Quintessence International, Pre-Print

Objectives: This study aimed to investigate periodontal stability and treatment needs in patients under antiresorptive therapy (ART) during supportive periodontal care (SPC), with a focus on medication-related osteonecrosis of the jaw (MRONJ) risk and reasons for tooth loss. Method and Materials: In this retrospective case-control study, records of 100 stage III/IV SPC patients (50 ART-exposed, 50 unexposed) were analyzed for probing pocket depth (PPD), clinical attachment level (CAL), bleeding on probing (BOP), history of periodontal surgery, tooth loss and MRONJ risk over a period of up to 15 years after active periodontal therapy. Results: Baseline patient characteristics were similar between ART-exposed and unexposed patients. Osteoporosis was the underlying condition for ART in 72% of cases, and 74% exhibited an intermediate MRONJ risk profile. Over time, no significant differences between the groups were found in number of teeth, CAL, PPD, or BOP. Periodontal re-treatment needs (teeth with PPD >=4 mm or >=6 mm) were relatively low and comparable between exposed and unexposed patients. However, periodontal surgery was performed more frequently in unexposed patients, also due to the risk of MRONJ in exposed patients. Both groups showed similar numbers of tooth loss, primarily due to periodontal and endodontic causes. Regression analyses identified ART, age, and diabetes mellitus as significant factors associated with higher BOP, while smoking and diabetes mellitus were linked to higher PPDs. Conclusion: Achieving periodontal stability during SPC in ART-patients, most of whom had an intermediate MRONJ risk profile, appeared comparable to unexposed patients. However, the different MRONJ risk profiles should be taken into consideration and further investigated. Keywords: Bisphosphonates, Denosumab, Medication-related osteonecrosis of the jaw, Periodontitis, Preventive dentistry

Objectives: Small-scale studies reported increased blood pressure in patients using chlorhexidine mouthwash with the rationale that the rinse mitigates nitric oxide production by oral bacteria. The present study evaluated whether prior use of chlorhexidine mouthwash can be associated with an increased odds ratio for primary hypertension in a large hospital cohort. Materials and Methods: The i2b2 NIH-established platform was used to search for deidentified medical information coded by ICD-10 for subjects with a hypertension diagnosis who have used chlorhexidine rinses before between October 2015 and May 2024. Binary statistics and logistic regression were used to calculate the odds ratio for hypertension in the group that used chlorhexidine mouth rinse before and after adjustments for demographic data, diabetes, and periodontal disease. Results: The unadjusted odds ratio for primary hypertension in subjects who used chlorhexidine gluconate mouthwash before was significantly elevated (OR 3.09, 95%CI 3.03 – 3.16, p<0.0001). It remained significant after adjusting for male gender (OR,1.44,95%CI 1.42 – 1.47, p<0.0001), age <45 years (OR 1.90 95%CI 1.86 – 1.93, p<0.0001), White race (OR 2.3, 95%CI 2.27 – 2.37, p<0.0001, diabetes (OR 1.99, 95%CI 1.93 -2.05, p< 0.001, and periodontal disease. (OR 3.28, 95%CI 3.21 – 3.34, p< 0.0001). The odds ratio for hypertension for subjects with gingivitis or periodontal disease after adjustment for chlorhexidine mouthwash was elevated. (OR 20.11, 95%CI 20.11 -21.44, p<0.0001) Conclusions: With the cavitate of a retrospective study design, the results indicate an increased odds ratio for primary hypertension for subjects with prior use of chlorhexidine mouthwash. Keywords: chlorhexidine, mouthwash, primary hypertension, blood pressure

Aim: There has been found that patients with chronic periodontitis showed higher salivary concentrations of reactive nitrogen species (RNS) than healthy subjects. However, only a study from elderly Koreans has reported that high salivary RNS concentrations are associated independently with periodontitis. Thus, the objective of this study was to determine whether salivary nitrites concentrations are associated with periodontitis controlling risk factors in other populations (such as European population). Methods: This was a prospective and observational study carried out in a Dental Clinic including European subjects without periodontitis (including subjects with periodontal health or with localized gingivitis in <30% sites) or with periodontitis (thus, with loss of periodontal tissue). The levels of nitrite in saliva were assessed using the Griess method. A multivariate regression analysis was performed to determine that variables were associated independently with periodontitis. To determine the association between salivary malondialdehyde levels and severity of periodontitis was used Spearman's rho correlation coefficient. A receiver operating characteristic analysis with salivary nitrites levels and periodontitis diagnostic was performed. Results: Subjects with periodontitis (n=54) in comparison to subjects without periodontitis (n=30) had higher salivary nitrites levels (p=0.003), higher rate of arterial hypertension history (p=0.02) and were older age (p<0.001). Nevertheless, differences between subject with and without periodontitis in other variables were not found. A positive correlation was found between salivary nitrites levels and periodontitis severity (rho=0.23; p=0.04). Multiple logistic regression analysis showed that elevated salivary nitrites levels > 209 nmol/mL were associated with periodontitis controlling for arterial hypertension history and age (OR=10.212; 95% CI=2.665-39.128; p=0.001) and controlling for diabetes mellitus and smoker (OR=8.793; 95% CI=3.038-24.450; p<0.001). The area under the curve for periodontitis diagnostic by salivary nitrites levels was of 69% (95% CI=58%-79%; p<0.001). The selected point of salivary nitrites levels > 209 nmol/mL for periodontitis diagnostic had 72% of sensitivity (58%-84%), 77% of specificity (58%-90%), 3.1 of p ositive likelihood ratio (1.6-6.1), 0.4 of negative likelihood ratio (0.2-0.6), 85% of positive predictive value (74%-92%) and 61% of negative predictive value (49%-71%). Conclusions: Salivary nitrites concentrations could be associated independently with periodontitis, could be associated with periodontitis severity and could help in periodontitis diagnosis in a European population according to the results of this preliminary study. Keywords: Oxidation, salivary, nitrites, nitric oxide, periodontitis, gingivitis

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 case report describes a multidisciplinary approach using a digital wax-up to fabricate a gingivectomy and crown lengthening guides, to reshape a lateral incisor into a central incisor and improve overall esthetics. Clinical Considerations: Comprehensive treatment planning is crucial when executing a multidisciplinary workflow, with digital tools proving to be invaluable aids. In the present case, a digitally designed wax-up was employed to generate a digital surgical guide for reshaping the gingival architecture of a lateral incisor into that of a central incisor, followed by composite restorations. Conclusion: The application of a digital wax-up for the design of a surgical guide and the fabrication of a silicone index led to a predictable and successful outcome in reshaping a lateral into a central incisor. Clinical Significance: Post-orthodontic reshaping using direct composite is widely accepted by patients due to its cost-effectiveness and minimally invasive nature. This approach highlights the efficacy of digital technology in achieving precise dental restorations, highlighting its growing importance in modern dental practice. Keywords: digital dentistry, 3D printing, crown lengthening, minimally invasive dentistry, composite veneers

Dental caries is one of the most common diseases globally and affects children and adults living in poverty who have limited access to dental care the most. Left unexamined and untreated in the early stages, treatments for late-stage and severe caries are costly and unaffordable for socioeconomically disadvantaged families. If detected early, caries can be reversed to avoid more severe outcomes and a tremendous financial burden on the dental care system. Building upon a dataset of 50,179 intraoral tooth photos taken by various modalities, including smartphones and intraoral cameras, this study developed a multi-stage deep learning-based pipeline of AI algorithms that localize individual teeth and classify each tooth into several classes of caries. This study initially assigned International Caries Detection and Assessment System (ICDAS) scores to each tooth and subsequently grouped caries into two levels: Level-1 for white spots (ICDAS 1 and 2) and level-2 for cavitated lesions (ICDAS 3-6). The system's performance was assessed across a broad spectrum of anterior andposterior teeth photographs. For anterior teeth, 89.78% sensitivity and 91.67% specificity for level-1 (white spots) and 97.06% sensitivity and 99.79% specificity for level-2 (cavitated lesions) were achieved, respectively. For the more challenging posterior teeth due to the higher variability in the location of white spots, 90.25% sensitivity and 86.96% specificity for level-1 and 95.8% sensitivity and 94.12% specificity for level-2 were achieved, respectively. The performance of the developed AI algorithms shows potential as a cost-effective tool for early caries detection in non-clinical settings. Keywords: Caries, artificial intelligence, deep learning, machine learning, convolutional neural network, dental public health

Objectives: This retrospective study analyzed zygomatic implant (ZI) survival and implant success (based on ORIS criteria) in patients treated for maxilla atrophy or after reconstruction failure. Material and methods: Implants were placed as quads (4 ZIs) or hybrids (ZIs and conventional implants in premaxilla) in edentulous patients using various surgical approaches, evolving from the sinus slot to Chow’s extended sinus lift technique with or without Bichat fat pad. The procedure was followed by immediate loading, while clinical and radiographic evaluations spanned at least 1 year after implantation. The primary outcome was the implant survival at follow-up, and the secondary was the implant success, assessed as complications according to ORIS criteria: prosthetic offset, sinus status, peri-implant soft tissue health, and implant stability. Results: A total of 73 consecutive patients, treated with 217 ZIs and 76 conventional implants, were included, with mean follow-up of 3.5 years (range, 1–9.8 years). Four ZIs failed in 3 patients, including 1 patient with a zygomatic bone fracture. The cumulative survival rate was 98.16%. Although in 2 additional cases, implants lost stability, they achieved delayed osseointegration. Other complications included 21 sinus reactions (excluding the 4 failures) and 28 peri-implant inflammatory reactions. Conclusion: ZIs offered a predictable treatment option for extreme upper jawbone atrophy with a relatively low complication rate and no severe injuries. The Chow technique with the Bichat fat pad positively impacted ZI success and survival, whereas smoking, implantation in fresh sockets, and the limited experience of the surgeon negatively affected the outcomes. Keywords: complications, maxillary atrophy, oral rehabilitation, retrospective study, risk factors, zygomatic implant

Objective: While a bidirectional relationship between sleep health and musculoskeletal (MSK)-pain have been established among chronic pain patients, few studies explored it among dental students. This cross-sectional study assessed the relationship of self-report MSK-pain with sleep health and psychological outcomes among dental students, and whether differences existed as a function of number and location of painful body-sites. Method and Materials: Validated questionnaires were sent through REDCap to dental students at a predoctoral dental school, assessing presence, location (head, shoulder/neck, jaw, back, body), and intensity of MSK-pain, sleep health (risk of sleep apnea, insomnia severity symptoms, sleep quality, daytime sleepiness, and chronotype), and psychological outcomes (anxiety/depression). Differences between those with and without MSK-pain, and across participants with different number and location of painful sites were tested with t-tests and ANOVA, adjusting for age/gender. Results: Out of 80 participants (82.5% females), 76.3% reported MSK-pain (68.9% in neck/shoulders). Those with MSK-pain scored significantly worse in sleep quality (7.7±3.7 vs. 4.8±2.1, p<.001), daytime sleepiness (6.1±4.2 vs. 3.3±2.7, p<.001). Those with >3 painful body-sites reported worse sleep quality (p=.006) and daytime sleepiness (p=.003) than pain-free controls. There were no differences on sleep and psychological outcomes as a function of number of painful body-sites. Those reporting back pain scored worse in insomnia (p=.037), daytime sleepiness (p=.002), and sleep quality (p=.006) than those without back pain. Conclusion: MSK-pain is prevalent among dental students and associated with worse sleep health. While number of painful sites may not influence sleep/psychological health, specific locations (e.g., back pain) were associated with worse sleep functioning. Keywords: back pain, dental students, musculoskeletal pain, sleep, symptoms

Background: Craniofacial fibrous dysplasia (CFD) affecting the jaws can result in facial asymmetry, posing a unique challenge for dental implant placement in edentulous areas. This case report introduces an innovative approach for rehabilitating the posterior maxilla affected by CFD using a computer-guided technique for maxillary recontouring and substitution bone grafting at implant sites. Case Presentation: A 58-year-old edentulous female with a craniofacial fibrous dysplasia bone lesion affecting the right maxilla was referred for correction of asymmetry and dental implant placement. A computer guide was devised for shaving and contouring the right maxilla. Following virtual maxillary reduction, a second guide was created over the osteomized 3D model to plan the location of future dental implants and guide bone ostectomies for allograft substitution. Particulate bone substitute was applied to ostectomy sites in the affected maxillary alveolar ridge. Four implants were placed successfully four months post-operation, with integration confirmed by clinical examination after one year of follow-up. Conclusion: This treatment approach emerges as a reliable and effective modality for simultaneous dental implant rehabilitation in edentulous alveolar bone and jaw contouring in CFD cases. Keywords: Fibrous Dysplasia of Bone, Dysplastic Alveolar Bone, Facial asymmetry, Bone Grafts, Dental Implants

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

Objectives: This study aims to investigate the impact of photobiomodulation (PBM) and/or azithromycin (AZM) therapy in combination with full-mouth subgingival instrumentation (FSI) on receptor activator of nuclear factor κB ligand (RANKL) and osteoprotegerin (OPG) levels and RANKL/OPG ratios in gingival crevicular fluid (GCF) on patients with stage III-IV grade C periodontitis. Materials and methods: The study was conducted on 77 stage III-IV grade C periodontitis patients and 20 periodontally healthy controls. Patients with stage III-IV grade C periodontitis were categorized into four treatment groups: 1) only FSI (FSI) group; 2) FSI+AZM (AZM) group; 3)FSI+PBM (PBM) group and 4) FSI+PBM+AZM (AZM+PBM) group. Clinical periodontalparameters and RANKL and OPG levels and RANKL/OPG ratios in GCF were measured at thebaseline and month 3rd of the therapy. Results: Compared with the periodontally healthy controls,all the baseline clinical parameters were higher in the Stage III-IV grade C periodontitis groups (P< 0.05); however, there were no statistically significant differences between the Stage III-IV gradeC periodontitis groups (P>0.05). In month 3rd, the lowest values in all clinical parameters weregenerally observed in the antibiotics groups whereas the highest values were observed in the FSIgroup. Furthermore, the highest RANKL and OPG values in antibiotic groups and the highestRANKL/OPG ratio in PBM group were observed in the third months. RANKL/OPG ratios did notchange in the FSI and antibiotics groups after the treatment, but it increased significantly in thePBM group. Conclusion: While PBM treatment combined with FSI increases the RANKL levels,AZM increases OPG levels. Also, PBM+AZM treatment shows additional clinical andimmunological beneficial efficacy. Keywords: laser, antibacterial agents, periodontology, periodontitis, medicaments

Objective: The study aims to evaluate the stress distribution on tooth and restoration of zirconia endocrowns with pulp chamber or intracanal extension and zirconia post performed maxillary first molar using finite element analysis. Method and materials: Three three-dimensional endodontically treated maxillary molars were modeled. Cortical bone and cementum were modeled 2 mm and 200 μm in thickness. Periodontal ligament at 250 μm thickness was constructed. Zirconia endocrown with pulp chamber extension of 2 mm (Model E+PCE), zirconia endocrown with intracanal extension of 4 mm (Model E+ICE), and zirconia post of 4 mm and crown (ZP) were modeled using software. All restoration models were placed on the maxillary molars. Models were subjected to 400 N loading from the three occlusal contact points. Von Mises stress was recorded. Results: Expectingly, points where the stress was applied showed high stress compared to other regions of the models. The stress did not occur at the trifurcation in any of the models. For the stresses occurring in the restoration material, there were 14.67 MPa, 57.79 MPa, and 155.56 MPa, in Models E+PCE, E+ICE, and ZP, respectively. At the remaining dentin, these values were 47.04 MPa, 32.85 MPa, and 33.42 MPa in Models E+PCE, E+ICE, and ZP, respectively. Conclusions: Within the limitation of the study, zirconia endocrowns with intracanal extension exhibit more favorable stress distribution in both restoration material and dentin compared to zirconia posts and pulpal extension endocrowns. These findings suggest that endocrown with intracanal extension may be a better restorative option for reducing stress. Keywords: endocrown, endodontically treated teeth, maxillary molar, zirconia

Objectives: To explore associations between periodontal disease (PD) severity and cardiometabolic risk factors, including body mass index (BMI), age, Type 2 Diabetes Mellitus (T2DM) risk, sex, and hypertension (HTN) in patients at an urban dental school clinic. Methods and Materials: A cross-sectional study design was used to analyze electronic health record data, including periodontal status, demographic characteristics, cardiometabolic risk factors and the American Diabetes Association Diabetes Risk Test (DRT) Score. Chi-square tests and ordinal logistic regression were conducted using SAS 9.4. Results: Of those with available data (n=6,778), 44% were male, 70.2% were overweight/obese, and the mean age was 50.9 (SD=16.6) years. Associations between PD severity and BMI, sex, age, DRT score, and HTN were statistically significant (all p<0.0001) in bivariate analyses. Using logistic regression, HTN (p=0.0006), sex (p<0.0001), and age (p<0.0001) were significant predictors of severe PD which was most common in those with HTN (35.9%), males (31.7%), those >60 years (36.6%). The odds of having severe PD for those with HTN were 1.2 times that of those without HTN. Males were 1.7 times more likely to have severe PD than females. Those aged 40-49 years, 50-59 years, and >60 years were 2.9, 4.2, and 4.3 times more likely to have severe PD than those who were 18-39 years, respectively. Conclusion: All cardiometabolic risk factors were associated with PD severity in bivariate analyses. In the logistic regression model, being older, male, and having HTN were significant predictors of PD severity. Future research is needed with a more diverse sample. Keywords: Body Mass Index, Cardiometabolic Risk Factors, Diabetes Risk, Hypertension, Periodontitis

Objectives: The aim of this study was to observe whether immediate implant placement (IIP) into damaged extraction sockets is a successful modality for treating hopeless teeth that require extraction. Data source: An electronic search was carried out through four databases (PubMed/MEDLINE, Web of Science, Scopus, and ScienceDirect) to identify randomized controlled trials (2013-2023) to understand whether IIP in damaged sockets is a successful treatment. The focus question was, “In a patient with a hopeless tooth that needs extraction with the indication for dental implant treatment, is IIP in damaged extraction sockets, compared to undamaged sockets or healed sites, an effective method for the replacement of hopeless teeth and achieving a favorable clinical result?” The risk of bias was appraised and a meta-analysis using random effect was applied. Five studies with 135 patients and 138 implants were included. The implant survival rate was 100% for all studies and period evaluated; the pink esthetic score (PES) scores had no statistically significant result for all articles that evaluated this parameter; the soft tissue changes was reported by two studies: one found no significant differences and the other showed that the test group experienced reduced soft tissue loss at the 1-year evaluation (measured with digital intraoral scanners); other two studies assessed the marginal bone loss, presenting no differences between groups. The meta-analysis showed homogeneity between the studies. There was an equilibrium among the groups in the various studies included, and age tended to be lower in the test group. The buccal bone tissue and pink esthetic score showed favoritism for the test group but without statistical significance. Conclusion: This study suggests that IIP in the presence of buccal bone defects can achieve comparable clinical and radiological outcomes to traditional methods in the short term of the limited studies available. The buccal aspect is not possible to be evaluated through radiographs. Bone regeneration was essential to reach optimal results. It is important to emphasize that IIP requires adherence to rigorous criteria to ensure functionally acceptable results. Keywords: Immediate implant placement, Dental implants, Fresh sockets, Buccal bone defect, Compromised extraction sockets

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