Quintessence International, Pre-Print

Objectives: This study aimed to evaluate the physical-mechanical behavior of resin composites when subjected to different prolonged heating protocols. Method and materials: A total of 150 specimens were divided into 15 groups (n = 10 per group) based on the restorative materials (Filtek Supreme, Viscalor, and Grandioso) and heating protocols: room temperature (22 ºC), 24 hours at 68 ºC, 7 days at 68 ºC, 30- and 100- cycles of artificial aging by thermocycling (5 and 68 ºC for 10 minutes each). The materials were inserted into a PVS matrix, cured for 20 seconds using a 1000 mW/cm² LED light-curing unit, stored for 24 hours in. The response variables measured were flexural strength and Knoop microhardness. Results: The flexural strength evaluation showed that Grandioso exhibited higher strength compared to Filtek Supreme and Viscalor, with no significant differences observed across the heating protocols. This indicates that prolonged heating did not affect the flexural strength of any of the tested resins. Knoop microhardness testing revealed significant differences among resins and heating protocols. Grandioso demonstrated the highest surface hardness across all protocols, while Filtek Supreme showed a decrease in hardness after 100 thermocycling cycles. Prolonged heating reduced surface hardness for Grandioso and Viscalor compared to room temperature, whereas Filtek Supreme maintained its hardness under extended heat exposure. Conclusion: These findings suggest that while flexural strength remains unaffected by heating, surface hardness varies depending on the resin type and the heating duration. Keywords: Flexural strength, Mechanical properties, Physical properties, Preheating, Resin composite

Objectives: Adolescents with intellectual and developmental disabilities (IDDs) are at increased risk of oral diseases due to physical limitations, poor oral health awareness, and inadequate dental hygiene practices. The aim of this study was to evaluate the oral health status of adolescents with IDDs and to analyze changes in their dental hygiene habits following subsequent visits and oral hygiene education. Method and Materials: This pilot longitudinal observational study involved students with mild to moderate IDDs from a special needs school. Oral health was assessed using the Decayed, Missing, and Filled Teeth (DMFT) index, International Caries Detection and Assessment System (ICDAS-II), Basic Erosive Wear Examination (BEWE), Developmental Defects of Enamel (DDE), and Simplified Oral Hygiene (OHI-S) indices. Participants received oral hygiene training, and their brushing techniques were evaluated using the Oral Hygiene Skills Survey. Data on brushing frequency, skills, toothpaste use, and OHI-S scores were collected at baseline and at 1-, 3-, and 6-month follow-ups. Results: Twenty-three participants aged 14–19 were evaluated, showing high DMFT scores (mean 10.91 ± 6.06), advanced caries in 78.3%, and enamel defects and erosive tooth wear in 65.2%. Significant improvements were observed in toothbrushing frequency (P = .008), with reductions in OHI-S scores (P = .001) and enhanced brushing skills (P = .016) during follow-ups. Conclusion: The findings indicate a high prevalence of dental caries, enamel defects, and erosive tooth wear among adolescents with IDDs. Despite poor baseline oral hygiene practices, regular follow-ups and oral hygiene education significantly improved oral hygiene habits and outcomes. Keywords: developmental enamel defects, dental caries, erosive tooth wear, intellectual disability, oral hygiene, special care needs

Objectives: To describe the second and third years of "Smiles", with the objective of demonstrating feasible, practical, and realistic aspects of enhancement of daily tooth brushing skills and integration of a supportive environment of daily-supervised tooth brushing in kindergartens. Methods and Materials: Thirty-six out of 180 kindergartens (20%) across Israel, which participated at the first year of the program, took part at the second and third years of the program. Eighteen kindergartens served as study group with a supervised tooth-brushing routine, and 18 kindergartens served as controls without supervised tooth-brushing routine. Tooth-brushing skills recorded by Simmons index at base line among 3-year-old children, after one year and finally after two years among 5-year-old children. ECC (early childhood caries) evaluated by deft index among 5-year-old childrenat the end of the program. Statistical analysis included Chi-square test, Mann-Whitney test, and aGeneral Linear Model. Results: One thousand and twenty eight (1,028) preschool children (503 of them in the daily toothbrushing kindergartens), their parents, and their educational staff took part in the program. The average number of brushing days per week at the daily-supervised tooth brushing kindergartens met the desired threshold of 3 days a week. The average daily percentage of preschool children brushing their teeth exceeded 80%. High levels of program cooperation and satisfaction (>80%) were recorded. Children in tooth brushing kindergartens demonstrated statistically significant three fold higher levels of tooth brushing skills improvement as compared to children in control kindergartens (33% as compared to 11%, p<0.001 respectively). Being in the Jewish sector and participation in daily tooth brushing program revealed as predictors of low dft scores among 5 year old children (OR=0.320, OR=0.552, p<0.001 respectively). Conclusion: The successful performance and positive atmosphere of "Smiles" in all its levels; the organization, the staff, the parents, and the children, made this endeavor an example of a large-scale demonstration program with practical and realistic enhancement of daily tooth brushing skills and integration of daily-supervised tooth brushing among preschool children in kindergartens. Following the introduction of "Smiles" program results to the Ministry of Health in 2017, this service has turn to a fait accompli as part of the dental health services for pupils in Israel in 2018. Keywords: caries, community program, kindergarten, oral health, toothbrushing

Background: Morgellons disease is a rare controversial illness in individuals which is characterized by having a fixed, false belief (delusion) in which they are infested by non-living organisms, despite medical evidence which proves the contrary. The symptoms can appear solely in the oral cavity, a condition that had not previously been described in the dental literature. The underlying mechanisms behind these findings remain unclear, moreover, established diagnostic criteria or effective treatments were unsuccessful. This case report highlights the sensations of feeling hair and threads between the teeth of patients with Morgellons disease, as well as an unusual perception of the tongue and saliva were self-reported. Conventional medical treatments have not been effective in alleviating those oral symptoms. Taking into account the scarcity of cases in dental literature, the article underscores the importance of interdisciplinary approaches, in order to enhance diagnosis and treatment by integrating oral and mental health care. Keywords: Morgellons disease, Ekbom syndrome, oral manifestation, oral cenesthopathy, Psychiatry

Objective: To examine the changes in dental practice in response to the COVID-19 pandemic 6 to 12 months after its outbreak. Method and materials: An electronic survey was disseminated among dental practitioners from Brazil, India, and Israel between August 2020 and April 2021. The questionnaire comprised two sections: 1) participant demographics and participant characteristics, and 2) working conditions during the COVID-19 pandemic. Results: In total, 979 respondents (72.6% females) completed the questionnaire (56.9% Brazilian, 24.6% Israeli, 18.5% Indian). About two-thirds of Brazilian (62.1%) and Indian respondents (68.4%) and 54.8% of Israeli respondents provided emergency care during the first wave of the pandemic; a fifth or lower treated patients with COVID-19. Most respondents reported changes in their appointment management, along with decreased income compared to the period before the pandemic, attributed to the decrease in the number of treatments together with increased expenses, mainly on equipment, protection, and disinfection. More than half of Indian and Israeli respondents reported that guidelines provided by the Ministry of Health were very clear, compared to 31% of Brazilian dental practitioners. Only 35.8% of Brazilian respondents reported that they had received clear instructions regarding conduct in the clinic compared to 69% and 72% of Indian and Israeli respondents, respectively. Conclusions: Dental practitioners from three very different countries around the world faced similar challenges in their practices during the first months of the COVID-19 pandemic. Although most participants adjusted to the alterations in their professional routines necessitated by pandemic-related restrictions, these modifications also resulted in shifts in clinicians’ workloads, elevated expenditures, and reduced income. Public health guidelines provided to dental practices by the authorities were not always clear. Understanding these challenges and how to deal with them should help cope better with future worldwide crises. (Quintessence Int 2025;56:2–16; doi: ##.####/j.qi.a#####) Keywords: COVID-19, dental clinic, dental practice, guidelines, protection

Objectives: The purpose of this study is to evaluate differences in marginal bone level (MBL) and survival rates of implants (ISR) placed in lateral-window sinus floor elevation (LSFE) sites compared to other sites. Method and Materials. Patient with a history of LSFE and following implant placement were identified. Clinical and radiographic data was collected by 2 calibrated examiners and divided into three cohorts for the analysis, including (1) implants placed in the LSFE-grafted sinus, (2) implants placed in the maxilla at sites other than grafted sinus, and (3) implants placed in the mandible. ISR and MBL were recorded and calculated. The potential influences of several host, implant, and surgically related factors on ISR and MBL were analyzed using generalized estimating equations. Results: 427 implants from 99 patients (63.8 ±12.5 years) with an average follow-up period of 32.3 ±29.2 months were analyzed. The cumulative ISR at the grafted sinuses was 93.63%. Mean MBL was 0.44 ± 0.79 mm, 0.84 ±1.21 mm, and 0.85 ±1.16 mm for implants in group 1 (n= 142), group 2 (n=129), and group 3 (n=147) (p=0.01). The majority of MBL occurred within the first 12 months after implant placement. The status of smoking and periodontal disease did not impact ISR or MBL for any group (P>0.05). Neither sinus membrane perforation (SMP) or grafting materials affected MBL (P>0.05) in group 1. Conclusion: The utilization of LSFE and the presence of SMP during LSFE had no negative impact on implant outcomes. Keywords: Sinus lift, sinus, oral surgery, dental implants, implantology, marginal bone level

Objectives: To assess blood flow alterations after horizontal Guided Bone Regeneration (GBR) and to evaluate correlations between blood flow and hard tissue changes. Method and Materials: Twelve mandibular surgical sites were involved in the current case series. GBR was carried out using a split-thickness flap design. Blood circulation was assessed with Laser Speckle Contrast Imaging at baseline as well as 1, 4, 6, 11, 13, 20, 27, and 34 days after the surgery, subsequently on a monthly basis until 6 months. Hard tissue alterations were measured horizontally and vertically using linear measurements. The first measurement point was 2 mm distal to the distal surface of the last tooth; additional measurement points were placed every 3 mm up to the 15th mm. Volumetric hard tissue loss and gain were also assessed. Results: Baseline blood circulation was statistically significantly higher on the buccal side. On the first postoperative day, all regions presented a statistically significant decrease in blood flow circulation. The buccal-inner region presented significant ischemia on day 6. Mean volumetric hard tissue gain and loss were 712.62 ± 317.08 mm3 and 222.431 ± 103.19 mm3, respectively. Mean baseline alveolar ridge width was 4.82 ± 1.02 mm, 6 months ridge width averaged 7.21 ± 0.99 mm. Vertical resorption measured 1.24 ± 0.5 mm. Correlations between blood flow changes and hard tissue alterations were only found on Day 34 and Day 60. Conclusion: Laser Speckle Contrast Imaging is an efficient method to measure flap microcirculation. No correlation was found between flap microcirculation changes hard tissue and alterations. Keywords: Bone graft, Case-report/series, Guided Bone Regeneration, Membranes, Ridge augmentation

Radiation treatment plays a mainstream role in the management of head and neck cancers (HNSCC). Adverse effects from radiation therapy include osteoradionecrosis of the jaw, and rarely, pathological fracture. Immune checkpoint inhibitors (ICI) such as pembrolizumab are of growing relevance to the management of metastatic and recurrent HNSCC. Adverse impact on bone secondary to medications such as pembrolizumab and nivolumab have been sporadically documented in the literature. The objective of this manuscript is to raise awareness of possible increase in risk for adverse jaw outcomes in patients with HNSCC exposed to both radiation treatment to the jaws and ICI therapy. This manuscript documents adverse jaw outcomes including osteonecrosis and pathological fracture of the mandible in two patients receiving pembrolizumab for management of HNSCC and had received prior radiation treatment. A potential link between immunotherapy and adverse jaw outcomes is consistent with our growing understanding of osteoimmunology, investigating the closely interrelated processes in bone remodeling and immune system function, in health and disease. It is important to ascertain if pembrolizumab poses an incremental risk for such outcomes, beyond the risk from prior radiation, for patients managed with radiation treatment and ICI therapy for HNSCC. The general dentist may encounter such patients either in the context of facilitating dental clearance prior to initiation of chemotherapy, or rarely, with poorly explained jaw symptoms and must be alert to the possibility of occurrence of such adverse jaw events to facilitate timely diagnosis and optimal patient management. Keywords: Cancer, Case-report/series, immunotherapy, Oral surgery , Osteonecrosis, Pathology, Radiation Therapy

Objective: Currently, there is no established treatment protocol to treat Interdental papillary loss. This research aimed to evaluate the outcomes of interdental papillary reconstruction using minimally invasive surgery, with injectable hyaluronic acid (HA) gel. Materials and Methods: Seventeen patients were included, each with five sites of class 1 papillary recession; (forty sites in the upper jaw and forty-five sites in the lower jaw). Subperiosteal tunneling was performed through a horizontal incision made apical to the base of the papilla without penetrating it. The free gingival sulcus was sealed by 000 retraction cord. After that a total of 0.2-0.6 mL HA was injected gradually. The incision was sutured with polyglycolic sutures. Treated sites underwent clinical and digital evaluation at three follow up time points (1 month, 3 months and 6 months). Results: The interdental papillary defect height in the upper jaw sites significantly reduced by 60%, 66%, and 42% at 1 month, 3 and 6 months, respectively. Also, in lower jaw sites, the reduction was of about 54%, 55%, and 40% at the same follow up time points. Regarding interdental papillary defect surface area in the upper jaw the reduction was about 65%, 71%, and 45% at 1 month, 3 and 6 months. In the lower jaw, a reduction of about 60%, 64%, and 48% was noticed at the same time points. Regarding patients’ pain level score, during the day of surgery, sixteen patients reported pain, the average pain score out of 10 was 3.94, and eleven patients (64.7%) needed to take analgesics. The pain generally subsided in the following days. Also, at the day of the treatment twelve out of the seventeen patients (70.6%) reported mild difficulty in speaking and eating. No complication, hypersensitivity or allergy was noted in any patient. Conclusion: Subperiosteal tunneling with HA injection demonstrates clinical improvements in papilla height and papillary recession surface area reduction after 3 months of follow-up with reduction in improvement after 6 months. Keywords: black triangle, dental papilla augmentation , hyaluronic acid, minimal invasive surgery, periodontal surgery, Periodontology

Objectives: To assess the effect of Community Water Fluoridation (CWF) in the prevalence of dental caries and dental fluorosis in 12-year-old children living in Israel. Considering that CWF is important in the prevention of dental caries. Between 2002 and 2014, the water in communities of at least 5000 individuals was fluoridated. In 2014 CWF in Israel stopped. Methods: Data on 12-year-old children from all areas in Israel from the national crosssectional epidemiological survey conducted in 2011-2012 were stratified by city water fluoridation and by city and school socio-economic status (SES). Two dependent variables were defined: (1) DMFT index -caries experience in the permanent dentition; (2) dental fluorosis in central incisors using the Thylstrup-Fejerskov (TF) classification of fluorosis. Results: Data from 2181, 12-year-olds was analyzed. the average DMFT was 1.17+1.72 and 49% were caries free. Based on DMFT, the caries experience was significantly higher in nonfluoridated cities (1.38 vs. 0.98 in fluoridated cities) and there were more caries free children 56.4% in fluoridated cities vs. 40.6% in non-fluoridated. DMFT was higher in cities with lower SES than high SES (1.29 vs. 1.05 respectively, p<0.001) and there were less caries free children in low SES (44.5% vs. 53% in high SES cities, p<0.0001). Almost all the 10.3% of children with signs of fluorosis (scoring at least 1 in TF index), had questionable to mild fluorosis (9.3%). Conclusions: CWF is a cheap, simple method of dental health protection that reaches all socio-economic levels and cessation of water fluoridation reduced the health of Israel's children. Clinical Significance: Water fluoridation provides substantial caries prevention, by reaching a substantial number of people. The relevance of this work is for policymakers to consider CWF as clinically proven method for reducing health inequalities. Keywords: Caries detection, DMFT, Epidemiology, Fluoride, Public health