Quintessence International, Pre-Print

Objectives: To analyze the effects of three osteotomy drill designs (conventional [CON], reverse helix [REX], and densification [DEN]) and running directions on heat generation, primary implant stability (PS), block-to-implant contact (BIC)%, peri-implant block volume (BV), and resistance to unscrewing forces in a low-density alveolar bone model. Method and Materials: Eighty-eight dental implants were inserted into artificial bone blocks using manual and computer-controlled osteotomies. Temperature changes (Δ°C), insertion torque value (ITV), resonance frequency analyses (ISQ), BIC%, and BV were measured. Statistical analyses used ANOVA and Kruskal-Wallis tests (p<0.05). Results: DEN drilling produced the lowest Δ°C (17.52±2.57°C and 28.06±4.35°C for 2nd and 3rd drills), while CON had the highest (27.53±5.17°C and 38.03±8.08°C). Counter-clockwise (CCW) CON drilling significantly reduced Δ°C compared to clockwise (CW). DEN achieved highest PS (38.01±1.87 N/cm, 65±4.69 ISQ) and removal torque (25.4±5.08 N/cm), while CON CW had lowest (33.23±2.91 N/cm, 61.83±4.28 ISQ). DEN showed the highest BV (87.71±4.23 mm³) but the lowest BIC (49.12%±2.93%). CCW CON drilling improved ITV over CW (36.21±3.63 vs 33.23±2.91 N/cm). Conclusion: DEN drilling demonstrated superior performance in heat reduction, PS, and BV, but had lower BIC%. CCW running of CON drills showed improvements over CW in several parameters. While DEN excelled in most aspects, its lower BIC% and the positive outcomes of CCW CON drilling warrant further investigation. Keywords: Bone Density, Dental Implants, Osteotomy, Temperature, Torque, osseodensification

Objective: This study aimed to evaluate the effect of recombinant human bone morphogenic protein type-2 (rhBMP-2) on the alveolar ridge in the post-extraction socket in humans. Materials and Methods: 20 subjects with 25 teeth of the maxilla were included (11 sockets in the control [blood clot] and 14 in the test group [rhBMP2]). The teeth were minimally and traumatically extracted. The cone-beam computed tomography (CBCT) images were obtained 2 (T0) and 120 (T1) days after extraction. The Buccal bone wall height (V Height, mm), palatal bone wall height (P Height, mm), and alveolar area (mm2) were compared between both groups as well as the volumetric contraction through overlapped images (T1-T0) using mimics software. The data was compared using the Mann–Whitney test (p<0.05). Results: The intragroup evaluation showed a significant buccal and palatal crest height resorption in the control group (p<0.05). In the intergroup assessment, the test group showed superior to the control group in maintaining the average alveolar ridge area since the control group showed an area loss of approximately 39% between T0 and T1, whereas this reduction was approximately 15% in the test group (p<0.05). Conclusion: It is possible to conclude that using rhBMP-2 after tooth extraction resulted in better socket preservation, maintaining bone availability in the alveolar ridge 2.5 times greater than that of the control group. Keywords: rhBMP-2, Alveolar ridge preservation, Graft, Growth factor, Dental implant

Objectives: In-vitro study to investigate the influence of different pre-treatments and surface coatings on the wear of different zirconia and their antagonists. Method and Materials: Zirconia specimens (3-, 4- and 5-mol yttria tetragonal zirconia; n=160/material) were subjected to pre-treatment (sandblasting 50 μm Al2O3 1 bar; 120 μm Al2O3 3 bar; polishing) and surface coating (spray glazing, micro-layering, layering, veneering). References comprised no pre-treatment or coating. Wear tests were performed (50 N, 120,000 cycles). Wear (mean, maximum, antagonist) and arithmetic mean roughness Ra and average roughness depth Rz were determined. Statistics: ANOVA, Bonferroni, Pearson correlation (α=0.05). Results: Ra/Rz showed significant (p < .001) differences (Ra: 0.01 ± 0.01 μm to 0.71 ± 0.06 μm, Rz: 0.31 ± 0.09 μm to 4.33 ± 0.44 μm). Two groups could be distinguished by mean and maximum wear with significant (p < .001) differences: I.) glaze sprayed and without coating (mean wear: 9.4 ± 2.6 μm to 57 ± 21.3 μm, max. wear: 24.1 ± 6.9 μm to 125.4 ± 18.2 μm) and II.) All coating procedures (mean wear: 129.2 ± 22.8 μm to 236.5 ± 62.0 μm, max. wear: 188.7 ± 21.4 μm to 444.2 ± 110.6 μm). Antagonist wear (9.2 ± 4.5% to 29.7 ± 5.0%) showed a significant (p < .001) correlation to surface coating, mean and maximum wear, Ra and Rz. Mean wear significantly (p < .001) correlated with surface coating, maximum wear, and antagonist wear. Conclusion: Under clinical conditions, layering or veneering can lead to increased wear of the restoration, but in return reduce the abrasion of antagonists. Excessively rough surface treatments should be avoided, as they might increase antagonist wear. Keywords: (micro-)layer, roughness, spray glaze, veneer, wear, zirconia

Objectives: This systematic review and meta-analysis aimed to evaluate and compare the comfort levels of custom-made mouthguards and self-adapted mouthguards used by athletes. Key parameters assessed included fit, speech interference, and breathing difficulties. Materials and Methods: The review was registered with the Prospective International Registration of Systematic Reviews (PROSPERO). A comprehensive literature search was conducted across PubMed, EBSCOhost, Scopus, and Google Scholar, supplemented by additional citation searches. Two independent reviewers assessed the relevance of the studies, and studies were included based on predefined eligibility criteria. Nine studies were included for qualitative analysis, with the risk of bias assessed using standard NIH and revised JBI tools. Meta-analysis was performed with three studies to synthesize the results. Results: The analysis demonstrated that custom-made mouthguards significantly outperformed self-adapted types in comfort metrics, particularly in fit (p=0.0002) and reducing speech difficulty (p<0.00001). At the same time, breathing difficulty was also less in custom-made mouthguards (p<0.00001). Conclusions: Custom-made mouthguards provide superior comfort (fit and speech) compared to self-adapted alternatives, enhancing their potential for widespread adoption. The findings highlight the need for further research as limited clinical studies were available for meta-analysis. Keywords: Custom-made mouthguards, self-adapted mouthguards, athlete comfort, speech interference, breathing difficulties

Objectives: Pathological root resorption in primary teeth affects dental health and future orthodontic needs. This study aimed to evaluate the prevalence and associated factors of pathological root resorption in a paediatric population. Method and Materials: A retrospective cross-sectional analysis was performed using panoramic radiographs from 691 pediatric patients aged 4–11 years at a university hospital in Türkiye. Teeth were evaluated for internal (IRR) and external pathological root resorption (ERR) by two calibrated observers, adhering to the 2023 European Society of Endodontics (ESE) Position Statement. Tooth status was categorized as healthy, carious (with or without pulp involvement), filled, or endodontically treated, and dental crowding was also recorded. Statistical analyses included chi-square tests, multiple logistic regression, and post-hoc analyses, with significance set at p < 0.05. Results: A total of 7,729 primary teeth (5,075 molars and 2,654 canines) were evaluated, with interobserver reliability of 82% and intraobserver reliability of 98.8%. The study cohort included 691 children (mean age: 7.05 ± 1.45 years; 49.8% boys, 50.2% girls). Pathological root resorption was observed in 21.2% of cases (n = 1,638), with ERR accounting for 81% and IRR for 19%. Among 2,654 healthy teeth, 3.76% exhibited pathological resorption, with no significant association with dental crowding. Significant relationships were identified between pathological root resorption and age (p = 0.000), tooth status (p = 0.049), and gender (p = 0.042). Conclusion: Reducing high caries levels in Türkiye is critical to lowering pathological root resorption and associated complications. Further studies should explore dental crowding and pathological root resorption relationships in larger samples. Keywords: Panoramic radiography, pathological root resorption, pediatric dentistry, primary teeth

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