Quintessence International, Pre-Print

Objectives: The aim of this study was to assess the antibacterial efficacy of nanostructured dental implant surfaces against Porphyromonas gingivalis, a crucial bacterium in the progression of peri-implantitis. Additionally, to evaluate the possible effect of the modified implant surface on the viability of human gingival fibroblasts (HGnFs). Method and materials: As detailed in prior research, helium ions sputtering was used to produce nanospiked titanium surfaces with a height of 1000 nm (Ti1000). Smooth machined (Ti machined) and SLA titanium disks (TiSLA) served as controls. The antibacterial characteristics of the samples against P. gingivalis were evaluated by conventional culturing and SEM. The vitality of HGnFs was assessed using the MTT assay. Results: Generally, nanostructured Ti1000 surfaces exhibited less bacterial counts than the two controls (Ti1000 vs TiSLA -36% and Ti1000 vs Ti machined -37%.) without being statistically significant. Moreover, the nanosurface did not affect the vitality of HGnFs. Conclusion: The nanospikes of the modified titanium implant surface did not hinder gingival fibroblasts' vitality or proliferation characteristics. Optimizing the spacing and height parameters of the nanospikes could further improve the antibacterial effects of this unique re-modification approach. Keywords: abutment design, adhesion, dental implants, implants, microbiology, peri-implantitis

Background: The wire syndrome (WS) or X-effect/twist-effect describes undesired long-term tooth movements following fixed retainer placement. Since it includes root torque changes that might cause gingival recession, those situations often require periodontal, orthodontic and conservative treatment. Aim of this study was to assess the effectiveness of fixed orthodontic treatment with completely customized lingual appliances (CCLA) and continuous archwires for a clinically significant reduction in the dimensions of labial gingival recessions in the anterior mandible, caused by the wire syndrome (WS), in a group of consecutive patients treated with the same approach. Moreover, the reduction in root prominence (ROP) of the affected teeth relative to the two neighboring teeth was evaluated. Subjects and methods: This retrospective cohort study from three centers included 20 consecutively recruited patients with labial gingival recession at lower incisors and canines due to WS. A total of 25 teeth were assessed. CCLA treatment with a standardized archwire sequence (0.012”/0.014” NiTi, 0.016”x0.022” NiTi, 0.018”x0.018” Beta-TMA with optional extra-torque) was identical in all three centers. Primary endpoints of recession depth (RD), recession width (RW), and recession surface (RS) were assessed on digital models at debonding (T1) and compared to baseline (T0) both as absolute differences (T0-T1), and as ratios ((T0-T1)/T0) by one-sample t-tests with p<0.05. As a secondary endpoint, the reduction of ROP relative to the gingival surface of the alveolar yoke of the two neighboring teeth was measured in millimeters. Results: Treatment resulted in a significant reduction in all dimensions of gingival recession. The mean reduction in RD was 1.86 mm (44.9%) and in RW 0.70 mm (35.6%). The mean RS was reduced from 10.77 mm2 to 3.93 mm2, indicating a mean RS reduction of 61.4%. All changes were statistically significant (p<0.001). The range of RS reduction was from 25.4% to 100%, while 18 out of the 25 recessions showed a reduction of more than 50%. The maximum reduction in ROP amounted to more than three millimeters. Conclusion: The use of completely customized lingual appliances to torque roots of the lower anterior teeth, exposed by the wire syndrome, towards the middle of the alveolar process reduces the area of subsequent labial gingival recession and reduces the root prominence of the affected teeth substantially. This is considered as a critical step in optimizing the predictability of the surgical recession coverage. Keywords: wire syndrome, retainer X-effect, retainer twist-effect, gingival recessions, recession depth, recession width, completely customized lingual appliances, torque, root coverage, root prominence, alveolar yoke

Objective: To evaluate the effectiveness of mandibular exercises (ME) in patients with temporomandibular disorders (TMD) diagnosed by Research Diagnostic Criteria for TMD (RDC/TMD). Material and methods: Thirty-two patients seeking clinical treatment for TMD were randomly assigned to groups based on the treatment modality: conservative therapy (CT), including occlusal splint therapy and counseling; and ME. Muscle and joint pain were assessed using a 4-point scale (0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain). The maximum unassisted mouth opening (MUMO) was measured in millimeters, both with and pain-free. Outcomes were evaluated at baseline (T0) and after a 3-months intervention period (T1). Results: Both treatments significantly reduced muscle and joint pain intensity at most assessed sites. The reduction in pain with ME compared to CT was statistically significant at the right lateral pole of the temporomandibular joint (TMJ) (p = 0.048; rrb = 0.348). After three months, ME resulted in greater pain-free MUMO (T0 vs. T1; p = 0.004; rrb = 0.594), and the increase in MUMO was greater than that observed with CT (p < 0.001; rrb = 0.742). Conclusion: ME and CT similarly reduced palpatory pain, with ME showing greater clinical impact at the right lateral pole. Both treatments led to significant improvements in the masseter and TMJ pole. ME also provided superior, clinically meaningful gains in pain-free MUMO, positioning it as a preferred option when enhancing jaw mobility is a primary goal in TMD management. Keywords: temporomandibular joint disorders, mandibular exercises, occlusal splints, counseling

Diffuse idiopathic skeletal hyperostosis (DISH) is a somewhat uncommon osteopathic disorder associated with interconnected ossifications along the anterior vertebrae and may be accompanied by systemic comorbidities. To date, there is limited information concerning DISH in the dental literature. The objective of this report is to provide an overview of DISH for the general dental practitioner and illustrated with a case report involving an asymptomatic patient. An 87-year-old man underwent a preprosthodontic assessment, including a cone beam computed tomography (CBCT) scan. Incidental CBCT findings included bridging ossification involving the anterior aspects of C3 and C4, resulting in mild airway displacement and mild reduction in airway volume, left calcified carotid atheroma, and bilateral intracranial carotid artery calcifications. At a 5-month follow-up telephone call, the patient admitted that he has remained asymptomatic and has not experienced dyspnea, dysphagia, throat pain, or episodic choking. Dental healthcare clinicians should remain vigilant for the radiologic evidence of DISH, especially involving older patients. Patients with suspected cases of DISH warrant timely referral for a comprehensive medical evaluation. Keywords: Case report, cone beam computed tomography scan, diffuse idiopathic skeletal hyperostosis, etiology, geriatric

Objective: This study aimed to evaluate the prevalence of different temporomandibular Disorder (TMD) diagnoses according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and to compare the diagnoses according to both guidelines. Method and Materials: Clinical examinations of 218 patients with TMD complaints were conducted according to both guidelines. Descriptive statistics were performed to analyze the frequency of diagnoses and differences between the guidelines. Results: Most patients diagnosed with TMD were women and middle-aged. The number of patients in the myofascial pain class was significantly lower for the RDC/TMD classification than for the DC/TMD classification (p=0.045). The number of patients in the disc displacement with reduction (DDWR) category was significantly higher for the RDC/TMD classification than for the DC/TMD classification (p<0.001). Other categories did not exhibit differences between the classifications. Conclusion: Women and middle-aged individuals are more affected by TMDs. Pain-related TMDs were the most common diagnosis, followed by DDWR according to DC/TMD. According to the RDC/TMD classification, myofascial pain, arthralgia, and DDWR were the most commonly observed diagnoses, respectively. Significant differences were observed between the pain-related TMD and DDWR groups. Keywords: Axis I, DC/TMD, RDC/TMD, Temporomandibular joint, Temporomandibular Disorders

Objectives: To evaluate changes in gingival recessions (GR) in periodontitis patients over ten years of supportive periodontal therapy (SPT) and to assess the impact of GR on oral health-related quality of life (OHRQoL). Materials and Methods: Fifty-one patients with over ten years of SPT were followed up (V1) with complete periodontal status including periodontal probing depth (PPD) and clinical attachment level (CAL) at 6 sites/tooth, oral hygiene indices, and recession status. Patient anamnesis, oral hygiene habits, and orthodontic history were assessed. Data were compared with records from 10-11.5 years prior (V0). GR changes were analyzed at patient level, and for all teeth with deep GR ≥3mm at tooth and site level (mid-buccal site). OHRQoL was assessed at V1 (OHIP-G14 questionnaire). Possible risk factors for GR progression and the associations between the number of deep GR and OHRQoL were tested (linear mixed-effects models, linear regression). Results: The analysis included 45 patients (stage III/IV periodontitis). Patients retained most teeth (V0: 23.87±4.38; V1: 22.53±4.78), with stable mean overall PPD (V0: 2.34±0.35mm; V1: 2.39±0.26mm) and CAL (V0: 3.56±0.94mm; V1: 3.56±0.89mm). Teeth with deep GR showed overall only minimal mean GR progression (0.16±0.97 mm). The mean increase at the mid-buccal sites was 0.66±1.58mm. 10% of patients had >1mm GR progression at the mid-buccal site. Molars showed less GR progression than anterior teeth. The number of deep GR did not significantly impact OHRQoL. Conclusions: Periodontitis patients on regular SPT showed high periodontal stability with minimal GR progression. The number of deep GR was not associated with OHRQoL. Keywords: gingival recessions, periodontitis, supportive periodontal therapy, maintenance, oral-health related quality of live

Objectives: The goal of this systematic review was to critically appraise the existing evidence evaluating osteoporosis’ effects on dental implant osseointegration and survival rate. Data source: A search was conducted in two databases, PubMed/MEDLINE and Scopus, until October 2024, using the keywords “osteoporosis,” “osteopenia,” “osseointegration,” and “dental implants”. The inclusion criteria were clinical studies that evaluated the implant placement, complications, and osseointegration results in patients with osteoporosis; literature reviews and clinical studies addressing the outcome were considered; and articles written in English and published since 2000. Descriptive data analysis included author, year of publication, study design, number of patients, osteoporosis assessment, follow-up, and main findings. JBI quality assessment was performed. 24 articles were included with a total of 2,102 patients; 5954 dental implants were considered and evaluated. Most studies evaluated bone density for osteoporosis by dual-energy x-ray technology. The follow-up ranged from 1 month to 25 years. Four studies evaluated implants with over 10 years of follow-up. All studies' survival rate was higher than 90%, even for osteoporotic patients. Most studies indicated no differences between osteoporotic and healthy patients regarding marginal bone loss (MBL), bone-to-implant contact, cytokine levels, and mineral bone density. A prospective cohort study found a small MBL (-0.34 mm) in osteoporotic female patients, but there was insufficient evidence to prove any causal relationship between MBL and osteoporosis. Another study showed no clinical differences between implants placed in osteoporotic and healthy individuals. In contrast, other studies showed lower stability scores for implants placed in osteoporotic sites and a higher risk of failure for implant placement. Osteoporosis status was not a risk factor for dental implant failure, which was also confirmed by histological studies. Three studies had a medium risk of bias and 21 a low risk. Conclusion: Osteoporosis is not a contraindication for dental implant placement. Osseointegration in patients with osteoporosis is feasible; however, planning must be cautious and personalized for the installation of dental implants. Keywords: Osteoporosis; Dental implants; Osseointegration; Review; Survival rate

Proper alignment of the teeth not only aids in functional occlusion but also promotes harmonious gingival contours, potentially reducing the risk of inflammation and gingival recession. This case series aimed to evaluate the effectiveness of optimizing axial inclination through clear aligner orthodontic treatment in addressing gingival recession defects. This case series included nine patients, aged 20-36 years, who presented with varying degrees of gingival recession on 12 mandibular incisors. All patients had undergone orthodontic treatment during childhood and were maintained with a fixed stainless-steel canine-to-canine retainer. The exhibited gingival recessions were potentially caused by inadvertent torque discrepancies in the teeth induced by the retention wire. Prior to treatment, a comprehensive radiographic and periodontal evaluation was performed, and clear aligner orthodontic treatment was used to correct the axial inclination of the affected teeth. Following the completion of the orthodontic treatment, patients were re-evaluated to assess changes in recession depth and width; those with remaining recession were considered for soft tissue grafting. The average treatment duration was 21.6 ± 3.7 months, ranging from 18 to 29 months. Root torque adjustments averaged 12 ± 9 degrees, ranging from a correction of 14 degrees lingually to 33 degrees labially, while bucco-lingual crown movement averaged 1.7 ± 1.2 mm, with a range from 3.4 mm lingually to 0.6 mm labially. All cases showed improvement in gingival recession, with complete recovery in one tooth and an average of 58 ± 21% reduction in recession depth and width for the remaining 11 teeth. Surgical intervention, consisting of soft tissue grafting, was required in four cases, while the remaining 8 teeth showed sufficient improvement and were monitored with follow-up care. Correcting axial inclination with clear aligner orthodontic treatment positively impacts both tooth alignment and gingival recession. These findings propose a new approach: initiating orthodontic treatment before periodontal surgery to streamline treatment and reduce the need for invasive procedures. Orthodontists, general dentists, and patients should be aware of the potential complications of fixed retainers and their possible orthodontic adjustments correction. Keywords: attachment loss, root coverage, root malposition, soft-tissue deformities, periodontitis

Aim: To evaluate the efficacy of sesame oil-pulling in periodontitis with/without Type2 Diabetes Mellitus (T2DM), compared to Chlorhexidine, for its oral and systemic health benefits. Material and Methods: Total of 120 periodontitis patients, without (Group A; 60)/with (Group B; 60) T2DM, underwent control (chlorhexidine 0.12%; Group A1 & B1) and test (sesame oil-pulling; Group A2 & B2) interventions. Plaque index, pocket depth, salivary total antioxidant capacity (T-AOC) enzyme-linked-immunosorbent-assay (ELISA), subgingival plaque BANA test, and serum CRP were evaluated at baseline and 30 days post-intervention using analysis of variance (ANOVA) with a significant p-value set at 0.05. Group B serum samples also analyzed for Fructosamine and lipid profile. Results: Both treatment regimens were equivalent in reduction of plaque, pocket depth, red complex periodontopathogens in Group A & B. Significant increase in salivary T-AOC post-intervention observed in Group B with both interventions (p<0.01). Sesame oil-pulling significantly decreased systemic CRP and triglyceride levels, with no difference observed with Chlorhexidine in Group B. Conclusion: Sesame oil-pulling is equivalent to Chlorhexidine for anti-plaque, antibacterial, and antioxidant effects in periodontitis patients with/without T2DM. Systemic anti-inflammatory, cardio-protective benefits (reduction of CRP and triglycerides) make it better adjunct to Chlorhexidine in periodontitis with T2DM. Keywords: Periodontitis, Diabetes Mellitus Type 2, Sesame oil, Antioxidant, antibacterial

Objectives: To assess blood flow alterations after horizontal Guided Bone Regeneration (GBR) and to evaluate correlations between blood flow and hard tissue changes. Method and Materials: Twelve mandibular surgical sites were involved in the current case series. GBR was carried out using a split-thickness flap design. Blood circulation was assessed with Laser Speckle Contrast Imaging at baseline as well as 1, 4, 6, 11, 13, 20, 27, and 34 days after the surgery, subsequently on a monthly basis until 6 months. Hard tissue alterations were measured horizontally and vertically using linear measurements. The first measurement point was 2 mm distal to the distal surface of the last tooth; additional measurement points were placed every 3 mm up to the 15th mm. Volumetric hard tissue loss and gain were also assessed. Results: Baseline blood circulation was statistically significantly higher on the buccal side. On the first postoperative day, all regions presented a statistically significant decrease in blood flow circulation. The buccal-inner region presented significant ischemia on day 6. Mean volumetric hard tissue gain and loss were 712.62 ± 317.08 mm3 and 222.431 ± 103.19 mm3, respectively. Mean baseline alveolar ridge width was 4.82 ± 1.02 mm, 6 months ridge width averaged 7.21 ± 0.99 mm. Vertical resorption measured 1.24 ± 0.5 mm. Correlations between blood flow changes and hard tissue alterations were only found on Day 34 and Day 60. Conclusion: Laser Speckle Contrast Imaging is an efficient method to measure flap microcirculation. No correlation was found between flap microcirculation changes hard tissue and alterations. Keywords: Bone graft, Case-report/series, Guided Bone Regeneration, Membranes, Ridge augmentation

Objective: This clinical trial aimed to evaluate and compare the effectiveness of diode laser gingivectomy, conventional gingivectomy, and nonsurgical periodontal treatment (NSPT) in the management of gingival enlargement (GE) during orthodontic treatment. Materials and Methods: forty-five healthy, orthodontic patients with labial gingival enlargement on the 6 anterior teeth were selected and randomly assigned to one of the groups (Conventional, Laser, and NSPT). Clinical parameters including clinical crown length (CCL) , periodontal pocket depth (PPD), and vertical gingival overgrowth index (vGOi) were recorded at baseline, 1 month, 3 months, and 6 months. Postoperative pain was evaluated at 1,3, and 7 days. Esthetic satisfaction and acceptance of the procedure were recorded on day 10 and repeated after 6 months. Results: Statistically significant results were obtained for mean reduction in PPD for conventional, laser, and NSPT groups (-1.43, -.1.75, and -0.9 mm, respectively; P < 0.001), CCL gain (1.45, 1.7, and 0.38 mm, respectively; P<0.001) and mean vGOi score (-1.14, -1.29 and -0.76, respectively; P<0.001) over 6 months. Both test groups showed greater statistically significant changes in clinical parameters over 6 months compared to NSPT (P<0.001). There was a gradual decrease in postoperative pain for all three groups over 7 days, with conventional group showing statistical difference in mean pain score on days 1 and 3 compared to other groups. Conclusion: Both conventional and laser gingivectomies were more effective in controlling enlargement over non-surgical periodontal treatment alone at 1, 3, and 6 months. Clinical Significance: laser and conventional gingivectomies as adjunctive treatments achieved superior results when compared to NSPT alone in the treatment of GE and gingival inflammation during orthodontic treatment, with no significant clinical differences between the two treatments. Keywords: Gingival Enlargement, Gingivectomy, Laser, Scalpel, Orthodontic Treatment

Radiation treatment plays a mainstream role in the management of head and neck cancers (HNSCC). Adverse effects from radiation therapy include osteoradionecrosis of the jaw, and rarely, pathological fracture. Immune checkpoint inhibitors (ICI) such as pembrolizumab are of growing relevance to the management of metastatic and recurrent HNSCC. Adverse impact on bone secondary to medications such as pembrolizumab and nivolumab have been sporadically documented in the literature. The objective of this manuscript is to raise awareness of possible increase in risk for adverse jaw outcomes in patients with HNSCC exposed to both radiation treatment to the jaws and ICI therapy. This manuscript documents adverse jaw outcomes including osteonecrosis and pathological fracture of the mandible in two patients receiving pembrolizumab for management of HNSCC and had received prior radiation treatment. A potential link between immunotherapy and adverse jaw outcomes is consistent with our growing understanding of osteoimmunology, investigating the closely interrelated processes in bone remodeling and immune system function, in health and disease. It is important to ascertain if pembrolizumab poses an incremental risk for such outcomes, beyond the risk from prior radiation, for patients managed with radiation treatment and ICI therapy for HNSCC. The general dentist may encounter such patients either in the context of facilitating dental clearance prior to initiation of chemotherapy, or rarely, with poorly explained jaw symptoms and must be alert to the possibility of occurrence of such adverse jaw events to facilitate timely diagnosis and optimal patient management. Keywords: Cancer, Case-report/series, immunotherapy, Oral surgery , Osteonecrosis, Pathology, Radiation Therapy

Objective: Currently, there is no established treatment protocol to treat Interdental papillary loss. This research aimed to evaluate the outcomes of interdental papillary reconstruction using minimally invasive surgery, with injectable hyaluronic acid (HA) gel. Materials and Methods: Seventeen patients were included, each with five sites of class 1 papillary recession; (forty sites in the upper jaw and forty-five sites in the lower jaw). Subperiosteal tunneling was performed through a horizontal incision made apical to the base of the papilla without penetrating it. The free gingival sulcus was sealed by 000 retraction cord. After that a total of 0.2-0.6 mL HA was injected gradually. The incision was sutured with polyglycolic sutures. Treated sites underwent clinical and digital evaluation at three follow up time points (1 month, 3 months and 6 months). Results: The interdental papillary defect height in the upper jaw sites significantly reduced by 60%, 66%, and 42% at 1 month, 3 and 6 months, respectively. Also, in lower jaw sites, the reduction was of about 54%, 55%, and 40% at the same follow up time points. Regarding interdental papillary defect surface area in the upper jaw the reduction was about 65%, 71%, and 45% at 1 month, 3 and 6 months. In the lower jaw, a reduction of about 60%, 64%, and 48% was noticed at the same time points. Regarding patients’ pain level score, during the day of surgery, sixteen patients reported pain, the average pain score out of 10 was 3.94, and eleven patients (64.7%) needed to take analgesics. The pain generally subsided in the following days. Also, at the day of the treatment twelve out of the seventeen patients (70.6%) reported mild difficulty in speaking and eating. No complication, hypersensitivity or allergy was noted in any patient. Conclusion: Subperiosteal tunneling with HA injection demonstrates clinical improvements in papilla height and papillary recession surface area reduction after 3 months of follow-up with reduction in improvement after 6 months. Keywords: black triangle, dental papilla augmentation , hyaluronic acid, minimal invasive surgery, periodontal surgery, Periodontology

Objectives: To assess the effect of Community Water Fluoridation (CWF) in the prevalence of dental caries and dental fluorosis in 12-year-old children living in Israel. Considering that CWF is important in the prevention of dental caries. Between 2002 and 2014, the water in communities of at least 5000 individuals was fluoridated. In 2014 CWF in Israel stopped. Methods: Data on 12-year-old children from all areas in Israel from the national crosssectional epidemiological survey conducted in 2011-2012 were stratified by city water fluoridation and by city and school socio-economic status (SES). Two dependent variables were defined: (1) DMFT index -caries experience in the permanent dentition; (2) dental fluorosis in central incisors using the Thylstrup-Fejerskov (TF) classification of fluorosis. Results: Data from 2181, 12-year-olds was analyzed. the average DMFT was 1.17+1.72 and 49% were caries free. Based on DMFT, the caries experience was significantly higher in nonfluoridated cities (1.38 vs. 0.98 in fluoridated cities) and there were more caries free children 56.4% in fluoridated cities vs. 40.6% in non-fluoridated. DMFT was higher in cities with lower SES than high SES (1.29 vs. 1.05 respectively, p<0.001) and there were less caries free children in low SES (44.5% vs. 53% in high SES cities, p<0.0001). Almost all the 10.3% of children with signs of fluorosis (scoring at least 1 in TF index), had questionable to mild fluorosis (9.3%). Conclusions: CWF is a cheap, simple method of dental health protection that reaches all socio-economic levels and cessation of water fluoridation reduced the health of Israel's children. Clinical Significance: Water fluoridation provides substantial caries prevention, by reaching a substantial number of people. The relevance of this work is for policymakers to consider CWF as clinically proven method for reducing health inequalities. Keywords: Caries detection, DMFT, Epidemiology, Fluoride, Public health