stomatology edu journal

Volume 1 issue 1 spring 2014

a world of educational resources for each practiceJ “Îndrumar pentru examenul practic în specialitatea ORL și chirurgie cervico-facială”

Apariție: 2013 Autori: Prof. Dr. Romeo Călărașu, Dr. Tiberiu Dimitriu, Dr. Daniela Safta Coautori: Dr. Ileana Linaru și Dr. Loredana Mitran Adresare: medici primari și specialiști ORL, chirurgi, studenți, rezidenți

“Numeroasele examene şi concursuri În acest context, ne-am gândit să pe specialităţile cu profi l pe care trebuie să le susţină fi ecare venim în ajutorul colegilor mai tineri, chirurgical, implică, obligatoriu, medic după terminarea facultăţii cu experienţa noastră, acumulată o probă practică, cu diferite solicită din partea fi ecărui cadru în decursul anilor, în activitatea operaţii, ce trebuie susţinută medical o susţinută şi continuă clinică, dar şi în pregătirea pe care şi practicată de către candidat.” documentare. În sprijinul acestora, noi înşine a trebuit să o facem, periodic s-au publicat diferite când am fost nevoiţi să susţinem Prof. Dr. Romeo Călăraşu, materiale, ce au folosit la buna diferite examene şi concursuri. Dr. Daniela Safta, desfăşurare a acestor examene. Tematica, stabilită de minister, Dr. Tiberiu Dimitriu

Cartea are 320 de pagini și o grafi că excepțională, desenele, fi gurile și imaginile vorbind de la sine. Pentru a comanda cartea, contactați-ne la tel. 031 - 432 82 30 sau la adresa de e-mail: offi [email protected]

MEDIA SYSTEMS COMMUNICATION Electromagnetica Business Park, Calea Rahovei nr. 266-268, Corp 2, Etaj 2, Cam. 22-23, 050912, Sector 5, Bucuresti, Romania Telefon/Fax: 031 - 432 82 30; E-mail: offi [email protected]; Website: www.medsysc.com Editorial 6 Why Peer Review? Jean-François Roulet Continuing Medical Education Program – a professional estimate in dentistry practice J Rolf Ewers Plea for a holistic approach in stomatology Vasile Astărăstoae Volume 1, Issue 1, Why a new journal? Pages 1-76, Spring, 2014 Marian-Vladimir Constantinescu 10 FDI Eastern Europe Continuing Education Programme Prevention for the Elderly Patients Alexandre Mersel

Cariology 12 REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE MATERIALS IN THE STEPWISE EXCAVATION TECHNIQUE CEO Sorin Andrian, Gianina Iovan, Simona Stoleriu, Claudiu Topoliceanu, Andrei Georgescu Alina NICOLEANU Business Development Manager Lavinia IOVIȚĂ 18 Orthodontics Production Manager NONEXTRACTION METHODS Bogdan LABER FOR CREATING SPACE IN ORTHODONTIC THERAPY Events Manager Mariana Păcurar, Ana Maria Jurcă, Doru Roman, Eugen Bud, Irina Nicoleta Zetu, Ioana Vâţă Aurelian GHEBAUR Art Director Periodontics Cristian CONSTANTINESCU 22 Salivary and serum enzymes as diagnostic biomarkers Sales & Marketing Manager in patients with periodontal disease Ionuţ NICOLEANU Daniela Miricescu, Alexandra Totan, Bogdan Calenic, Brânduşa Mocanu, Maria Greabu Administrative Manager Mihai MĂGEANU occlusion 28 ETIOLOGICAL CONSIDERATIONS IN BRUXISM Subscriptions Cristiana Ileana Croitoru, Iulia Roxana Marinescu, Emma Cristina Drăghici, Tel./Fax: 031.432.82.30 Sanda Mihaela Popescu, Monica Scrieciu, Veronica Mercuț E-mail: [email protected] orofacial pain 33 Headache - an interdisciplinary problem. Address: Aspects of dental functional diagnostics and therapy SC MEDIA SYSTEMS COMMUNICATION SRL, Georg B. Meyer, Olaf Bernhardt, Arnd Küppers Electromagnetica Business Park, Rahovei Street, no 266-268, 2nd Building, 2nd Floor, 22-23 Offices, 5 Sector, Bucharest, Romania, 41 overdenture Tel./Fax: 031 - 432 82 30 Functional evaluation of implant supported prostheses E-mail: [email protected] Gianluca Martino Tartaglia, Chiarella Sforza www.mediasyscom.ro 47 GERODONTOLOGY Copyright © 2014 Factors affecting recent dental services utilisation MEDIA SYSTEMS COMMUNICATION by an urban older population in Athens The author rights for all the published articles Vasilia Petraki, Philippos Thomopoulos, Anastassia E. Kossioni and photographs are owned exclusively by Media Systems Communication S.R.L. Partial and total reproduction, under any form, 52 oral implantology printed or electronic, or the distribution An Implant Supported Maxillary Fixed Prosthesis with of published materials can only be done a Substructure/ Suprastructure Design: A Clinical Case with the written approval of Media Systems Communication S.R.L. Joanna Kempler 59 oral rehabilitation ISSN 2360 – 2406 PREVALENCE OF COMORBIDITIES ISSN – L 2360 – 2406 IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME Aranka Ilea, Dan Buhățel, Minodora Moga, Claudia Feurdean, Anca Ionel, Arin Sava, All the original content published is the sole Ondine Lucaciu, Adina Sârbu, Radu Septimiu Câmpian responsibility of the authors. All the interviewed persons are responsible for their declaration and the advertisers are 67 Books Review responsible for the information included in their commercials. 72 Author’s guidelines J

Edited by

Jean-François Roulet, DDS, PhD, Prof hc Rolf Ewers, MD, DMD, PhD Marian-Vladimir Constantinescu, DDS, PhD Editorial Board

Editors-in-Chief

Jean-François Roulet Rolf Ewers Marian-Vladimir Constantinescu DDS, PhD, Prof hc MD, DMD, PhD DDS, PhD Professor Professor and Chairman em. Professor Department of Restorative Dental Science, University Hospital for Cranio Department of Prosthetic Dentistry College of Dentistry Maxillofacial and Oral Surgery “Carol Davila” University University of Florida Medical University of Vienna of Medicine and Pharmacy Gainesville, FL, USA Vienna, Austria Bucharest, Romania

Senior Editors

David C. Watts Bruce R. Donoff Ecaterina Ionescu BSc, PhD, DSc, FRSC, FInstP, DMD, MD DDS, PhD FADM, FSB Professor of Oral and Professor Professor Maxillofacial Surgery Discipline of Orthodontics Department of Biomaterials Science Department of Oral and Dento - Facial Orthopedics School of Dentistry & and Maxillofacial Surgery Faculty of Dental Medicine Photon Science Institute Dean, Harvard School Vice-Rector, “Carol Davila” University of Manchester of Dental Medicine University Manchester M13 9PL, Harvard University of Medicine and Pharmacy United Kingdom Boston, MA, USA Bucharest, Romania

Associate Editors Board

Associate Editors-in-Chief Cristina Maria Borțun, DDS, PhD Galip Gürel, DDS, MSc Professor Professor Poul Erik Petersen, DDS, Dr Odont, BA, MSc Discipline Prosthetic Technology Dentis Dental Clinic (Sociology), WHO Senior Consultant and Dental Materials Istanbul, Turkiye Professor, Department for Global Oral Health Dean, Faculty of Dental Medicine and Community Dentistry School of Dentistry “Victor Babeș” University of Medicine Anastassia E Kossioni, DDS, PhD University of Copenhagen and Pharmacy, Timișoara, Romania Assistant Professor Copenhagen K, Denmark Department of Prosthodontics Alexandru Bucur, DDS, MD, PhD Athens Dental School University of Athens Lakshman Samaranayake, DSc(hc) Professor Athens, Greece DDS(Glas), DSRCSE(hon), Discipline Oral - Maxillofacial Surgery FRCPath(UK), FRACDS(hon) Dean, Faculty of Dental Medicine Amid I Ismail, BDS, MPH, MBA, Dr PH Professor and Head of School “Carol Davila” University Professor University of Queensland of Medicine and Pharmacy Department of Restorative Dentistry Brisbane, Australia Bucharest, Romania Dean, Maurice H. Kornberg School of Dentistry Temple University Luigi M Gallo, dipl. El.-Ing. ETH Asja Celebic, DDS, MSc, PhD Philadelphia, PA, Usa Professor and Chairman Professor University of Zurich Department of Prosthodontics Armelle Maniere-Ezvan, DDS, PhD CH-Zurich, Switzerland School of Dental Medicine Professor University of Zagreb, Zagreb, Croatia Department of Orthodontics Veronica Mercuţ, DMD, PhD Dean, Faculty of Odontology Professor Prosthetics Department Ingrīda Čēma, DDS Nice Sophia-Antipolis University Dean, Faculty of Dental Medicine Professor Nice, France University of Medicine and Pharmacy Craiova, Department of Oral Pathology Dolj, Romania Dean, Faculty of Dental Medicine Domenico Massironi, DDS, PhD Riga Stradins University, Riga, Latvia Professor Radu Septimiu Câmpian, DMD, MD MSC Massironi Study Club Professor and Head Oral Rehabilitation Daniel Edelhoff, CDT, DMD, PhD Melegnano Milano, Italy Oral Health and Management of Dental Office Professor Department Department of Prosthodontics Noshir R. Mehta, DMD, MDS, MS Dean, Faculty of Dentistry Dental School Ludwig-Maximilians-University Professor and Chair Department “Iuliu Hațieganu” University of Medicine and Munich, Germany of General Dentistry Pharmacy, Cluj-Napoca, Romania Associate Dean of Global Relations Norina Consuela Forna, DDS, PhD School of Dental Medicine, Boston, Ion Lupan, DMD, MD Professor MA Tufts University Profesor OMF pediatric surgery Department Clinics and Boston, MA, Usa Pedodontics & Orthodontics Therapy of Partial Reduced Interrelated Dean, Faculty of Stomatology Edentation Alexandre Mersel, DDS, PhD State Medical and Pharmaceutical University Dean, Faculty of Dental Medicine Professor “N. Testemitanu”, Chişinău, Moldova “Gr. T. Popa” University of Medicine Director Fdi Eastern Europe and Pharmacy, Jassy, Romania Jerusalem, Israel Associate Editors Roland Frankenberger, DMD, PhD Georg B. Meyer, DMD, PhD, Dr hc Rafael Benoliel, BDS FICD, FADM, FPFA, Hon Prof Professor and Chairman Professor, Department of Diagnostic Sciences Professor and Chairman Zentrums für Zahn-, Mund- und Associate Dean for Research Department of Operative Kieferheilkunde Rutgers School of Dental Medicine The State Dentistry and Endodontics Ernst-Moritz-Arndt Universität University of New Jersey Newark, NJ, USA Dean, Dental School, University of Marburg Greifswald, Germany Marburg, Germany Dana Cristina Bodnar, DDS, PhD Takahiro Ono, DDS, PhD Assistant Professor Klaus Gotfredsen, DDS, PhD, Dr Odont Associate Professor Discipline of Restaurative Professor Department of Prosthodontics and Oral Odontotherapy Department of Oral Rehabilitation Rehabilitation Vice-Dean, Faculty of Dental Medicine Faculty of Health Science Graduate School of Dentistry “Carol Davila” University of Medicine and University of Copenhagen Osaka University Pharmacy, Bucharest, Romania København, Denmark Osaka, Japan Jean-Daniel Orthlieb, DDS, PhD Nardi Caspi, DMD, MD Lucien Reclaru, Eng, PhD Professor and Chairman Associate Professor Hebrew University Professor Px Holding SA Department of Dental Anatomy & HadassaH Jerusalem La Chaux De Fonds, Switzerland Occlusodontology Jerusalem, Israel Matjaz Rode, DDS, PhD Vice-Dean, Faculty of Odontology Arnaldo Castellucci, DDS, PhD Professor University of Ljubljana Aix Marseille University Professor Florence, Italy Ljubljana, Slovenia Marseille, France Romeo Călărașu, MD, PhD Stephen F. Rosenstiel, BDS, MSD Professor “Carol Davila” University of Medicine Professor Emeritus The Ohio State University Mariana Păcurar, DDS, PhD and Pharmacy Bucharest, Romania Columbus, OH, USA Professor Discipline of Orthodontics Rayleigh Ping-Ying Chiang, MD, MMS Mare Saag, DDS, PhD and Dento - Facial Orthopedics Taipei Veterans General Hospital Professor University of Tartu, Tartu, Estonia Dean, Faculty of Dental Medicine Taipei, Taiwan Martina Schmid-Schwap, DDS, PhD University of Medicine and Pharmacy Paulo G. Coelho, DDS, PhD Associate Professor Bernhard-Gottlieb University Târgu Mureș, Romania Associate Professor Biomaterials Vienna, Austria and Biomimetics Department Gregor Slavicek, DDS, PhD Gabriela Pițigoi-Aron, DDS, PhD New York University, USA Steinbeis University Professor New York, NY, USA Berlin, Germany Department of Integrated Reconstructive Robert A. Convissar, DDS, FAGD Marius Steigmann, DDS, PhD Dental Sciences New York Hospital Medical Center of Queens Associate Professor Steigmann Arthur A. Dugoni School of Dentistry New York, NY, Usa Implant Institute Neckargemund University of the Pacific Antonino Marco Cuccia, DDS, PhD Germany San Francisco, CA, usa Professor University of Palermo Jon B Suzuki, DDS, PhD Palermo, Italy Professor Temple University George E. Romanos, DDS, DMD, PhD Ioan Dănilă, DDS, PhD Philadelphia, PA, Usa Professor Department of Periodontology/ Professor “Gr. T. Popa” University of Medicine Gianluca Martino Tartaglia, DDS, PhD Implant Dentistry and Pharmacy, Jassy, Romania Associate Professor University of Milan Associate Dean, SUNY Stony Brook School Yuri Dekhtyar, Eng, Dr phys Milano, Italy of Dental Medicine Professor Mihai C. Teodorescu, MD, PhD Stony Brook University Riga Technical University, Riga, Latvia Associate Professor University of Wisconsin Stony Brook, NY, Usa Mohamed Sherine El-Attar, DDS, PhD Hospitals and Clinics Madison Professor Pharos Alexandria WI, Usa Mugurel C. Rusu, MD, PhD University Douglas A. Terry, DDS, PhD Associate Professor Alexandria, Egypt Professor Esthetics Institute of Esthetic & Faculty of Dental Medicine Paul B. Feinmann, DDS, PhD Restorative “Carol Davila” University of Medicine and Professor Canton of Geneva, Dentistry, Houston, TX, Usa Pharmacy Switzerland Bernard Touati, DDS, PhD Bucharest, Romania Claudia Maria de Felicio, MD, PhD Professor Paris V University Professor Universidade De São Paulo (Usp) Paris, France Anton Sculean, DMD, Dr hc, MS Ribeirão Preto, Brazil Jacques Vanobbergen, DDS, PhD Professor and Chairman Luis J. Fujimoto, DDS, PhD Professor Gent University, Gent, Belgium Department of Periodontology Associate Professor Irina Nicoleta Zetu, DDS, PhD University of Bern New York University, New York, Usa Associate Professor “Gr. T. Popa” University Bern, Switzerland Adi A. Garfunkel, DDS, PhD of Medicine and Pharmacy Professor Hebrew University Hadassah Jassy, Romania Chiarella Sforza, MD, PhD Jerusalem, Jerusalem, Israel Professor Daniela Aparecida Godoi Gonçalves, DDS, PhD Department of Biomedical Sciences for Health Assistant Professor Unesp - Univ Est Editorial Review Board Faculty of Medicine Paulista, Araraquara, Brazil University of Milan, Milano, Italy Maria Greabu, MD, PhD Professor “Carol Davila” University of Medicine Reviewers-in-Chief Roman Šmucler, MD, PhD and Pharmacy Associate Professor Bucharest, Romania Stephen F. Rosenstiel, BDS, MSD Department of Maxillofacial Surgery Martin D Gross, BDS, LDS, RCS, MSc Professor Emeritus First Faculty of Medicine and Associate Professor Tel Aviv University The Ohio State University General University Hospital Tel Aviv, Israel Columbus, OH, USA Charles University Emilian Hutu, DDS, PhD Mihaela Rodica Păuna, DDS, PhD Prague, Czech Republic Professor “Carol Davila” University of Medicine Professor and Pharmacy, Bucharest, Romania “Carol Davila” University of Medicine and Sorin Uram-Țuculescu, DDS, PhD Joannis Katsoulis, DMD, PhD, MAS Pharmacy, Bucharest, Romania Assistant Professor Associate Professor University of Bern Sheldon Dov Sydney, DDS, FICD Department of Prosthodontics Bern, Switzerland Associate Professor School of Dentistry Joanna Kempler, DDS, PhD University of Maryland Baltimore, Virginia Commonwealth University Associate Professor University of Maryland Maryland, USA, World Editor, International Richmond, VA, USA Baltimore, MD, Usa College of Dentists Robert L. Ibsen, DDS, OD David Wray, MD (Honours), BDS, MB ChB, FDS Santa Maria, CA, USA RCPS (Glasgow) Werner Lill, DDS, PD Reviewers FDS RCS (Edinburgh), F Med Sci Austrian Society of Periodontology (Oegp) Professor Emeritus, Professor and Chairman Vienna, Austria Petr Bartak, Prague, Czech Republic Department of Oral Medicine Tomas Linkevičius, DDS, PhD Gabriela Băncescu, Bucharest, Romania Dean, Dubai School of Dental Medicine Associate Professor Vilnius University Bogdan Calenic, Bucharest, Romania Dubai, United Arab Emirates Vilnius, Lithuania Cristian Niky Cumpătă, Bucharest, Romania Mauro Marincola, DDS, PhD Barbara Janssens, Gent, Belgium Professor State University of Cartagena Hercules Karkazis, Athens, Greece EmeritusEmeritus Editors-in-Chief Editors-in-Chief Cartagena, Colombia John Kois, Seattle, WA, USA Nicoleta Măru, MD, PhD Henriette Lerner, Baden-Baden, Germany Birte Melsen, DDS, Dr Odont Associate Professor “Carol Davila” University of Cinel Maliţa, Bucharest, Romania Professor Aarhus University, Aarhus, Denmark Medicine and Pharmacy Marina Meleșcanu-Imre, Bucharest, Romania Bucharest, Romania Hazem Mourad, Qassim, Saudi Arabia Prathip Phantumvanit, DDS, MS, FRCDT Rodolfo Miralles, MD, PhD Paula Perlea, Bucharest, Romania Professor Thammasat University, Professor University of Chile Nikola Petricevic, Zagreb, Croatia Bangkok, Thailand Santiago, Chile Laurențiu Popa, Dallas, TX, USA Annalisa Monaco, DDS, PhD Robert Sabiniu Şerban, Bucharest, Romania Rudolf Slavicek, MD, DMD Professor University of L’Aquila DA Elina Teodorescu, Bucharest, Romania Professor Medical University of Vienna L’aquila, Italy Luc De Visschere, Gent, Belgium Vienna, Austria Marian Neguț, MD, PhD Maciej Zarow, Krakow, Poland Professor “Carol Davila” University of Medicine Julian B. Woelfel, DDS, FACD, FICD and Pharmacy, Bucharest, Romania Professor The Ohio State University, Columbus, USA Mutlu Özcan, DDS, PhD English Language Editor Professor University of Zurich Zurich, Switzerland Valeria Clucerescu, Biol. EEditorsditors Ion Pătrașcu, DDS, PhD Cristina Alina Huidiu, LIS Professor “Carol Davila” University of Medicine Niculina Smaranda Ion, Phil. Marcus Oliver Ahlers, DDS, PD and Pharmacy Hamburg University Eppendorf Bucharest, Romania Hamburg, Germany Sever Popa, DDS, PhD Honorary Statistical Adviser Orlando Alves Da Silva, MD, PhD Professor “Iuliu Hațieganu” University Professor Universitary Hospital of Santa Maria of Medicine and Pharmacy Radu Burlacu, PhD, Bucharest, Romania Lisbon, Portugal Cluj-Napoca, Romania Sorin Andrian, DDS, PhD Sanda Mihaela Popescu, DDS, PhD Professor “Gr. T. Popa” University of Medicine Associate Professor University of Medicine and Editorial Book Reviewer and Pharmacy, Jassy, Romania Pharmacy, Craiova, Romania Wilson Martins Aragão, DDS, PhD Sorin Claudiu Popșor, DDS, PhD Florin Eugen Constantinescu Professor Catholic University of Rio De Janeiro Professor University of Medicine and Pharmacy Bucharest, Romania Rio De Janeiro, Brasil Tg. Mureș, Romania Vasile Astărăstoae, MD, PhD Xiaohui Rausch-Fan, DDS, PhD Professor, Rector, “Gr. T. Popa” University of Professor Bernhard-Gottlieb-University Project Editor Medicine and Pharmacy, Jassy, Romania Vienna, Austria Emanuel Adrian Bratu, DDS, MD, PhD Mihaela Răescu, Valentin Rădoi, MD Professor “Victor Babeș” DDS, PhD Faculty of Medicine University of Medicine and Professor Associate “Titu Maiorescu” University "Carol Davila" University of Medicine Pharmacy, Timișoara, Romania Bucharest, Romania and Pharmacy, Bucharest, Romania Why Peer Review? Jean-Francois Roulet DDS, PhD, Prof hc Professor University of Florida, Gainesville, FL, USA

Dear Readers, As dentists we are part of the medical community. We are the experts in everything related to the health of the oral cavity and its surroundings. Therefore ethical guidelines require us to deliver treatment or provide advice of the highest quality for the benefit of our patients. This sounds great; however it includes an inherent E ditorial conflict: how to define quality. This is very difficult in medicine and dentistry. Quality may be divided into process quality (in simple terms: do the right thing) and outcome quality (in simple terms: do it right). Both need definitions, what is good or bad; and this is where the problem sits. Once upon a time our teachers were setting the requirement for what is considered good quality, often based on their opinion, and we students had to comply. These days things got more complicated. We need to base our definitions on facts or results based on experiments. For dental care and medicine the ultimate measurement of good quality is the survival of the restoration or the patient after an intervention or therapy. “Evidence based” is the magic word here. However we cannot base all our doing only on results of clinical studies, as we would postpone good treatment options to our patients for years. Therefore we need to accept lower evidence levels such as in vitro studies as well, to make up our mind. In the age of the internet information is available instantaneously and globally, which is a very good thing. The back side of this is the information overload and the black side is that the average user cannot distinguish anymore which information is relevant or true, or which information is pure claim or just intended to motivate the target reader to use it, or to use the product described. This is where peer review becomes important. Anders Linde, the Editor of the European Journal of Oral Sciences once stated: “Nothing is scientifically shown or proven before it has been published in a scientific journal with a peer review system, so one can critically judge what was done, how it was done and evaluate how solid it is.” The application of this by an editorial team means that a group of experts in the field (the peers) will have very carefully looked at every document which is finally published. They will check if the information provided is new, if the formatting is correct, if the language is used correctly, if the methods used make sense and are free of bias. Statisticians will look at the results to make sure that the outcome is really a function of the experimental variables. The experts will also ask themselves “Does it make sense?” and will critically look at results which may significantly differ from other similar tests. Finally, the editorial team will make sure that the conclusions drawn are strictly related to the outcome of the experiments. If there are questions, which is almost always the case, then the authors are challenged to address them. These are a few facts that make the difference between a non peer reviewed publication and a peer reviewed publication. Of course during the review process some manuscripts get rejected. These are the ones that do not fulfill the quality requirements or do not survive the critical review because of incurable flaws (mostly in the methodology). Notwithstanding, the main objective of the review process is to improve the quality of the manuscript, so you, readers, can trust the information provided. So, in order to be credible, there is no alternative to peer review! Continuing Medical Education Program – a professional estimate in dentistry practice

Rolf Ewers MD, DMD, PhD Professor and Chairman em. Medical University of Vienna, Vienna, Austria

Prof. Dr. Constantinescu has asked me to serve as an Editor in Chief for the Stomatology Edu Journal (Stoma Edu J) and consequently to be in charge with the editors for Western and Central Europe. I am very happy to accept this and I am looking forward to do so. As Prof. Constantinescu pointed out this new dental journal will serve as a new information tool for dentists and doctors to treat patients better with the up to date knowledge which they will get in all our specialty fields by reading the peer-reviewed articles. I am convinced that the questionnaire at the end of each article will help the reader to really concentrate on the subject he is reading, controlling his understanding and last but not least getting points for the Continuing Medical Education Program. I am very happy that I will have the opportunity to work together with Professor Jean-François Roulet from University of Florida and Professor Stephen F. Rosenstiel, from Ohio State University. I am sure that with the help and enthusiasm of Prof. Constantinescu we will achieve together with all the other editors an excellent journal for the benefit of all. How Prof. Constantinescu says: Stoma Edu J will be indeed a world of educational resources for each practice. E ditorial Plea for a holistic approach in stomatology

Vasile Astărăstoae MD, PhD, Licensed in Law Professor Rector, “Gr.T.Popa” University of Medicine and Pharmacy, Jassy, Romania E ditorial President of the Romanian College of Physicians

The ethos of the medical profession derives from its tradition. Since the first medical acts, the approach of this profession was anthropological and holistic. This is why, during its evolution, medicine has evolved combining two tendencies: asklepian (knowing) and the samaritan one (feeling compassion for your patient). In the contemporary age, new forces have begun acting: financers influencing health systems while being preoccupied by the rationalization of resources, the importance given to evidence based medicine, guidelines and protocols, subspecialties, the fragmentation of medical care, an excess of technology which removes the human touch (the patient becomes a subject not a person) and, last but not least, the influence of the commercial market which is run by pharmaceutical companies. Slowly, medicine has become institutionalized and instrumentalized, affecting not only the classic doctor-patient relationship but also the performances related to protecting people's health. Among the many branches of medicine, dental medicine (stomatology) emerged as a specialty. One of the many perceptions related to it is that it is a standalone specialty and that only the technical aspects need to be considered. In other words, the stomatologist needs only to be an exquisite technician (professionist) for the dental and buco-maxillary apparatuses. This approach is not only wrong, but also dangerous for the future of stomatology. It is wrong because contemporary medicine is turning back to a holistic approach and parts of a whole cannot be treated if we do not take into account the interactions between these parts and the whole. Dangerous because those who work in this domain might be considered technicians in the future and not what they are, doctors. This is why a source for doctors and researchers was needed, one that could show that the medical aspects are well kept in stomatology. This source will be the journal you are reading. This is why a forensic pathologist happily and gratefully accepts to be a part of this beneficial project for all the specialties and doctors out there. Why a new journal?

Marian-Vladimir Constantinescu DDS, PhD Professor “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Stomatology.edu is a new quarterly dental journal whose main purpose is to inform researchers, educators, graduates, postgraduates and practitioners about the latest trends in the field, which followed, would bring immediate and lasting benefits to the patients; and about opinions of the most authorized specialists on what is best in current practice, for the good of both, patient and dentist. Stomatology.edu is a peer-reviewed, open access European dental journal to be database indexed, meant to contribute to the development and completion of the medical training of practitioners from Romania, Republic of Moldova and other Central and Eastern Europe countries for, as Dr. Greene Vardiman Black stated: “the professional man has no right to be other than a continual student”. To get points under the Continual Medical Education Program, at the end of each article there is a questionnaire. The authors will approach such dental practice topics, as: Dental Anatomy, Anesthesiology, Cario­ logy, Community Dentistry, Dentoalveolar Surgery, Oral and Maxillofacial Surgery, Oral and Dental Diagnosis, Endodontics, Cosmetic Dentistry, Dental Ergonomics, Dental Hygiene, Dental Laser, Dental Materials, Dental Microscopy, Dental Photography, Dental Public Health, Dental Radiology, Gerodontology, Oral Implantology, Oral Microbiology, Oral Pathology, Oro-Dental Management, Oro-Dental Prevention, Occlusion and TMJ, Orofacial Pain, Orthodontics and Dento-Facial Orthopedics, Pedodontics, Periodontology, Posturology, Prosthetic Dentistry, Computerized Dental Prosthetics, Minimally Invasive Dentistry, Dental Technology and Emergencies at the Dentist’s. We underline the high professional status of editorial team members and the exceptional importance in the field of Editors-in-Chief: Professor Rolf Ewers from Medical University of Vienna; Professor Jean-François Roulet from University of Florida (Editor-in-Chief of three ISI quoted journals) and Reviewer-in-Chief, Professor Stephen F. Rosenstiel, from Ohio State University (Editor-in-Chief of Journal of Prosthetic Dentistry) accepting to share their expertise with us. By national and international scientific contribution of editors and of peer review experts we hope for a clear improvement of the medical care quality through better and more effective treatments applied by professionals in Romania, Republic of Moldova and Central and Eastern Europe, thus proving that Stomatology.edu Journal is indeed a world of educational resources for each practice. SO HELP US, GOD! E ditorial FDI Eastern Europe Continuing Education Programme

Prevention for the Elderly Patients

Prof. Alexandre The aging of the elderly population is a dramatic and actions are compulsory. The profession must Mersel demographic fact. start with an education program both for the Senior Research Fellow One of the most important challenges of the practitioner and the patients. Department of dental profession in the coming years will be in Salivary hypo function Community Dentistry Hadassah, Faculty of Dental providing oral care to geriatric patients. With aging a great decrease of the saliva flow is Medicine Jerusalem The new trend is that the elderly will have more noted. Aside from the normal gland hypo function Regional Director FDI Continuing Education retained teeth and that their expectation will be more than 700 medications are known to cause Programme greater. On the other hand the increase of their dry mouth. Bad taste, bad breath and more root life–span will increasingly affect their medical caries are the direct consequences. Prevention status, therefore the profession has to develop an and control of the salivary pH is indicated. adapted prevention management and treatment Periodontal Prevention strategy. With the loss of periodontal attachments, bad The main field of action will be: habits (smoking), poor conservative restoration Prevention of the Dental caries and poor prosthodontic rehabilitation, the elderly A special preventive protocol and a conservative are often subject to chronic periodontal diseases. approach is necessary in order to achieve a maximum This situation will finally lead to the loss of of teeth when aging “20 teeth for the eighties”. their teeth, in a way that step by step they will be Oral cancer edentulous. Oral cancer has a high morbidity and mortality Edentulism is now recognized by the WHO as rate. The 5-year survival rate is 75% for local lesions a real disability. Special attention should be taken but only 17% for those with distant metastasis. in order to provide a large preventive treatment Oral cancer constitutes 13-16 % of all cancers, including, of course, the education and motivation therefore early detection, and preventive attitudes of these patients.

Alexandre Mersel Senior Research Fellow Department of Community Dentistry Hadassah Faculty of Dental Medicine Jerusalem Regional Director FDI Continuing Education Programme

Prof. Alexandre Mersel is a Professor at the Faculty of Dental Medicine in Jerusalem, having worked in research for over 30 years He has published 87 scientific articles and 3 chapters in academic textbooks. He is also a Senior Research Fellow at the Department of Community Dentistry Hadassah, a Member of the Education Committee of the FDI, the Regional Director for the FDI Continuing Education Program and a Member in the Editorial board of several CV International Journals. Among his past accomplishments we mention the City of Paris Silver Medal (1986), the fact that he was a Consultant on the Prime Minister’s commission of Public Health (1982) and Co-founder and vice-President of the International Association of Gerodontology (1985- 1986).

10 Stoma.eduJ (2014) 1 (1) DENTISTRY CONFERENCES

36th Asia Pacific Dental Congress 14th World Congress for Laser Dentistry Date: 17–19 June 2014 Date: 2–4 July 2014 Location: Dubai, United Arab Emirates Location: Paris, France Event types: Conference Event types: Conference, Course, Workshop Visit event website: http://www.apdentalcongress.org/ Visit event website: http://www.wfld-paris2014.com 2014 DentalXP Global Symposium 61st Congress of the European Organisation Date: 18–21 June 2014 for Caries Research – ORCA 2014 Location: Hollywood, Florida 33019, USA Date: 2-5 July 2014 Event types: Conference Location: Greifswald, Germany Visit event website: http://dentalxp.com/symposium/index.html Event types: Conference Visit event website: http://www.orca2014.org Advancing Excellence in Healthcare 2014 Date: 19–20 June 2014 Congress of the International Location: Glasgow, United Kingdom Society of Oral Rehabilitation – Event types: Conference Visit event website: http://aeh2014.rcp.sg/ Forum Odontologicum Date: 3-5 July 2014 18th World Congress on Dental Traumatology Location: Lausanne, Switzerland Date: 19–21 June 2014 Event types: Conference, Workshop Location: Istanbul, Turkey Visit event website: http://www.medicalsummit.eu Event types: Conference Visit event website: http://www.iadt-dentaltrauma.org/2014conference/ The Sheffield Oral & Maxillofacial Pathology Course EFAAD 2014 - IV Congress of the European Federation Date: 11-12 July 2014 for the Advancement of Anaesthesia in Dentistry Location: Sheffield, United Kingdom Date: 20–21 June 2014 Event types: Conference, Interactive Lectures, Slide Seminars Location: Padova, Italy Visit event website: http://www.sheffield.ac.uk/dentalschool/ Event types: Conference, Course, Workshop courses/oral_max_path/index Visit event website: http://www.meetandwork.it/efaad2014/ homeefaad.pdf The American Dental Association 28th New Dentist Conference 2014 IADR (International Association for Dental Date: 17-19 July 2014 Research) General Session Location: Kansas City, Missouri, USA Date: 25–28 June 2014 Event types: Conference Location: Cape Town, South Africa Visit event website: http://www.ada.org/en/education- Event types: Conference careers/events/new-dentist-conference/conference- Visit event website: http://www.iadr.org/i4a/pages/ schedule-at-a-glance index cfm?pageid=4212#. U3iiwPmSwWJ Teeth for a Lifetime: Interdisciplinary The 2nd International Symposium on Esthetic, Evidence for Clinical Success - AAE/AAP/ACP Restorative and Implant Dentistry Joint Symposium The 8th BDIZ EDI European Symposium Date: 19-20 July 2014 Date: 26–28 June 2014 Location: Chicago, Illinois, USA Location: Barcelona, Spain Event types: Conference Event types: Conference Visit event website: http://www.perio.org/meetings/ Visit event website: http://quintevent.com/erid/index.php joint-symposium2014.htm AGD 2014 Annual Meeting (Academy of General Practical Updates in Pediatric Dentistry: Dentistry) Duluth, Minnesota Date: 26–29 June 2014 Date: 19-20 July 2014 Location: Detroit, Michigan, USA Location: Duluth, Minnesota, USA Event types: Conference Event types: Conference Visit event website: www.agd.org/education-events/2014-annual- Visit event website: http://www.dentistry.umn.edu/dentalce/ meeting-exhibits.aspx courses/duluth-pediatric-dentistry/index.htm 11 cariology

Cite this article: Andrian S, Iovan G, REMINERALISATION OF AFFECTED Georgescu A. Remineralisation of affected dentine by different bioactive DENTINE BY DIFFERENT BIOACTIVE materials in the stepwise excavation tehnique. Stoma Edu J. 2014; MATERIALS IN THE STEPWISE 1(1):12-17. EXCAVATION TECHNIQUE

Sorin Andriana*, Gianina Iovanb, Abstract Simona Stoleriuc, Claudiu Topoliceanud, Andrei Georgescue Introduction. The aim of this study was to assess dentine remineralisation Department of Odontology, Periodontology and the possibility to maintain the pulp vitality using several bioactive and Fixed Prosthodontics, Faculty of Dental materials applied in the „stepwise” excavation technique after the carious Medicine, „Gr.T.Popa” University of Medicine dentine was removed using the CarisolvTM system (Sävedalen, Sweden). and Pharmacy, Jassy, Romania Methodology. The study was performed on 25 patients with a high caries a. DDS, PhD, Professor risk, between 18-34 years old. 30 posterior teeth with acute dental caries b. DDS, PhD, Associate Professor were treated using the „stepwise” excavation technique. The patients were c. DDS, PhD, Lecturer d. DDS, PhD student, Assistant Professor divided in three study groups, according to the type of bioactive materials: e. DDS, PhD, Assistant Professor group 1 (10 acute dental caries) - Ca(OH)2 liner (Dycal, DeTreyDentsply) and zinc-oxyde-eugenol (Caryosan, Spofa Dental); group 2 (10 acute dental caries) - zinc-oxyde-eugenol (Caryosan, Spofa Dental); group 3 (10 acute

dental caries) - Ca(OH)2 liner (Dycal, DeTreyDentsply) and glassionomer cement (Ketac Molar Easymix, 3M ESPE). After 6 months the changes of color and consistency of dentine were assessed using both clinical examination and radiographs, and pulp vitality was tested. Results. In study group 1, the dental vitality was maintained in 100% percent of the cases. In study group 2, a case of chronic pulpitis was recorded. In this study group, the dental vitality was maintained in 90% cases. In study group 3 a case of pulp necrosis associated with a periapical lesion was recorded. This study group also presented therapeutical success in 90% cases. Conclusion. The „stepwise” technique used after the removal of infected dentine with the CarysolvTM system provided remineralisation of affected dentine in 70-80% percent of the patients and maintained the pulp vitality in 90%-100% cases. Key words: acute dental caries, „stepwise” excavation technique, CarisolvTM, remineralisation, dentine.

Introduction Acute dental caries, characterized by deep demineralization and high risk of pulp involvement, require a progressive therapeutical approach more adequate in maintaining pulp vitality. The therapy of acute dental caries, using the „stepwise” excavation technique, requires the monitoring of pulp-dentine response to the materials applied for pulp capping. The traditional evaluation uses clinical examination, recording of the changes of dentine color and consistency during Received: 27 November 2013 Accepted: 11 December 2013 therapy. The neodentinogenesis and remineralisation reactions represent an important part of the pulp-dentin protection system, blocking the invasion of bacteria and their co-products. *Corresponding author: There are two layers of altered dentine with different characteristics: the layer of infected Professor Sorin Andrian, DDS, PhD dentine which is heavily contaminated and the layer of affected dentine with a lower degree Department of Odontology, Periodontology and of bacterial contamination. The infected dentine is soft and yellow and it is characterized by Fixed Prosthodontics, Faculty of Dental Medicine, „Gr.T.Popa” University of extensive breakdown of the organic matrix. This layer should be removed as its remineralisation Medicine and Pharmacy, Jassy, Romania potential is lost. The affected layer consists of dentine with medium consistency and some 16 Universitatii Str., RO-700115, Jassy, Romania. Tel/Fax: +40232301618 degree of elasticity. In many cases of acute dental caries it is difficult to clearly differentiate e-mail: [email protected] the limit between the two layers. Since most of the recent data recommend the maintenance

12 Stoma.eduJ (2014) 1 (1) REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE MATERIALS IN STEPWISE - EXCAVATION TECHNIQUE

Table 1. Results regarding the changes of dentine color in the three groups (in accordance with the different bioactive materials used)

Group 1/ Group 2/ Group 3/ Ca(OH)2 +

Ca(OH)2+ZOE ZOE glassionomer cement

Dark-brown 50% 30% 30%

Brown-yellow 30% 40% 50%

Unchanged (yellow) 20% 30% 20%

Table 2. Mann Whitney statistical test results when comparing the color changes of the remineralized dentine after 6 months; Group 1-Ca(OH)2+ZOE; Group 2-ZOE; Group 3-Ca(OH)2+glassionomer cement

Group 1 Group 2 Group 3

Group 1 - 0.397 0.516

Group 2 0.397 - 0.776

Group 3 0.516 0.776 - of the affected dentine, the „stepwise” excavation microscopic delimitation between necrotic dentine technique is focused on its preservation and and affected dentine (that can be remineralized), the remineralisation (1-7). For the asymptomatic cases use of the chemo-mechanical technique based on where the pulp exposure seems possible during the CarisolvTM system was proposed. the treatment, the „stepwise” excavation technique The aim of study was to assess the capacity of the is the most recommended therapeutical approach. mentioned bioactive materials to stimulate dentine The practical application of this technique presents remineralisation and to preserve pulp tissue vitality, considerable variations. The acceptable consistency following the removal of carious dentine with the of remaining dentine can vary from soft to hard, while CarisolvTM system. color can vary from yellow to brown. There are also different opinions regarding the optimal moment for Methods the removal of carious dentine. The study included 25 patients with ages between Acute caries is characterized by periods of intense 18-34 years, having 30 posterior teeth affected by activity of the pulp tissue alternating with periods acute dental caries and high caries risk. The presence of pulp inactivity. Despite the scientific data that of systemic diseases was an exclusion criteria. The highlight the possibility to preserve affected dentine patients were informed about the structure and in deep dental caries, most practitioners continue objectives of study and informed consent was to apply basic surgical principles. Most practitioners obtained. The ethics Committee of the „Gr.T.Popa” are also focused on the complete removal of carious University of Medicine and Pharmacy gave its dentine even with the risk of pulp exposure (3). approval for this study. Also, for the treatment of temporary teeth, most The removal of carious dentine was performed dentists perform pulpotomy instead of the stepwise with the CarisolvTM system (Sävedalen, Sweden) by technique. However many researchers are focused a single practitioner. The CarisolvTM gel was applied on finding efficient therapeutical procedures aimed on the carious dentine surface. The Carisolv gel was at stimulating the defensive pulp-dentine complex applied to cover the carious dentine from the lesion. processes (6,7). There are different recommendations After 30 seconds, the gel in the carious lesion was regarding the bioactive materials used in the agitated using the excavators. The moist material „stepwise” excavation technique (calcium hydroxide- was removed. A new layer of gel was applied and based products, zinc-oxyde-eugenol, glassionomer the procedure continued after waiting 30 seconds. cements). The intervals between treatment stages The removal of the carious dentine was considered can also vary, from 4 to 8 weeks or from 2 to 6 months completed when the surface of the dentine had (1-5). leather consistency. During the last decades new methods have been The treatment was performed using the „stepwise developed for removal of carious dentine in an excavation” approach. Depending on the bioactive attempt to increase the efficacy, speed and patient materials, three study groups were formed: group comfort. In the absence of a clear macroscopic or 1 (10 acute dental caries) - calcium-hydroxide liner

13 cariology

Table 3. Results regarding the changes of dentine consistency (in accordance with different bioactive materials)

Group 1/ Group 2/ Group 3/ Ca(OH)2 +

Ca(OH)2+ZOE ZOE glassionomer cement

Hard 50% 40% 30%

Leather 40% 40% 50%

Soft 10% 20% 20%

Table 4. Mann Whitney statistical test results when comparing the consistency changes of the dentine after

6 months; Group 1-Ca(OH)2+ZOE; Group 2-ZOE; Group 3-Ca(OH)2+glassionomer cement

Group 1 Group 2 Group 3

Group 1 - 0.565 0.344

Group 2 0.565 - 0.744

Group 3 0.344 0.744 -

(Dycal, DeTreyDentsply) and zinc-oxyde-eugenol Study group 1 (Ca(OH)2 + zinc-oxyde-eugenol) (Caryosan, Spofa Dental); group 2 (10 acute dental included 50% cases with hard dentine (total caries) zinc-oxyde-eugenol (Caryosan, Spofa Dental); remineralisation), 40% cases with leather consistency group 3 (10 acute dental caries) - calcium-hydroxide (partial remineralisation) and only 10% cases with liner (Dycal, DeTreyDentsply) and glassionomer cement soft dentine (absent remineralisation). Study group (Ketac Molar Easymix, 3M ESPE). The assessment of 2 (zinc-oxyde-eugenol) included 40% cases with the affected dentine was performed using two criteria: hard dentine (total remineralisation), 40% cases with the color (yellow, brown-yellow, dark-brown) and leather consistency (partial remineralisation) and the consistency (soft, leather, hard) immediately after 20% cases with soft dentine (absent remineralisation).

completing the excavation procedure and 6 months Study group 3 (Ca(OH)2 + glassionomer cement) later. The presence of dentine remineralisation was also included 30% cases with hard dentine (total assessed on the radiographic images. The vitality tests, remineralisation), 50% cases with leather consistency assessing the vitality of pulp tissue, were performed (partial remineralisation) and 20% cases with soft using an electric pulp test device (Digitest, Parkell Inc, dentine (absent remineralisation). USA). Statistical analyzes of the results were performed No significant statistical differences were obtained using the Mann Whitney test with a significance level when comparing consistency changes of the dentine p<0.05, two-tailed. after 6 month in groups 1, 2 and 3 (p>0.05) (table 4) An analysis of the radiographic images showed Results that in the study group 1 (Ca(OH)2 + zinc-oxyde- The results regarding the color changes of the eugenol) dentine remineralisation was present in 90% remineralized dentine (Leksell indices) are as follows: of the cases. In this study group, the remineralisation

in study group 1 (Ca(OH)2 + zync-oxide-eugenol) processes were absent in 10% of the cases. This was the color of the affected dentine remained yellow the lowest percent of failure from all the study groups. in 20% of the cases, while color changed in 30% of In study group 2 (zinc-oxyde-eugenol) dentinal the cases in yellow-brown, and in 50% of the cases remineralisation was present in 80% of the cases.

in dark-brown; for study group 2, the dentine color In study group 3 (Ca(OH)2 + glassionomer cement) was yellow in 30% of the cases, yellow-brown in 40% dentinal remineralisation was present in 80% of the of the cases, and dark-brown in 30% of the cases; for cases. In Figure 1 is presented the radiographic study group 3, the dentine color was yellow in 20% aspect of demineralised dentine in deep acute of the cases, yellow-brown in 50% of the cases, and carious lesion at 46 tooth. Figure 2 presents dark-brown in 30% of the cases (Table 1). the radiographic aspect after 6 months of pulp No significant statistical differences were capping with Ca(OH)2 and ZOE. It can be seen the obtained when comparing the color changes of the area of dentinal remineralisation associated with remineralized dentine after 6 month in groups 1, 2 neodentinogenesis and retraction of pulp beneath and 3 (p>0.05) (table 2). the mesial horn (Figure 2). Table 3 presents the results regarding the Pulp tissue vitality was preserved in 100% of the consistency changes (Leksell indices) after 6 months. cases in the study group, 6 months after indirect pulp

14 Stoma.eduJ (2014) 1 (1) REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE MATERIALS IN STEPWISE - EXCAVATION TECHNIQUE

Figure 1. Demineralised dentine in contact with Figure 2. The remineralised dentine, mesial pulp horn (arrow). Acute dental caries neodentinogenesis and the retraction of mesial (tooth 46) pulp horn (arrow), following indirect pulp capping

with Ca(OH)2 and ZOE (tooth 46) capping with Ca(OH)2 and zinc-oxyde-eugenol. For cements also release aluminum ions that increase teeth undergoing pulp capping with zinc-oxyde- the enamel resistance to acidic attack. Our results eugenol, one case of chronic pulpitis was recorded. regarding the reactions of the pulp-dentine complex, This study group presented 90% therapeutical are similar with the results of several studies and success, regarding the preservation of pulp tissue support the widespread use of the „stepwise” vitality. For teeth undergoing pulp capping with excavation technique. Some authors recommend

Ca(OH)2 and glassionomer cement, one case of pulp the association between Ca(OH)2 liners and zinc- necrosis associated with chronic apical periodontitis oxyde-eugenol for at least 3 months, with a 80%-90% was recorded. For this study group, the failure rate success rate, following the environment alcalinisation was 10%. and odontoblast stimulation by eugenol (1). The

calcium ions released by Ca(OH)2-based liners Discussion influence both passive and active remineralisation Preserving and remineralizing affected dentine by the activation of enzymes associated with the minimizes the risk of pulp exposure during the remineralisation processes. Some studies have treatment of acute caries. This approach usually reported preservation of the pulp vitality in teeth with requires materials which seal the cavity and medicate dentine remineralisation and neodentinogenesis, the dentine-pulp complex, allowing the preservation in 100% of cases, at an interval of 3-6 months (2). of the pulp vitality and apposition of tertiary dentin. In this study, the researchers demonstrated that

These two aspects prove the importance of the Ca(OH)2-based liners associated with zinc-oxyde- temporary restorations in the treatment of acute eugenol initiate neodentinogenesis and dentine dental caries. remineralisation in 82,5% of the cases after 8-24 Remineralisation is not a simple precipitation, weeks. For the cases treated by indirect pulp capping but also a result of complex biochemical with zinc-oxyde-eugenol, the authors reported a mechanisms initiated by the pulp tissue. The dentine 94% success rate after the removal of temporary remineralisation is also performed by odontoblasts restoration (1). Similar success rates were recorded through the transfer of mineral salts from the systemic in the „stepwise” excavation technique using the circulation to the mineralization area. In the cases association of Ca(OH)2-based liners with zinc-oxyde- where the remineralisation processes are stimulated eugenol or glassionomer cements (9). Other studies by glassionomer cements, the essential elements reported a 100% success rate after a 6-12 months are represented by fluoride, calcium and strontium. interval, following the „stepwise” technique in acute Some glassionomer cements contain a high percent dental caries (10). Results of some studies proved of calcium ions and a low percent of strontium ions, the association between dentinal remineralisation while others contain a high percent of strontium and a massive decrease of bacterial concentration ions. The calcium ions have a major influence in in carious dentine, after 6 months of „stepwise” the remineralisation of the affected dentine, while therapy with zinc-oxyde-eugenol (11). Similar studies strontium ions have an important antibacterial effect proved the dentine remineralisation following the and also stimulate the remineralisation processes. penetration of dentinal tubules by fluoride and Fluoride ions and strontium ions can penetrate the strontium ions (12,13). demineralized dentine and become components Some authors sustain that the use of the “stepwise” of apatite crystals (8). For a short time, glassionomer excavation technique in deep dental caries plays a

15 cariology

primary role in protecting the pulp-dentine complex The „stepwise” excavation technique is included (14). When using this technique, the practitioner can in the category of new operatory treatment arrest the acute progression of the carious lesion, options for dental caries, but some authors claim by modifying the cariogenic environment. The soft potential failures in the long-term follow up of the demineralized dentine is changing in most cases, treated teeth (17). Performing a critical review of into a dentine with increased consistency and brown- 23 studies focused on this technique, the authors yellow or dark-brown appearance. The efficiency sustain the use of this technique on a large scale of the „stepwise” excavation technique was also for the treatment of deep acute dental caries. A assessed after 6-12 months by other authors (15). similar critical review of such studies concluded The clinical changes of demineralized dentine that the „stepwise” excavation technique presents were associated with a high reduction of bacterial positive results in the long-term, regarding the contamination. After 6 months, in 90% of the cases vitality preservation of the pulp-dentine complex the consistency of demineralized dentine increased, (18). while in 20% of the cases there was a complete sterilization of demineralized dentine. Using a Conclusion standardized scale of consistency and color changes, 1. The remineralisation of the affected dentine some authors found the remineralisation of dentine from acute carious lesions performed with zinc- in 94% of the cases after 2-19 months following the oxide-eugenol or with calcium-hydroxide liner and „stepwise” excavation technique (16). The clinical glassionomer cement in „stepwise” excavation and radiographical changes of the demineralized technique was present in 80% of the cases. dentine, following indirect pulp capping with 2. After 6 months, 90% of the acute carious lesions

Ca(OH)2 and zinc-oxyde-eugenol, after an interval of treated with calcium-hydroxide liner and zinc-oxide- 6-7 months, were assessed by different authors (4). eugenol in the „stepwise” excavation technique The affected dentine became hard dentine in 80% presented dentine remineralisation. of the treated teeth, while 16,67% of teeth presented 3. The „stepwise” excavation technique is an demineralized dentine with medium consistency. efficient approach in the treatment of acute dental In the same study, only 3,3% cases were associated caries maintaining pulp vitality in 90-100% of the with total absence of remineralisation processes. cases.

Bibliography

1. Oliveira EF, Carminatti G, Fontanella V, Maltz M.The 9. Goldberg M, Six N, Decup F. Bioactive molecules and the monitoring of deep caries lesions after incomplete dentine future of pulp therapy. Am J Dent. 2003;16(1):66–76. caries removal: results after 14-18 months. Clin Oral 10. Iovan Gianina. Diagnosis and Management of Patients Investig. 2006;10(2):134-139. with High Caries Activity. Apollonia Press, 2002 2. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after 11. Banerjee A, Kidd EAM, Watson TF. In vitro evaluation stepwise versus direct complete excavation of deep carious of five alternative methods of carious dentine excavation. lesions in young posterior permanent teeth. Endod Dent Caries Res. 2000;34 (2):144-150. Traumatol. 1996;12(4):192-196 12. Banerjee A, Kidd EAM, Watson T F. Scanning electron 3. Ricketts D. Management of the deep carious lesion and the microscopic observations of human dentine after mechanical vital pulp dentine complex. Br Dent J. 2001;191(11):606- caries excavation. J Dent. 2000;28 (3):179-186. 610. 13. Braut A, Kollar EEEJ, Mina M. Analysis of the odontogenic 4. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep and osteogenic potentials of dental pulp in vivo using a Col1a1- caries lesions after incomplete dentine caries removal:40- 2.3-GFPtransgene. Int J Dev Biol. 2003;47 (4):281-292. month follow-up study. Caries Res. 2007;41(6):493–496 14. Banerjee A., Watson T, Kidd E.A.M. Carious dentine excavation 5. Duque C, Negrini TD, Sacono NT, Spolidorio DM, de using Carisolv™ gei:a quantitative, autofluorescence assess¬ment Souza Costa CA, Hebling J. Clinical and microbiological using scanning microscopy. Caries Res. 1999;33(4):313 performance of resin-modified glass-ionomer liners after 15. Carneiro F.C, Teixeira F, Guimaraes L, Dias K, Naclanovsky incomplete dentine caries removal. Clin Oral Investig. P. Clinical comparison between chemo-mechanical and hand 2009;13 (4):465-471 instruments caries removal. J Dent Res. 2000;79 (5):295 6. Manton D. Partial caries removal may have advantages 16. Fure S, Lingstrom P, Birkhed D. Evaluation of Carisolv(TM) but limited evidence on restoration survival. Evid Based for the Chemo-Mechanical Removal of Primary Root Caries. Dent. 2013;14(3):74-75 Caries Res. 2000;34(3):275-280. 7. Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. 17. Love RM, Jenkinson HF. Invasion of dentinal tubules by Operative caries management in adults and children. Br oral bacteria. Crit Rev Oral Biol Med. 2002;13(2):171-183. Dent J. 2001;191(11):606-610. 18. Perdigäo J, Cardoso PEC, Lopes M, Moura SK, Geraldeli 8. Studervant CM. The art and science of operative dentistry. S, Cardoso. JMS. Effect of carisolv ™ on the hybrid layer. J. 3rd ed. St Louis:Mosby,1995 Dent. Res. 2000;79 (1 suppl):537

16 Stoma.eduJ (2014) 1 (1) REMINERALISATION OF AFFECTED DENTINE BY DIFFERENT BIOACTIVE MATERIALS IN STEPWISE - EXCAVATION TECHNIQUE

Sorin Andrian Professor, DDS, PhD, Department of Odontology, Periodontology and Fixed Prosthodontics, Faculty of Dental Medicine, „Gr.T.Popa” University of Medicine anf Pharmacy, Jassy, Romania

Doctor Sorin Andrian is professor of Cariology and Operative Dentistry at the Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, Jassy and he is a doctorate manager. He was head of the Department of Odontology and Periodontology and he was also deputy dean of the faculty. He has a masters degree in Medical Management and is the manager of postgraduate master in CV Odontology. He is also the deputy editor of the International Journal of Medical Dentistry and member in the editorial board of the Romanian Journal of Oral Rehabilitation. He participated at the ORCA and ADEE meeting in Berlin for developing the European core curriculum in Cariology. He is also a member of the University’s Ethical Committee and he is the president of the Romanian General Dental Council Disciplinary Committee.

Questions Regarding this study: q a. all the patients had a high cariogenic risk q b. all patients were old (over 50 years) q c. there were over 100 patients q d. There were only two study groups Regarding the changes of dentine colour accordingly to different bioactive materials: q a. 50% of the patients in group 1 presented a dark-brown colour q b. 50% of the patients in group 2 presented a dark-brown colour q c. 50% of the patients in group 3 presented a dark-brown colour q d. All the patients had a change in colour Regarding the changes of dentine consistency accordingly to different bioactive materials q a. 50% of the patients in group 1 presented a hard consistency q b. 50% of the patients in group 2 presented a hard consistency q c. 50% of the patients in group 3 presented a hard consistency q d. 50% of the patients in group 1 presented a soft consistency Regarding the pulp tissue: q a. The pulp tissue vitality was preserved in 75% of the cases q b. The pulp tissue was assesed 6 months after indirect pulp capping with Ca(OH)2 and zinc-oxyde-eugenol q c. no cases of chronic pulpitis were recorded q d. The study group presented 90% therapeutical success

17 orthodontics

Cite this article: Pacurar M, Jurca AM, NONEXTRACTION METHODS Roman D, Bud E, Zetu I, Vata I. Nonextraction methods for creating space in FOR CREATING SPACE orthodontic therapy. Stoma Edu J. 2014; 1(1):18-21. IN ORTHODONTIC THERAPY

Mariana Păcurar1a, Ana Maria Jurcă1c, Abstract Doru Roman1b*, Eugen Bud1c, Irina Nicoleta Zetu2b, Introduction: Molar distalization is an alternative treatment method in dento-maxillary Ioana Vâţă2c anomalies, to avoid extraction especially in low angle cases. The orthodontic literature 1. Orthodontic Department, Faculty of Dentistry, indicates that upper molar distalization is a tipping movement, combined with mesiobuccal University of Medicine and Pharmacy of rotation and buccally-crown torque. The aim of the study was to analyze the advantages Târgu-Mureş, Târgu-Mureş, Romania to create space during upper first molar distalization movement, by using different 2. Orthodontic Department, Faculty of Dentistry, „Gr.T.Popa” University of Medicine and devices. We used this method in skeletal Angle Class II, dental Class II/2 malocclusion with Pharmacy, Jassy, Romania crowding and low profile.

a. DDS, PhD, Professor, Methodology: The study consisted of a retrospective statistical analysis on 435 patients Dean of Faculty of Dentistry aged 11-13 years treated with fixed appliances (straight wire technique), between 2009- b. DDS, PhD, Lecturer 2012. The patients were divided in two groups: group A (83) who worn distalization c. DDS, Assistant Professor devices and group B (352) who did not. Group B was divided in: B1 (278) with other nonextraction appliances and B2 (74) with extraction during orthodontic treatment. Results: Upper molar distalization was successful in 45% of the cases, the values of the space being: 2,13- 2,33 mm, by tipping movement. Bodily distal upper molar movement was successfully obtained only when the rotational axis is at infinite and the compressive stress is homogeneously distributed in the periodontal ligament. The success rate depended on: eruption of the second molar, overjet and overbite size. Conclusions: 1. Molar distalization is a challenge in orthodontic treatment and is indicated for Angle Class II, crowding and low angle (extraction makes the profile worse). 2. Molar distalization depends on the position of the second molar and this technique is not singular, but associated with multibracket appliance . Key words: distalization, second molar, class II, extraction, fixed appliances.

Introduction

Modern orthodontic therapy attempts, whenever possible, a nonextraction treatment, with convenient means for the patient, which would allow current activities and it would not affect facial harmony (1). In this context, molar distalization is an useful treatment method in obtaining arcade space, especially in anomalies Angle Class II/2 with accentuated retrognatic profile and hipodivergent growth pattern, cases where extraction would obviously create aesthetic facial damage (2) . The authors propose in this paper an assessment of the molar distalization method in comparison with other nonextraction therapy methods (expansion, frontal protrusion and stripping). Methods Received: 19 November 2013 We conducted a retrospective statistical study on a sample of 435 patients, aged between Accepted: 11 March 2014 11-13 years, who were treated at the Orthodontic Department of the Faculty of Dentistry in * Corresponding author: Târgu Mureș in the period 2009-2012, for various malocclusions. Lecturer Doru Roman, DDS, PhD The initial sample was divided into two subgroups: group A - 83 patients average age Orthodontic Department, Faculty of Dentistry, 11,25 with upper or lower molar distalization. The following parameters were evaluated: University of Medicine and Pharmacy of Târgu- Mureş, Târgu-Mureş, Romania. - duration of treatment; 38 Gh. Marinescu Str., RO-540139, - type of distalization; Târgu-Mureş, Romania. - type of used appliance; Tel/Fax: +40265210407. e-mail: tudorroman2000@ yahoo.com - obtained results.

18 Stoma.eduJ (2014) 1 (1) Nonextraction methods for space regane in orthodontic therapy

Figure 1. Cases distributrion Figure 2. Correlation betwen owerjet and distalization

Figure 3. Correlation between Figure 4. Correlation between molar owerbite and distalization distalization and anomalies

Group B - represented by the rest of the In group A, represented by patients with molar patients, average age 12,15 were divided in distalization, the distribution on the arches was the two subgroups: B1 – cases of permanent teeth following: the upper jaw 11,26%, lower jaw 4,83% extractions and B2 - nonextraction cases, treated and bimaxilarry: 2.99% of cases (Table 2). with other methods than distalization. Table 2. The distribution of arches Results The distribution of cases by gender demonstrated No. cases % a predominance of female patients, representing Molar distalization 83 19.08% 64% of the studied group (Figure 1). Analysis of cases depending on the type Upper arch 49 11.26% of anomaly revealed a higher frequency of Angle Class I malocclusion (56,09%), Class II Lower arch 21 4.83% represented by 35% of which 20,69% Class II/1, and 14,71% Class II/2, and Angle Class III Upper and lower 13 2.99% malocclusion represented only 8,51% of the studied group (Table 1). Total 166

Table 1. The distribution of anomalies The distribution of cases from subgroup B2 includes: Angle Class No. cases % - upper expansion plate 34%; Angle Class I anomalies 244 56.09% - lower expansion plate 8%; - maxillary disjunction (rapid palatal expander) 4%; Angle Class II/1 anomalies 90 20.69% - functional therapy 2,5%; - class II elastics 37%; Angle Class II/2 anomalies 64 14.71% - lee-way-space maintenance 1,5%; - stripping (interproximal reduction) 13%. Angle Class III anomalies 37 8.51% Correlational analysis of the type of extractional/ Total 435 nonextractional treatment related to overjet shows that: for overjet values between 0-2 mm,

19 orthodontics

the most frequent therapy is nonextractional (other than distalization) in 60% of cases, followed by dental extraction in 28% of cases and molar distalization in 12% of cases. The frequency with which distalization was used decreases with the growth of overjet value (Figure 2) . Correlational analysis of the type of extractional/nonextractional treatment related to overbite shows that in open bite cases the extraction treatment is more frequent and in deep bite cases the most frequent treatment is nonextraction. (expander or stripping), followed by distalization cases (Figure 3). Figure 5. Correlation between type of Our study showed an increased incidence dentition and molar distalization of therapy with molar distalization in Class II/2 anomalies (28,13%), followed by Angle class I In the orthodontic field it is better to have (11,07%) and class II/1 (4,44%) (Figure 4). dental movement by translation (7). Regarding the type of dentition, we found But during distalization we obtain a distal that the difference in the incidence of upper tipping, is important to follow the maintenance molar distalization is not significant, between of initial molar angulation, adding to the initial permanent (10,81%) and mixed dentition coronal tipping a root distal tipping (8). (11,57%), as opposed to the lower jaw, with a Molar distalization is not a single orthodontic frequency of 7,02% in the mixed dentition and therapy, but has to be followed by fixed 2,16% in the permanent dentition (Figure 5). orthodontic treatment, which uses the obtained A major issue in this kind of therapy is the space for aligning the tooth and for overjet timing of treatment initiation. In group A the correction. mean age of the patients was 11,25 years and in Most authors recommend that distalization group B the mean age was 12,15 years. appliances should be inserted on an oral part of The highest chances of molar distalization the arch in order to be nearer to the resistance success are when the second molar has not yet centre. erupted. The other possibilities to have a translation movement during distalization is to put an extra- Discussion oral force (9). The updated data from the literature indicates that during molar distalization we obtain a distal Conclusions tipping and less corporal displacement because Molar distalization is a challenge in orthodontic the force application point is at a distance from treatment and is indicated for Angle II Class, the resistance center of the tooth (3,4). For crowding and low angle (extraction makes the bodily movement, the moment/force ratio at the profile worse). molar centre of resistance must be zero, so it is The rate of success in molar distalization is necessary to reduce the moment on the molar less than that in other nonextraction methods bond using a counterbalancing couple (CBC) and sometimes this method is followed by with effects in the vertical plane (5,6). extraction.

Bibliography

1. Proffit WR. Biomechanics and mechanics. Contemporary 6. Kinzinger GSM, Fritz UB, Sander FG, Diedrich PR. Efficiency of a Orthodontics 3rd ed. St Louis: Mosby Inc; 2000:298-305. pendulum appliance for molar distalization related to second and 2. Baccetti T, Franchi L, Kim LH. Effect of timing on the outcomes third molar eruption stage. Am J Orthod Dentofacial Orthop 2004; of 1-phase nonextraction therapy of Class II malocclusion. Am J 125 (1):8-23. Orthod Dentofacial Orthop. 2009;136(4):501-509. 7. Birte M. Biological reaction of alveolar bone to orthodontic tooth 3. Antonarakis GS, Kiliaridis S. Maxillary molar distalization with movement. The Angle Ortodontist. 1999;69(2):151-158. noncompliance intramaxillary appliances in Class II malocclusion. 8. Papadopoulos MA, Mavropoulos A, Karamouzos A. Cephalometric A systematic review. Angle Orthod 2008, 78(6):1133-1140. changes following simultaneous first and second maxillary molar 4. Escobar SA, Tellez PA, Moncada CA, Villegas CA, Latorre CM, Oberti G. distalization. J Orofac Orthop 2004;65 (2):123-136. Distalization of maxillary molars with the bone supported pendulum. A 9. Klontz H. The Extraction/nonextraction dilemma – the Class II clinical study. Am J Orthod Dentofacial Orthop 2007;131(4):545-549. solution. The Tweed Profile. 2006;5:25-30. 5. Henneman S, Von den Hoff JW, Maltha J.C. Mechanobiology of 10. Korkmaz S, Fulya I, Ferdi A, Tülin A. Unilateral molar distalization tooth movement. Eur J Orthod. 2008;30(3):299-306. with a modified slider. Eur J Orthod. 2006;28(4):361-365.

20 Stoma.eduJ (2014) 1 (1) Nonextraction methods for space regane in orthodontic therapy

Mariana Păcurar Professor, DDS, PhD, University of Medicine and Pharmacy Târgu-Mureş, Faculty of Dentistry, Orthodontic Department, Târgu-Mureş, România

Mariana Pacurar is a full professor of Pedodontics and Orthodontics at the University of Medicine and Pharmacy Târgu-Mureş and dean of the Faculty of Dental Medicine. In 1983 graduated from the Faculty of Dental Medicine (MD degree), the University of Medicine and Pharmacy Târgu-Mureş. Doctor in Dental Medicine (PhD, 1999) at the University of Medicine and CV Pharmacy Târgu-Mureş. Competence in radiological diagnosis in dental medicine at University of Medicine and Pharmacy Cluj-Napoca (2000). She is head of Pediatric Dentistry Clinics at Târgu-Mureş, and also head of Pedodontics-Orthodontics Department of the Faculty of Dental Medicine in Târgu-Mureş. She is author of more than 150 research papers and 7 books on several topics in orthodontics, pedodontics and general dentistry.

Questions This study was: q a. Prospective q b. Retrospective q c. A case presentation q d. A case series Regarding the participants to the study: q a. There were more male patients q b. Class I Angle malocclusions represented over half (50%) of all the anomalies q c. Class II represented over half (50%) of all the anomalies q d. Cass III Angle malocclusions were over a quarter (25%) of all the anomalies Regarding molar distalization: q a. Almost 50% of patients presented with molar distalization q b. The upper jaw was involved in 20% of all the patients q c. The lower jaw was affected in 7.5% of all cases q d. Both the upper and lower arches were affected in almost 3% of all the cases Among the conclusions of this study: q a. Molar distalization was successful in over half the cases; q b. The average treatment period for molar distalization was 9 months q c. Molar distalization has a smaller or the same chance of success in patients in whom the second molar hasn’t erupted q d. An increase in overjet is associated with the success of the treatment

21 Periodontics

Cite this article: Miricescu D, Totan A, Salivary and serum enzymes as Calenic B, Mocanu B, Greabu M. Salivary and serum enzymes as diagnostic biomarkers in diagnostic biomarkers in patients patients with periodontal disease. Stoma Edu J. 2014; 1(1):22-27. with periodontal disease

Daniela Miricescu1a, Alexandra Totan1b, Abstract Bogdan Calenic1c, Brânduşa Mocanu2c, Maria Greabu1d* Introduction: Periodontitis is a common oral affection characterized by inflammation, connective tissue breakdown and, finally, alveolar bone loss. One feature of the 1. Department of Biochemistry, Faculty of Dental Medicine, "Carol Davila" University of Medicine inflammatory process is the release of enzymes from different oral tissues.T he general and Pharmacy, Bucharest, Romania aim of the present study was to detect salivary and serum enzyme levels in patients with 2. Department of Periodontology, Faculty of Dental Medicine, "Carol Davila" University of periodontitis. Medicine and Pharmacy, Bucharest, Romania Methodology: We included 20 patients with chronic periodontitis and 20 controls. a. PhD, Teaching Assistant Unstimulated whole saliva and serum was used to detect the enzymes employing b. PhD, Lecturer c. DDs, PhD, Teaching Assistant the kinetic method and an automatic analyzer. Patients and healthy controls were d. PhD, Professor, Head of Department investigated for plaque index (PI), bleeding index (GI) and probing depth (PD) (p<0.05). The following enzymes were analyzed: aspartate aminotransferase (AST), lactate dehydrogenase (LDH), alkaline phosphatase (ALP) and gamaglutamil transferase (GGT). Results: The saliva of patients with periodontal disease presented significantly decreased levels of LDH and ALP. Significantly increased levels of serumALP and GGT were observed in patients with periodontal disease. At the same time no statistical difference was found between controls and periodontitis patients for AST and LDH. Also salivary levels for GGT were decreased, while for AST the levels were increased but the difference was not statistically significant. Conclusion: The activity of these enzymes in the saliva and serum of patients with periodontal disease may represent a useful tool in diagnosing, monitoring and treating chronic periodontitis. Keywords: saliva, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, gamaglutamil transferase, periodontitis.

Introduction Whole saliva is secreted by three major and many minor salivary glands. It contains locally produced biomolecules as well as other molecules derived from the systemic circulation. Whole saliva can contain proteins, serum products, electrolytes, immune and epithelial cells and gingival crevicular fluid (GCF) (1,2). Periodontal disease is one of the most widespread oral diseases. It is a chronic bacterial infection characterized by inflammation, connective tissue breakdown and, finally, alveolar bone loss (3).F ollowing general inflammatory processes, periodontal affections are characterized by the release of enzymes from stromal, bacterial, inflammatory and epithelial cells (4). These intracellular enzymes are released from damaged cells in the periodontal tissues into the GCF, saliva and surrounding fluids (4). Studies show that the most important enzymes Received: 11 December 2013 involved in the process include: aspartate and alanine aminotransferases (AST and ALT), lactate Accepted: 15 January 2014 dehydrogenase (LDH), alkaline phosphatase (ALP), gamaglutamil transferase (GGT), creatine kinase (CK) and acidic phosphatase (PAP) (4-6). However, to date, there is limited data on the * Corresponding author: levels of these enzymes in the saliva and serum of patients with periodontal diseases. The main Professor Maria Greabu, PhD, aim of our study was to detect the activities of AST, LDH, ALP and GGT in the saliva and serum Head of Department Department of Biochemistry, of patients with periodontal disease. Faculty of Dental Medicine, "Carol Davila" University of Medicine and Methods Pharmacy, Bucharest, Romania 8 Blvd. Eroii Sanitari, Sector 5, RO-050474 Patients Bucharest, Romania This study was reviewed and approved by the ethics board of the “Carol Davila” University Tel: +40755044047, Fax: +4021 3110984. e-mail: [email protected] of Medicine and Pharmacy, Faculty of Dental Medicine. Informed consent was obtained

22 Stoma.eduJ (2014) 1 (1) Salivary and serum enzymes as diagnostic biomarkers at patients with periodontal disease

Table 1. Clinical parameters for periodontal disease

Patients Controls Variable p value (n=20) (n=20)

PI (%) 48±0.21 19±0.60 <0.05

GI (%) 62.8±0.34 14.6±0.32 <0.05

PD (>5 mm) 4.41 ±0.42 0 <0.05 from each participant who agreed to participate Chemical reaction: p-Nitro-phenylphosphate + voluntarily in this study. The study was carried in H20 → p-Nitrophenol + Phosphate 20 patients with chronic periodontitis (5 males and Salivary and serum assay for LDH 15 females; mean age 51.26±7.4 years). Twenty Chemical reaction: L-lactate + pyruvate + NAD+ healthy subjects with no gingival inflammation, ← → NADH + H+ good oral hygiene and no history of periodontal Salivary and serum assay for GGT disease were grouped as controls. All patients GGT catalyzes the transfer of γ-glutamate included in the study fulfilled the following from L-γ-glutamyl-3-carboxy-4-nitroanilide in criteria: absence of any systemic disease; no use glycylglycine to form L-γ-glutamilglicilglicine and of systemic medications like antibiotics within the 5-amino-2-nitrobenzene yellow. The absorbance preceding three months, anti-inflammatory drugs is read at 405 nm. or anti-oxidant drugs, no history of tobacco usage Chemical reaction: or alcoholism. Periodontal status was determined L-γ-glutamyl-3-carboxy-4 nitroanilide + glycylglycine by measuring PD (probing depth), gingival index → L-γ glutamilglicilglicine + 5 amino 2-nitrobenzene. (GI) and plaque index (PI). Statistical analysis Saliva sampling Data distributions were expressed as means, The subjects included in this study were told standard deviations (SD), ranges, and percentages, not to eat or drink anything in the morning before as appropriate. The Pearson’s correlation the collection of the samples. Unstimulated whole coefficient and ANOVA test were used. The data saliva was collected into sterile tubes between 9 were analyzed statistically on the computer using and 10 a.m. after a single mouth rinse with 10 mL of StataIC 11 (StataCorp. 2009. Stata: Release 11. distilled water to wash out exfoliated cells. About StatisticalSoftware. College Station, TX, USA). 2 mL of unstimulated whole saliva collected was A p-value < 0.05 was considered statistically immediately centrifuged at 3000 rpm for 10 min significant. to remove cell debris. The supernatant was kept and stored in small aliquots at -80ºC until further Results analysis. Patients and healthy controls were investigated Serum sampling for plaque index (PI), bleeding index (GI), and At the same time, 5 ml of blood were collected probing depth (PD) (p<0.05). Results are detailed and the serum obtained was used for our in Table 1. determinations. All biomarkers were performed In the saliva of patients with chronic periodontitis, using the kinetic method at an automatic analyzer significantly decreased levels ofLDH and ALP were (A15 Biosystems, Spain). detected. The salivary level of GGT was decreased Serum and salivary AST and the salivary level of AST was increased but AST catalyzes the transfer of amino groups from both were not statistically significant (Table 2). the aspartate molecule to 2-oxoglutarate, forming Significantly increased levels for serum ALP and oxaloacetate and glutamate. Enzyme activity is GGT were obtained from patients with periodontal determined by measuring the decrease in NADH disease. Increased serum levels for AST and LDH concentration at 340nm through the reaction were also found (Table 3). catalyzed by malate dehydrogenase (MDH). Chemical reaction: Aspartam+2-oxoglutarate → Discussion glutamate + oxaloacetate During the past few decades, many biomarkers Oxaloacetate + NADH + H+ → L-malate + NAD+ have been proposed for the diagnosis of Salivary and serum assay for ALP periodontal disease, such as intracellular enzymes. Under the action of ALP, p-nitrophenilphosphate Their activity can be detected in unstimulated (colorless) is converted to p-nitrophenol, the saliva and in GCF. If the periodontal tissue is yellow colored compound. The color intensity is damaged or if the cells are affected due to edema proportional to the activity of ALP in the sample. or cellular damage, intracellular enzymes are

23 Periodontics

Table 2. Salivary levels

Parameters Patients Controls p value

LDH U/mg proteins 102,89±96 179,06 <0.005

ALP U/mg proteins 24,76±25,81 66,82±26,27 <0.005

GGT U/mg proteins 6,81 7 <0.3

AST U/mg proteins 20,31±25,65 13,27 <0.43

Table 3. Serum levels from patients with periodontal disease

Parameters Patients Controls p value

LDH U/L 261,83±45,97 224,6±45,36 <0.1

ALP U/L 56,5±20,04 17,04±0,18 <0.005

GGT U/L 25,33±8,64 14,04±3,37 <0.001

AST U/L 15,15±16,78 13,58 <0.6

released into the GCF and saliva (4,7). LDH, AST, et al. detected an increased salivary level of LDH and GGT are intracellular enzymes also present in in patients with periodontal probing pocket depth oral soft tissues. Their activity is increased in saliva > 5mm (13). Atici et al. measured LDH in GCF and as a consequence of release from damaged cells observed that the progression of periodontal in the periodontal soft tissue and inflamed gums. disease is associated with this enzyme (14). GGT In our study, these enzymes have been detected in is a key enzyme which can be regarded as a unstimulated whole saliva (8). ALP is an intracellular new important oxidative stress biomarker and a enzyme present predominantly in the bone, indicator of cellular damage (8,15). Dabra et al. being the first enzyme determined in periodontal detected an increased level of GGT in stimulated disease (7,8). Dabra et al. detected an increased saliva of patients with periodontal disease (6). level of this enzyme in the stimulated saliva of Todorovic et al. obtained an increased level of GGT patients with periodontal disease (6). Todorovic in unstimulated saliva. In our study we detected et al. also reported an increased activity of ALP decreased levels of GGT but without a statistically in the unstimulated saliva of 187 patients with significant difference (4). The decreased level of periodontal disease (4). In our study we obtained GGT, may reflect the presence of oral oxidative a statistically significant decrease of salivary ALP stress in patients with periodontitis. The only enzyme in patients with periodontal disease compared to that showed increased levels in unstimulated the healthy patients group. Studies have shown a whole saliva of patients with periodontitis was remarkable increase of this enzyme in the acute AST. Increased levels of AST were also reported by phase of periodontal disease (7-10). Increased Todorovic et al. in unstimulated saliva of patients activity in saliva is probably a consequence of with periodontal disease (4). The results obtained the destructive processes in the alveolar bone in in our study may have several explanations: after advanced stages of periodontal disease. Yan F determining these intracellular enzymes patients et al. considered that ALP was increased in the included in the study may or may not have been acute phase of periodontal disease, suggesting in an advanced stage of periodontal disease. that the periodontal disease is well advanced (11). At the time of collection of the biological samples, The salivary enzymatic activity of ALP significantly it is possible that patients were in different stages of decreases during periodontal ligament attachment periodontal disease. Our study used unstimulated loss and bone resorption. Release of cytokines (IL- whole saliva vs GCF because saliva collection has 1β) during bone resorption may inhibit proliferation several clear advantages: no need for specialized of periodontal ligament cells such as osteoblasts equipment or techniques, much faster and more (12). The LDH level was also significantly decreased convenient for both the patient and the medical in the saliva of patients with periodontal disease staff. Because whole saliva contains numerous compared to healthy patients group. Zappacosta biomarkers derived from all the structures of the

24 Stoma.eduJ (2014) 1 (1) Salivary and serum enzymes as diagnostic biomarkers at patients with periodontal disease oral cavity, analyzing biomarkers in saliva may LDH was increased but the increase was not statistically provide a thorough overview of the periodontal significant.T his increase in LDH levels may be a warning status compared with GCF. Studies show that sign even if it was not a statistically significant value. different results are due primarily to different Beck and colleagues have postulated a connection processing methods for the saliva. Therefore the between periodontal disease and atherosclerosis. As study design requires careful standardization in such, people suffering from periodontal disease may be the collection and processing of saliva. Numerous at increased risk of atherosclerosis (26). GGT is present studies show that there is a direct relationship in the kidney, pancreas and liver. Significant increases between periodontal complications and many of GGT activity have been recorded in cholestasis, systemic diseases such as cardiovascular disease, alcoholism and hepatic tumors. Moderate increases metabolic syndrome or diabetes (16-20). Another were observed for chronic hepatitis and pancreatitis aim of the present study was to test the hypothesis (22). In our experiments, GGT levels were statistically that periodontal disease can influence general increased in the serum from patients with periodontal health by analyzing enzymatic levels. In the serum of disease versus the healthy subjects. AST is a widespread patients with periodontal disease we have obtained enzyme, mainly localized in the liver, myocardium or a series of changes in the enzymatic activity of ALP, muscle, but also present in small amounts in the lungs, LDH, GGT and AST in patients with periodontal kidneys, pancreas and erythrocytes. Marked increments disease when compared with the control group. of AST are present in myocardial infarction, acute ALP is present especially in bones and the liver, hepatitis or toxic liver damage. Moderate increases duodenum and kidney. Increased levels of this are observed in patients with chronic hepatitis and enzyme have been recorded in skeletal damage infectious mononucleosis (22,27). The enzymatic associated with osteoblastic reaction and cholestasis activity of AST was increased (p>0.05) in the serum of (21, 22). Our overall results show that the serum levels patients with periodontal disease versus the healthy of the enzyme in patients with periodontal disease group. are statistically increased when compared to the control group. Previous studies show an association Conclusion between periodontal disease and osteoporosis, The salivary and serum enzymes detected in our especially in postmenopausal women (23,24). Our study can be useful in the monitoring of patients group of patients with periodontal disease included with periodontal disease. 15 females with the average age of over 50 years so they present higher risk of osteoporosis. LDH is Acknowledgements present especially in the muscle, liver, myocardium, This study was supported by the Sectorial kidney and erythrocytes. Marked increase of the enzyme Operational Programme Human Programme activity of LDH is found in myocardial infarction, toxic Human Resources Development (SOP HRD), liver damage or testicular cancer. Moderate increments financed from the European social Fund and by of LDH were also found in muscle disease, hemolysis the Romanian Government under the contract and malignant lymphoma (22,25). In our experiments, number POSDRU/6/1.5/S/S17.

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1. Miller CS, King CP, Chris-Langub Jr M, Kryscio J, Thomas 8. Ozmeric N: Advances in periodontal disease markers. Clin MV: Salivary biomarkers of existing periodontal disease: A Chim Acta 2004, 343 (1-2):1-16. cross-sectional study. J Am Dent Assoc 2006, 137(3): 322-329. 9. Nomura Y, Shimada Y, Hanada N, Numabe Y, Kamoi K, Sato 2. Spielmann N, Wong DT: Saliva: diagnostics and therapeutic T, Gomi K, Arai T, Inagaki K, Fukuda M, Noguchi T, Yoshie H: perspectives. Oral Dis 2011, 17(4):345-354. Salivary biomarkers for predicting the progression of chronic 3. Ridgeway EE: Periodontal disease: diagnosis and periodontitis. Arch Oral Biol 2012, 57(4):413-420 management. J Am Acad Nurse Pract 2000,12(3):79-84. 10. Totan A, Greabu M, Totan C, Spinu T: Salivary aspartate 4. Todorov T, Dozic I, Barrero MV, Ljuskovic B, Pejovic J, Marjanovic aminotransferase, alanine aminotransferase and alkaline M, Knezevic M: Salivary enzymes and periodontal disease. Med phoshatase: possible markers in periodontal diseases?. Clin Oral Patol Oral Circ Bucal 2006, 11(2): E115-119. Chem Lab Med 2006, 44(5):612-615. 5. Miller CS, Foley JD, Bailey AL, Campell CL, Humphries RL, 11. Yan F: Alkaline phosphatise level in gingival crevicular Floriano NCP, Simmons G: Curent developments in salivary fluid of periodontities before and after periodontal treatment. diagnostics. Biomarkers Med 2010, 4(1):171-189. Chung Hua Kou Chiang Hseuch Tsa Chin 1995, 30(4):204-206, 6. Dabra S, China K, Kaushik A: Salivary enzymes as diagnostic 255-256. markers for detection of gingival/periodontal disease and 12. Agawal S, Chandra CS, Piesco NP, Langkamp HH, Bowen L, their correlation with the severity of the disease. J Indian Soc Baran C: Regulation of periodontal ligament cell functions by Periodontol 2012, 16(3):358-364. interleukin-1 beta. Infect Immun 1998, 66(3):932-937. 7. Kaufman E, Lamster I: Analysis of saliva for periodontal 13. Zappacosta B, Manni A, Persichilli S, Boari A, Scribano D, diagnosis. J Clin Periodontol 2000, 27(7):453-465. Minucci A, Raffaelli L, Giardina B, De Sole P: Salivary thiols and

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26 Stoma.eduJ (2014) 1 (1) Salivary and serum enzymes as diagnostic biomarkers at patients with periodontal disease

Daniela Miricescu Teaching Assistant, PhD, Department of Biochemistry, Faculty of Dental Medicine “Carol Davila”, University of Medicine and Pharmacy, Bucharest, Romania.

Her PhD, focused on the study oxidative stress as a new pathological biochemical mechanism in oral diseases, using saliva as a new diagnostic fluid in oral diseases. In the spring of 2011, during an exchange program, she worked at the Università Politecnica delle Marche, Italia, under the direct supervi- sion of Maurizio Battino, PhD, DSc, MS, MD (Hon), focusing on the CV biochemical mechanisms of oxidative stress and antioxidants. Her current research interests are, oxidative stress, oral stem cells prop- erties, nanoparticles, and their possible interaction with the oral stem cells and generation of oxidative stress.

Questions Regarding this study:

q a. 40 patients were included in the study group q b. The general aim of the present study was to detect ONLY the salivary enzyme activities q c. no laboratory markers were studied q d. Periodontal status was established using classic clinical parameters, plaque index, bleeding index and probing depth Regarding the plaque index (PI), bleeding index (GI) and probing depth (PD):

q a. all the results were statistically significant q b. The PI in the study group was 48±0.21 q c. The GI in the study group was 48±0.21 q d. The PD in the study group was 48±0.21 Regarding the salivary levels:

q a. The LDH in the patients was 102,89±96 q b. The ALP in the patients was 102,89±96 q c. The GGT in the patients was 102,89±96 q d. The AST in the patients was 102,89±96 Regarding the serum levels from patients with periodontal disease:

q a. The LDH in the patients was 25,33±8,64 q b. The ALP in the patients was 25,33±8,64 q c. The GGT in the patients was 25,33±8,64 q d. The AST in the patients was 25,33±8,64

27 occlusion

Cite this article: Croitoru CI, Marinescu ETIOLOGICAL CONSIDERATIONS IR, Draghici EC, Popescu SM, Scrieciu M, Mercut V. Etiological consideration in bruxism. Stoma Edu J. IN BRUXISM 2014; 1(1):28-32.

Cristiana Ileana Croitoru1a, Iulia Roxana Marinescu1a, Abstract Emma Cristina Drăghici2b, Sanda Mihaela Popescu2c*, Monica Scrieciu3d, The etiology of bruxism is controversial, many factors being implicated, like occlusion, Veronica Mercuţ3e psycho-behavioral factors, and genetic factors. The aim of the present review was 1. University of Medicine and Pharmacy to systematically assess the literature and identify main theories regarding the of Craiova, Craiova, Romania etiology of bruxism. Data extraction was carried out according to the standard 2. Oral Rehabilitation Department, Faculty of Cochrane systematic review methodology. The following databases were searched: Dental Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania PubMed, Google Scholar, Medline and the Google library. The primary outcome 3. Prosthetics Department, Faculty of Dental was bruxism etiology. Screening of eligible studies and data extraction were conducted Medicine, University of Medicine and Pharmacy independently and in duplicate. The references were analyzed by two reviewers using of Craiova, Craiova, Romania a. DDS, PhD student the same search strategy and the same inclusion criteria were applied to the selected b. DDS, Asisstant Professor, PhD student studies. Query terms used were „bruxism”, „etiology” and „mechanism”. Among the 95 c. MDM, PhD, Associate Professor, related articles that were critically assessed, 31 were included in the critical appraisal. d. MDM, PhD, Associate Professor e. MDM, PhD, Professor, There is convincing evidence that the etiology of bruxism is various, involving local, Dean of Faculty of Dental Medicine systemic and psycho-behavioral factors. Key words: bruxism etiology, psycho-behavioral factors

1.INTRODUCTION Bruxism is a term generally used to define daytime and night time parafunctional activities of the masticatory system, which includes strained jaw and teeth grinding friction associated with tooth wear, myalgia of the masticatory muscles, temporomandibular joint disorders and morning fatigue. Hippocrates, quoted by Rozencweig (1), pointed out that “dental wear is soul’s clutter”. This aphorism shows the dimension of this condition, which is outside the oro-dental sphere. In 1907, Karolyi then Marie and Pietkiewicz, used the term “bruxomania”, considering that “dental wear brings together at the same time the damages of the central nervous system”(2). The term bruxism was first used in the literature in 1931 by Frohman for “non-functional grinding and rubbing the teeth” (3). Over time there had been an ongoing concern for establishing a complete and comprehensive definition, related to the clinical manifestations of bruxism to explain at the same time the etiopathogenic mechanisms involved in the production and maintenance of bruxism. Lavigne et al. (4) performed several studies on bruxism and concluded that the definition has evolved from the first considerations which were mainly referring to dental contacts and muscle contractions to considerations that relate to behavioral aspects and in particular the Received: 09 November 2013 knowledge of sleep problems. Accepted: 06 December 2013 The aim of the present review was to systematically assess the literature and identify main theories regarding etiology of bruxism. * Corresponding author: Associate Professor Sanda Mihaela Popescu, 2. METHODS MDM, PhD Faculty of Dental Medicine, University of In the literature, more than 400 articles on bruxism are available. Medicine and Pharmacy of Craiova, Craiova, Romania. Data Sources: Data extraction was carried out according to the standard Cochrane 2-4 Petru Rares Str., RO-200349 Craiova, systematic review methodology. The following databases were searched: PubMed, Google Dolj, Romania. Tel/Fax: +40251524442. Scholar, Medline and the Google library. Case reports, reports with reviews and systematic e-mail: [email protected] review articles written in English were included.

28 Stoma.eduJ (2014) 1 (1) ETIOLOGICAL CONSIDERATIONS IN BRUXISM

Data Selection: The primary outcome According to Minagi et al (12) muscular dynamics was bruxism etiology. during sleep are unique compared to that during Data Extraction: Screening of eligible studies and voluntary clenching, and exert a greater mechanical data extraction were conducted independently and load to the balancing side temporomandibular joint. in duplicate. The references were analyzed by two In 2001, Rosales et al. (13) showed that the reviewers using the same search strategy and the relationship between occlusal disorders and bruxism same inclusion criteria were applied to the selected was not very consistent. Also, in a review in 2012, studies. Query terms used were „bruxism”, „etiology”, Lobezzo et al (14) concluded that to date, there is and „mechanism”. Among the 95 related articles no evidence whatsoever for a causal relationship that were critically assessed, 31 were included in the between bruxism and the bite. critical appraisal. 3.2. MUSCLE ETIOLOGY HYPOTHESIS There are authors who associated muscle 3. DATA SYNTHESIS pathology and bruxism. Hellmann et al (15) argued Internationally, the recent data published in the that anterior and posterior neck muscles co-contract literature, shows that there is a consensus regarding during jaw clenching, their findings supporting the a various etiologic involvement (5) in the pathogenic assumption of a relationship between jaw clenching mechanisms of bruxism. and the activity of the neck muscles investigated. The first opinions on the etiology of bruxism were 3.3. THE HYPOTHESIS OF PSYCHO-BEHAVIORAL considered to be the dental bite and the pathology ETIOLOGY of muscle contractions. Behavioural factors and The psycho-behavioural factors whose influence in particular, aspects related to sleep, were also on bruxism etiopathology is accepted by the majority included as etiological factors (6). of the specialists are: stress, anger, fear, repressed Attanasio R. (7), Lobbezoo et al (8), and Nascimento aggressiveness etc. During the evolution of research, et al. (9) showed that the etiology of sleep bruxism which had the goal of establishing the etiopathology involved local factors, systemic factors, psychological of bruxism, an important moment was considered to factors and hereditary factors. be the one when stress was regarded as a decisive 3.1. THE HYPOTHESIS OF OCCLUSAL ETIOLOGY factor. Regarding local occlusal etiology of bruxism there Rugh and Solberg (16,17) demonstrated the were different opinions over time. If in 1966 Ramfjord increase in intensity of bruxism episodes together et al. (10) believed that occlusal factors, particularly with the increase of stress level. Kato (18) took into occlusal interference, would have an important role consideration the cognitive - behavioural factors in the determination of bruxism, in 1984 Rugh et such as stress, personality and anxiety in the etiology al. (11) proved, by creating experimental occlusal of bruxism and considered that patients with bruxism interference, that the role of occlusal disharmony presented an anxious personality and that the is secondary to bruxism, since correcting occlusal dominant of their personality represents the reaching interference did not lead to the disappearance of / fulfillment of personal goals. bruxism. The same situation occurred in patients with Okeson (19) showed that patients with bruxism complete edentulism, which in the dentate period had a greater emotional stability, were more had bruxism. After wearing dentures, the bruxism meticulous and got better learning results. Lavigne reappeared. (20) showed that bruxism was connected to anxiety However, the first affirmation on the role of occlusal and was secondary to micro excitations during sleep interference in bruxism was based on the fact that (the increase of the cortical activity and cardiac occlusal interference suppression in patients with frequency) followed by the grinding of teeth. Lavigne bruxism produced an improvement in symptoms. (21) pointed out that nocturnal bruxism must be This is evident in current dental practice. Ramfjord differentiated from diurnal bruxism, the latter being (10) called centric bruxism the frequent jaw clenching. linked to the organism’s reaction to stress or anxiety The author argued that when clenching teeth were and being manifested like a contraction tic of the accompanied by grinding, this occurred in the central mobilizing muscles of the mandible. occlusal area, in the absence of occlusal interference 3.3.1. BRUXISM AS A SLEEP DISORDER even in the presence of a stable occlusion, with slight Sleep is an active state which takes 30% of our slip of the teeth, of the mandible from centric relation time, and is part of our vital behavior being essential to maximum intercuspidation. to the survival and life quality of any individual. Sleep Occlusal contacts during sleep, specific to is made up of a succession of repeated stages which bruxism, could be interrupted by swallowing, and can be pointed out through EEG, EKG, EMG and eye muscle forces that appear during bruxism might movements. Specialists described two types of sleep exceed those of mastication. During sleep grinding, REM (Rapid Eye Movement) and NREM (Non Rapid electromyographic bursts of the masseter muscle Eye Movement). There are several stages described: were observed mainly with mediotrusive mandibular in NREM there are stages 1 and 2 corresponding to movement from the canine edge-to-edge position. light sleep as well as stages 3 and 4 corresponding

29 occlusion

to deep sleep, and in REM there is the paradoxical The role of dopamine, as a causing factor of sleep which includes the dreaming period. bruxism, is that of dopaminergic psycho stimulus These stages of sleep alternate during a period (the same as amphetamines), worsening the bruxism of approximately 90 minutes on the average and episodes. The dopaminergic system has been repeat themselves four or five times. placed in an important position in the regulation of The idea that bruxism was produced during stereotypical movements and in control of motion paradoxical sleep has been present, but it seems that problems during sleep (4,24). bruxism might also be present during stages 1 and 2 Yet, the voices announcing that dopamine plays of the NREM sleep. These periods were associated a key role in bruxism etiology, are today more with episodes of micro wakening, body movements temperate. The selective inhibitors for the reuptake of and temporary acceleration of the cardiac rhythm serotonin have a direct influence on the dopaminergic (6). system. Lobezzo et al. (25,26) stated that dopamine Nascimento underlined the fact that nocturnal did not have an essential role in producing bruxism, bruxism was found in all the stages of sleep but more as the selective inhibitors for the serotonin reuptake often in stages 1 and 2 (9). receptors had a direct influence on the dopaminergic Kato (22) did polysomnographic recordings in system. These serotonin inhibitors are represented which he specified the events which took place in by antidepressants currently prescribed and which, stage 2 of sleep in normal subjects with bruxism. In used for a long time, can maintain or induce bruxism. the second stage the increase of cardiac frequency In spite of these, the authors consider that bruxism has been noticed through the intensification of the can be adjusted at the central nervous system level autonomous cardiac system, and during the last stage and not at the peripheral one. rhythmic activity of the masticatory muscles (ARMM) 3.4. GENETIC ETIOLOGY HYPOTHESIS was observed. The authors have ascertained that in The genetic etiology hypothesis (27) was advanced, normal subjects the endogenous micro excitations but the transmission mechanism could not be appear approximately four seconds before ARMM demonstrated. Clinically, bruxism occurrences have while in bruxism they appear 10-60 seconds before. been observed in patients belonging to the same The increase of cardiac frequency, in normal subjects, families (parents, children or brothers). The original appears at the beginning of an ARMM episode, hypothesis about the fact that nocturnal bruxism while in patients with bruxism a gradual increase of may be associated with a familial predisposition was cardiac frequency appears before the beginning of supported by studies on twins (27). Obviously, these ARMM and an acceleration of the cardiac frequency observations cannot be considered as the results of is detected at the beginning of the bruxism episode. a research process. It is still unclear why the ARMM is three times more In a case-control study, Abe et al (28) investigated frequent and 30% more ample in bruxers than in the association of genetic, psychological and patients without bruxism (20). Hence the hypothesis behavioural factors with sleep bruxism in a Japanese that bruxism is a parasomnia. population. Their analysis revealed that only the In 2005, the American Academy of Sleep C allele carrier of the HTR2A single nucleotide Medicine published the International Classification polymorphism rs6313 (102C>T) was significantly of Sleep Disorders 2nd ed. Westchester, showing associated with an increased risk of sleep bruxism that „nocturnal bruxism is defined as a disorder of (odds ratio = 4.250, 95% confidence interval: 1.599- the stereotypical movements during sleep and is 11.297, p = 0.004), suggesting a possible genetic characterized by the grinding of teeth or/and the contribution to the etiology of sleep bruxism. clenching of teeth.” According to this classification 3.5. OTHER FACTORS POSSIBLY INVOLVED IN nocturnal bruxism is a sleep disorder, being included BRUXISM’S ETIOLOGY in the parasomnias (23). In 2003, Winocur et al. (29) published a study 3.3.2. THE ROLE OF THE CHEMICAL MEDIATORS showing the correlations between the consumption IN BRUXISM of alcohol, tobacco, drugs and pills and bruxism During recent years, at Lavigne’s insistences, the occurrences. In 2006, Lobezzo et al (8) showed research paths have lead towards neuropsychology that bruxism might be a brain injury consequence in order to explain the mechanisms involved in the and might be associated with some psychiatric or apparition and maintenance of bruxism, by invoking neurological diseases. Also, bruxism was linked to the role of some neuromediators such as dopamine the use of amphetamines, levodopa, phenothiazines and serotonin. Dopamine and serotonin are and alcohol. Lavigne et al. (21) stated that the ARMM neurotransmitters which ensure the communication and nocturnal bruxism episodes were influenced by between neurons. Dopamine is involved in lust, an increase in the electrical activity of the brain and pleasure and movement. Its deficit is met inP arkinson by the stimulation of the ascending reticular system, disease which is accompanied by a deficit of which increased the activity of the motor neuronal movement and in schizophrenia. Serotonin has a role network and of the cardiac autonomic system. in adjusting sleep, appetite and humour. Its deficit is According to Behr et al (30), theories on factors met in case of anxious states and depressions (4,24). causing bruxism are a matter of controversy in the

30 Stoma.eduJ (2014) 1 (1) ETIOLOGICAL CONSIDERATIONS IN BRUXISM current literature, two main etiological models occlusal interferences in the etiology of bruxism, but being the most important. The first one were affirmed that, until now, there could not exist a clearly peripheral local morphological disorders, such as established direct causal link between a specific malocclusion. This etiological model is based on etiologic factor and bruxism (31). Just like the occlusal the theory that occlusal maladjustment results in trauma, it is sure that only one etiologic factor cannot reduced masticatory muscle tone. In the absence be incriminated in the etiology of bruxism. of occlusal equilibration, motor neuron activity of The evidence of this finding is that, to date, there is masticatory muscles is triggered by periodontal not a single therapeutic method to obtain the removal receptors. The second theory assumes that central or improvement of bruxism; there are always more disturbances in the area of the basal ganglia are associated therapeutic procedures (31). the main cause of bruxism. An imbalance in circuit processing of the basal ganglia is supposed to 4. CONCLUSIONS be responsible for muscle hyperactivity during * Bruxism is a dental disorder that deeply alters the nocturnal dyskinesia such as bruxism. dento-maxillary system’s normal functionality. In Romania, the recent most important views * The etiology of bruxism is varied, involving local, on bruxism considered particularly the stress and systemic and psycho-behavioural factors.

Bibliography

1. Rozencweig D. Algies et dysfonctionnements de l’appareil evaluation of bruxism patients undergoing short term splin therapy. manducateur. Paris:CdP;1994. J Oral Rehabil. 1975; 2(3):215-223. 2. Marie MM, Pietkiewicz M. La bruxomanie. Rev de Stomat.1907;14:107- 18. Kato T, Thie NM; Huynh N, Miyawaki S, Lavigne GJ. Topical review: 116. sleep bruxism and the role of peripheral sensory influence. J Orofac 3. Graf H. Bruxism. Dent Clin North Am. 1969;13(3):659-665. Pain 2003 Summer; 17(3):191-213. 4. Lavigne GI, Montplaisir JY. Bruxism: epidemiology, diagnosis, 19. Okeson JP. A simplified technique for biteguard fabrication in pathophysiology, and pharmacology. In: Fricton JR, Dubner R, editors. bruxism. J Ky Dent Assoc. 1977; 29(4)11-16. Orofacial pain and temporomandibular disorders. New York: Raven 20. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological mechanisms Press;1995; 387-404. involved in sleep bruxism. Crit Rev Oral Biol Med. 2003; 14(1): 30-46. 5. Lobbezoo F, Naeije M. Bruxism is mainly regulated centrally, not 21. Lavigne GJ, Huynh N, Kato T, Okura K, Adachi K, Yao D, Sessle B. peripherally. J Oral Rehabil. 2001; 28(12): 1085-1091. Genesis of sleep bruxism. Motor and autonomic-cardiac interactions. 6. Brocard D, Laluque JF, Knellesen C. La gestion de bruxisme. Paris: Arch Oral Biol. 2007; 52(4):381-384. Quintessence International; 2007:15-18. 22. Kato T, Rompre P, Montplaisir JY, Sessle BJ, Lavigne GJ. Sleep 7. Attanasio R. Nocturnal bruxism and its clinical management. Dent bruxism: an oromotor activity secondary to micro-arousal. J Dent Res. Clin North Am. 1991; 35(1):245-252. 2001; 80 (10): 1940-1944. 8. Lobbezoo F, Van Der Zaag J, Naeije M. Bruxism: its multiple causes 23. American Academy of Sleep Medicine. International classification and its effects on dental implants-an updated review. J Oral Rehabil. of sleep disorders, 2nd ed. Diagnostic and coding manual. American 2006;3(4):293-300. Academy of Sleep Medicine. Westchester: IL; 2005. 9. Nascimento LL, Amorim CF, Giannasi LC, Oliveira CS, Nacif SR, Silva 24. Chapotat B, Lin JS, Robin O, Jouvet M. Bruxism du sommeil: Ade M, Nascimento DF, Marchini L, de Oliveira LV. Occlusal splint for aspects fondamentaux et cliniques. J Parodontol Implant Orale.1999; sleep bruxism: an electromyographic associated to Helkimo Index 18(3): 277-289. evaluation. Sleep Breath. 2008; 12(3):275-280. 25. Lobbezoo F, Naeije M. Bruxism is mainly regulated centrally, not 10. Ramfjord SP, Ash MM. Occlusion. Philadelphia: WB Saunders peripherally. J Oral Rehabil. 2001; 28(12):1085-1091. Company;1996. 26. Lobbezoo F, Van Der ZaagJ, Naeije M. Bruxism: its multiple causes 11. Rugh JD, Barghi N, Drago CJ. Experimental occlusal discrepancies and its effects on dental implants- un updated review. J Oral Rehabil. and nocturnal bruxism. J Prosthet Dent.1984; 51(4):548-553. 2006;33(4):293-300. 12. Minagi S, Akamatsu Y, Matsunaga T, Sato T. Relationship between 27. Hublin C, Kaprio J, Partinen M, Koskenvuo M. Sleep bruxism based on mandibular position and the coordination of masseter muscle activity self- report in a nationwide twin cohort. J Sleep Res.1998;7(1):61-67. during sleep in humans. J Oral Rehabil. 1998 Dec;25(12):902-907. 28. Abe Y, Suganuma T, Ishii M, Yamamoto G, Gunji T, Clark GT, Tachikawa 13. Rosales VP, Ikeda K, Hizaki K, NaruoT, Nozoe S, Ito G. Emotional T, Kiuchi Y, Igarashi Y, Baba K. Association of genetic, psychological and stress and brux-like activity of the masseter muscle in rats. Eur J Orthod. behavioral factors with sleep bruxism in a Japanese population. J 2002; 24(1):107-117. Sleep Res. 2012;21(3):289-296. 14. Lobbezoo F, Ahlberg J, Manfredini D, Winocur E. Are bruxism and 29. Winocur E, Gavish A, Vokovitch M, Emodi-Perlman A, Eli I. Drugs the bite causally related? J Oral Rehabil. 2012;39(7):489-501. and bruxism: a critical review. J Orofac Pain.2003;17(2):99-111. 15. Hellmann D, Giannakopoulos NN, Schmitter M, Lenz J, Schindler 30. Behr M, Hahnel S, Faltermeier A, Bürgers R, Kolbeck C, Handel HJ. Anterior and posterior neck muscle activation during a variety of G, Proff P. The two main theories on dental bruxism. Ann Anat. biting tasks. Eur J Oral Sci. 2012;120(4):326-334. 2012;194(2):216-219. 16. Rugh JD, Solberg WK. Psychological implications in 31. Mercuţ V, Scrieciu M, Popescu SM, Craitoiu M, Marasescu P, temporomandibular pain and dysfunction. Oral Sci Rev.1976;7:3-30. Marinescu R, Extended Case report. Bruxism with a history of early 17. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic onset in a 25-year-old male. OHDM. 2011;10(4):209-214. 31 occlusion

Cristiana Croitoru DDS, PhD student, Faculty of Dental Medicine, University of Medicine and Pharmacy Craiova, Craiova, România

Ileana Cristiana Croitoru was born on April 8th, 1988 in Craiova, Dolj. She graduated the Faculty of Dental Medicine in 2012. She became a PhD student the same year and a resident in Prosthetics Dentistry in 2013. She graduated the master program “Prosthetics Reconstructions Implant Support” in July 2013. From March 2013 she is an assistant professor - Faculty of Dentistry UMF Craiova, Department of Prosthet- CV ics. Doctor Croitoru collaborated on a book as co-author together with Prof. Veronica Mercut, Dean of the Faculty of Dental Medicine. She also wrote several articles published in various journals. She participated at all the dental conferences held at the UMF Craiova and she is also a member of the Dental College Dolj.

Questions Regarding the etiology of bruxism

q a. Is unifactorial q b. Behavioral factors are not involved q c. The original definition refers mainly to dental contacts and muscle contractions q d. Sleep problems are not a part of the etiology of bruxism Which of the following are not involved in bruxism research:

q a. Electromyography q b. Electroencephalography q c. Telemetry q d. Radiography Which of following are not psycho-behavioral factors:

q a. Stress q b. Anger q c. Repressed aggressiveness q d. Hunger Regarding chemical mediators in bruxism:

q a. neurotransmitters do not ensure the communication between neurons q b. Dopamine is not involved in lust and movement q c. Serotonin does not have a role in adjusting sleep q d. Selective serotonin inhibitors did not present the expected results

32 Stoma.eduJ (2014) 1 (1) orofacial pain

Cite this article: Meyer GB, Bernhardt Q, Headache – Küppers A. Headache - an interdisciplinary problem. Aspects of dental functional an interdisciplinary problem diagnostics and therapy. Stoma Edu J. 2014; Aspects of dental functional 1(1):33-40. diagnostics and therapy

Georg B. Meyer1a*, Abstract Olaf Bernhardt2b, Arnd Küppers2c 1. Zentrum für Zahn-, Aim: Craniofacial pain is one of the most common disorders affecting the general Mund-, und Kieferheilkunde population. The aim of this article is to show the importance of interdisciplinary Universitätsmedizin Greifswald, approach in solving complicated cases with headache and atypical facial pain. Greifswald, Germany 2. Poliklinik für Zahnerhaltung, Summary: Two case reports are presented, with severe craniofacial pain, with Parodontologie und underlying intricate causes. The case of a 23 aged female with tension headaches, Endodontologie bilateral tinnitus and atypical facial pain, but also with anterior open bite from Universitätsmedizin Greifswald, Greifswald, Germany premolars who was admitted to a neurological clinic, was finally resolved only after a a. DMD, PhD, Dr hc, Professor splint therapy. The other case was a 42 year old woman with severe unilateral facial and Chairman pain, caused by an endometric tissue from maxillary bone that produced multiple b. DMD, PhD, Professor c. DMD, PhD hollows or cavities in the adjacent teeth. The pain was alleviated after teeth extractions and appropriate hormonal therapy. Key learning points: Because headache causes are manifold, diagnostics and therapy require an interdisciplinary medical approach. From the dental and maxillofacial standpoint, diseases and disorders of the teeth, periodontium, other craniofacial hard and soft tissues, as well as craniomandibular dysfunction (CMD) must be taken into consideration in treating such patients. Keywords: unspecific headache, tension headache, muscle relaxation, craniomandibular dysfunction, Michigan splint

Introduction The reasons for acute and chronic craniofacial pain can be extremely diverse. An exact identification of causes is often impossible without close cooperation between various medical disciplines, and monocausal treatment approaches to pain relief are often unsatisfactory (1,2,3). Understanding these multilayered symptoms is fundamentally made more difficult due to the great diversity and inherently variable risk factors that may play a role (4,5). They frequently occur in combination, and interactions arise with complex amplifying effects, so that scientific studies require particularly great, interdisciplinary efforts. In the past, the fields of dentistry and oral medicine have, for different reasons, not always played a sufficient role in the treatment of craniofacial pain, although experienced pain therapists have long demanded including the dental/oral medicine sector in Received: 17 October 2013 the diagnostics and treatment of such disorders (Fig. 1). Although craniomandibular Accepted: 07 January 2014 dysfunctions (CMD) are the focus of this article, it should be mentioned that irritations and diseases of the pulp, periodontium, glands, nasal sinuses, and other hard and soft * Corresponding tissues in the craniofacial area including space-occupying processes/structures such author: as tumors can cause comparable craniofacial pain, which is sometimes erroneously Professor Georg B. Meyer, DMD, interpreted as a functional disorder and treated with, for instance, occlusal splints. PhD, Dr hc, Chairman Zentrum für Zahn-, Mund- und Given this background, failed splint therapy should not be blamed on the method, Kieferheilkunde, but rather on the differential diagnostic exclusion of masticatory functional causes of Ernst-Moritz-Arndt Universität, Rotgerberstraße 8, D-17475 the respective symptoms. Recent controlled studies unambiguously show that with Greifswald, Germany. individually adjusted centric splints (Michigan splints), significant improvements result in Tel: +493834867130, Fax:+493834867171. the therapy of CMD, especially compared to merely vacuum-drawn, non-individualized e-mail: [email protected] 33 OROMulti-/interdisciplinarFACIAL PAIN y approch

Multi-/interdisciplinary approach

Neurology Orthopedics

Neurology Orthopedics Pain patient

Pain patient Psychology Dentistry

Psychology Dentistry

U.T. Egle, Psychosomatik/Psychotherapie Figure 1. For patients with chronic headache, dental diagnostic and therapy are as valuable as that of other disciplines (taken from Egle, Mainz, 2000) U.T. Egle, Psychosomatik/Psychotherapie

splints (6). Significant associations between CMD and frequent headaches were demonstrated in an epidemiological survey of over 4000 subjects in the Study of Health in Pomerania (SHIP) (4). In a diagnostically and therapeutically oriented dental follow-up study of patients whom neurologists and neurosurgeons had diagnosed with trigeminal neuralgia, Lotzmann et al. (7) found that in up to 50 % of the cases, CMD was the true cause of the neuralgic symptoms. Interestingly, over 70 % of these cases presented infraocclusion in the posterior dentition in centric relation, which was often the result of prostheses with insufficient height or orthodontic treatment. Craniofacial pain is frequently accompanied by temporomandibular joint (TMJ) and otological symptoms (8). The SHIP study showed correlations Figure 2. In the Physiology of a healthy masticatory organ is characterized by receptors in the teeth, between tinnitus and CMD (9). Evaluating 200 periodontium, muscles, and TMJs that transmit CMD patients who simultaneously suffered from signals about the current status via afferent nerves tinnitus, earache, and dizziness, Wright (8) found (aff.N.) to the central nervous system. Based on this that after successful treatment of masticatory sensory information, a synaptic transformation to functional disorders, these associated symptoms movement follows. Along efferent nerves (eff.N.), improved significantly. the corresponding motoric units of the musculature While interactions between CMD and are activated, so that all masticatory functions can unspecific headaches, tension headaches, and run in a coordinated manner trigeminal neuralgia have been proven (4,7,10), the dental contribution to the etiology of migraine or migraine-like pain is controversial. Masticatory functional aspects Based on individual instances of successful Physiology dental treatment, particularly in cases of migraine During the growth of a healthy masticatory symptoms unchangingly confined to one half organ, the occlusal structures of all teeth of the face, some neurologists recommend a and the TMJ adapt themselves to each clinical dental consultation (11,12,13,14). other to follow a uniform geometry. Starting

34 S T OMA.E D U J (2014) 1 (1) Headache an interdisciplinary problem Aspects of dental functional diagnostics nd therapy

Figure 3. Dental risk factors for CMD are mainly occlusal interferences and/or psycho-emotional stress

Figure 4. The Ahlers and Jakstat clinical summary report for CMD risk identification was extended by a test of physiological centric position

from maximum occlusion in which the TMJ manner. Psychological and cortical interactions structures are also centered, the interplay are possible (15). of cusps and fissures of antagonistic teeth is The mandible assumes the physiological characterized by the disturbance-free course centric relation or “zero position” to the maxilla of all excentric movements (Fig. 2). Receptors when protractors as well as retractors are in the teeth, periodontium, muscles, and TMJs maximally relaxed, and the integral of all muscle are connected by afferent nerves to the central activity is thus at the lowest level (16). In this nervous system, and transmit signals about the position, maximum intercuspation is possible as given status, e.g., the consistency and location long as there are no occlusal interferences. By of the to-be-chewed food near or on the teeth. activating the retractors, about 90% of all adults Based on this sensory information, a synaptic can perform a tooth-guided, ca. 1 to 3 mm transformation to movement follows. Along mandibular retral limit movement from centric efferent nerves, the corresponding motoric position, which was formerly known as the retral units of the musculature are activated, so that all contact position and erroneously considered to masticatory functions can run in a coordinated be the same as centric relation (16,17).

35 orofacial pain

Table 1. Extra - and intra-oral findings

The following extra-oral findings were recorded: - mandibular mobility, i.e., opening, pro- trusion, and lateral movements unrestricted and normal; - palpation pain in both TMJs; - pressure sensitive musculature in right anterior Temporalis, left Masseter, right shoulder muscles; - hypersensitive nerve exit points in left infraor- bital area, right mandible.

The following intra-oral findings were recorded (Figs 5 to 7): - complete, well-maintained dentition without wisdom teeth; - partial crowns on 16 and 26, gold, with compo­site fillings on 17,14, 24, 25, 27, 37, 36, 46, and 47; - suspected dentin fracture in tooth 17; - bilateral tongue impressions; - anterior open bite from/to premolars bilaterally; - premature contacts 17/47 in physiological centric position/cotton-roll test centric.

Pathology Masticatory functional disorders are primarily caused by occlusal discrepancies when these are noticeably above or below the 10- to 20- µm range of desmodontal tactility (18). In experimental examinations, Kobayashi and Hansson (19) found that premature occlusal contacts of a magnitude of 100 µm on fillings, Figure 5-7. Open bite despite orthodontic i.e., 10 times the desmodontal tactility, can treatment, with support exclusively on the molars, contribute to increased muscle activity, bruxism, which could explain the pain in these areas sleep disorders, increased adrenaline excretion, sleep apnea, TMJ complaints etc. An essential, Patient examination even decisive exacerbating factor is psycho- As part of the interdisciplinary diagnostics of emotional stress (“grinding your teeth”); thus, craniofacial pain patients, the anamnesis must the initial dental diagnostics must pay particular determine whether a dental risk exists. After attention to such symptoms (5,10,11,20). The taking the general dental findings, it has proven same is true of primarily orthopedic problems effective to perform a CMD screening (11), that which can have an immediate interaction with is, a scientifically founded clinical summary CMD (17,21). report to determine masticatory functional risk From a scientific point of view, it is not primarily factors. We have added a diagnostic test of the occlusal disturbance but rather the hyperactive, physiological centric relation (cotton-roll test) pressure-sensitive masticatory and craniofacial to this screening (13,17) (Fig. 4). These are yes- muscles which are a significant correlate for or-no findings, quickly determined, which very the neuromuscular dyscoordination or CMD reliably identify CMD patients, for whom more (Fig. 3). But the grosser occlusal interferences comprehensive diagnostics and therapy must are, the higher is their risk potential for causing then be performed (11,12). CMD (22). Therapeutically, every treatment that In the following, two patient cases of craniofacial leads to muscle relaxation or re-coordination pain are documented, from which an exact of the neuromuscular system makes sense, for description of the practical dentally recommended instance, treatment with a dental (relaxation) splint diagnostic steps has been omitted. The same (23,24), information consulting, self-observation, goes for the therapeutic clinical concept based physiotherapy, medication, psychotherapy, and on the centric (Michigan) splint, supplemented other forms of treatment (5,15,20,25,26). with adjunct treatment such as instructions for

36 Stoma.eduJ (2014) 1 (1) Headache an interdisciplinary problem Aspects of dental functional diagnostics nd therapy

Figure 8. Individual centric splint made in the articulator self-observation, relaxation, and muscle massage, as these steps and concepts were previously described.

Case report 1

Patient history

A 23-year-old female patient presented at our clinic with intermittent tension headaches, which had otherwise only occurred in the right half of the face, but were now present both right and left. Particulary under tension and stress, Figure 9-11. The splint creates an individual bilateral tinnitus also arose, in addition to pain balance of the bite position in all quadrants. in the maxillary molar region and sinus chiefly on The patient became symptom-free the right side. Examination by an ear-nose-throat doctor found no cause. The patient reported having undergone orthodontic treatment from and pouring the models, the facebow and the age of 11 to 15 years. protrusion registration were placed in the At the age of 17, extreme atypical pain in the articulator with the help of the clinical centric right half of the face arose, for which the patient registration of both jaws so that it corresponded was admitted to the neurology department of a to the clinical situation. As expected, even clinic. When no cause was found there, she was after placement in the articulator, centric moved to a psychosomatic clinic. Meanwhile, premature contacts were found on teeth 17 severe pain arose in the left half of her face. and 47, which indicated that the working steps During the subsequent 4-week stay at a pain had been done correctly. Using a hard, 1.5- clinic (Mainz, Germany), dental findings were mm-thick piece of composite foil, a vacuum- taken for the first time during an interdisciplinary drawn splint was constructed and individually consultation. corrected in the articulator – according to the This led to initiating splint therapy, which finally occlusal concept of the Michigan splint – first – after her 8-month ordeal – alleviated her pain by grinding and then by applying composite (Fig. 8-11, Table.1) and let her live a normal life. on certain sites in order to create equal support She visited our clinic because the original splint in all quadrants and canine guidance during was worn out and the headaches, maxillary pain, excentric movements (Figs 8 to 11). and tinnitus had returned. Wearing instructions/Follow-up Therapy During the initial treatment phase, the splint After providing the patient with educational should be worn as much as possible, i.e., both information, instructions on self-observation, day and night. Exceptions can be made for eating relaxation, and muscle massage, an exercise and lengthy periods of speech such as during DVD (20,25), and a calculation of costs, presentations etc. The patient should be informed splint therapy was performed. Subsequent to that after overcoming initial awkwardness, impression taking of the maxilla and mandible accustomization occurs within just a few days

37 orofacial pain

Figure 12. This patient Figure 13. Even after extraction of teeth 13 to 16 from the periodically had severe pain pre-viously fully dentate maxilla, no improvement of symptoms attacks in the right facial half occurred in that side of the face (mirror image photo)

(even faster for mandibular splints), providing considerable relief. It is necessary to perform the first follow-up after 3 or 4 days.A fter “cotton- roll relaxation”, any corrections required will be done to ensure equal support in all quadrants. Only when this support remains stable can the follow-up intervals be lengthened. The patient introduced here was symptom- free again after just a few weeks. It may be recommendable to shorten the splint wearing time, for instance, using it only in particulary stressful situations. When not in use, the splint should be stored under moist conditions to avoid Figure 14. On the roots of the extracted teeth, drying out and thus deforming and becoming hollows or cavities are visible, which are perhaps brittle. related to extra-genital endometriosis Case report 2 splint remained stable, and no further occlusal corrections were necessary. Patient history Surprisingly, the patient returned after ca. 4 weeks with facial pain so severe that we A 42-year-old patient presented with periodic, had to have her admitted to the University severe headache attacks limited to the right Clinic’s pain station. Symptomatic medication side of her face (Fig. 12). Neurological and relieved the pain, but no cause for it could be otorhinolaryngological examination had found found. Examinations at the dental clinic, also no cause. conducted by oral and maxillofacial surgeons and the dental radiology department, Findings discovered multiple hollows or cavities in the Asymmetrical tension in the masticatory and maxillary lateral teeth of the face-half affected; shoulder-muscle areas. Mandibular mobility teeth 13, 14, and 15 were thus extracted (Figs was not restricted, but deflection to the right 13 and 14). In spite of this, the severe unilateral was observed upon mouth opening. Except facial pain returned almost exactly 4 weeks for wisdom teeth, the patient was completely later. dentate. The only restorations were some mid- Finally, it was the patient’s physician who sized amalgam fillings in the posterior teeth. In suspected menstrual cycle involvement and centric position (cotton-roll test), equal support referred her to the gynecology clinic. There, the rare was found in all quadrants. but correct diagnosis of extragenital endometriosis was made. During embryonic development, Therapy endometrial tissue had scattered into the right Relaxation splint therapy was conducted, which half of the face and later became active once a the patient found very pleasant and helpful and month, causing facial pain. Appropriate hormonal completely alleviated the pain. The well-fitting treatment alleviated the symptoms.

38 Stoma.eduJ (2014) 1 (1) Headache an interdisciplinary problem Aspects of dental functional diagnostics nd therapy

Conclusion In terms of costs, it makes sense for health Both current research and the patient cases insurance to reimburse the diagnostic and presented here clearly demonstrate the need therapeutic measures provided by our discipline for the fields of dentistry and oral medicine in cases such as those described here, thus to become more involved in answering motivating dental professionals to get involved, interdisciplinary medical questions, as was especially considering the fact that misdirected expressly demanded by Germany’s Council of treatment by other medical disciplines and the Sciences in its 2005 declaration on the future associated increase in sick-leave are ultimately of dentistry. much more expensive, as the first patient case Epidemiological data suggest that many who described above shows. At the very least, state suffer from craniofacial pain can be helped health insurance should finance the rapidly by dental diagnostics and therapy, so that an performed yet very informative clinical summary interdisciplinary examination of craniofacial report on CMD risk for every patient, since this pain without considering the oral/dental would probably ultimately save a great deal of aspects is unjustifiable (see Fig. 1). money elsewhere.

Bibliography

1. Ash MM. Schienentherapie. München-Jena: Urban & Fischer headache in individuals with temporomandibular disorders. J Verlag; 2006. Orofac Pain. 2010; 24(3):287-292. 2. Göbel H. Erfolgreich gegen Kopfschmerzen und Migräne. 15. Kindler S, Samietz S, Houshmand M, Grabe HJ, Bernhardt Aufl. Berlin: Springer; 2002. O, Biffar R, Kocher T, Meyer G, Völzke H, Metelmann HR, 3. Slavicek R. Das Kauorgan: Funktionen und Dysfunktionen. Schwahn C. Depressive and anxiety symptoms as risk factors Klosterneuburg: Gamma-Verlag; 2000. for temporomandibular joint pain: a prospective cohort study 4. Bernhardt O, Gesch D, Mundt T, Mack F, Schwahn C, Meyer in the general population. J Pain. 2012; 13(12):1188-1197. G, Hensel E, John U. Risk factors for headache, including TMD 16. Meyer G. Die physiologische Zentrik im Rahmen der signs and symptoms, and their impact on quality of life. Results instrumentellen Okklusionsdiagnostik. In: Funktionslehre. of the Study of Health in Pomerania (SHIP). Quintessence Int. Schriftenreihe APW. München: Carl Hanser; 1993. 2005; 36(1):55-64. 17. Lotzmann U. The effect of divergent positions of maximum 5. Graber G. Der Einfluss von Psyche und Stress bei intercuspation on head posture. J Gnath. 1991; 10(1):63-68. funktionsbedingten Erkrankungen des stomatognathen 18. Utz KH. Untersuchungen über die interokklusale taktile Systems. In: Funktionsstörungen des Kauorgans. Hrsg.: B. Feinsensibilität natürlicher Zähne mit Hilfe von Aluminium- Koeck. München: Urban & Schwarzenberg; 1995. Oxid-Teilchen. Dtsch Zahnärztl Z. 1986; 41(3):313-315. 6. Ekberg E, Vallon D, Nilner, M. The efficacy of appliance 19. Kobayashi Y, Hansson TL. Auswirkungen der Okklusion auf therapy in patients with temporomandibular disorders of den menschlichen Körper. Phillip J Restaur Zahnmed. 1988; mainly myogenous origin. A randomized, controlled, short- 5(5):255-263. term trial. J Orofac Pain. 2003; 17(2):133-139. 20. Schulte W. Die exzentrische Okklusion. Berlin: Quintessenz; 7. Lotzmann U, Vadokas V, Steinberg JM, Kobes L. Dental aspect 1983. of the differential diagnosis of trigeminal neuralgia. J Gnathol. 21. Fu AS, Mehta NR, Forgione AG, Al-Badawi EA, Zawawi KH. 1994; 13(1):15-22. Maxillomandibular Relationship in TMD Patients Before and 8. Wright EF. Otologic symptom improvement through TMD After Short-Term Flat Plane Bite Plate Therapy. Cranio. 2003; therapy. Quintessence Int. 2007; 38(9):e564-571. 21(3):172-179. 9. Bernhardt O, Gesch D, Schwahn C, Bitter K, Mundt T, 22. Troeltzsch M, Troeltzsch M, Cronin RJ, Brodine AH, Mack F, Kocher T, Meyer G, Hensel E, John U. Signs of Frankenberger R, Messlinger K. Prevalence and association of temporomandibular disorders in tinnitus patients and in a headaches, temporomandibular joint disorders, and occlusal population-based group of volunteers: results of the Study interferences. J Prosthet Dent. 2011; 105(6):410-417. of Health in Pomerania. J Oral Rehabil. 2004; 31(4):311- 23. Hupfauf L, Weitkamp J. Ergebnisse der Behandlung 319. von funktionsbedingten Erkrankungen des Kausystems mit 10. Kreyer G. Das Orofazialsystem als Schnittstelle zwischen Aufbissbehelfen. Dtsch Zahnärztl Z. 1969; 24(5):347-352. Psyche und Soma. Zahnärztl Mitt 2005; 95(6):1366-1371. 24. Lotzmann U. Okklusionsschienen und andere 11. Ahlers MO, Jakstat HA. Klinische Funktionsanalyse. Aufbissbehelfe. München: Verlag Neuer Merkur; 1992. Hamburg: Denta Concept Verlag; 2007 25. Graber G. Orale Physiotherapie. Video-Anleitung zur 12. Freesmeyer WB. Zahnärztliche Funktionstherapie. München Entspannung und Selbstmassage. Basel: Univ.-Zahnklinik; Wien: Carl Hanser Verlag; 1993. 1992. 13. Meyer G, Bernhardt O, Asselmeyer T. Schienentherapie 26. Bernhardt O, Hawali S, Sümnig W, Meyer G. Electrical heute. Quintessenz. 2007; 58(5):489-500. stimulation of the temporalis muscle during sleep of 14. Franco AL, Goncales DA, Castanharo SM, Speciali JG, Bigal myofacial pain - a pilot study. J Cranio Mand Func. 2012; ME, Camparis CM. Migraine is the most prevalent primary 4(3):197-210.

39 orofacial pain

Georg B. Meyer DMD, PhD, Dr hc, Professor and Chairman Zentrums für Zahn-, Mund- und Kieferheilkunde Ernst-Moritz-Arndt Universität, Greifswald, Germany

Prof. Dr. Georg B. Meyer is the Head of Department Head for the Departments of Restorative Dentistry, Periodontology and Pedodontics at Ernst-Moritz-Arndt University of Greifswald / Germany and Head Instructor of Gnathology Department at the Academy of Practice and Science (APW) as well as President of the German Society of Dental, Oral and Cranium-mandible Sciences (DGZMK) and member of the CV Association of German Research Council (DFG). In 2006 he has received the title of “Professor Doctor Honoris Causa” awarded by the University of Dentistry - “Moscow State University”. He has published several academics textbooks and many articles in international journals from over 30 countries.

Questions Which of the following specialties is not involved in the multidisciplinary approach of the treatment of chronic headache:

q a. neurology q b. orthopedics q c. psychology q d. dentistry q e. thoracic surgery Regarding masticatory functional disorders:

q a. these are primarily caused by occlusal discrepancies q b. premature occlusal contacts of less than 10 can lead to increased muscle activity, bruxism, sleep disorders, etc. q c. Psycho-emotional stress does not influence masticatory functional disorders q d. The occlusal disturbance represents the significant correlate for the neuromuscular dyscoordina- tion or CMD from a scientific point of view Regarding the first patient:

q a. Presented tension headaches only on the right half of the face q b. Bilateral tinnitus was present q c. No pain was present q d. The patient had no history of orthodontic treatment Regarding the second patient:

q a. The patient presented with constant pain q b. The neurological examination was positive q c. Mandibular movement was restricted q d. The patient was completely dentate

40 Stoma.eduJ (2014) 1 (1) overdenture

Cite this article: Tartaglia GM, Sforza C. FUNCTIONAL EVALUATION OF Functional evaluation of implant supported prostheses. Stoma Edu J. IMPLANT SUPPORTED PROSTHESES 2014; 1(1):41-47.

Gianluca Martino Abstract Tartagliaa, Chiarella Sforzab Purpose: Surface electromyography is currently considered a useful tool for dentistry allowing LAFAS, Laboratorio di Anatomia Funzionale dell'Apparato the validation of conventional morphological evaluations with an accurate and objective Stomatognatico, Dipartimento quantification of the functional activity.A n evaluation of full mouth resin prostheses on implants Scienze Biomediche per la Salute, was performed including both a morphological evaluation of occlusion and a measurement of Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, the actual impact of morphology on stomatognathic function. Milano, Italy Methodology: The measurement was performed using masticatory muscle electromyographic a. DDS, PhD, Associate Professor recordings with ad-hoc software algorithms. In the present study, five patients with full mouth b. MD, PhD, Professor resin prostheses on implants have been evaluated at the beginning of their prosthetic reconstructions and after one year using surface electromyography. To verify the static neuromuscular equilibrium of occlusion, functional evaluation of the left and right masseter and temporalis anterior muscles was performed in all patients, and a set of indices was computed: the Percentage Overlapping Coefficient – POC (an index of the symmetric distribution of the muscular activity determined by the occlusion), the Torque Coefficient -TC (an index of the possible presence of a mandibular torque) and the antero-posterior coefficient (an index of the possible relative position of the occlusal center of gravity). Results: One year after surgery during the maximum voluntary clench, all patients had symmetric standardized potentials (POC values between 80% and 100%, and TC values larger than 90%). Conclusions: Surface electromyography indices were well super imposable to the values found in healthy subjects with natural and normal occlusion, thus indicating that, at short time follow up, a functionally stable occlusion could protect from resin prosthodontic fractures. Keywords: electromyography, prostheses, implants

Introduction Today, several clinical tools can support the daily clinical practice in dentistry with a quantitative support helpful for diagnosis, measuring the effects of therapy, and timely detection of the possible failures or relapses. Surface electromyography (EMG) is able to support conventional morphological evaluations with an accurate and objective quantification of functional activity and it is currently considered a useful tool for dentistry. Engineers, biological and dental researchers have developed useful EMG protocols that couple the scientific accuracy, indispensable in all instrumental evaluations (1), with the simplicity necessary for daily use in dental practice. Therefore, starting from the multiple information collected during the computerized analysis, a selection of simple and well reproducible indices (with a clear biological and clinical significance, and easily comprehensible), should be made. Moreover, the Received: 09 November 2013 quantitative data should be coupled with a graphic support allowing an easier and more Accepted: 16 December 2014 efficient communication between the clinician and the patient. In other words, diagnosis * Corresponding should be supported “at a glance” (1,3). Author: A correct evaluation of prostheses should include both the morphological evaluation Professor Chiarella Sforza, of occlusion, and the measurement of the impact of customized morphology of dental MD, PhD contacts on stomatognathic function in each single patient. Among the various clinical Dipartimento Scienze Biomediche per la Salute, protocols currently used in prosthodontics, the immediate loading of implants with full Facoltà di Medicina e Chirurgia, mouth resin restorations has been proposed as simpler, less time and money consuming Università degli Studi di Milano, Milano, Italy. than delayed loading of implants. via Luigi Mangiagalli 31, In our prosthodontic practice, we tried to develop a practical application of well- I-20133 Milano, Italy. Tel. +390250315385, standardized sEMG protocols developed in research laboratories (1-7) to help clinical Fax +390250315387 work. A quantitative clinical tool may reduce complications in implant supported, all- e-mail: [email protected]

41 overdenture

acrylic resin prostheses, with immediate load. These measurements can be well performed using surface EMG recordings of the main masticatory muscles, such as the temporalis anterior and the masseter (1,4,5,8). For instance, occlusal stability has been found to be related to muscular performance, significant associations may exist among dentition status, chewing ability, muscle strength and balance both in the young and the elderly po¬pulation (9,10) Figure 1. Immediately post-operatory x-ray EMG allows not only to measure the electric potentials produced by the single masticatory muscles (values that are somehow related to the developed masticatory forces) (1,4,5,8), but it also allows the verification and quantification of muscular balance, between couples of muscles of the two sides of the body (symmetry), between couples of muscles with a possible later deviant effect on the mandible (torque) (1), and between couples of muscles with an action line positioned more forward or more backward to identify a hypothetic center of gravity of occlusion. Indeed, occlusion both on natural teeth and on prostheses with premature or sliding contacts can provoke a mandibular torque (4) or an unfavorable center of gravity. The consequent altered muscular activity is not macroscopically evident, but, in the medium- long time, it could cause alterations in the bone. Figure 2. Digitized prosthetic CAM Framework In the present study, patients with full-mouth prostheses on implants have been evaluated at contacts and vertical dimensions were adjusted the end of their prosthetic reconstructions and to obtain normal values of the EMG standardized after one year with surface EMG. indices (see below). Articulating paper (Bausch, Germany) was used to morphologically finalize Methods the occlusion and adjust it with respect to the Patients functional parameters (Fig 3 a-b). Morphological On September 2013, five male patients were occlusion consisted of central contacts on all the selected from a dental practice in Milan during masticatory units. Dynamic occlusion consisted dental hygiene clinical recall appointments. These of group function guidance regardless of the patients had received full mouth rehabilitation on opposite arch settings. This stereotyped occlusion 4 implants (Milde® implants) in each dental arch was functionalized in each patient by means of from the same private practice between June 2012 the patient-specific neuromuscular response on and September 2012. All the patients were in good rehabilitation. The EMG test was repeated during health and edentulous in both arches. All of them the recall appointment one year after the surgery have presented severe atrophy in the posterior (Fig 4). regions of the arches. Clinical and radiographic EMG analysis diagnoses were performed, using preoperative Details on the protocol have been reported by panoramic radiographs and Cone Beam CT scans. Ferrario et al. (1,4). In brief, four disposable bipolar All patients gave their informed consent to the surface electrodes (Duo-Trode; Myo-Tronics Inc., immediate loading procedure. Immediately after Seattle, WA, USA) were positioned on the muscular the surgery (Fig 1), full-resin prosthesis with a resin bellies identified by palpation during a voluntary CAD-CAM framework (Fig 2) was placed with distal clench. EMG potentials were detected, amplified, cantilever extension – first molar area (12 teeth). digitized, digitally filtered and recorded using To avoid the incidence of prosthetic four of the six channels of the above mentioned complications, the neuromuscular equilibrium of computerized electromyography (1,2,4). occlusion in static conditions was evaluated in all During the test, all the patients sat with their head patients with a surface EMG (TMJoint, BTS, Italy) unsupported, the feet flat on the floor and the arms of the masseter (MM) and temporalis anterior resting on the legs; they were asked to maintain (TA) muscles of both sides (left and right) one a natural upright position. They performed both week after the surgery. In all patients, dental a standardization test and a 3 seconds maximum

42 Stoma.eduJ (2014) 1 (1) Functional evaluation of implant supported prostheses

Table 1. Maximum voluntary teeth clenching in patients one week after surgery (prosthesis delivery).

POC masseter POC Temporalis Activity standardized Patient Age TC % APC % % % µV/µV s %

1 71 88 89 91 91 105

2 57 84 82 88 90 92

3 71 85 87 88 85 95

4 65 86 85 90 78 93

5 70 88 87 89 87 92

POC, percentage overlapping coefficient (index of left–right muscular symmetry);TC , torque coefficient (potential lateral displacing component);APC , antero-posterior coefficient (relative activities of masseter and temporalis muscles). voluntary clench test. During the standardization (right temporalis and left masseter vs. left temporalis test (lasting 3 seconds), a maximum voluntary and right masseter). Its value ranges between 0% clench performed on two cotton rolls positioned (complete presence of lateral displacing effect) on the mandibular second premolar and molars and 100% (no lateral displacing effect) (normal was recorded. This record obtains a series of values >90%) (6). reference values to standardize all further EMG The Impact Coefficient (IC, μV/μV%; 14) was used potentials recorded during the maximum clench to measure the global muscular activity computed performed directly on the occlusal surfaces (1). as the mean EMG standardized potentials over All values were expressed as a percentage of the time (normal values range between 87 µV/µVs% standardization recordings (mV/mV x 100), and and 107 µV/µVs%) (6). indices were computed as follows. The Percentage Overlapping Coefficient (POC, Results %) was computed to quantify the muscular The EMG evaluation allowed us to measure the symmetry. Its value ranges between 0% and 100%. good functional impact of the dental contacts When two paired muscles contract with perfect on the full mouth prosthetic reconstructions. symmetry, a POC of 100% is obtained (normal Normal values of all EMG indices were obtained values >83%) (6). TA and MM POCs were obtained in each patient adjusting the occlusal contacts; a for each patient. well harmonized contraction of the masticatory To compare the standardized muscular activities muscles allowed the force imbalance over of masseter and temporalis muscles, an antero- the resin prosthesis and the bone. During the posterior coefficient (APC, unit %) was obtained maximum voluntary clench one week after surgery, as the ratio between the non-overlapped all patients had symmetric standardized potentials and the overlapped masseter and temporalis (POC values between 80% and 100%, and TC muscle areas of both sides (normal values > values larger than 90%, as shown in Table 1). None 90%) (6). When the standardized masseter and of the fixed prostheses (Fig. 5) were lost during the temporalis potentials are well comparable, observation time, yielding a survival rate of 100%. the index is equal to 100%; when the patients Only one of the all-acrylic resin prosthesis displayed have unbalanced standardized masseter and fracture of the resin material (Fig. 6). No occlusal temporalis potentials, the index is equal to 0%. screw loosening was observed. At the 1-year recall When standardized muscular potentials are not appointments, all the patients still had symmetric balanced between the masseter and temporalis standardized potentials (POC values between 80% muscles, the occlusal center of gravity (MVC on and 100%, and TC values larger than 90%, Table 2). the occlusal surfaces as compared to MVC on In general, at the second visit, we observed larger the cotton rolls) might be displaced backwards values on the standardized Activity than at the first (masseter prevalent) or onwards (temporalis one. prevalent). The Torque Coefficient (TC,%) was used to Discussion measure the tendency of the mandible to move In the current investigation, patients with full mouth toward one side during a symmetric bilateral resin rehabilitation on implants were analyzed. All clenching, given by unbalanced contractile activity patients were satisfied with their prostheses, and of contralateral masseter and temporalis muscles reported an adequate stability on swallow and

43 overdenture

Figure 3a. Results of two sEMG functional tests obtained during the procedure of occlusal adjustment at prosthesis delivery (patient 1) TA: Temporalis anterior; MM: Masseter; POC TA: Figure 3b. sEMG test results at the end of the Standardized muscular symmetry for temporalis procedure of customized occlusal adjustment anterior muscles; POC MM: Standardized (patient 1). For abbreviations, see Figure 3a muscular symmetry for masseter muscles; APC: Standardized overlapped muscular rehabilitations were chosen independently from activity between masseter vs. temporalis; TC: the present investigations. Only well-satisfied Standardized overlapped activity between right patients in private practice were asked to undergo temporalis and left masseter vs. left temporalis and the present protocol. Therefore, the extrapolation right masseter; R: Displacing static effect toward of the present results to a wider population should right - in brackets the correspondent percentage be done with caution (12-14). of muscular asymmetry component; L: Displacing The detection of the relationship between static effect toward left side; A: Displacing onwards function and its morphological substrates has static effect (temporalis prevalent); P: Displacing always been one of the most intriguing matters in backwards static effect (masseter prevalent); dentistry. In particular, one still debated question is Normal, Normal range of indices (gray areas in the the relationship between dental contacts, and the graphical view) function of jaw elevator muscles (15,16). In clinical practice, values recorded in healthy subjects with a masticatory efficiency.T he EMG tests were performed full natural dentition are considered the reference one week and one year after the completion of their norm (1,6). prosthetic reconstructions, a time considered more In the patients analyzed in the present study, than sufficient for the development of good muscle the EMG indices computed from the electrical activity and force generation (7,11). potentials recorded during the maximum It has to be underlined that the current five patients voluntary clench test were well super imposable were not randomly selected, and their prosthetic to the values found in healthy subjects with

Table 2. Maximum voluntary teeth clenching in patients at the 1-year recall appointment.

POC masseter POC Temporalis Activity standardized Patient Age TC % APC % % % µV/µV s %

1 71 85 83 91 88 95

2 57 83 85 90 88 97

3 71 82 86 87 82 95

4 65 83 84 89 83 98

5 70 85 86 88 91 95

POC, percentage overlapping coefficient (index of left–right muscular symmetry);TC , torque coefficient (potential lateral displacing component); APC, antero-posterior coefficient (relative activities of masseter and temporalis muscles).

44 Stoma.eduJ (2014) 1 (1) Functional evaluation of implant supported prostheses

Figure 4. One year functional test results, “at a glance” view (patient 1) MVC on cotton rolls pie chart: non-standardized EMG average amplitude activity (raw data) during a 3 s maximum voluntary clench on cotton rolls between R = right L = left TA (temporalis anterior) muscles, and R = right L = left MM muscles. The higher the raw value, the wider the chart sector. MVC pie chart: non-standardized EMG average amplitude activity (raw data) during a 3 s maximum voluntary clench on dental surfaces. Percentage pie chart: ratios between raw data on dental surfaces and raw data on cotton rolls (standardized EMG average amplitude activity). Graph sectors with equal area and centered on the origin axis indicate a normal functional occlusal equilibrium

Figure 5. Final prosthetic result Figure 6. Particular of prosthesis fracture natural and normal occlusion (1,6), and they muscles. Nevertheless, continuous microstresses could be useful to clinically address some of can be dangerous for the muscles themselves, the aforementioned questions. In a situation of the temporomandibular joint (20), and the bone, perfect symmetry, the POC, TC and APC indices with altered load patterns. should be 100%. Of course, this hypothesis is The increased standardized activity recorded in only theoretical, and, starting from the statistical the second assessment can be explained with the evaluation of data collected in healthy individuals, effect of one year “training”: the patients regained POC values larger than 83%, TC larger than 90%, confidence with their stomatognathic system and APC larger than 90% and EMG standardized used well their masticatory muscles and their new potentials over time between 87 µV/µV s% and occlusal surfaces. 107 µV/µV s% are considered to be normal (6). Surface EMG of the masseter and temporal The limited TC values show that patients muscles, therefore, allowed an objective had no premature and sliding contacts due to quantification of the good functional characteristics the natural and prosthetic occlusal surfaces. of the new occlusal equilibrium of the patients’ Morphological alterations of the occlusal prosthesis analyzed in the current study. surfaces can generate a mandibular torsion (4). The results are also in accord with literature Indeed, even if an actual mandibular torsion has findings: a correct prosthetic reconstruction on already been observed in several experimental implants can restore a good functional situation. models (17-19), in most cases this phenomenon The relevant static characteristics are not is not macroscopically appreciable, because obviously superimposable to those measured in several other muscles (the medial pterygoid, subjects with a natural dentition, but are better for instance) could counterbalance the torque than those that can be obtained with removable effect provoked by the masseter and temporal dentures (21).

45 overdenture

Conclusions The present surface EMG analysis of a static A dentist should be able to control and detect (clenching) task showed that the analyzed occlusal alterations produced by a non-equilibrated prostheses need stable dental contacts between rehabilitation using the most correct methods. The the opposing dental arches. method used in the present investigation allows This functional condition could be protective a static evaluation of occlusion and can detect for full-mouth prosthetic resin complications over mandibular torsions and alterations between implants. It should be underlined that the simplicity the two sides that cannot be controlled only with of the current tests with a minimal effort could qualitative or purely morphological methods provide useful clinical information for the day-to- (articulation paper). day clinical practice.

Bibliography

1. Ferrario VF, Sforza C, Colombo A, Ciusa V. An electromyographic 11. Van Kampen FM, van der Bilt A, Cune MS, Bosman F. The investigation of masticatory muscles symmetry in normo-occlusion influence of various attachment types in mandibular implant- subjects. J Oral Rehabil. 2000;27(1):33-40. retained overdentures on maximum bite force and EMG. J Dent 2. De Felício CM, Sidequersky FV, Tartaglia GM, Sforza C. Res. 2002;81(3):170-173. Electromyographic standardized indices in healthy Brazilian young 12. Al-Omiri M, Hantash RA, Al-Wahadni A. Satisfaction with dental adults and data reproducibility. J Oral Rehabil. 2009;36(8):577-583. implants: a literature review. Implant Dent. 2005;14(4):399-406. 3. De Felício CM, Ferreira CL, Medeiros AP, Rodrigues Da Silva 13. Flanagan D. An overview of complete artificial fixed dentition MA, Tartaglia GM, Sforza C. Electromyographic indices, orofacial supported by endosseous implants. Artif Organs. 2005;29(1):73- myofunctional status and temporomandibular disorders severity: 81. A correlation study. J Electromyogr Kinesiol. 2012;22(2):266-272. 14. Feine JS, Lund JP. Measuring chewing ability in randomized 4. Ferrario VF, Sforza C, Serrao G, Colombo A, Schmitz JH. The controlled trials with edentulous populations wearing implant effects of a single intercuspal interference on electromyographic prostheses. J Oral Rehabil. 2006;33(4):301-308. characteristics of human masticatory muscles during maximal 15. Farella M, Bakke M, Michelotti A, Rapuano A, Martina R. voluntary teeth clenching. Cranio. 1999;17(3):184-188. Masseter thickness, endurance and exercise-induced pain in 5. Tartaglia GM, Testori T, Pallavera A, Marelli B, Sforza C. Electromyographic subjects with different vertical craniofacial morphology. Eur J analysis of masticatory and neck muscles in subjects with natural Oral Sci. 2003; 111:183–8. Eur J Oral Sci. 2003;111(3):183- dentition, teeth-supported and implant-supported prostheses. Clin 188. Oral Implants Res. 2008;19(10):1081-1088. 16. Garcia-Morales P, Buschang PH, Throckmorton GS, English 6. Ferrario VF, Tartaglia GM, Galletta A, Grassi GP, Sforza C. The JD. Maximum bite force, muscle efficiency and mechanical influence of occlusion on jaw and neck muscle activity: a surface advantage in children with vertical growth patterns. Eur J Orthod. EMG study in healthy young adults. J Oral Rehabil. 2006;33(5):341- 2003;25(3):265-272. 348. 17. Christensen LV, Rassouli NM. Experimental occlusal 7. Ferrario VF, Tartaglia GM, Maglione M, Simion M, Sforza C. interferences. Part II. Masseteric EMG responses to an intercuspal Neuromuscular coordination of masticatory muscles in subjects interference. J Oral Rehabil. 1995; 22:521-531. J Oral Rehabil. with two types of implant-supported prostheses. Clin Oral Implants 1995;22(7):521-531. Res. 2004;15(2):219-225. 18. Karlsson S, Cho S-A, Carlsson GE. Changes in mandibular 8. Jacobs R, Van Steenerghe D, Naert I. Masseter muscle fatigue masticatory movements after insertion of nonworking-side before and after rehabilitation with implant-supported prostheses. interference. J Craniomandib Disord. 1992;6(3):177-183. J Prosthet Dent. 1995;73(3):284-289. 19. Rassouli NM, Christensen LV. Experimental occlusal 9. Moriya S, Notani K, Murata A, Inoue N, Miura H. Analysis of interferences. Part III. Mandibular rotations induced by a rigid moment structures for assessing relationships among perceived interference. J Oral Rehabil. 1995;22(10):781-789. chewing ability, dentition status, muscle strength, and balance 20. Baba K, Ai M, Mizutani H, Enosawa S. Influence of experimental in community-dwelling older adults. Gerodontology. 2012. doi: occlusal discrepancy on masticatory muscle activity during 10.1111/ger.12036. clenching. J Oral Rehabil. 1996;23(1):55-60. 10. Grosdent S, O’Thanh R, Domken O, Lamy M, Croisier JL. Dental 21. Fontijn-Tekamp FA, Slagter AP, van’t Hof MA, Geertman ME, Kalk occlusion influences knee muscular performances in asymptomatic W. Bite forces with mandibular implant-retained overdentures. J females. J Strength Cond Res. 2014;28(2):492-498. Dent Res. 1998;77(10):1832-1839.

46 Stoma.eduJ (2014) 1 (1) Functional evaluation of implant supported prostheses

Gianluca Martino Tartaglia, DDS, PhD DDS, PhD, Associate Professor, Department of Biomedical Sciences for Health, Faculty of Medicine, University of Milan, Milano, Italy

Gianluca Martino Tartaglia received his DDS degree from the Uni- versity of Milan, School of Dentistry, Italy, in 1991, and his PhD in Morphological Sciences from the same university in 1996. He is cur- rently a staff member of the Laboratory of Functional Anatomy of the Stomatognathic Apparatus, and he works in private practice in Milan. He authored more than 100 international research papers on CV the stomatognathic system. In particular, he is an expert of surface electromyography of masticatory and neck muscles.

Questions What should be included in a correct evaluation of prostheses: q a. the stomatognathic function; q b. the morphological evaluation of the occlusion is not required; q c. the measurement of the actual impact of the morphology on the stomatognathic function; q d. the previous prosthetic reconstruction. The values for the EMG indices in the five study patients were:

q a. abnormal; q b. normal; q c. unusually high; q d. unusually low. How many patients were followed in this study and for how long:

q a. 5 patients for 10 years; q b. 50 patients for 1 year; q c. 5 patients for 1 year; q d. 50 patients for 10 years. In what interval was the TC (torque coefficient) for the study patients:

q a. 25-50% q b. 50-75% q c. 85-95% q d. 25-75%

47 GERODONTOLOGY

Cite this article: Petraki V, Thomopoulos P, Kossioni AE. Factors Factors affecting recent dental affecting recent dental services utilization by an urban older population services utilization by an urban in Athens. Stoma Edu J. 2014; 1(1):48-51. older population in Athens

Vasilia Petraki1a, Philippos Thomopoulos2b, Abstract Anastassia E. Kossioni3c* 1. Department of Operative Dentistry, Dental School, Introduction: The purpose of this study was to investigate the percentage of older people National and Kapodistrian University of Athens, in an urban area visiting a dentist within the last 12 months and explore the particular effect Athens, Greece 2. General Dental Practitioner, Glifada, Greece of age, gender, education and dental status. 3. Department of Prosthodontics, Dental School, Methodology: Athens Dental School organized educational visits to a day center for older National and Kapodistrian University of Athens, people in Athens, where the older visitors were interviewed and clinically examined. The Athens, Greece a. DDS, Clinical Associate patients’ social and medical history and the time of the last dental visit were recorded. The b. DDS, General Dental Practitioner clinical examination included the presence of natural teeth using appropriate portable c. DDS, PhD, Assistant Professor equipment. Results: A total of 77 older people, 53 females and 24 males, with a mean age of 73.8 years were recorded. Dental visits in the last 12 months were statistically significantly related to higher level of education (more than 6 years) (p=0.037) and the presence of natural teeth (p=0.014). More women had visited a dentist in the past 12 months but not to a statistically significant level. Fewer older old (aged 85 years and over) had recently visited a dentist but not statistically significantly. Conclusion: The findings in the present study are in accordance to previous investigations in community-dwelling older adults indicating the importance of education and natural teeth in the utilization of dental services. Key words: elderly, gender, edentulism, education, dental service utilization

Introduction During the last decades the number of older people has continuously grown, as a result of increased life expectancy and low fertility rates (1). By the year 2050, the persons aged 60 years and over will be almost two billion world-wide and the large majority of them (80%) will live in developing countries (2). The oldest old age group (80 years and over) is the most rapidly increasing proportion of the population, and is expected to increase from 0.5% in 1950 to 4.3% by 2050 (2). This demographic change will put significant strains on social security systems, including provision of general and oral health care. More older people in the developed countries tend to maintain their natural dentition but the rates of oral disease, such as tooth loss, periodontal diseases, dental caries, xerostomia and oral cancer are still high (3-5). The use of dental services has been investigated in relation to many factors, such as age, gender, dental status, ethnicity, income, education, general health status, dental and Received: 09 November 2013 medical insurance (6-9). Increasing age, lower education and compromised self-rated Accepted: 21 January 2014 health have been related to lower use of dental services by older Europeans (10). * Corresponding author: The purpose of this study was to investigate the percentage of older people in an Assistant Professor Anastassia E Kossioni, urban area, visiting a dentist within last 12 months and to explore the particular effect DDS, PhD of age, gender, education and dental status. Department of Prosthodontics, Dental School, National and Kapodistrian University of Athens, Athens, Greece. Methods Thivon 2 Goudi, GR-11527Athens, Greece. Gerodontology is a lecture-based course taught in the 8th semester of the Tel: +302107461212, Fax: +302107461240. e-mail: [email protected] undergraduate studies at the Athens Dental School. Within this course, the students visit

48 Stoma.eduJ (2014) 1 (1) Factors affecting recent dental services utilisation by an urban older population in Athens

Figure 1. Dental visits by older adults in the past Figure 2. Dental visits by older adults in the past 12 months in relation to gender (%) , p>0.05 12 months in relation to age (%), p>0.05 day centers for the elderly in the Metropolitan p=0.014). For 51% of the women and 42% of Athens area on a voluntary basis. In 2012, 34 the men, prosthodontic treatment was the main students participated in these visits that included reason for the last dental visit. a thorough medical and dental history taking and an oral examination using portable equipment Discussion (11). The students and the members of the staff This study offers an insight on the parameters of the Dental School informed the older people that may affect dental consultation rates in an about their current oral problems, provided oral older urban European population. hygiene instructions and advised on the proper More than half of the older participants had use of dentures. One of the questions asked visited a dentist within the last 12 months. A were if they had visited a dentist in the past 12 previous study in a Greek population aged 57- months. 99 years has shown that 37% of the participants The effect of gender (men, women), age (<66 had visited a dentist in the past year (9). The years, 66-75 years, 76-85 years and 85 years and higher percentage in the present study could over), education level (≤6 years and >6 years) and be related to the specific sociodemographic dental status (dentate, edentulous), on visiting a characteristics of the sample (urban area, middle- dentist within the past 12 months were analyzed. class, motivation to be examined by a dentist in The statistical analyses included descriptive the day centre). statistics, chi-square tests and Fisher’s Exact The two most important predictors for seeking Tests. The level of statistical significance was set dental care in the past 12 months were the at p ≤0.05. higher level of education and having a natural dentition. On the other hand, sex and age did Results not significantly affect the time of the last dental A total of 77 older people were examined, 53 visit. women and 24 men, with a mean age of 73.8 years The level of education is a significant predictor (SD: ±7.3). Their age ranged from 59 to 92 years. of dental utilization among older adults (6,10). A total of 55.8% of them had attended fewer Previous surveys in Greece have also reported than 7 years of education and only 15.6% had that, and low educational level was associated with completed tertiary education. A total of 15.6% lower use of dental services (8,9). Similar were the were edentulous and 84.4% were dentate. findings in senior citizens in Canada (7). Almost half of the participants (53.3%) had A total of 60% of the dentate adults had visited visited a dentist in the past 12 months. More a dentist in the last year, while this percentage women than men had recently visited a dentist decreased to approximately 17% in the edentulous (Figure 1) but this was not statistically significant ones. Similar were the findings in a previous study (chi-square test, p=0.528). Fewer older old (85 in 1751 older participants in Manitoba, Canada years and over) had visited a dentist in the past with a mean age of 76.2 years. The dental visits year (Figure 2) but the statistical analysis did not in the past 6 months in the dentate seniors were record any statistical significance (chi-square test, 36.2%, compared to 13.5% in the edentulous ones p=0.521). Most of the people who had visited a (7). Furthermore, 46% percent of the edentulous dentist in the past 12 months had completed at Australians aged 55-74 years had visited a dentist least primary school education (6 years) (Figure more than 5 years ago compared to 8% by the 3) (Fishers Exact Test, p=0.037). More dentate dentate ones (12). (60%) than edentulous persons had visited a Fewer men had visited a dentist in the past dentist in the last year (Figure 4) (chi-square test, 12 months compared to women but not to a

49 GERODONTOLOGY

Figure 3. Dental visits by older adults in the past 12 Figure 4. Dental visits by older adults in the past months in relation to the level of education (%), p=0.037 12 months in relation to dental status (%), p=0.014

statistically significant level. In a previous study Conclusions in Mexico City the male gender was associated with reduced dental service utilization (13). Taking into account the limitations of this study, Similar were the findings inA ustralia (12). it may be concluded that the higher level of Fewer older persons aged 85 years and over education and the dentate status are related to had recently visited a dentist but again this was increased percentages of older people visiting a not statistically significant. A previous study in a dentist in the past 12 months. The male gender Greek population has shown a lower percentage and the older age were related to fewer visits but of dental services’ users in the past 12 months not to a statistically significant level. with increasing age (9). It may be suggested that the fewer recent dental visits by the older old is Acknowledgments related to the higher rates of edentulism. The authors would like to thank the municipality This study had some limitations. The sample size was of Zografos and the Director of the 1st day center small and included participants from a Metropolitan for older people Mr. George Dimarides for the urban area with medium socio-economic status. substantial assistance throughout the educational Further research is needed to investigate utilization of visits. Special thanks to the dental educators who dental services by the older population in more urban participated in the program and Johnson and and rural areas in the country. Johnson Hellas for the financial support.

Bibliography

1. Kossioni AE. Is Europe prepared to meet the oral health needs of 9. Koletsi-Kounari H, Tzavara C, Tountas Y. Health-related lifestyle older people? Gerodontology. 2012; 29(2):1230-1240. behaviours, socio-demographic characteristics and use of dental 2. United Nations. World Economic and Social Survey 2007. health services in Greek adults. Community Dent Health. 2011; Development in an Ageing World. New York: Department of Economic 28(1):47-52. and Social Affairs, United Nations; 2007. 10. Santos-Eggimann B, Junod J, Cornaz S. Health services 3. Petersen PE, Yamamoto TI. improving the oral health of older people: utilisation in older Europeans. In: Borsch- Supan A, Brugiavini the approach of the WHO Global Oral Health Programme. Community A, Jurges H et al. eds. Health, Ageing and Retirement in Europe. Dent Oral Epidemiol. 2005; 33(2):81-92. First Results from the Survey of Health, Ageing and Retirement 4. Petersen PE, Kandelman D, Arpin S, Ogawa H. Global oral health of in Europe. Mannheim: Mannheim Research Institute for the older people – Call for public health action. Community Dent Health. Economics of Aging (MEA); 2005:133–140. 2010; 27(Suppl 2):257–267. 11. Petraki V, Michael L, Gavela G, Kossioni AE. Dental status in older 5. Kossioni AE. Current status and trends in oral health in the community-dwelling people in a day-center in Attica- A pilot study. community-dwelling older adults. A global perspective. Oral Health Hellenic Stom Rev. 2012; 56(4):271-282. Prev Dent. 2013; 11(4):331-340. 12. Slade GD, Spencer AJ. Roberts-Thomson KF. Australia’s dental 6. Kiyak HA, Reichmuth M. Barriers to and enablers of older adults’ use generations. The National Survey of Adult Oral Health 2004–06. of dental services. J Dent Educ. 2005; 69(9):975–986. Canberra: Australian Institute of Health and Welfare (Dental Statistics 7. Brothwell DJ, Jay M, Schönwetter DJ. Dental service utilization by and Research Series No. 34); 2007. AIHW cat. no. DEN 165. independently dwelling older adults in Manitoba, Canada. J Can Dent 13. Sánchez-García S, de la Fuente-Hernández J, Juárez-Cedillo T, Assoc. 2008; 74(2):161-161f. Mendoza JM, Reyes-Morales H, Solórzano-Santos F, García-Peña C. 8. Pavi E, Karampli E, Zavras D, Dardavesis T, Kyriopoulos J. Social Oral health service utilization by elderly beneficiaries of the Mexican determinants of dental health services utilisation of Greek adults. Institute of Social Security in México city. BMC Health Serv Res. Community Dent Health. 2010; 27(3):145-150. 2007;7:211.

50 Stoma.eduJ (2014) 1 (1) Factors affecting recent dental services utilisation by an urban older population in Athens

Vasilia Petraki DDS, Clinical Associate, Department of Operative Dentistry, National and Kapodistrian University of Athens Dental School, Athens, Greece

Dr. Vasilia Petraki was born in Rhodes and has recently (2013) gradu- ated from the National and Kapodistrian University of Athens Dental School. She is currently clinical associate in Operative Dentistry at the same University. During her undergraduate dental studies she re- ceived several awards and distinctions for best academic performance. She co-authored 3 publications in peer-reviewed scientific journals CV and participated in 8 oral presentations in national and international conferences. She was an active member of the European Dental Students Association and one of her studies won the 1st prize at the 13th Athens dental students’ conference. One of her main research interests is Gerodontology.

Questions What was the mean age of the patients? q a. 23 yrs. q b. 53 yrs. q c. 93 yrs. q d. 73.8 yrs. What percent of the patients had attended fewer than 7 years of education? q a. 0% q b. 100% q c. 25% q d. 55.8% What percent of the patients had completed tertiary education? q a. 0% q b 100% q c. 75% q d. 15.6% What percent of the participants had visited a dentist in the past 12 months? q a. 10% q b. 25% q c. 53.3% q d. 75%

51 oral implantology

Cite this article: Kempler J. An implant supported maxillary An Implant Supported fixed prosthesis with a substructure/suprastructure design: a clinical case. Maxillary Fixed Prosthesis Stoma Edu J. 2014; 1(1);52-58. with a Substructure/ Suprastructure Design: A Clinical Case

Joanna Kempler* Department of Endodontics, Prosthodontics and Abstract Operative Dentistry, Baltimore College of Dental Surgery, Baltimore, MD, USA DDS, MS, Clinical Assistant Professor This article describes a clinical case in which a moderately compromised maxillary arch is restored with a fixed implant supported prosthesis with a substructure/suprastructure design. The prosthetic rehabilitation of the edentulous maxilla can be achieved using different types of prostheses, including removable implant-retained, implant-supported, or fixed implant- supported prostheses. The treatment performed is presented step-by-step. The prosthetic design is discussed in detail and compared to other types of fixed implant supported prostheses.A dvantages and disadvantages of this type of design are also presented. The substructure/suprastructure design is indicated when the prosthesis must replace both soft and hard tissues. Although it involves multiple steps and it is costly, the substructure/ suprastructure design represents a great alternative to any removable prosthesis and provides patients with great esthetics and function. Keywords: implants, edentulous maxilla, fixed prosthesis

Introduction The predictability of successful osseointegration in the rehabilitation process of an edentulous arch, as described by Branemark et al (1), introduced an entire new concept of management of the edentulous patients. According to a study by Douglas and Watson, the actual number of individuals requiring complete denture therapy by the year 2030 will not decrease, and maxillary edentulism may represent up to a third of the denture market (2). A 2006 study by Jemt showed that implant treatment in the edentulous upper jaw functioned well in a long time perspective. The 15-year implant and fixed prosthesis cumulative survival rate was 90.9 and 90.6%, respectively (3). This is important for us as practitioners as more edentulous patients will present for implant reconstruction. Implant treatment of the edentulous maxilla can be a complex scenario and the outcome Received: 04 December 2013 Accepted: 06 January 2014 does not always fulfill the expectations in terms of esthetics and function (4). The maxillary arch presents multiple potential challenges for both the surgical and the * Corresponding author: restorative providers. Implant therapy for the maxillary arch is often compromised by reduced Clinical Assistant Professor bone quantity and quality and by the presence of higher biomechanical forces (5). Joanna Kempler, DDS, MS Maxillary implants are often angled facially due to resorptive patterns, while the replacement Department of Endodontics, Prosthodontics and Operative Dentistry, Baltimore College of Dental teeth are usually arranged anterior and inferior to the residual ridge (6). Thicker masticatory Surgery, Baltimore, MD, USA. mucosa on the maxilla often necessitates longer implant abutments increasing the lever arm 3460 Old Washington Road, Suite 102, Waldorf, MD, 20602, USA. length. Unlike the mandible, with its shock absorbing effect and buttressing lingual bone, the e-mail: [email protected] thin buccal bone of the maxilla may not tolerate the applied forces as well (7).

52 Stoma.eduJ (2014) 1 (1) An Implant Supported Maxillary Fixed Prosthesis with a Substructure/ Suprastructure Design: A Clinical Case

Figure 1. Initial presentation (frontal view) Figure 2. Initial presentation (profile view)

Figure 3. Intraoral frontal view Figure 4. Initial panoramic radiograph (the shadow is due to the screws) The design of the final maxillary implant supported substructure cases require complex laboratory prosthesis is influenced by the following: procedures and tend to be more costly. 1. The Anatomy of the residual ridge. The degree Some of the design options for a fixed maxillary of ridge resorption can significantly alter the size implant supported prosthesis include the following: and position of future implants and can determine 1. Ceramo-metal cement retained on custom whether teeth, or teeth and other tissues must be abutments; replaced (8). 2. Ceramo-metal screw retained prosthesis; 2. Some functional considerations include 3. Fixed-detachable or “hybrid” prosthesis; the opposing dentition, whether the patient 4. Suprastructure/Substructure design which can has natural teeth or a removable prosthesis. be achieved either by: Also, the maxillo-mandibular relationship is -spark erosion technique very important, as an increased vertical space -milled/ cast bar, cast suprastructure with set and horizontal discrepancies create greater screws lever arms and complicate the design of the -milled bar with individual abutments and single final prosthesis (9). crowns cemented on the abutments (13,14). 3. Esthetics plays a crucial role in prosthesis The substructure/suprastructure design has its design. Careful assessment of the patient’s smile advantages and disadvantages. line and necessity for a buccal flange must be Some of the advantages of this type of design performed before the final treatment plan decision include providing the patient with a fixed prosthesis is made (10). when no other designs are feasible. It also has the 4. Altered speech can occur when patients ability to replace both missing hard and soft tissue cannot adapt to the new contours of the prosthesis. and improve unfavorable biomechanics seen in Implants placed too far palatally often require off-ridge relations (15). Esthetics and phonetics are bulky restorations, which in turn can significantly usually very good with this type of design. alter speech (11). However, there are also disadvantages to this 5. To promote favorable oral hygiene, access design. must be provided for effective removal of plaque The cost is usually very high due to precise and food debris from around the abutments and and complicated laboratory procedures that are underneath the framework (12). required and it unfortunately can be prohibitive for 6. Lastly, cost plays a significant role in selecting some patients. Passive fit of the bar and framework a prosthesis design. Usually suprastructure/ is also difficult to achieve. Long span frameworks

53 oral implantology

Figure 5. Cone Beam CT scan Figure 6. Occlusal view of maxillary arch during implant placement

Figure 7. Tooth arrangement in wax Figure 8. Esthetic try-in to determine the necessity without the buccal flange of a buccal flange

are difficult to apply porcelain to and porcelain opening which was 30mm and right laterotrusive, fracture is challenging and costly to repair. Also, which was 1-2 mm. loss of a strategic implant may compromise the Patient’s radiologic examination revealed entire prosthesis. Hygiene can be challenging multiple root tips, periodontally involved teeth and for some patients, especially those with limited a horizontal root fracture of tooth #11. Panoramic dexterity (16). radiograph showed abnormal temporomandibular left joint due to a car accident during early age, with Case Report otherwise normal trabecular bone pattern. (Fig. 4). A 45-year-old female patient presented to the A problem list was put together before Advanced Education Program in Prosthodontics at establishing the final treatment plan. the Baltimore College of Dental Surgery, with the The patient’s maxillary arch anatomy represented following chief complaint: “I would like to have my a challenge especially on her left side, where she teeth fixed.” Patient said that she never had pretty had a pronounced horizontal discrepancy between teeth and now she is ready to do something to the maxillary and the mandibular alveolar ridge improve her smile. Patient had lost her teeth mainly crest and also an increased inter-arch distance. due to periodontal disease. The patient’s desire was to have a fixed final She showed some facial asymmetry, scarring on prosthesis, however she refused any grafting the left corner of the mouth, pronounced labio- procedures. She was educated about the nasal folds and lip asymmetry during smiling (Fig. complexity of her treatment plan and was 1). Patient had a convex profile with adequate lip explained that a fixed prosthesis might not be support (Fig. 2). possible in her case. Intraoral examination revealed missing posterior All maxillary teeth were extracted atraumatically teeth, retained root tips and periodontally involved and an immediate maxillary complete denture maxillary anterior teeth (Fig. 3). Mandibular range was fabricated. The patient was very pleased of motion was restricted, especially maximum with the esthetics of the denture, which allowed

54 Stoma.eduJ (2014) 1 (1) An Implant Supported Maxillary Fixed Prosthesis with a Substructure/ Suprastructure Design: A Clinical Case

Figure 9. Screw retained acrylic provisional Figure 10. GC pattern substructure before casting

Figure 11. Substructure bar tried in the mouth Figure 12. Full contour wax-up of the metal suprastructure proceeding by duplicating the immediate denture -Implant distribution was fair on the right side and fabricating a radiographic guide based on the and very good on the left side; immediate denture’s tooth arrangement. -Implants 22, 24, 27 were buccally angled. The patient was sent for cone beam CT scan Another very critical step was performed before wearing the radiographic guide. Based on bone committing to a final prosthesis design: determining availability, six maxillary implants were planned in the need for a buccal flange.A wax set-up was made areas: 15,14,13, 22,14, 27 (Fig. 5). excluding the buccal flange and tried in (Fig. 7). The number of implants was based on the Extraoral clinical examination addressed facial availability of bone and the patient’s denial of any parameters such as facial support, lip support, extensive bone grafting procedures. This was also smile line, and upper lip length. Facial support in conjunction with the literature, as Beumer et al is a critical factor for decision making because recommended a minimum of six implants to be soft tissue support can be obtained mainly by placed with an anterior-posterior span of at least the buccal flange of a removable restoration and 20 mm for a fixed maxillary prosthesis (17). the position of the denture teeth. The thickness Six implants were placed as planned with a of the buccal flange of an existing complete second stage approach (Nobel Active Regular denture can also be indicative of the necessary Platform] [RP 4.3mm] and Narrow platform [NP lip and cheek support. It was determined that an 3.5mm], Nobel Biocare USA, Yorba Linda, CA) (Fig. adequate esthetic result can be obtained without 6). Following second stage surgery, an implant the buccal flange (Fig. 7, 8). impression was made using pick-up copings in an A fixed screw retained acrylic provisional open custom tray. A verification jig was fabricated on temporary abutments was fabricated. The on the master cast using GC pattern resin (GC abutments were contoured to allow for proper America, Alsip, IL). soft tissue profile and the patient was given oral The maxillary master cast was articulated and at hygiene instructions on how to adequately clean this point the treatment plan was re-evaluated and her new prosthesis (Fig. 9). some implant factors were added to the problem There are many advantages to providing a fixed list: provisional before placing the final ceramo-metal -Implant size: there were 2 regular platform and restoration. Evaluation of esthetics, reassessment 4 narrow platform implants ; of the occlusal scheme, adjustment of the vertical

55 oral implantology

Figure 13. Metal suprastructure Figure 14. View of the left lateral set screw openings

Figure 15. Superfloss passing underneath prosthesis dimension, and equilibration by addition or subtraction can be made in this manner. Occlusal harmony should improve the load distribution and reduce component failure. A mutually protected occlusal scheme was achieved in the provisional stage. The substructure was fabricated by first milling a GC pattern framework on non-engaging gold adapt cylinders (Nobel Biocare USA, Yorba Linda, CA) (Fig. 10). Figure 16. Final prosthesis (frontal view) A putty matrix of the cross-mounted provisionals was used by the laboratory technician for reference. The GC pattern was precision milled with a 3 degree At this point, the master cast articulation was taper on both sides, which provided frictional verified by making an interocclusal record on the retention for the future metal suprastructure. The articulator, then transferring it to the mouth and GC pattern was invested and cast in a noble alloy. verifying the accuracy of the mounting. The substructure was tried in the mouth (Fig. 11). The next step was the porcelain application The passive fit of the substructure was assessed on the suprastructure and delivery of the final by performing the one screw test, the quarter turn prosthesis. test, by tactile and radiographic examination. The The final prosthesis was examined for adequate verification radiographs were taken to assess any fit esthetics and fit. Four lingual set screws were discrepancies. A full contour wax-up was created drilled. Due to the patient’s limited mouth opening, prior to the fabrication of the metal suprastructure insertion of the set screws was a tedious and (Fig. 12). The full contour wax up was cut back challenging process (Fig. 14). to allow for adequate room for porcelain The substructure was inserted and torqued application. The wax pattern was invested and to 35 Ncm. The suprastructure was placed over cast in noble metal alloy. The suprastructure the substructure, the set screws were carefully was examined on the articulator for fit, proper manipulated in position. contours and adequate interocclusal clearance The patient was educated on proper oral hygiene (Fig. 13). and maintenance of her new prosthesis (Fig. 15).

56 Stoma.eduJ (2014) 1 (1) An Implant Supported Maxillary Fixed Prosthesis with a Substructure/ Suprastructure Design: A Clinical Case

The mutually protected occlusal scheme supported restoration are most interested in a fixed established in the provisional was replicated in the restoration. Accompanying the loss of supporting final prosthesis. A mandibular occlusal guard was alveolar structure due to resorption is the necessity fabricated. for soft tissue support in order to achieve optimum During an exaggerated smile there is a fair esthetic results. The substructure/suprastructure display of pink porcelain, however, the junction design can replace missing both hard and soft tissue between patient’s soft tissue and pink porcelain is and improve unfavorable biomechanics seen in off- not visible. The patient was very pleased with the ridge relations. However, this design is very difficult result (Fig.16). to achieve due to the high precision required for the substructure and the suprastructure, challenging Summary laboratory steps and it is very costly. It does however With edentulism on the rise, patients seeking provide the patients with a prosthesis that offers replacement of their upper denture with an implant- optimum esthetics and function.

Bibliography

1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study 9. Sadowsky SJ. The implant-supported prosthesis for the of osseointerated implants in the treatment of the edentulous edentulous arch: Design considerations. J Prosthet Dent. jaw. Int J Oral Surg. 1981; 10(6): 387-416. 1997; 78(1): 28-33. 2. Douglass CW, Watson AJ. Future needs for fixed and 10. Henry P. A review of guidelines for implant rehabilitation of the removable partial dentures in the United States. J Prosthet edentulous maxilla. J Prosthet Dent. 2002; 87(3): 281-288. Dent. 2002; 87(1): 9-14. 11. Graser GN, Myers ML, Iranpour B. Resolving esthetic 3. Jemt T, Johansson J. Implant treatment in the edentulous and phonetic problems associated with maxillary implant- maxillae: a 15-year follow-up study on 76 consecutive patients supported prostheses: a clinical report. J Prothet Dent.1989; provided with fixed prostheses. Clin Implant Dent Relat Res. 62: 376-378. 2006; 8(2): 61-69. 12. Sadowsky SJ. Treatment considerations for maxillary 4. Bosse LT, Taylor TD. Problems associated with implant implant overdentures: a systematic review. J Prosthet Dent. rehabilitation of the edentulous maxilla. Dent Clin North Am. 2007; 97: 340-348. 1998; 42(1): 117-127. 13. Morgano SM, Verde MA, Haddad MJ. A fixed-detachable 5. Zitzmann NU, Marinello CP. Treatment plan for restoring implant-supported prosthesis retained with precision the edentulous maxilla with implant-supported restorations: attachments. J Prosthet Dent. 1993; 70: 438-442. Removable overdenture versus fixed partial denture design. J 14. Ercoli C, Graser GN, Tallents RH, Hagan ME. Alternative pro­ Prosthet Dent .1999; 82(2): 188-196. cedure for making a metal superstructure in a milled bar implant- 6. Razavi R, Zena RB, Khan Z, Gould AR. Anatomic site evaluation supported overdenture. J Prosthet Dent. 1988; 80: 253-258. of edentulous maxillae for dental implant placement. J 15. Eisenmann E, Mokabberi A, Walter MH, Freesmeyer WB. Prosthdont. 1995; 4(2): 90-94. Improving the fit of implant-supported superstructures using the 7. Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. spark erosion technique. Int J Prosthodont. 1999;12: 167-178. Fixed-prosthetic implant restoration of the edentulous maxilla: 16. Sherry JS, Balshi TJ, Sims LO, Balshi SF. Treatment of a a systematic pretreatment evaluation method. J Oral Maxillofac severly atrophic maxilla using an immediately loaded, implant- Surg. 2008; 66(1): 112-122. supported fixed prosthesis without the use of bone grafts: a 8. Wee AG, Aquilino SA, Schneider RL. Strategies to achieve clinical report. J Prosthet Dent. 2010; 103:133-138. fit in implant prosthodontics: a review of the literature. Int J 17. Beumer J. Hamada MO. Lewis S. A prosthodontic overview. Prosthodont. 1999; 12(2): 167-178. Int J Prosthodontics. 1993; 6: 126-130.

57 oral implantology

Joanna Kempler DDS, MS, Clinical Assistant Professor, Department of Endodontics, Prosthodontics and Operative Dentistry, Baltimore College of Dental Surgery, Baltimore, MD, USA

Dr. Joanna Kempler, Diplomate of the American Board of Prostho- dontics, owns her private practice in Waldorf, MD as well as being a Clinical Assistant Professor for the Prosthodontics Residency at the University of Maryland, Baltimore. Dr. Kempler obtained her DDS degree from the University of Maryland Baltimore College of Dental Surgery in 2008. She gradu- CV ated Summa Cum Laude and received multiple awards. Dr. Kempler completed her three-year specialty training in Prosthodontics in conjunction with a Master’s Degree program at the University of Maryland. During her specialty training, Dr. Kempler lectured about dental implants and cosmetic dentistry at numerous national meetings. She is a fellow of the American College of Prosthodontists, a member of the American Academy of Fixed Prosthodontics and Academy of Osseointegration.

Questions Which of the following is true regarding design required for replacing both soft and hard tissue:

q a. a substructure design is required; q b. a suprastructure design is required q c. a substructure/suprastructure design is indicated q d. a substructure/suprastructure design does not provide great esthetics Which does not influence the design of the final maxillary implant:

q a. The Anatomy of the residual ridge q b. Esthetics q c. Speech q d. Cost does not play a role Regarding the maxillary:

q a. several teeth were extracted traumatically q b. an immediate maxillary complete denture was fabricated q c. the patient was pleased with the esthetics q d. no maxillary implants were planned In regards to edentulism:

q a. its prevalence is lowering q b. the substructure/ suprastructure design can replace missing both hard and soft tissue q c. the required design is easy to achieve q d. the required design is cheap

58 Stoma.eduJ (2014) 1 (1) COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME

Cite this article: Ilea A, Buhatel D, Moga M, PREVALENCE OF COMORBIDITIES Feurdean C, Ionel A, Sava A, Lucaciu O, Sarbu A, Campian RS. Comorbities prevalence IN SOCIALLY ASSISTED PATIENTS IN in socially assisted patients in the sanodentaprim programme. Stoma Edu J. THE SANODENTAPRIM PROGRAMME 2014; 1(1):59-64.

Abstract Aranka Ileaa*, Dan Buhățelb, Minodora Mogab, b Introduction: Once with the growth of the population’s life expectancy in the world but also Claudia Feurdean , b in Romania, the patients in dental offices often suffer from associated diseases for which Anca Ionel , b they are under constant medication. Arin Sava , Ondine Lucaciuc, The objectives of the study were to evaluate the prevalence of the associated diseases and Adina Sârbub, of constant medication for a group of socially assisted patients. Radu Septimiu Methods: The study included a total of 1176 socially assisted patients from the Câmpiand SANODENTAPRIM program who were seen during the period from April 15, 2010 to December 1, 2010. The observation files, medical notes and certificates from the general Oral Rehabilitation Department, Oral Health and Management practitioner or from the attending specialist physician were studied. of the Dental Office Department, Results: The patients from the studied group presented a prevalence of comorbidities of Faculty of Dentistry, "Iuliu 92%. The most frequent associated diseases were cardiovascular (36%). A percentage of Hațieganu" University of Medicine and Pharmacy, 84% of the studied patients were under constant medication. Cluj-Napoca, Romania Conclusion: The risks of the patient with general disease have to be evaluated according a. MD, DMD, Assistant Professor to a detailed anamnesis corroborated with paraclinical examinations and, if needed, in b. DMD, Assistant Professor c. DMD, Lecturer collaboration with the attending doctor. The adverse effects of constant medication need a d. DMD, MD, Professor, Head of special attention, especially when certain classes of drugs interfere with dental treatments. Oral Rehabilitation Department, Keywords: associate diseases, medication, prevalence, socially assisted Dean of Faculty of Dentistry

Introduction The relationship between general diseases and the pathology of the stomatognathic system is multiple and bidirectional. The oral health has consequences upon the general health and the correlation between the dental foci and the cardiovascular diseases or, recently, between the parodontal disease and cardiovascular disease, is well known (1). The gravity of the parodontal disease together with the high value of the reactive C protein with high sensitivity (hPCR) could be predictive for the imminence of installation of an acute cardiovascular incident (2). Also, general diseases have an echo upon the oral health. General conditions could have oral manifestations and could influence the evolution, the manifestations and the responses to the therapy instituted in the oro-maxillo-facial diseases. In the study realized by Anders Holmlund, Gunnar Holm and Lars Lind it is shown that life expectancy is related to the number of teeth on the dental arcades: the mortality Received: 17 November 2013 due to cardiovascular disease is higher in patients with less than 10 dental units remaining (3). Accepted: 16 December 2013 Knowing the general diseases of the patient is also crucial for the dentist. The decision of the opportunity, of the time of intervention, the specific preparation and the type of applied treatment *Corresponding depends on the presence or lack of associated diseases, on the degree of metabolic and functional author: Assistant Professor Ilea Aranka, compensation or on the patient’s hemodynamic balance. In this sense it is important to evaluate MD, DMD the prevalence of the associated diseases for the patients who are accessing the services of dental Oral Rehabilitation, Oral Health medicine. These data are very important especially if we correlate this information with social and Management of Dental Office Department, Faculty of Dentistry, aspects. "Iuliu Hațieganu" University of SANODENTAPRIM is a program for socially disadvantaged patients (retired with incomes below Medicine and Pharmacy, Cluj-Napoca, Romania. 1000 RON, retired due to illness, the unemployed, patients with disabilities and people with varying 8, Victor Babeş st., RO-400012, degrees of disability that require a registered nurse) and runs through the partnership between the Cluj-Napoca, Romania. Tel: 0746151210, Town Hall of Cluj-Napoca and the Faculty of Dentistry of the University of Medicine and Pharmacy, Fax: 0040-0264596291. Cluj-Napoca. Under this program, patients benefit from free dental care. e-mail: [email protected]

59 oral rehabilitation

Considering that the data concerning the prevalence The objectives of the study were: of the general diseases in Romania is scarce and 1. Assessing the prevalence of comorbidities in incomplete, the authors proposed to evaluate this aspect socially disadvantaged patients who accessed the for a group of socially assisted patients who accessed SANODENTAPRIM program between April 15, 2010 the SANODENTAPRIM program. The prevalence and December 1, 2010. represents the frequency of the disease cases (new 2. Evaluate the types and classes of constant and old) existing in a defined population at a certain medicines used by these patients. moment – the actual prevalence – or during a certain period – the periodic prevalence. The prevalence is a Methods specific indicator of the study of morbidity by chronic The retrospective study of the prevalence of associate diseases. In the case of prevalence, the observation unit diseases was made upon a number of 1176 patients is the new and old cases of disease. having accessed the SANODENTAPRIM program The need for oral rehabilitation is different from one during the period of April 15, 2010 – December patient to another and it is determined by the gravity of 1, 2010. Observation files, the medical notes and the dental/parodontal diseases and the diseases from certificates from the general practitioner or from the the oro-maxillo-facial area. The socially assisted patient attending physician have been studied. These files has a low revenue and this is the reason why they are were completed after the patient history, clinical and accessing the dental medicine services in the private paraclinical examinations of the patients by the dentists, system in a small proportion or even not at all. The specialist doctors or students during their classes in the social insurance system in Romania concerning dental Oral Rehabilitation Department. medicine has a low budget, each insured patient having the amount of about 3 RON per year. This social program Results offers the possibility for these social disadvantaged From the group of 1176 patients, the women groups to access free dental medicine services. The accounted for 59% as can be seen in Fig. 1. The age primary prevention and the early interception of these histogram shows that the majority of patients had ages diseases of the stomatognathic system may reduce the between 60 and 65 years as can be noticed in Fig. 2. need of complex oral rehabilitation. The actual prevalence of the associated diseases in the

Figure 1. Gender distribution

Figure 2. Distribution of the study group by age

60 Stoma.eduJ (2014) 1 (1) COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME

Figure 3. Presence of comorbidities

Figure 4. Actual comorbidities

Figure 1. Gender distribution

Figure 5. Cardiac diseases

study group was high and accounted for 92% as shown (18%) as seen in Fig. 6. Among the most frequent allergies in Fig. 3. The specific prevalence on different types of to drugs were the allergy to antibiotics (41%) followed affections is represented in Fig. 4. The most frequent by the allergy to anesthetic drugs (18%) as seen in Fig. comorbidities were those of the cardiovascular system 7. Diabetes mellitus type 2 was the most frequent (63%) (36%), some of the patients presenting two or more according to the average age of the study group as associated diseases. Cardiovascular diseases were shown in Fig. 8. The most frequent endocrine disorders followed by liver diseases with a prevalence of 12%. were represented by hypothyroidism (30%) followed From the cardiovascular diseases, the most prevalent very closely by hyperthyroidism (29%) as shown in was high blood pressure (HBP) (69%) as seen in Fig. Fig. 9. Hypoacusis (38%) was the most common ORL 5. Similar prevalence within the hepatic diseases was illness, but 19% of the patients from the study group represented by viral hepatitis type A (19%) and type B suffered from ORL infectious diseases like chronic otitis,

61 oral rehabilitation

Figure 6. Hepatic diseases

Figure 7. Drug allergies

Figure 8. Diabetes mellitus

chronic rhinitis or nasal sinusitis, as can be seen in Fig. under constant medication for their actual disorders 10. Nephrolithiasis (47%) was the most frequent kidney as seen in Fig. 14. Almost half of the drugs were disorder. 5% of the patients had chronic kidney failure represented by ß-blockers and diuretics as shown in as shown in Fig.11. Fig.15. Among respiratory disorders, the most frequent was asthma (63%), and 37% of the patients reported Discussion pulmonary tuberculosis in their medical history (Fig. From the 1176 patients, most of them were female. 12). Among the neurologic disorders the most frequent This shows a better compliance of women to dental was epilepsy (72%), and 20% of the patients had stroke treatments and a higher interest for oral health. Most in their medical history as can be seen in Fig. 13. of the patients were between 56 and 65 years old. From the 1176 patients, a percentage of 84% were The high actual prevalence of comorbidities was 92%

62 Stoma.eduJ (2014) 1 (1) COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME

Figure 6. Figure 9. Hepatic diseases Endocrine diseases

Figure 10. Otolaryngology diseases

Figure 8. Figure 11. Diabetes mellitus Kidney diseases

because the majority of the subjects were elders. % in an urban environment and between 42.6% and The total of the associated diseases was 1593, 56.9% in a rural environment (4). The prevalence of exceeding the number of patients in the study group, cardiac failure in Eastern areas of Africa was 41%, and which shows that certain patients had one or more coronary heart disease has a prevalence of 69% in Latin associated comorbidities. America and of 75% in North Africa (5). Our results are The specific prevalence of different disorders lower than those founde in the mentioned studies, showed that among heart diseases, HBP presented probably due to the smaller size of our sample. the highest prevalence (24.84%) in comparison The prevalence of hepatic disorders was 12% with coronary heart disease (3.96%) or with chronic from which 2.16% were infections with viral cardiac failure (2.16%). HBP prevalence in Latin hepatitis C (VHC) and 1.92% with viral hepatitis B America, India and China is between 52.6% and 79.8 (VHB).

63 oral rehabilitation

Figure 12. Respiratory diseases

Figure 13. Neurological diseases

Figure 14. Permanent medication

Our study shows values lower than those of the valued reported among the Turkish population. Chinese researchers. The prevalence of infection with The prevalence of epilepsy in Turkey was reported VHB in China is ~10% at the general population level between 0.08/1000 inhabitants to 8.5/1000 inhabitants, and 3.2% for VHC (6). in the Arabian countries it was of 0.9/1000, and in The prevalence of Diabetes Mellitus was 9%. The Sudan, 6.5/1000 inhabitants (9). prevalence of diabetes mellitus in New Zeeland is of The discrepancies when comparing our data with the 20.9% and the study was conducted on 53911 adult scientific literature may be due to the following factors: patients (7). -the size of the study sample which was much smaller The prevalence of respiratory disorders was 6% (even 53 times smaller than some studies); from which 3.78% were represented by asthma. The -not all the patients presented medical certificates to prevalence of asthma among the Italian population in attest the associated disorders; 2010 was 6.6% (8). -the patient’s omission to declare certain associated The prevalence of neurologic disorders was 2% conditions (either intentionally or not); of which 1.44% was represented by epilepsy. The -the limited experience of the students and resident values obtained are almost two times higher as the doctors in collecting the data. From the 1176 patients,

64 Stoma.eduJ (2014) 1 (1) COMORBIDITIES PREVALENCE IN SOCIALLY ASSISTED PATIENTS IN THE SANODENTAPRIM PROGRAMME

Figure 12. Respiratory diseases

Figure 15. Permanent medication for heart disorders

84% were under constant medication, which represents 3. The adverse events of the chronic medication need an additional risk for these patients in the dental office a special attention especially if certain classes of drugs due to the adverse events of these drugs and due to interfere with dental treatments. the interference with dental treatments. The medication 4. The risks of the patient with general disorders with ß-blockers, diuretics and converting enzyme have to be evaluated after a detailed patient history Figure 13. inhibitors accounted for 60%. Chronic anticoagulant corroborated with paraclinical examinations and, Neurological diseases therapy requires specific training of the patient in if needed, with the cooperation of the attending collaboration with the attending doctor. doctor. 5. The risks of the patient with comorbidities in the Conclusion dental office are determined by functional, metabolic 1. The prevalence of comorbidities was high (92%) and hemodynamic imbalances. among patients from the SANODENTAPRIM program. 6. The need of specific training of the patient 2. The specific prevalence of the disorders was smaller with comorbidities in order to correctly follow an than the data from the scientific literature due to the size of anticoagulant treatment for the removal of dental foci the study group and to the way the data was collected. or for performing other treatments.

Bibliography

1. Blaizot A, Vergnes JN, Nuwwareh S, Amar J, Sixou M. Periodontal (Identification of Patients With Heart Failure and PREserved Figure 14. diseases and cardiovascular events: metaanalysis of observational Systolic Function: an epidemiological regional study). Am J Cardiol. Permanent medication studies. Int Dent J. 2009; 59(4):197-209. 2011;108(9):1289-1296. 2. Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR. C-reactive 6. Tanaka M, Katayama F, Kato H, Tanaka H, Wang J, Qiao YL, Inoue protein and parental history improve global cardiovascular risk M. Hepatitis B and C virus infection and hepatocellular carcinoma prediction: The Reynolds Risk Score for men. Circulation. 2008; in China: a review of epidemiology and control measures. J 118 (22):2243-2251 Epidemiol. 2011; 21(6):401-416. 3. Holmlund A, Holm G, Lind L. Number of teeth as a predictor of 7. Thornley S, Marshall R, Jackson G, Smith J, Chan WC, Wright cardiovascular mortality in a cohort of 7,674 subjects followed for C, Gentles D, Jackson R. Estimating diabetes prevalence in South 12 years. J Periodontol. 2010; 81(6):870-876. Auckland: how accurate is a method that combines lists of linked 4. Prince MJ, Ebrahim S, Acosta D, Ferri CP, Guerra M, Huang Y, Jacob health datasets? N Z Med J. 2010; 123(1327):76-86. KS, Jimenez-Velazquez IZ, Rodriguez JL, Salas A, Sosa AL, Williams 8. de Marco R, Cappa V, Accordini S, Rava M, Antonicelli L, Bortolami JD, Gonzalez-Viruet M, Jotheeswaran AT, Liu Z. Hypertension O, Braggion M, Bugiani M, Casali L, Cazzoletti L, Cerveri I, Fois AG, prevalence, awareness, treatment and control among older Girardi P, Locatelli F,Marcon A, Marinoni A, Panico MG, Pirina P, people in Latin America, India and China: a 10/66 cross-sectional Villani S, Zanolin ME, Verlato G, GEIRD Study Group. Trends in the population-based survey. J Hypertens. 2012; 30(1):177-187. prevalence of asthma and allergic rhinitis in Italy between 1991 5. Magaña-Serrano JA, Almahmeed W, Gomez E, Al-Shamiri M, and 2010. Eur Respir J. 2012; 39(4):883-892. Adgar D, Sosner P, Herpin D, I PREFER Investigators. Prevalence 9. Angalakuditi M, Angalakuditi N. A comprehensive review of the of heart failure with preserved ejection fraction in Latin American, literature on epilepsy in selected countries in emerging markets. Middle Eastern, and North African Regions in the I PREFER study Neuropsychiatr Dis Treat. 2011; 7:585-597.

65 oral rehabilitation

Aranka Ilea "Iuliu Haţieganu" University of Medicine and Pharmacy, Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, Cluj-Napoca, România

Dr. Aranka Ilea is an Assistant Professor of Oral Rehabilitation, Oral Health and Management of Dental Office Department at the Faculty of Dentistry of the “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, since 2008. She graduated the Faculty of Medicine in 1996 and Faculty of Dentistry in 2000. She is a specialist in dento-alveolar surgery and pediatric neurology. Dr. Aranka Ilea participated at national and international confer- CV ences as a speaker or as a lecturer with over 50 scientific papers. She is an author of 8 articles which were published in Romanian and international journals. Her academic activity was crowned by her election by students as the “Dean of the soul” in 2013. Her main area of interest is the correlation between general conditions and oro-maxillo-facial pathology. Also, she conducted researches in facial nerve pathology and traumatology.

Questions

What was the prevalence of comorbities in the studied cohort?

q 100% q 92% q 75% q 44% What were the most frequently associated commorbidities?

q Respiratory q Cardiovascular q Gastrointestinal q Metabolical What was the most frequent drug allergy?

q Antibiotics q Local anaethetics q Warfarin q Other drugs What determines the risk of the patients with comorbidities in the dental office?

q Functional imbalances q Metabolic imbalances q Hemodynamic imbalances q All of the above

66 Stoma.eduJ (2014) 1 (1) Treating The Triad: Teeth, Muscles, TMJs

Giuseppe Cozzani Quintessence Publishing Company, Inc Language: English 408 pages, 1707 illustrations ISBN: 978-88-7492-152-2 Publication Date: March, 2011 Price: 248.00 €

If we carefully follow the specialty literature we'll find that over time many books which addressed the function and dysfunction of TMJ were published. The interest raised by this book written by Dr. Giuseppe Cozzani, specialist in orthodontics, is to discuss the relationship between teeth, muscles and After the completion of all the examinations TMJ focusing on the diagnosis, on the principles and tests, the clinician should be able to reach of maintaining or recovery of the stomatognathic a clear diagnosis and plan in the next chapter, system function as part of orthodontic treatment, "Phase I: Musculoarticular Therapy" that describes particularly in dealing with facial pain and postural considerations on compromise and adaptability, R eview problems. The author achieves a systematic coordination between articular eminence approach of this group of disorders planning the inclination, cusp inclination and incisal guidance, treatment, from the simpler to the most complex assessment of changes in pretreatment and cases, in two phases: Musculoarticular Therapy posttreatment condylar position, bite registration, and Orthodontic Occlusal Finishing. splints, therapeutic procedure sequence, The book contains 408 pages and is divided into pain, TMD and postural disorders, occlusion, six distinct chapters. posture and MRI, musculodental extracapsular The first chapter, "Basic Concepts", introduces pathology, intermediate pathology, intracapsular us in the anatomy and pathophysiology of the pathology: dislocation with and without reduction, stomatognathic system for a better understanding intracapsular pathology: destruction, PHASE of the philosophy of the Temporomandibular I: virtual ARS musculoarticular rehabilitation Disorders (TMDs) treatment, presenting us the treatment and intracapsular pathology: condylar temporomandibular joints, the true articulating hypermobility and ligamentous laxity . surface, the skeletal muscle apparatus, the basic The author also discusses Phase II: Orthodontic muscle anatomy, the axial alignment of joint Occlusal Finishing, its principal aim being to structures, the old and new concept of centric obtain a correct interarch relationship in harmony relation, the physiology of jaw opening and closure, with the muscle and joints considering other joints the anatomical parts involved in mastication, the and the TMJ, temporomandibular disorders in tooth dynamics and esthetics . children including case presentations as well as the B ooks In the second chapter, "Diagnosis: Patient Records", innovative orthodontic treatment of teeth, muscles the patient assessment, the basic medical history, and temporomandibular disorders. clinical records, clinical analysis, medical imaging, For a better understanding, the text comes imaging diagnostics of TMJs, the importance of with 1707 illustrations, diagrams, MRI and clinical checking 3D mandibular movements, TMJ palpation photographs, constituting an essential reference and auscultation and diagnostic - therapeutic manual for the orthodontists interested in the treatment of techniques are presented. temporomandibular disorders (TMDs).

Florin Eugen Constantinescu DDS, PhD Student Holistic Dental Institute Bucharest, Romania E-mail: [email protected]

67 Percrestal Sinuslift: From Illusion to Reality

George Watzek Quintessence Publishing Company, Inc Language: English 248 pages, 535 illustrations, DVD included ISBN: 978-1-85097-222-8 Publication Date: December, 2011 Price: 128.00 €

Minimally invasive surgical techniques are used more and more in medicine. Based on the popularity gained by their introduction in medicine, the 11 contributors of Bernhard Gottlieb School of Dentistry at the Medical University of Vienna under the direction of Professor George Watzek give us a guide for transcrestal sinus floor elevation in oral implantology of the posterior maxillary. The book Chapter 8, "Transcrestal osteotomy: technological is divided into 12 chapters. considerations and options for bone perforation", In the first chapter, "Maxillary sinus anatomy and presents the osteotome technique, the drill physiology", the authors present the morphologic osteotomy technique, the ultrasonic technique variability, the innervation and blood supply, the and the laser osteotomy technique. sinus ventilation and the mucociliary activity. Chapter 9, "Insights into sinus augmentation: The second chapter, "Biological Aspects of preclinical and clinical research", outlines general sinus augmentation", describes the histology aspects of sinus augmentation and terminology, of bone regeneration in the augmented sinus, preclinical and clinical models for investigating graft regeneration and repair, mechanically stable consolidation, graft consolidation gradient (GCG), conditions: a key factor of bone regeneration, injectable grafts, combination of grafts and growth angiogenesis: a key factor of bone regeneration, factors and combination of grafts and cells. configuration changes of the augmented sinus, In Chapter 10, "Clinical experiences using innovative form follows function, augmented sinus and equipment", the preoperative planning, trephination principle of guided bone regeneration. Bone of the bony sinus floor, liquid-pressure-mediated morphogenetic proteins: osteoinductive growth membrane elevation, intraoperative evidence of factors, platelet-derived growth factor-BB and iatrogenic membrane perforation, implant placement PRP: non - osteoinductive growth factors, cell and postoperative procedures, clinical results and therapy in sinus augmentation, compromised clinical considerations are described. bone regeneration: impact on graft consolidation In Chapter 11 the "Compromised results and and current knowledge and future perspectives complications" are analyzed: sinus membrane injury are presented. and its consequences, dealing with a perforated In Chapter 3, "Generally accepted procedures" sinus membrane, problems of membrane elevation, and in Chapter 4, "Status quo analysis", techniques problems of grafting, implant placement and

ooks R eview B ooks of bone instrumentation, techniques for elevating potential problems of maxillary sinusitis. the sinus membrane and methods of assessing the In the last chapter, "Summary and Outlook", Professor membrane integrity are described. Watzek makes a synthesis on transcrestal sinus floor Chapter 5, "Biomechanics of transcrestal sinus elevation in terms of a flapless minimally invasive membrane elevation", describes transcrestal procedure, concluding that for a good success of the membrane elevation techniques, the method we must use three-dimensional X-ray imaging biomechanical properties of the maxillary sinus and a minimum volume of elevating liquid. membrane, the transmission of elevation forces and This book is an excellent guide for both the the impact of internal sinus membrane elevation experienced oral implantologist and the beginner, anatomy and patterns with multiple osteotomies. who want more information on sinus augmentation. Chapter 6, "Radiologic assessment", describes The text contains 535 color illustrations that make the general and specific preoperative assessment, it easy to follow. It is accompanied by a DVD Florin Eugen the intraoperative imaging and the postoperative - ROM including images of percrestal sinuslift Constantinescu imaging. surgery using the pressure gel technique. The DDS, PhD Student Chapter 7, "Preoperative measures for assuring book of Professor Watzek is a documentary source Holistic Dental Institute success", contains local preoperative diagnostic indispensable for any oral implantologist that Bucharest, Romania E-mail: work-up , local treatment modalities and the general wants to successfully practice the technique of [email protected] preoperative work-up. transcrestal sinus floor elevation.

68 Stoma.eduJ (2014) 1 (1) Photography in Dentistry: Theory and Techniques in Modern Documentation

Pasquale Loiacono, Luca Pascoletti Quintessence Publishing Company, Inc Language: English 336 pages, 847 color illustrations ISBN: 978-88-7492-169-0 Publication Date: February, 2012 Price: 122.00 €

Nowadays, when dentistry resorts more and more to the concept of evidence-based medicine, the dentist uses images to communicate with the patient or with the dental technician, in order to record the clinical situation in the pre-treatment phase, for medical or forensic considerations or for a scientific presentation. As dental photography does not yet have a set of standards allowing reproducibility for clinical In the chapter “Equipment and Accessories”, and scientific documentation, the authors cameras and accessories (intraoral mirrors, present, in 13 chapters, the guidelines for cheek retractors and additional accessories), modern photographic documentation. image quality and synergy between practitioner The book is structured in two parts: “Theory” and assistant are presented. and “Techniques”. The following chapters describes “Extraoral In the first part, “Theory”, divided in nine Series” and “Intraoral Series” suggestively chapters, the general principles, the optical illustrating all the norms and positions which system, the exposure concepts, the principles of must be known for an eloquent photographic digital photography, the role of photography in documentation. clinical practice, the settings of the camera for The last chapter includes documentary dentistry, the orthography of images, the flash photography for orthodontics, periodontics, units and the photographing radiographs are prosthetics, conservative dentistry and the presented. communication with the dental technician. The second part, “Techniques”, is divided in In its 336 pages, the book contains 847 high- four chapters. The authors eloquently describe quality illustrations, being a necessary guide the equipment and accessories, and the extraoral for any dentist who aims to succeed in dental and intraoral settings. photography. ooks R eview B ooks

Florin Eugen Constantinescu DDS, PhD Student Holistic Dental Institute Bucharest, Romania E-mail: [email protected]

69 Péri-implantites

Jean-Louis Giovannoli, Stefan Renvert Quintessence International Language: French 272 pages, 800 iIlustrations ISBN :978-2-912550-96-5 Publication Date: May, 2012 Price:169.00 €

Today, to practice oral implantology, it is essential to learn to identify the factors that prevent infectious risk and the appearance of

eview peri-implantitis. Thirty years after the first clinical use of osseointegrated implants, peri-implant diseases are beginning to be identified. The book “Peri-implantitis” is structured in 8 chapters: “The Etio-Pathogenesis”, “Diagnosis”, foreign body, endodontic infections in teeth “Prevalence”, “Early Infection”, “Risk Factors”, “Treatment”, neighboring the presence of keratinized mucosa) “The Mucosal Terms” and “Maintenance”. are mentioned. In “The Etio-Pathogenesis”, the bacterial The chapter “Treatments” explains the choice flora, histopathology and occlusal overload are of different modes of treatment of peri-implant presented. In “Diagnosis” the author describes diseases, treatment of mucositis and peri- diagnostic methods of clinical examinations, peri- implantitis, non-surgical and surgical, and a implant probing, bleeding on probing, Rx exams, literature review on the means of treatment. laboratory tests and differential diagnosis for The chapter “Mucosal conditions” shows the clinical forms. importance of the height of keratinized tissue The chapter “Prevalence” is a systematic review on the quality of hygiene and the onset of of prospective studies published on implant recession. complications and peri-implantitis. In the chapter “Maintenance” the supportive In the chapter “Early infection” the authors treatment, maintenance organization - personal present the etiology, diagnosis, prevalence and and professional, frequency of maintenance ooks R ooks treatment. sessions and instrumentation are described. In the chapter “Risk factors” the general factors The authors, Jean-Louis Giovannoli and Stefan (oral hygiene and cooperation of the patient, Renvert summarize the current knowledge on state of periodontal health, tobacco use, genetic the etiology, clinical features and diagnosis of B character, diabetes, alcohol consummation, peri-implantitis, develop therapeutic proposals, psychological profile and stress) and local factors based on very recent scientific and clinical (the accessibility to hygiene and shape of dentures, achievements. They also offer diagnostic and the remaining teeth with periodontitis pocket therapeutic protocols for the management depth, peri-implant surface state, transmucosal of infection and the conservation of the implants and parts, the type of implant and of implant, essential to all dentists practicing oral the connection, the presence of a submucosal implantology .

Marian-Vladimir Constantinescu DDS, PhD Department of Prosthetic Dentistry “Carol Davila” University of Medicine and Pharmacy Bucharest, Romania Email: [email protected]

70 Stoma.eduJ (2014) 1 (1) Péri-implantites Traitement des classes II De la prévention à la chirurgie

Antonio PATTI Quintessence International Language: French ISBN: 978-29-1255-066-8 Publication Date: October 1, 2010 496 pages, 1890 illustrations Price: 282.00 €

Dr. Antonio Patti, in collaboration with the best specialists in the field wrote a modern orthodontic book, which meets the requirements of clinicians who want a comprehensive overview of Angle Class II. The book is structured in three parts: "Growth", "Diagnosis" and "Treatments". and orthopedic therapeutic" describes and illustrates The first part the following aspects are described: the rigid monoblock activators, enhancers and the the cephalic growth in Angle Class II, the development elastic timing and functional orthopedic treatment. of the cephalic skeleton and conceptual basis of The chapter "The Distal Active Concept (DAC)", craniofacial architectural analysis. is a presentation of orthopedic devices together The second part develops the "Diagnosis" in five with indications and contraindications and modes chapters. The chapter "Aetiology: The Class II Medical of therapeutic action. In “Forward Activators” the syndrome" describes the evolution of the diagnostic authors describe activators for protrusion. The approach in orthodontics. The chapter "Clinical Forms chapter "Processing Vertical " describes clinical and Classification ofC lass II" describes the orthopedic forms, diagnosis and treatment. The chapter "Multi- Class II, the prognathic maxilla, the retrognathic Attaches Treatment" shows the visualization of mandible, dental Class II and Class II mandibular treatment goals. The chapter "Treatment of Class II position. The chapter "Clinical Examination and with Reciprocal Mini Chin " describes reciprocal mini Examination of Models”, describes the extraoral and chin while "Rational Use of Intermaxillary Elastic" intraoral examination, the examination of models and shows generalities on elastics and Angle Class II clinical and instrumental examination. The chapter elastic. "The Radiological Examination and Complementary" The chapter "Correction of Class II Molar by points at radiological examinations, ENT Decline" shows situations necessitating a Class II examinations, postural examination, examination molar distalization and appliances. The chapter models mounted on an articulator and mandibular "Using Miniscrews as Anchor" describes use of position indicator (MPI) and axiography. The miniscrews in the treatment of Angle Class II. chapter "Cephalometric Diagnosis" describes the The chapter "Classes II and TMJ" shows the joint teleradiographic cephalometric exam according to classification, clinical verification of joint position, Ricketts - Gugino in "diagnostic bioprogressive flow". diagnosis and treatment. The third part focuses on "Treatments" in The chapter "Surgical Treatment Planning" shows three directions: "Interceptive, Orthopedic and diagnosis and treatment planning. In the chapter Orthodontic Treatment Planning", "Surgical Treatment "Surgical Treatment of Class II" surgical options and Planning" and "Contention and Recurrence". clinical example are presented. The chapter "Interceptive, Orthopedic and The section "Joint Diseases" shows technical Orthodontic Treatment Planning" describes mandibular advanced by the retrocondylar cartilage ooks R eview B ooks diagnostic and therapeutic flow, interceptive graft. In the chapter "Contention and Recurrence" treatment, orthopedic treatment and multi-attaches restraint and recurrence and type of malocclusion orthodontic treatment. are shown. In "Preventive Treatment in Deciduous Dentition Dr. Antonio Patti and collaborators have and Mixed Dentition Interceptive" the author succeeded to develop a comprehensive approach describes the functional education devices and to diagnosis and treatment of different types of Class Marian-Vladimir mode of action of classes II in combination with II. A well documented reference book, it details all Constantinescu exercises education. The chapter "The correction of therapeutic options, beginning with the diagnostic DDS, PhD transverse" describes abnormalities, diagnosis and analysis and ending with the treatment of Class II, Department of Prosthetic Dentistry “Carol Davila” University treatment of transverse direction, while "Orthopedics an overall summary of these malocclusions with of Medicine and Pharmacy and mandibular growth" describes biological and a predominantly clinical focus which meets the Bucharest, Romania Email: therapeutic peculiarities. The chapter "The functional requirements of orthodontists. [email protected] 71 1. Submitting the Article from all his subjects. All studies must respect the All articles will be accompanied by the Helsinki Declaration (1975). signed copyright form which can be returned For human and animal studies, the authors by fax, e-mail (as scanned documents). 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