Quintessence International, 02/2025

Objective: It has been found that patients with chronic periodontitis showed higher salivary concentrations of reactive nitrogen species than healthy subjects. However, only a study of elderly Koreans has reported that high salivary reactive nitrogen species concentrations are associated independently with periodontitis. The objective of the present study was to determine whether salivary nitrite concentrations are associated with periodontitis-controlling risk factors in other populations (such as a European population). Method and materials: This was a prospective and observational study carried out in a dental clinic including European subjects without periodontitis (including subjects with periodontal health or with localized gingivitis in 30% sites) or with periodontitis (thus, with loss of periodontal tissue). The levels of nitrite in saliva were assessed using the Griess method. A multivariate regression analysis was performed to determine that variables were associated independently with periodontitis. To determine the association between salivary malondialdehyde levels and the severity of periodontitis, Spearman rho correlation coefficient was used. A receiver operating characteristic analysis with salivary nitrite levels and periodontitis diagnosis was performed. Results: Subjects with periodontitis (n = 54) in comparison to subjects without periodontitis (n = 30) had higher salivary nitrite levels (P = .003), a higher rate of arterial hypertension history (P = .02), and were older (P .001). Nevertheless, differences between subjects with and without periodontitis in other variables were not found. A positive correlation was found between salivary nitrite levels and periodontitis severity (rho = 0.23; P = .04). Multiple logistic regression analysis showed that elevated salivary nitrite levels > 209 nmol/mL were associated with periodontitis, controlling for arterial hypertension history and age (OR = 10.212; 95% CI = 2.665 to 39.128; P = .001) and controlling for diabetes mellitus and smoking (OR = 8.793; 95% CI = 3.038 to 24.450; P .001). The area under the curve for periodontitis diagnosis by salivary nitrite levels was 69% (95% CI = 58% to 79%; P .001). The selected point of salivary nitrite levels > 209 nmol/mL for periodontitis diagnosis had 72% sensitivity (58% to 84%), 77% specificity (58% to 90%), a 3.1 positive likelihood ratio (1.6 to 6.1), 0.4 negative likelihood ratio (0.2 to 0.6), 85% positive predictive value (74% to 92%), and 61% negative predictive value (49% to 71%). Conclusions: Salivary nitrite concentrations could be associated independently with periodontitis, could be associated with periodontitis severity, and could help in periodontitis diagnosis in a European population according to the results of this preliminary study. (Quintessence Int 2025;56:100–107; doi: 10.3290/j.qi.b5872791) Keywords: gingivitis, nitric oxide, nitrites, oxidation, periodontitis, salivary

Objectives: This study aimed to investigate periodontal stability and treatment needs in patients under antiresorptive therapy (ART) during supportive periodontal care (SPC), with a focus on medication-related osteonecrosis of the jaw (MRONJ) risk and reasons for tooth loss. Method and materials: In this retrospective case-control study, records of 100 stage III/IV SPC patients (50 ART-exposed, 50 unexposed) were analyzed for probing pocket depth, clinical attachment level, bleeding on probing, history of periodontal surgery, tooth loss, and MRONJ risk over a period of up to 15 years after active periodontal therapy. Results: Baseline patient characteristics were similar between ART-exposed and unexposed patients. Osteoporosis was the underlying condition for ART in 72% of cases, and 74% exhibited an intermediate MRONJ risk profile. Over time, no significant differences between the groups were found in number of teeth, clinical attachment level, probing pocket depth, or bleeding on probing. Periodontal retreatment needs (teeth with probing pocket depth ≥ 4 mm or ≥ 6 mm) were relatively low and comparable between exposed and unexposed patients. However, periodontal surgery was performed more frequently in unexposed patients, also due to the risk of MRONJ in exposed patients. Both groups showed similar numbers of tooth loss, primarily due to periodontal and endodontic causes. Regression analyses identified ART, age, and diabetes mellitus as significant factors associated with higher bleeding on probing, while smoking and diabetes mellitus were linked to higher probing pocket depths. Conclusion: Achieving periodontal stability during SPC in ART-patients, most of whom had an intermediate MRONJ risk profile, appeared comparable to unexposed patients. However, the different MRONJ risk profiles should be taken into consideration and further investigated. (Quintessence Int 2025;56:108–118; doi: 10.3290/j.qi.b5876508) Keywords: bisphosphonates, denosumab, medication-related osteonecrosis of the jaw, periodontitis, preventive dentistry

Objective: The study aimed to evaluate the stress distribution on tooth and zirconia endocrown restoration with pulp chamber or intracanal extension and zirconia post, performed on maxillary first molars, using finite element analysis. Method and materials: Three 3D endodontically treated maxillary molars were modeled. Cortical bone and cementum were modeled at 2 mm and 200 µm in thickness. Periodontal ligament of 250 µm thickness was constructed. Zirconia endocrown with pulp chamber extension of 2 mm (Model E+PCE), zirconia endocrown with intracanal extension of 4 mm (Model E+ICE), and zirconia post of 4 mm and crown (ZP) were modeled using software. All restoration models were placed on the maxillary molars. Models were subjected to 400 N loading from the three occlusal contact points. Von Mises stress was recorded. Results: Points where the stress was applied showed high stress compared to other regions of the models. The stress did not occur at the trifurcation in any of the models. For the stresses occurring in the restoration material, these were 14.67 MPa, 57.79 MPa, and 155.56 MPa, in Models E+PCE, E+ICE, and ZP, respectively. At the remaining dentin, these values were 47.04 MPa, 32.85 MPa, and 33.42 MPa in Models E+PCE, E+ICE, and ZP, respectively. Conclusions: Within the limitations of the study, zirconia endocrowns with intracanal extension exhibit more favorable stress distribution in both restoration material and dentin compared to zirconia posts and pulpal extension endocrowns. These findings suggest that endocrown with intracanal extension may be a better restorative option for reducing stress. (Quintessence Int 2025;56:120–129; doi: 10.3290/j.qi.b5798352) Keywords: endocrown, endodontically treated teeth, maxillary molar, zirconia

Objective: Craniofacial fibrous dysplasia affecting the jaws can result in facial asymmetry, posing a unique challenge for dental implant placement in edentulous areas. This case report introduces an innovative approach for rehabilitating the posterior maxilla affected by craniofacial fibrous dysplasia using a computer-guided technique for maxillary recontouring and substitution bone grafting at implant sites. Case presentation: A 58-year-old edentulous woman with a craniofacial fibrous dysplasia bone lesion affecting the right maxilla was referred for correction of asymmetry and dental implant placement. A computer guide was devised for shaving and contouring the right maxilla. Following virtual maxillary reduction, a second guide was created over the osteomized 3D model to plan the location of future dental implants and guide bone ostectomies for allograft substitution. Particulate bone substitute was applied to ostectomy sites in the affected maxillary alveolar ridge. Four implants were placed successfully 4 months postoperatively, with integration confirmed by clinical examination after 1 year of follow-up. Conclusion: This treatment approach emerges as a reliable and effective modality for simultaneous dental implant rehabilitation in edentulous alveolar bone and jaw contouring in craniofacial fibrous dysplasia cases. (Quintessence Int 2025;56:130–137; doi: 10.3290/j.qi.b5826619) Keywords: bone grafts, dental implants, dysplastic alveolar bone, facial asymmetry, fibrous dysplasia of bone

Objectives: Small-scale studies reported increased blood pressure in patients using chlorhexidine mouthwash with the rationale that the rinse mitigates nitric oxide production by oral bacteria. The present study evaluated whether prior use of chlorhexidine mouthwash can be associated with an increased odds ratio (OR) for primary hypertension in a large hospital cohort. Method and materials: The i2b2 NIH-established platform was used to search for deidentified medical information coded by ICD-10 for subjects with a hypertension diagnosis who have used chlorhexidine rinses before between October 2015 and May 2024. Binary statistics and logistic regression were used to calculate the OR for hypertension in the group that used chlorhexidine mouth rinse before and after adjustments for demographic data, diabetes, and periodontal disease. Results: The unadjusted OR for primary hypertension in subjects who used chlorhexidine gluconate mouthwash before was significantly elevated (OR 3.09, 95% CI 3.03 to 3.16, P .0001). It remained significant after adjusting for male sex (OR 3.07, 95% CI 3.00 to 3.13, P .0001), age 45 years (OR 4.00, 95% CI 3.92 to 4.09, P .0001), White race (OR 2.49, 95% CI 2.44 to 2.55, P .0001), diabetes (OR 2.68, 95% CI 2.61 to 2.74, P .001), and periodontal disease (OR 3.21, 95% CI 3.21 to 3.34, P .0001). The OR for hypertension for subjects with gingivitis or periodontal disease after adjustment for chlorhexidine mouthwash was elevated (OR 20.11, 95% CI 20.11 to 21.44, P .0001). Conclusions: With the caveat of a retrospective study design, the results indicate an increased OR for primary hypertension for subjects with prior use of chlorhexidine mouthwash. (Quintessence Int 2025;56:138–142; doi: 10.3290/j.qi.b5872795) Keywords: blood pressure, chlorhexidine, mouthwash, primary hypertension

Objectives: This pilot study aimed to evaluate the quality of legends associated with diagnostic images in the published oral and maxillofacial radiology literature using a novel rating scale. Method and materials: Images and their corresponding legends were randomly selected from published manuscripts over the last 10 years in the Oral Radiology journals, namely Dentomaxillofacial Radiology, Imaging Science in Dentistry, Oral Radiology, and Oral Surgery Oral Medicine Oral Pathology Oral Radiology. An Image Legend Quality Scale (ILQS) was introduced to assess the quality of the legends associated with images. A program was developed for the rating scale form using Google Apps Script API to gather and analyze the data. The rating scale ranged from 1 to 5, with 5 as the highest rating. Results: The highest average ILQS rating for one journal was 3.04. The overall ILQS rating average across all four journals was 2.87, which is a 2.13 rating score lower than the ideal score of 5. Conclusions: There is room for improvement in the legends that accompany diagnostic images and figures in the oral and maxillofacial radiology literature. A proper legend provides an excellent diagnostic teaching opportunity for the reader and enhances the quality of a publication. (Quintessence Int 2025;56:144–152; doi: 10.3290/j.qi.b5907061) Keywords: cone-beam computed tomography, dentistry, publications, radiography, radiology

Objective: Injuries to branches of the trigeminal nerve can occur during various dental procedures, leading to neurosensory deficits. The aim of this article is to educate those who are not specialized in diagnosis and management of iatrogenic trigeminal nerve injuries what to do if such a situation arises in their practice. Data sources: Treatment protocols, prospective and retrospective studies, and literature reviews were reviewed. Results: Patient history, neurosensory testing, and radiographic imaging are used to diagnose trigeminal nerve injuries. Based on findings, patients are either immediately referred to a specialist or managed conservatively. Conservative management includes pharmacologic treatment, neurosensory training exercises, and serial neurosensory testing. Consulting with local oral and maxillofacial surgeons or orofacial pain specialists, contacting local and state societies, or searching for providers on websites such as the American Association of Oral and Maxillofacial Surgeons, Academy for Orofacial Pain, American Board of Orofacial Pain, Oral and Maxillofacial Surgery National Insurance Company, or Axogen are different methods that can be used to find a specialist to refer to if indicated. Conclusions: Many providers are not trained to diagnose and manage iatrogenic trigeminal nerve injuries. Understanding indications for monitoring, conservative treatment, and when to refer these patients to orofacial pain specialists or oral and maxillofacial surgeons trained in trigeminal nerve microsurgery is critical to maximize positive patient outcomes and to minimize medicolegal exposure. (Quintessence Int 2025;56:154–160; doi: 10.3290/j.qi.b5984306) Keywords: inferior alveolar nerve, lingual nerve, nerve injury, nerve repair

Objective: Allergic reactions during dental procedures are suspected frequently. Still, data on the confirmed allergens are rare. This study aimed to identify allergens in dentistry and potential cofactors in sensitization. Method and materials: Patients with suspected allergic reactions in the context of dental (study group) or surgical (control group) procedures were analyzed in a monocentric 3-year retrospective and 2-year prospective file chart analysis between 2018 and 2023. Descriptive statistics and multiple logistic regression analysis were performed. Results: In total, 129 patients were allocated to the study group and 123 to the control group. Confirmed allergy was less frequent in the study group (10%) than in the control group (28%, P .001). Local anesthetics triggered most dental reactions, but were rarely confirmed allergic (1 of 55 cases). Dental materials and implant material in the control group were confirmed in 16% and 15% of clinically relevant sensitizations, respectively. Multiple logistic regression identified reactions to local anesthetics or dental materials/implant material with a 33.33- or 2.63-fold lower risk of sensitization. A concomitant immune disease was associated with higher risk for a confirmed allergic reaction in dentistry in the cohort (OR 9.12, 95% CI 2.40 to 35.10). Conclusion: Allergy to dentally administered drugs is rare. Most local anesthetic–triggered reactions were unspecific. Reactions to dental materials resulting in objective symptoms require allergy diagnostics. (Quintessence Int 2025;56:162–170; doi: 10.3290/j.qi.b5907068) Keywords: allergy, antibiotics, dental material, local anesthetics, nonopioid analgesics