Quintessence International, Pre-Print

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

Objective: Occlusal splints are commonly used in the management of temporomandibular joint (TMJ) disorders (TMD). However, it is unclear if it should be used after a second-line therapy like arthrocentesis. We systematically reviewed the evidence on the efficacy of post-arthrocentesis splint therapy in the management of TMD. Methods: PubMed, Embase, Scopus, Web of Science, CENTRAL, and Google Scholar were searched for studies published until 5th August 2024. The outcomes assessed were pain and maximal mouth opening (MMO). Results: Eight studies were included. Five studies reported data for the meta-analysis. The pooled analysis found that there was no statistically significant difference in pain scores in the arthrocentesis + splint group vs arthrocentesis group at 1 month (MD: -0.01 95% CI: -0.46, 0.44), 3 months (MD: -0.02 95% CI: -0.67, 0.63) and 6 months (MD: 0.06 95% CI: -0.25, 0.37). The pooled analysis also showed that splint therapy after arthrocentesis may not significantly improve MMO as compared to no splint therapy at 1 month (MD: 0.08 95% CI: -2.11, 2.27), 3 months (MD: 0.76 95% CI: -0.84, 2.35) and 6 months (MD: 0.56 95% CI: -0.65, 1.78). Descriptive analysis of three studies showed that two supported the use of splints while one found no added improvement in outcomes. Conclusions: Limited evidence from low-quality studies shows that the use of splint therapy after arthrocentesis may not improve pain and MMO in patients with TMD. High-quality randomized controlled trials are needed to improve evidence. Keywords: Disc displacement, Lavage, Occlusal splint, TMJ, Arthralgia, Mouth opening

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

Aims: The aim of this study was to elucidates the nuanced interactions between antihypertensive medications and the risk of periodontitis using Mendelian randomization (MR) analysis method. Methods: Our study adopted a drug-target Mendelian randomization method to assess the long-term effects of nine antihypertensive drug categories on the risk of periodontitis in both acute and chronic cases. We selected genetic variants located in or near genes relevant to the targets of these drugs and associated with systolic blood pressure (SBP) to simulate the influence of antihypertensive treatments. Genetic information on SBP and periodontitis susceptibility was extracted from extensive genome wide association studies for both acute and chronic conditions. Additionally, we conducted a secondary analysis using expression quantitative trait loci for the genes of interest as alternative proxies.Colocalizaion analysis was performed to explore shared variants between antihypertensive drugs and periodontitis. Results: Our analysis revealed that the use of angiotensin converting enzyme inhibitors with an increased risk of acute periodontitis (odds ratio [OR] [95% confidence interval]: 1.43 [1.11, 1.85] per 1 mmHg reduction in SBP; p = 5.93×10-3) and loop diuretics with a decreased risk of chronic periodontitis (OR: 0.94 [0.90, 0.98]; p = 2.94×10-3). Moreover, genetically mimicking the use of a suggestive protective effect of thiazides and related diuretics on acute periodontitis was observed in both acute (OR: 0.95 [0.90, 0.99]; p = 0.021) and chronic (OR: 0.98 [097, 1.00]; p = 0.045) periodontitis. Colocalizaion analysis revealed antihypertensive drugs and periodontitis shared causal variants in ACE and SLC12A2 locus. Conclusion: The research indicates that loop diuretics might decrease the risk of 31 periodontitis, while angiotensin-converting enzyme inhibitors could heighten the risk. Further investigations are required to evaluate the potential of reusing antihypertensive drugs for periodontitis prevention. Keywords: antihypertensive drugs, periodontitis, Mendelian randomization study, genetic analysis, genetic epidemiology

Objective: This prospective case series aimed to clinically evaluate the bleaching effect, spontaneous tooth sensitivity and variation in the thermal sensation threshold of different groups of teeth undergoing in-office bleaching. Method and materials: Ten patients received conventional bleaching treatment: 35% hydrogen peroxide with 3 bleaching sessions of 45 minutes, evaluating color change (ΔE and ΔE00), whitening index (WID), and tooth sensitivity (VAS). Thermal stimulus-generating devices were used to simulate sensitivity caused by low temperatures through Quantitative Sensory Tests (QST). Analyses were conducted individually on different teeth groups (n=20) (lower incisors LI, upper incisors UI, canines C, upper first premolars PM). Results: Regarding color change, LI and UI did not statistically differ from each other but showed significant difference and greater bleaching potential compared to C and PM (P =.018). Regarding sensitivity, LI and UI presented the highest spontaneous sensitivity values (P =.032), while PM did not display painful symptoms, also observed in provoked sensitivity analysis (P =.025). Conclusions: The general analysis of the results indicates that the tooth type responds differently to the whitening treatment, both in relation to the aesthetic benefit and the occurrence of tooth sensitivity. It was observed that lower incisors reach the degree of chromatic saturation before canines and premolars, in addition to presenting greater bleaching sensitivity. Personalizing the treatment, based on prior knowledge of the degree of saturation, anatomical factors and the risk of sensitivity, can provide considerable advantages in the whitening technique. Keywords: analysis, color, dentistry, hydrogen peroxide, tooth bleaching, tooth sensitivity, Whitening Index

Objectives: Combined oral contraceptives are used for the management of hyperandrogenism and menstrual abnormalities in polycystic ovarian syndrome (PCOS). There is a dearth of literature addressing the effect of ethinyl estradiol/norethisterone acetate (EE/NETA) on gingival and systemic inflammation in these patients. This randomized trial aims to evaluate the effect of EE/NETA with and without scaling on periodontium and high sensitivity C-reactive protein (hsCRP) levels in women with PCOS having gingivitis. Methods: Women having PCOS along with gingivitis were randomly divided into two groups: Test Group (TG, n=30) received EE/NETA + scaling with oral hygiene instructions (OHI) and Control Group 1 (CG1, n=30) received EE/NETA + OHI. Another Control Group (CG2, n=30) consisting of systemically healthy females having gingivitis and who were age and BMI matched with the test group participants received scaling along with OHI. Periodontal and anthropometric parameters were measured at baseline, 3 months and 6 months follow-up. Serum hsCRP levels were also estimated. Results: Serum hsCRP levels and periodontal parameters were significantly decreased in all the groups after 6 months (p≤0.05). The decrease in hsCRP levels was similar among the groups (p>0.05). Significantly more reduction in gingival inflammation was observed in TG compared to CG1 (p≤0.05). Conclusion: EE/NETA used alone and with scaling showed no detrimental effect on gingiva and could reduce systemic and gingival inflammation in women with PCOS having gingivitis. Keywords: C-reactive protein, dental scaling, gingivitis, inflammation, norethisterone acetate, polycystic ovary syndrome

Stabilization appliances (Michigan splints) are considered well-studied and widely adopted for managing bruxism and temporomandibular disorders (TMDs). Traditionally, these appliances have been fabricated by wax modeling and pressing resin onto casts made from irreversible hydrocolloid or silicone impressions. This article provides a detailed description of an all-digital workflow that uses intraoral scanning and computer-aided design (CAD) software to design a stabilization splint on a digital cast that can be manufactured autonomously by a computer-aided manufacturing (CAM) grinding machine in a subtractive procedure. The workflow is applicable to both dentists and technicians. Special attention is given to aspects and procedures that are important for the successful fabrication of the splint. Working without a cast can save time and money, and the use of CAD-CAM technology provides a homogeneous splint material quality. Keywords: bruxism, CAD/CAM, digital, occlusal device, stabilization splint, temporomandibular disorders

Objectives: Our aim was to investigate the impact of smoking on pocket closure at six months after treatment of severe periodontitis, in relation to residual clinical inflammation. Method and materials: The clinical records of deep pockets (probing depth≥6 mm, n=984) in 46 individuals with periodontitis were analyzed. Following baseline clinical assessments (plaque index, probing depth, clinical attachment level, and bleeding on probing), non-surgical periodontal treatment was performed. Clinical assessments were repeated at 2 and 24 weeks after periodontal therapy. A logistic regression model using generalised estimation equations (GEE) adapting the cluster robust standard errors was performed to investigate potential associations between bleeding on probing and pocket closure at post-treatment 24 weeks. Results: Absence of bleeding at two weeks after non-surgical treatment related to pocket closure after six-months. Pockets that do not bleed neither at baseline nor two weeks (OR=2.7; P <.005) and pockets of non-smokers (OR=6.32; P <.001) and females (OR=1.79; P =.022) associated with pocket closure at six months. Conclusion: Pocket closure is associated with being a non-smoker and the absence of inflammation after non-surgical periodontal treatment, which indicates the importance of smoking cessation and inflammation control in achieving optimal clinical outcomes. Keywords: periodontitis, bleeding, inflammation, initial treatment, maintenance, smoking

Objective: To evaluate the ability of near-infrared light transillumination (NIR-LT) to detect interproximal enamel and dentinal caries lesions compared to clinical-visual inspection (VI) aided by fibre-optic transillumination (FOTI). Method and Materials: From 170 Finnish adolescents aged 15-17 years, 5294 interproximal surfaces of premolars and molars were examined first clinical-visually aided by FOTI (VI+FOTI) using the International Caries Detection and Assessment System (ICDAS) classification. Subsequently, the surfaces were examined using NIR-LT. The extent of lesions was determined using the modified NIR-LT classification based on the Söchtig criteria. For the analyses, data on upper and lower premolars and molars were combined. Distributions of lesions were presented as frequencies. Differences between VI+FOTI and NIR-LT at the tooth and tooth surface levels were analysed by Chi-square and Fisher’s exact tests. Sensitivity and specificity of the NIR-LT method to detect any lesion was performed using VI+FOTI as the gold standard. Results: By VI+FOTI, 92.4% surfaces were classified as sound and by NIR-LT, 88.2%. Enamel caries lesions were found on 7.0% of the surfaces by VI+FOTI and on 11.6% by NIR-LT. Enamel lesions identified by NIR-LT were nearly double for all examined teeth groups, except for lower molars it was 1.3-fold. In 66% of the surfaces, the differences between NIR-LT and VI+FOTI findings were statistically significant (p<0.001). The sensitivity for all teeth of NIR-LT was 48.4% and the specificity was 91.1%. Conclusion: Radiation-free NIR-LT method shows considerable potential as a supplementary method for early detection of caries lesions among low caries prevalence adolescents. Keywords: adolescent, caries detection, enamel caries, interproximal caries, NIR-LT, radiation-free

Objective: To evaluate two methods for assessing the changes in periodontitis grading in patients undergoing supportive periodontal therapy (SPT) ten years (T10) after retrospective baseline (BL) grading. Materials and Methods: The periodontitis grade of 51 SPT-patients was assessed using indirect evidence as the primary criterion for periodontitis progression at BL and T10 (radiographic bone loss/age index, periodontitis phenotype). Grading at T10 was also performed using the direct evidence for periodontitis progression (clinical attachment loss over the previous five years). The use of indirect evidence for periodontal progression at BL and T10 was defined as method 1 (M1) to assess the changes in periodontitis grading. The use of indirect evidence at BL and direct evidence at T10 was defined as method 2 (M2). Changes in periodontitis grading using M1 and M2 were evaluated (Wilcoxon signed-rank test). Agreement between M1 and M2 was assessed (Cohen's kappa). Results: Indirect BL-grading revealed five grade B and 46 grade C patients. The indirect grading at T10 revealed 17 grade B and 34 grade C patients. The direct T10-grading classified all patients as grade C. M1 led to an overall improvement in periodontitis grading after ten years of SPT (p=0.00297), whereas M2 led to a deterioration (p=0.0369). The comparison between M1 and M2 showed that they lead to different results in terms of grading (Cohen's Kappa=0.116208). Conclusions: Periodontitis grading may change during SPT. Using indirect or direct evidence as the primary grading criterion during SPT may lead to different results. Keywords: Periodontitis, Periodontitis grade, Prognosis, Periodontal diseases, Periodontitis classification

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