Oral Health and Preventive Dentistry, Volume 20/2022

Purpose: To determine if an interactive electric toothbrush and smartphone application (app) can reduce self-reported gingival bleeding and promote better brushing behaviour based on global, in-market usage data. Materials and Methods: Anonymised data were collected worldwide between July 2020 and January 2021 from users of interactive oscillating-rotating electric toothbrushes and app (Oral-B Genius, GeniusX and iO). Self-reported gingival bleeding and brushing behaviour data captured via the app were sent to Google Firebase and Google BigQuery to aid processing and analysis. Results: Data from 16.7 million brushing sessions were analysed. 439,481 new users responded at least once to the app question: ‘Do you have gum bleeding?’ Of users answering the question over their first two weeks of app use (153,201), the proportion reporting bleeding decreased statistically significantly from week 1 to 2 (28.8% to 17.1%, p < 0.0001). Of users answering the question over each of the first five weeks (43,060) a further statistically significant decrease in those reporting bleeding was seen in each consecutive week, with the week-5 rate being 12.7% (p < 0.0001 vs any previous week). Decreases in duration of excessive pressure (i.e. > 2.5 N – 3.0 N depending on the handle) decreased the proportion of self-reported gingival bleeding (p < 0.0001). Users brushed longer and with less overpressure (p < 0.0001) with vs without live feedback from the app, and showed 94.4% average coverage with live feedback. Conclusion: The interactive oscillating-rotating electric toothbrushes and app, particularly with live feedback, promote good brushing behaviour. Self-reported gingival bleeding occurred less frequently the longer the system was used. Keywords: compliance, gum bleeding, in-market evaluation, interactive electric toothbrush

Purpose: To evaluate the use of hydrogen peroxide as an adjunct to ultrasonication (US) in biofilm removal and whether it can limit the spread of viable microorganisms in the aerosol. Materials and Methods: Multi-species biofilms were formed on dentin disks and titanium disks fixed on a plastic surface. After placing the specimens in a periodontal pocket model, an ultrasonic scaler was applied for 30 s, in part combined with 0.25% or 0.5% H2O2. After treatment, the remaining biofilm was analysed for bacterial counts (colony forming units [CFU]), biofilm quantity and metabolic activity. Further, the cytotoxic effect of hydrogen peroxide on periodontal ligament fibroblasts was assessed and the spread of bacteria in aerosol was quantified. Results: Ultrasonication reduced bacterial counts in biofilm, biofilm mass and metabolic activity on both dentin and titanium disks. Adjunctive use of 0.25% and 0.5% H2O2 more effectively reduced the viable bacteria in biofilm than ultrasonication alone; this was also found on both dentin and titanium. The different concentrations of H2O2 did not lead to corresponding differences in bacterial mass and metabolic activity. The spread of bacteria through aerosols was statistically significantly reduced when adjunctive H2O2 was used. However, a certain cytotoxic effect on periodontal ligament fibroblasts by H2O2 could not be ruled out. Conclusions: Irrigating with H2O2 during periodontal instrumentation with an ultrasonic scaler increases the reduction of viable bacteria within biofilms. It might limit bacterial spreading via aerosols. Keywords: aerosol, biofilm, hydrogen peroxide, periodontal therapy

Purpose: To compare the analgesic efficacy of orally administered Curcuma longa (curcumin) and mefenamic acid (MA) after surgical periodontal therapy (SPT). Materials and Methods: Seventy-six periodontitis patients were randomly divided into two groups. In the test group, patients received curcumin capsules (200 mg), and in the control group, patients received MA (500 mg). All patients underwent post-operative antibiotic therapy using 500 mg amoxicillin and 400 mg metronidazole for 7 days. Post-operative pain and discomfort were evaluated using the numerical rating scale (NRS) and verbal rating scale (VRS), respectively. Evaluation were performed after 24 (T1), 48 (T2), and 72 h (T3). Group comparisons were done using Student’s t-test and the Mann-Whitney U-test. The level of statistical significance was established at p < 0.05. Results: All patients had stage 3/grade C periodontitis. The mean age of individuals in the test and control groups were 58.4 ± 7.3 and 57.2 ± 5.2 years, respectively. A family history of periodontal diseases was reported by 37.5% and 47.4% individuals in the test and control groups, respectively. In the test and control groups, the total mean duration of periodontal surgery was 168.2 ± 12.2 and 173.4 ± 10.7 min, respectively. There was no statistically significant difference in the mean NRS and VRS scores among patients in the test and control groups. In both groups, there was no statistically significant difference in the change in NRS scores at any time point. Conclusions: Compared with MA, curcumin is ineffective for pain and discomfort management after SPT. The possibility of the results being biased due to lack of operator blinding cannot be overlooked. Keywords: curcumin, mefenamic acid, pain, periodontal flap surgery

Purpose: To reach a consensus on a consistent strategy to adopt when screening patients for the clinical management of dentin hypersensitivity. Materials and Methods: A panel consisting of members of the Advanced Technology in Oral Hygiene Sciences Academy (ATASIO) was formed to start a review process on dentin hypersensitivity (DH) and subsequently elaborate a decision tree to manage DH, from diagnosis to prognosis. The panel employed the RAND in their deliberations. After an initial systematic literature review, it became evident that a consensually validated protocol for the management of patients affected by dentin hypersensitivity has to be considered mandatory by all dental professionals. However, the outcome of the systematic review made it evident that the treatment options to be provided, as well as their prognosis and timing, had never been defined. The panel produced documents that addressed the topic and were subsequently used to generate a questionnaire. A workshop of expert dental professionals was organised to reach consensus on the main steps of the decision tree. Each member completed the questionnaire independently, and then a panel discussion was held to reach a consensus. Results: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated was answered. A clinical decision threshold was created. Conclusions: The dissemination of the information to a wide dental audience should commence upon publication of this consensus document. The authors hope that this consensus will become a model for the development of a dedicated protocol to manage DH. Keywords: consensus, dentin hypersensitivity, diagnosis, Italy, prognosis

Purpose: To evaluate the knowledge and practices of Swiss women regarding oral health during pregnancy. Materials and Methods: Self-reported questionnaires were attributed to 385 women from 4 public hospitals in the French speaking part of Switzerland from February 2015 to June 2016.The questionnaire consisted of 32 questions including demographic characteristics, oral health habits and awareness of oral changes during pregnancy. Results: The majority of women (64%) were in the 3rd trimester of pregnancy and had a university education (41%). Oral health was considered very important for half of the women (52%) and moderately important for 38% of them. 71% of the women did not notice any change concerning their oral health conditions. Of the remaining 29%, gingival bleeding was the main symptom reported, followed by gingival redness and oedema. Pain and sensitivity were also reported by a few participants. Most of the pregnant women attended dental appointments during their pregnancy, but not on a regular basis, mainly because of lack of time. Almost half of the population had an adequate oral hygiene routine and adapted their eating habits to a much healthier pattern during pregnancy. A large proportion of the participants (71%) was aware that pregnancy renders teeth and gums more vulnerable and that oral health is related to adverse pregnancy outcomes. However, this information was rarely imparted to them by health professionals. Conclusion: Although pregnant women in the French speaking part of Switzerland seem to be moderately informed about the importance of oral health during pregnancy, health-care professionals do not seem to participate actively. Health professionals need to more actively inform pregnant patients about the importance of preventive oral health measures and oral health care during pregnancy. Keywords: education, oral health, pregnancy, self-care

Purpose: To investigate inflammatory responses in peri-implant crevicular fluid (PICF) in comparison to periodontal tissue. Materials and Methods: Nineteen participants with healthy implants restored with titanium or gold-casting abutment were included. PICF and gingival crevicular fluid (GCF) were collected for inflammatory cytokine detection by ELISA. Cytokine levels in PICF or GCF of the same individual were compared using the paired t-test, and those from titanium or gold-casting (UCLA) abutment were compared using the independent t-test. Human gingival fibroblast responses to PICF and GCF were then evaluated with one-way ANOVA. Results: The results demonstrated that IL-6, IL-8, TNFα, and IFNγ expressed in PICF are similar to GCF in the same individual. However, IL-1β (p = 0.032) and IL-1α (p = 0.030) was statistically significantly higher in PICF than in GCF. IL-8 level was statistically significantly higher with gold-casting than with titanium abutments (p = 0.003). PICF statistically significantly stimulated higher expression of RANKL, IL-1β, IL-6, and IL-8 mRNA in human gingival fibroblasts (HGF), while focal adhesion kinase (FAK) suppressed mRNA. Conclusion: The inflammatory cytokines, including IL-1α and IL-1β, are higher in healthy peri-implant tissues. Abutment materials may also influence the level of inflammatory cytokines in PICF. Inflammatory mediators in crevicular fluid may affect HGF inflammatory responses and peri-implant tissue integration. Keywords: cytokines, fibroblast, gold alloy, inflammatory response, peri-implant fluid, titanium

Purpose: To determine acid-formation potential of saliva and evaluate whether this method corresponds with microbiome composition of individuals with and without caries. Materials and Methods: A clinical, controlled pilot study was performed with two groups: individuals without caries (n = 25; DMFT = 0) and individuals with at least one active carious lesion (n = 25; DMFT>0). A detailed intraoral examination was performed, and the gingival bleeding index (GBI) and plaque index (PI) were recorded. The acid-formation potential was measured (ΔpH) after 1 h. Streptococcus mutans (SM) and lactobacilli (LB) were also quantified. Intergroup comparisons were made using the Mann-Whitney U-test. The diagnostic value was evaluated using the receiver operating characteristics (ROC) method and area under the curve (AUC) values were calculated. The saliva microbiome was analysed by 16S rDNA next-generation sequencing. Results: A statistically significant difference was found in ΔpH, with the ‘caries’ group showing a higher mean value after 1 h (‘healthy’ = 1.1,’caries’ = 1.4; p = 0.035). The AUC values were moderate to good (ΔpH = 0.67; SM = 0.83; LB = 0.83;1 = ideal). Streptococcus mutans and Lactobacilli were more frequently detected in the ‘caries’ group (p < 0.001), as were statistically significantly higher GBI (p = 0.006) and PI (p = 0.001). The saliva microbiome had a higher α-diversity and greater richness in individuals with active caries. The incidence of the genera Alloprevotella, Prevotella, Campylobacter and Veillonella was statistically significantly higher in the ‘healthy’ group. The incidence of the genera Fretibacterium, Lactobacillus, and Leptotrichia, as well as the phyla Spirochaetes and Synergistetes, was statistically significantly higher in the ‘caries’ group. Conclusion: Further studies must be carried out to determine the extent to which both tests are suitable for predicting future caries development. Keywords: acid formation, bacterial tests, caries, oral microbiome, saliva

Purpose: A number of disinfectants and sanitisers are used in dentistry, and there are numerous commercial solutions available. Nonetheless, because each cleaning solution has its own set of indications and limits, there is no one-size-fits-all approach for processing all types of dental equipment. Functional water, such as electrolysed hypochlorite microbubbled water, efficiently eliminates and sterilises biofilms. The objective of the study was to evaluate whether ozonated water could be used to sterilise and disinfect dental-unit water pipelines (DUWP) that had been contaminated with micro-organisms, including Gram-positive and Gram-negative bacilli and cocci. Materials and Methods: Three different groups were formed: group A – ozonated water (Cantoosh); group B – 1% povidine iodine; and group C: conventional distilled water. Group A was the test group, group B the control group, and group C was the positive control group. The water sterilising system was replaced with the appropriate sterilising agent as per the allocated group classification, with 2 min of purging, so that the complete DUWP was filled with the water sterilising system. Samples were collected and analysed, along with a 2-min purge after 24 h, 7 days and 21 days, at the 3 outlet (OL) points: the 3-way syringe at the dental tray(OL1), the cup filler (OL2), and the 3-way syringe of the assistant zone (OL3). Repeated measures ANOVA was used to test for statistical significance between colony-forming units of control and experimental groups (p < 0.05). Results: The cup filler yielded higher counts than did the 3-way syringe at the dental tray (OL1) (6.40 and 8.05 on the log scale, respectively). A statistically significant difference in the CFUs was also observed between samples taken after 24 h vs 21 days between groups A, B and C. Conclusion: The findings showed that exposing DUWP tube systems to ozonated water for an extended length of time drastically lowered the number of microorganisms adhering to their surfaces. Keywords: biofilms, dental-unit water pipelines, disinfection, microbial contamination, ozonated water

Purpose: The intention of the study was to evaluate whether Sub-Saharan schoolteachers may play a key role in oral health promotion of primary schoolchildren, particularly in terms of prevention of HIV/AIDS-related oral health problems. Materials and Methods: The study examined the level of knowledge about oral disease and the prevention of HIV/AIDS oral lesions amongst schoolteachers of Tanzania and Burkina Faso, identified their sources of information, and evaluated their ability for HIV/AIDS intervention. A multi-centre cross-sectional study was implemented in the two Sub-Saharan African countries. Participants comprised primary school teachers selected by stratified cluster sampling: 261 teachers from Tanzania and 313 teachers from Burkina Faso. All participants completed a structured questionnaire prepared for self-administration. The questions were designed from a standardised questionnaire developed by the World Health Organization. Results: Most teachers knew about the principal causes of the major oral diseases and the means of disease prevention. Nearly all teachers (95.6%) were aware of HIV/AIDS and they knew (92.3%) a virus was the direct cause of AIDS. Teachers were well informed of the general symptoms of HIV/AIDS, although oral symptoms were mentioned less often. In all, 17.6% of schoolteachers reported that children suffering from HIV/AIDS were found in their classes and 10.3% of teachers were conscious of students receiving anti-retroviral therapy (ART). Knowledge about the disease seemed to reflect mass media as a source, while teacher colleagues and health personnel played a somewhat lesser role in communication. In total, 83.2% emphasised that they should teach children about HIV/AIDS and the mouth. Schoolteachers from Tanzania (70.5%) were more often engaged in classroom-based oral health education than were the Burkinabe teachers (53.9%). Conclusion: The study confirms that schoolteachers may be a relevant source in the fight against HIV/AIDS among children. However, they would benefit from interaction with health personnel. Keywords: HIV/AIDS oral lesions, oral disease prevention, schoolteachers, public health

Purpose: Fixed retainers have been advocated for the prevention of anterior mandibular crowding after orthodontic treatment. However, limited data is available to help clinicians choose a retention protocol that is acceptable in terms of stability, emergencies, and side effects in the long term. It was the aim of this study to assess survival and alignment stability of the 0.016” x 0.022” stainless steel wire compared to more common protocols. Materials and Methods: Three different mandibular fixed retention protocols were compared in 600 consecutive patients: 1. 0.0215” multistrand wire (MW) with separate curing of resin and composite; 2. 0.016” x 0.022” stainless-steel wire with simultaneous curing of resin and composite (SS1C); and 3. 0.016” x 0.022” stainless-steel wire with separate curing of resin and composite (SS2C). The hazard rate for detachment across wire groups was assessed with a Cox frailty model. Results: Incisor alignment was maintained with all retention wires. One incisor with unexpected torque change was observed in group MW. The average annual emergency rate was below 2% for all three protocols. Fewer emergency visits were found in patients with solid steel wires than with multistrand wires. Detachment of the wire is the most common cause of emergency visits with no difference between wire types. Multistrand wires were more often damaged than were solid steel wires. There was no evidence that direct application of the composite on the uncured primer influenced retainer adhesion to the enamel. Conclusions: The mandibular anterior teeth can be predictably stabilised with a 0.016” x 0.022” stainless steel wire. Keywords: adverse effects, bond failure, enamel adhesion, fixed retainers, relapse, retainer failure, retention, stability of orthodontic treatment

Purpose: To identify the gaps in the Jordanian population’s knowledge about oral cancer, screening and attitudes toward screening, in addition to determining the barriers to oral cancer screening. Materials and Methods: A cross-sectional web-based study was conducted. The first section of the questionnaire employed collected the participants’ sociodemographic data. A question about whether patients had heard about oral cancer was then included, and those who answered ‘no’ were instructed to submit the questionnaire. The subsequent parts evaluated the participants’ knowledge of oral cancer and screening, attitudes toward screening, and barriers against screening. ANOVA and chi-squared tests were conducted to investigate the sample characteristics associated with the participants’ unfamiliarity with oral cancer. Binary regression was conducted to predict the variables associated with the participants’ knowledge and attitudes. Results: The questionnaire was filled by 1307 participants (1011 females). Most of the participants (70.01%) stated that they had heard of oral cancer, and the variables associated with awareness of oral were sex, monthly income, health insurance coverage, working status, and educational level. Sources of information and age were significantly associated with knowledge and attitude levels. The most ‘agree/strongly agree’ responses about barriers were lack of knowledge and lack of awareness. Conclusion: The study participants had moderate knowledge about oral cancer and satisfactory attitudes toward screening. Nearly all barriers to screening can be overcome by the joint efforts of healthcare providers and health authorities. Keywords: attitudes, barriers, Jordan, knowledge, oral cancer, screening

Purpose: This cross-sectional observational study evaluated the frequency of dental erosion in 12-year-old schoolchildren in Hungary and its connection to gender, geographical region, eating/drinking habits, and to socioeconomic factors, such as the educational level of their mothers. Materials and Methods: 579 randomly selected children aged 12 (287 boys and 292 girls) were examined in our cross-sectional study from 14 different regions in Hungary. Clinical examinations were carried out by the same examiner, using the ‘Basic Erosive Wear Examination’ (BEWE) index. A self-administered questionnaire was filled in by each child, surveying their oral hygiene, nutritional habits and socioeconomic status. Results: 21.2% of the children showed dentitions with signs of erosion. We found statistically significantly higher BEWE scores in urban than in rural areas (p = 0.0058). There was no difference between genders. Among children drinking carbonated soft drinks once or more daily, the prevalence of BEWE score < 3 was statistically significantly lower than among those who consumed these kinds of beverages less frequently (83.6% vs 90%, respectively, p = 0.034). Children of mothers with a highschool diploma had a BEWE score ≥ 3 statistically significantly less frequently than those whose mothers had not graduated from highschool (8.4% vs 22.5%, respectively, p = 0.000). Conclusions: The prevalence of dental erosion among 12-year-old children in Hungary is not as high as reported previously in Western European countries. A positive correlation was observed between the consumption of carbonated soft drinks, the educational level of the mothers and the level of erosion. These factors statistically significantly affected the prevalence and severity of erosive dental lesions. Keywords: dental erosion, national survey, prevalence, risk factors, 12-year-old-children

Purpose: To compare the levels of salivary IGF-1, IGFBP-3, and CTX with periodontal status among patients belonging to various skeletal maturity groups. Materials and Methods: This cross-sectional study was conducted on 80 participants 6 to 25 years of age. Based on skeletal maturity, the participants were categorised into 3 different stages: prepubertal, pubertal, and post-pubertal stages. The periodontal status of the participants was assessed using the simplified oral hygiene index (OHI-S), bleeding on probing (BOP), probing pocket depth (PPD), clinical attachment loss (CAL), and community periodontal index (CPI). The saliva samples were examined for IGF-1, IGFBP-3, and CTX using the respective ELISA kits. One-way ANOVA was used to determine statistically significant differences of means across the study groups for continuous variables. Results: The study demonstrated statistically significant differences for the parameters OHI-S, bleeding on probing, PPD, CPI, and CAL (p < 0.05) depending on skeletal maturity stage. ANOVA test showed a statistically significant difference by stage in IGF-1, IGFPB3, and CTX (p < 0.01). Conclusion: An association exists between periodontal status and levels of salivary IGF-1, IGFBP-3, and CTX in patients belonging to various skeletal maturity groups. Keywords: C-terminal telopeptide region of type I collagen, IGF-binding protein-3, insulin-like growth factors, periodontitis, skeletal maturity

Purpose: Early childhood caries (ECC) and childhood obesity are among the most prevalent health conditions affecting children. ECC is associated with obesity through the common risk factor of sugar consumption. The present study aimed to assess the association between ECC and obesity in preschool children. Materials and Methods: A cross-sectional study was conducted among 1250 preschool children (698 girls, 552 boys; mean age: 4.3 [1.1] years). The children’s body mass index was determined (BMI: weight/height in kg/m2). The World Health Organization criteria were used for the diagnosis of caries. Multivariable logistic regression was used to analyse the relationship between ECC prevalence and childhood obesity. Results: ECC was detected in 929 (74.3%) children. The mean dmft and dmfs was 5.91 (1.13) and 8.92 (2.07), respectively. The multiple regression model showed a statistically significant association between ECC prevalence and obesity with an adjusted odds ratio (OR) of 2.59 (95% CI: 1.88 – 3.57; P = 0.001). The logistic regression model showed that in children with a monthly family income > $2666, sugar consumption, preterm low birth-weight/full-term low birth-weight (PTLBW/FTLBW), and toothbrushing frequency ≤ 1 time/day were statistically significantly associated with ECC prevalence. Conclusion: ECC was positively associated with obesity. Keywords: ECC, obesity, preschool, prevalence

Purpose: To evaluate the performance of sealing materials used in the screw-access holes of screw-retained implant final superstructures in vivo and in vitro. Materials and Methods: Twenty-one screw-access holes in the final superstructures were randomly divided into three groups (each group, n = 7). Following disinfection and isolation, all access holes were initially filled with sterilised cotton pellets of the same weight. Depending on the group, the access holes were finally sealed with either provisional composite restorations (group A), self-curing resin for provisional sealing (group B), or acrylic resin (group C). After one month of the functional period, the inner cotton pellets were collected as bacterial reservoirs. Results: Total aerobic bacteria and total gram-negative anaerobic bacteria were measured after bacterial culture for 48 h and 72 h, respectively. In vitro evaluation of porosity using scanning electron microscopy (SEM) was also performed. Samples from superstructures sealed with provisional composite restorations showed fewer bacteria and less porosity than samples from superstructures sealed with self-curing resin for provisional sealing and acrylic resin. In this study, provisional composite restorations showed the best sealing properties. Provisional composite restorations may prevent bacterial invasion of the access holes of the final superstructures. Conclusion: In this study, provisional composite restorations showed the best sealing properties. Provisional composite restorations may prevent bacterial invasion of the access holes of the final superstructures. Keywords: access hole, dental prosthesis, implant restoration, microbiological evaluation, prevention of peri-implantitis, sealing material, sealing properties

Purpose: To the assess whole salivary cotinine and interleukin 1β (IL-1β) levels among individuals involuntarily exposed to vapor from electronic nicotine delivery systems (ENDS) (test group) and unexposed individuals (control group). Materials and Methods: Demographic data and information related to ENDS vapor exposure were collected using a questionnaire. Unstimulated whole saliva samples were collected, unstimulated whole-saliva flow rate (UWSFR) was calculated, and cotinine and IL-1β levels were determined using enzyme-linked immunosorbent assay. Sample-size estimation and statistical analysis were performed. Regression analysis was performed to determine the correlation between whole salivary cotinine and IL-1β levels. Statistical significance was set at p < 0.05. Results: Forty-eight individuals (24 and 24 in test and control groups, respectively) were included. Mean ages of individuals in the test and control groups were comparable. In the test group, the mean duration for which the individuals inhaled vapor from ENDS in each session was 22.3 ± 9.5 min and they were exposed to ENDS vapor 12.2 ± 2.4 times daily. There was no difference in the UWSFR between patients in the test (0.21 ± 0.02 ml/min) and control (0.22 ± 0.04 ml/min) groups. Whole salivary cotinine (p < 0.001) and IL-1β (p < 0.001) levels were significantly higher in the test than control group. Conclusion: Young adults involuntarily exposed to vapor from ENDS express elevated whole salivary cotinine and IL-1β levels. Long-term exposure to ENDS vapor may potentially predispose vulnerable populations to oral and systemic inflammatory diseases. Keywords: cotinine, electronic nicotine delivery systems, interleukin 1 beta, unstimulated whole saliva, vaping

Purpose: Regenerative periodontal therapy using platelet-rich plasma (PRP) and bone substitutes with guided tissue regeneration (GTR) have been proposed as a therapeutic method to enhance the outcome of regenerative surgery. This includes light microscopic evaluation of retrieved ePTFE membranes to assess formation of new connective tissue attachment, and following the regeneration process. The objectives of this study were to evaluate the histological findings of retrieved ePTFE membranes using PRP and bone substitutes, the effect of PRP on graft materials, and the correlation of the findings with the clinical outcomes. Materials and Methods: Seventy-two (72) patients with chronic periodontitis, each of whom had one deep intrabony defect, were randomly included in two studies and treated using the same type of membrane and different bone substitutes. In the first study, 17 cases were treated with a natural bone mineral and a non-resorbable membrane (NBM + GTR), and 17 cases were treated with PRP + NBM + GTR. In the second study, 19 patients were treated with β-tricalcium phosphate and a non-resorbable membrane (β-TCP + GTR), and 19 patients were treated with PRP + β-TCP + GTR. In both studies, tissue integration of the retrieved ePTFE membranes and attached remnants were evaluated histologically. Results: Histological scores showed that membranes combined with NBM are better integrated than membranes combined with β-TCP; the difference between the two decreased with the addition of PRP. The application of PRP had no significant effect on the quality of membrane integration combined with NBM, whilst significantly improving the integration quality when combined with β-TCP. No correlations were detected between the histological scores and the clinical attachment level (CAL) gain in any of the groups. Conclusions: The present results indicate that: a) application of β-TCP and PRP may enhance membrane integration and periodontal healing, and b) histological examination of retrieved membranes may provide valuable additional information with regard to the clinical findings. Keywords: β-tricalcium phosphate, guided tissue regeneration, histological evaluation, natural bone mineral, platelet-rich plasma

Purpose: To analyse the epidemiological profile of dental caries in children aged 5 and 12 years in the city of Benguela, Angola. Materials and Methods: This was an observational, analytical, cross-sectional study conducted in 2019 with 190 12-year-old schoolchildren and 240 5-year-old schoolchildren from the public education system in Benguela, Angola. The relationship between dental caries and dental characteristics, sociodemographic factors, access to dental services, oral hygiene practices, and eating habits was analysed. Dental condition was evaluated using the dmft and decayed, missing, and filled teeth (DMFT) indices. Results: It was found that 62.63% (n = 119) of 12-year-old students and 42.08% (n = 101) of 5-year-old students were free from dental caries. The average DMFT was 0.76 + 1.35 and dmft was 2.19 + 2.95. The majority of children (56.51%) had never been to the dentist, had no dental elements restored, and none of the students used dental floss. The proportion of students who consumed sweets every day was higher at 5 years of age (46.25%) than at 12 years of age (22.63%). There was a statistically significant association (P = 0.01) between the higher incidence of dental caries and peri-urban location among 5-year-old schoolchildren. Conclusion: This study showed that the prevalence of dental caries in the permanent dentition of schoolchildren in Benguela is very low; however, the situation is critical in the primary dentition, especially in the peri-urban area. The limited access to dental surgeons and lack of treatment for affected teeth highlight the need to implement and develop public policies to promote oral health. Keywords: dental caries, child, Angola, health services accessibility

Summary: The Minamata Convention resulted in restrictions in the use of amalgam in daily dental practice. This opens up new discussions about the biocompatibility of amalgam, but also of composites as alternative materials. In the following review article, these issues will be discussed in more detail to provide dentists with a knowledge base for themselves and for communication with their patients. In addition to mercury in amalgam or monomers in composites, bisphenol A and nanoparticles generated during the grinding, polishing or removal of restorations must also be included in the biocompatibility evaluation. In laboratory tests, these substances cause toxic reactions, and bisphenol A also exhibits estrogen-like effects. However, it must be taken into account that the concentrations used in laboratory tests are much higher than in clinical practice. Thus, both amalgam and composite can be used in the general population. Nevertheless, for scientifically, politically and legally defined risk groups (e.g. dental personnel, allergic persons, pregnant or lactating women, children under 15 years of age, people with certain systemic diseases), indication restrictions and precautionary measures must be observed. The well-known amalgam discussion has taught us the importance of thorough and open risk communication with the patient. Keywords: bisphenol-A, child, lactation, mercury, pregnancy

Purpose: This study analysed the relationship between caregiver-related factors (dental knowledge, attitude, behaviour, and health status) and early childhood caries. It aimed to explore better intervention methods for reducing caries prevalence in preschool children. Materials and Methods: This cross-sectional investigation was carried out in Zhejiang, China. A total of 1344 guardians (parents and grandparents) paired with their children aged 3–5 years old were enrolled. The guardians completed structured questionnaires, which included their attitude, knowledge level and oral health status. The children received dental examinations. All of the data were analysed with R software. Chi-squared and Fisher’s exact tests were used to analyse different variables. Multinomial logistic regression with stepwise procedures and curve fitting was used to explore the relationship between guardians’ risk factors and the level of early childhood caries. Results: Guardians have a great influence on the incidence of early childhood dental caries. When guardians pay attention to oral health and have a good command of relevant knowledge, then the risk of early dental caries in children is low (p = 0.027). The guardians’ dental problems, e.g. dental caries (p = 0.0002), gingival bleeding problems (p = 0.049) and chewing discomfort experience (p = 0.049), demonstrated statistically significant correlations with early childhood caries levels. Conclusion: Guardians’ attitudes, knowledge, and oral health status had a statistically significant relationship with the level of early childhood caries in their children/grandchildren. Instead of instructing schoolchildren about oral health, multiple-level dental knowledge instruction of guardians is needed to prevent early childhood caries. Keywords: child health, dental caries, guardians, risk factors

Purpose: To investigate the anti-caries effects of the school-based fluoride varnish (FV) application at 3-month intervals and weekly fluoride mouthrinsing (FMR) on primary teeth and to evaluate the anti-microbial effects of FV or FMR on cariogenic bacteria among Myanmar children. Materials and Methods: A 6-month interventional study was conducted on 234 schoolchildren who were divided into three groups: group A received FV application at 3-month intervals, group B received weekly FMR, and group C received no fluoride application. A clinical oral examination and caries risk tests were performed at baseline and the 6-month follow-up. Results: Caries prevalence and the debris score did not change statistically significantly from baseline to the 6-month follow-up in all groups, whereas the dmfs score statistically significantly increased in group C (p = 0.001). The plaque and saliva scores of Dentocult SM statistically significantly decreased in group A (p = 0.049 and p = 0.006), but those scores statistically significantly increased in group C (p = 0.001 and p = 0.014) after six months. On the other hand, no statistically significant changes were observed in group B. Although the Cariostat scores decreased from baseline to the 6-month follow-up in group A and group B, but increased in group C, no statistically significant differences were observed in any of the groups. Conclusion: Better anti-microbial effects were obtained for children who received FV application than for those who received FMR, but no statistically significant difference existed between the anti-caries effects of these two approaches. Keywords: caries experience, caries risk tests, fluoride mouthrinse, fluoride varnish.

Purpose: Recently, increasing attention has been paid to the function of long non-coding RNAs (lncRNAs) in osteogenic differentiation (OD) of dental pulp stem cells (DPSCs). LINC01133 was reported to have a close relationship with tumorigenesis for multiple cancers, but no study has yet explored the role of LINC01133 in modulating OD of DPSCs. Materials and Methods: Alizarin red S (ARS) staining and alkaline phosphatase (ALP) staining were perfomed to assess the OD potential of DPSCs. Osteogenic markers including runt-related transcription factor 2 (RUNX2), osterix (OSX) and ALP expression levels in DPSCs were monitored by qRT-PCR and Western blot before and after cell transfection. Luciferase reporter gene assay detected the relationship between LINC01133 and miR-199b-5p. Results: The expression of LINC01133 was low, while miR-199b-5p was increasingly expressed during OD of DPSCs. Overexpression of LINC01133 in DPSCs resulted in decreased expression of RUNX2, OSX, ALP, DSPP and DMP1, whose expression was reversed in DPSCs after transfections of miR-199b-5p overexpression. Co-transfection of pcDNA3.1-LINC01133 and miR-199b-5p mimic led to elevated expression of RUNX2, OSX, ALP, DSPP and DMP1 compared with pcDNA3.1-LINC01133 transfection alone. LINC01133 served as a sponge of miR-199b-5p. AKT3 was verified as a downstream effector of miR-199b-5p in DPSCs. Conclusion: LINC01133 inhibits the OD of DPSCs by upregulating AKT3 via sponging miR-199b-5p, which may act as a potential diagnostic biomarker for dentin regeneration in the dental pulp. Keywords: AKT3, DPSCs, competitive endogenous RNA, LINC01133, miR-199b-5p, osteogenic differentiation

Purpose: The oral cavity is an important entry point for SARS-CoV-2 infection. This study tested whether four commercially available mouthrinses and dentifrices have in vitro virucidal activity against SARS-CoV-2 (≥4 log10 reduction in viral titer). Materials and Methods: One part of stock SARS-CoV-2 virus plus one part 0.3 g/l bovine serum albumin were mixed with eight parts of test product solution. After 30 s for the rinses, or 60 s for the dentifrices, the mixture was quenched in an appropriate neutralizer, serially diluted, and inoculated onto Vero E6 cells to determine viral titer. Triplicate runs were performed for each test condition with appropriate controls for test product cytotoxicity, viral interference, and neutralizer effectiveness. Test products included: 1.5% hydrogen peroxide (H2O2) rinse; 0.07% cetylpyridinium chloride (CPC) rinse; 0.454% stannous fluoride (SnF2) dentifrice A; and 0.454% SnF2 dentifrice B. Results: The 1.5% H2O2 rinse, 0.07% CPC rinse, SnF2 dentifrice A, and SnF2 dentifrice B all produced > 4 log10 reduction in SARS-CoV-2 titer. Conclusion: All four test products displayed potent virucidal activity in vitro. Clinical studies are warranted to determine what role, if any, these oral care products might play in preventing transmission of SARS-CoV-2 or in the management of patients currently diagnosed with COVID-19 illness. Keywords: COVID-19, dentifrice, mouthwash, SARS-CoV-2, virucide

Purpose: The effectiveness of using different laser therapy strategies in adjunct to scaling and root planing (SRP) for treatment of periodontitis remains unclear. This study compared the treatment outcome of SRP and its combination with Er:YAG laser and/or photobiomodulation on patients with severe periodontitis. Materials and Methods: A total of 50 patients were included, whose teeth were divided into 4 quadrants: 1. SRP+Er:YAG laser irradiation+photobiomodulation treatment; 2. SRP+Er:YAG laser irradiation treatment; 3. SRP+photobiomodulation treatment; 4. SRP treatment only. An Er:YAG laser at powers of 50 or 40 mJ and an Nd:YAG laser at 50 mJ were used. Patients were followed-up for 3 months. Periodontal clinical parameters (probing depth [PD], clinical attachment level [CAL], plaque index [PLI] and bleeding index [BI]), inflammation factors (melatonin and MMP-8 levels) and pain intensity were compared among the 4 quadrants. Results: The quadrant treated by SRP combined with Er:YAG laser irradiation and photobiomodulation had statistically significantly lower PD (p = 0.0081 at 1 month; p < 0.0001 at 3 months), CAL (p = 0.003), PLI (p = 0.0011) and BI levels (p = 0.005 at 1 month; p = 0.0236 at 3 months) compared with the other 3 quadrants. In addition, melatonin (p = 0.0006 at 1 month; p = 0.0002 at 3 months) and MMP-8 levels (p = 0.0012; only at 1 month) were also statistically significantly higher. Conclusion: Of the treatments tested here, SRP combined with Er:YAG laser irradiation and photobiomodulation had the best short-term outcome for severe periodontitis. Keywords: YAG laser, inflammation, laser therapy, periodontitis, photobiomodulation

Purpose: The role of developmental endothelial locus-1 (DEL-1) in Porphyromonas gingivalis (P. gingivalis)-induced periodontitis and the related molecular mechanisms are unclear. This study aimed to investigate the effect of DEL-1 on SH3 Domain Binding Protein 2 (SH3BP2) expression, and to explore the regulatory role of DEL-1 in periodontal inflammation. Materials and Methods: We constructed a P. gingivalis-induced rat experimental periodontitis model, and cultured P. gingivalis-stimulated THP-1 cells in vitro. THP-1 cell viability and cell cycle were examined by CCK-8 and flow cytometry. Rat gingival tissues were collected for hematoxylin-eosin staining. The expression of SH3BP2 and nicotinamide phosphoribosyltransferase (NAMPT) was examined using Western blot. Results: We found that the proliferation of P. gingivalis-infected THP-1 cells was increased by DEL-1. DEL-1 inhibited the expression of NAMPT and SH3BP2 in gingiva tissues of rats with periodontitis as well as in P. gingivalis-infected THP-1 cells. Conclusions: Overexpression of DEL-1 downregulated SH3BP2 expression and reduced gingival inflammation induced by P. gingivalis. DEL-1 presents some regulatory effects on gingival inflammation in a P. gingivalis-induced rat experimental periodontitis model, suggesting the therapeutic potential of DEL-1 in regulating periodontal inflammation. Keywords: developmental endothelial locus-1, periodontitis, Porphyromonas gingivalis, nicotinamide phosphoribosyl- transferase, SH3 domain binding protein 2

Purposes: The aim of this sytematic review was to evaluate the potential association of COVID-19 infection with oral health. Materials and Methods: Screening in different databases (PubMed/MEDLINE, Google Scholar, and Embase databases) was performed to identify relevant articles, focusing on the oral health of patients with COVID-19, and published up to November 2021. 5194 articles were identified, and 29 fulfilled the inclusion criteria. Results: Patients presenting more severe periodontal or dental diseases were at an increased risk of developing COVID-19 complications and being admitted to intensive care units. According to the included articles, U-shaped lingual papillitis and aphthous-like ulcers on the tongue are the most frequent lesions assessed in the oral cavity of COVID-19 patients, while xerostomia seems to be an early COVID-19 diagnostic symptom. Apart from the presence of the virus, the global lockdown had a detrimental impact on oral health. The occurrence of dental emergencies was augmented during this time due to the postponement of numerous non-emergency dental procedures. Conclusions: The presence of SARS-CoV-2 in periodontal tissues and salivary fractions may explain the presence of oral lesions during the infection. However, the virus’s direct or indirect effect on oral mucosa is unclear. It is important to consider that these manifestations might be attributed to underlying comorbidities, or co-existing or subsequent lesions produced by local irritants. Keywords: COVID-19, oral health, oral manifestation, periodontal diseases, SARS-CoV-2

Purpose: Cortisol levels (CL) in peri-implant sulcular fluid (PISF) samples in relation to type-2 diabetes mellitus (T2DM) and peri-implantitis remain unaddressed. It is hypothesised that PISF CL are higher in patients with type-2 diabetes and peri-implantitis than in healthy patients without and with peri-implantitis. The aim was to assess the PISF CL of peri-implantitis patients without and with T2DM. Materials and Methods: Peri-implantitis patients with T2DM (group 1), T2DM patients without peri-implantitis (group 2), non-diabetic patients with peri-implantitis (group 3) and non-diabetic patients without peri-implantitis (group 4) were included. Demographics were recorded; and patients’ medical and dental records were assessed. Peri-implant modified plaque-index (mPI), modified gingival index (mGI), and probing depth (PD) and crestal bone loss (CBL) were recorded. The PISF was collected and CL were determined. p < 0.01 was considered statistically significant. Results: Each of the four groups included 16 subjects (n = 64) with no difference in mean age. In groups 1 and 2, the mean duration of T2DM was 10.5 ± 0.8 and 10.6 ± 0.4 years, respectively. Mean HbA1c levels (p < 0.01) were higher and clinicoradiographic parameters (p < 0.001) were worse in group 1 than in the other groups. The median PISF volume and mean CL were higher in groups 1 (p < 0.01) and 3 (p < 0.01) than groups 2 and 4. There was a statistically significant correlation between PD and CL in group 3 (p < 0.001). Conclusion: Cortisol levels in the PISF are higher in T2DM and non-diabetic patients with peri-implantitis than in healthy individuals with and without peri-implantitis. Hyperglycemia did not influence peri-implant clinicoradiographic parameters and CL in the present patient population. Keywords: cortisol, dental implant, inflammation, peri-implantitis, unstimulated whole saliva

Purpose: The authors hypothesize that ginger (Zingiber officinale) tablets and non-steroidal anti-inflammatory drugs (NSAIDs) are effective in reducing postoperative self-rated pain and periodontal parameters (plaque index [PI], gingival index [GI], and probing depth [PD], clinical attachment loss [AL] and marginal bone loss) following non-surgical periodontal therapy (NSPT) in patients with periodontitis. The aim was to compare the postoperative analgesic and anti-inflammatory effectiveness of ginger tablets and NSAIDs as adjuncts to nonsurgical periodontal therapy for the management of periodontitis. Materials and Methods: Patients with periodontitis were included. All patients underwent NSPT. In groups 1 and 2, patients received postoperative ginger (400 mg) and non-steroidal anti-inflammatory drugs (400 mg), respectively. Demographic data were collected, and full-mouth periodontal parameters (PI, GI, PD and CAL) were evaluated at baseline and at 7, 14 and 21 days. Self-rated pain scores were assessed at baseline, and at 24 h, 3 and 7 days of follow-up. In both groups, self-rated pain was assessed pre- and postoperatively using the numeric rating scale (NRS). Power analysis was performed on data from a pilot investigation and group comparisons were done. Statistical significance was set at p < 0.01. Results: Baseline mean NRS scores in groups 1 and 2 were 4.19 ± 0.12 and 4.13 ± 0.08, respectively. All participants had stage II/grade B periodontitis. At baseline, self-rated pain scores were significantly higher among patients in groups 1 and 2 at 24 h (p < 0.01) and 3 days (p < 0.01) of follow-up. In groups 1 (p < 0.01) and 2 (p < 0.01), self-rated pain scores were significantly higher at 24 h compared with 3 days of follow-up. In both groups, there was a significant reduction in PI (p < 0.01), GI (p < 0.01) and PD (p < 0.01) at 7, 14 and 21 days of follow-up compared with baseline. Conclusion: Ginger and traditional NSAIDs are effective in reducing postoperative pain and inflammation following NSPT in patients with moderate periodontitis. Keywords: inflammation, interleukin 1-beta, periodontal disease, probing depth, soluble urokinase plasminogen activator receptor

Purpose: The aim of the present systematic review with meta-analysis was to investigate the clinical effectiveness of EMD (enamel matrix derivative) using a minimally invasive surgical technique (MIST) or flapless approach for the treatment of severe periodontal probing depths. Materials and Methods: A systematic review of the literature including searches in PubMed/Medline, Cochrane Library, Google Scholar, and Grey Literature databases as well as manual searches was performed on September 1st, 2021. Studies utilising EMD in a non-surgical or minimally invasive approach were included. The eligibility criteria comprised randomised controlled trials (RCTs) comparing minimally-invasive/flapless approaches with/without EMD for the treatment of probing depths >5 mm. Results: From 1525 initial articles, 7 RCTs were included and 12 case series discussed. Three studies investigated a MIST approach, whereas 3 studies utilised a flapless approach. One study compared EMD with either a MIST or a flapless approach. The RCTs included ranged from 19–49 patients with at least 6 months of follow-up. While 5 of the studies included smokers, patients smoking >20 cigarettes/day were excluded from the study. The meta-analysis revealed that EMD with MIST improved recession coverage (REC) and bone fill (BF) when compared to MIST without EMD. However, no difference in CAL or PD was observed between MIST + EMD vs MIST without EMD. No statistically significant advantage was found for employing the EMD via the flapless approach. Conclusions: Implementing EMD in MIST procedures displayed statistically significant improvement in REC and BF when compared to MIST alone. These findings suggest that MIST in combination with EMD led to improved clinical outcomes while EMD employed in nonsurgical flapless therapy yielded no clinical benefits when compared to nonsurgical therapy alone without EMD. More research is needed to substantiate these findings. Keywords: EMD, enamel matrix derivative, enamel matrix proteins, intrabony defect, minimally invasive surgery

Purpose: To determine the possibility of screening for the risk for Obstructive Sleep Apnea (OSA) in periodontitis patients. Materials and Methods: Periodontitis patients and non-periodontitis controls were recruited and asked to complete a validated screening questionnaire to calculate individual probabilities (%) of OSA. Also, for both groups, the risk for OSA was classified as low, medium and high. Results: Seventy periodontitis patients (49% male) and 77 controls (60% male) were included and both had an average age of 54 years. There was no statistically significant difference in the probability of the risk of OSA between periodontitis patients and controls, 38.6% ± 29.7%, and 34.2% ± 23.3%, respectively (p = 0.31). After sub-grouping individuals in “not high risk” (low plus intermediate) and “high OSA risk” categories, we observed statistically significantly more periodontitis patients than controls in the “high risk” category for OSA (21% vs 9%, p = 0.041, OR 2.73 [95% CI = 1.04 – 7.15]). Conclusion: These findings suggest that screening for OSA among periodontitis patients may help in early recognition of a “high risk” of OSA, but further research is needed. Keywords: immune disorders, obstructive sleep apnea, obstructive sleep apnea syndrome, periodontitis

Purpose: This randomized, controlled clinical trial aimed to evaluate the clinical, adjunctive effects of an approved botanical barrier device or patch on probing parameters in patients with periodontitis. Materials and Methods: Eighty patients with periodontitis were recruited for this single-blinded trial. Patient demographic data, including gender, age, self-reported smoking status, and history of diabetes or cardiovascular disease, were collected. At baseline, all patients received a full-mouth probing examination followed by scaling and root planing (SRP). Thereafter, patients were randomized to receive either adjunctive botanical patch applications (i.e. at 2–4 treatment sites with baseline pocket depth PD ≥6 mm) or no additional therapy (SRP alone, control). Patients applied botanical patch devices per randomization to treatment sites three times on day 0 and once daily on days 1–6. Study devices were spontaneously shed or removed by the patient at 2–2.5 h after each application. Patients were recalled for probing reexaminations at 1, 2 and 3 months. Statistical analyses focused on intergroup differences in probing parameters and included ANOVA for baseline measures and ANCOVA controlling for baseline measures at 1, 2 and 3 months in the overall population and in subpopulations (e.g. smokers vs nonsmokers). Results: Randomized patient groups were balanced with respect to baseline periodontal status (mean and extent PD) but not smoking, with statistically significantly more smokers clustering in the control group (p = 0.002). For the overall population and the non-smoking subpopulation, statistically significantly improved PD and clinical attachment levels (CAL) were observed with adjunctive botanical patch therapy vs control at 1 and 2 months (p < 0.05) but not 3 months (p = 0.08 for PD). For smokers, no statistically significant intergroup differences in PD or CAL were detected with botanical patch treatment. Conclusions: The data from this trial indicate short-term improvements in probing parameters with the botanical patch device when used adjunctively with SRP, especially with non-smoking periodontitis patients. Keywords: botanical, clinical trial, inflammation, periodontal disease, periodontitis

Purpose: Pulpitis is a common disease in stomatology, which is caused by dental pulp infection. It was found that long non-coding RNA regulates inflammation and repair responses through competitively sponging microRNAs. This study explored the expression and clinical significance of PVT1 in pulpitis patients, and further investigated the possible regulatory mechanism of PVT1 on pulpitis through in-vitro experiments. Materials and Methods: The expression of PVT1 and miR-128-3p was detected through RT-qPCR. An ROC curve was drawn to estimate the diagnostic significance of PVT1 and miR-128-3p for pulpitis. An in-vitro pulpitis cell model was constructed to evaluate the effects of PVT1 or miR-128-3p on cell proliferation, apoptosis, and inflammatory response. The Luciferase reporter gene explored the interaction between PVT1 and miR-128-3p. Results: The expression of PVT1 increased, while the miR-128-3p level decreased, in the saliva of pulpitis patients. ROC curves showed that both PVT1 and miR-128-3p had the potential to diagnose pulpitis. This in-vitro study revealed that the expression of PVT1 was increased in the pulpitis cell model. A low level of PVT1 suppressed the hDPCs injury induced by LPS. The Luciferase reporter gene verified the targeting relationship between PVT1 and miR-128-3p, and the latter was negatively regulated by PVT1. Further in-vitro studies showed that inhibition of miR-128-3p could reverse the effect of si-PVT1 on cell viability, cell apoptosis and inflammatory response. Conclusion: This study revealed that knockdown of PVT1 may suppress the damage in pulpitis cell models induced by LPS via targeting miR-128-3p. Keywords: LPS, miR-128-3p, pulpitis, PVT1

Purpose: Conservative restorations of endodontically treated premolars have yielded mixed results. The present study aimed to compare fracture resistance of endodontically treated premolars with Class II mesial-occlusal cavity preparations, restored with either Smart Dentin Replacement (SDR; Dentsply Sirona) material, Biodentine (Septodont) or ceramic inlays. Materials and Methods: Thirty-two extracted premolars were randomly divided into four equal groups (n = 8): Group 1 served as a control group with teeth left intact; teeth in the remaining three groups received root canal treatment followed by a mesio-occlusal cavity preparation. These crowns were restored with: Biodentine in group 2, SDR in group 3 and ceramic inlays in group 4. A computer-controlled Instron universal testing machine subjected all specimens to compressive load until failure. Force at failure and fracture mode (above or below the cementoenamel junction) were recorded. The data were analysed using Fisher’s exact test and one-way ANOVA followed by the post-hoc Tukey’s test. Statistical significance was set at p < 0.05. Results: The lowest mean load at failure was recorded for the inlay group. Loads at failure were statistically significantly higher for teeth restored with Biodentine than with SDR (p = 0.012) and ceramic inlays (p = 0.007). There were no statistically significant differences between the groups in terms of fracture mode (p = 0.440). Conclusion: Endodontically treated premolars with mesial-occlusal cavity preparation restored with Biodentine were more resistant to fracture than those restored with either SDR or ceramic inlays. Biodentine may prove a promising material to restore endodontically treated teeth with one missing proximal wall. Keywords: Biodentine, endodontically treated teeth, fracture resistance, restoration, Smart dentin replacement

Purpose: To summarise the available data on the effects of chlorhexidine (CHX) mouthwash in treating gingivitis during treatment with fixed orthodontic appliances. Materials and Methods: Multiple electronic databases were searched up to December 7th, 2021. Only randomised controlled trials (RCTs) were eligible for inclusion. The quality of the included RCTs was assessed with the Cochrane risk of bias tool for randomised trials (RoB 2.0). After data extraction and risk of bias assessment, differences were recorded in several oral hygiene indices in time and mean percentage change in those indices using different antimicrobial solutions. Results: Fourteen studies were deemed eligible for inclusion, reporting on a total of 602 patients with an age range of 11–35 years. The experimental solution was a 0.06%, 0.12%, or 0.2% CHX mouthwash with the control either a placebo mouthwash or a selection from a variety of mouthwashes. Treatment duration varied from 1 day to almost 5 months and the follow-up period varied from 1 min to 5 months. Chlorhexidine mouthrinses led to reduced plaque accumulation and gingival inflammation during orthodontic treatment, while at the same time, some of the control group mouthrinses were deemed equally effective. No statistically significant difference was detected in the meta-analysis between CHX and mouthwashes with propolis/probiotics/herbs in terms of the gingival index at 3 to 4 weeks (mean difference 0.07, 95% CI: -0.18, 0.31, p = 0.59). Conclusion: Chlorhexidine mouthwash in orthodontic patients successfully controls gingival inflammation and bleeding when compared to untreated controls, but is equally effective as other mouthrinses where various oral health indices are concerned. Keywords: chlorexidine mouthwash, gingivitis, orthodontic treatment

Purpose: Current discoveries imply a connection between periodontitis and metabolic associated fatty liver disease (MAFLD). This study aimed to determine the prevalence of periodontitis and MAFLD in obese patients with BMI >40, employing the most reliable diagnostic methods, namely liver biopsy, and detailed periodontal examination. Materials and Methods: Liver biopsy and periodontal examination were performed in 30 obese patients with BMI BMI >40 undergoing bariatric surgery. Kleiner’s classification was used to determine non-alcoholic steatohepatitis (NAS) activity score, non-alcoholic steatohepatitis (NASH) and liver fibrosis. The periodontal condition was classified following the recent AAP/EFP classification. Patients were divided into periodontitis (PG) and non-periodontitis groups (NPG). Data on systemic health parameters were collected from patients’ medical records. Descriptive statistics and simple statistical tests were used to determine the differences between the two groups. Results: The prevalence of NASH in the sample was 43% (13/30), borderline NASH 37% (11/30), while fibrosis stage 1 was most common (72%, [22/30]). Periodontitis prevalence was 67% (20/30), while all non-periodontitis patients (33%; 10/30) exhibited gingivitis. PG and NPG did not differ in NAS or NASH prevalence (p > 0.05). However, the periodontitis group showed higher C-reactive protein levels, while NPG showed higher gamma-glutamyl transpeptidase levels (p < 0.05). Conclusion: The study results suggest the considerable prevalence of MAFLD, periodontitis and gingivitis in obese patients with BMI >40 undergoing bariatric surgery. Patients with periodontitis had higher CRP levels, while those with gingivitis presented higher gamma-glutamyl transpeptidase levels. Keywords: gingivitis, liver biopsy, metabolic associated fatty liver disease, periodontitis, risk factor

Purpose: To clinically assess the effects of a mouthwash containing an extract of Sambucus williamsii var. coreana, a natural ingredient, on halitosis and halitosis-causing bacteria. Materials and Methods: This randomised, double-blind, placebo-controlled study included 77 participants. The experiment was conducted at Misoplant Dental Clinic in Busan, South Korea. Participants were divided into two groups: a control group consisting of 38 participants, to who whom a saline gargle was administered 1x/day for 30 s, and an experimental group consisting of 39 participants, who used a mouthwash containing Sambucus williamsii var. coreana extract 1x/day for 30 s for 1 day or 5 days. Halitosis was measured for 30 s in the absence of brushing or moisture. A sterile #15 paper point was placed in the gingival sulcus for 10 s, after which it was analysed using the polymerase chain reaction (PCR) method. The measurement time points were defined as follows: ‘baseline’: before starting the gargling routine; ‘1 day of treatment’: immediately after gargling once on day 1; ‘5 days of treatment ’: after gargling once a day for 5 days. Clinical results were statistically analysed using SPSS 24.0 for Windows. Results: Compared to the control group, halitosis clearly decreased in the experimental groups ‘5 days of treatment’ and ‘1 day of treatment’ (p < 0.05). There were statistically significant differences in the levels of halitosis-causing bacteria between the two groups; bacterial concentration in the experimental group decreased statistically significantly from day 1 to day 5 day of gargling with Sambucus williamsii var. coreana extract (p < 0.05). Accordingly, we clinically verified that Sambucus williamsii var. coreana has antibacterial effects against oral bacteria. Conclusion: The application of Sambucus williamsii var. coreana extracts effectively reduced halitosis and halitosis-causing bacteria. Therefore, mouthwashes containing Sambucus williamsii var. coreana extract can be used as an effective substitute for chemical formulations for treating halitosis. Keywords: halitosis, mouthwash, oral health promotion, Sambucus williamsii var. coreana extract

Purpose: To examine the association between the intake of various nutrients (phosphorus, riboflavin, thiamine, niacin, vitamin C, calcium, protein, carbohydrates, and fat) and the prevalence of periodontal disease in Korean adults. Materials and Methods: The data used for analysis were obtained from the 7th Korea National Health and Nutrition Examination Survey (2016–2018). Data from 12,689 adults aged ≥ 19 years who had a periodontal examination were analysed. Data were analysed using the Chi2 and t-tests. Multiple regression analysis was used to assess the association between the selected nutrients and periodontal diseases. Results: After adjusting for sex, age, income, body mass index, diabetes, smoking, alcohol consumption, and toothbrushing frequency, a statistically significant relationship between phosphorus, carbohydrate, and fat intake and the risk of periodontal disease was identified by multiple logistic regression analysis (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.66–0.97; OR: 0.85, 95% CI: 0.70–0.98, OR: 1.41, 95% CI: 1.13–1.75, respectively). Conclusion: Phosphorus, carbohydrates and fat were associated with periodontal disease. Therefore, the improvement of diet should be emphasised to prevent and manage periodontal disease. Further research is needed based on various nutrients related to periodontal disease in the future. Keywords: Korea National Health and Nutrition Examination Survey (KNHANES), nutrients, oral health, periodontal disease

Purpose: To present updated information on odontogenic keratocyst (OKC) classification, etiology, genetic and molecular alterations, epidemiology, clinical presentation, radiographic characteristics, histological and immune histochemical features, differential diagnosis, treatment, and controversies, as well as a literature review of case frequencies in different countries. Materials and Methods: Studies were selected using the key words ‘odontogenic keratocyst,’ ‘odontogenic cysts,’ ‘odontogenic keratocyst and clinical study’. Full-text papers were reviewed on the basis of the inclusion and exclusion criteria. The literature search aimed to find articles that would show the frequency of OKC, dentigerous cyst, radicular cyst, and other cysts. Results: OKC presents local aggression and high recurrence; therefore, a better understanding of its clinical characteristics and the genetic and molecular factors involved in this peculiar and controversial lesion is required. It is always essential to discuss treatment alternatives. Although OKC is an entity with a high recurrence, aggressive treatment is not advisable in all cases because factors such as commitment to anatomical structures and possible complications should be considered. However, periodic radiographic controls are advised. Conclusion: To reduce the high number of present cases worldwide, it is important to improve knowledge on this pathology so that accurate diagnoses can be achieved and appropriate treatment can be provided. OKC presents local aggression and high recurrence; therefore, a better understanding is needed of the clinical characteristics and genetic and molecular factors involved in OKC. Furthermore, it is always essential to discuss treatment alternatives. Keywords: keratocysts, odontogenic cyst, review literature

Purpose: This study compared the success of dental students with flipped classroom and traditional classroom learning in the restorative dentistry course for the first time at the Faculty of Dentistry of Reims during the 2019- 2020 academic year, influenced by the Covid-19 pandemic, and analysed the correlation with students’ feelings. The use of an active learning method can improve success during final exams and increase the motivation of students. Materials and Methods: The same teacher taught half of the restorative dentistry course in the flipped classroom approach and the other half as traditional classroom. For the flipped classroom, students were required to complete their homework online before the face-to-face sessions. An exam at the beginning and the end of the semester was conducted with questions about concepts learned with each learning method. Statistical analysis was performed using a t-test at the 0.05 significance level. A questionnaire on satisfaction was conducted to determine the students’ opinion on this new learning method in the flipped classroom compared to the traditional classroom. Results: The flipped classroom learning method enabled students to achieve better results on the final exam, with a statistically significant difference compared to traditional classroom learning. Student responses to the satisfaction questionnaire showed an increase in motivation and interest in the lessons and correspond to the increase in exam success. Conclusion: The use of the flipped classroom for lower cognitive-level activities is more appreciated by students and yields better results than knowledge acquisition in the traditional classroom. Keywords: Covid-19, flipped classroom, lower cognitive level, restorative dentistry

Purpose: Oral submucous fibrosis (OSF) is a common chronic condition with poor prognosis, and existing therapies for OSF are limited in effectiveness. This study was designed to explore the role of miR-497 in arecoline (AR)-induced OSF. Materials and Methods: After miR-497 was silenced or overexpressed in buccal mucosa fibroblasts (BMFs), different concentrations of AR (5–200 μg/ml) were applied to incubate BMFs, and 50 μg/ml of AR was chosen for subsequent experiments. Thereafter, collagen gel contraction assay was used to detect the contractile capacity of BMFs. Transwell assay and wound healing assay were applied to detect migration and invasiveness of the cells. In addition, immunofluorescence staining, qRT-PCR and western blot were conducted to measure the expression of miR-497, collagen I and α-SMA, as well as the phosphorylation of Smad2 and Smad3. Results: After successful inhibition or overexpression of miR-497 in AR-induced BMFs, the results showed that miR- 497 inhibition suppressed the contractility, migration and invasiveness of AR-induced BMFs, whereas overexpression of miR-497 produced the opposite. In addition, miR-497 inhibition down-regulated the expression level of collagen I and α-SMA in AR-exposed BMFs. Furthermore, TGF-β1 expression, Smad2 and Smad3 phosphorylation were also repressed in AR-induced BMFs after miR-497 inhibition. Correspondingly, overexpression of miR-497 reversed the expression of the aforementioned proteins. Conclusion: miR-497 inhibition may attenuate OSF by inhibiting myofibroblast transdifferentiation in BMFs via the TGF-β1/Smads signaling pathway, indicating that miR-497 might represent an underlying target for treating OSF. Keywords: buccal mucosal fibroblasts, miR-497, myofibroblast transdifferentiation, oral submucous fibrosis, TGF-β1/Smads signaling pathway

Purpose: To determine the prevalence of COVID-19 infection among dental professionals at an Academic Center in Madrid (Spain) at the beginning of the pandemic’s de-escalation phase. Materials and Methods: A cross-sectional study was designed. COVID-19 infection was determined by membrane-based immunoassay qualitative detection of IgG and IgM antibodies in human whole blood. Age, sex, race and professional qualification were recorded, as were symptoms compatible with COVID-19 infection whenever present. Data collected were analysed by means of descriptive and qualitative (X2) statistical analyses. Results: A total of 195 individuals were included (40 administrative professionals and 155 dentists). Seroprevalence at the end of the de-escalation phase was 20.0% among all the participants. The highest prevalence was found among the orthodontists (34.8%), followed by the paediatric dentists (28.6%) and oral surgeons (14.7%). Most subjects were positive for IgG and negative for IgM (79.5%). Conclusions: The seroprevalence of SARS-CoV-2 among dental professionals at the end of the de-escalation phase after the first wave of the pandemic was almost double the seroprevalence of the general population. Orthodontists had the highest rates of SARS-CoV-2 infection. Keywords: COVID-19, antibodies, seroprevalence, dental clinics, orthodontics.

Purpose: To investigate the effects and mechanisms of lemon essential oil products on dental caries prevention. Materials and Methods: Lemon essential oil microemulsions (LEOM) with concentrations of 1/8 minimum inhibitory concentration (MIC), 1/4 MIC, and 1/2 MIC were applied to S. mutans at concentrations of 0.2%, 1%, and 5% glucose, respectively. Changes in acid production capacity of S. mutans were measured based on changes in pH. The effect of the reductive coenzyme I oxidation method on LDH activity was examined. The effect of lemon essential oil microemulsion on the expression of the lactate dehydrogenase gene (ldh) was detected by a quantitative real-time polymerase chain reaction. Results: Lemon essential oil microemulsion at 1/2 MIC concentration reduced the environmental pH value at different glucose concentrations, compared to those observed in the control group (p 0.05). LDH activity of S. mutans was decreased at three subinhibitory concentrations of lemon essential oil microemulsions (p 0.05). The effect of lemon essential oil microemulsions on S. mutans LDH activity and bacterial acid production were positively correlated (r = 0.825, p 0.05). Lemon essential oil microemulsion at 1/2 MIC concentration downregulated the expression of the ldh gene of S. mutans at different glucose concentrations (p 0.05). In different glucose environments, lemon essential oil microemulsions at subminimum inhibitory concentrations can inhibit the acid production of S. mutans by reducing ldh expression and LDH activity in the glycolytic pathway, proving its anti-caries potential. Conclusions: LEOM can effectively prevent dental caries and maintain the microecological balance of the oral environment. Keywords: dental caries, lemon essential oil microemulsion, Streptococcus mutans, acid production, lactate dehydrogenase

Purpose: The aim of this study was to investigate the possible association between periodontitis and preterm birth in Ivory Coast. Materials and Methods: A cohort study including 446 volunteers (pregnant women) aged 15–50 years was performed in the Gynecology-Obstetrics Department of the University Hospital Center of Cocody-Abidjan in Ivory Coast. Socioeconomic and periodontal status was obtained during pregnancy. After delivery, obstetric data was collected. Periodontitis was diagnosed according to the new 2018 EFP/AAP classification of Periodontal and Peri-Implant Diseases and Conditions, as follows: a subject presenting with interdental CAL at two non-adjacent teeth or buccal/oral CAL ≥ 3 mm with pocketing > 3 mm was diagnosed with periodontitis. Any birth before the 37th week was considered a preterm birth (PTB). Results: The prevalence of periodontitis and preterm birth were 59.47% and 18.34%, respectively. Periodontitis was mainly stage 1. PTB was statistically significantly higher in pregnant women with periodontitis compared to women without periodontitis (p = 0.0002). Multivariate analysis showed that periodontitis was associated with PTB (p = 0.0002). Logistic regression showed that periodontitis is a risk factor for preterm birth (OR = 3.62; 95% CI: 1.80–7.31; p = 0.0003). Conclusion: The results of this study suggest that periodontitis is an additional risk factor for preterm birth in Ivory Coast. Keywords: adverse pregnancy outcomes, periodontal medicine, periodontitis, pregnancy, preterm birth

Purpose: This in-vitro study aimed to evaluate the effectiveness and acid resistance on dentin surfaces following the application of a linear-oscillating device (LOD) with a hydroxyapatite-based polishing fluid, Er:YAG laser or sodium fluoride (NaF) used alone or in combinations for desensitising purposes. Materials and Methods: Freshly extracted impacted third molars were used to obtain 120 specimens, all completely immersed in 1% citric acid for 5 min and divided randomly into 6 groups. Group I, with no treatment, served as the control; group II: Er:YAG laser (30 Hz, 60 mJ/pulse, 10 s); group III: NaF gel; group IV: LOD; groups V and VI: the combinations of NaF+Er:YAG and LOD+Er:YAG, respectively, were applied. Following these treatments, the effectiveness of each was evaluated in half of the specimens in each group (n = 10). The other half of the specimens (n = 10) served for acid-resistance testing. All evaluations were made on SEM photomicrographs. Results: The post-treatment tubule diameters and numbers were the lowest with LOD+Er:YAG, followed by NaF+Er:YAG, LOD, Er:YAG and NaF. Paired comparisons revealed LOD+Er:YAG to be the best treatment method (p 0.05). After 3 h of acid immersion, all treatments revealed significant increases (p 0.05) in both tubule number and diameter study between post-treatment and post-acid immersion values. The exception was LOD+Er:YAG. LOD+Er:YAG showed the highest resistance to acid challenge, presenting the lowest increase in tubular diameters and numbers followed by NaF+Er:YAG, LOD, Er:YAG and NaF. Conclusion: Combined LOD+Er:YAG treatment revealed the highest effectiveness and acid resistance. Further clinical studies are warranted to confirm these in-vitro results. Keywords: YAG laser, human dentin tubules, linear-oscillating device

Purpose: To investigate dentists’ work conditions, awareness, protective measures, economic effects and perceived stress during the first two waves of the COVID-19 pandemic. Materials and Methods: This cross-sectional survey was conducted among 126 dentists working in the Frenchspeaking part of Switzerland, in particular in the Cantons of Vaud and Geneva. Data consisted of the answers to 40 questions assessing the knowledge, attitudes, workload and mental condition of the dentists during the first 2 waves of the COVID-19 pandemic. Results: Swiss dentists received sufficient information about the COVID-19 pandemic and implemented protective measures. Differences were found between the 1st and the 2nd wave concerning the workload; during the first wave, the workload was low for the majority of dentists (60%), whereas during the second, it was moderate (53.4%) or high (41.3%). During both waves, the mental burden was also important, and was related mainly to financial issues and fear of infection. Conclusions: This survey reported that Swiss dentists were, in general, satisfied with the transmission of precise operating guidelines during the pandemic. However, a considerable psychological impact, mainly during the first wave, was revealed. With the implementation of proper strategic measures during the COVID-19 outbreak, dental practitioners will be prepared for future global health-care disruptions. Keywords: dentistry, COVID-19, questionnaire, awareness, protective measures, stress

Purpose: To explore the relationship between of self-reported health (SRH) and educational attainment with pastyear dental visits in older adults in México. Materials and Methods: For this cross-sectional study, data were derived from the Mexican Health and Aging Study 2018 (MHAS-2018), which used a nationally-representative sample of older adults (50 years or older) in Mexico (n = 14,085). Variables taken from the MHAS questionnaire included residence (rural/urban), years of education, SRH, multimorbidity, pain severity, and past-year dental visits. A logistic regression model was used to identify the association between the variables and past-year dental visits. Results: While the percentage of past-year dental visits reported was 39.8%, this number declined with age [OR=0.76, p < 0.001], with older adults living in rural areas 34% less likely to report past-year dental visits than older adults living in urban areas. Older adults with no formal education were 73% less likely (OR=0.27; p < 0.001) to report past-year dental visits than older adults ≥10 years education. Older adults with poor SRH were 32% less likely (OR=0.68; p < 0.001) to report past-year dental visits than older adults with good/very good/excellent SRH. Sex, degree of multimorbidity, and pain level ([OR=1.37; p < 0.001] [OR=1.37; p < 0.001] and [OR=1.17; p < 0.001]) were all found to be positively associated with past-year dental visits in the study population. Conclusion: The present study highlights the association between poor SRH, a low level of educational attainment, and less frequent past-year dental visits, as well as the finding that past-year dental visits declined with age in the older adults sampled. Keywords: educational status, multimorbidity, older adults, past-year dental visits, self-report

Purpose: The aim of this work is to evaluate the impact of prenatal vitamin D levels on oral health in offspring. Materials and Methods: The search was carried out in three databases: MEDLINE (PubMed), ResearchGate and Wiley Online Library. The inclusion criteria were randomised controlled trials and cohort studies published between June 16, 2017 and June 16, 2022, laboratory assessment of prenatal vitamin D status and evaluation of primary or mixed dentition for observation of dental caries and developmental defects of enamel. The risk of bias for randomised controlled trials was analysed according to the Cochrane risk-of-bias tool and Newcastle-Ottawa scale was used to assess risk of bias for cohort studies. Results: A total of 177 studies were identified, 11 were included in the data synthesis. Eight out of 11 studies were considered as high quality and the other 3 studies had moderate risk of bias. The synthesis of data revealed that the impact of prenatal vitamin D status on oral health in children is quite controversial and subsequent studies are necessary to examine whether vitamin D levels affect the risk of developing dental caries and enamel defects. Conclusion: The effect of prenatal vitamin D on oral health in offspring is not entirely clear. Since disturbances in dental hard tissues have a polyetiological origin, health specialists need to notify mothers about other possible risk factors and emphasise the importance of eating habits and individual oral hygiene in early childhood. Keywords: dental caries, developmental defects of enamel, pregnancy, vitamin D

Purpose: This study aimed to assess the efficacy of three techniques for preventing dental erosion and thereby identify effective methods. The three techniques were: 1) adding calcium to fermented milk (2% Ca and 0.5% Ca); 2) topical application of fluoride to the teeth before exposure to fermented milk (acidulated phosphate fluoride [APF] gel and 0.05% NaF); and 3) a combination of the two techniques (APF gel + 0.5% Ca, 0.05% NaF + 0.5% Ca). Materials and Methods: pH cycling was performed on bovine-tooth specimens alternately immersed in experimental solutions and artificial saliva. After treatment, the microhardness and roughness of the enamel surfaces were measured, and changes in the surface morphology were observed using atomic force microscope images. Results: Microhardness did not differ statistically significantly between the 2% Ca and mineral water (negative control) groups (2% Ca: 295.34 ± 11.50; mineral water group: 294.76 ± 10.67; p > 0.05). Surface roughness did not differ statistically significantly between the 2% Ca, 0.05% NaF + 0.5% Ca, and mineral water groups (2% Ca: 16.81 ± 7.23; 0.05% NaF + 0.5% Ca: 15.77 ± 2.86; mineral water group: 13.35 ± 5.53; p > 0.05). The surface morphology did not change in the mineral water and 2% Ca groups. Conclusion: Considering that 2% calcium is a high concentration, adding a low concentration of calcium to fermented milk and applying a low concentration of fluoride daily decreased the reduction of surface microhardness and reduced the increase in surface roughness without causing marked changes in surface morphology. This confirms that combining the two techniques is an effective strategy to prevent dental erosion in-vitro. Keywords: calcium, dental erosion, fermented milk, fluoride

Purpose: To explore the effects of oral health promotion management on the improvement of oral healthcare knowledge, attitudes, and behaviours in pregnant women. Materials and Methods: This randomised study included pregnant women in Shanghai (China) who were randomly assigned to receive oral-health promotion management (intervention group) or no interventions (control group). The primary outcome for this study was overall oral health. The secondary outcomes included oral health awareness and attitudes, oral health knowledge, oral healthcare behaviours, medical visits, and risk factors. The Fourth National Oral Health Questionnaire was self-administered in this study, and oral examinations included caries and periodontal status. Data consistency was assessed by the Kappa coefficient. Results: After intervention, periodontal outcomes in the intervention group had improved statistically significantly, and the proportion of those without periodontal diseases had statistically significantly increased to 14.4% (p 0.05). In the intervention group, statistically significant improvements were also observed in the number of active caries (p 0.001), number of filled teeth (p = 0.014), and community periodontal index (CPI) scores (p 0.001). Overall, after intervention, pregnant women demonstrated comprehension of the importance of children’s deciduous teeth, and their knowledge of the importance of good oral health had greatly improved. Further, oral healthcare habits in the intervention group also showed statistically significant improvement: 56.8% established the habit of cleaning the tongue every week (p 0.05) and 39.6% established the habit of regular oral examination (p 0.05). Conclusion: Oral healthcare education and promotion management for pregnant women can effectively improve their oral health, knowledge, attitudes, and behaviours of oral health care. Keywords: behaviour modification, intervention effect, oral health, pregnancy, women

Purpose: The aim of this review is to analyse the use of hyaluronic acid injection in the interdental space to reconstruct the papilla in animal models and humans. Materials and Methods: Electronic databases were searched up to May 2022, and additional hand searching was performed. The search strategy was implemented according to the PRISMA guidelines. The inclusion criteria were: studies written in English, studies using hyaluronic acid, in vivo studies, studies with a precise number of specimens, case series with ≥6 patients, and studies published after 2010. The risk of bias was assessed for each study that could be evaluated. Results: A total of 19 articles were selected and reviewed in this review. Due to the great heterogeneity of the protocols and materials, comparison between studies was not possible. However, using this technique, the studies found statistically significant improvements in most cases. The filling percentages ranged from 19% to 100%. Regarding patient satisfaction, the few studies that evaluated this parameter found statistically significant results with most patients willing to repeat the experience. Regarding side effects, only two studies reported them. Moreover, the procedure does not seem to be very painful. Conclusion: The results suggest that hyaluronic acid injections seem to be effective in reconstructing papillary volume. However, to date, too few clinical trials with a high level of proof have been conducted on this technique. Future studies will have to work on the size of the sample, the concentration of the product, the number of injections and the injection method. Keywords: gingival papilla, hyaluronic acid, periodontal plastic surgery, periodontitis

Purpose: To identify and assess any changes in the pulp tissue complex following orthodontic force application. Materials and Methods: Published and unpublished literature was searched in seven databases until 9 August 2022 for randomised controlled trials (RCTs) and prospective trials (nR-PCT). Representative key words included ‘pulp response’, ‘pulp tissue’, ‘orthodontic force’, and ‘tooth movement’. Study selection, data extraction, risk of bias and certainty of evidence assessment were conducted independently by two reviewers. Random effects meta-analyses with respective confidence intervals (95%CIs) were conducted where applicable. Results: A total of 363 records were screened, a final number of 24 articles were eligible for qualitative synthesis, while 8 of those contributed to meta-analyses. There was evidence that pulpal blood flow (PBF) decreased after 3 weeks of tooth movement compared to no force application (4 studies, mean difference: -1.68; 95% CI: -3.21, -0.15; p = 0.03). However, this was not the case after 6 months of treatment (p = 0.68). A rise in the activity of aspartate aminotransferase (AST) was detected after 7 days of treatment, but combining 2 studies, this was not statistically significant (p = 0.25). Other outcomes were assessed through single studies. Risk of bias was within the range of ‘some concerns/moderate to high/critical overall’, while certainty of evidence was low to very low according to GRADE. Conclusions: As a short-term effect, PBF decreased upon initiation of orthodontic force application, while enzymatic and peptide activity within the pulp was transiently affected. Further long-term evidence of improved quality and certainty is needed. Keywords: orthodontic force, meta-analysis, pulp tissue, systematic review

Purpose: To assess the level of health-related quality of life (HRQoL) and its predictors among individuals with dental conditions requiring treatment during the COVID-19 pandemic in Jordan, and to highlight COVID-19 impacts on these individuals’ mental health and dental care. Materials and Methods: A cross-sectional online-based survey was conducted. The study questionnaire was composed of items related to stress during COVID-19. Descriptive analyses were used to describe the study’s main outcome measures, and multiple variable regression analysis was conducted to identify the quality of life predictors. Results: Participants’ HRQoL mean scores as measured by SF-12 were 69.5 (± 19.3) for the physical component and 58.9 (± 21.1) for the mental component. Mean scores for depression, anxiety, and stress measured by DASS21 were 10.1, 7.8, and 11.7, respectively. The regression model showed depression (β = -0.76 [95%CI -0.92 to -0.59], p < 0.001), stress (β = -1.74 [95%CI -2.53 to -0.94], p < 0.001), and oral HRQoL (β = -1.25 [95%CI -1.95 to -0.55], p = 0.001) as statistically significant negative predictors for HRQoL. Finally, family income was identified as positive significant predictor for HRQoL (β = 2.51 [95%CI 0.06 to 4.95], p = 0.045). Conclusion: This study found that patients with dental issues had a low quality of life and a high level of mental health symptoms during COVID-19 in Jordan. Healthcare policymakers should consider the continuation of dental services when planning for similar emergencies in the future, particularly if accompanied by lockdowns. Keywords: corona virus, dental health care, pandemic, quarantine

Purpose: This in-vitro study deals with the question of whether the wear and tear of the manual toothbrush over a simulated timeframe up to 24 months has an effect on its cleaning performance. The purpose was to find indications as to whether and when a toothbrush needs to be replaced based on its cleaning performance. Materials and Methods: Models equipped with artificial teeth (coated with titanium dioxide) were brushed in-vitro using a brushing machine with clamped manual toothbrushes. The machine carried out even, horizontal brush strokes (120 brush strokes/min) for 1 min with a constant contact pressure of 2.5 N. The percentage of the area of titanium dioxide removed from the buccal, mesial and distal surfaces of the artificial teeth corresponded to the cleaning performance. The manual toothbrushes were used on bovine roots to simulate the wear and tear after 2, 4, 6, 12, 18, 24 months of use. The cleaning performance was re-evaluated after each simulated timepoint of wear. In addition, the brushes were photographed after each cycle.  Results: An increase in the in-vitro cleaning performance of the toothbrush was observed up to 6 months of wear compared to the starting point. After that, the cleaning performance decreased somewhat, but always remained above the initial cleaning performance. Conclusion: Based on the in-vitro cleaning performance after 24 months, the toothbrush would not have to be replaced. However, this in-vitro study cannot determine when a toothbrush should be replaced, because in-vivo it is also dependent on a variety of other factors such as fraying and microbial colonisation. Direct transfer of results from this study to everyday clinical practice is therefore difficult. Keywords: cleaning, performance, toothbrush, wear and tear

Purpose: To determine the salivary flow rate and subsequent dilution of toothpaste and assess the pH of oral fluids during toothbrushing with toothpastes of various pHs. Materials and Methods: The study was conducted as an in-vivo trial involving 30 healthy volunteers. The participants took part in a series of trials distributed over four appointments. After a screening check, in which the participants’ stimulated and unstimulated salivary flow rate and buffering capacities were determined, four test series involving toothbrushing were conducted. Participants brushed their teeth using a manual toothbrush for 2 min: once without toothpaste and three times using toothpastes of varying pHs. The salivary flow rate and subsequent dilution of the toothpaste was determined. Additionally, the pH of the collected oral fluid was analysed. Results: Brushing teeth with toothpaste caused a statistically significant increase in salivary flow rate (median/IQR in ml/min) (Elmex Kariesschutz 3.29/1.36, Colgate Total Original 3.23/1.08, Elmex Sensitive Professional 3.18/1.39) when compared to brushing teeth using a manual toothbrush without toothpaste (1.85/0.78) (p < 0.05). The variation in pH of the oral fluid samples was dictated primarily by the pH of the toothpaste used. Conclusion: The salivary flow rate when brushing using toothpaste was similar across all tested toothpastes, independent of pH, and had an average median of 3.23 ml/min. The dilution of 1 g of toothpaste during a standard toothbrushing procedure of 2 min is therefore approximately at a ratio of one part toothpaste to 6.5 parts saliva. Keywords: hydrogen ion concentration, saliva, salivary flow rate, toothbrushing, toothpastes

Purpose: To critically evaluate the periodontal parameters of patients receiving fixed labial and lingual orthodontic therapy. Materials and Methods: The current systematic review was registered at PROSPERO. Clinical studies comparing the periodontal parameters between fixed labial and lingual orthodontic treatment were searched up to June 2022 in four electronic databases, and unpublished literature was searched at ClinicalTrial.gov. The risk of bias of randomised controlled clinical trials (RCTs) and non-randomised clinical trials (n-RCTs) was assessed using the Cochrane risk-of-bias tool 2.0 and the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) assessment tool, respectively. The pooled periodontal parameters were calculated in random-effect meta-analyses. The confidence of evidence was assessed via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Eight studies involving 223 patients were included in the current study. The risk of bias was high for 2 RCTs and 3 n-RCTs, and moderate for 3 n-RCTs. Patients receiving fixed lingual orthodontic treatment showed a lower plaque index (MD = -0.14; 95%CI -0.27 to -0.02). No statistically significant difference was found in the bleeding on probing index (MD = 0.11; 95%CI -0.03 to 0.25), gingival index (MD = 0.02; 95%CI -0.06 to 0.11), and periodontal pocket depth ( MD = 0.06; 95%CI -0.16 to 0.27) between the two groups. The overall quality of the evidence was very low to low. Conclusion: The present study indicates no obvious difference in periodontal parameters between the fixed labial and lingual orthodontic systems, although the overall quality was very low to low. Further RCTs with standardised outcome measures are needed.   Keywords: meta-analysis, periodontal health, orthodontics, systematic review

Summary: Most available antiseptic solutions have strong antibacterial effects, but many also possess major cytotoxic effects on gingival fibroblasts, osteoblasts, osteoprogenitor cells, and/or epithelial cells. A novel VEGA Oral Care Recovery Kit (StellaLife) consisting of 16 active ingredients that are monographed in the Homeopathic Pharmacopeia of the United States (HPUS) has gained tremendous momentum as a replacement for more cytotoxic oral rinses such as chlorhexidine. While accumulating evidence has thus far supported its use, little of the gathered data have fully described the properties of the oral formulation. Therefore, the aim of the present review article was 3-fold. First, a biological characterization regarding the active ingredients found in StellaLife Recovery Kit including their biological properties was assessed in 4 predominant categories; 1) antimicrobial resistance, 2) accelerated wound healing, 3) pain management control, and 4) anti-cancer properties. The second aim of this review article was to assess both fundamental and clinical research to date comparing VEGA oral rinse (StellaLife) to the more commonly utilized CHX for differences regarding their effect on decreasing bacterial loads as well as cell viability, survival, proliferation, and expression of both regenerative cytokines and inflammatory markers. Lastly, clinical case examples are presented describing the use of StellaLife remedies in a variety of clinical situations. These include but are not limited to wisdom-tooth extraction, extraction site management, dental implants and ridge augmentation, soft-tissue grafting procedures, frenectomies, and also temporary relief of dry sockets, dry mouth, aphthous ulcers, mucositis, lichen planus, among others. In summary, findings from the present review article provide evidence from basic laboratory experiments that validate clinical studies supporting the use of the StellaLife oral rinse regarding its superior biocompatibility and wound healing properties when compared to common antiseptic solutions such as CHX. Keywords: antiseptic solution, cell viability, chlorhexidine, oral rinses, periodontal disease, StellaLife, wound healing

Purpose: To compare the effectiveness of two varieties of special needs toothbrushes in terms of dental plaque removal and bacterial contamination vs a conventional toothbrush in patients with Down syndrome. Materials and Methods: This single-blinded, two-group, randomised clinical trial included 16 patients diagnosed with Down syndrome (age 6–15 years) from various special needs centers located in the Jazan Province of Saudi Arabia. The patients were randomly allocated to two groups based on the type of special needs toothbrush provided (Collis Curve or superfine nano). The plaque and bleeding indices of the patients in both groups were measured at baseline (T0) and both groups were initially given a conventional toothbrush to use for four weeks. After this period, the plaque and bleeding indices were re-evaluated (T1). The patients were instructed to use the special needs toothbrush for 4 weeks, after which the periodontal indices were re-evaluated (T2). Microbial contamination on the bristles of the special needs brushes was evaluated at T2. Results: No notable changes in the mean plaque and bleeding indices were observed between the two groups at each visit; however, statistically significant reductions were noted between visits in both groups (p < 0.05). The CFU scores in cultures from the Collis Curve toothbrush bristles (1411.5 ± 541.1) were higher than those obtained from the superfine nano-toothbrush bristles (1118.3 ± 423.9), but without statistically significant differences. Conclusion: The findings indicate that the use of special needs toothbrushes can statistically significantly improve the gingival health status in individuals with Down syndrome in terms of both resolution of periodontal inflammation and reduction of plaque accumulation. Keywords: bleeding index, customised brush, Down syndrome, microbial contamination, plaque index, special needs toothbrush

Purpose: To analyse the effects of aloe vera on the treatment of oral ulcers. Materials and Methods: Relevant studies were identified from PubMed, Embase, ClinicalTrials.gov, SinoMed, Web of Science and Cochrane Library. Randomised controlled trials (RCTs) involving aloe vera (AV) in the treatment of oral ulcers were included. The data were extracted and pooled for meta-analysis to compare the clinical outcomes of patients with oral ulcers in terms of treatment effect, the size of ulcers, Visual Analogue Scale (VAS) for pain, and therapy duration. The standardised mean differences (SMD) with 95% confidence intervals (CI) were determined for the main outcomes, heterogeneity was analysed using the I² test, and the studies’ risk of bias was evaluating using the Cochrane risk of bias assessment tool. Results: The study included 9 trials with a total of 847 participants. Seven trials were included in the meta-analysis. The results indicated no statistically significant differences in pain scores as assessed by the VAS (I² = 95%, p = 0.89; SMD: -0.12, 95% CI: -1.84, 1.60) and size of ulcers (I² = 88%, p = 0.60; SMD: -0.29, 95% CI: -1.39, 0.81). Clinical efficacy of the aloe vera group was better compared to control group (I² = 89%, p = 0.007; RR: 2.25, 95% CI: 1.25, 4.06). Therapy duration was statistically significantly lower following AV gel application in two of the studies (I² = 0%, p < 0.001; SMD: -1.32, 95% CI: -1.84, -0.79). Considering the results in a systematic manner, AV accelerated tissue epithelialisation and the wound-healing process. Conclusion: Compared with other interventions, aloe vera has a better therapeutic effect and shorter healing time. It is comparable with other interventions in relieving pain and reducing ulcer size, but it has higher safety and almost no side effects. Keywords: Aloe vera, clinical therapeutic effect assessment, meta-analysis, randomised controlled trials (RCTs), treatment of oral ulcers

Purpose: To assess mandibular incisor inclination after leveling the curve of Spee (CoS) in patients treated with fixed appliances. Materials and Methods: This was a retrospective study, which included 80 consecutive patients with a mild CoS treated without extraction but with various biomechanical approaches. The depth of CoS was digitally measured on scanned plaster casts and mandibular incisor inclination was assessed with lateral cephalograms pre- and posttreatment. Patients were treated with 0.018”-slot edgewise fixed appliances and cinched back wires. Data were analyzed using linear regression modeling at 5%. Results: A total of 80 patients (40% female; mean age 13.8 years) were included with mean ANB = 4.4 ± 1.9°, mean SN/ML = 31.7 ± 4.7°, mean L1/ML = 95.0 ± 7.7°, and a mean depth of CoS = 1.1 ± 0.4 mm. The depth of CoS was leveled by -0.85 ± 0.39 mm to a post-treatment median of 0.18 mm (interquartile range = 0.09 to 0.35 mm). A small mandibular incisor proclination was observed through treatment (2.49 ± 9.1°), but this was not associated with the reduction in the depth of CoS (p > 0.05) and no statistically significant modifying effect from the different treatment mechanics was observed. Conclusion: Under the limitations of this study, leveling a mild CoS was not associated with mandibular incisor proclination during fixed-appliance treatment. Keywords: cephalometry, Curve of Spee, fixed appliances, mandibular incisors, proclination

Purpose: Several studies have demonstrated the role of periodontal disease as risk factor of adverse pregnancy outcomes, including preterm birth, low birthweight and pre-eclampsia. As such, midwives can play an essential role in prevention and early screening as the preferred intermediary of pregnant women. The purpose of this study was to assess the knowledge, training and daily practice habits of midwives to determine if they fulfill their role in oral health prevention. Materials and Methods: A questionnaire was sent by e-mail to practicing midwives and fifth-year midwifery students in the Brittany region of France. Data were collected online and descriptive data analyses were conducted. Results: A total of 192 practicing midwives and 13 students participated in the survey. The results showed that the majority of midwives were not familiar with the correlation between periodontal disease and adverse pregnancy outcomes and did not implement screening and prevention to a sufficient extent. Conclusion: The explanation for this lack of knowledge seems to come from the initial training, since the topic of oral health is almost never discussed during midwives’ studies. Most agreed they needed more training on periodontal disease and adverse pregnancy outcomes. Improving and integrating oral health education into the midwife academic curriculum can enhance midwives’ engagement in oral health. Keywords: adverse pregnancy, midwifery education, oral health, periodontal disease, pregnancy, prevention, outcomes

Purpose: To assess the acceptance of silver diamine fluoride (SDF) application on children’s teeth among parents and children in the United Arab Emirates (UAE). Materials and Methods: A pre-tested questionnaire and clinical photographs of SDF-treated teeth were employed to determine preferences among 370 parents for its use in managing dental caries in their children’s teeth. A similar number of children ages 4 to 8 years were also interviewed, and their reaction to SDF was assessed through a facial image scale after showing pictures of pre- and post-SDF treated primary teeth. Results: 265 mothers and 105 fathers participated in this study. The Χ2 test was used to test for the statistically significant differences between parental perceptions. Almost all parents responded that SDF was either unacceptable or extremely unacceptable for their children’s anterior teeth in comparison to 63% for posterior teeth (p = 0.009). Fathers were more comfortable with SDF treatment for posterior teeth on a scale of 3.1 out of 4, in comparison to 1.8 for mothers (p = 0.007). Parents with limited education (up to primary school) showed greater SDF acceptance in comparison to college-graduate parents (p = 0.000). The level of parental SDF acceptance increased with the children’s behavioural barriers. The older children had a lower acceptance rate, at 1.2 and 2.5 for anterior and posterior teeth, respectively (p = 0.000). Conclusions: SDF was acceptable to UAE-based parents for posterior teeth; however, they preferred it for anterior teeth only when advanced behavioural management (e.g., sedation) was advocated. Socioeconomic factors moderated their SDF preference regarding the location of tooth and treatment difficulty. Younger children were relatively more receptive to SDF use than were older children. Keywords: children, parent preferences, primary teeth, silver diamine fluoride, United Arab Emirates