Quintessence International, Pre-Print

Statement of Problem: While intraoral scanners (IOS) demonstrate high accuracy in single-tooth and partial-arch applications, their reliability in full-arch scans with varying edentulous spans remains uncertain. Increasing span length may compromise scanning accuracy and prosthetic outcomes. Objectives: To assess the influence of edentulous span length on the accuracy of two IOS devices Primescan (Dentsply Sirona) and Trios 3 (3Shape) in complete-arch scenarios. The hypothesis was that accuracy would decline with increasing span length, with performance differences between scanners. Material and Methods: An in vitro study was conducted using a maxillary complete-arch model with a central incisor implant. Twelve span-length scenarios (FA1–FA12) were created by sequentially removing adjacent teeth. Each condition was scanned 10 times using both IOS devices (n = 240). A laboratory scanner (Identica blue, MEDIT) provided reference scans. Trueness (vs. reference) and precision (intra-group) were evaluated using root mean square (RMS) error. Scans were aligned via automatic and local best-fit in Medit Design. Statistical analysis included two-way mixed ANOVA, repeated measures ANOVA, and linear regression with Bonferroni correction (α = 0.004). Results: Trios 3 demonstrated lower overall RMS values (0.296 ± 0.043 mm) than Primescan (0.338 ± 0.049 mm), with significant differences in 9 of 12 scenarios (p < 0.001). Correlation with span length was stronger for Primescan (R² = 0.892) than Trios 3 (R² = 0.674). Both devices showed high reliability. Conclusions: Increasing edentulous span length negatively impacts scanner accuracy. Devices demonstrating consistent performance are preferable for reliable full-arch digital workflows. Keywords: Dental Impression Technique; Digital Dentistry, Edentulous Jaw; Imaging Accuracy, Intraoral Scanners, Trueness and Precision

Objectives: The aim of this study was to investigate the factors influencing the success of biopsy quality in oral squamous cell carcinoma (OSCC) of the oral cavity. Method and Materials: This retrospective study included patient records of primary OSCC patients, diagnostic pathology reports of the primary biopsies, and corresponding resection tumor sections. The outcome variable was unsuccessful biopsy, defined as an inconclusive biopsy specimen for proper OSCC diagnosis. The primary predictor variable was the biopsy method used, grouped as punch or scalpel biopsy. Secondary predictor variables were sample area, depth, site, and number of samples. Patient- and tumor-related variables, background of the healthcare professional, and the healthcare unit were analyzed as additional predictor variables. Results: Data from 312 OSCC patients were included in the study. Primary biopsy was inconclusive in 7.7% of the cases. Area with punch biopsies yielded smaller (P<.001) but diagnostically as accurate samples as scalpel biopsies. Biopsies from the floor of the mouth and gingiva had higher failure rates, while tongue and palate biopsies had higher success rates (P=.037). Punch and scalpel biopsies had similar diagnostic reliability. There were deficiencies in the documentation of prognostic features of the OSCC. Inflammation was the most consistently reported (33.3% in biopsies, 43.9% in resection samples), while tumor budding was documented in only one-third of biopsy samples (6.4%) compared to final resection samples (18.6%). Depth of invasion was reported in 55.1% of biopsies, with 6.1% indicating a minimum invasion depth. Conclusion: General dentists must be both alert and properly trained to perform biopsies. However, considering the internationally varying role of general dentists in biopsy procedures, this requirement must be understood within the context of each country’s healthcare system. OSCC biopsies generally yield high diagnostic success; however, small biopsy size especially impairs diagnostic accuracy. Ensuring larger or several biopsy samples in general and ensuring representative biopsies from particularly challenging areas, such as gingiva and floor of the mouth, improves the likelihood of conclusive diagnosis in primary OSCC diagnostics. Additionally, clinicians should pay more attention not only to the area but also to biopsy depth. Taken together, there may be a need for more precise biopsy guidelines and protocols for lesions suspicious for OSCC to optimize patient treatment planning. Keywords: Biopsy, Diagnosis, Histopathology, Oral Cancer, Oral Squamous Cell Carcinoma

The objective of this case series was to report the outcomes of patients diagnosed with MRONJ and seek a remission through surgical management associated with local and systemic adjuvant therapies. A total of 14 patients were followed for up to 3 years, of whom 1 had MRONJ stage Zero; 3 with stage I; 7 with stage II; and 4 with stage III. Twelve patients underwent conservative sequestrectomy. In seven of these cases, the surgery was guided by fluorescence, using doxycycline preoperatively to remove necrotic bone tissue more accurately. In four participants, platelet-rich fibrin (PRF) membranes were positioned at the surgical site before suturing. All 14 patients were instructed to perform daily mouthwashes with 0.12% chlorhexidine, and all underwent weekly sessions of antimicrobial photodynamic therapy (aPDT) according to the following protocol: Pre-irradiation with methylene blue (100 μg/ml) for 60 s, followed by irradiation with a low-level laser (600 nm; 100 mW; 214 J/cm2; 6 J/point; 60 s/point). Other adjuvant therapies were employed, such as the prescription of a combination of pentoxifylline and tocopherol, in addition to metronidazole paste. The proposed therapies led to remission in most patients, and although some of the patients did not achieve complete remission, they showed a significant reduction in pain complaints. These results demonstrate that the protocols used in this study are promising for the management of MRONJ in different stages. As such, they offer potential for the practice of surgeons and should be the object of further clinical investigations. Keywords: Bisphosphonate-Associated Osteonecrosis of the Jaw, Complementary Therapies, Bone Density Conservation Agents

Objective: The objectives of this study were to: (1) describe how general dentists (GDs) in the National Dental Practice-Based Research Network (“Network”) classify the severity of post-operative bleeding; and (2) examine the association between bleeding severity classification and whether the GD had residency training. Methods: An electronic questionnaire was developed to assess GDs’ classification of bleeding severity for various scenarios following scaling or a single-tooth simple extraction, and to collect information about respondents’ experience with bleeding scenarios. A total of 1815 GD members of the Network were invited to participate. Results: A total of 866 GDs responded. Strong agreement (low variability) was observed for scenarios that were classified as “severe bleeding” (94.7-96.8%), and lower agreement (higher variability) was observed for scenarios classified as “moderate bleeding” (53.2-65.2%). The GD’s classification of bleeding severity was not correlated with training in a General Practice Residency (GPR) or Advanced Education in General Dentistry (AEGD). A minority of respondents had experience with ‘major bleeding’ that may lead to hemodynamic emergency (15.5%) or a referral to an emergency department (4.8%). Conclusion: This study identified scenarios for which there is high agreement and low agreement regarding bleeding severity classification among GDs in the US. A small percentage of respondents had actual experience with major bleeding in their patients. Based on these results, we propose a new tool to assess severity of oral bleeding intended to foster better communication between dental professionals. The new tool may assist GDs to standardize documentation and communication with other health care professionals. Keywords: Anticoagulant agents, Bleeding, Classification, Dental, Hemostasis, Scaling, Tooth extraction

Juvenile idiopathic arthritis (JIA) is the most prevalent chronic rheumatic disease in children. Temporomandibular joint (TMJ) involvement is common but often asymptomatic with overlapping temporomandibular disorders (TMD) making diagnosis challenging. This report describes 10 pediatric patients diagnosed with both TMD and JIA. Evaluation included clinical, psychological, hematological, and radiological assessments. TMD symptoms were assessed after six months of dental and rheumatological management. TMJ involvement in JIA frequently precedes systemic symptoms and may occur even when blood markers appear negative, highlighting the importance of imaging for early diagnosis and timely intervention. Conventional TMD treatment combined with rheumatologic interventions generally yield favorable results even when JIA underlies TMD symptoms. Keywords: case report, CBCT, imaging, juvenile idiopathic arthritis, temporomandibular disorders, temporomandibular joint

Objective: This study aimed to investigate the causal relationship between metabolites and periodontitis using Mendelian randomization (MR) and validate findings through gingival crevicular fluid (GCF) metabolomic profiling. Methods and materials: A two-sample MR analysis used genetic data from 486 metabolite Genome-Wide Association Study (GWAS) and periodontitis statistics, with IVW as the primary method, supported by MR-Egger, weighted median, and weighted mode. Sensitivity analyses included Cochran’s Q, MR-Egger, and MR-PRESSO tests. GCF metabolomics compared 5 periodontitis patients and 5 controls, identifying differential metabolites via t-tests and PLS-DA, with KEGG pathway enrichment. Results: MR analysis identified 17 metabolites causally linked to periodontitis, spanning amino acids, lipids, energy metabolism, and cofactors/vitamins. Protective metabolites included betaine (OR: 0.478, 95% CI:0.235–0.975), laurate (0.51, 0.267–0.974), and glycerol 3-phosphate (0.312, 0.105–0.926), while phenylalanine (39.651, 2.173–723.565), pelargonate (2.527, 1.059–6.03), and 3-methylhistidine (1.481, 1.074–2.042) increased risk. Sensitivity analyses confirmed minimal heterogeneity, no pleiotropy (except 4-acetamidobutanoate), and no reverse causation. GCF metabolomics revealed 75 upregulated and 245 downregulated metabolites, with pathway enrichment in lipid, amino acid, and vitamin metabolism. Notably, betaine—protective in MR analysis—was significantly reduced in periodontitis, aligning with its anti-inflammatory role. Conclusion: This study indicates that some circulating metabolites (e.g., betaine) may protect against periodontitis. Integrating MR and GCF analyses, we identified key metabolic risk factors. Clinically, metabolites like betaine and glycerol 3-phosphate could serve as non-invasive early biomarkers, providing new avenues for personalized periodontitis prevention and treatment. Keywords: Periodontitis, Metabolites, Mendelian randomization, Metabolomics

Background: Periodontitis is a severe oral health condition that damages the supporting bone and soft tissues surrounding the teeth. In recent years, it has become evident that periodontitis could increase systemic inflammatory markers. Some studies showed a potential link between periodontitis and autoinflammatory diseases, including Familial Mediterranean fever (FMF), which is a hereditary autoinflammatory condition. The current study aimed to comprehensively evaluate the association between FMF and periodontitis by analyzing clinical periodontal parameters—Plaque Index (PI), Gingival Index (GI), and Clinical Attachment Loss (CAL)—through a meta-analysis. Methods: A thorough search was conducted across different databases, including PubMed, Scopus, Web of Science, and Google Scholar, covering publications up to July 2024. Eleven studies were included, consisting of one cohort and ten case controls. Following established methods, we performed data extraction and quality assessment of the selected publications. We conducted a meta-analysis to gather the effect sizes obtained from the eligible publications. Results: The meta-analysis highlighted a statistically significant increase in PI among FMF patients compared to controls, with a pooled mean difference of 0.1833 (95% CI: 0.0012, 0.3655; p=0.0485), indicating higher plaque accumulation in FMF patients. On the other hand, CAL exhibited a non-significant mean difference of –0.0933 (95% CI: –0.2928 to 0.1062; p = 0.3596), and the GI similarly did not reach statistical significance, presenting a mean difference of 0.3223 (95% CI: –0.0713 to 0.7158; p = 0.1085). Conclusion: Our investigation underscores a potential association between FMF and periodontitis, as seen by elevated levels of PI in FMF patients. These results suggest that FMF patients experience higher levels of periodontal inflammation, emphasizing the importance of periodontal care in this population. Keywords: Familial Mediterranean fever, Periodontitis, Oral health, Autoinflammatory disease, Inflammasome

Objective: Describe how advancements in digital technologies and material's science provide additional restorative alternatives and material combinations for single and multiple unit implant-supported restorations, such those incorporating the clinical use of nitride coated titanium bases (TiN) in combination with the 2-piece, CAD/CAM, screw-retained, zirconia-ceramic, hybrid implant-supported restoration concept. Materials and methods: Two partially edentulous patients with missing teeth in the maxillary esthetic zone were treated with a novel technical and restorative concept using the 2-piece CAD/CAM screw-retained zirconia-ceramic hybrid-abutment crown concept bonded to nitride coated titanium bases. Clinical outcomes: Biologic outcomes showed that tissues were maintained healthy with the patients showing an adequate oral hygiene level, no detectable plaque present upon probing and no bleeding on probing. Esthetic evaluation demonstrated an excellent esthetic outcome and peri-implant soft-tissue integration with adjacent natural teeth and pontic tissue areas, together with post-treatment stability of the gingival zenith position. None of the two patients showed technical complications such screw loosening or porcelain chipping/fracture. Radiographic evaluation reveals a precise fit between TiN bases and the implant connecting interfaces, no marginal bone loss and a stable implant osseointegration. The principal advantages of incorporating nitride coated titanium bases (TiN) in implant supported restorations rely on the favorable esthetic outcomes, improved technical, mechanical, and biological aspects, as well as the physicochemical characteristics of TiN hard thin film coatings and their positive impact on titanium biocompatibility. Conclusions: The short term promising clinical outcomes of the 2-piece CAD/CAM screw-retained, zirconia ceramic hybrid abutment crown concept bonded to nitride coated titanium bases, would indicate the potential clinical benefits of the described restorative alternative. However, additional in vitro investigations and randomized clinical trials are needed to validate these initial observations, especially those evaluating the 2-piece CAD/CAM screw-retained, zirconia ceramic hybrid abutment crown bonded to TiN bases when compared to the conventional 2-piece hybrid design as well as stock/custom, metal/zirconia/lithium disilicate, screw/cemented implant supported restorations. Keywords: CAD-CAM, hybrid abutment, Implant esthetics, soft tissue., titanium bases, titanium nitride

Introduction: Dentists provide treatment of anatomical structures innervated by the trigeminal system such as the teeth, gingiva etc., which can be subject to injury even following routine and well performed dental procedures. As a result, the dental clinician is often presented with patients with neuropathic pain or unusual sensory distortions. In addition, the dental clinician treats patients following facial and oral trauma which may result in chronic pain. Therefore, recognition of posttraumatic trigeminal neuropathic pain (PTTNP) and its management must be considered essential for the dental clinician. Painful neuropathies, including PTTNP, can present as a debilitating form of neuropathic pain that often defies treatment normally effective for other types of somatic pain disorders. Treatment of PTTNP typically involves the use of various classes of medications including antiseizure medications (AEDs) and tricyclic antidepressants (TCAs)1. Many patients suffering with PTTNP may have contraindications for these medications due to comorbidities, occupational responsibilities, or medication side effects. An alternative to AEDs and TCAs is the use of low-dose naltrexone (LDN)2. Methods: This study is a retrospective extended case series of patients with PTTNP. The records of twenty-one patients diagnosed with painful post-traumatic trigeminal neuropathic pain at the Center for Temporomandibular Disorders and Orofacial Pain of the Rutgers School of Dental Medicine. They met the criteria of PTTNP according to the ICOP and were prescribed LDN. Though a total of twenty-one patients were included, twelve with all the data present were included into the final analysis. The sex distribution was equal with 6 females and 6 males, with a combined average age of 59.33 ± 13.96 years. Results: LDN significantly reduced the patients’ report of pain using a Visual Analogue Scale (VAS) 0-10 subjective pain ratings at the follow-up visits compared to the initial VAS. Interestingly, the small group of patients who used LDN in combination with Serotonin Norepinephrine Reuptake Inhibitors (SNRI), demonstrated a lower average VAS score at the first follow-up visit, compared to those who took LDN with other medications. There were no significant side effects reported by the patients. No adverse effects of LDN therapy were reported. Side effects of the medication are rare and as reported the literature, include mild abdominal distress or vivid dreams. None were reported among this group of subjects. Based on our retrospective extended case series, LDN appears to be a safe and effective medication for use in chronic PTTNP. These results, highlight the need for future studies to elucidate LDN’s analgesic mechanism of actions and to decisively demonstrate the analgesic effect of LDN in larger cohorts using randomized, double blinded, placebo controlled clinical studies. Keywords: trigeminal neuropathic pain, low dose naltrexone, chronic pain, opioid antagonist

Purpose: To evaluate parents’ knowledge of the Israeli Ministry of Health guidelines on basic oral health practices and appropriate toothpaste usage for different pediatric age groups. Method: Anonymous questionnaires were distributed to parents attending the Pedodontics Department. The questionnaire included two sections: general questions and questions that were completed for all children in the family, categorizing them into three age groups—under 2 years, 2–6 years, and over 6 years. Results: A total of 242 questionnaires and 410 responses across different age groups were collected. Most respondents knew that teeth should be brushed as soon as the first tooth appears and believed that the first dental visit should be at age two (60.5% and 26.9%, respectively). However, only 15% of parents answered boths questions correctly. Toothpaste selection was primarily based on age (46.6%), with no significant differences across age groups for correct answer (p = 0.130). Awareness of the recommended fluoride concentration was low (16.1%), though parents of older children showed better knowledge (p = 0.040). Appropriate toothpaste amounts were used in 30.2% of the cases, with the 2–6 year age group demonstrating the highest awareness (p < 0.001). Only 3.7% of parents correctly answered all three toothpaste-related questions. Overall, the knowledge score for toothpaste guidelines was highest in the middle-aged group (31.21%, SD = 28.66, p < 0.001). Conclusion: A minority of parents are familiar with recommended early dental care practices and correct toothpaste usage. The findings emphasize the need to improve parental awareness from the very beginning of a child’s development. Keywords: Toothpaste selection, Fluoride concentration, Toothpaste amount, Dental prophylaxis, Parents’ knowledge

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