon P, Morillo JM, Ramirez-Tortosa MC, Quiles JL, Newman<br />
HN, Battino M: Metabolic syndrome and periodontitis: is oxidative<br />
stress a common link?. J Dent Res 2009, 88(6):503-518.<br />
19. Floriano PN, Christodoulides N, Miller CS, Ebersole JL,<br />
Spertus J, Rose BG, Kinane DF, Novak MJ, Steinhubl S, Acosta<br />
S, Mohanty S, Dharshan P, Yeh CK, Redding S, Furmaga W,<br />
McDevitt JT: Use of saliva –based nano-biochip tests for<br />
scutemyocardial infarction at the point of care: a feasibility<br />
study. Clin Chem 2009, 55(8):1530-1538.<br />
20. Galli C, Passeri G, Macaluso GM: FoxOs, Wnts and oxidative<br />
stress-induced bone loss: new players in the periodontitis<br />
arena? J Periodontal Res 2011, 46(4):397-406.<br />
21. Wiwanitkit V: High serum alkaline phosphatase levels, a<br />
study in 181 Thai adult hospitalized patients. BMC Fam Pract<br />
2001, 2:2.<br />
22. Dobreanu M: Biochimie clinică. Implicaţii practice, Editia a<br />
II – a. Editura Medicală, 2010, Capitolul 12: 223-259.<br />
23. Bullon P, Goberna B, Guerrero JM, Segura JJ, Perez-Cano R,<br />
Martinez-Sahuquillo A: Serum, saliva and gingival crevicular fluid:<br />
their relation to periodontal status and bone mineral density in<br />
postmenopausal woman. J Periodontol 2005, 76(4): 513-519.<br />
24. Bullon P, Chandler L, Segura Egea JJ, Cano PR, Sahuquillo AM:<br />
Osteocalcin in serum, saliva and gingival crevicular fluid: their<br />
relation with periodontal treatment outcome in postmenopausal<br />
woman. Med Oral Patol Oral Cir Bucal 2007, 12(3):E193-197.<br />
25. Kornberg A, Polliak A: Serum lactate dehydrogenase<br />
levels in acute leukemia. Marked elevations in lymphoblastic<br />
leukemia. Blood 1980, 56(3):351-355.<br />
26. Beck JD, Slade G, Offenbacher S: Oral disease, cardiovascular<br />
disease and systemic inflammation. Periodontology 2000<br />
2000, 23:110-120.<br />
27. Annoni G, Chirillo R, Swanie D: Prognostic value of<br />
mitochondrial aspartate amniotrasferase in acute myocardial<br />
infarction. Clin Biochem 1986, 19(4): 235-239.<br />
26 Stoma.eduJ (<strong>2014</strong>) 1 (1)
occlusion<br />
Cite this article:<br />
Croitoru CI, Marinescu<br />
IR, Draghici EC, Popescu<br />
SM, Scrieciu M, Mercut V.<br />
Etiological consideration<br />
in bruxism. Stoma <strong>Edu</strong> J.<br />
<strong>2014</strong>; 1(1):28-32.<br />
ETIOLOGICAL CONSIDERATIONS<br />
IN BRUXISM<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.5<br />
Cristiana Ileana Croitoru 1a ,<br />
Iulia Roxana Marinescu 1a ,<br />
Emma Cristina Drăghici 2b ,<br />
Sanda Mihaela Popescu 2c *,<br />
Monica Scrieciu 3d ,<br />
Veronica Mercuţ 3e<br />
1. University of Medicine and Pharmacy<br />
of Craiova, Craiova, Romania<br />
2. Oral Rehabilitation Department, Faculty of<br />
Dental Medicine, University of Medicine and<br />
Pharmacy of Craiova, Craiova, Romania<br />
3. Prosthetics Department, Faculty of Dental<br />
Medicine, University of Medicine and Pharmacy<br />
of Craiova, Craiova, Romania<br />
a. DDS, PhD student<br />
b. DDS, Asisstant Professor, PhD student<br />
c. MDM, PhD, Associate Professor,<br />
d. MDM, PhD, Associate Professor<br />
e. MDM, PhD, Professor,<br />
Dean of Faculty of Dental Medicine<br />
Abstract<br />
The etiology of bruxism is controversial, many factors being implicated, like occlusion,<br />
psycho-behavioral factors, and genetic factors. The aim of the present review was<br />
to systematically assess the literature and identify main theories regarding the<br />
etiology of bruxism. Data extraction was carried out according to the standard<br />
Cochrane systematic review methodology. The following databases were searched:<br />
PubMed, Google Scholar, Medline and the Google library. The primary outcome<br />
was bruxism etiology. Screening of eligible studies and data extraction were conducted<br />
independently and in duplicate. The references were analyzed by two reviewers using<br />
the same search strategy and the same inclusion criteria were applied to the selected<br />
studies. Query terms used were „bruxism”, „etiology” and „mechanism”. Among the 95<br />
related articles that were critically assessed, 31 were included in the critical appraisal.<br />
There is convincing evidence that the etiology of bruxism is various, involving local,<br />
systemic and psycho-behavioral factors.<br />
Key words: bruxism etiology, psycho-behavioral factors<br />
1.INTRODUCTION<br />
Received: 09 November 2013<br />
Accepted: 06 December 2013<br />
* Corresponding author:<br />
Associate Professor Sanda Mihaela Popescu,<br />
MDM, PhD<br />
Faculty of Dental Medicine, University of<br />
Medicine and Pharmacy of Craiova,<br />
Craiova, Romania.<br />
2-4 Petru Rares Str., RO-200349 Craiova,<br />
Dolj, Romania.<br />
Tel/Fax: +40251524442.<br />
e-mail: sm_popescu@hotmail.com<br />
Bruxism is a term generally used to define daytime and night time parafunctional<br />
activities of the masticatory system, which includes strained jaw and teeth grinding friction<br />
associated with tooth wear, myalgia of the masticatory muscles, temporomandibular joint<br />
disorders and morning fatigue.<br />
Hippocrates, quoted by Rozencweig (1), pointed out that “dental wear is soul’s clutter”.<br />
This aphorism shows the dimension of this condition, which is outside the oro-dental<br />
sphere.<br />
In 1907, Karolyi then Marie and Pietkiewicz, used the term “bruxomania”, considering<br />
that “dental wear brings together at the same time the damages of the central nervous<br />
system”(2).<br />
The term bruxism was first used in the literature in 1931 by Frohman for “non-functional<br />
grinding and rubbing the teeth” (3).<br />
Over time there had been an ongoing concern for establishing a complete and<br />
comprehensive definition, related to the clinical manifestations of bruxism to explain at the<br />
same time the etiopathogenic mechanisms involved in the production and maintenance<br />
of bruxism.<br />
Lavigne et al. (4) performed several studies on bruxism and concluded that the definition<br />
has evolved from the first considerations which were mainly referring to dental contacts and<br />
muscle contractions to considerations that relate to behavioral aspects and in particular the<br />
knowledge of sleep problems.<br />
The aim of the present review was to systematically assess the literature and identify main<br />
theories regarding etiology of bruxism.<br />
2. METHODS<br />
In the literature, more than 400 articles on bruxism are available.<br />
Data Sources: Data extraction was carried out according to the standard Cochrane<br />
systematic review methodology. The following databases were searched: PubMed, Google<br />
Scholar, Medline and the Google library. Case reports, reports with reviews and systematic<br />
review articles written in English were included.<br />
28 Stoma.eduJ (<strong>2014</strong>) 1 (1)
ETIOLOGICAL CONSIDERATIONS IN BRUXISM<br />
Data Selection: The primary outcome<br />
was bruxism etiology.<br />
Data Extraction: Screening of eligible studies and<br />
data extraction were conducted independently and<br />
in duplicate. The references were analyzed by two<br />
reviewers using the same search strategy and the<br />
same inclusion criteria were applied to the selected<br />
studies. Query terms used were „bruxism”, „etiology”,<br />
and „mechanism”. Among the 95 related articles<br />
that were critically assessed, 31 were included in the<br />
critical appraisal.<br />
3. DATA SYNTHESIS<br />
Internationally, the recent data published in the<br />
literature, shows that there is a consensus regarding<br />
a various etiologic involvement (5) in the pathogenic<br />
mechanisms of bruxism.<br />
The first opinions on the etiology of bruxism were<br />
considered to be the dental bite and the pathology<br />
of muscle contractions. Behavioural factors and<br />
in particular, aspects related to sleep, were also<br />
included as etiological factors (6).<br />
Attanasio R. (7), Lobbezoo et al (8), and Nascimento<br />
et al. (9) showed that the etiology of sleep bruxism<br />
involved local factors, systemic factors, psychological<br />
factors and hereditary factors.<br />
3.1. THE HYPOTHESIS OF OCCLUSAL ETIOLOGY<br />
Regarding local occlusal etiology of bruxism there<br />
were different opinions over time. If in 1966 Ramfjord<br />
et al. (10) believed that occlusal factors, particularly<br />
occlusal interference, would have an important role<br />
in the determination of bruxism, in 1984 Rugh et<br />
al. (11) proved, by creating experimental occlusal<br />
interference, that the role of occlusal disharmony<br />
is secondary to bruxism, since correcting occlusal<br />
interference did not lead to the disappearance of<br />
bruxism. The same situation occurred in patients with<br />
complete edentulism, which in the dentate period<br />
had bruxism. After wearing dentures, the bruxism<br />
reappeared.<br />
However, the first affirmation on the role of occlusal<br />
interference in bruxism was based on the fact that<br />
occlusal interference suppression in patients with<br />
bruxism produced an improvement in symptoms.<br />
This is evident in current dental practice. Ramfjord<br />
(10) called centric bruxism the frequent jaw clenching.<br />
The author argued that when clenching teeth were<br />
accompanied by grinding, this occurred in the central<br />
occlusal area, in the absence of occlusal interference<br />
even in the presence of a stable occlusion, with slight<br />
slip of the teeth, of the mandible from centric relation<br />
to maximum intercuspidation.<br />
Occlusal contacts during sleep, specific to<br />
bruxism, could be interrupted by swallowing, and<br />
muscle forces that appear during bruxism might<br />
exceed those of mastication. During sleep grinding,<br />
electromyographic bursts of the masseter muscle<br />
were observed mainly with mediotrusive mandibular<br />
movement from the canine edge-to-edge position.<br />
According to Minagi et al (12) muscular dynamics<br />
during sleep are unique compared to that during<br />
voluntary clenching, and exert a greater mechanical<br />
load to the balancing side temporomandibular joint.<br />
In 2001, Rosales et al. (13) showed that the<br />
relationship between occlusal disorders and bruxism<br />
was not very consistent. Also, in a review in 2012,<br />
Lobezzo et al (14) concluded that to date, there is<br />
no evidence whatsoever for a causal relationship<br />
between bruxism and the bite.<br />
3.2. MUSCLE ETIOLOGY HYPOTHESIS<br />
There are authors who associated muscle<br />
pathology and bruxism. Hellmann et al (15) argued<br />
that anterior and posterior neck muscles co-contract<br />
during jaw clenching, their findings supporting the<br />
assumption of a relationship between jaw clenching<br />
and the activity of the neck muscles investigated.<br />
3.3. THE HYPOTHESIS OF PSYCHO-BEHAVIORAL<br />
ETIOLOGY<br />
The psycho-behavioural factors whose influence<br />
on bruxism etiopathology is accepted by the majority<br />
of the specialists are: stress, anger, fear, repressed<br />
aggressiveness etc. During the evolution of research,<br />
which had the goal of establishing the etiopathology<br />
of bruxism, an important moment was considered to<br />
be the one when stress was regarded as a decisive<br />
factor.<br />
Rugh and Solberg (16,17) demonstrated the<br />
increase in intensity of bruxism episodes together<br />
with the increase of stress level. Kato (18) took into<br />
consideration the cognitive - behavioural factors<br />
such as stress, personality and anxiety in the etiology<br />
of bruxism and considered that patients with bruxism<br />
presented an anxious personality and that the<br />
dominant of their personality represents the reaching<br />
/ fulfillment of personal goals.<br />
Okeson (19) showed that patients with bruxism<br />
had a greater emotional stability, were more<br />
meticulous and got better learning results. Lavigne<br />
(20) showed that bruxism was connected to anxiety<br />
and was secondary to micro excitations during sleep<br />
(the increase of the cortical activity and cardiac<br />
frequency) followed by the grinding of teeth. Lavigne<br />
(21) pointed out that nocturnal bruxism must be<br />
differentiated from diurnal bruxism, the latter being<br />
linked to the organism’s reaction to stress or anxiety<br />
and being manifested like a contraction tic of the<br />
mobilizing muscles of the mandible.<br />
3.3.1. BRUXISM AS A SLEEP DISORDER<br />
Sleep is an active state which takes 30% of our<br />
time, and is part of our vital behavior being essential<br />
to the survival and life quality of any individual. Sleep<br />
is made up of a succession of repeated stages which<br />
can be pointed out through EEG, EKG, EMG and eye<br />
movements. Specialists described two types of sleep<br />
REM (Rapid Eye Movement) and NREM (Non Rapid<br />
Eye Movement). There are several stages described:<br />
in NREM there are stages 1 and 2 corresponding to<br />
light sleep as well as stages 3 and 4 corresponding<br />
29
occlusion<br />
to deep sleep, and in REM there is the paradoxical<br />
sleep which includes the dreaming period.<br />
These stages of sleep alternate during a period<br />
of approximately 90 minutes on the average and<br />
repeat themselves four or five times.<br />
The idea that bruxism was produced during<br />
paradoxical sleep has been present, but it seems that<br />
bruxism might also be present during stages 1 and 2<br />
of the NREM sleep. These periods were associated<br />
with episodes of micro wakening, body movements<br />
and temporary acceleration of the cardiac rhythm<br />
(6).<br />
Nascimento underlined the fact that nocturnal<br />
bruxism was found in all the stages of sleep but more<br />
often in stages 1 and 2 (9).<br />
Kato (22) did polysomnographic recordings in<br />
which he specified the events which took place in<br />
stage 2 of sleep in normal subjects with bruxism. In<br />
the second stage the increase of cardiac frequency<br />
has been noticed through the intensification of the<br />
autonomous cardiac system, and during the last stage<br />
rhythmic activity of the masticatory muscles (ARMM)<br />
was observed. The authors have ascertained that in<br />
normal subjects the endogenous micro excitations<br />
appear approximately four seconds before ARMM<br />
while in bruxism they appear 10-60 seconds before.<br />
The increase of cardiac frequency, in normal subjects,<br />
appears at the beginning of an ARMM episode,<br />
while in patients with bruxism a gradual increase of<br />
cardiac frequency appears before the beginning of<br />
ARMM and an acceleration of the cardiac frequency<br />
is detected at the beginning of the bruxism episode.<br />
It is still unclear why the ARMM is three times more<br />
frequent and 30% more ample in bruxers than in<br />
patients without bruxism (20). Hence the hypothesis<br />
that bruxism is a parasomnia.<br />
In 2005, the American Academy of Sleep<br />
Medicine published the International Classification<br />
of Sleep Disorders 2nd ed. Westchester, showing<br />
that „nocturnal bruxism is defined as a disorder of<br />
the stereotypical movements during sleep and is<br />
characterized by the grinding of teeth or/and the<br />
clenching of teeth.” According to this classification<br />
nocturnal bruxism is a sleep disorder, being included<br />
in the parasomnias (23).<br />
3.3.2. THE ROLE OF THE CHEMICAL MEDIATORS<br />
IN BRUXISM<br />
During recent years, at Lavigne’s insistences, the<br />
research paths have lead towards neuropsychology<br />
in order to explain the mechanisms involved in the<br />
apparition and maintenance of bruxism, by invoking<br />
the role of some neuromediators such as dopamine<br />
and serotonin. Dopamine and serotonin are<br />
neurotransmitters which ensure the communication<br />
between neurons. Dopamine is involved in lust,<br />
pleasure and movement. Its deficit is met in Parkinson<br />
disease which is accompanied by a deficit of<br />
movement and in schizophrenia. Serotonin has a role<br />
in adjusting sleep, appetite and humour. Its deficit is<br />
met in case of anxious states and depressions (4,24).<br />
The role of dopamine, as a causing factor of<br />
bruxism, is that of dopaminergic psycho stimulus<br />
(the same as amphetamines), worsening the bruxism<br />
episodes. The dopaminergic system has been<br />
placed in an important position in the regulation of<br />
stereotypical movements and in control of motion<br />
problems during sleep (4,24).<br />
Yet, the voices announcing that dopamine plays<br />
a key role in bruxism etiology, are today more<br />
temperate. The selective inhibitors for the reuptake of<br />
serotonin have a direct influence on the dopaminergic<br />
system. Lobezzo et al. (25,26) stated that dopamine<br />
did not have an essential role in producing bruxism,<br />
as the selective inhibitors for the serotonin reuptake<br />
receptors had a direct influence on the dopaminergic<br />
system. These serotonin inhibitors are represented<br />
by antidepressants currently prescribed and which,<br />
used for a long time, can maintain or induce bruxism.<br />
In spite of these, the authors consider that bruxism<br />
can be adjusted at the central nervous system level<br />
and not at the peripheral one.<br />
3.4. GENETIC ETIOLOGY HYPOTHESIS<br />
The genetic etiology hypothesis (27) was advanced,<br />
but the transmission mechanism could not be<br />
demonstrated. Clinically, bruxism occurrences have<br />
been observed in patients belonging to the same<br />
families (parents, children or brothers). The original<br />
hypothesis about the fact that nocturnal bruxism<br />
may be associated with a familial predisposition was<br />
supported by studies on twins (27). Obviously, these<br />
observations cannot be considered as the results of<br />
a research process.<br />
In a case-control study, Abe et al (28) investigated<br />
the association of genetic, psychological and<br />
behavioural factors with sleep bruxism in a Japanese<br />
population. Their analysis revealed that only the<br />
C allele carrier of the HTR2A single nucleotide<br />
polymorphism rs6313 (102C>T) was significantly<br />
associated with an increased risk of sleep bruxism<br />
(odds ratio = 4.250, 95% confidence interval: 1.599-<br />
11.297, p = 0.004), suggesting a possible genetic<br />
contribution to the etiology of sleep bruxism.<br />
3.5. OTHER FACTORS POSSIBLY INVOLVED IN<br />
BRUXISM’S ETIOLOGY<br />
In 2003, Winocur et al. (29) published a study<br />
showing the correlations between the consumption<br />
of alcohol, tobacco, drugs and pills and bruxism<br />
occurrences. In 2006, Lobezzo et al (8) showed<br />
that bruxism might be a brain injury consequence<br />
and might be associated with some psychiatric or<br />
neurological diseases. Also, bruxism was linked to<br />
the use of amphetamines, levodopa, phenothiazines<br />
and alcohol. Lavigne et al. (21) stated that the ARMM<br />
and nocturnal bruxism episodes were influenced by<br />
an increase in the electrical activity of the brain and<br />
by the stimulation of the ascending reticular system,<br />
which increased the activity of the motor neuronal<br />
network and of the cardiac autonomic system.<br />
According to Behr et al (30), theories on factors<br />
causing bruxism are a matter of controversy in the<br />
30 Stoma.eduJ (<strong>2014</strong>) 1 (1)
ETIOLOGICAL CONSIDERATIONS IN BRUXISM<br />
current literature, two main etiological models<br />
being the most important. The first one were<br />
peripheral local morphological disorders, such as<br />
malocclusion. This etiological model is based on<br />
the theory that occlusal maladjustment results in<br />
reduced masticatory muscle tone. In the absence<br />
of occlusal equilibration, motor neuron activity of<br />
masticatory muscles is triggered by periodontal<br />
receptors. The second theory assumes that central<br />
disturbances in the area of the basal ganglia are<br />
the main cause of bruxism. An imbalance in circuit<br />
processing of the basal ganglia is supposed to<br />
be responsible for muscle hyperactivity during<br />
nocturnal dyskinesia such as bruxism.<br />
In Romania, the recent most important views<br />
on bruxism considered particularly the stress and<br />
occlusal interferences in the etiology of bruxism, but<br />
affirmed that, until now, there could not exist a clearly<br />
established direct causal link between a specific<br />
etiologic factor and bruxism (31). Just like the occlusal<br />
trauma, it is sure that only one etiologic factor cannot<br />
be incriminated in the etiology of bruxism.<br />
The evidence of this finding is that, to date, there is<br />
not a single therapeutic method to obtain the removal<br />
or improvement of bruxism; there are always more<br />
associated therapeutic procedures (31).<br />
4. CONCLUSIONS<br />
* Bruxism is a dental disorder that deeply alters the<br />
dento-maxillary system’s normal functionality.<br />
* The etiology of bruxism is varied, involving local,<br />
systemic and psycho-behavioural factors.<br />
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1. Rozencweig D. Algies et dysfonctionnements de l’appareil<br />
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2. Marie MM, Pietkiewicz M. La bruxomanie. Rev de Stomat.1907;14:107-<br />
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3. Graf H. Bruxism. Dent Clin North Am. 1969;13(3):659-665.<br />
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7. Attanasio R. Nocturnal bruxism and its clinical management. Dent<br />
Clin North Am. 1991; 35(1):245-252.<br />
8. Lobbezoo F, Van Der Zaag J, Naeije M. Bruxism: its multiple causes<br />
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2006;3(4):293-300.<br />
9. Nascimento LL, Amorim CF, Giannasi LC, Oliveira CS, Nacif SR, Silva<br />
Ade M, Nascimento DF, Marchini L, de Oliveira LV. Occlusal splint for<br />
sleep bruxism: an electromyographic associated to Helkimo Index<br />
evaluation. Sleep Breath. 2008; 12(3):275-280.<br />
10. Ramfjord SP, Ash MM. Occlusion. Philadelphia: WB Saunders<br />
Company;1996.<br />
11. Rugh JD, Barghi N, Drago CJ. Experimental occlusal discrepancies<br />
and nocturnal bruxism. J Prosthet Dent.1984; 51(4):548-553.<br />
12. Minagi S, Akamatsu Y, Matsunaga T, Sato T. Relationship between<br />
mandibular position and the coordination of masseter muscle activity<br />
during sleep in humans. J Oral Rehabil. 1998 Dec;25(12):902-907.<br />
13. Rosales VP, Ikeda K, Hizaki K, NaruoT, Nozoe S, Ito G. Emotional<br />
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14. Lobbezoo F, Ahlberg J, Manfredini D, Winocur E. Are bruxism and<br />
the bite causally related? J Oral Rehabil. 2012;39(7):489-501.<br />
15. Hellmann D, Giannakopoulos NN, Schmitter M, Lenz J, Schindler<br />
HJ. Anterior and posterior neck muscle activation during a variety of<br />
biting tasks. Eur J Oral Sci. 2012;120(4):326-334.<br />
16. Rugh JD, Solberg WK. Psychological implications in<br />
temporomandibular pain and dysfunction. Oral Sci Rev.1976;7:3-30.<br />
17. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic<br />
evaluation of bruxism patients undergoing short term splin therapy.<br />
J Oral Rehabil. 1975; 2(3):215-223.<br />
18. Kato T, Thie NM; Huynh N, Miyawaki S, Lavigne GJ. Topical review:<br />
sleep bruxism and the role of peripheral sensory influence. J Orofac<br />
Pain 2003 Summer; 17(3):191-213.<br />
19. Okeson JP. A simplified technique for biteguard fabrication in<br />
bruxism. J Ky Dent Assoc. 1977; 29(4)11-16.<br />
20. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological mechanisms<br />
involved in sleep bruxism. Crit Rev Oral Biol Med. 2003; 14(1): 30-46.<br />
21. Lavigne GJ, Huynh N, Kato T, Okura K, Adachi K, Yao D, Sessle B.<br />
Genesis of sleep bruxism. Motor and autonomic-cardiac interactions.<br />
Arch Oral Biol. 2007; 52(4):381-384.<br />
22. Kato T, Rompre P, Montplaisir JY, Sessle BJ, Lavigne GJ. Sleep<br />
bruxism: an oromotor activity secondary to micro-arousal. J Dent Res.<br />
2001; 80 (10): 1940-1944.<br />
23. American Academy of Sleep Medicine. International classification<br />
of sleep disorders, 2nd ed. Diagnostic and coding manual. American<br />
Academy of Sleep Medicine. Westchester: IL; 2005.<br />
24. Chapotat B, Lin JS, Robin O, Jouvet M. Bruxism du sommeil:<br />
aspects fondamentaux et cliniques. J Parodontol Implant Orale.1999;<br />
18(3): 277-289.<br />
25. Lobbezoo F, Naeije M. Bruxism is mainly regulated centrally, not<br />
peripherally. J Oral Rehabil. 2001; 28(12):1085-1091.<br />
26. Lobbezoo F, Van Der ZaagJ, Naeije M. Bruxism: its multiple causes<br />
and its effects on dental implants- un updated review. J Oral Rehabil.<br />
2006;33(4):293-300.<br />
27. Hublin C, Kaprio J, Partinen M, Koskenvuo M. Sleep bruxism based on<br />
self- report in a nationwide twin cohort. J Sleep Res.1998;7(1):61-67.<br />
28. Abe Y, Suganuma T, Ishii M, Yamamoto G, Gunji T, Clark GT, Tachikawa<br />
T, Kiuchi Y, Igarashi Y, Baba K. Association of genetic, psychological and<br />
behavioral factors with sleep bruxism in a Japanese population. J<br />
Sleep Res. 2012;21(3):289-296.<br />
29. Winocur E, Gavish A, Vokovitch M, Emodi-Perlman A, Eli I. Drugs<br />
and bruxism: a critical review. J Orofac Pain.2003;17(2):99-111.<br />
30. Behr M, Hahnel S, Faltermeier A, Bürgers R, Kolbeck C, Handel<br />
G, Proff P. The two main theories on dental bruxism. Ann Anat.<br />
2012;194(2):216-219.<br />
31. Mercuţ V, Scrieciu M, Popescu SM, Craitoiu M, Marasescu P,<br />
Marinescu R, Extended Case report. Bruxism with a history of early<br />
onset in a 25-year-old male. OHDM. 2011;10(4):209-214.<br />
31
orofacial pain<br />
Headache –<br />
an interdisciplinary problem<br />
Aspects of dental functional<br />
diagnostics and therapy<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.6<br />
Abstract<br />
Aim: Craniofacial pain is one of the most common disorders affecting the general<br />
population. The aim of this article is to show the importance of interdisciplinary<br />
approach in solving complicated cases with headache and atypical facial pain.<br />
Summary: Two case reports are presented, with severe craniofacial pain, with<br />
underlying intricate causes. The case of a 23 aged female with tension headaches,<br />
bilateral tinnitus and atypical facial pain, but also with anterior open bite from<br />
premolars who was admitted to a neurological clinic, was finally resolved only after a<br />
splint therapy. The other case was a 42 year old woman with severe unilateral facial<br />
pain, caused by an endometric tissue from maxillary bone that produced multiple<br />
hollows or cavities in the adjacent teeth. The pain was alleviated after teeth extractions<br />
and appropriate hormonal therapy.<br />
Key learning points: Because headache causes are manifold, diagnostics and therapy<br />
require an interdisciplinary medical approach.<br />
From the dental and maxillofacial standpoint, diseases and disorders of the teeth,<br />
periodontium, other craniofacial hard and soft tissues, as well as craniomandibular<br />
dysfunction (CMD) must be taken into consideration in treating such patients.<br />
Keywords: unspecific headache, tension headache, muscle relaxation, craniomandibular<br />
dysfunction, Michigan splint<br />
Cite this article:<br />
Meyer GB, Bernhardt Q,<br />
Küppers A. Headache - an<br />
interdisciplinary problem.<br />
Aspects of dental functional<br />
diagnostics and therapy.<br />
Stoma <strong>Edu</strong> J. <strong>2014</strong>;<br />
1(1):33-40.<br />
Georg B. Meyer 1a *,<br />
Olaf Bernhardt 2b ,<br />
Arnd Küppers 2c<br />
1. Zentrum für Zahn-,<br />
Mund-, und Kieferheilkunde<br />
Universitätsmedizin Greifswald,<br />
Greifswald, Germany<br />
2. Poliklinik für Zahnerhaltung,<br />
Parodontologie und<br />
Endodontologie<br />
Universitätsmedizin Greifswald,<br />
Greifswald, Germany<br />
a. DMD, PhD, Dr hc, Professor<br />
and Chairman<br />
b. DMD, PhD, Professor<br />
c. DMD, PhD<br />
Introduction<br />
The reasons for acute and chronic craniofacial pain can be extremely diverse. An exact<br />
identification of causes is often impossible without close cooperation between various<br />
medical disciplines, and monocausal treatment approaches to pain relief are often<br />
unsatisfactory (1,2,3). Understanding these multilayered symptoms is fundamentally<br />
made more difficult due to the great diversity and inherently variable risk factors that<br />
may play a role (4,5). They frequently occur in combination, and interactions arise<br />
with complex amplifying effects, so that scientific studies require particularly great,<br />
interdisciplinary efforts.<br />
In the past, the fields of dentistry and oral medicine have, for different reasons, not<br />
always played a sufficient role in the treatment of craniofacial pain, although experienced<br />
pain therapists have long demanded including the dental/oral medicine sector in<br />
the diagnostics and treatment of such disorders (Fig. 1). Although craniomandibular<br />
dysfunctions (CMD) are the focus of this article, it should be mentioned that irritations<br />
and diseases of the pulp, periodontium, glands, nasal sinuses, and other hard and soft<br />
tissues in the craniofacial area including space-occupying processes/structures such<br />
as tumors can cause comparable craniofacial pain, which is sometimes erroneously<br />
interpreted as a functional disorder and treated with, for instance, occlusal splints.<br />
Given this background, failed splint therapy should not be blamed on the method,<br />
but rather on the differential diagnostic exclusion of masticatory functional causes of<br />
the respective symptoms. Recent controlled studies unambiguously show that with<br />
individually adjusted centric splints (Michigan splints), significant improvements result in<br />
the therapy of CMD, especially compared to merely vacuum-drawn, non-individualized<br />
Received: 17 October 2013<br />
Accepted: 07 January <strong>2014</strong><br />
* Corresponding<br />
author:<br />
Professor Georg B. Meyer, DMD,<br />
PhD, Dr hc, Chairman<br />
Zentrum für Zahn-, Mund- und<br />
Kieferheilkunde,<br />
Ernst-Moritz-Arndt Universität,<br />
Rotgerberstraße 8, D-17475<br />
Greifswald, Germany.<br />
Tel: +493834867130,<br />
Fax:+493834867171.<br />
e-mail: gemeyer@uni-greifswald.de<br />
33
OROFACIAL<br />
Multi-/interdisciplinary<br />
PAIN<br />
approch<br />
Multi-/interdisciplinary approach<br />
Neurology<br />
Neurology<br />
Psychology<br />
Psychology<br />
Pain patient<br />
Pain patient<br />
Orthopedics<br />
Orthopedics<br />
Dentistry<br />
Dentistry<br />
U.T. Egle, Psychosomatik/Psychotherapie<br />
Figure 1. For patients with chronic headache, dental diagnostic and therapy are as valuable as that<br />
of other disciplines (taken from Egle, Mainz, 2000)<br />
U.T. Egle, Psychosomatik/Psychotherapie<br />
splints (6). Significant associations between CMD<br />
and frequent headaches were demonstrated in<br />
an epidemiological survey of over 4000 subjects<br />
in the Study of Health in Pomerania (SHIP) (4).<br />
In a diagnostically and therapeutically<br />
oriented dental follow-up study of patients<br />
whom neurologists and neurosurgeons had<br />
diagnosed with trigeminal neuralgia, Lotzmann<br />
et al. (7) found that in up to 50 % of the cases,<br />
CMD was the true cause of the neuralgic<br />
symptoms. Interestingly, over 70 % of these<br />
cases presented infraocclusion in the posterior<br />
dentition in centric relation, which was often the<br />
result of prostheses with insufficient height or<br />
orthodontic treatment.<br />
Craniofacial pain is frequently accompanied by<br />
temporomandibular joint (TMJ) and otological<br />
symptoms (8). The SHIP study showed correlations<br />
between tinnitus and CMD (9). Evaluating 200<br />
CMD patients who simultaneously suffered from<br />
tinnitus, earache, and dizziness, Wright (8) found<br />
that after successful treatment of masticatory<br />
functional disorders, these associated symptoms<br />
improved significantly.<br />
While interactions between CMD and<br />
unspecific headaches, tension headaches, and<br />
trigeminal neuralgia have been proven (4,7,10),<br />
the dental contribution to the etiology of<br />
migraine or migraine-like pain is controversial.<br />
Based on individual instances of successful<br />
dental treatment, particularly in cases of migraine<br />
symptoms unchangingly confined to one half<br />
of the face, some neurologists recommend a<br />
clinical dental consultation (11,12,13,14).<br />
Figure 2. In the Physiology of a healthy masticatory<br />
organ is characterized by receptors in the teeth,<br />
periodontium, muscles, and TMJs that transmit<br />
signals about the current status via afferent nerves<br />
(aff.N.) to the central nervous system. Based on this<br />
sensory information, a synaptic transformation to<br />
movement follows. Along efferent nerves (eff.N.),<br />
the corresponding motoric units of the musculature<br />
are activated, so that all masticatory functions can<br />
run in a coordinated manner<br />
Masticatory functional aspects<br />
Physiology<br />
During the growth of a healthy masticatory<br />
organ, the occlusal structures of all teeth<br />
and the TMJ adapt themselves to each<br />
other to follow a uniform geometry. Starting<br />
34 S T OMA.E D U J (<strong>2014</strong>) 1 (1)
Headache an interdisciplinary problem Aspects<br />
of dental functional diagnostics nd therapy<br />
Figure 3. Dental<br />
risk factors for CMD<br />
are mainly occlusal<br />
interferences and/or<br />
psycho-emotional stress<br />
Figure 4. The Ahlers<br />
and Jakstat clinical<br />
summary report for<br />
CMD risk identification<br />
was extended by a test<br />
of physiological centric<br />
position<br />
from maximum occlusion in which the TMJ<br />
structures are also centered, the interplay<br />
of cusps and fissures of antagonistic teeth is<br />
characterized by the disturbance-free course<br />
of all excentric movements (Fig. 2). Receptors<br />
in the teeth, periodontium, muscles, and TMJs<br />
are connected by afferent nerves to the central<br />
nervous system, and transmit signals about the<br />
given status, e.g., the consistency and location<br />
of the to-be-chewed food near or on the teeth.<br />
Based on this sensory information, a synaptic<br />
transformation to movement follows. Along<br />
efferent nerves, the corresponding motoric<br />
units of the musculature are activated, so that all<br />
masticatory functions can run in a coordinated<br />
manner. Psychological and cortical interactions<br />
are possible (15).<br />
The mandible assumes the physiological<br />
centric relation or “zero position” to the maxilla<br />
when protractors as well as retractors are<br />
maximally relaxed, and the integral of all muscle<br />
activity is thus at the lowest level (16). In this<br />
position, maximum intercuspation is possible as<br />
long as there are no occlusal interferences. By<br />
activating the retractors, about 90% of all adults<br />
can perform a tooth-guided, ca. 1 to 3 mm<br />
mandibular retral limit movement from centric<br />
position, which was formerly known as the retral<br />
contact position and erroneously considered to<br />
be the same as centric relation (16,17).<br />
35
orofacial pain<br />
Table 1. Extra - and intra-oral findings<br />
The following extra-oral findings<br />
were recorded:<br />
- mandibular mobility, i.e., opening, protrusion,<br />
and lateral movements unrestricted<br />
and normal;<br />
- palpation pain in both TMJs;<br />
- pressure sensitive musculature in right anterior<br />
Temporalis, left Masseter, right shoulder muscles;<br />
- hypersensitive nerve exit points in left infraorbital<br />
area, right mandible.<br />
The following intra-oral findings were<br />
recorded (Figs 5 to 7):<br />
- complete, well-maintained dentition without<br />
wisdom teeth;<br />
- partial crowns on 16 and 26, gold, with compo site<br />
fillings on 17,14, 24, 25, 27, 37, 36, 46, and 47;<br />
- suspected dentin fracture in tooth 17;<br />
- bilateral tongue impressions;<br />
- anterior open bite from/to premolars bilaterally;<br />
- premature contacts 17/47 in physiological<br />
centric position/cotton-roll test centric.<br />
Pathology<br />
Masticatory functional disorders are primarily<br />
caused by occlusal discrepancies when these<br />
are noticeably above or below the 10- to 20-<br />
µm range of desmodontal tactility (18). In<br />
experimental examinations, Kobayashi and<br />
Hansson (19) found that premature occlusal<br />
contacts of a magnitude of 100 µm on fillings,<br />
i.e., 10 times the desmodontal tactility, can<br />
contribute to increased muscle activity, bruxism,<br />
sleep disorders, increased adrenaline excretion,<br />
sleep apnea, TMJ complaints etc. An essential,<br />
even decisive exacerbating factor is psychoemotional<br />
stress (“grinding your teeth”); thus,<br />
the initial dental diagnostics must pay particular<br />
attention to such symptoms (5,10,11,20). The<br />
same is true of primarily orthopedic problems<br />
which can have an immediate interaction with<br />
CMD (17,21).<br />
From a scientific point of view, it is not primarily<br />
the occlusal disturbance but rather the hyperactive,<br />
pressure-sensitive masticatory and craniofacial<br />
muscles which are a significant correlate for<br />
the neuromuscular dyscoordination or CMD<br />
(Fig. 3). But the grosser occlusal interferences<br />
are, the higher is their risk potential for causing<br />
CMD (22). Therapeutically, every treatment that<br />
leads to muscle relaxation or re-coordination<br />
of the neuromuscular system makes sense, for<br />
instance, treatment with a dental (relaxation) splint<br />
(23,24), information consulting, self-observation,<br />
physiotherapy, medication, psychotherapy, and<br />
other forms of treatment (5,15,20,25,26).<br />
Figure 5-7. Open bite despite orthodontic<br />
treatment, with support exclusively on the molars,<br />
which could explain the pain in these areas<br />
Patient examination<br />
As part of the interdisciplinary diagnostics of<br />
craniofacial pain patients, the anamnesis must<br />
determine whether a dental risk exists. After<br />
taking the general dental findings, it has proven<br />
effective to perform a CMD screening (11), that<br />
is, a scientifically founded clinical summary<br />
report to determine masticatory functional risk<br />
factors. We have added a diagnostic test of<br />
physiological centric relation (cotton-roll test)<br />
to this screening (13,17) (Fig. 4). These are yesor-no<br />
findings, quickly determined, which very<br />
reliably identify CMD patients, for whom more<br />
comprehensive diagnostics and therapy must<br />
then be performed (11,12).<br />
In the following, two patient cases of craniofacial<br />
pain are documented, from which an exact<br />
description of the practical dentally recommended<br />
diagnostic steps has been omitted. The same<br />
goes for the therapeutic clinical concept based<br />
on the centric (Michigan) splint, supplemented<br />
with adjunct treatment such as instructions for<br />
36 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Headache an interdisciplinary problem Aspects<br />
of dental functional diagnostics nd therapy<br />
Figure 8. Individual centric splint made in the<br />
articulator<br />
self-observation, relaxation, and muscle massage,<br />
as these steps and concepts were previously<br />
described.<br />
Case report 1<br />
Patient history<br />
A 23-year-old female patient presented at<br />
our clinic with intermittent tension headaches,<br />
which had otherwise only occurred in the right<br />
half of the face, but were now present both right<br />
and left. Particulary under tension and stress,<br />
bilateral tinnitus also arose, in addition to pain<br />
in the maxillary molar region and sinus chiefly on<br />
the right side. Examination by an ear-nose-throat<br />
doctor found no cause. The patient reported<br />
having undergone orthodontic treatment from<br />
the age of 11 to 15 years.<br />
At the age of 17, extreme atypical pain in the<br />
right half of the face arose, for which the patient<br />
was admitted to the neurology department of a<br />
clinic. When no cause was found there, she was<br />
moved to a psychosomatic clinic. Meanwhile,<br />
severe pain arose in the left half of her face.<br />
During the subsequent 4-week stay at a pain<br />
clinic (Mainz, Germany), dental findings were<br />
taken for the first time during an interdisciplinary<br />
consultation.<br />
This led to initiating splint therapy, which finally<br />
– after her 8-month ordeal – alleviated her pain<br />
(Fig. 8-11, Table.1) and let her live a normal life.<br />
She visited our clinic because the original splint<br />
was worn out and the headaches, maxillary pain,<br />
and tinnitus had returned.<br />
Therapy<br />
After providing the patient with educational<br />
information, instructions on self-observation,<br />
relaxation, and muscle massage, an exercise<br />
DVD (20,25), and a calculation of costs,<br />
splint therapy was performed. Subsequent to<br />
impression taking of the maxilla and mandible<br />
Figure 9-11. The splint creates an individual<br />
balance of the bite position in all quadrants.<br />
The patient became symptom-free<br />
and pouring the models, the facebow and<br />
protrusion registration were placed in the<br />
articulator with the help of the clinical centric<br />
registration of both jaws so that it corresponded<br />
to the clinical situation. As expected, even<br />
after placement in the articulator, centric<br />
premature contacts were found on teeth 17<br />
and 47, which indicated that the working steps<br />
had been done correctly. Using a hard, 1.5-<br />
mm-thick piece of composite foil, a vacuumdrawn<br />
splint was constructed and individually<br />
corrected in the articulator – according to the<br />
occlusal concept of the Michigan splint – first<br />
by grinding and then by applying composite<br />
on certain sites in order to create equal support<br />
in all quadrants and canine guidance during<br />
excentric movements (Figs 8 to 11).<br />
Wearing instructions/Follow-up<br />
During the initial treatment phase, the splint<br />
should be worn as much as possible, i.e., both<br />
day and night. Exceptions can be made for eating<br />
and lengthy periods of speech such as during<br />
presentations etc. The patient should be informed<br />
that after overcoming initial awkwardness,<br />
accustomization occurs within just a few days<br />
37
orofacial pain<br />
Figure 12. This patient<br />
periodically had severe pain<br />
attacks in the right facial half<br />
Figure 13. Even after extraction of teeth 13 to 16 from the<br />
pre-viously fully dentate maxilla, no improvement of symptoms<br />
occurred in that side of the face (mirror image photo)<br />
(even faster for mandibular splints), providing<br />
considerable relief. It is necessary to perform<br />
the first follow-up after 3 or 4 days. After “cottonroll<br />
relaxation”, any corrections required will be<br />
done to ensure equal support in all quadrants.<br />
Only when this support remains stable can the<br />
follow-up intervals be lengthened.<br />
The patient introduced here was symptomfree<br />
again after just a few weeks. It may be<br />
recommendable to shorten the splint wearing<br />
time, for instance, using it only in particulary<br />
stressful situations. When not in use, the splint<br />
should be stored under moist conditions to avoid<br />
drying out and thus deforming and becoming<br />
brittle.<br />
Case report 2<br />
Patient history<br />
A 42-year-old patient presented with periodic,<br />
severe headache attacks limited to the right<br />
side of her face (Fig. 12). Neurological and<br />
otorhinolaryngological examination had found<br />
no cause.<br />
Findings<br />
Asymmetrical tension in the masticatory and<br />
shoulder-muscle areas. Mandibular mobility<br />
was not restricted, but deflection to the right<br />
was observed upon mouth opening. Except<br />
for wisdom teeth, the patient was completely<br />
dentate. The only restorations were some midsized<br />
amalgam fillings in the posterior teeth. In<br />
centric position (cotton-roll test), equal support<br />
was found in all quadrants.<br />
Therapy<br />
Relaxation splint therapy was conducted, which<br />
the patient found very pleasant and helpful and<br />
completely alleviated the pain. The well-fitting<br />
Figure 14. On the roots of the extracted teeth,<br />
hollows or cavities are visible, which are perhaps<br />
related to extra-genital endometriosis<br />
splint remained stable, and no further occlusal<br />
corrections were necessary.<br />
Surprisingly, the patient returned after ca.<br />
4 weeks with facial pain so severe that we<br />
had to have her admitted to the University<br />
Clinic’s pain station. Symptomatic medication<br />
relieved the pain, but no cause for it could be<br />
found. Examinations at the dental clinic, also<br />
conducted by oral and maxillofacial surgeons<br />
and the dental radiology department,<br />
discovered multiple hollows or cavities in the<br />
maxillary lateral teeth of the face-half affected;<br />
teeth 13, 14, and 15 were thus extracted (Figs<br />
13 and 14). In spite of this, the severe unilateral<br />
facial pain returned almost exactly 4 weeks<br />
later.<br />
Finally, it was the patient’s physician who<br />
suspected menstrual cycle involvement and<br />
referred her to the gynecology clinic. There, the rare<br />
but correct diagnosis of extragenital endometriosis<br />
was made. During embryonic development,<br />
endometrial tissue had scattered into the right<br />
half of the face and later became active once a<br />
month, causing facial pain. Appropriate hormonal<br />
treatment alleviated the symptoms.<br />
38 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Headache an interdisciplinary problem Aspects<br />
of dental functional diagnostics nd therapy<br />
Conclusion<br />
Both current research and the patient cases<br />
presented here clearly demonstrate the need<br />
for the fields of dentistry and oral medicine<br />
to become more involved in answering<br />
interdisciplinary medical questions, as was<br />
expressly demanded by Germany’s Council of<br />
Sciences in its 2005 declaration on the future<br />
of dentistry.<br />
Epidemiological data suggest that many who<br />
suffer from craniofacial pain can be helped<br />
by dental diagnostics and therapy, so that an<br />
interdisciplinary examination of craniofacial<br />
pain without considering the oral/dental<br />
aspects is unjustifiable (see Fig. 1).<br />
In terms of costs, it makes sense for health<br />
insurance to reimburse the diagnostic and<br />
therapeutic measures provided by our discipline<br />
in cases such as those described here, thus<br />
motivating dental professionals to get involved,<br />
especially considering the fact that misdirected<br />
treatment by other medical disciplines and the<br />
associated increase in sick-leave are ultimately<br />
much more expensive, as the first patient case<br />
described above shows. At the very least, state<br />
health insurance should finance the rapidly<br />
performed yet very informative clinical summary<br />
report on CMD risk for every patient, since this<br />
would probably ultimately save a great deal of<br />
money elsewhere.<br />
Bibliography<br />
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2. Göbel H. Erfolgreich gegen Kopfschmerzen und Migräne.<br />
Aufl. Berlin: Springer; 2002.<br />
3. Slavicek R. Das Kauorgan: Funktionen und Dysfunktionen.<br />
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4. Bernhardt O, Gesch D, Mundt T, Mack F, Schwahn C, Meyer<br />
G, Hensel E, John U. Risk factors for headache, including TMD<br />
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5. Graber G. Der Einfluss von Psyche und Stress bei<br />
funktionsbedingten Erkrankungen des stomatognathen<br />
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Koeck. München: Urban & Schwarzenberg; 1995.<br />
6. Ekberg E, Vallon D, Nilner, M. The efficacy of appliance<br />
therapy in patients with temporomandibular disorders of<br />
mainly myogenous origin. A randomized, controlled, shortterm<br />
trial. J Orofac Pain. 2003; 17(2):133-139.<br />
7. Lotzmann U, Vadokas V, Steinberg JM, Kobes L. Dental aspect<br />
of the differential diagnosis of trigeminal neuralgia. J Gnathol.<br />
1994; 13(1):15-22.<br />
8. Wright EF. Otologic symptom improvement through TMD<br />
therapy. Quintessence Int. 2007; 38(9):e564-571.<br />
9. Bernhardt O, Gesch D, Schwahn C, Bitter K, Mundt T,<br />
Mack F, Kocher T, Meyer G, Hensel E, John U. Signs of<br />
temporomandibular disorders in tinnitus patients and in a<br />
population-based group of volunteers: results of the Study<br />
of Health in Pomerania. J Oral Rehabil. 2004; 31(4):311-<br />
319.<br />
10. Kreyer G. Das Orofazialsystem als Schnittstelle zwischen<br />
Psyche und Soma. Zahnärztl Mitt 2005; 95(6):1366-1371.<br />
11. Ahlers MO, Jakstat HA. Klinische Funktionsanalyse.<br />
Hamburg: Denta Concept Verlag; 2007<br />
12. Freesmeyer WB. Zahnärztliche Funktionstherapie. München<br />
Wien: Carl Hanser Verlag; 1993.<br />
13. Meyer G, Bernhardt O, Asselmeyer T. Schienentherapie<br />
heute. Quintessenz. 2007; 58(5):489-500.<br />
14. Franco AL, Goncales DA, Castanharo SM, Speciali JG, Bigal<br />
ME, Camparis CM. Migraine is the most prevalent primary<br />
headache in individuals with temporomandibular disorders. J<br />
Orofac Pain. 2010; 24(3):287-292.<br />
15. Kindler S, Samietz S, Houshmand M, Grabe HJ, Bernhardt<br />
O, Biffar R, Kocher T, Meyer G, Völzke H, Metelmann HR,<br />
Schwahn C. Depressive and anxiety symptoms as risk factors<br />
for temporomandibular joint pain: a prospective cohort study<br />
in the general population. J Pain. 2012; 13(12):1188-1197.<br />
16. Meyer G. Die physiologische Zentrik im Rahmen der<br />
instrumentellen Okklusionsdiagnostik. In: Funktionslehre.<br />
Schriftenreihe APW. München: Carl Hanser; 1993.<br />
17. Lotzmann U. The effect of divergent positions of maximum<br />
intercuspation on head posture. J Gnath. 1991; 10(1):63-68.<br />
18. Utz KH. Untersuchungen über die interokklusale taktile<br />
Feinsensibilität natürlicher Zähne mit Hilfe von Aluminium-<br />
Oxid-Teilchen. Dtsch Zahnärztl Z. 1986; 41(3):313-315.<br />
19. Kobayashi Y, Hansson TL. Auswirkungen der Okklusion auf<br />
den menschlichen Körper. Phillip J Restaur Zahnmed. 1988;<br />
5(5):255-263.<br />
20. Schulte W. Die exzentrische Okklusion. Berlin: Quintessenz;<br />
1983.<br />
21. Fu AS, Mehta NR, Forgione AG, Al-Badawi EA, Zawawi KH.<br />
Maxillomandibular Relationship in TMD Patients Before and<br />
After Short-Term Flat Plane Bite Plate Therapy. Cranio. 2003;<br />
21(3):172-179.<br />
22. Troeltzsch M, Troeltzsch M, Cronin RJ, Brodine AH,<br />
Frankenberger R, Messlinger K. Prevalence and association of<br />
headaches, temporomandibular joint disorders, and occlusal<br />
interferences. J Prosthet Dent. 2011; 105(6):410-417.<br />
23. Hupfauf L, Weitkamp J. Ergebnisse der Behandlung<br />
von funktionsbedingten Erkrankungen des Kausystems mit<br />
Aufbissbehelfen. Dtsch Zahnärztl Z. 1969; 24(5):347-352.<br />
24. Lotzmann U. Okklusionsschienen und andere<br />
Aufbissbehelfe. München: Verlag Neuer Merkur; 1992.<br />
25. Graber G. Orale Physiotherapie. Video-Anleitung zur<br />
Entspannung und Selbstmassage. Basel: Univ.-Zahnklinik;<br />
1992.<br />
26. Bernhardt O, Hawali S, Sümnig W, Meyer G. Electrical<br />
stimulation of the temporalis muscle during sleep of<br />
myofacial pain - a pilot study. J Cranio Mand Func. 2012;<br />
4(3):197-210.<br />
39
overdenture<br />
FUNCTIONAL EVALUATION OF<br />
IMPLANT SUPPORTED PROSTHESES<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.7<br />
Cite this article:<br />
Tartaglia GM, Sforza C.<br />
Functional evaluation<br />
of implant supported<br />
prostheses. Stoma <strong>Edu</strong> J.<br />
<strong>2014</strong>; 1(1):41-47.<br />
Abstract<br />
Purpose: Surface electromyography is currently considered a useful tool for dentistry allowing<br />
the validation of conventional morphological evaluations with an accurate and objective<br />
quantification of the functional activity. An evaluation of full mouth resin prostheses on implants<br />
was performed including both a morphological evaluation of occlusion and a measurement of<br />
the actual impact of morphology on stomatognathic function.<br />
Methodology: The measurement was performed using masticatory muscle electromyographic<br />
recordings with ad-hoc software algorithms. In the present study, five patients with full mouth<br />
resin prostheses on implants have been evaluated at the beginning of their prosthetic<br />
reconstructions and after one year using surface electromyography. To verify the static<br />
neuromuscular equilibrium of occlusion, functional evaluation of the left and right masseter and<br />
temporalis anterior muscles was performed in all patients, and a set of indices was computed:<br />
the Percentage Overlapping Coefficient – POC (an index of the symmetric distribution of the<br />
muscular activity determined by the occlusion), the Torque Coefficient - TC (an index of the<br />
possible presence of a mandibular torque) and the antero-posterior coefficient (an index of the<br />
possible relative position of the occlusal center of gravity).<br />
Results: One year after surgery during the maximum voluntary clench, all patients had<br />
symmetric standardized potentials (POC values between 80% and 100%, and TC values larger<br />
than 90%).<br />
Conclusions: Surface electromyography indices were well super imposable to the values found<br />
in healthy subjects with natural and normal occlusion, thus indicating that, at short time follow<br />
up, a functionally stable occlusion could protect from resin prosthodontic fractures.<br />
Keywords: electromyography, prostheses, implants<br />
Gianluca Martino<br />
Tartaglia a ,<br />
Chiarella Sforza b<br />
LAFAS, Laboratorio di Anatomia<br />
Funzionale dell'Apparato<br />
Stomatognatico, Dipartimento<br />
Scienze Biomediche per la Salute,<br />
Facoltà di Medicina e Chirurgia,<br />
Università degli Studi di Milano,<br />
Milano, Italy<br />
a. DDS, PhD, Associate Professor<br />
b. MD, PhD, Professor<br />
Introduction<br />
Today, several clinical tools can support the daily clinical practice in dentistry with a<br />
quantitative support helpful for diagnosis, measuring the effects of therapy, and timely<br />
detection of the possible failures or relapses.<br />
Surface electromyography (EMG) is able to support conventional morphological<br />
evaluations with an accurate and objective quantification of functional activity and it is<br />
currently considered a useful tool for dentistry. Engineers, biological and dental researchers<br />
have developed useful EMG protocols that couple the scientific accuracy, indispensable in<br />
all instrumental evaluations (1), with the simplicity necessary for daily use in dental practice.<br />
Therefore, starting from the multiple information collected during the computerized<br />
analysis, a selection of simple and well reproducible indices (with a clear biological<br />
and clinical significance, and easily comprehensible), should be made. Moreover, the<br />
quantitative data should be coupled with a graphic support allowing an easier and more<br />
efficient communication between the clinician and the patient. In other words, diagnosis<br />
should be supported “at a glance” (1,3).<br />
A correct evaluation of prostheses should include both the morphological evaluation<br />
of occlusion, and the measurement of the impact of customized morphology of dental<br />
contacts on stomatognathic function in each single patient. Among the various clinical<br />
protocols currently used in prosthodontics, the immediate loading of implants with full<br />
mouth resin restorations has been proposed as simpler, less time and money consuming<br />
than delayed loading of implants.<br />
In our prosthodontic practice, we tried to develop a practical application of wellstandardized<br />
sEMG protocols developed in research laboratories (1-7) to help clinical<br />
work. A quantitative clinical tool may reduce complications in implant supported, all-<br />
Received: 09 November 2013<br />
Accepted: 16 December <strong>2014</strong><br />
* Corresponding<br />
Author:<br />
Professor Chiarella Sforza,<br />
MD, PhD<br />
Dipartimento Scienze<br />
Biomediche per la Salute,<br />
Facoltà di Medicina e Chirurgia,<br />
Università degli Studi di Milano,<br />
Milano, Italy.<br />
via Luigi Mangiagalli 31,<br />
I-20133 Milano, Italy.<br />
Tel. +390250315385,<br />
Fax +390250315387<br />
e-mail: chiarella.sforza@unimi.it<br />
41
overdenture<br />
acrylic resin prostheses, with immediate load.<br />
These measurements can be well performed using<br />
surface EMG recordings of the main masticatory<br />
muscles, such as the temporalis anterior and<br />
the masseter (1,4,5,8). For instance, occlusal<br />
stability has been found to be related to muscular<br />
performance, significant associations may exist<br />
among dentition status, chewing ability, muscle<br />
strength and balance both in the young and the<br />
elderly po¬pulation (9,10)<br />
EMG allows not only to measure the electric<br />
potentials produced by the single masticatory<br />
muscles (values that are somehow related to the<br />
developed masticatory forces) (1,4,5,8), but it<br />
also allows the verification and quantification of<br />
muscular balance, between couples of muscles<br />
of the two sides of the body (symmetry), between<br />
couples of muscles with a possible later deviant<br />
effect on the mandible (torque) (1), and between<br />
couples of muscles with an action line positioned<br />
more forward or more backward to identify a<br />
hypothetic center of gravity of occlusion. Indeed,<br />
occlusion both on natural teeth and on prostheses<br />
with premature or sliding contacts can provoke a<br />
mandibular torque (4) or an unfavorable center of<br />
gravity. The consequent altered muscular activity is<br />
not macroscopically evident, but, in the mediumlong<br />
time, it could cause alterations in the bone.<br />
In the present study, patients with full-mouth<br />
prostheses on implants have been evaluated at<br />
the end of their prosthetic reconstructions and<br />
after one year with surface EMG.<br />
Methods<br />
Patients<br />
On September 2013, five male patients were<br />
selected from a dental practice in Milan during<br />
dental hygiene clinical recall appointments. These<br />
patients had received full mouth rehabilitation on<br />
4 implants (Milde® implants) in each dental arch<br />
from the same private practice between June 2012<br />
and September 2012. All the patients were in good<br />
health and edentulous in both arches. All of them<br />
have presented severe atrophy in the posterior<br />
regions of the arches. Clinical and radiographic<br />
diagnoses were performed, using preoperative<br />
panoramic radiographs and Cone Beam CT scans.<br />
All patients gave their informed consent to the<br />
immediate loading procedure. Immediately after<br />
the surgery (Fig 1), full-resin prosthesis with a resin<br />
CAD-CAM framework (Fig 2) was placed with distal<br />
cantilever extension – first molar area (12 teeth).<br />
To avoid the incidence of prosthetic<br />
complications, the neuromuscular equilibrium of<br />
occlusion in static conditions was evaluated in all<br />
patients with a surface EMG (TMJoint, BTS, Italy)<br />
of the masseter (MM) and temporalis anterior<br />
(TA) muscles of both sides (left and right) one<br />
week after the surgery. In all patients, dental<br />
Figure 1. Immediately post-operatory x-ray<br />
Figure 2. Digitized prosthetic CAM Framework<br />
contacts and vertical dimensions were adjusted<br />
to obtain normal values of the EMG standardized<br />
indices (see below). Articulating paper (Bausch,<br />
Germany) was used to morphologically finalize<br />
the occlusion and adjust it with respect to the<br />
functional parameters (Fig 3 a-b). Morphological<br />
occlusion consisted of central contacts on all the<br />
masticatory units. Dynamic occlusion consisted<br />
of group function guidance regardless of the<br />
opposite arch settings. This stereotyped occlusion<br />
was functionalized in each patient by means of<br />
the patient-specific neuromuscular response on<br />
rehabilitation. The EMG test was repeated during<br />
the recall appointment one year after the surgery<br />
(Fig 4).<br />
EMG analysis<br />
Details on the protocol have been reported by<br />
Ferrario et al. (1,4). In brief, four disposable bipolar<br />
surface electrodes (Duo-Trode; Myo-Tronics Inc.,<br />
Seattle, WA, USA) were positioned on the muscular<br />
bellies identified by palpation during a voluntary<br />
clench. EMG potentials were detected, amplified,<br />
digitized, digitally filtered and recorded using<br />
four of the six channels of the above mentioned<br />
computerized electromyography (1,2,4).<br />
During the test, all the patients sat with their head<br />
unsupported, the feet flat on the floor and the arms<br />
resting on the legs; they were asked to maintain<br />
a natural upright position. They performed both<br />
a standardization test and a 3 seconds maximum<br />
42 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Functional evaluation of implant supported prostheses<br />
Table 1. Maximum voluntary teeth clenching in patients one week after surgery (prosthesis delivery).<br />
Patient<br />
Age<br />
POC masseter<br />
%<br />
POC Temporalis<br />
%<br />
TC % APC %<br />
Activity standardized<br />
µV/µV s %<br />
1 71 88 89 91 91 105<br />
2 57 84 82 88 90 92<br />
3 71 85 87 88 85 95<br />
4 65 86 85 90 78 93<br />
5 70 88 87 89 87 92<br />
POC, percentage overlapping coefficient (index of left–right muscular symmetry); TC,<br />
torque coefficient (potential lateral displacing component); APC, antero-posterior coefficient<br />
(relative activities of masseter and temporalis muscles).<br />
voluntary clench test. During the standardization<br />
test (lasting 3 seconds), a maximum voluntary<br />
clench performed on two cotton rolls positioned<br />
on the mandibular second premolar and molars<br />
was recorded. This record obtains a series of<br />
reference values to standardize all further EMG<br />
potentials recorded during the maximum clench<br />
performed directly on the occlusal surfaces (1).<br />
All values were expressed as a percentage of the<br />
standardization recordings (mV/mV x 100), and<br />
indices were computed as follows.<br />
The Percentage Overlapping Coefficient (POC,<br />
%) was computed to quantify the muscular<br />
symmetry. Its value ranges between 0% and 100%.<br />
When two paired muscles contract with perfect<br />
symmetry, a POC of 100% is obtained (normal<br />
values >83%) (6). TA and MM POCs were obtained<br />
for each patient.<br />
To compare the standardized muscular activities<br />
of masseter and temporalis muscles, an anteroposterior<br />
coefficient (APC, unit %) was obtained<br />
as the ratio between the non-overlapped<br />
and the overlapped masseter and temporalis<br />
muscle areas of both sides (normal values ><br />
90%) (6). When the standardized masseter and<br />
temporalis potentials are well comparable,<br />
the index is equal to 100%; when the patients<br />
have unbalanced standardized masseter and<br />
temporalis potentials, the index is equal to 0%.<br />
When standardized muscular potentials are not<br />
balanced between the masseter and temporalis<br />
muscles, the occlusal center of gravity (MVC on<br />
the occlusal surfaces as compared to MVC on<br />
the cotton rolls) might be displaced backwards<br />
(masseter prevalent) or onwards (temporalis<br />
prevalent).<br />
The Torque Coefficient (TC,%) was used to<br />
measure the tendency of the mandible to move<br />
toward one side during a symmetric bilateral<br />
clenching, given by unbalanced contractile activity<br />
of contralateral masseter and temporalis muscles<br />
(right temporalis and left masseter vs. left temporalis<br />
and right masseter). Its value ranges between 0%<br />
(complete presence of lateral displacing effect)<br />
and 100% (no lateral displacing effect) (normal<br />
values >90%) (6).<br />
The Impact Coefficient (IC, μV/μV%; 14) was used<br />
to measure the global muscular activity computed<br />
as the mean EMG standardized potentials over<br />
time (normal values range between 87 µV/µVs%<br />
and 107 µV/µVs%) (6).<br />
Results<br />
The EMG evaluation allowed us to measure the<br />
good functional impact of the dental contacts<br />
on the full mouth prosthetic reconstructions.<br />
Normal values of all EMG indices were obtained<br />
in each patient adjusting the occlusal contacts; a<br />
well harmonized contraction of the masticatory<br />
muscles allowed the force imbalance over<br />
the resin prosthesis and the bone. During the<br />
maximum voluntary clench one week after surgery,<br />
all patients had symmetric standardized potentials<br />
(POC values between 80% and 100%, and TC<br />
values larger than 90%, as shown in Table 1). None<br />
of the fixed prostheses (Fig. 5) were lost during the<br />
observation time, yielding a survival rate of 100%.<br />
Only one of the all-acrylic resin prosthesis displayed<br />
fracture of the resin material (Fig. 6). No occlusal<br />
screw loosening was observed. At the 1-year recall<br />
appointments, all the patients still had symmetric<br />
standardized potentials (POC values between 80%<br />
and 100%, and TC values larger than 90%, Table 2).<br />
In general, at the second visit, we observed larger<br />
values on the standardized Activity than at the first<br />
one.<br />
Discussion<br />
In the current investigation, patients with full mouth<br />
resin rehabilitation on implants were analyzed. All<br />
patients were satisfied with their prostheses, and<br />
reported an adequate stability on swallow and<br />
43
overdenture<br />
Figure 3a. Results of two sEMG functional tests<br />
obtained during the procedure of occlusal<br />
adjustment at prosthesis delivery (patient 1)<br />
TA: Temporalis anterior; MM: Masseter; POC TA:<br />
Standardized muscular symmetry for temporalis<br />
anterior muscles; POC MM: Standardized<br />
muscular symmetry for masseter muscles;<br />
APC: Standardized overlapped muscular<br />
activity between masseter vs. temporalis; TC:<br />
Standardized overlapped activity between right<br />
temporalis and left masseter vs. left temporalis and<br />
right masseter; R: Displacing static effect toward<br />
right - in brackets the correspondent percentage<br />
of muscular asymmetry component; L: Displacing<br />
static effect toward left side; A: Displacing onwards<br />
static effect (temporalis prevalent); P: Displacing<br />
backwards static effect (masseter prevalent);<br />
Normal, Normal range of indices (gray areas in the<br />
graphical view)<br />
masticatory efficiency. The EMG tests were performed<br />
one week and one year after the completion of their<br />
prosthetic reconstructions, a time considered more<br />
than sufficient for the development of good muscle<br />
activity and force generation (7,11).<br />
It has to be underlined that the current five patients<br />
were not randomly selected, and their prosthetic<br />
Figure 3b. sEMG test results at the end of the<br />
procedure of customized occlusal adjustment<br />
(patient 1). For abbreviations, see Figure 3a<br />
rehabilitations were chosen independently from<br />
the present investigations. Only well-satisfied<br />
patients in private practice were asked to undergo<br />
the present protocol. Therefore, the extrapolation<br />
of the present results to a wider population should<br />
be done with caution (12-14).<br />
The detection of the relationship between<br />
function and its morphological substrates has<br />
always been one of the most intriguing matters in<br />
dentistry. In particular, one still debated question is<br />
the relationship between dental contacts, and the<br />
function of jaw elevator muscles (15,16). In clinical<br />
practice, values recorded in healthy subjects with a<br />
full natural dentition are considered the reference<br />
norm (1,6).<br />
In the patients analyzed in the present study,<br />
the EMG indices computed from the electrical<br />
potentials recorded during the maximum<br />
voluntary clench test were well super imposable<br />
to the values found in healthy subjects with<br />
Table 2. Maximum voluntary teeth clenching in patients at the 1-year recall appointment.<br />
Patient<br />
Age<br />
POC masseter<br />
%<br />
POC Temporalis<br />
%<br />
TC % APC %<br />
Activity standardized<br />
µV/µV s %<br />
1 71 85 83 91 88 95<br />
2 57 83 85 90 88 97<br />
3 71 82 86 87 82 95<br />
4 65 83 84 89 83 98<br />
5 70 85 86 88 91 95<br />
POC, percentage overlapping coefficient (index of left–right muscular symmetry); TC, torque coefficient<br />
(potential lateral displacing component); APC, antero-posterior coefficient (relative activities of masseter<br />
and temporalis muscles).<br />
44 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Functional evaluation of implant supported prostheses<br />
Figure 4. One year functional test results, “at a glance” view (patient 1)<br />
MVC on cotton rolls pie chart: non-standardized EMG average amplitude activity (raw data) during<br />
a 3 s maximum voluntary clench on cotton rolls between R = right L = left TA (temporalis anterior)<br />
muscles, and R = right L = left MM muscles. The higher the raw value, the wider the chart sector.<br />
MVC pie chart: non-standardized EMG average amplitude activity (raw data) during a 3 s maximum<br />
voluntary clench on dental surfaces.<br />
Percentage pie chart: ratios between raw data on dental surfaces and raw data on cotton rolls<br />
(standardized EMG average amplitude activity). Graph sectors with equal area and centered on the<br />
origin axis indicate a normal functional occlusal equilibrium<br />
Figure 5. Final prosthetic result<br />
natural and normal occlusion (1,6), and they<br />
could be useful to clinically address some of<br />
the aforementioned questions. In a situation of<br />
perfect symmetry, the POC, TC and APC indices<br />
should be 100%. Of course, this hypothesis is<br />
only theoretical, and, starting from the statistical<br />
evaluation of data collected in healthy individuals,<br />
POC values larger than 83%, TC larger than 90%,<br />
APC larger than 90% and EMG standardized<br />
potentials over time between 87 µV/µV s% and<br />
107 µV/µV s% are considered to be normal (6).<br />
The limited TC values show that patients<br />
had no premature and sliding contacts due to<br />
the natural and prosthetic occlusal surfaces.<br />
Morphological alterations of the occlusal<br />
surfaces can generate a mandibular torsion (4).<br />
Indeed, even if an actual mandibular torsion has<br />
already been observed in several experimental<br />
models (17-19), in most cases this phenomenon<br />
is not macroscopically appreciable, because<br />
several other muscles (the medial pterygoid,<br />
for instance) could counterbalance the torque<br />
effect provoked by the masseter and temporal<br />
Figure 6. Particular of prosthesis fracture<br />
muscles. Nevertheless, continuous microstresses<br />
can be dangerous for the muscles themselves,<br />
the temporomandibular joint (20), and the bone,<br />
with altered load patterns.<br />
The increased standardized activity recorded in<br />
the second assessment can be explained with the<br />
effect of one year “training”: the patients regained<br />
confidence with their stomatognathic system and<br />
used well their masticatory muscles and their new<br />
occlusal surfaces.<br />
Surface EMG of the masseter and temporal<br />
muscles, therefore, allowed an objective<br />
quantification of the good functional characteristics<br />
of the new occlusal equilibrium of the patients’<br />
prosthesis analyzed in the current study.<br />
The results are also in accord with literature<br />
findings: a correct prosthetic reconstruction on<br />
implants can restore a good functional situation.<br />
The relevant static characteristics are not<br />
obviously superimposable to those measured in<br />
subjects with a natural dentition, but are better<br />
than those that can be obtained with removable<br />
dentures (21).<br />
45
overdenture<br />
Conclusions<br />
A dentist should be able to control and detect<br />
occlusal alterations produced by a non-equilibrated<br />
rehabilitation using the most correct methods. The<br />
method used in the present investigation allows<br />
a static evaluation of occlusion and can detect<br />
mandibular torsions and alterations between<br />
the two sides that cannot be controlled only with<br />
qualitative or purely morphological methods<br />
(articulation paper).<br />
The present surface EMG analysis of a static<br />
(clenching) task showed that the analyzed<br />
prostheses need stable dental contacts between<br />
the opposing dental arches.<br />
This functional condition could be protective<br />
for full-mouth prosthetic resin complications over<br />
implants. It should be underlined that the simplicity<br />
of the current tests with a minimal effort could<br />
provide useful clinical information for the day-today<br />
clinical practice.<br />
Bibliography<br />
1. Ferrario VF, Sforza C, Colombo A, Ciusa V. An electromyographic<br />
investigation of masticatory muscles symmetry in normo-occlusion<br />
subjects. J Oral Rehabil. 2000;27(1):33-40.<br />
2. De Felício CM, Sidequersky FV, Tartaglia GM, Sforza C.<br />
Electromyographic standardized indices in healthy Brazilian young<br />
adults and data reproducibility. J Oral Rehabil. 2009;36(8):577-583.<br />
3. De Felício CM, Ferreira CL, Medeiros AP, Rodrigues Da Silva<br />
MA, Tartaglia GM, Sforza C. Electromyographic indices, orofacial<br />
myofunctional status and temporomandibular disorders severity:<br />
A correlation study. J Electromyogr Kinesiol. 2012;22(2):266-272.<br />
4. Ferrario VF, Sforza C, Serrao G, Colombo A, Schmitz JH. The<br />
effects of a single intercuspal interference on electromyographic<br />
characteristics of human masticatory muscles during maximal<br />
voluntary teeth clenching. Cranio. 1999;17(3):184-188.<br />
5. Tartaglia GM, Testori T, Pallavera A, Marelli B, Sforza C. Electromyographic<br />
analysis of masticatory and neck muscles in subjects with natural<br />
dentition, teeth-supported and implant-supported prostheses. Clin<br />
Oral Implants Res. 2008;19(10):1081-1088.<br />
6. Ferrario VF, Tartaglia GM, Galletta A, Grassi GP, Sforza C. The<br />
influence of occlusion on jaw and neck muscle activity: a surface<br />
EMG study in healthy young adults. J Oral Rehabil. 2006;33(5):341-<br />
348.<br />
7. Ferrario VF, Tartaglia GM, Maglione M, Simion M, Sforza C.<br />
Neuromuscular coordination of masticatory muscles in subjects<br />
with two types of implant-supported prostheses. Clin Oral Implants<br />
Res. 2004;15(2):219-225.<br />
8. Jacobs R, Van Steenerghe D, Naert I. Masseter muscle fatigue<br />
before and after rehabilitation with implant-supported prostheses.<br />
J Prosthet Dent. 1995;73(3):284-289.<br />
9. Moriya S, Notani K, Murata A, Inoue N, Miura H. Analysis of<br />
moment structures for assessing relationships among perceived<br />
chewing ability, dentition status, muscle strength, and balance<br />
in community-dwelling older adults. Gerodontology. 2012. doi:<br />
10.1111/ger.12036.<br />
10. Grosdent S, O’Thanh R, Domken O, Lamy M, Croisier JL. Dental<br />
occlusion influences knee muscular performances in asymptomatic<br />
females. J Strength Cond Res. <strong>2014</strong>;28(2):492-498.<br />
11. Van Kampen FM, van der Bilt A, Cune MS, Bosman F. The<br />
influence of various attachment types in mandibular implantretained<br />
overdentures on maximum bite force and EMG. J Dent<br />
Res. 2002;81(3):170-173.<br />
12. Al-Omiri M, Hantash RA, Al-Wahadni A. Satisfaction with dental<br />
implants: a literature review. Implant Dent. 2005;14(4):399-406.<br />
13. Flanagan D. An overview of complete artificial fixed dentition<br />
supported by endosseous implants. Artif Organs. 2005;29(1):73-<br />
81.<br />
14. Feine JS, Lund JP. Measuring chewing ability in randomized<br />
controlled trials with edentulous populations wearing implant<br />
prostheses. J Oral Rehabil. 2006;33(4):301-308.<br />
15. Farella M, Bakke M, Michelotti A, Rapuano A, Martina R.<br />
Masseter thickness, endurance and exercise-induced pain in<br />
subjects with different vertical craniofacial morphology. Eur J<br />
Oral Sci. 2003; 111:183–8. Eur J Oral Sci. 2003;111(3):183-<br />
188.<br />
16. Garcia-Morales P, Buschang PH, Throckmorton GS, English<br />
JD. Maximum bite force, muscle efficiency and mechanical<br />
advantage in children with vertical growth patterns. Eur J Orthod.<br />
2003;25(3):265-272.<br />
17. Christensen LV, Rassouli NM. Experimental occlusal<br />
interferences. Part II. Masseteric EMG responses to an intercuspal<br />
interference. J Oral Rehabil. 1995; 22:521-531. J Oral Rehabil.<br />
1995;22(7):521-531.<br />
18. Karlsson S, Cho S-A, Carlsson GE. Changes in mandibular<br />
masticatory movements after insertion of nonworking-side<br />
interference. J Craniomandib Disord. 1992;6(3):177-183.<br />
19. Rassouli NM, Christensen LV. Experimental occlusal<br />
interferences. Part III. Mandibular rotations induced by a rigid<br />
interference. J Oral Rehabil. 1995;22(10):781-789.<br />
20. Baba K, Ai M, Mizutani H, Enosawa S. Influence of experimental<br />
occlusal discrepancy on masticatory muscle activity during<br />
clenching. J Oral Rehabil. 1996;23(1):55-60.<br />
21. Fontijn-Tekamp FA, Slagter AP, van’t Hof MA, Geertman ME, Kalk<br />
W. Bite forces with mandibular implant-retained overdentures. J<br />
Dent Res. 1998;77(10):1832-1839.<br />
46 Stoma.eduJ (<strong>2014</strong>) 1 (1)
GERODONTOLOGY<br />
Cite this article:<br />
Petraki V, Thomopoulos<br />
P, Kossioni AE. Factors<br />
affecting recent dental<br />
services utilization by an<br />
urban older population<br />
in Athens. Stoma <strong>Edu</strong> J.<br />
<strong>2014</strong>; 1(1):48-51.<br />
Factors affecting recent dental<br />
services utilization by an urban<br />
older population in Athens<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.8<br />
Vasilia Petraki 1a ,<br />
Philippos Thomopoulos 2b ,<br />
Anastassia E. Kossioni3 c *<br />
1. Department of Operative Dentistry,<br />
Dental School,<br />
National and Kapodistrian University of Athens,<br />
Athens, Greece<br />
2. General Dental Practitioner, Glifada, Greece<br />
3. Department of Prosthodontics, Dental School,<br />
National and Kapodistrian University of Athens,<br />
Athens, Greece<br />
a. DDS, Clinical Associate<br />
b. DDS, General Dental Practitioner<br />
c. DDS, PhD, Assistant Professor<br />
Abstract<br />
Introduction: The purpose of this study was to investigate the percentage of older people<br />
in an urban area visiting a dentist within the last 12 months and explore the particular effect<br />
of age, gender, education and dental status.<br />
Methodology: Athens Dental School organized educational visits to a day center for older<br />
people in Athens, where the older visitors were interviewed and clinically examined. The<br />
patients’ social and medical history and the time of the last dental visit were recorded. The<br />
clinical examination included the presence of natural teeth using appropriate portable<br />
equipment.<br />
Results: A total of 77 older people, 53 females and 24 males, with a mean age of 73.8 years<br />
were recorded. Dental visits in the last 12 months were statistically significantly related to<br />
higher level of education (more than 6 years) (p=0.037) and the presence of natural teeth<br />
(p=0.014). More women had visited a dentist in the past 12 months but not to a statistically<br />
significant level. Fewer older old (aged 85 years and over) had recently visited a dentist but<br />
not statistically significantly.<br />
Conclusion: The findings in the present study are in accordance to previous investigations<br />
in community-dwelling older adults indicating the importance of education and natural<br />
teeth in the utilization of dental services.<br />
Key words: elderly, gender, edentulism, education, dental service utilization<br />
Received: 09 November 2013<br />
Accepted: 21 January <strong>2014</strong><br />
* Corresponding author:<br />
Assistant Professor Anastassia E Kossioni,<br />
DDS, PhD<br />
Department of Prosthodontics, Dental School,<br />
National and Kapodistrian University of Athens,<br />
Athens, Greece.<br />
Thivon 2 Goudi, GR-11527Athens, Greece.<br />
Tel: +302107461212, Fax: +302107461240.<br />
e-mail: akossion@dent.uoa.gr<br />
Introduction<br />
During the last decades the number of older people has continuously grown, as<br />
a result of increased life expectancy and low fertility rates (1). By the year 2050, the<br />
persons aged 60 years and over will be almost two billion world-wide and the large<br />
majority of them (80%) will live in developing countries (2). The oldest old age group<br />
(80 years and over) is the most rapidly increasing proportion of the population, and is<br />
expected to increase from 0.5% in 1950 to 4.3% by 2050 (2). This demographic change<br />
will put significant strains on social security systems, including provision of general and<br />
oral health care.<br />
More older people in the developed countries tend to maintain their natural dentition<br />
but the rates of oral disease, such as tooth loss, periodontal diseases, dental caries,<br />
xerostomia and oral cancer are still high (3-5).<br />
The use of dental services has been investigated in relation to many factors, such as<br />
age, gender, dental status, ethnicity, income, education, general health status, dental and<br />
medical insurance (6-9). Increasing age, lower education and compromised self-rated<br />
health have been related to lower use of dental services by older Europeans (10).<br />
The purpose of this study was to investigate the percentage of older people in an<br />
urban area, visiting a dentist within last 12 months and to explore the particular effect<br />
of age, gender, education and dental status.<br />
Methods<br />
Gerodontology is a lecture-based course taught in the 8th semester of the<br />
undergraduate studies at the Athens Dental School. Within this course, the students visit<br />
48 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Factors affecting recent dental services utilisation by an urban older population in Athens<br />
Figure 1. Dental visits by older adults in the past<br />
12 months in relation to gender (%) , p>0.05<br />
day centers for the elderly in the Metropolitan<br />
Athens area on a voluntary basis. In 2012, 34<br />
students participated in these visits that included<br />
a thorough medical and dental history taking and<br />
an oral examination using portable equipment<br />
(11). The students and the members of the staff<br />
of the Dental School informed the older people<br />
about their current oral problems, provided oral<br />
hygiene instructions and advised on the proper<br />
use of dentures. One of the questions asked<br />
were if they had visited a dentist in the past 12<br />
months.<br />
The effect of gender (men, women), age (6 years) and<br />
dental status (dentate, edentulous), on visiting a<br />
dentist within the past 12 months were analyzed.<br />
The statistical analyses included descriptive<br />
statistics, chi-square tests and Fisher’s Exact<br />
Tests. The level of statistical significance was set<br />
at p ≤0.05.<br />
Results<br />
A total of 77 older people were examined, 53<br />
women and 24 men, with a mean age of 73.8 years<br />
(SD: ±7.3). Their age ranged from 59 to 92 years.<br />
A total of 55.8% of them had attended fewer<br />
than 7 years of education and only 15.6% had<br />
completed tertiary education. A total of 15.6%<br />
were edentulous and 84.4% were dentate.<br />
Almost half of the participants (53.3%) had<br />
visited a dentist in the past 12 months. More<br />
women than men had recently visited a dentist<br />
(Figure 1) but this was not statistically significant<br />
(chi-square test, p=0.528). Fewer older old (85<br />
years and over) had visited a dentist in the past<br />
year (Figure 2) but the statistical analysis did not<br />
record any statistical significance (chi-square test,<br />
p=0.521). Most of the people who had visited a<br />
dentist in the past 12 months had completed at<br />
least primary school education (6 years) (Figure<br />
3) (Fishers Exact Test, p=0.037). More dentate<br />
(60%) than edentulous persons had visited a<br />
dentist in the last year (Figure 4) (chi-square test,<br />
Figure 2. Dental visits by older adults in the past<br />
12 months in relation to age (%), p>0.05<br />
p=0.014). For 51% of the women and 42% of<br />
the men, prosthodontic treatment was the main<br />
reason for the last dental visit.<br />
Discussion<br />
This study offers an insight on the parameters<br />
that may affect dental consultation rates in an<br />
older urban European population.<br />
More than half of the older participants had<br />
visited a dentist within the last 12 months. A<br />
previous study in a Greek population aged 57-<br />
99 years has shown that 37% of the participants<br />
had visited a dentist in the past year (9). The<br />
higher percentage in the present study could<br />
be related to the specific sociodemographic<br />
characteristics of the sample (urban area, middleclass,<br />
motivation to be examined by a dentist in<br />
the day centre).<br />
The two most important predictors for seeking<br />
dental care in the past 12 months were the<br />
higher level of education and having a natural<br />
dentition. On the other hand, sex and age did<br />
not significantly affect the time of the last dental<br />
visit.<br />
The level of education is a significant predictor<br />
of dental utilization among older adults (6,10).<br />
Previous surveys in Greece have also reported<br />
that, and low educational level was associated with<br />
lower use of dental services (8,9). Similar were the<br />
findings in senior citizens in Canada (7).<br />
A total of 60% of the dentate adults had visited<br />
a dentist in the last year, while this percentage<br />
decreased to approximately 17% in the edentulous<br />
ones. Similar were the findings in a previous study<br />
in 1751 older participants in Manitoba, Canada<br />
with a mean age of 76.2 years. The dental visits<br />
in the past 6 months in the dentate seniors were<br />
36.2%, compared to 13.5% in the edentulous ones<br />
(7). Furthermore, 46% percent of the edentulous<br />
Australians aged 55-74 years had visited a dentist<br />
more than 5 years ago compared to 8% by the<br />
dentate ones (12).<br />
Fewer men had visited a dentist in the past<br />
12 months compared to women but not to a<br />
49
GERODONTOLOGY<br />
Figure 3. Dental visits by older adults in the past 12<br />
months in relation to the level of education (%), p=0.037<br />
statistically significant level. In a previous study<br />
in Mexico City the male gender was associated<br />
with reduced dental service utilization (13).<br />
Similar were the findings in Australia (12).<br />
Fewer older persons aged 85 years and over<br />
had recently visited a dentist but again this was<br />
not statistically significant. A previous study in a<br />
Greek population has shown a lower percentage<br />
of dental services’ users in the past 12 months<br />
with increasing age (9). It may be suggested that<br />
the fewer recent dental visits by the older old is<br />
related to the higher rates of edentulism.<br />
This study had some limitations. The sample size was<br />
small and included participants from a Metropolitan<br />
urban area with medium socio-economic status.<br />
Further research is needed to investigate utilization of<br />
dental services by the older population in more urban<br />
and rural areas in the country.<br />
Figure 4. Dental visits by older adults in the past<br />
12 months in relation to dental status (%), p=0.014<br />
Conclusions<br />
Taking into account the limitations of this study,<br />
it may be concluded that the higher level of<br />
education and the dentate status are related to<br />
increased percentages of older people visiting a<br />
dentist in the past 12 months. The male gender<br />
and the older age were related to fewer visits but<br />
not to a statistically significant level.<br />
Acknowledgments<br />
The authors would like to thank the municipality<br />
of Zografos and the Director of the 1st day center<br />
for older people Mr. George Dimarides for the<br />
substantial assistance throughout the educational<br />
visits. Special thanks to the dental educators who<br />
participated in the program and Johnson and<br />
Johnson Hellas for the financial support.<br />
Bibliography<br />
1. Kossioni AE. Is Europe prepared to meet the oral health needs of<br />
older people? Gerodontology. 2012; 29(2):1230-1240.<br />
2. United Nations. World Economic and Social Survey 2007.<br />
Development in an Ageing World. New York: Department of Economic<br />
and Social Affairs, United Nations; 2007.<br />
3. Petersen PE, Yamamoto TI. improving the oral health of older people:<br />
the approach of the WHO Global Oral Health Programme. Community<br />
Dent Oral Epidemiol. 2005; 33(2):81-92.<br />
4. Petersen PE, Kandelman D, Arpin S, Ogawa H. Global oral health of<br />
older people – Call for public health action. Community Dent Health.<br />
2010; 27(Suppl 2):257–267.<br />
5. Kossioni AE. Current status and trends in oral health in the<br />
community-dwelling older adults. A global perspective. Oral Health<br />
Prev Dent. 2013; 11(4):331-340.<br />
6. Kiyak HA, Reichmuth M. Barriers to and enablers of older adults’ use<br />
of dental services. J Dent <strong>Edu</strong>c. 2005; 69(9):975–986.<br />
7. Brothwell DJ, Jay M, Schönwetter DJ. Dental service utilization by<br />
independently dwelling older adults in Manitoba, Canada. J Can Dent<br />
Assoc. 2008; 74(2):161-161f.<br />
8. Pavi E, Karampli E, Zavras D, Dardavesis T, Kyriopoulos J. Social<br />
determinants of dental health services utilisation of Greek adults.<br />
Community Dent Health. 2010; 27(3):145-150.<br />
9. Koletsi-Kounari H, Tzavara C, Tountas Y. Health-related lifestyle<br />
behaviours, socio-demographic characteristics and use of dental<br />
health services in Greek adults. Community Dent Health. 2011;<br />
28(1):47-52.<br />
10. Santos-Eggimann B, Junod J, Cornaz S. Health services<br />
utilisation in older Europeans. In: Borsch- Supan A, Brugiavini<br />
A, Jurges H et al. eds. Health, Ageing and Retirement in Europe.<br />
First Results from the Survey of Health, Ageing and Retirement<br />
in Europe. Mannheim: Mannheim Research Institute for the<br />
Economics of Aging (MEA); 2005:133–140.<br />
11. Petraki V, Michael L, Gavela G, Kossioni AE. Dental status in older<br />
community-dwelling people in a day-center in Attica- A pilot study.<br />
Hellenic Stom Rev. 2012; 56(4):271-282.<br />
12. Slade GD, Spencer AJ. Roberts-Thomson KF. Australia’s dental<br />
generations. The National Survey of Adult Oral Health 2004–06.<br />
Canberra: Australian Institute of Health and Welfare (Dental Statistics<br />
and Research Series No. 34); 2007. AIHW cat. no. DEN 165.<br />
13. Sánchez-García S, de la Fuente-Hernández J, Juárez-Cedillo T,<br />
Mendoza JM, Reyes-Morales H, Solórzano-Santos F, García-Peña C.<br />
Oral health service utilization by elderly beneficiaries of the Mexican<br />
Institute of Social Security in México city. BMC Health Serv Res.<br />
2007;7:211.<br />
50 Stoma.eduJ (<strong>2014</strong>) 1 (1)
Cite this article:<br />
Kempler J. An implant<br />
supported maxillary<br />
fixed prosthesis with a<br />
substructure/suprastructure<br />
design: a clinical case.<br />
Stoma <strong>Edu</strong> J. <strong>2014</strong>;<br />
1(1);52-58.<br />
oral implantology<br />
An Implant Supported<br />
Maxillary Fixed Prosthesis<br />
with a Substructure/<br />
Suprastructure Design:<br />
A Clinical Case<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.9<br />
Joanna Kempler*<br />
Department of Endodontics, Prosthodontics and<br />
Operative Dentistry, Baltimore College of Dental<br />
Surgery, Baltimore, MD, USA<br />
DDS, MS, Clinical Assistant Professor<br />
Abstract<br />
This article describes a clinical case in which a moderately compromised<br />
maxillary arch is restored with a fixed implant supported prosthesis with<br />
a substructure/suprastructure design. The prosthetic rehabilitation of the<br />
edentulous maxilla can be achieved using different types of prostheses,<br />
including removable implant-retained, implant-supported, or fixed implantsupported<br />
prostheses. The treatment performed is presented step-by-step.<br />
The prosthetic design is discussed in detail and compared to other types<br />
of fixed implant supported prostheses. Advantages and disadvantages of<br />
this type of design are also presented. The substructure/suprastructure<br />
design is indicated when the prosthesis must replace both soft and hard<br />
tissues. Although it involves multiple steps and it is costly, the substructure/<br />
suprastructure design represents a great alternative to any removable<br />
prosthesis and provides patients with great esthetics and function.<br />
Keywords: implants, edentulous maxilla, fixed prosthesis<br />
Received: 04 December 2013<br />
Accepted: 06 January <strong>2014</strong><br />
* Corresponding author:<br />
Clinical Assistant Professor<br />
Joanna Kempler, DDS, MS<br />
Department of Endodontics, Prosthodontics and<br />
Operative Dentistry, Baltimore College of Dental<br />
Surgery, Baltimore, MD, USA.<br />
3460 Old Washington Road, Suite 102,<br />
Waldorf, MD, 20602, USA.<br />
e-mail: jkwaldorfdds@umaryland.edu<br />
Introduction<br />
The predictability of successful osseointegration in the rehabilitation process of an<br />
edentulous arch, as described by Branemark et al (1), introduced an entire new concept of<br />
management of the edentulous patients. According to a study by Douglas and Watson, the<br />
actual number of individuals requiring complete denture therapy by the year 2030 will not<br />
decrease, and maxillary edentulism may represent up to a third of the denture market (2).<br />
A 2006 study by Jemt showed that implant treatment in the edentulous upper jaw<br />
functioned well in a long time perspective. The 15-year implant and fixed prosthesis<br />
cumulative survival rate was 90.9 and 90.6%, respectively (3).<br />
This is important for us as practitioners as more edentulous patients will present for<br />
implant reconstruction.<br />
Implant treatment of the edentulous maxilla can be a complex scenario and the outcome<br />
does not always fulfill the expectations in terms of esthetics and function (4).<br />
The maxillary arch presents multiple potential challenges for both the surgical and the<br />
restorative providers. Implant therapy for the maxillary arch is often compromised by reduced<br />
bone quantity and quality and by the presence of higher biomechanical forces (5).<br />
Maxillary implants are often angled facially due to resorptive patterns, while the replacement<br />
teeth are usually arranged anterior and inferior to the residual ridge (6). Thicker masticatory<br />
mucosa on the maxilla often necessitates longer implant abutments increasing the lever arm<br />
length. Unlike the mandible, with its shock absorbing effect and buttressing lingual bone, the<br />
thin buccal bone of the maxilla may not tolerate the applied forces as well (7).<br />
52 Stoma.eduJ (<strong>2014</strong>) 1 (1)
An Implant Supported Maxillary Fixed Prosthesis<br />
with a Substructure/ Suprastructure Design: A Clinical Case<br />
Figure 1. Initial presentation (frontal view)<br />
Figure 2. Initial presentation (profile view)<br />
Figure 3. Intraoral frontal view<br />
The design of the final maxillary implant supported<br />
prosthesis is influenced by the following:<br />
1. The Anatomy of the residual ridge. The degree<br />
of ridge resorption can significantly alter the size<br />
and position of future implants and can determine<br />
whether teeth, or teeth and other tissues must be<br />
replaced (8).<br />
2. Some functional considerations include<br />
the opposing dentition, whether the patient<br />
has natural teeth or a removable prosthesis.<br />
Also, the maxillo-mandibular relationship is<br />
very important, as an increased vertical space<br />
and horizontal discrepancies create greater<br />
lever arms and complicate the design of the<br />
final prosthesis (9).<br />
3. Esthetics plays a crucial role in prosthesis<br />
design. Careful assessment of the patient’s smile<br />
line and necessity for a buccal flange must be<br />
performed before the final treatment plan decision<br />
is made (10).<br />
4. Altered speech can occur when patients<br />
cannot adapt to the new contours of the prosthesis.<br />
Implants placed too far palatally often require<br />
bulky restorations, which in turn can significantly<br />
alter speech (11).<br />
5. To promote favorable oral hygiene, access<br />
must be provided for effective removal of plaque<br />
and food debris from around the abutments and<br />
underneath the framework (12).<br />
6. Lastly, cost plays a significant role in selecting<br />
a prosthesis design. Usually suprastructure/<br />
Figure 4. Initial panoramic radiograph<br />
(the shadow is due to the screws)<br />
substructure cases require complex laboratory<br />
procedures and tend to be more costly.<br />
Some of the design options for a fixed maxillary<br />
implant supported prosthesis include the following:<br />
1. Ceramo-metal cement retained on custom<br />
abutments;<br />
2. Ceramo-metal screw retained prosthesis;<br />
3. Fixed-detachable or “hybrid” prosthesis;<br />
4. Suprastructure/Substructure design which can<br />
be achieved either by:<br />
-spark erosion technique<br />
-milled/ cast bar, cast suprastructure with set<br />
screws<br />
-milled bar with individual abutments and single<br />
crowns cemented on the abutments (13,14).<br />
The substructure/suprastructure design has its<br />
advantages and disadvantages.<br />
Some of the advantages of this type of design<br />
include providing the patient with a fixed prosthesis<br />
when no other designs are feasible. It also has the<br />
ability to replace both missing hard and soft tissue<br />
and improve unfavorable biomechanics seen in<br />
off-ridge relations (15). Esthetics and phonetics are<br />
usually very good with this type of design.<br />
However, there are also disadvantages to this<br />
design.<br />
The cost is usually very high due to precise<br />
and complicated laboratory procedures that are<br />
required and it unfortunately can be prohibitive for<br />
some patients. Passive fit of the bar and framework<br />
is also difficult to achieve. Long span frameworks<br />
53
oral implantology<br />
Figure 5. Cone Beam CT scan<br />
Figure 6. Occlusal view of maxillary arch during<br />
implant placement<br />
Figure 7. Tooth arrangement in wax<br />
without the buccal flange<br />
are difficult to apply porcelain to and porcelain<br />
fracture is challenging and costly to repair. Also,<br />
loss of a strategic implant may compromise the<br />
entire prosthesis. Hygiene can be challenging<br />
for some patients, especially those with limited<br />
dexterity (16).<br />
Case Report<br />
A 45-year-old female patient presented to the<br />
Advanced <strong>Edu</strong>cation Program in Prosthodontics at<br />
the Baltimore College of Dental Surgery, with the<br />
following chief complaint: “I would like to have my<br />
teeth fixed.” Patient said that she never had pretty<br />
teeth and now she is ready to do something to<br />
improve her smile. Patient had lost her teeth mainly<br />
due to periodontal disease.<br />
She showed some facial asymmetry, scarring on<br />
the left corner of the mouth, pronounced labionasal<br />
folds and lip asymmetry during smiling (Fig.<br />
1). Patient had a convex profile with adequate lip<br />
support (Fig. 2).<br />
Intraoral examination revealed missing posterior<br />
teeth, retained root tips and periodontally involved<br />
maxillary anterior teeth (Fig. 3). Mandibular range<br />
of motion was restricted, especially maximum<br />
Figure 8. Esthetic try-in to determine the necessity<br />
of a buccal flange<br />
opening which was 30mm and right laterotrusive,<br />
which was 1-2 mm.<br />
Patient’s radiologic examination revealed<br />
multiple root tips, periodontally involved teeth and<br />
a horizontal root fracture of tooth #11. Panoramic<br />
radiograph showed abnormal temporomandibular<br />
left joint due to a car accident during early age, with<br />
otherwise normal trabecular bone pattern. (Fig. 4).<br />
A problem list was put together before<br />
establishing the final treatment plan.<br />
The patient’s maxillary arch anatomy represented<br />
a challenge especially on her left side, where she<br />
had a pronounced horizontal discrepancy between<br />
the maxillary and the mandibular alveolar ridge<br />
crest and also an increased inter-arch distance.<br />
The patient’s desire was to have a fixed final<br />
prosthesis, however she refused any grafting<br />
procedures. She was educated about the<br />
complexity of her treatment plan and was<br />
explained that a fixed prosthesis might not be<br />
possible in her case.<br />
All maxillary teeth were extracted atraumatically<br />
and an immediate maxillary complete denture<br />
was fabricated. The patient was very pleased<br />
with the esthetics of the denture, which allowed<br />
54 Stoma.eduJ (<strong>2014</strong>) 1 (1)
An Implant Supported Maxillary Fixed Prosthesis<br />
with a Substructure/ Suprastructure Design: A Clinical Case<br />
Figure 9. Screw retained acrylic provisional<br />
Figure 10. GC pattern substructure before casting<br />
Figure 11. Substructure bar tried in the mouth<br />
proceeding by duplicating the immediate denture<br />
and fabricating a radiographic guide based on the<br />
immediate denture’s tooth arrangement.<br />
The patient was sent for cone beam CT scan<br />
wearing the radiographic guide. Based on bone<br />
availability, six maxillary implants were planned in<br />
areas: 15,14,13, 22,14, 27 (Fig. 5).<br />
The number of implants was based on the<br />
availability of bone and the patient’s denial of any<br />
extensive bone grafting procedures. This was also<br />
in conjunction with the literature, as Beumer et al<br />
recommended a minimum of six implants to be<br />
placed with an anterior-posterior span of at least<br />
20 mm for a fixed maxillary prosthesis (17).<br />
Six implants were placed as planned with a<br />
second stage approach (Nobel Active Regular<br />
Platform] [RP 4.3mm] and Narrow platform [NP<br />
3.5mm], Nobel Biocare USA, Yorba Linda, CA) (Fig.<br />
6). Following second stage surgery, an implant<br />
impression was made using pick-up copings in an<br />
open custom tray. A verification jig was fabricated<br />
on the master cast using GC pattern resin (GC<br />
America, Alsip, IL).<br />
The maxillary master cast was articulated and at<br />
this point the treatment plan was re-evaluated and<br />
some implant factors were added to the problem<br />
list:<br />
-Implant size: there were 2 regular platform and<br />
4 narrow platform implants ;<br />
Figure 12. Full contour wax-up of the metal<br />
suprastructure<br />
-Implant distribution was fair on the right side<br />
and very good on the left side;<br />
-Implants 22, 24, 27 were buccally angled.<br />
Another very critical step was performed before<br />
committing to a final prosthesis design: determining<br />
the need for a buccal flange. A wax set-up was made<br />
excluding the buccal flange and tried in (Fig. 7).<br />
Extraoral clinical examination addressed facial<br />
parameters such as facial support, lip support,<br />
smile line, and upper lip length. Facial support<br />
is a critical factor for decision making because<br />
soft tissue support can be obtained mainly by<br />
the buccal flange of a removable restoration and<br />
the position of the denture teeth. The thickness<br />
of the buccal flange of an existing complete<br />
denture can also be indicative of the necessary<br />
lip and cheek support. It was determined that an<br />
adequate esthetic result can be obtained without<br />
the buccal flange (Fig. 7, 8).<br />
A fixed screw retained acrylic provisional<br />
on temporary abutments was fabricated. The<br />
abutments were contoured to allow for proper<br />
soft tissue profile and the patient was given oral<br />
hygiene instructions on how to adequately clean<br />
her new prosthesis (Fig. 9).<br />
There are many advantages to providing a fixed<br />
provisional before placing the final ceramo-metal<br />
restoration. Evaluation of esthetics, reassessment<br />
of the occlusal scheme, adjustment of the vertical<br />
55
oral implantology<br />
Figure 13. Metal suprastructure<br />
Figure 14. View of the left lateral set screw openings<br />
Figure 15. Superfloss passing underneath<br />
prosthesis<br />
dimension, and equilibration by addition or<br />
subtraction can be made in this manner. Occlusal<br />
harmony should improve the load distribution and<br />
reduce component failure. A mutually protected<br />
occlusal scheme was achieved in the provisional<br />
stage. The substructure was fabricated by first<br />
milling a GC pattern framework on non-engaging<br />
gold adapt cylinders (Nobel Biocare USA, Yorba<br />
Linda, CA) (Fig. 10).<br />
A putty matrix of the cross-mounted provisionals<br />
was used by the laboratory technician for reference.<br />
The GC pattern was precision milled with a 3 degree<br />
taper on both sides, which provided frictional<br />
retention for the future metal suprastructure. The<br />
GC pattern was invested and cast in a noble alloy.<br />
The substructure was tried in the mouth (Fig. 11).<br />
The passive fit of the substructure was assessed<br />
by performing the one screw test, the quarter turn<br />
test, by tactile and radiographic examination. The<br />
verification radiographs were taken to assess any fit<br />
discrepancies. A full contour wax-up was created<br />
prior to the fabrication of the metal suprastructure<br />
(Fig. 12). The full contour wax up was cut back<br />
to allow for adequate room for porcelain<br />
application. The wax pattern was invested and<br />
cast in noble metal alloy. The suprastructure<br />
was examined on the articulator for fit, proper<br />
contours and adequate interocclusal clearance<br />
(Fig. 13).<br />
Figure 16. Final prosthesis (frontal view)<br />
At this point, the master cast articulation was<br />
verified by making an interocclusal record on the<br />
articulator, then transferring it to the mouth and<br />
verifying the accuracy of the mounting.<br />
The next step was the porcelain application<br />
on the suprastructure and delivery of the final<br />
prosthesis.<br />
The final prosthesis was examined for adequate<br />
esthetics and fit. Four lingual set screws were<br />
drilled. Due to the patient’s limited mouth opening,<br />
insertion of the set screws was a tedious and<br />
challenging process (Fig. 14).<br />
The substructure was inserted and torqued<br />
to 35 Ncm. The suprastructure was placed over<br />
the substructure, the set screws were carefully<br />
manipulated in position.<br />
The patient was educated on proper oral hygiene<br />
and maintenance of her new prosthesis (Fig. 15).<br />
56 Stoma.eduJ (<strong>2014</strong>) 1 (1)
An Implant Supported Maxillary Fixed Prosthesis<br />
with a Substructure/ Suprastructure Design: A Clinical Case<br />
The mutually protected occlusal scheme<br />
established in the provisional was replicated in the<br />
final prosthesis. A mandibular occlusal guard was<br />
fabricated.<br />
During an exaggerated smile there is a fair<br />
display of pink porcelain, however, the junction<br />
between patient’s soft tissue and pink porcelain is<br />
not visible. The patient was very pleased with the<br />
result (Fig.16).<br />
Summary<br />
With edentulism on the rise, patients seeking<br />
replacement of their upper denture with an implantsupported<br />
restoration are most interested in a fixed<br />
restoration. Accompanying the loss of supporting<br />
alveolar structure due to resorption is the necessity<br />
for soft tissue support in order to achieve optimum<br />
esthetic results. The substructure/suprastructure<br />
design can replace missing both hard and soft tissue<br />
and improve unfavorable biomechanics seen in offridge<br />
relations. However, this design is very difficult<br />
to achieve due to the high precision required for the<br />
substructure and the suprastructure, challenging<br />
laboratory steps and it is very costly. It does however<br />
provide the patients with a prosthesis that offers<br />
optimum esthetics and function.<br />
Bibliography<br />
1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study<br />
of osseointerated implants in the treatment of the edentulous<br />
jaw. Int J Oral Surg. 1981; 10(6): 387-416.<br />
2. Douglass CW, Watson AJ. Future needs for fixed and<br />
removable partial dentures in the United States. J Prosthet<br />
Dent. 2002; 87(1): 9-14.<br />
3. Jemt T, Johansson J. Implant treatment in the edentulous<br />
maxillae: a 15-year follow-up study on 76 consecutive patients<br />
provided with fixed prostheses. Clin Implant Dent Relat Res.<br />
2006; 8(2): 61-69.<br />
4. Bosse LT, Taylor TD. Problems associated with implant<br />
rehabilitation of the edentulous maxilla. Dent Clin North Am.<br />
1998; 42(1): 117-127.<br />
5. Zitzmann NU, Marinello CP. Treatment plan for restoring<br />
the edentulous maxilla with implant-supported restorations:<br />
Removable overdenture versus fixed partial denture design. J<br />
Prosthet Dent .1999; 82(2): 188-196.<br />
6. Razavi R, Zena RB, Khan Z, Gould AR. Anatomic site evaluation<br />
of edentulous maxillae for dental implant placement. J<br />
Prosthdont. 1995; 4(2): 90-94.<br />
7. Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T.<br />
Fixed-prosthetic implant restoration of the edentulous maxilla:<br />
a systematic pretreatment evaluation method. J Oral Maxillofac<br />
Surg. 2008; 66(1): 112-122.<br />
8. Wee AG, Aquilino SA, Schneider RL. Strategies to achieve<br />
fit in implant prosthodontics: a review of the literature. Int J<br />
Prosthodont. 1999; 12(2): 167-178.<br />
9. Sadowsky SJ. The implant-supported prosthesis for the<br />
edentulous arch: Design considerations. J Prosthet Dent.<br />
1997; 78(1): 28-33.<br />
10. Henry P. A review of guidelines for implant rehabilitation of the<br />
edentulous maxilla. J Prosthet Dent. 2002; 87(3): 281-288.<br />
11. Graser GN, Myers ML, Iranpour B. Resolving esthetic<br />
and phonetic problems associated with maxillary implantsupported<br />
prostheses: a clinical report. J Prothet Dent.1989;<br />
62: 376-378.<br />
12. Sadowsky SJ. Treatment considerations for maxillary<br />
implant overdentures: a systematic review. J Prosthet Dent.<br />
2007; 97: 340-348.<br />
13. Morgano SM, Verde MA, Haddad MJ. A fixed-detachable<br />
implant-supported prosthesis retained with precision<br />
attachments. J Prosthet Dent. 1993; 70: 438-442.<br />
14. Ercoli C, Graser GN, Tallents RH, Hagan ME. Alternative procedure<br />
for making a metal superstructure in a milled bar implantsupported<br />
overdenture. J Prosthet Dent. 1988; 80: 253-258.<br />
15. Eisenmann E, Mokabberi A, Walter MH, Freesmeyer WB.<br />
Improving the fit of implant-supported superstructures using the<br />
spark erosion technique. Int J Prosthodont. 1999;12: 167-178.<br />
16. Sherry JS, Balshi TJ, Sims LO, Balshi SF. Treatment of a<br />
severly atrophic maxilla using an immediately loaded, implantsupported<br />
fixed prosthesis without the use of bone grafts: a<br />
clinical report. J Prosthet Dent. 2010; 103:133-138.<br />
17. Beumer J. Hamada MO. Lewis S. A prosthodontic overview.<br />
Int J Prosthodontics. 1993; 6: 126-130.<br />
57
COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME<br />
PREVALENCE OF COMORBIDITIES<br />
IN SOCIALLY ASSISTED PATIENTS IN<br />
THE SANODENTAPRIM PROGRAMME<br />
Cite this article:<br />
Ilea A, Buhatel D, Moga M,<br />
Feurdean C, Ionel A, Sava A,<br />
Lucaciu O, Sarbu A, Campian<br />
RS. Comorbities prevalence<br />
in socially assisted patients<br />
in the sanodentaprim<br />
programme. Stoma <strong>Edu</strong> J.<br />
<strong>2014</strong>; 1(1):59-64.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).art.10<br />
Abstract<br />
Introduction: Once with the growth of the population’s life expectancy in the world but also<br />
in Romania, the patients in dental offices often suffer from associated diseases for which<br />
they are under constant medication.<br />
The objectives of the study were to evaluate the prevalence of the associated diseases and<br />
of constant medication for a group of socially assisted patients.<br />
Methods: The study included a total of 1176 socially assisted patients from the<br />
SANODENTAPRIM program who were seen during the period from April 15, 2010 to<br />
December 1, 2010. The observation files, medical notes and certificates from the general<br />
practitioner or from the attending specialist physician were studied.<br />
Results: The patients from the studied group presented a prevalence of comorbidities of<br />
92%. The most frequent associated diseases were cardiovascular (36%). A percentage of<br />
84% of the studied patients were under constant medication.<br />
Conclusion: The risks of the patient with general disease have to be evaluated according<br />
to a detailed anamnesis corroborated with paraclinical examinations and, if needed, in<br />
collaboration with the attending doctor. The adverse effects of constant medication need a<br />
special attention, especially when certain classes of drugs interfere with dental treatments.<br />
Keywords: associate diseases, medication, prevalence, socially assisted<br />
Aranka Ilea a *,<br />
Dan Buhățel b ,<br />
Minodora Moga b ,<br />
Claudia Feurdean b ,<br />
Anca Ionel b ,<br />
Arin Sava b ,<br />
Ondine Lucaciu c ,<br />
Adina Sârbu b ,<br />
Radu Septimiu<br />
Câmpian d<br />
Oral Rehabilitation Department,<br />
Oral Health and Management<br />
of the Dental Office Department,<br />
Faculty of Dentistry, "Iuliu<br />
Hațieganu" University of<br />
Medicine and Pharmacy,<br />
Cluj-Napoca, Romania<br />
a. MD, DMD, Assistant Professor<br />
b. DMD, Assistant Professor<br />
c. DMD, Lecturer<br />
d. DMD, MD, Professor, Head of<br />
Oral Rehabilitation Department,<br />
Dean of Faculty of Dentistry<br />
Introduction<br />
The relationship between general diseases and the pathology of the stomatognathic system<br />
is multiple and bidirectional. The oral health has consequences upon the general health and the<br />
correlation between the dental foci and the cardiovascular diseases or, recently, between the<br />
parodontal disease and cardiovascular disease, is well known (1). The gravity of the parodontal<br />
disease together with the high value of the reactive C protein with high sensitivity (hPCR) could be<br />
predictive for the imminence of installation of an acute cardiovascular incident (2). Also, general<br />
diseases have an echo upon the oral health. General conditions could have oral manifestations and<br />
could influence the evolution, the manifestations and the responses to the therapy instituted in the<br />
oro-maxillo-facial diseases. In the study realized by Anders Holmlund, Gunnar Holm and Lars Lind<br />
it is shown that life expectancy is related to the number of teeth on the dental arcades: the mortality<br />
due to cardiovascular disease is higher in patients with less than 10 dental units remaining (3).<br />
Knowing the general diseases of the patient is also crucial for the dentist. The decision of the<br />
opportunity, of the time of intervention, the specific preparation and the type of applied treatment<br />
depends on the presence or lack of associated diseases, on the degree of metabolic and functional<br />
compensation or on the patient’s hemodynamic balance. In this sense it is important to evaluate<br />
the prevalence of the associated diseases for the patients who are accessing the services of dental<br />
medicine. These data are very important especially if we correlate this information with social<br />
aspects.<br />
SANODENTAPRIM is a program for socially disadvantaged patients (retired with incomes below<br />
1000 RON, retired due to illness, the unemployed, patients with disabilities and people with varying<br />
degrees of disability that require a registered nurse) and runs through the partnership between the<br />
Town Hall of Cluj-Napoca and the Faculty of Dentistry of the University of Medicine and Pharmacy,<br />
Cluj-Napoca. Under this program, patients benefit from free dental care.<br />
Received: 17 November 2013<br />
Accepted: 16 December 2013<br />
*Corresponding<br />
author:<br />
Assistant Professor Ilea Aranka,<br />
MD, DMD<br />
Oral Rehabilitation, Oral Health<br />
and Management of Dental Office<br />
Department, Faculty of Dentistry,<br />
"Iuliu Hațieganu" University of<br />
Medicine and Pharmacy,<br />
Cluj-Napoca, Romania.<br />
8, Victor Babeş st., RO-400012,<br />
Cluj-Napoca, Romania.<br />
Tel: 0746151210,<br />
Fax: 0040-0264596291.<br />
e-mail: cseh.aranka@umfcluj.ro<br />
59
oral rehabilitation<br />
Considering that the data concerning the prevalence<br />
of the general diseases in Romania is scarce and<br />
incomplete, the authors proposed to evaluate this aspect<br />
for a group of socially assisted patients who accessed<br />
the SANODENTAPRIM program. The prevalence<br />
represents the frequency of the disease cases (new<br />
and old) existing in a defined population at a certain<br />
moment – the actual prevalence – or during a certain<br />
period – the periodic prevalence. The prevalence is a<br />
specific indicator of the study of morbidity by chronic<br />
diseases. In the case of prevalence, the observation unit<br />
is the new and old cases of disease.<br />
The need for oral rehabilitation is different from one<br />
patient to another and it is determined by the gravity of<br />
the dental/parodontal diseases and the diseases from<br />
the oro-maxillo-facial area. The socially assisted patient<br />
has a low revenue and this is the reason why they are<br />
accessing the dental medicine services in the private<br />
system in a small proportion or even not at all. The<br />
social insurance system in Romania concerning dental<br />
medicine has a low budget, each insured patient having<br />
the amount of about 3 RON per year. This social program<br />
offers the possibility for these social disadvantaged<br />
groups to access free dental medicine services. The<br />
primary prevention and the early interception of these<br />
diseases of the stomatognathic system may reduce the<br />
need of complex oral rehabilitation.<br />
The objectives of the study were:<br />
1. Assessing the prevalence of comorbidities in<br />
socially disadvantaged patients who accessed the<br />
SANODENTAPRIM program between April 15, 2010<br />
and December 1, 2010.<br />
2. Evaluate the types and classes of constant<br />
medicines used by these patients.<br />
Methods<br />
The retrospective study of the prevalence of associate<br />
diseases was made upon a number of 1176 patients<br />
having accessed the SANODENTAPRIM program<br />
during the period of April 15, 2010 – December<br />
1, 2010. Observation files, the medical notes and<br />
certificates from the general practitioner or from the<br />
attending physician have been studied. These files<br />
were completed after the patient history, clinical and<br />
paraclinical examinations of the patients by the dentists,<br />
specialist doctors or students during their classes in the<br />
Oral Rehabilitation Department.<br />
Results<br />
From the group of 1176 patients, the women<br />
accounted for 59% as can be seen in Fig. 1. The age<br />
histogram shows that the majority of patients had ages<br />
between 60 and 65 years as can be noticed in Fig. 2.<br />
The actual prevalence of the associated diseases in the<br />
Figure 1.<br />
Gender distribution<br />
Figure 2.<br />
Distribution of the study<br />
group by age<br />
60 Stoma.eduJ (<strong>2014</strong>) 1 (1)
COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME<br />
Figure 3.<br />
Presence of comorbidities<br />
Figure 4.<br />
Actual comorbidities<br />
Figure 5.<br />
Cardiac diseases<br />
study group was high and accounted for 92% as shown<br />
in Fig. 3. The specific prevalence on different types of<br />
affections is represented in Fig. 4. The most frequent<br />
comorbidities were those of the cardiovascular system<br />
(36%), some of the patients presenting two or more<br />
associated diseases. Cardiovascular diseases were<br />
followed by liver diseases with a prevalence of 12%.<br />
From the cardiovascular diseases, the most prevalent<br />
was high blood pressure (HBP) (69%) as seen in Fig.<br />
5. Similar prevalence within the hepatic diseases was<br />
represented by viral hepatitis type A (19%) and type B<br />
(18%) as seen in Fig. 6. Among the most frequent allergies<br />
to drugs were the allergy to antibiotics (41%) followed<br />
by the allergy to anesthetic drugs (18%) as seen in Fig.<br />
7. Diabetes mellitus type 2 was the most frequent (63%)<br />
according to the average age of the study group as<br />
shown in Fig. 8. The most frequent endocrine disorders<br />
were represented by hypothyroidism (30%) followed<br />
very closely by hyperthyroidism (29%) as shown in<br />
Fig. 9. Hypoacusis (38%) was the most common ORL<br />
illness, but 19% of the patients from the study group<br />
suffered from ORL infectious diseases like chronic otitis,<br />
61
oral rehabilitation<br />
Figure 6.<br />
Hepatic diseases<br />
Figure 7.<br />
Drug allergies<br />
Figure 8.<br />
Diabetes mellitus<br />
chronic rhinitis or nasal sinusitis, as can be seen in Fig.<br />
10. Nephrolithiasis (47%) was the most frequent kidney<br />
disorder. 5% of the patients had chronic kidney failure<br />
as shown in Fig.11.<br />
Among respiratory disorders, the most frequent<br />
was asthma (63%), and 37% of the patients reported<br />
pulmonary tuberculosis in their medical history (Fig.<br />
12). Among the neurologic disorders the most frequent<br />
was epilepsy (72%), and 20% of the patients had stroke<br />
in their medical history as can be seen in Fig. 13.<br />
From the 1176 patients, a percentage of 84% were<br />
under constant medication for their actual disorders<br />
as seen in Fig. 14. Almost half of the drugs were<br />
represented by ß-blockers and diuretics as shown in<br />
Fig.15.<br />
Discussion<br />
From the 1176 patients, most of them were female.<br />
This shows a better compliance of women to dental<br />
treatments and a higher interest for oral health. Most<br />
of the patients were between 56 and 65 years old.<br />
The high actual prevalence of comorbidities was 92%<br />
62 Stoma.eduJ (<strong>2014</strong>) 1 (1)
COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME<br />
Figure 9.<br />
Endocrine diseases<br />
Figure 10.<br />
Otolaryngology diseases<br />
Figure 11.<br />
Kidney diseases<br />
because the majority of the subjects were elders.<br />
The total of the associated diseases was 1593,<br />
exceeding the number of patients in the study group,<br />
which shows that certain patients had one or more<br />
associated comorbidities.<br />
The specific prevalence of different disorders<br />
showed that among heart diseases, HBP presented<br />
the highest prevalence (24.84%) in comparison<br />
with coronary heart disease (3.96%) or with chronic<br />
cardiac failure (2.16%). HBP prevalence in Latin<br />
America, India and China is between 52.6% and 79.8<br />
% in an urban environment and between 42.6% and<br />
56.9% in a rural environment (4). The prevalence of<br />
cardiac failure in Eastern areas of Africa was 41%, and<br />
coronary heart disease has a prevalence of 69% in Latin<br />
America and of 75% in North Africa (5). Our results are<br />
lower than those founde in the mentioned studies,<br />
probably due to the smaller size of our sample.<br />
The prevalence of hepatic disorders was 12%<br />
from which 2.16% were infections with viral<br />
hepatitis C (VHC) and 1.92% with viral hepatitis B<br />
(VHB).<br />
63
oral rehabilitation<br />
Figure 12.<br />
Respiratory diseases<br />
Figure 13.<br />
Neurological diseases<br />
Figure 14.<br />
Permanent medication<br />
Our study shows values lower than those of the<br />
Chinese researchers. The prevalence of infection with<br />
VHB in China is ~10% at the general population level<br />
and 3.2% for VHC (6).<br />
The prevalence of Diabetes Mellitus was 9%. The<br />
prevalence of diabetes mellitus in New Zeeland is of<br />
20.9% and the study was conducted on 53911 adult<br />
patients (7).<br />
The prevalence of respiratory disorders was 6%<br />
from which 3.78% were represented by asthma. The<br />
prevalence of asthma among the Italian population in<br />
2010 was 6.6% (8).<br />
The prevalence of neurologic disorders was 2%<br />
of which 1.44% was represented by epilepsy. The<br />
values obtained are almost two times higher as the<br />
valued reported among the Turkish population.<br />
The prevalence of epilepsy in Turkey was reported<br />
between 0.08/1000 inhabitants to 8.5/1000 inhabitants,<br />
in the Arabian countries it was of 0.9/1000, and in<br />
Sudan, 6.5/1000 inhabitants (9).<br />
The discrepancies when comparing our data with the<br />
scientific literature may be due to the following factors:<br />
-the size of the study sample which was much smaller<br />
(even 53 times smaller than some studies);<br />
-not all the patients presented medical certificates to<br />
attest the associated disorders;<br />
-the patient’s omission to declare certain associated<br />
conditions (either intentionally or not);<br />
-the limited experience of the students and resident<br />
doctors in collecting the data. From the 1176 patients,<br />
64 Stoma.eduJ (<strong>2014</strong>) 1 (1)
COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME<br />
Figure 15.<br />
Permanent medication<br />
for heart disorders<br />
84% were under constant medication, which represents<br />
an additional risk for these patients in the dental office<br />
due to the adverse events of these drugs and due to<br />
the interference with dental treatments. The medication<br />
with ß-blockers, diuretics and converting enzyme<br />
inhibitors accounted for 60%. Chronic anticoagulant<br />
therapy requires specific training of the patient in<br />
collaboration with the attending doctor.<br />
Conclusion<br />
1. The prevalence of comorbidities was high (92%)<br />
among patients from the SANODENTAPRIM program.<br />
2. The specific prevalence of the disorders was smaller<br />
than the data from the scientific literature due to the size of<br />
the study group and to the way the data was collected.<br />
3. The adverse events of the chronic medication need<br />
a special attention especially if certain classes of drugs<br />
interfere with dental treatments.<br />
4. The risks of the patient with general disorders<br />
have to be evaluated after a detailed patient history<br />
corroborated with paraclinical examinations and,<br />
if needed, with the cooperation of the attending<br />
doctor.<br />
5. The risks of the patient with comorbidities in the<br />
dental office are determined by functional, metabolic<br />
and hemodynamic imbalances.<br />
6. The need of specific training of the patient<br />
with comorbidities in order to correctly follow an<br />
anticoagulant treatment for the removal of dental foci<br />
or for performing other treatments.<br />
Bibliography<br />
1. Blaizot A, Vergnes JN, Nuwwareh S, Amar J, Sixou M. Periodontal<br />
diseases and cardiovascular events: metaanalysis of observational<br />
studies. Int Dent J. 2009; 59(4):197-209.<br />
2. Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR. C-reactive<br />
protein and parental history improve global cardiovascular risk<br />
prediction: The Reynolds Risk Score for men. Circulation. 2008;<br />
118 (22):2243-2251<br />
3. Holmlund A, Holm G, Lind L. Number of teeth as a predictor of<br />
cardiovascular mortality in a cohort of 7,674 subjects followed for<br />
12 years. J Periodontol. 2010; 81(6):870-876.<br />
4. Prince MJ, Ebrahim S, Acosta D, Ferri CP, Guerra M, Huang Y, Jacob<br />
KS, Jimenez-Velazquez IZ, Rodriguez JL, Salas A, Sosa AL, Williams<br />
JD, Gonzalez-Viruet M, Jotheeswaran AT, Liu Z. Hypertension<br />
prevalence, awareness, treatment and control among older<br />
people in Latin America, India and China: a 10/66 cross-sectional<br />
population-based survey. J Hypertens. 2012; 30(1):177-187.<br />
5. Magaña-Serrano JA, Almahmeed W, Gomez E, Al-Shamiri M,<br />
Adgar D, Sosner P, Herpin D, I PREFER Investigators. Prevalence<br />
of heart failure with preserved ejection fraction in Latin American,<br />
Middle Eastern, and North African Regions in the I PREFER study<br />
(Identification of Patients With Heart Failure and PREserved<br />
Systolic Function: an epidemiological regional study). Am J Cardiol.<br />
2011;108(9):1289-1296.<br />
6. Tanaka M, Katayama F, Kato H, Tanaka H, Wang J, Qiao YL, Inoue<br />
M. Hepatitis B and C virus infection and hepatocellular carcinoma<br />
in China: a review of epidemiology and control measures. J<br />
Epidemiol. 2011; 21(6):401-416.<br />
7. Thornley S, Marshall R, Jackson G, Smith J, Chan WC, Wright<br />
C, Gentles D, Jackson R. Estimating diabetes prevalence in South<br />
Auckland: how accurate is a method that combines lists of linked<br />
health datasets? N Z Med J. 2010; 123(1327):76-86.<br />
8. de Marco R, Cappa V, Accordini S, Rava M, Antonicelli L, Bortolami<br />
O, Braggion M, Bugiani M, Casali L, Cazzoletti L, Cerveri I, Fois AG,<br />
Girardi P, Locatelli F,Marcon A, Marinoni A, Panico MG, Pirina P,<br />
Villani S, Zanolin ME, Verlato G, GEIRD Study Group. Trends in the<br />
prevalence of asthma and allergic rhinitis in Italy between 1991<br />
and 2010. Eur Respir J. 2012; 39(4):883-892.<br />
9. Angalakuditi M, Angalakuditi N. A comprehensive review of the<br />
literature on epilepsy in selected countries in emerging markets.<br />
Neuropsychiatr Dis Treat. 2011; 7:585-597.<br />
65
Treating The Triad: Teeth, Muscles, TMJs<br />
Giuseppe Cozzani<br />
Quintessence Publishing Company, Inc<br />
Language: English<br />
408 pages, 1707 illustrations<br />
ISBN: 978-88-7492-152-2<br />
Publication Date: March, 2011<br />
Price: 248.00 €<br />
If we carefully follow the specialty literature we'll<br />
find that over time many books which addressed the<br />
function and dysfunction of TMJ were published.<br />
The interest raised by this book written by Dr.<br />
Giuseppe Cozzani, specialist in orthodontics, is to<br />
discuss the relationship between teeth, muscles and<br />
TMJ focusing on the diagnosis, on the principles<br />
of maintaining or recovery of the stomatognathic<br />
system function as part of orthodontic treatment,<br />
particularly in dealing with facial pain and postural<br />
problems. The author achieves a systematic<br />
approach of this group of disorders planning the<br />
treatment, from the simpler to the most complex<br />
cases, in two phases: Musculoarticular Therapy<br />
and Orthodontic Occlusal Finishing.<br />
The book contains 408 pages and is divided into<br />
six distinct chapters.<br />
The first chapter, "Basic Concepts", introduces<br />
us in the anatomy and pathophysiology of the<br />
stomatognathic system for a better understanding<br />
of the philosophy of the Temporomandibular<br />
Disorders (TMDs) treatment, presenting us the<br />
temporomandibular joints, the true articulating<br />
surface, the skeletal muscle apparatus, the basic<br />
muscle anatomy, the axial alignment of joint<br />
structures, the old and new concept of centric<br />
relation, the physiology of jaw opening and closure,<br />
the anatomical parts involved in mastication, the<br />
tooth dynamics and esthetics .<br />
In the second chapter, "Diagnosis: Patient Records",<br />
the patient assessment, the basic medical history,<br />
clinical records, clinical analysis, medical imaging,<br />
imaging diagnostics of TMJs, the importance of<br />
checking 3D mandibular movements, TMJ palpation<br />
and auscultation and diagnostic - therapeutic manual<br />
techniques are presented.<br />
After the completion of all the examinations<br />
and tests, the clinician should be able to reach<br />
a clear diagnosis and plan in the next chapter,<br />
"Phase I: Musculoarticular Therapy" that describes<br />
considerations on compromise and adaptability,<br />
coordination between articular eminence<br />
inclination, cusp inclination and incisal guidance,<br />
assessment of changes in pretreatment and<br />
posttreatment condylar position, bite registration,<br />
splints, therapeutic procedure sequence,<br />
pain, TMD and postural disorders, occlusion,<br />
posture and MRI, musculodental extracapsular<br />
pathology, intermediate pathology, intracapsular<br />
pathology: dislocation with and without reduction,<br />
intracapsular pathology: destruction, PHASE<br />
I: virtual ARS musculoarticular rehabilitation<br />
treatment and intracapsular pathology: condylar<br />
hypermobility and ligamentous laxity .<br />
The author also discusses Phase II: Orthodontic<br />
Occlusal Finishing, its principal aim being to<br />
obtain a correct interarch relationship in harmony<br />
with the muscle and joints considering other joints<br />
and the TMJ, temporomandibular disorders in<br />
children including case presentations as well as the<br />
innovative orthodontic treatment of teeth, muscles<br />
and temporomandibular disorders.<br />
For a better understanding, the text comes<br />
with 1707 illustrations, diagrams, MRI and clinical<br />
photographs, constituting an essential reference<br />
for the orthodontists interested in the treatment of<br />
temporomandibular disorders (TMDs).<br />
Books Review<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).bookreview.1<br />
Florin Eugen<br />
Constantinescu<br />
DDS, PhD Student<br />
Holistic Dental Institute<br />
Bucharest, Romania<br />
E-mail:<br />
dr.florin.constantinescu@gmail.com<br />
67
Percrestal Sinuslift: From Illusion to Reality<br />
Books Review<br />
Florin Eugen<br />
Constantinescu<br />
DDS, PhD Student<br />
Holistic Dental Institute<br />
Bucharest, Romania<br />
E-mail:<br />
dr.florin.constantinescu@gmail.com<br />
George Watzek<br />
Quintessence Publishing Company, Inc<br />
Language: English<br />
248 pages, 535 illustrations, DVD included<br />
ISBN: 978-1-85097-222-8<br />
Publication Date: December, 2011<br />
Price: 128.00 €<br />
Minimally invasive surgical techniques are<br />
used more and more in medicine. Based on the<br />
popularity gained by their introduction in medicine,<br />
the 11 contributors of Bernhard Gottlieb School of<br />
Dentistry at the Medical University of Vienna under<br />
the direction of Professor George Watzek give us<br />
a guide for transcrestal sinus floor elevation in oral<br />
implantology of the posterior maxillary. The book<br />
is divided into 12 chapters.<br />
In the first chapter, "Maxillary sinus anatomy and<br />
physiology", the authors present the morphologic<br />
variability, the innervation and blood supply, the<br />
sinus ventilation and the mucociliary activity.<br />
The second chapter, "Biological Aspects of<br />
sinus augmentation", describes the histology<br />
of bone regeneration in the augmented sinus,<br />
regeneration and repair, mechanically stable<br />
conditions: a key factor of bone regeneration,<br />
angiogenesis: a key factor of bone regeneration,<br />
configuration changes of the augmented sinus,<br />
form follows function, augmented sinus and<br />
principle of guided bone regeneration. Bone<br />
morphogenetic proteins: osteoinductive growth<br />
factors, platelet-derived growth factor-BB and<br />
PRP: non - osteoinductive growth factors, cell<br />
therapy in sinus augmentation, compromised<br />
bone regeneration: impact on graft consolidation<br />
and current knowledge and future perspectives<br />
are presented.<br />
In Chapter 3, "Generally accepted procedures"<br />
and in Chapter 4, "Status quo analysis", techniques<br />
of bone instrumentation, techniques for elevating<br />
the sinus membrane and methods of assessing the<br />
membrane integrity are described.<br />
Chapter 5, "Biomechanics of transcrestal sinus<br />
membrane elevation", describes transcrestal<br />
membrane elevation techniques, the<br />
biomechanical properties of the maxillary sinus<br />
membrane, the transmission of elevation forces and<br />
the impact of internal sinus membrane elevation<br />
anatomy and patterns with multiple osteotomies.<br />
Chapter 6, "Radiologic assessment", describes<br />
the general and specific preoperative assessment,<br />
the intraoperative imaging and the postoperative<br />
imaging.<br />
Chapter 7, "Preoperative measures for assuring<br />
success", contains local preoperative diagnostic<br />
work-up , local treatment modalities and the general<br />
preoperative work-up.<br />
Chapter 8, "Transcrestal osteotomy: technological<br />
considerations and options for bone perforation",<br />
presents the osteotome technique, the drill<br />
osteotomy technique, the ultrasonic technique<br />
and the laser osteotomy technique.<br />
Chapter 9, "Insights into sinus augmentation:<br />
preclinical and clinical research", outlines general<br />
aspects of sinus augmentation and terminology,<br />
preclinical and clinical models for investigating graft<br />
consolidation, graft consolidation gradient (GCG),<br />
injectable grafts, combination of grafts and growth<br />
factors and combination of grafts and cells.<br />
In Chapter 10, "Clinical experiences using innovative<br />
equipment", the preoperative planning, trephination<br />
of the bony sinus floor, liquid-pressure-mediated<br />
membrane elevation, intraoperative evidence of<br />
iatrogenic membrane perforation, implant placement<br />
and postoperative procedures, clinical results and<br />
clinical considerations are described.<br />
In Chapter 11 the "Compromised results and<br />
complications" are analyzed: sinus membrane injury<br />
and its consequences, dealing with a perforated<br />
sinus membrane, problems of membrane elevation,<br />
problems of grafting, implant placement and<br />
potential problems of maxillary sinusitis.<br />
In the last chapter, "Summary and Outlook", Professor<br />
Watzek makes a synthesis on transcrestal sinus floor<br />
elevation in terms of a flapless minimally invasive<br />
procedure, concluding that for a good success of the<br />
method we must use three-dimensional X-ray imaging<br />
and a minimum volume of elevating liquid.<br />
This book is an excellent guide for both the<br />
experienced oral implantologist and the beginner,<br />
who want more information on sinus augmentation.<br />
The text contains 535 color illustrations that make<br />
it easy to follow. It is accompanied by a DVD<br />
- ROM including images of percrestal sinuslift<br />
surgery using the pressure gel technique. The<br />
book of Professor Watzek is a documentary source<br />
indispensable for any oral implantologist that<br />
wants to successfully practice the technique of<br />
transcrestal sinus floor elevation.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).bookreview.2<br />
68 STOMA.EDUJ (<strong>2014</strong>) 1 (1)
Photography in Dentistry:<br />
Theory and Techniques in Modern Documentation<br />
Pasquale Loiacono, Luca Pascoletti<br />
Quintessence Publishing Company, Inc<br />
Language: English<br />
336 pages, 847 color illustrations<br />
ISBN: 978-88-7492-169-0<br />
Publication Date: February, 2012<br />
Price: 122.00 €<br />
Nowadays, when dentistry resorts more and<br />
more to the concept of evidence-based medicine,<br />
the dentist uses images to communicate with<br />
the patient or with the dental technician, in<br />
order to record the clinical situation in the<br />
pre-treatment phase, for medical or forensic<br />
considerations or for a scientific presentation.<br />
As dental photography does not yet have a set<br />
of standards allowing reproducibility for clinical<br />
and scientific documentation, the authors<br />
present, in 13 chapters, the guidelines for<br />
modern photographic documentation.<br />
The book is structured in two parts: “Theory”<br />
and “Techniques”.<br />
In the first part, “Theory”, divided in nine<br />
chapters, the general principles, the optical<br />
system, the exposure concepts, the principles of<br />
digital photography, the role of photography in<br />
clinical practice, the settings of the camera for<br />
dentistry, the orthography of images, the flash<br />
units and the photographing radiographs are<br />
presented.<br />
The second part, “Techniques”, is divided in<br />
four chapters. The authors eloquently describe<br />
the equipment and accessories, and the extraoral<br />
and intraoral settings.<br />
In the chapter “Equipment and Accessories”,<br />
cameras and accessories (intraoral mirrors,<br />
cheek retractors and additional accessories),<br />
image quality and synergy between practitioner<br />
and assistant are presented.<br />
The following chapters describes “Extraoral<br />
Series” and “Intraoral Series” suggestively<br />
illustrating all the norms and positions which<br />
must be known for an eloquent photographic<br />
documentation.<br />
The last chapter includes documentary<br />
photography for orthodontics, periodontics,<br />
prosthetics, conservative dentistry and the<br />
communication with the dental technician.<br />
In its 336 pages, the book contains 847 highquality<br />
illustrations, being a necessary guide<br />
for any dentist who aims to succeed in dental<br />
photography.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).bookreview.3<br />
Books Review<br />
Florin Eugen<br />
Constantinescu<br />
DDS, PhD Student<br />
Holistic Dental Institute<br />
Bucharest, Romania<br />
E-mail:<br />
dr.florin.constantinescu@gmail.com<br />
69
Books Review<br />
Péri-implantites<br />
Jean-Louis Giovannoli, Stefan Renvert<br />
Quintessence International<br />
Language: French<br />
272 pages, 800 iIlustrations<br />
ISBN :978-2-912550-96-5<br />
Publication Date: May, 2012<br />
Price:169.00 €<br />
Today, to practice oral implantology, it is<br />
essential to learn to identify the factors that<br />
prevent infectious risk and the appearance of<br />
peri-implantitis. Thirty years after the first clinical<br />
use of osseointegrated implants, peri-implant<br />
diseases are beginning to be identified.<br />
The book “Peri-implantitis” is structured in 8<br />
chapters: “The Etio-Pathogenesis”, “Diagnosis”,<br />
“Prevalence”, “Early Infection”, “Risk Factors”, “Treatment”,<br />
“The Mucosal Terms” and “Maintenance”.<br />
In “The Etio-Pathogenesis”, the bacterial<br />
flora, histopathology and occlusal overload are<br />
presented. In “Diagnosis” the author describes<br />
diagnostic methods of clinical examinations, periimplant<br />
probing, bleeding on probing, Rx exams,<br />
laboratory tests and differential diagnosis for<br />
clinical forms.<br />
The chapter “Prevalence” is a systematic review<br />
of prospective studies published on implant<br />
complications and peri-implantitis.<br />
In the chapter “Early infection” the authors<br />
present the etiology, diagnosis, prevalence and<br />
treatment.<br />
In the chapter “Risk factors” the general factors<br />
(oral hygiene and cooperation of the patient,<br />
state of periodontal health, tobacco use, genetic<br />
character, diabetes, alcohol consummation,<br />
psychological profile and stress) and local factors<br />
(the accessibility to hygiene and shape of dentures,<br />
the remaining teeth with periodontitis pocket<br />
depth, peri-implant surface state, transmucosal<br />
implants and parts, the type of implant and of<br />
the connection, the presence of a submucosal<br />
foreign body, endodontic infections in teeth<br />
neighboring the presence of keratinized mucosa)<br />
are mentioned.<br />
The chapter “Treatments” explains the choice<br />
of different modes of treatment of peri-implant<br />
diseases, treatment of mucositis and periimplantitis,<br />
non-surgical and surgical, and a<br />
literature review on the means of treatment.<br />
The chapter “Mucosal conditions” shows the<br />
importance of the height of keratinized tissue<br />
on the quality of hygiene and the onset of<br />
recession.<br />
In the chapter “Maintenance” the supportive<br />
treatment, maintenance organization - personal<br />
and professional, frequency of maintenance<br />
sessions and instrumentation are described.<br />
The authors, Jean-Louis Giovannoli and Stefan<br />
Renvert summarize the current knowledge on<br />
the etiology, clinical features and diagnosis of<br />
peri-implantitis, develop therapeutic proposals,<br />
based on very recent scientific and clinical<br />
achievements. They also offer diagnostic and<br />
therapeutic protocols for the management<br />
of infection and the conservation of the<br />
implant, essential to all dentists practicing oral<br />
implantology .<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).bookreview.4<br />
Marian-Vladimir<br />
Constantinescu<br />
DDS, PhD<br />
Department of Prosthetic Dentistry<br />
“Carol Davila” University<br />
of Medicine and Pharmacy<br />
Bucharest, Romania<br />
Email:<br />
dr.vladimir.constantinescu@gmail.com<br />
70 STOMA.EDUJ (<strong>2014</strong>) 1 (1)
Traitement des classes II<br />
De la prévention à la chirurgie<br />
Antonio PATTI<br />
Quintessence International<br />
Language: French<br />
ISBN: 978-29-1255-066-8<br />
Publication Date: October 1, 2010<br />
496 pages, 1890 illustrations<br />
Price: 282.00 €<br />
Dr. Antonio Patti, in collaboration with the best<br />
specialists in the field wrote a modern orthodontic<br />
book, which meets the requirements of clinicians who<br />
want a comprehensive overview of Angle Class II.<br />
The book is structured in three parts: "Growth",<br />
"Diagnosis" and "Treatments".<br />
The first part the following aspects are described:<br />
the cephalic growth in Angle Class II, the development<br />
of the cephalic skeleton and conceptual basis of<br />
craniofacial architectural analysis.<br />
The second part develops the "Diagnosis" in five<br />
chapters. The chapter "Aetiology: The Class II Medical<br />
syndrome" describes the evolution of the diagnostic<br />
approach in orthodontics. The chapter "Clinical Forms<br />
and Classification of Class II" describes the orthopedic<br />
Class II, the prognathic maxilla, the retrognathic<br />
mandible, dental Class II and Class II mandibular<br />
position. The chapter "Clinical Examination and<br />
Examination of Models”, describes the extraoral and<br />
intraoral examination, the examination of models and<br />
clinical and instrumental examination. The chapter<br />
"The Radiological Examination and Complementary"<br />
points at radiological examinations, ENT<br />
examinations, postural examination, examination<br />
models mounted on an articulator and mandibular<br />
position indicator (MPI) and axiography. The<br />
chapter "Cephalometric Diagnosis" describes the<br />
teleradiographic cephalometric exam according to<br />
Ricketts - Gugino in "diagnostic bioprogressive flow".<br />
The third part focuses on "Treatments" in<br />
three directions: "Interceptive, Orthopedic and<br />
Orthodontic Treatment Planning", "Surgical Treatment<br />
Planning" and "Contention and Recurrence".<br />
The chapter "Interceptive, Orthopedic and<br />
Orthodontic Treatment Planning" describes<br />
diagnostic and therapeutic flow, interceptive<br />
treatment, orthopedic treatment and multi-attaches<br />
orthodontic treatment.<br />
In "Preventive Treatment in Deciduous Dentition<br />
and Mixed Dentition Interceptive" the author<br />
describes the functional education devices and<br />
mode of action of classes II in combination with<br />
exercises education. The chapter "The correction of<br />
transverse" describes abnormalities, diagnosis and<br />
treatment of transverse direction, while "Orthopedics<br />
and mandibular growth" describes biological and<br />
therapeutic peculiarities. The chapter "The functional<br />
and orthopedic therapeutic" describes and illustrates<br />
the rigid monoblock activators, enhancers and the<br />
elastic timing and functional orthopedic treatment.<br />
The chapter "The Distal Active Concept (DAC)",<br />
is a presentation of orthopedic devices together<br />
with indications and contraindications and modes<br />
of therapeutic action. In “Forward Activators” the<br />
authors describe activators for protrusion. The<br />
chapter "Processing Vertical " describes clinical<br />
forms, diagnosis and treatment. The chapter "Multi-<br />
Attaches Treatment" shows the visualization of<br />
treatment goals. The chapter "Treatment of Class II<br />
with Reciprocal Mini Chin " describes reciprocal mini<br />
chin while "Rational Use of Intermaxillary Elastic"<br />
shows generalities on elastics and Angle Class II<br />
elastic.<br />
The chapter "Correction of Class II Molar by<br />
Decline" shows situations necessitating a Class II<br />
molar distalization and appliances. The chapter<br />
"Using Miniscrews as Anchor" describes use of<br />
miniscrews in the treatment of Angle Class II.<br />
The chapter "Classes II and TMJ" shows the joint<br />
classification, clinical verification of joint position,<br />
diagnosis and treatment.<br />
The chapter "Surgical Treatment Planning" shows<br />
diagnosis and treatment planning. In the chapter<br />
"Surgical Treatment of Class II" surgical options and<br />
clinical example are presented.<br />
The section "Joint Diseases" shows technical<br />
mandibular advanced by the retrocondylar cartilage<br />
graft. In the chapter "Contention and Recurrence"<br />
restraint and recurrence and type of malocclusion<br />
are shown.<br />
Dr. Antonio Patti and collaborators have<br />
succeeded to develop a comprehensive approach<br />
to diagnosis and treatment of different types of Class<br />
II. A well documented reference book, it details all<br />
therapeutic options, beginning with the diagnostic<br />
analysis and ending with the treatment of Class II,<br />
an overall summary of these malocclusions with<br />
a predominantly clinical focus which meets the<br />
requirements of orthodontists.<br />
https://doi.org/10.25241/stomaeduj.<strong>2014</strong>.1(1).bookreview.5<br />
Books Review<br />
Marian-Vladimir<br />
Constantinescu<br />
DDS, PhD<br />
Department of Prosthetic Dentistry<br />
“Carol Davila” University<br />
of Medicine and Pharmacy<br />
Bucharest, Romania<br />
Email:<br />
dr.vladimir.constantinescu@gmail.com<br />
71
Author’s Guidelines<br />
72<br />
1. Submitting the Article<br />
All articles will be accompanied by the<br />
signed copyright form which can be returned<br />
by fax, e-mail (as scanned documents). All the<br />
responsibility for the originality of the sent<br />
material belongs to the author(s) alone.<br />
Each article will be evaluated by the peer-review<br />
committee composed of two independent peerreviewers,<br />
in a blinded fashion, according to the<br />
peer-review protocol.<br />
All articles will be sent to the editor-in-chief at<br />
the following e-mail address:<br />
stomatology.edu@gmail.com<br />
2. Articles sent for publishing<br />
<strong>Stomatology</strong> <strong>Edu</strong> <strong>Journal</strong> (Stoma <strong>Edu</strong> J) publishes:<br />
- original articles;<br />
- reviews;<br />
- case reports;<br />
- consensus declaration coming from an association<br />
or from a group of specialists;<br />
- letters to the editor.<br />
All articles must be between 10.000 and<br />
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to the editor can have a maximum length of 2500<br />
characters with spaces. Letters to the editor can<br />
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the journal or it can represent original scientific<br />
contributions or events news/presentations etc.<br />
of interest for the reader.<br />
If, following the peer-review process, the<br />
article requires only minor changes (language<br />
changes etc.) then the manuscript is accepted<br />
for publication in its revised form without further<br />
input from the author. In case the changes are<br />
considered more important (scientific errors or<br />
an incorrect use of the language that can affect<br />
the quality of the scientific message) the author<br />
will be contacted by a member of the editorial<br />
committee and it will only be published after<br />
he approves the changes considered necessary<br />
by the peer reviewers. In some cases, based on<br />
the written approval of the author(s), the peerreviewers<br />
and the chief-editor or the publisher<br />
the article may be published alongside the<br />
comments of the reviewer(s).<br />
3. Authors<br />
Each author must be able to prove his active<br />
participation in the study by contributing to the<br />
concept, protocol, data gathering or analysis,<br />
their interpretation or by critically revising<br />
the manuscript. Any other persons who have<br />
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or colleagues, will be mentioned in the<br />
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4. Permissions and Ethics<br />
For citations, tables, figures etc. which are not<br />
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For human and animal studies, the authors<br />
must have obtained the approval of the ethics<br />
committee from the University/Institute/etc.<br />
where the study was done.<br />
5. Writing the article<br />
The article must be written in conformity with<br />
the general recommendations of the ICMJE (www.<br />
icmje.org). The journal publishes articles written<br />
in English. The articles must be sent either as a<br />
Microsoft Word 2000 document (*.doc) or as a<br />
Microsoft Word 2003 document (*.docx). The<br />
article will be written using Arial font a size 12 for<br />
the characters with one and half (1 1/2) spaces<br />
between paragraphs. The manuscript must be sent<br />
in its final form. The pages will be numbered with<br />
the manuscript containing the following sections:<br />
Title, Authors, Abstract, keywords, the text of<br />
article, thanks and/or contributions, bibliography,<br />
the figure and the table legend. Please also check<br />
the Author’s Guidelines for the Abstract.<br />
A. The Title of the manuscript will have a<br />
maximum of 100 characters without spaces and<br />
will represent the main idea of the article.<br />
B. The author(s) will send their full name(s) and<br />
surname(s), the highest academic position, their<br />
full tittles and their affiliations. The correspondent<br />
author will send his/her full name and surname,<br />
the highest academic position, his/her full title,<br />
his/her affiliation, his/her institution address, his/<br />
her telephone, fax and e-mail. The authors will<br />
send this information in the same format as that<br />
in published articles.<br />
C. The abstract can have a maximum 250<br />
words. After the abstract, the author(s) must<br />
mention a maximum of 5 keywords.<br />
The abstract for Original Scientific Articles<br />
should be no more than 250 words using the<br />
following structure: Introduction; Methodology;<br />
Results; Conclusion.<br />
The abstract for Review Articles should be no<br />
more than 250 words with the authors covering<br />
all the following information regarding the<br />
subject: Background, Objective, Data Sources,<br />
Data Selection, Data Extraction, Data Synthesis<br />
(in one to three paragraphs without using the<br />
subtitles mentioned here).<br />
The abstract for Case Reports should be<br />
no more than 250 words using the following<br />
structure: Aim, Summary and Key learning<br />
points: provide up to 5 short statements of the<br />
report.<br />
The abstract for Clinical Articles should be<br />
no more than 250 words using the following<br />
structure: Aim, Methodology, Results and<br />
Conclusions. Abbreviations are not accepted in<br />
the title or the abstract.<br />
D. The Article Text<br />
For original articles:<br />
Introduction - a presentation of the most<br />
important aspects in the studied domain without<br />
doing a review of the literature. The purpose of<br />
this part is to present and backup the hypothesis<br />
on which the study was based.<br />
Methods - this section will include all required<br />
information so that the reader can verify the<br />
validity of the study including, but not limited<br />
to, subjects, measurements, statistics and ethics.<br />
The methods used should be discussed (why<br />
the methods have been chosen, which the<br />
limitations/advantages). A paragraph about the<br />
statistical analysis is required as well.<br />
Results - the results of the study will be<br />
STOMA.EDUJ (<strong>2014</strong>) 1 (2)
presented in a descending order of importance.<br />
An interpretation of the results will not be done<br />
in this section.<br />
Discussion - the authors will present the way<br />
the results backup the original hypothesis, as<br />
well as the way in which the results are backed<br />
up or contradicted by the published literature. A<br />
paragraph must be dedicated to presenting the<br />
limitations of the study.<br />
Conclusion - The conclusion presents the<br />
implications of this latest work. In addition,<br />
authors may consider discussing future plans or<br />
recommendations for future research etc.<br />
For all other types of articles we recommend<br />
the use of a clear structure based on sections<br />
and sub-sections.<br />
E. Bibliography<br />
Bibliography will be written using the Vancouver style.<br />
The references will be written using the<br />
Vancouver style. The references will be<br />
numbered, in the order they appear in the text as<br />
such: “ (1). All sources found in the text must be<br />
present in the bibliography and all the papers<br />
mentioned in the bibliography must appear<br />
in the text. All journals will be abbreviated<br />
according to international standards. Information<br />
obtained from sources which are not published<br />
yet, but accepted for publishing will include at<br />
the end of the reference the mention “in print”<br />
between round parentheses. If the cited results<br />
have not been published yet the mention will<br />
be “personal communication” written in the<br />
text of article between round parentheses. Only<br />
references read by the authors of the article will<br />
be cited.<br />
An original article will have at most 50<br />
references, a review will have at most 100<br />
references, a letter to the editor 5 references,<br />
whilst all other types of articles will have the<br />
minimum number of references required.<br />
Examples of correct citations:<br />
- For journals: author(s), article title, abbreviated<br />
name of the journal, year, volume, number, first<br />
and last page. Example:<br />
Roulet JF, Geraldeli S, Sensi L, Özcan M. Relation<br />
between handling characteristics and application<br />
time of four photo-polymerized resin composites.<br />
Chin J Dent Res. 2013;16(1):55-61.<br />
For articles which aren’t published in print yet<br />
(example):<br />
Evans JD, Gomez DR, Chang JY, Gladish GW,<br />
Erasmus JJ, Rebueno N, Banchs J, Komaki R,<br />
Welsh JW. Cardiac 18F-fluorodeoxyglucose<br />
uptake on positron emission tomography after<br />
thoracic stereotactic body radiation therapy.<br />
Radiother Oncol. 2013; doi: http://dx.doi.<br />
org/10.1016/j.radonc.2013.07.021.<br />
- For books: author(s), title, city, publishing<br />
house, year. Example:<br />
Cheers B, Darracott R, Lonne B. Social care<br />
practice in rural communities. Sydney: The<br />
Federation Press; 2007.<br />
- For book chapters: chapter author(s), chapter<br />
name, editor(s), book name, edition, city,<br />
publishing house, year. Example:<br />
Rowlands TE, Haine LS. Acute limb ischaemia.<br />
In: Donnelly R, London NJM, editors. ABC<br />
of arterial and venous disease. 2nd ed. West<br />
Sussex: Blackwell Publishing; 2009.<br />
- For websites: Author(s) (if known). Webpage<br />
name [internet]. Year [date of last change, date<br />
of citation]. Exact web address. Example:<br />
Atherton, J. Behavior modification [Internet].<br />
2010 [updated 2010 Feb 10; cited 2010 Apr 10].<br />
Available from: http://www.learningandteaching.<br />
info /learning/behaviour_mod.htm<br />
The references will be placed in the text in the<br />
following way: “leading to lymphocytosis (1)”.<br />
6. Curriculum Vitae – Ultra Short version<br />
Following the bibliography please also provide<br />
a brief presentation of the first author and his<br />
contribution in the field, of maximum 130 words<br />
(namely the USV Curriculum Vitae thereof, with a<br />
3.5x4.5 cm color photo).<br />
7. Figures, Images, Tables<br />
Figures and Images will be drawn<br />
professionally and sent in separate file(s) as<br />
jpeg, tiff or png files at a quality of a minimum<br />
of 300 dpi at a minimum size of 10 cm by<br />
10cm (bigger figures can be sent if the author<br />
considers it necessary). In the text, each figure<br />
must be represented by a number, a title and<br />
a description. The authors will indicate where<br />
should the figure be placed in the text. All<br />
images or figures must come from the author’s<br />
personal collection or the author must have<br />
rights to publish the image or figure. We do<br />
not accept images or figures taken from the<br />
Internet.<br />
Tables will be included in the text and each<br />
table will have a number and a short description<br />
if required.<br />
8. Ownership Rights<br />
By sending the article for publication the<br />
author(s):<br />
- take full responsibility for the scientific<br />
content of the text and for the accuracy of the<br />
send data;<br />
- become (co)author(s) of the manuscript (all<br />
further plagiarism accusation are addressed<br />
solely to the author(s) who signed the<br />
manuscript);<br />
- declare they are the rightful owners of the<br />
images, figures and/or information sent for<br />
publishing and that they have the permission to<br />
publish all the materials for which they do not<br />
own the intellectual property rights;<br />
- declare that the message/content of the<br />
manuscript is not influenced in anyway by<br />
commercial interests/previous engagements/<br />
any sort of relations with other people or companies;<br />
- transfer all rights for the manuscript to Media<br />
System Communications.<br />
9. Other<br />
Previously mentioned limitations can be<br />
ignored in special cases with the agreement of<br />
the chief-editor and/or the publisher.<br />
All published materials cannot be returned.<br />
The editorial office reserves the right to publish<br />
the materials in any other journals/magazines.<br />
The official recommendations for medical<br />
journals can be consulted at : www.icmje.org.<br />
Not taking into consideration the reco mmendations<br />
mentioned before can lead to delay in<br />
publishing the materials or may lead to not publishing<br />
the article.<br />
STOMA.EDUJ (<strong>2014</strong>) 1 (2) 73
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