EDITORIAL
Clinical Research in Dentistry Everything is up for change, from research design to treatment protocols. The times couldn’t be more challenging, or exciting.
BY NOW, THE TERM EVIDENCE-BASED DENTISTRY has become something of a cliché, having been bantered around in practically every dental publication and in many of the presentations and forums we attend. There is no doubt that the development of clinical protocols that are based upon meaningful investigations, investigations that meet the “gold standard” of fundamental research design and implementation,is a priority on dentistry’s agenda.But this admirable quest is fraught with potential problems and challenges, while still holding out hope of benefits to both the dental practitioner and to our patients. Identifying areas of clinical practice that merit further investigation must rely upon input from clinicians themselves to maximize the benefits to individual patients and/or the profession at large. The “so what?” criteria should be met so that measurable differences that might potentially be found in clinical outcomes—if that is what is being investigated—represent a meaningful statement that could and should have an impact upon cogent recommendations for changes in clinical treatment protocols. The role of the clinician as an important member of the research team now becomes more important than ever.As such, the clinical dentist and dentist researcher/academic and biostatistician must have an unprecedented dialogue and relationship. Dental education on the predoctoral and postdoctoral levels will also have an opportunity to broaden research design perspectives and will be a significant benefit for all of us. While the ability to critically assess the professional literature found in our peer reviewed publications has always been and will continue to be an important responsibility of all dentists, editors and editorial 4 NYSDJ • APRIL 2007
boards, the expectations for clinician participation in small and large research projects will undoubtedly be raised. The National Institute of Dental and Craniofacial Research (NIDCR) has taken a bold and proactive position in forging a new model for clinical research in dentistry. Practice-based research networks (PBRNs) have been utilized in medicine, and this has resulted in significant clinical protocol changes. Similarly, the PBRN structure, as envisioned by the NIDCR, is an inclusive concept that combines the rigorous standards of academic research with the practical demands of clinical practice.As such, the NIDCR committed approximately $75 million, over seven years, to three dental PBRNs. Each PBRN will be mandated to recruit at least 100 general dental practitioners as participants in the PBRN investigation projects. This unprecedented hybrid structure of clinical investigation represents the ultimate meeting of “town and gown” in dentistry. One of the three dental PBRNs is based in the Northeast and was awarded to New York University College of Dentistry and The EMMES Corp. from Rockville, Maryland. It is referred to as the PEARL Network, an abbreviation for Practitioners Engaged in Applied Research and Learning. I am certain we will be hearing a great deal more about all of these dental PBRNs in the near future. As the dental profession charts its course of continued excellence and relevance to the public in this millennium, clinical research will play a powerful role in the process. Indeed, the rules of engagement have been profoundly changed.What an exciting time for all of us! D.D.S. M.Sd
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OFFICERS Steven Gounardes, President 351 87th St., Brooklyn 11209
Foundation to Recognize GRADUATING DENTISTS Annual Deans Award aimed at bolstering oral health workforce in New York State. ENSURING A GROWING and sustainable oral health workforce is crucial to expanding the availability of oral health services to all New Yorkers, particularly the underserved and members of the state’s growing culturally diverse communities. To help address this critical issue, the New York State Dental Foundation has established a Deans Award, which will be presented annually to graduating students or postdoctoral trainees who have demonstrated an exceptional level of achievement as measured by the following criteria: ● Outstanding academic performance. ● A demonstrated commitment to enhancing and improving the oral health of underserved populations. ● Membership in the American Dental Student Association. Candidates for the NYSDF Deans Award, valued at $5,000, must be nominated by the dean of each of the following academic dental institutions: Columbia University College of Dental Medicine; New York University College of Dentistry; University at Buffalo School of Dental Medicine; Stony Brook University School of Dental Medicine; and the University of Rochester Eastman Dental Center. Upon review by the Foundation Board, the deans' candidates will each be presented with a $5,000 check at their respective commencement ceremonies. “This is such a wonderful opportunity for the Foundation to partner with the state’s dental schools,” said Foundation Chair Edward J. Downes. “At the same time, we are promoting the value of organized dentistry, making this new program a remarkable win-win for everybody involved.” Winners of the 2007 Deans awards are expected to be announced soon.
Alfonso J. Perna, Immediate Past President Sixth District Dental Society, 55 Oak St. Binghamton, 13905
Stephen B. Gold, President Elect 8 Medical Drive, Port Jefferson Station 11776 Roy E. Lasky, Executive Director 121 State St., Albany 12207 Michael R. Breault, Vice President 1368 Union St., Schenectady 12308 John Asaro, Secretary-Treasurer 2707 Sheridan Drive, Tonawanda 14150
William R. Calnon, ADA Trustee 3220 Chili Ave., Rochester, NY 14624
BOARD OF GOVERNORS NY County-Lawrence Bailey 215 W. 125th St., New York 10027 NY County-Matthew J. Neary 501 Madison Ave., Fl. 22, New York 10022 NY County-Robert B. Raiber 630 Fifth Ave., #1869, New York 10111 2-Michael L. Cali 2003 E. 60th St., #1A, Brooklyn 11234 2-Craig S. Ratner 1011 Richmond Rd., Staten Island 10304-2413 2-James J. Sconzo 1666 Marine Parkway, Brooklyn 11234 3-Lawrence J. Busino 2 Executive Park Dr., Albany 12203 3-John P. Essepian 180 Old Loudon Rd., Latham 12110 4-Mark A. Bauman 157 Lake Ave., Saratoga Springs 12866 4-Frederick W. Wetzel 1556 Union St., Niskayuna 12309 5-William H. Karp 472 S. Salina St., #222, Syracuse 13202 5-John J. Liang 2813 Genessee St., Utica 13501 6-Robert W. Baker, Jr. 412 N. Tioga St., Ithaca 14850 6-Scott Farrell 39 Leroy St., Binghamton 13905 7-Richard F. Andolina 74 Main St., Hornell 14843
7-Andrew G. Vorrasi 2005-A Lyell Ave., Rochester 14606 8- Jeffrey A. Baumler 2145 Lancelot Dr., Niagara Falls 14304 8- Kevin J. Hanley 959 Kenmore Ave., Buffalo 14223-3160 9-Malcolm S. Graham 170 Maple Ave., White Plains 10601 9-David H. Kraushaar 6 Woodthrush Drive, W. Nyack 10994 9- Neil R. Riesner 111 Brook St., 3rd Floor, Scarsdale 10583-5149 N- Peter M. Blauzvern 366 N. Broadway, Jericho 11753-2032 N-David J. Miller 467 Newbridge Rd., E. Meadow 11554 N-Robert M. Peskin 601 Franklin Ave., #225, Garden City 11530-5742 Q-Chad P. Gehani 35-49 82nd St., Jackson Heights 11372 Q-Robert L. Shpuntoff 28 Beverly Rd., Great Neck 11021 S-Paul R. Leary 80 Maple Ave., #206, Smithtown 11787 S-Steven I. Snyder Suffolk Oral Surgery Associates, 264 Union Ave., Holbrook 11741 B-Stephen B. Harrison 1668 Williamsbridge Rd., Bronx 10461 B-Richard P. Herman 20 Squadron Blvd., New City 10956
COUNCIL CHAIRPERSONS Annual Meetings James E. Spencer 2 Burlington Pl., Woodcliff Lake, NJ 07671 Awards Mark J. Feldman 5 Vanad Dr., Roslyn 11576 Chemical Dependency Robert J. Herzog 16 Parker Ave., Buffalo 14214 Dental Benefit Programs Ian M. Lerner One Hanson Pl., #2900 Brooklyn, NY 11243-2907 Dental Health Planning/ Hospital Dentistry Robert A. Seminara 281 Benedict Rd., Staten Island 10304 Dental Practice Brendan P. Dowd 6932 Williams Rd., #1900, Niagara Falls 14304 Dental Education & Licensure Madeline S. Ginzburg 2600 Netherland Ave., #117 Riverdale 10463 Ethics Kevin A. Henner 163 Half Hollow Rd., #1 Deer Park 11729
Governmental Affairs OFFICE Joseph R. Caruso 40-29 Utopia Pky., Flushing, 11358 121 State Street Albany, NY 12207 Insurance (518) 465-0044 Roland C. Emmanuele (800) 255-2100 4 Hinchcliffe Dr., Newburgh, NY 12550 Roy E. Lasky Membership & Executive Director Communications Margaret Surowka Rossi Deborah A. Pasquale General Counsel 391 Manhattan Ave., Brooklyn 11211-1422 Michael J. Herrmann Assistant Executive Director New Dentist Finance-Administration David C. Bray 18 Leroy St., Binghamton 13905 Judith L. Shub Assistant Executive Director Nominations Health Affairs Alfonsa J. Perna Sixth District Dental Society Sandra DiNoto 55 Oak St., Binghamton, NY 13905 Director Public Relations Peer Review & Quality Assurance Mary Grates Stoll Richard Rausch Managing Editor 1 Rockefeller Plaza., #2201, Beth M. Wanek New York 10020-2003 Assistant Executive Director Relief Anthony V. Maresca 207 Hallock Rd. NYSDJ • AUGUST/SEPTEMBER 2006 5 Stony Brook, NY 11790 NYSDJ • APRIL 2007 5
FOUNDATION PLEDGES $10,000 for Fluoridation THE BOARD OF TRUSTEES of the New York State Dental Foundation has approved a request for funding in the amount of $10,000 from the Chemung County-Corning Coalition for Water Fluoridation. The Chemung County-Corning Coalition for Water Fluoridation is an affiliation of advocates for completion of the 25-mile corridor of municipal water fluoridation from Chemung County to Painted Post. The eastern portion of Chemung County has been fluoridated since 1953, a system that currently serves 70,000 of the 92,000 residents of the county. To the west, Painted Post has fluoridated since 1976, serving 9,100 residents. In the intervening years, from initial fluoridation to today, many studies have shown that children in the non-fluoridated 25-mile corridor exhibited elevated numbers of decayed, missing and filled teeth. Following a decades-long struggle against vitriolic anti-fluoridationists, public health advocates were able to successfully lobby the Corning Board of Health and the Corning City Council to agree to fluoridate the remaining water supply. The one catch was that the Chemung County-Corning Coalition for Water Fluoridation would have to come up with $100,000, half of the capital costs to start water fluoridation, hence, the request for funding from the New York State Dental Foundation. “We were greatly impressed by the level of support garnered for this project from all possible stakeholders but most notably from the local dental communities,” said Foundation Vice Chairman Robert Raiber. By the time the coalition made its appeal the NYSDF, it had already received $11,000 in pledges from indi12 NYSDJ • APRIL 2007
vidual, local dentists; a $2,500 donation from the Steuben County Dental Society; and a $10,000 donation from the Seventh District Dental Society. In addition, the Ferraioli Dental Lecture has pledged $5,000. Among the NYSDF’s missions is the goal of increasing public understanding of and access to dental services. Clearly, fluoridation is an essential aspect of oral health. The Centers for Disease Control has called fluoridation one of the 10 greatest public health achievements of the 20th century. In its “MMWR Weekly,” the CDC noted: “Fluoridation of drinking water began in 1945 and in 1999 reached an estimated 144 million persons in the United States. Fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions of tooth decay (40% - 70% in children) and of tooth loss in adults (40% - 60%).” The Foundation commends the hard work and efforts of the Chemung County-Corning Coalition for Water Fluoridation and is thankful for the opportunity to support and assist efforts to improve the oral health of all New Yorkers. Foundation Honors Eisenbud
The Board of Trustees of the New York State Dental Foundation recently honored the memory and outstanding achievements of Dr. Leon Eisenbud, with a contribution of $1,000 to a campaign to ren-
Save The Date F O U N D AT I O N S
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EXCELLENCE
Awards Luncheon HONORING Excellence in Community Service & Corporate Leadership
Friday October 12, 2007 12:00 noon to 2:00 p.m. The St. Regis Two East 55th Street At Fifth Avenue, NYC
ovate and rename the dental department at Long Island Jewish Medical Center in his honor. “Dr. Eisenbud,” said Foundation Chair Edward Downes, “will long be remembered by members of our Board as well as the leadership of the New York State Dental Association as the ‘father of the modern dental residency program.’” In a letter written in the fall of 2002 to NYSDA Executive Director Roy E. Lasky, Dr. Eisenbud called passage of the PGY-1 legislation “a grand achievement”and referred to the State Board exam process as “archaic and unfair”: “…I am writing now to congratulate you on this grand achievement, which indeed was only a dream. The substitution of a residency for the unfair and archaic state board exam is the most important step forward for the profession in my lifetime. I congratulate you because I know the way you guide things through the legislative system. I think maybe this would not have happened without you.” “Dr. Eisenbud’s impeccable reputation and his ability to instruct and inform others without a doubt helped NYSDA in its efforts to remove the exam requirement in New York State,” Dr. Downes said. A committee has been formed at Long Island Jewish Medical Center to spearhead the campaign to rename the dental department in Dr. Eisenbud’s memory. It is the committee’s hope that everybody in the dental community will do what he or she can to ensure that Dr. Eisenbud’s legacy will be appropriately memorialized. ■ NYSDJ • APRIL 2007 13
PERSPECTIVES
Practice-Based Research Networks A Win-Win for Private-Practice Dentists and the Future of Dentistry
Analia Veitz-Keenan, D.D.S.; Gary S. Berkowitz, D.D.S.; Irene Brandes, D.D.S., P.C.; Kenneth L. Goldberg, D.M.D.; David A. Hamlin, D.M.D.; Robert Margolin, D.D.S.; Kay Oen, D.D.S. A NEW AND EXCITING TREND in dental research is embodied by the inauguration of three practice-based research networks funded by the National Institute for Dental and Craniofacial Research, an arm of the National Institutes of Health. One is based in the Northwest, a second in the Southeast, and the third, closer to home, at the New York University College of Dentistry. This last, the PEARL Network— PEARL stands for Practitioners Engaged in Applied Research and Learning—has since its inception in 2005 enrolled more than 100 practitioner-investigators and has eight studies either underway or in the planning stages. Practice-based research networks (PBRNs), which have existed in the United States since the 1980s but until recently only among physicians, generate research of immediate relevance to the profession by combining the expertise of a central academic research center with the savvy of the practitioner working “in the trenches.” The PBRN concept arose from recognition of the fact that while the majority of clinical research is conducted in academic health centers, only a minority of patients receive their medical or dental care there. In contrast, in the PBRN model, network participants—clinicians involved in private practice, who represent 70 percent of the profession—submit their own ideas for research to a coordinating academic center, where NIH-approved protocols are developed and in turn are implemented by these same practitioners.Improvements in clinical practice traditionally have proceeded in a top-down manner: a study begins in a laboratory or academic site and ends at an academically based faculty practice.The PBRN model seeks to complement this process by including the primary means of achieving 14 NYSDJ • APRIL 2007
the greatest impact in terms of change: the general practitioner. The PBRN model furthermore seeks to make up for the lack of data available for clinical decision making and to create a mechanism for comparing clinical outcomes reported by practitioners who have decades of experience with findings generated by academic research centers. Dentists Make Good Candidates
In terms of the practical implementation of such a model, experience has demonstrated that private-practice dentists and their office staff are uniquely suited to participate in network-based research, for several reasons. They include the following: ● The research focus of PBRNs is primarily problem based. ● Dentists are trained to be detail oriented and in control of the office environment. ● The essential elements of clinical research are mirrored by the dentist’s experience with implementing a treatment plan. ● Dedicated private-practice staff are familiar with the team approach to clinical care, which parallels the environment required for research coordination. A typical dental PBRN study may last anywhere from one month to three years, although most are of six months’ duration. It is an observational study that addresses a fundamental clinical question: Why we do what we do; and how can we do it better? All studies relate to the day-to-day clinical needs of private dentists and their patients and involve minimal additional work on the part of the practitioner. Current topics under investigation by NYUCD PEARL Network practitioner-investigators, for example, include:
● Causes of postoperative hypersensitivity in Class I composite restorations; and ● The effects of partial vs. complete caries removal on patient outcomes. Studies in the planning stages deal with: ● The effects of endodontic therapy and restoration on tooth longevity; and ● The effects of sealing vs.restoration on caries extending into dentin. Time Well Spent
While the individual dentist’s involvement in a PBRN involves a substantial personal commitment of time and effort, most practitioner-investigators regard the rewards of their participation as more than commensurate. For example: ● Participation in cutting-edge research has a positive impact on the practitioner-investigator’s practice in addition to leading to improvements in the practice of dentistry. ● The Network practitioner-investigator gains training in the methods and ethics of clinical research from specially trained Network personnel—a “gift that keeps on giving.” ● Network administration assumes the burden of paperwork necessary for study approval and reporting, thereby freeing up the practitioner-investigator to concentrate on the nuts and bolts of the study. ● The private-practice dentist, who is typically isolated from the research environment, enjoys a new collegiality with other practitioner-investigators, with a prestigious academic center and with NIH. The PBRN acts as a link connecting dental offices, integrating these offices into a larger organization and uniting practitioners and academic researchers. ● Participation in a Network study helps satisfy the practitioner’s continuing education requirements. Multiple Rewards
More and more dentists are viewing PBRNs as a means for becoming involved with the advancement of the profession by applying scientific guidelines to generate significant—and practice-applicable—clinical data. PBRNs function at the interface between research and quality improvement. They have the potential to have a substantial impact on dentistry by adding a learning dimension to the dental practice while improving primary dental care and creating a connected learning community. They provide opportunities to address patient-centered issues that previously were neglected. The ultimate measure of the success of dental PBRNs will be their ability to influence dentistry, to change clinical procedures on the basis of objective and reproducible evidence gathered by multiple practitioners representing a wide range of patients, clinical expertise and office locations. ■ The authors are all practitioner-investigators in the PEARL network and members of the PEARL Practitioner Advisory Group. More information on the PEARL Network is available at http://www.pearlnetwork.org/ NYSDJ • APRIL 2007 15
NYSDJ Editor Elliott Moskowitz, left, discusses issues facing dental education with Columbia University College of Dental Medicine Dean Ira Lamster.
A C ONVERSATION
WITH
I RA L AMSTER
Dean of Columbia University College of Dental Medicine talks about challenges and rewards of sitting at the helm of one of America’s premier dental schools.
Elliott M. Moskowitz, D.D.S., M.Sd Editor, The New York State Dental Journal THE DENTAL SCHOOL OF COLUMBIA UNIVERSITY officially opened on September 27, 1916, with a combined MD/DDS program. Dr. Joseph Schroff was the first recipient of a dental degree from Columbia, in 1922. Fast forward almost 100 years and we are witness to outstanding contributions to the dental profession by the teachers and graduates of what is now Columbia University College of Dental Medicine. The NYSDJ had an opportunity to visit with Ira Lamster,D.D.S.,M.M.Sc., dean of the College of Dental Medicine.In the interview that follows,Dr. Lamster illuminates Columbia University’s unique approach and commitment to dental education, research, clinical training and community service in an ever-changing and complex health care environment. Dr. Moskowitz: You have been dean of the Columbia University College of Dental Medicine for approximately five years. How are you enjoying the job? Dean Lamster: I enjoy my job immensely. I am fortunate to work with a fine faculty, who are intelligent and dedicated. Our dental students and postdoctoral students are very bright and motivated. In addition, the College of Dental Medicine is positioned within the Columbia University Medical Center, which is a remarkably col16 NYSDJ • APRIL 2007
laborative institution with many outstanding health care scientists and clinicians in medicine, public health and nursing. Many of our academic, research and patient care programs occur in the context of the health sciences, and that is the best position for a dental school to be in. The job of dean has its challenges, and there are many demands on your time and energy. This is not a job you can do effectively unless you believe in your school. Dr. Moskowitz: Are there any special challenges for Columbia University College of Dental Medicine because of its location in a large urban area? Dean Lamster: Being in an urban setting provides challenges and opportunities. The patients we serve are often those who have difficulty accessing services, and they present with a significant disease burden. On the other hand, there is enormous satisfaction for our trainees when they provide a service that changes a person’s ability to function or smile. In addition, we have a large pediatric dentistry service, and starting children in the right direction is a major accomplishment that can prevent a lifetime of dental problems. Dr. Moskowitz: Historically, deans of dental schools have been somewhat inaccessible or, at least, not terribly visible to the profession at large. You, however, are very visible in the dental pro-
fession.You attend dental meetings, on the local, state and national levels, scholarly forums and associated social functions. How does this visibility and accessibility help you in your role as dean? Dean Lamster: It is important for a dean of a dental school to acknowledge his or her constituency. At many of the meetings I attend, I see our faculty and alumni. It is important to be a part of these events.As with all of us, by being there, I can demonstrate my feelings about the importance of an organization or a particular meeting. I am still involved in research and still have an active NIH grant. That is a part of my professional life, but demands on my time are making this difficult to maintain. Dr. Moskowitz: What is your vision for Columbia in the next five years? Dean Lamster: The Columbia University College of Dental Medicine is uniquely positioned to bridge the gap between medicine and dentistry. I appreciate the fact that dentistry is a distinct profession but with close ties to medicine; therefore, defining our role in the health care system is a critical goal for the future.We see our predoctoral program evolving into training that allows greater time for electives and for more interactions with medicine and public health. We are continuing to expand our offsite clinical care initiatives, as well as our research initiatives that look at dental and craniofacial research in the context of health sciences research. Dr. Moskowitz: What differences do you see in the student body at Columbia today as compared to previous eras? Dean Lamster: Our student body is truly outstanding. Like all dental schools in the United States, Columbia is seeing a large number of applicants.And those accepted are among the finest students applying to dental school. They come to us with a variety of experiences prior to entering the college. Many are interested in what we can think of as nontraditional careers, including academics, research, business—we have a combined DDS/MBA program— and public health/public service—we also have a combined DDS/MPH program. Further, many of our students understand the importance of community service and act on those beliefs while at Columbia. Dr. Moskowitz: Columbia has always been identified with having a strong connection to the surrounding community.What is so special about this relationship? Dean Lamster: This effort is special because it acknowledges that the college considers patient care to be an equal mission with training and research. Our connection to the surrounding community formally began in 1996 with formation of the DentCare program, which focused on delivery of dental services to children in the community. This was accomplished through the establishment of small clinics in local schools or through affiliations with community health centers. More recently, we developed the ElderSmile program, which focused on the oral health care needs of older adults. The patient care component of that program includes visits to what we term prevention sites, often located in senior centers.We
Dental school at Columbia University, in New York City, awarded first dental degree in 1922, six years after it opened.
provide both oral hygiene education and screenings for attendees. Individuals in need of services are then referred to a number of community treatment centers that specialize in providing dental services to older adults. Dr. Moskowitz: What role do your alumni play in the overall workings of the dental college? Dean Lamster: The alumni play a very important role. First, a significant percentage of our full-time, part-time and volunteer faculty are alumni of the predoctoral and/or postdoctoral programs. Second, the alumni support the school in a variety of ways besides serving on the faculty. For example, they participate in our continuing education program as lecturers and presenters; they contribute to our annual fund; and we are soon to announce a new capital campaign. They have helped the campaign get off to a fine start. In addition, I am continuously impressed with the accomplishments of our alumni. We have started to feature these individuals and their accomplishments in our alumni magazine Primus and our alumni newsletter Primusnotes. Dr. Moskowitz: What makes Columbia University College of Dental Medicine different from other dental institutions? Dean Lamster: We have redefined the predoctoral curriculum on the basis of three tenets. First, our dental students take their basic science courses with the students at the College of Physicians and Surgeons. Second, we stress the critical importance of postdoctoral education, be that a general practice residency or an AEGD program or a specialty program. In fact, over the past few years, more than 97% of our students have continued their education. Third, we have made dual-degree training an important part of our NYSDJ • APRIL 2007 17
Dean Lamster presides over one of regularly scheduled lunch meetings with small groups of second-year predoctoral students. From left: students Helen Park and Charles Yau; Dean Lamster; student Phillip Mann; NYSDJ Editor Elliott Moskowitz.
curriculum. These offerings include DDS/MPH and DDS/MBA programs, as well as a newly introduced DDS/MA in education with our Teacher’s College. This is intended for those interested in an academic career. We have also just started our first DDS/PhD program, in Bioinformatics. Similar changes are being introduced into the postdoctoral/residency programs. In addition, our place within the Columbia University Medical Center makes us one of only a few dental schools that are truly integrated into their health sciences campus. As you know, we do not have our own building, but, rather, we have floors within the Medical Center. This promotes collaboration with the medicine, public health and nursing programs on a variety of levels. Dr. Moskowitz: Dental schools tend to be somewhat insular with respect to other parts of their universities. What is the relationship between the College of Dental Medicine and other colleges within Columbia University? Dean Lamster: That is not the case at Columbia.While we and the other CUMC schools are physically separated from the 116th Street campus, we are clearly part of Columbia, and the ties between the campuses continue to grow. For example, one of our faculty members is the co-chair of the Columbia University Diversity Council for the professional schools. Our faculty is also involved in the new CTSA grants for clinical research funded by NIH; and one of our junior faculty received a K12 award through that program. In addition, we have a robust research program with Biomedical Engineering, which is located primarily on the 116th Street campus. There are other examples, but you can see the pattern. Dr. Moskowitz: How are you preparing your predoctoral students and postdoctoral residents to cope with an increasingly complex health care environment? Dean Lamster: We feel the environment here at the college is 18 NYSDJ • APRIL 2007
the best teacher. That is, we see dentistry as an integral part of the health sciences environment, and our predoctoral students, postdoctoral students and hospital residents learn from the outset that they are treating a patient and not just a set of dental problems. We also have developed a “curricular map,” which defines the four years of the curriculum into basic, behavioral and clinical tracks so the students can see how these three components fit together. There is also time in the curriculum for discussion of larger issues facing the dental profession, including access to care, dental health care services for older adults and understanding the current role of the profession, as well as the possibilities for the future. Just today, I heard a report on our efforts to introduce smoking cessation into the predoctoral program. This program has made great strides in the past three years, and we believe that our graduates will incorporate this aspect of primary health care into their practices. We are fortunate to attract an excellent group of dental students, postdoctoral students and residents. They are well read and socially conscious when they come to us.We try to nurture that attitude. Dr. Moskowitz: Funding is always a critical issue in private academic institutions. How does Columbia manage this situation? Dean Lamster: The economics of a private dental school are challenging. We are structured so that we are not too dependent on any one source or revenue. Tuition accounts for only one-third of our budget, with clinical income accounting for 40%, and 25% is everything else, including research, extramural programs and fund-raising activities. Each school within Columbia budgets in a similar manner. We capture all of our income, including tuition, clinic fees and all direct and indirect costs associated with grants. In turn, we pay a “common cost” to both the University and the Medical Center.
Dr. Moskowitz: How do you balance allocating resources for scholarly academic matters and clinical areas? Dean Lamster: This is one of the most challenging parts of the job. There are many good ways to spend money—new clinical faculty, adding additional research faculty, construction of new facilities, a new clinic information system, to name a few. I rely on the faculty, and, in particular, the senior faculty, to help guide these decisions. Over the past few years, we have added to the clinical faculty and recruited new research faculty who are engaged in collaborative research across the Medical Center and the University. In addition, we have built new research laboratories and renovated some clinical areas.We are now constructing a new faculty practice on the Medical Center campus. Our next task is to renovate one of our main clinical floors. So, I guess the response to your question is actually, balance. Dr. Moskowitz: Where do ethics fit into the curriculum of your Columbia students? What special challenges do you see in this area? Dean Lamster: Maintaining ethical standards is a challenge for the professions and for society in general.We recently revamped our ethics program and now include instruction in ethics in all four years of the curriculum. In fact, ethical behavior is addressed at orientation for the new first-year students and is reinforced during that week with the White Coat Ceremony. We have also established an Ethics Committee for the College, with representation from the senior and junior full-time faculty, the part-time faculty and the student body. Dr. Moskowitz: Can you tell me if there are any significant problems in attracting our younger colleagues to either full-time or part-time faculty positions? And if so, why? Dean Lamster: In the past few years, we have increased the full-time faculty by 10%. For the most part, these have been recent graduates who have completed their specialty training or completed a general practice residency. They are engaged in teaching, research and clinical care. These are terrific people who are joining the full-time faculty for the right reasons. They enjoy teaching and do it well, and are enthusiastic about an academic career. Many, but not all, are Columbians. I believe we have opened our students’ eyes to the advantages of an academic career, in part by offering dual degree programs—we now even have a DDS/MA joint degree program with the Teacher’s College. I would like to see more young graduates joining the volunteer faculty. Dr. Moskowitz: What would be some incentives for motivating our colleagues to return to their alma mater as either part-time or full-time faculty? Dean Lamster: There are many reasons to join the volunteer faculty. First, as we know, the dental profession is attracting excellent students. It is rewarding to be involved in their education. Second, serving on the volunteer faculty provides opportu-
College of Dental Medicine, on 168th Street, is positioned within Columbia University Medical Center. Mix of patients seen at College reflects its urban setting.
nities for professional interaction that may not be available to the full-time clinician. Third, it is the right thing to do. Dental schools need volunteer faculty. Members of our profession have realized many terrific advantages as a result of their education. We should be giving back so our dental schools remain strong and vibrant Dr. Moskowitz: Academic institutions and the American Dental Association have not always worked harmoniously. How can each support the other’s efforts? Dean Lamster: I agree that the dental schools and the ADA have not always worked well together. If one steps back to examine the situation, there are many reasons why we should work well together. We are educating the future members of the ADA, and we can do more if we work together to address problems faced by the profession. We have, however, developed a good working relationship with the New York State Dental Association. The four dental schools in New York—Columbia, NYU, SUNY Buffalo and SUNY Stony Brook—along with the Eastman Dental Center at the University of Rochester, a graduate dental institution, work together on projects of mutual interest through the New York State Academic Dental Centers group. We often work with NYSDA, and we have found that we have common goals. A mutual respect has developed, and I anticipate that this collaboration will continue to expand in the future. Dr. Moskowitz: I want to thank you for allowing The NYSDJ to interview you. You have provided us with valuable and interesting insight into the educational mission of Columbia University and the challenges of being dean of such a unique academic institution. ■ NYSDJ • APRIL 2007 19
Bacterial Contamination and Decontamination of Toothbrushes after Use Abhishek Mehta, B.D.S.; Peter Simon Sequeira, M.D.S.; Gopalkrishna Bhat, Ph.D. Abstract The purpose of this study was to determine the extent of bacterial contamination of toothbrushes after use and the efficacy of chlorhexidine and Listerine in decontaminating toothbrushes. The effectiveness of covering a toothbrush head with a plastic cap in preventing contamination was also evaluated. It was found that 70% of the used toothbrushes were heavily contaminated with different pathogenic microorganisms. Use of a cap leads to growth of opportunistic microorganisms like Pseudomonas aeruginosa, which may cause infection in the oral cavity. Overnight immersion of a toothbrush in chlorhexidine gluconate (0.2%) was found to be highly effective in preventing such microbial contamination.
THE USE OF ORAL CLEANING INSTRUMENTS, such as a toothbrush and dental floss, is essential for removing dental plaque, a contributor to dental caries and periodontitis. Although various types of toothbrushes and methods of toothbrushing are described, procedures required for maintaining their cleanliness are addressed infrequently. 20 NYSDJ • APRIL 2007
The concept that toothbrushes are contaminated after use was proposed as early as 1920 by Cobb,1 who implicated the contaminated toothbrush as a cause of repeated infections of the mouth. Microorganisms can gain entry into a toothbrush from the oral cavity or from the external environment, such as contaminated fingers, aerosols from toilet flushing and bacteria present in moist, humid conditions found in the bathroom. Various studies1-6 have reported contamination of toothbrushes with microorganisms and have recommended methods of decontamination. However, no studies have been conducted to find out the effectiveness of covering the toothbrush head with a plastic cap in reducing/preventing contamination, as claimed by various toothbrush manufacturers. Also, literature is scarce on the effectiveness of Listerine, a commonly used mouthwash in decontaminating toothbrushes. Therefore, the present study was conducted to determine the level of contamination in used toothbrushes that were kept open and toothbrushes whose heads were covered with a plastic cap (Figure 1). Further, the effectiveness of chlorhexiFigure 1. Different toothdine and Listerine in decontaminating brushes tested for contamination. used toothbrushes was evaluated.
In the third phase, where a plastic cap-covered toothbrush was For the present study, the subjects selected were students from a given, 7 out of 10 toothbrushes showed microbial contamination. hostel, so the environmental conditions were similar. Students who Pseudomonas aeruginosa and Klebsiella spp were isolated from six had open carious lesions, severe gingivitis and throat infections toothbrushes and one toothbrush, respectively (Table 3). None of were excluded from the study. Ten individuals, aged 24 to 27, were the packed toothbrushes (control) showed microbial growth. selected, and written informed consents were obtained. Two unused toothbrushes (control) were cultured to check for any Discussion microbial growth in packed toothbrushes before starting the study. Toothbrushes can get contaminated easily during their use. RetenThe study was conducted in three phases. In all three phases, tion of moisture and the presence of organic matter that has come each lasting one week, subjects were provided with a TABLE 1 brand new toothbrush and were instructed to brush Bacterial Contamination of Toothbrushes after Use with it twice daily and rinse it in running tap water for at least 30 seconds. The toothpaste used by all the subSerial Bacterial Bacteria No.of Contamination jects was the same. Toothbrush In the first phase, subjects were instructed to keep 1 Present Acinetobacter spp, S. aureus, Viridans streptococci their toothbrushes in the open air for drying after use. 2 Present Acinetobacter spp, S. aureus, Viridans streptococci In the second phase, retrieved brushes were immersed 3 Present Acinetobacter spp, S. epidermidis in either a 0.2% solution of chlorhexidine gluconate 4 Absent Absent (ICPA Health Products, India) or Listerine (Pfizer, Ltd., USA) 5 Absent Absent mouthwash for 12 hours by the investigator. 6 Present Acinetobacter spp, S. aureus In the third phase, a new toothbrush, whose head 7 Present Acinetobacter spp, S. aureus was covered with a plastic cap, was given. Along with 8 Present Acinetobacter spp, S. aureus the instructions given in the previous phases, subjects 9 Absent Absent were told to keep the toothbrush head covered with a 10 Present Acinetobacter spp, S. aureus plastic cap after every use. Used toothbrushes were recovered after one week TABLE 2 in each phase and were transported in separate sterile Effect of Antiseptics on Decontamination of Toothbrushes test tubes with a cotton plug for microbiological analysis. The handle of the toothbrush was disinfected with Serial No. of Treatment with Chlorhexidine Treatment with Listerine a surgical spirit and the head part was immersed in 10 Toothbrush No growth No growth ml of phosphate buffered saline (PBS) and vortexed for 1 2 No growth Contaminated five minutes to dislodge the bacteria. Serial 10-fold 3 No growth Contaminated dilutions were made and 10 µl was spread on a blood o No growth No growth agar plate. The inoculated plates were incubated at 370 C 4 No growth No growth for 24 hours. Colony count was determined and bacte- 5 7 ria were defined by standard procedures. PBS (0.1 ml) TABLE 3 was inoculated into 10 ml of tryptic soy broth and o Bacterial Contamination of Toothbrushes with Cap incubated at 370 C for 24 hours and observed for any bacterial growth. Material and Methods
Serial No. of Toothbrush
Bacterial Contamination
Bacteria
Results
1
Present
P. aeruginosa
In the first phase, bacterial contamination was observed in 7 of the 10 tested toothbrushes. Staphylococcus aureus, Viridans streptococci, S. epidermidis and Acinetobacter spp were isolated (count >10 5 cfu / ml) (Table 1). In the second phase,immersion of used toothbrushes (n=5) in chlorhexidine gluconate (0.2%) could kill bacteria.Listerine was found to be less effective, as two of the five brushes showed microbial growth (Table 2).
2
Present
P. aeruginosa
3
Absent
Absent
4
Present
P. aeruginosa
5
Absent
Absent
6
Present
Klebsiella spp
7
Present
P. aeruginosa
8
Present
P. aeruginosa
9
Present
P. aeruginosa
10
Absent
Absent NYSDJ • APRIL 2007 21
from the mouth may promote growth of microorganisms on the toothbrush bristles. Such contamination may lead to colonization of microorganisms in the mouth and possibly infection. It is also possible that contamination of toothbrushes can occur through insects. In the present study, microbial contamination was seen in 7 out of 10 toothbrushes (70%), whereas some previous studies found microbes on all of the tested toothbrushes.2-5 Predominant microorganisms isolated were Acinetobacter spp, S. aureus, S. epidermidis and Viridans streptococci. This is in agreement with most similar studies.2-4 The bacteria were present in count >10 5 cfu / ml, which is the infective dose for many bacteria.A previous study also could show similar rates of bacterial contamination in toothbrushes after use.3 In the present study, chlorhexidine was found to be effective in disinfecting contaminated toothbrushes. These results are consistent with previous reports.2-4 However, one of the previous studies showed that Listerine was more effective.1 The higher efficacy of chlorhexidine could be the result of the extended spectrum of action. Also, it is relatively non-toxic, odorless and is commonly used as a mouthwash. These properties may make chlorhexidine a good choice for disinfection of contaminated toothbrushes. Before commencement of the study, two packed test tooth-
22 NYSDJ • APRIL 2007
brushes were cultured to check for the presence of any microorganisms. No microbial growth was reported from either of the brushes. This shows that contamination came from the external environment. We found no clinical studies reporting levels of microbial contamination of toothbrushes whose heads can be covered with plastic caps. In our study, we found that the use of a plastic cap leads to the growth of microorganisms like Pseudomonas aeruginosa, a gram negative aerobe and opportunistic pathogen. Therefore, it is not advisable to cover a toothbrush head with a plastic cap. Use of a cap may help retention of moisture that promotes growth of P. aeruginosa. ■ REFERENCES 1. Caudry SD, Klitorinos A, Chan ECS. Contaminated toothbrushes and their disinfection. J Can Dent Assoc 1995;61:511-15. 2. Suma Sogi HP, Subbareddy VV, Shashi Kiran ND. Contamination of toothbrush at different time intervals and effectiveness of various disinfecting solutions in reducing the contamination of toothbrush. J Ind Soc Pedo Prev Dent 2002;20:81-85. 3. Bhat SS, Hedge KS, George RM. Microbial contamination of toothbrushes and their decontamination. J Ind Soc Pedo Prev Dent 2003;21:108-112. 4. Filho PN, Macari S, Faria G,Assed S, Ito IY. Microbial contamination of toothbrushes and their decontamination. Paediatric Dent 2000;22:381-4. 5. Taji SS, Rogers AH. The microbial contamination of toothbrushes. A pilot study. Aust Dent J 1998;43:128-30. 6. Kozai K, Iwai T, Miura K. Residual contamination of toothbrushes by microorganisms. J Dent Child 1989;56:201-4. 7. Collee JG, Fraser AG, Marmion BP, Simmons AS. Mackey and McCartney. Practical Medical Microbiology. 14th Edition. New York:Churchill Livingstone. 1996.
SIMPLIFIED METHOD FOR RECORDING Maxillomandibular Relations in Complete Dentures Paul J. Boulos, D.D.S. Abstract A simplified technique for recording maxillomandibular relations in complete dentures is described. This technique enables the practitioner to construct a mandibular occlusal mini-rim directly in the mouth, to adjust it to the required vertical dimension and to record the maxillomandibular relations during a single appointment. The mandibular record is formed with wax, used to hold the occlusal vertical dimension anteriorly, and impression
tioned the validity of the swallowing procedure in determining the reference position in the sagittal plane for the maxillomandibular relationships of complete dentures.6 Of these techniques, the direct interocclusal records using the occlusal rims (wax or plastic modeling impression compound) on record bases remains the most popular technique,7 even though it still needs considerable clinical time to adjust the height of the occlusal rims to match the desired vertical height of the face. Several materials have been used to record maxillomandibular relations in edentulous patients, but impression plaster has gained in popularity because of its accuracy and repeatability.8,9,10
plaster, to record the centric relation posteriorly.
Simplified Method
THE ACCURACY OF maxillomandibular relations is of utmost importance in the construction of complete dentures. The use of such dentures is highly dependent upon a correct centric relation record,1 especially during the first post-insertion months.2 Several methods have been described to record maxillomandibular relations for the fabrication of complete dentures. These include the use of extraoral and intraoral3 tracing devices (Gothic arch), which require additional clinical time, complicated instrumentation and a high level of skill. They also include the swallowing procedure, using the soft wax (cones) recording as described by different authors.4,5 However, some authors have ques-
This technique consists of preparing the record bases (Formatray, Kerr USA, Romulus, MI) with the maxillary occlusal rim only prior to the appointment. The height and orientation of the maxillary rim should be adjusted in the mouth as per the conventional methods (that is, the occlusal plane parallel to the camper plane). The vertical dimension measurements should be performed according to the preferred methods—the phonetic “emma” and the respiratory methods are typically used. The occlusal vertical dimension (OVD) will be the difference between the rest vertical dimension (RVD) and the interocclusal rest space. The next step should consist of lubricating the maxillary rim with petroleum jelly and putting a drop of wax on the middle of the
24 NYSDJ • APRIL 2007
posterior border of the maxillary rim to indicate the position of the tip of the tongue during closure in centric relation. A deeply softened wax wafer, in wet heat preferably (Cavex Set Up regular modeling wax, Cavex Holland B.V., Haarlem, the Netherlands), should then be prepared and fixed in the anterior region of the mandibular base using a hot spatula (Figure 1). However, in extreme angle Class II jaw relationship cases, the mandibular mini-rim would be extended to the first premolar region for better stability of the occlusal rims during the recording. Both record bases should be inserted in the mouth and the mandibular occlusal mini-rim arranged in such a way that its direction closely meets the maxillary rim. The patient should then be asked to put the tip of his or her tongue on the drop of wax situated on the posterior border of the maxillary base, according to the Schuyler technique.11 In the meantime, the practitioner’s left hand should be inverted, the thumb and index finger introduced between the maxillary rim and the mandibular record base posteriorly to hold the bases steady and against the ridges. The patient should be asked to close gently while his or her chin is held between the thumb and the index finger of the practitioner’s right hand (Figure 2). The purpose is to gently guide the closure movement. During closure, the fingers of the left hand should slide out progressively12 to clear the way for the closing mandible, which should close until the height that is judged correct for the vertical dimension is reached. The closing movement of the mandible should be stopped, and the height of the face should be checked with a ruler or a caliper. The mandibular wax mini-rim should be rubbed with the thumb of the right hand to adapt it against the maxillary rim. The patient should then be asked to further close his or her mandible in case it falls short of the calculated dimension; otherwise, the softened wax is rearranged to meet the calculated height. Next, the mandibular base should be retrieved from the mouth and the excess wax trimmed, guided by the imprint of the maxillary rim on the mandibular mini-rim. The mandibular mini-rim, which should then be chilled in cold water, serves to hold the mandible at the desired vertical height. With the record bases back in the mouth in closing position, three vertical lines should be scratched, one in the midline and two laterally, on the maxillary and the mandibular rims. This enables the practitioner to control and guide the centric relation recording later on (Figure 3). Two non-parallel V-shaped notches should be cut on the maxillary rim in the molar region in preparation for the index with the recording material. While the maxillary rim is in the mouth, fast-setting impression plaster (Xanthano, Heraeus-Kulzer, Dormagen, Germany) should be mixed to a creamy blend and spread, slightly in excess occlusally, on
Figure 1. Wax wafer in anterior region of mandibular base.
Figure 2. Closure of mandible stopped at desired vertical height.
Figure 3. Occlusal rims in mouth, with vertical control lines. NYSDJ • APRIL 2007 25
fixed together. If there are doubts about the recording, separate rims should be kept and retried in the mouth to make sure that the plaster index fits the upper notches perfectly at closure. Alternative Method
Figure 4. Interocclusal recording in mouth with impression plaster record.
After setting the height of the vertical dimension and adjusting the mandibular mini-rim, the patient should be asked to close slowly in centric relation, as described earlier, until the mandibular rim touches the maxillary rim. The patient should hold his or her mandible lightly in that position. Meanwhile, a fast-setting impression plaster should be mixed, charged into a 20 cc plastic syringe (Pronto Siringa, Artsana S.P.A., Como, Italy) and injected into the posterior region, on the buccal aspect of the mandibular base. It should be built up until it reaches the maxillary rim (Figure 5). The cheeks should be gently massaged to make sure that the plaster has spread all over the maxillary rim. The plaster has to set before retrieving the record from the mouth. The application of this alternative method is easier, especially for the practitioner who is not familiar with the manipulation of the plaster. Discussion
The advantages of the simplified method over the classical method are described below.
Figure 5. Alternative method: injection of impression plaster between maxillary rim and mandibular record base.
the posterior portions of the mandibular record base. The mandibular base should be put inside the mouth and held in place with the fingers of the left hand, placed intraorally. The patient should be asked to close his or her jaw slowly, with the tip of the tongue on the posterior border of the maxillary base. The movement should be guided gently by the practitioner through the chin and into centric relation. The closure would stop as the mandibular mini-rim contacts the maxillary rim in the already set position. The continuity of the vertical lines would prove the correct position (Figure 4). The latter position should be kept unchanged until the setting of the plaster. Before the plaster sets, the cheeks of the patient should be massaged gently to make sure the plaster has spread evenly against the maxillary rim. As the final setting of the plaster (heat reaction) is completed, both bases should be retrieved from the mouth that is 26 NYSDJ • APRIL 2007
Rapidity The rapidity of the technique reduces considerably the time needed for the recording. In the conventional technique, the mandibular occlusal rim is constructed outside the mouth to an arbitrary height and adjusted to contact evenly the maxillary rim to meet the height of the occlusal vertical dimension already calculated. This procedure will be achieved with many limited readjustments of the occlusal surface of the mandibular rim to attain the hiatus-free contact between the rims. Certainly, the occlusal rims need to be tested in the mouth after every readjustment to assess the progress of the procedure. In addition, the risk of deviation of the mandible due to arising posterior prematurities is always possible with the conventional technique, especially for the inexperienced practitioner. By contrast, when using the simplified technique, the mandibular anterior mini-rim is constructed directly in the mouth devoid of the posterior portions of the occlusal rim and adjusted easily to the required height with a single maneuver. The posterior regions will be filled later by the impression plaster record. Reliability The results of the new method are reliable because the risks of deviation of the mandible and displacement of the soft tissues under the record bases13 are significantly reduced. This is mostly because the properties of the impression plaster, which is fluid during the first stage of mixing, do not present any resistance for closure during the recording of the centric relation. The pressure will
be minimal and evenly distributed on both sides of the arch. Once it is set, the hard and unyielding nature of the plaster will keep the stability of the centric record in contrast to other recording materials (wax, zinc oxide bite registration paste or plastic modeling impression compound). Simplicity The application of the new method is relatively simple and does not require special skills. Finally, according to this technique, the maxillomandibular relations are recorded with two different materials best fit for each component of these relations: wax for the occlusal vertical dimension and impression plaster for the centric relation. Conclusion
A simplified method for recording the maxillomandibular relations in complete dentures is presented. This method, which is based on the conventional techniques of investigation of the vertical dimension and the centric relation, offers the advantages of time, reliability and simplicity over previously described techniques. ■
REFERENCES 1. Fenlon MR, Sherrif M,Walter JD.Association between the accuracy of the intermaxillary relations and complete denture usage. J Prosthet Dent 1999 May;81:520-525. 2. Dervis E.The influence of the accuracy of the intermaxillary relations on the use of complete dentures: a clinical evaluation. J of Oral Rehabil 2004;31:35-41. 3. Langer A, Michman J. Intraoral technique for recording vertical horizontal maxillomandibular relations in complete dentures. J Prosthet Dent 1969;21:599-606. 4. Hakim-Abdel AM. The swallowing position as a centric relation record. J Prosthet Dent 1982; 47:12-15. 5. Ismail YH, George WA. The consistency of the swallowing technique in determining occlusal vertical relation in edentulous patients. J Prosthet Dent 1968;19:230-236. 6. Millet C, Jeannin C,Vincent B, Malquarti G. Report on the determination of occlusal vertical dimension and centric relation using swallowing in edentulous patients. J Oral Rehabil 2003;30: 1118-1122. 7. Jaggers JH, Javid NS, Colaizzi FA. Complete denture curriculum survey of dental schools in the United States. J Prosthet Dent 1985;53:736-739. 8. Urstein M, Fitzig S, Moskona D, Cardash HS. A clinical evaluation of materials used in registering interjaw relationships. J. Prosthet Dent 1991; 65:372-377. 9. Frazier QZ, Wesley RC, Lutes MR, et al. The relative repeatability of plaster interocclusal eccentric records for articulator adjustment in construction of complete dentures. J Prosthet Dent 1971;26: 456-67. 10. Müller J, Götz G, Hörz W, Kraft E. Study of the accuracy of different recording materials. J Prosthet Dent 1990;63:41-46. 11. Schuyler Ch. Intraoral method of establishing maxillomandibular relation. JADA 1932; 19:1012-1021. 12. Hickey JC, Zarb GA, Bolender CL. Boucher’s Prosthodontic Treatment for Edentulous Patients. 9th Ed. St Louis:Mosby. 1985:288-290. 13. Hemphill CD, Parker ML, Regli CP. Effects of uneven occlusal contact when registering maxillomandibular relations. J Prosthet Dent 1972;28:357-359.
NYSDJ • APRIL 2007 27
Effect of Different Surfaces and Surface Applications on Bonding Strength of Porcelain Repair Material Zeynep Duymus Yesil, D.D.S., Ph.D.; Serpil Karaoglanoglu, D.D.S., Ph.D.; Nilgün Akgül, D.D.S., Ph.D.; Nur Ozdabak, Dr. Med. Dent.; Nurcan Ozakar Ilday, Med. Dent. Abstract
were prepared with an air abrasion tool; the lowest bond-
This study was done to analyze the effect of different sur-
ing strength was observed in the samples with a metal
faces and different surface applications on the bonding
substructure, the surfaces of which were prepared with a
strength of porcelain repair material and to compare these
diamond bur. When different substructures were examined
factors with one another. Three different substructures of
in terms of bonding strength, the highest bonding strength
10 mm diameter and 4 mm thickness were used for the
was statistically observed in metal-on-porcelain substruc-
repair surface: metal, metal on porcelain and porcelain.
tures, and the lowest bonding strength was observed in
The surfaces of half of the samples were roughened with
the porcelain substructure. When they were examined in
an air abrasion tool; the surfaces of the other half were
terms of surface processes, the highest bonding strength
treated with a diamond bur. The specimens were ultrason-
was statistically observed in the samples whose surfaces
ically cleaned in distilled water. A silane coupling agent
were prepared with an air abrasion tool, and the lowest
and a bonding agent were applied to the surfaces of all
bonding strength was observed in the samples whose sur-
the samples. Resin composite was applied to each spec-
faces were prepared with a diamond bur.
imen. All specimens were stored in distilled water for 24 hours before being thermocycled. After thermocycling, specimens were stored in distilled water for an additional seven days before being subjected to a shear load. The highest bonding strength was observed in the samples with a metal substructure, the surfaces of which 28 NYSDJ • APRIL 2007
PORCELAIN-FUSED-TO-METAL CROWNS are widely accepted and used in clinical practice. However, they occasionally demonstrate fracture of the brittle ceramic veneer. Failure resulting from porcelain fracture has been reported to range from 2.3% to 8%.1-3 The cause of clinical fracture of veneering porcelain on ceramometal crowns is multifactorial. Lack of proper framework support for the
porcelain, intraceramic defects or parafunctional occlusion can cause this inconvenient problem.4 Ideally, remake of the restoration is desirable, but is not always feasible. The ability to perform an intraoral repair can be of great benefit to the patient.5 However, for the repair to withstand functional loads, the bond between the repair material and remaining restoration must be strong and durable.6 Three conditions are suggested for repair of porcelain fractures: 1. fracture in porcelain only with no metal exposure; 2. fracture with both porcelain and metal exposed; and 3. fracture with substantial metal exposure.7 Various methods have been introduced to repair fractured porcelain with composite.8-11 Mechanical roughing of porcelain surfaces with a coarse diamond bur has improved repair strengths.12,13 Sandblasting with aluminum oxide is another method of surface roughing.7 And porcelain can also be etched with hydrofluoric (HF) acid or acidulated phosphate fluoride gel to facilitate micromechanical retention of the composite.14-16 Until recently, composite repair of fractured porcelain achieved little clinical success. Intraoral repair of fractured porcelain traditionally relied on mechanical roughening of the fractured surface, followed by application of a silane coupling agent to enhance the resin to porcelain bond.17 If a small part of the porcelain is missing, it might be a reasonable solution to repair it intraorally with a light-curing composite resin. A large fracture of porcelain can also be repaired by the same technique, but the result will never be as durable or esthetic as the original restoration.18 This study was done to analyze the effect of different surfaces and different surface applications on the bonding strength of porcelain repair material and to compare these factors with one another. Materials and Methods
A total of 42 cylindrical specimens were fabricated: 14 from porcelain (Ceramco, Burlington NJ, Weybridge UKKT 15 2S, USA); 14 from a Ni-Cr alloy (Wiron 99, Bego, Bremen, Germany); and 14 from a Ni-Cr alloy and porcelain. Fabrication of the specimens was as follows: ● Porcelain specimens. Porcelain was condensed in a split brass mold (1.0 cm diameter and 0.4 cm thickness) with Modisol separating agent (Vident). Condensed cylinders were o placed on a platinum foil sagger tray and fired at 940 C under vacuum in a calibrated porcelain furnace (Ugin/Dentaire [Elips], France). ● Porcelain and metal specimens. Inlay wax cylinders (1.0 cm diameter; half of the cylinders 0.4 cm thickness, and the other half 0.2 cm thickness) were invested and cast with the use of Ni-Cr alloy. The metal cylinders were air abraded with 50 µm aluminum oxide. The opaque was applied to the side with the thinner section surfaces and the porcelain was condensed. The metal and porcelain surface was finished flat with a laboratory medium-grit sintered diamond bur.
Figure 1. Metal, porcelain and metal-porcelain specimens.
● Metal specimens. Inlay wax was flowed into a silicone mold (1.0 cm diameter and 0.4 cm thick). The wax cylinder was invested and cast with the use of a Ni-Cr alloy. The cylinders were cleaned in an ultrasonic unit in distilled water (Figure 1). Each of the substrates was embedded in a phenolic ring (Buehler Ltd, Lake Bluff, IL) with polymethyl methacrylate resin (De Trey RR, Dentsply, England). Metal, metal on porcelain and porcelain sample groups were divided into two equal-numbers groups of 14 samples each. The surfaces of half of the samples (seven metals, seven metal on porcelains and seven porcelains) were air abraded with 50 µm aluminum oxide particles for 15 seconds with an intraoral sandblasting device (Prepstar, Danville Engineering, Danville, USA), rinsed and dried. The surfaces of the other half of the samples were roughened with a coarse diamond bur (No. 520.4, Abrasive Technologies, Columbus, Ohio), and each material to be tested was bonded to the prepared porcelain by following the manufacturer’s directions. The specimens were ultrasonically cleaned in distilled water for 10 minutes. A silane coupling agent and a bonding agent were applied to the mid parts of all the samples in accordance with the recommendations of the manufacturers. The adhesives were used in accordance with the manufacturer.A silane coupling agent (Clearfil Se Bond Primer; Kuraray, Ltd., J Morita USA, Inc., Tustin, Calif.) and bonding agent (Clearfil Se Bond; Kuraray, Ltd., J Morita USA, Inc., Tustin, Calif.) were applied to the complete samples (metal, metal on porcelain and porcelain) and allowed to air dry. The adhesives were used in accordance with the manufacturer. Resin composite (Valux Plus 3M ESPE, Seefeld, Germany) was applied to each specimen according to the manufacturer’s instruction using a Teflon split matrix, 3.5 mm diameter and 2 mm thick (Ultradent, South Jordan, Utah). Resin composite was polymerized with 40-second visible light applications (Elipar II, 3M ESPE, Seefeld, Germany).After the matrix was removed, an additional 40 seconds of visible light was applied. o All specimens were stored in 37 Co distilled water for 24 hours o before being thermocycled between 5 C and 55 C for 300 cycles with a 30-second dwell time. After thermocycling, specimens were o stored in 37 C distilled water for an additional seven days before being subjected to a shear load. The Hounsfield testing machine (Hounsfield Test Equipment Company, HTE 37 Fullerton Road, Croydon, England), with a 0.5 cm/min crosshead speed and chisel apparatus, was used to direct a parallel shearing force as close as possible to the resin/substrate interface. NYSDJ • APRIL 2007 29
TABLE 1 Results of Analysis of Variance Source
Type III Sum of Squares
df
Mean Square
F
Surface Treatments (ST)
10.073
1
10.073
1.698
Substrate
13.770
2
6.885
1.160
ST X Substrate
21.251
2
10.626
1.791
Error
284.803
48
5.933
TABLE 2 Mean and Standard Deviation Results of Results Obtained Tecniques
Substrate
N
Mean(MPa)
SD
Air Abraz
M
7
11.99
2.09
Diamond Bur
M-P
7
11.30
2.76
P
7
9.99
2.55
M
7
9.35
2.89
M-P
7
11.25
1.83
P
7
10.04
2.32
TABLE 3 Mean(MPa)
SD
Metal
10.67
2.80
Metal-porcelain
11.27
2.28
Porcelain
10.04
2.49
The shear load in newtons at the point of failure was noted and force was calculated in megapascals (MPa). An analysis of variance (ANOVA) was applied to the data. Mean and standard deviations were calculated. Results
The results of the variance analysis used to evaluate the data are shown in Table 1. It was statistically determined that the type of substructure used for repair, the surface application and interactions are not important (p> 0.05). The mean and standard deviation results of the data obtained are shown in Table 2. The highest bonding strength was observed in the samples with metal substructure, the surfaces of which were prepared with air abrasion (11.99 MPa); then came the samples with metal-on-porcelain substructure, the surfaces of which were roughened with air abrasion (11.30 MPa). The lowest bonding strength was observed in the samples with metal substructure, the surfaces of which were prepared with a diamond bur (9.35 MPa). When different substructures were examined in terms of bonding strength, the highest bonding strength was statistically observed in the metal-on-porcelain substructures (11.27 MPa) and the lowest bonding strength was observed in the porcelain substructure (10.03 MPa) (Table 3). When they were examined in terms of surface processes, the highest bonding strength was statistically observed in the samples whose surfaces were prepared with air abrasion, and the lowest bonding strength was observed in the samples whose surfaces were prepared with a diamond bur. Discussion
This study examined the shear bond strengths of composite material used for repair in three representative situations: fracture within porcelain; fracture within porcelain with exposure of some ceramic alloy; and fracture with complete porcelain delamination and exposure of a large section of alloy. When the fracture occurs with metal exposure, the repair is more problematic. Traditionally, attempts to bond resin to metal have involved roughening the metal to provide mechanical retention of the resin. One easy method of enhancing bond strength is roughening the surface by air abrasion with aluminum oxide, thereby increasing the surface area for bonding and decreasing surface tension.19 High composite alloy bonds have been reported with base metal alloys treated with sandblasting.20,21 A previous study reported that the alumina content of base alloys increased up to 37% after sandblasting, and ultrasonic cleaning resulted in only minor removal of the embedded alumina.22 Sandblasting the base alloy surface that resulted in the surface containing a significant amount of alumina particles, which affects bond strength, has been reported.23 Porcelain surface sandblasted with alumina resulted in micromechanical roughening and covering with small alumina parti30 NYSDJ • APRIL 2007
cles.24 The reported bond strengths of the sandblasted porcelain surface ranged from 9 to 17 MPa.25 The present study yielded results within the limits mentioned by the above researchers. Chung and Hwang6 reported a significant increase in bond strength of composite-to-base alloy when the surface was air abraded with aluminum oxide. Suliman et al25 noted no significant differences between diamond roughening, air abrasion and hydrofloric acid treatment. Unglazed porcelain surfaces have been shown to contribute to stronger composite-porcelain bonding,10 and the application of silane, regardless of prior surface treatment, has consistently raised bond strengths in laboratory studies.14,26 Kupiec et al27 found that hydrofluoric acid treatment enhanced bond strength, especially when used with a silane agent. Similarly, Stangel et al14 demonstrated that etching porcelain with hydrofloric acid significantly contributed to increased bond strength of the composite. Roughening with air abrasion and diamond bur was used as the surface application in the present study. As hydrofluoric acid was present in the bond used; it was applied to all the samples. Mechanical alteration of a porcelain surface is more important than agents that promote chemical bonding of composite resin to porcelain.28 With the above researchers’ views in mind, silane, a cou-
pling agent, and a bonding agent were applied to the surfaces to which the composite would be applied following the mechanical roughening. According to Anusavice,29 an infinite number of fracture paths of the veneer porcelain can occur.Clinically,porcelain fracture can be seen with no exposure of the metal substrate or with complete deveneering of porcelain with extensive metal exposure. Repairs made on multiple substrates may behave differently than those made only on a ceramic surface. Previous studies have primarily examined repairs made solely to a porcelain or alloy substrate.4,10,30-32 Few have tested bond strengths to a combined surface.6 Bond strength values depended on the system used, with the strongest bonds to porcelain resulting in cohesive failure in the porcelain substrate.11,33 Chung and Hwang,6 in their study, in which they applied different composite resins and their bonds to different substrates, determined that the highest degree of bonding strength was in the samples with the metal substrates. It was found that the best bond between the fractured surface and the repair composite resin was obtained with a porcelain instead of metal surface.8,18 Because the success of the adherence depends on the amount of remaining porcelain surface, it was proposed to extend the bonding surface of the fractured porcelain to improve the bond strength of the repair material.34
NYSDJ • APRIL 2007 31
There is little information on the bond strength of porcelain repair materials to the metal porcelain combined surface.6 When the repaired surfaces were compared in terms of the bonding strength, the highest bonding strength was determined in the subjects with metal-on-porcelain substructure. This result is in harmony with the findings of the above-mentioned researchers. Research on porcelain repair has included shear, tensile and three-point loading. The porcelain-resin interface has also been subjected to fatigue loads.30 The concept of fatigue testing is applicable to brittle ceramic materials;29 but when such testing is applied to the porcelain-resin interface, large standard deviations suggest an abnormally distributed population because some specimens do not fail.30 A shear test was chosen for this study because multiple substrates were used. In addition, anterior restorations are subjected primarily to shear stresses, and the shear test is considered appropriate for quantifying the strength of porcelain repairs.35 The use of thermocycling is variable in the literature. Most studies using thermocycling have reported that bond strengths are reduced by thermocycling.11,36 A common finding among many of these studies was a reduction in shear bond strength after prolonged water storage and/or thermocycling.2,10,11,30-32 The effects of moisture, thermal stress and fatigue on bond strength have been explored.3,11,30 Since the effect of thermocycling was not examined in our study, we could not form a control group. So thermocycling was applied in the way recommended in the literature.3,10,11,30,31,32,36 Conclusion
It was statistically determined that the type of substructure, the surface application and the interactions were not important. The highest bonding strength was observed in the samples with metal substructure, the surfaces of which were prepared with air abrasion. The lowest bonding strength was observed in the samples with metal substructure, the surfaces of which were prepared with a diamond bur. When different substructures were examined in terms of bonding strength, the highest bonding strength was statistically observed in metal-on-porcelain substructures, and the lowest bonding strength was observed in the porcelain substructure. When they were examined in terms of surface processes, the highest bonding strength was statistically observed in the samples whose surfaces were prepared with air abrasion, and the lowest bonding strength was observed in the samples whose surfaces were prepared with a diamond bur. ■ REFERENCES 1. Libby G, Arcuri MR, LaVelle WE, Hebl L. Longevity of fixed partial dentures. J Prosthet Dent 1997;78:127-131. 2. Strub JR, Stiffler S, Schärer P. Causes of failure following oral rehabilitation: biological versus technical factors. Quintessence Int 1988;19:215-222. 3. Coornaert J,Adriaens P, De Boever J. Long-term clinical study of porcelain-fused-to-gold restorations. J Prosthet Dent 1984;51:338-342. 32 NYSDJ • APRIL 2007
4. Bello JA, Myers ML, Graser GN, Jarvis RH. Bond strength and microleakage of porcelain repair materials. J Prosthet Dent 1985;54:788-791. 5. Haselton DR, Diaz-Arnold AM, Dunne JT. Shear bond strengths of 2 intraoral porcelain repair systems to porcelain or metal substrates. J Prosthet Dent 2001;86:526-531. 6. Chung KH, Hwang YC. Bonding strengths of porcelain repair systems with various surface treatments. J Prosthet Dent 1997;78:267-274. 7. Bertolotti RL, Lacy AM, Watanabe LG. Adhesive monomers for porcelain repair. Int J Prosthodont 1989;2:483-489. 8. Beck DA, Janus DE, Douglas HB. Shear bond strength of composite resin porcelain repair materials bonded to metal and porcelain. J Prosthet Dent 1990;64:529-533. 9. Bailey JH. Porcelain-to-composite bond strengths using four organosilane materials. J Prosthet Dent 1989;61:174-177. 10. Diaz-Arnold AM, Schneider RL,Aquilino SA. Bond strength of intraoral porcelain repair materials. J Prosthet Dent 1989;61:305-309. 11. Pratt RC, Burgess JO, Schwarts RS, Smith JH. Evaluation of bond strength of six porcelain repair systems. J Prosthet Dent 1989;62:11-13. 12. Jochen DG, Caputo AA. Composite resin repair of porcelain denture teeth. J Prosthet Dent 1977;38:673-679. 13. Ferrando JM, Graser GN, Tallents RH, Jarvis RH. Tensile strength and microleakage of porcelain repair materials. J Prosthet Dent 1983;50: 44-50. 14. Stangel I, Nathanson D, Hsu CS. Shear strength of the composite bond to etched porcelain. J Dent Res 1987;66:1460-1465. 15. Tylka DF, Stewart GP. Comparison of acidulated phosphate fluoride gel and hydrofluoric acid etchants for porcelain-composite repair. J Prosthet 1994;72:121-127. 16. Della Bona A, van Noort R. Shear vs. tensile bond strength of resin composite bonded to ceramic. J Dent Res 1995;74:1591-1596. 17. Council on dental materials, instruments and equipment, porcelain repair materials. J Am Dent Assoc 1991;122:124-130. 18. Hirschfeld Z, Rehany A. Esthetic repair of porcelain in a complete-mouth reconstruction: a case report. Quintessence Int 1991;22:945-947. 19. Swift EJ Jr. New adhesive resins. A status report for the American Journal of Dentistry. Am J Dent 1989;2:258-260. 20. Aquilono SA, Diaz-Arnold AM, Priotrowski TJ. Tensile fatigue limits of prosthodontics adhesives. J Dent Res 1991;70:208-210. 21. Chang JC, Powers JM, Hart D. Bond strength of composite to alloy treated with bonding systems. J Prosthodont 1993;2:110-114. 22. Kern M, Thompson VP. Sandblasting and silica coating of dental alloys: volume loss, morphology, and changes in the surface composition. Dent Mater 1993;9:155-161. 23. Diaz-Arnold A, Keller JC, Wightman JP, Williams VD. Bond strength and surface characterization of a Ni- Cr- Be alloy. Dent Mater 1996;12:58-63. 24. Kern M, Thompson VP. Sandblasting and silica coating of a glass-infiltrated alumina ceramic: volume loss, morphology, and changes in the surface composition. J Prosthet Dent 1994;71:453-461. 25. Suliman AH, Swift EJ Jr, Perdigao J. Effects of surface treatment and bonding agents on bond strength of composite resin to porcelain. J Prosthet Dent 1993;70:118-120. 26. Hayakawa T, Horie K,Aida M, Kanaya H, Kobayashi T, Murato Y. The influence of surface conditions and silane agents on the bond of resin to dental porcelain. Dent Mater 1992;8:238-240. 27. Kupiec KA,Wuertz KM, Burkmeier WW,Wilwerding TM. Evaluation of porcelain surface treatments and agents for composite- to- porcelain repair. J Prosthet Dent 1996;76: 119124. 28. Thurmond JW, Burkmeier WW, Wilwerding TM. Effect of porcelain surface treatments on bond strength of composite bonded to porcelain. J Prosthet Dent 1994;72:355-359. 29. Anusavice KJ. Phillips’ science of dental materials. 10th Ed. Philadelphia:WB Saunders Co, 1996:63,309,606. 30. Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue life of porcelain repair systems. Int J Prosthodont 1992;5:205-213. 31. Appeldoorn RE, Wilwerding TM, Burkmeier WW. Bond strength of composite resin to porcelain with newer generation of porcelain repair systems. J Prosthet Dent 1993;70:611. 32. Cooley RL, Tseng EY, Evans JG. Evaluation of a 4-META porcelain repair systems. J Esthet Dent 1991;3:11-13. 33. Wolf DM, Powers JM, O’Keefe KL. Bond strength of composite to porcelain treated with new porcelain repair agents. Dent Mater 1992;8:158-161. 34. Berksun S, Kedici PS, Saglam S. Repair of fractured porcelain restorations with composite bonded porcelain laminate contours. J Prosthet Dent 1993;69:457-458. 35. Leibrock A, Degenhart M, Behr M, Rosentritt M, Handel G. In vitro study of the effect of thermo- and load-cycling on the bond strength of porcelain repair systems. J Oral Rehabil 1999;26:130-137. 36. Newburg R, Pameijer CH. Composite resins bonded to porcelain with silane solution. J Am Dent Assoc 1978;96:288-291.
Alport Syndrome Report of a Case with Severe Maxillofacial Manifestations Kurt Friedman, D.D.S., M.S.; Ines Velez, D.D.S., M.S. Abstract Alport syndrome (AS) represents a genetic cause of renal failure that affects about 1 in 5,000 Americans. In cases of AS, the problem resides on the X chromosome. Specific mutations to the gene cause defects in one of several subunits of Type IV collagen. Accumulation of collagen types V and VI, with subsequent abnormalities in the permeability and sclerosis of the kidney, leads to renal failure. Renal failure causes severe bone disease since the kidney processes vitamin D, which is necessary for calcium absorption from the intestine. Therefore, in a patient with chronic renal disease, vitamin D is not produced, resulting in a decrease in intestinal absorption of calcium and subsequent lower serum calcium levels. Furthermore, the decreased phosphate excretion by the kidney leads to elevation of plasma phosphate, which increases the amounts of parathyroid hormone required to move calcium from bone (secondary hyperparathyroidism) to maintain plasma calcium at a constant level and preserve an appropriate calcium-phosphorous ratio. We have described AS, reviewed the pathogenesis and presented an interesting extreme case with numerous craniofacial manifestations. 34 NYSDJ • APRIL 2007
ALSO KNOWN AS hereditary deafness nephropathy, Alport syndrome (AS) presents as a genetic cause of kidney failure and afflicts about 1 in 5,000 Americans. It also affects the cochlea and the eye. AS is identified by its presence on the X chromosome, specifically, the gene COL 4A5. Mutations to the gene cause defects in one of several subunits of Type IV collagen, specifically, ␣ 3- ␣ 4- and ␣ 5- chains, which may be absent. As a compensatory response, there is an accumulation of collagen types V and VI in the basement membrane of the glomerulus. Subsequent abnormalities in the permeability and sclerosis of the kidney tissue will lead to renal failure.1 A group of hereditary diseases characterized by thrombocytopenia, renal disease, cataracts and deafness are called Alport-like syndromes because they are clinically similar. But the genetic mutations linked to this group of disorders are different from those seen in AS.2,3 There are two genetic types: autosomal dominant (1% of the cases), and autosomal recessive (14% of the cases). The Xlinked AS constitutes 85% of the cases of Alport and Alport-like syndromes. The condition is more severe in males than females, but there is no racial predilection.4 Renal Dysfunction
Approximately one million nephrons are present in each normal kidney, but since chronic renal failure (CRF) is characterized by a loss of nephrons, AS patients exhibit progressive destruction of them. To compensate for the destroyed renal tissue, hypertrophy of the remaining healthy kidney proceeds to maintain the glomerular filtration rate and continues until the renal reserve has been exhausted. But the kidney hypertrophy leads to increased glomerular capillary pressure, which damages the capillaries and represents yet another cause of renal dysfunction.
Since there is no specific treatment that can cure AS, a kidney transplant is usually needed. Unfortunately, the immune system may react against the normal collagen of the new
Figure 1. Clinical view. Facial deformity is evident.
kidney, destroying the transplant and leading to end stage renal failure.8 The involvement of the glomerulus in patients with AS produces hematuria as an earliest manifestation. Proteinuria and hypertension develop in adulthood, with severity increasing with age. Initially, the clinical findings are unremarkable, but with time, progressive renal failure, manifested by edema, chronic anemia, severe bone alterations and hypertension, is observed.5 Hearing defects, including bilateral high frequency hearing loss, become apparent by late childhood, before the onset of renal failure. Some patients with AS also exhibit ocular manifestations, such as lenticonus and retinopathy, which manifest at the time of kidney failure. Proliferation of the smooth muscle of the esophagus and the tracheobronchial system is seen in some cases,6 as is mental retardation.7
Figure 2. Alveolar ridge and gingival enlargement. Diastemas.
Establishing a Diagnosis
The diagnosis of AS is based upon family history, physical examination, immunohistochemical analysis of basement membrane Type IV collagen—using skin or kidney tissue—and electron microscopic renal biopsy analysis. Genetic testing is available for Xlinked cases. Since there is no specific treatment that can cure AS, a kidney transplant is usually needed. Unfortunately, the immune system may react against the normal collagen of the new kidney, destroying the transplant and leading to end stage renal failure.8 Renal failure causes severe bone disease since the kidney processes vitamin D, which is necessary for calcium absorption from the intestine. Therefore, in a patient with chronic renal disease, vitamin D is not produced, resulting in a decrease in intestinal absorption of calcium and subsequent lower serum calcium levels. Furthermore, the decreased phosphate excretion by the kidney leads to an elevation of plasma phosphate,which increases the amounts of
Figure 3. CT scan; axial view. Craniofacial lesions. NYSDJ • APRIL 2007 35
Figure 4. CT scan; sagital view. Craniofacial lesions.
Figure 5. CT scan; tri-dimensional view. Surface rendering. Generalized lesions. Loss of cortical bone (secondary hyperparathyroidism) is evident.
parathyroid hormone required to move calcium from bone (secondary hyperparathyroidism) to maintain plasma calcium at a constant level and preserve an appropriate calcium-phosphorous ratio. The turnover of the bone increases, as does the number of bone remodeling centers; and if calcification of osteoid is inhibited, bone disease becomes severe with the possibility of pathologic fracture. The result is osteomalacia with generalized loss of the lamina dura being seen as an early manifestation of the condition. A decrease in trabecular density is observed, and brown tumors (sometimes multiple) of hyperparathyroidism usually develop. Osteomalacic bone may show mineralization and osteosclerosis later. Anemia is always present,mainly as a result of the decreased production of red blood cells by the bone marrow.This is due to the inability of the kidneys to secrete erythropoietin, the hormone needed to stimulate normal bone marrow to produce red cells.Blood loss,resulting from the malfunction of platelets in patients suffering from uremia,and hemolysis,seen in advanced renal failure,are also factors that contribute to the severe anemia observed in those cases.Furthermore, the normal life span of erythrocytes is about four months.But in renal failure patients, the life of the red blood cells is reduced due to the chemical effect of the uremia. In addition, the accumulation of uremic toxins may play a role in depressing bone marrow function. A person with severe anemia tries to compensate for this condition by increasing bone marrow tissue, and, subsequently, blood cell production. It can be done easily by somebody with normal bone marrow, but in renal failure, the bone marrow’s capacity to compensate is decreased, even though bone marrow tissue may be generated in sites such as the mandible and skull. The effects of CRF on bone are primarily due to secondary hyperparathyroidism. The condition that develops in these patients
is called osteitis fibrosa cystica, and it results from the degeneration of the multiple brown tumors. One clinical manifestation of this entity is the striking enlargement of the jaws.9 Bone deformity and widening of bone plates also occur as a result of the body’s efforts to compensate for anemia. This combination of anemia, secondary hyperparathyroidism, osteomalacia, osteitis fibrosa cystica and osteosclerosis leads to the alteration of bone in end stage renal disease patients.
36 NYSDJ • APRIL 2007
Case Report
A 29-year-old black female was referred to the oral and maxillofacial surgeon because of severe bleeding of the gingiva. Medical history showed a previously confirmed diagnosis of Alport syndrome. The patient developed progressive loss of renal function, and a kidney transplant was necessary. Failure of two renal transplants and end stage renal disease led to dialysis as the only treatment option. Examination revealed a terminally ill black female patient exhibiting severe cosmetic and functional deformity. Significant observations included painless, bilateral and symmetrical severe swelling of the maxilla with involvement of the orbital floor, extreme bilateral enlargement of the mandible and multiple diastemas. The bone expansion caused swelling and distortion of the face and subsequent widening of the alveolar ridge, as well as tooth displacement and tooth mobility, impaired mastication and speech difficulties. Fibrosis and bleeding of the gingiva and very poor oral hygiene were factors also recorded. The radiographs and CT scan exhibited generalized expansive, mixed, radiolucent and radioopaque areas over the entire craniofacial skeleton. Most of the radiographic lesions were completely dif-
fuse and some areas exhibited ground glass appearance. The skull bones showed radiopaque areas and radiolucent lesions with widening of bone plates. The radiolucent lesions may have represented bone marrow defects or brown tumors. The severe bone deformity present in this case may have been caused by a combination of compensatory anemia lesions, secondary hyperparathyroidism, osteomalacia, osteitis fibrosa cystica and posterior hypercalcification. The gingival bleeding noticed in this patient was due to malfunction of the platelets and decrease in bone marrow cell production, usually present in patients with an accumulation of uremic toxins and exacerbated by poor oral hygiene. Conclusion
We have described Alport syndrome, reviewed the pathogenesis and presented an extreme case with numerous craniofacial manifestations. Besides extreme bone deformities, patients may show fractures, epistaxis, gingival bleeding, anemia, lenticonus and retinopathy. Other associated maxillofacial problems include hearing and speech difficulties and malocclusion. AS is a condition initiated by a genetic alteration of Type IV collagen, followed by subsequent abnormalities in the permeability of the kidney, resulting in renal failure. In advanced cases, a combination of secondary hyperparathyroidism, osteomalacia, osteitis fibrosa cystica and osteosclerosis leads to dramatic bone changes.
Renal failure also causes anemia, the result of different mechanisms, such as lack of erythropoietin, decreased life span of erythrocytes, blood loss produced by platelet malfunction and toxic depression of bone marrow function. A compensatory increase in bone marrow production may also lead to maxillary, mandibular and skull lytic lesions and enlargement. The pathogenesis of the mechanisms previously described may be enough to explain the severe bone changes observed in this patient. ■ REFERENCES 1. Gross O, Netzer KO, Lambrecht R, Seibold S, Weber M. Meta-analysis of genotype-phenotype correlation in X-linked Alport syndrome: impact on clinical counseling. Nephrol Dial Transplant 2002;17:1218-1227. 2. Epstein CJ, Sahud MA, Piel CF, Goodman JR, Bernfield MR, Kushner JH, Ablin AR. Hereditary macrothrombocytopenia, nephritis and deafness.Am J Med 1972;52:299-310. 3. Rocca B, Laghi F, Zini G, Maggiano N, Landolfi R. Brit J Haemat 1993;85:423-426. 4. Longo I, Porcedda P, Mari F et al. COL 4A3/COL 4A4 mutations from familial hematuria to autosomal dominant or recessive Alport syndrome. Kidney Int 2002;61(6): 1947-1956. 5. Mothes H, Heidet L, Arrondel C, Richter KK, et al. Alport syndrome associated with diffuse leiomyomatosis: COL4A5-COL 4A6 deletion associated with a mild form of Alport nephropathy. Nephrol Dial Transplant 2002;17:70-74. 6. Dische FE, Weston MJ, Parsons V. Abnormally thin glomerular basement membranes associated with hematuria, proteinuria or renal failure in adults. Am J Nephrol 1985;5: 103-109. 7. Meloni I, Vitelli F, Pucci L et al. Alport syndrome and mental retardation: clinical and genetic dissection of the contiguous gene deletion syndrome in Xq 22.3 J Med Genet 2002;39(5):359-365. 8. Byrne MC, Budisavljevic MN, Fan Z, et al. Renal transplant in patients with Alport’s syndrome. Am J Kidney Dis 2002;39(4):769-775. 9. Gavalda C, Bagan JV, Scully C, et al. Renal Hemodialysis Patients. Oral, salivary, dental and periodontal findings in 105 adult cases. Oral Dis 1999;5:292-302.
NYSDJ • APRIL 2007 37
Figure 1a. Preoperative.
Figure 1b. Laser at 0.5W.
Figure 1c. Laser at 0.75W.
Figure 1d. Laser at soft tissue setting; G4 tip.
Laser Exposure of Unerupted Teeth Ali Asgari, D.D.S.; Barry L. Jacobson, D.M.D.; Manisha Mehta, D.M.D.; John L. Pfail, D.D.S.
Abstract Surgical soft tissue exposure of impacted teeth can now be performed with little to no discomfort and excellent postoperative healing. This paper focuses on the techniques used in performing this procedure.
THE IMPLEMENTATION of lasers in dentistry has given dentists a completely new instrument in their armamentarium. In recent years, lasers have proven to be an integral part of many dental practices.1-3 Use of the laser allows the general clinician to perform a variety of procedures without the adjunctive use of local anesthesia, alleviating patient anxiety, while increasing the clinician’s own capabilities to perform procedures they might otherwise have referred to a specialist.4 Laser use has also facilitated specialty practice by allowing the specialist to perform many soft tissue surgical procedures more expeditiously and with excellent postoperative healing. It also has eliminated the need for local anesthesia in many cases.1,5,6 The Er,Cr:YSGG dental laser can accomplish these tasks by using a wavelength of 38 NYSDJ • APRIL 2007
2,780 nm to energize water particles delivered at the fiber optic tip through various ratios of water and air to cut both hard and soft tissue effectively without causing microcrazing in the enamel matrix.7,8 With respect to soft tissue, it can use the existing hydration of the oral soft tissue to perform its task.7,9 This interaction at the tissue surface with energized water particles is termed “hydrokinetic” energy.6 With use of the Er, Cr:YSGG laser, the clinician is able to achieve exceptional results in both the operating procedure and in postoperative healing. Clinical Technique
Case One An 8-year-old child presented to the dental clinic with both maxillary central incisors impacted in the soft tissue. Because of the age of the child and the possible sequelae of the laterals drifting mesially and future orthodontic complications,the decision was made to surgically expose the teeth.7 The laser technique was employed using a T4 tip and three consecutive settings to first obtain laser anesthesia. One of the many benefits of using the laser is being able to forgo the traditional injection anesthetic in
performing the procedure. Although not effective in every situation, with proper case selection and repeated practice, the laser can yield excellent results in obtaining laser anesthesia. The first setting of 0.25 W with 10% air and no water was used while slowly outlining the area of exposure. The proper distance can be gauged by evaluating the white chalky outline as the laser begins to excise the tissue. Excessive darkening of the tissue should not be seen this early on in the procedure.1-5 The setting was then increased to 0.5 W with 10% air and no water and the same outline followed. Third, 0.75 W was used with 10% air and no water. This is done to achieve anesthesia and to serve as a guideline for outlining the area to be surgically exposed.8,10 The tissue begins to darken as the power increases and the cutting becomes more aggressive. Once anesthesia is established, the soft tissue settings of the laser are used at 1.5 W with 7% water and 11% air.3,4 The tip is changed to the G4 tip, which allows more precise cutting of the tissue. The water is not being used as the cutting agent in the soft tissue procedures because the tissue is already hydrated.11 Thus, the
Figure 1e. One week postoperative.
Figure 2a. Preop.
Figure 2b. Operative.
Figure 2c. Soft tissue settings.
Figure 2d. Postoperative view.
Figure 2e. Setting at 0.25W.
water and air settings are decreased from the hard tissue setting to act mainly as a cooling mechanism as the laser cuts soft tissue.8,9 The G4 tip is moved back and forth along the exposure line already delineated by the T4 tip. Deeper cuts are made until the soft tissue impeding the eruption of the central incisors is removed.11 The patient was seen one week postoperatively and reported no discomfort.3-5 The central incisors began erupting into their proper alignment.
A procedural protocol similar to the one used in Case One was followed,with certain modifications to the laser settings. The procedure began again by obtaining soft tissue anesthesia. In this situation, we maintained the same wattage settings, but the air was increased by 4%. The procedure began with the settings at 0.25 W with 14% air and no water, slowly outlining the area of the exposure. The setting was then increased to 0.5 W with 14% air and no water, and the same outline was followed. Finally, 0.75 W was used with 14% air and no water, thereby completing the laser anesthesia technique. The laser was focused and defocused,according to the patient’s response. Once proper soft tissue anesthesia was obtained, the setting was switched to the soft tissue ablation settings and gentle removal of the tissue was initiated. The G4 tip was used in a continuous sweeping motion, and the proper distance was established by gauging the color change in the tissue to a darker appearance. Enough tissue was removed until the crown of the tooth was exposed. Once the crown became apparent, cutting was ceased to prevent damage to the underlying tooth structure.
Case Two A second case presented with a similar situation of an impacted left central incisor. The 8-year-old child with a soft tissue impacted maxillary left central incisor was brought in for routine care. The child displayed an otherwise normal eruption pattern, and the tooth was treatment planned for a surgical exposure. Along with functional challenges to mastication, the soft tissue-impacted central incisor was also causing the patient emotional distress, as he was being teased by his peers. The decision was made to expose the incisor to facilitate its eruption into proper alignment, treat the patient’s chief complaint and correct his dental malocclusion.
Figure 2f. Setting at 0.5W.
Figure 2g. Setting at 0.75W.
Figure 2h. Setting at 2.0 W. NYSDJ • APRIL 2007 39
The laser offers the clinician a multitude of advantages in performing soft tissue dentistry.11 First and foremost, it has eliminated the need for local anesthesia in many cases.
Figure 3a. Preop.
Figure 3b. Operative.
Figure 3c. Immediate postop.
Figure 3d. One week postop.
Subsequent to sufficient tissue removal, the tooth will be able to erupt into the proper position unhindered. Case Three The third case involves a 10-year-old female with both permanent central incisors and a right lateral incisor still not erupted. The radiograph demonstrated more than two-thirds root development and possible impaction of the teeth if the roots continued to grow without the teeth erupting through the gingiva. The child presented with speech difficulties and, based on her reserved manner in the clinic, psychological difficulties, arising from her missing front teeth.The decision was made to expose the teeth using the above-mentioned laser settings. In this case, the patient was experiencing discomfort from the procedure even with repeated efforts to obtain laser anesthesia. Local anesthetic of three-quarters of a Carpule of 3% Carbocaine was used for anesthesia. It was explained to the parent that further exposure might be required for the right lateral incisor because of the extent of the impaction. Also, an insufficient amount of space was presented as a possible complication in allowing the lateral incisor to erupt into place. It was also possible that maxillary expansion would be needed in the future. Within one week of the procedure, the central incisors had begun erupting. The patient was followed up three months later. The central had erupted completely. An additional surgical exposure of tooth #7 was completed and within one week, the tooth had begun erupting. Discussion
Figure 3e. Three months postop. 40 NYSDJ • APRIL 2007
The laser offers the clinician a multitude of advantages in performing soft tissue dentistry.11 First and foremost, it has eliminat-
ed the need for local anesthesia in many cases. This is of particular importance in pediatric dentistry because it not only does away with the anxiety and fear associated with receiving an injection, it also removes the risk of post-anesthetic complications, such as the child accidentally injuring himself.12 The reasons for the numbing effect of the laser have only been postulated at this point to result from its transient anesthetic effect, since the laser is not in continuous contact with the tissue.12 The pulsation of the laser allows it to be in contact intermittently in rapid sequence, relieving the pain stimulus associated with the procedures. The laser also removes the need for a scalpel in performing these procedures. Although a skilled surgeon can use the scalpel with great accuracy, once an incision is made, there is no digressing from the cut.With the laser, the clinician can better control how aggressively he or she wants to be in removing tissue.11,12 Therefore, a less experienced clinician can use the laser at a lower setting and cut the tissue more slowly to reach the same result but at a pace more fitting to his or her comfort level.11,12 This affords orthodontists, for example, who may not have been trained extensively in performing these soft tissue exposures, the opportunity to begin treating cases such as soft tissue impacted teeth, which they encounter on a regular basis.7 This will allow them to expand their practice and have more control over individual cases. The hemostatic effect of the laser is also of note.13 Compared to the traditional scalpel and suture method of performing soft tissue dentistry, the laser greatly reduces the trauma placed on the tissue, thereby expediting the healing time and effect.7,11 The laser can cauterize the tissue as it cuts, greatly reducing the amount of heme in the field.11,13 It also negates the
need for sutures in many situations and, as evident in the cases cited here, the postoperative healing is excellent both in patient comfort and appearance of the surgical site.7 The tissue appears pink, stippled and healthy one week following a resection of soft tissue and surgical exposure of the teeth.7 What the laser has done for patient acceptance of cases and patient apprehension is also significant.4,6,14 With use of the Er,Cr:YSGG laser, a clinician can confidently offer a patient a painless surgical procedure performed in a short amount of time. This may be a foreign concept to many patients, but it is the reality of what clinicians can provide today.4,6,8,14 ■ REFERENCES 1. Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium: yttrium, scandium, gallium, garnet laser on mucocutanous soft tissues.J Perio 2001;72 (9):1178-1182.
2. Eversole LR, Rizoiu IM. Preliminary investigations on the utility of an erbium, chromium YSGG Laser. J Calif Dent Assoc 1995:41-47. 3. Margolis, F. Point of care. J Canad Dent Assoc 2002; 70(5): 334-335. 4. Eversole LR, et al. Osseous repair subsequent to surgery with an erbium hydrokinetic laser system. Proceedings, International Laser Congress,Athens Greece. September 1996:25-28. 5. Pick RM, Powell GL.Laser in dentistry. Soft-tissue procedures. Dent Clin North Am 1993;37(2):281-96. 6. Flax HD, Radz GM. Closed-flap laser-assisted esthetic dentistry using Er:YSGG technology. Compend Contin Educ Dent 2004;25(8):622, 626, 628-30. 7. Marx I, Op’t HJ. The Er,Cr:YSGG hydrokinetic laser system for dentistry-clinical applications. So Afr Dent J 2002;57(8):323-6. 8. Colvard, MD, Pick RM. Future direction of lasers in dental medicine. Curr Opin Periodontol 1993:144–150. 9. Smith TA, Thompson JA, Lee. Assessing patient pain during dental laser treatment. J Am Dent Assoc. 1993;124(5):12. 10. Sulieman M. An overview of the use of lasers in general dental practice: 1. Laser physics and tissue interactions. Dent Update 2005;32 (4):228-30, 233-4, 236. 11. Stabholz A, Zeltser R, Sela M, Peretz B, Moshonov J, Ziskind D,Stabholz A.The use of lasers in dentistry: principles of operation and clinical applications. Compend Contin Dent Educ 2003;24(12):935-48; quiz 949. 12. Scott A. Use of an erbium laser in lieu of retraction cord: a modern technique. Gen Dent. 2005;53 (2):116-9.
13. Midda M. The use of lasers in periodontology. Curr Opin Dent 2 1992:104–108. 14. Shulkin NH. The American dental laser: initial patient response. Dent Today 1991;10:60-61. 14. Sun G. The role of lasers in cosmetic dentistry. Dent Clin North Am. 2000; 44(4):831-50. 15. Rossman JA,Cobb CM. Lasers in periodontal therapy. Periodontology 2000 1995;9:150–164. 16. Sarver DM,Yanosky M. Principles of cosmetic dentistry in orthodontics: part 3. Laser treatment for tooth eruption and soft tissue problems.Am J Orthod Dentofacial Orthop 2005; in press. 17. Ishikawa I, Sasaki KM, Aoki A, Watanabe H. Effects of Er:YAG laser on periodontal therapy. J Int Acad Periodontol. 2003;5(1):23-8. 18. Rosenberg SP. The use of erbium,chromium:YSGG laser in microdentistry. Dent Today 2003;22(6):70-3. 19. Coluzzi DJ. An overview of laser wavelengths used in dentistry. In: The Dental Clinics of North America. Philadelphia:WB Saunders. 2000:753-66. 20. Kutsch, VK. The history of dental lasers. Proceedings from the World Clinical Laser Institute. August 2003, Atlantic City, NJ. 21. Passes H, Furman M, Rosenfeld D, Jurim A. A case study of lasers in cosmetic dentistry. Curr Opin Cosmet Dent. 1995:92-9.
NYSDJ • APRIL 2007 41
Early Manifestation of Pemphigus Vulgaris A C A S E R E P O RT Keith Da Silva; Louis Mandel, D.D.S. Abstract Pemphigus vulgaris (PV) is traditionally viewed as an autoimmune disease of the skin, but it almost always involves the oral cavity. It can be fatal if left untreated and allowed to progress to advanced stages. Early recognition and intervention are essential for a favorable prognosis. Since oral lesions represent an initial manifestation of PV, dentists are in an ideal position to make an early diagnosis and initiate treatment. Here we report a case of PV that was diagnosed in its earliest stage.
PEMPHIGUS VULGARIS (PV) is a chronic autoimmune, intraepithelial blistering disease. It is a potentially fatal dermatological disorder characterized by the production of auto-antibodies directed against the epithelium. PV is classically viewed as a disease of the skin, but it almost always affects the oral cavity.1,2 In 50% of cases, the oral cavity represents the initial site of presentation before any skin or other mucosal lesions arise.3,4 Dentists are, therefore, in the unique position to make the preliminary diagnosis and initiate early treatment of this life-threatening disease. Here, we report a case of PV that was detected within weeks of the initial onset. The significance of this report rests on the fact that the presenting clinical lesions were extremely modest and representative of an early form of PV. Case Report
A 58-year-old female presented to the Salivary Gland Center at Columbia University College of Dental Medicine with a three-week 42 NYSDJ • APRIL 2007
history of burning sensations in the oral cavity. Her medical history was not significant, and the patient was in good health. At the time of examination, she was not taking any medications. The intraoral examination revealed what appeared to be a small, 2 mm x 4 mm, healing ulcer with an erythematous border situated on the attached gingiva in the mandibular premolar area (Figure 1). A second small, 2 mm x 3 mm, irregular mild erythematous lesion was found in the mucosal fold of the left retromolar area (Figure 2). Extraorally, there were no signs of any skin or mucosal lesions. An excisional biopsy of the lesion in the premolar area was performed. Sloughing of the mucosal tissue was noted during the biopsy procedure. Because this desquamation aroused a suspicion of PV, a specimen of the adjacent normal tissue was also harvested and subjected to a direct immunofluorescence (DIF) study. The histological examination revealed fragments of stratified squamous epithelium exhibiting a suprabasilar-intraepithelial split (Figure 3).Acantholysis and strips of epithelium demonstrating complete detachment from the connective tissues were also observed.The DIF study was positive and revealed IgG and C3 deposits in the intercellular spaces throughout the epithelium. Both the histological and DIF results were consistent with a diagnosis of PV. Discussion
Pemphigus can exist alone, or it may be associated with thymoma, myasthenia gravis, lupus erythematous, bullous pemphigoid and some neoplasias.5,6 Pemphigus has an incidence of about 0.1 to 0.5 per 100,000 in the U.S.7,8 It affects all races, but the condition is more common among Ashkenazi Jews and people of Mediterranean descent.9 Both sexes are equally involved, usually in the fifth to sixth decades of life. Rare cases in children and the elderly have also been reported.6,10
Pemphigus includes PV, pemphigus foliaceus and paraneoplastic pemphigus, but PV is the most common and represents 80% of all cases.6 PV is a tissue-specific autoimmune disease. It is characterized by the deposition of an IgG autoantibody against the desmosomal glycoproteins, desmoglein-1 and desmoglein-3, which are found on the surface of keratinocytes and act as glue holding the epithelium together.11 The circulating IgG antibodies interfere with cell-to-cell adhesion and lead to flaccid blister formation and skin separation.1 The initial causative factors for the production of these autoantibodies are unknown, but they may be linked to the presence of a human leukocyte antigen (HLA) complex.12 PV can also be induced by certain medications, such as captopril and penicillamine.13,14 Oral lesions of PV can develop up to four to six months before skin lesions appear.15 The most common site in the oral cavity is the buccal or labial mucosa, with the gingiva and palate being less frequently involved. The patient often complains of a persistent sore throat or burning of the mouth. Clinically, multiple large, flat, variable-sized blisters with a red or white necrotic slough and surrounding erythema are characteristically seen.1 The lesions are superficial and will rupture easily, leaving painful coalesced ulcers that involve large areas of the oral mucosa. These large denuded areas become susceptible to secondary infection. Gingival involvement may take the form of desquamative gingivitis. Pressure applied to an adjacent area will form a new blister (Nikolsky’s sign), an important diagnostic aid for several bullous diseases.1 PV must be distinguished from other bullous lesions, such as erosive lichen planus, bullous pemphigoid, erythema multiforme, dermatitis herpetiformis, epidermolysis bullosa and Darier’s disease. Definitive diagnosis of PV is dependent upon biopsy results. For histological examination, it is best to obtain tissue samples from intact vesicles of recent onset.When PV is suspected, adjacent normal tissue is required for DIF study. The classic histological feature seen in PV is acantholysis, or loss of cell-to-cell contact in the epithelial layer. In PV, intercellular edema occurs within the epithelium, resulting in widening of the intercellular spaces and formation of suprabasilar blisters.16 The pathognomonic suspended acantholytic epithelial cells (Tzanck cells) within the suprabasilar blister can also be detected with exfoliative cytology (Tzanck smear).1 DIF is also necessary for diagnosis of PV. Such a diagnosis is best obtained by submitting a specimen from an area immediately adjacent to the suspected lesion. DIF reveals deposits of linear IgG and C3 on the surface of keratinocytes within the intercellular spaces.17,18 Indirect immunofluorescence can also be used to obtain serum titer values of IgG, which may be proportional to the severity of the disease.1 Early diagnosis of PV is paramount to successful treatment. In our case, a modest healing ulcer of unknown etiology was found,
Figure 1. Healing ulcer with erythematous border situated on attached gingiva (black arrow).
Figure 2. Mild erythematous lesion observed in mucosal fold (white arrow).
Figure 3. H&E stain of specimen reveals fragments of stratified squamous epithelium exhibiting suprabasilar-intraepithelial split. Tzanck cells are indicated by black arrow. NYSDJ • APRIL 2007 43
prompting the decision to biopsy. It was only during the biopsy procedure that the sloughing of tissue was noted and PV suspected. Improved Outcome
PV was once associated with a high morbidity rate. However, the advent of systemic corticosteroids and immunosuppressive therapy has reduced the mortality rate to below 10%.4,19 Treatment of PV is designed to inhibit production of the aggressor antibodies.The initial treatment involves administering high doses of a systemic corticosteroid such as prednisolone.7 Once the initial lesion has disappeared, the dose of corticosteroids can be tapered,until a maintenance dose is achieved. When the initial systemic dose is not sufficient, adjuvant immunosuppressives, such as cyclophosphamide, azathioprine and mycophenolate mofetil,are added for their steroid sparing effect.7 The need for high systemic doses of corticosteroids can also be reduced with the additional use of topical corticosteroids in the form of mouthrinses or ointments. When PV is severe and unresponsive to standard corticosteroid and oral immunosuppressive agents, pulse therapy with large doses of intravenous methylprednisone or cyclophosphamide may be required.4 Plasmapheresis or high-dose intravenous immunoglobulin therapies have also been shown to be
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[email protected]
44 NYSDJ • APRIL 2007
effective and may be considered as alternatives.4,7,20 The required duration of systemic immunosupression is variable and unclear. The chances of achieving complete remission are much higher when the initial presentation is mild and there is an early and rapid response to treatment.4 As in our case, the recognition of an early lesion and subsequent initiation of treatment resulted in a favorable prognosis. Conclusion
Pemphigus vulgaris is a rare autoimmune mucocutaneous blistering disease that can be fatal if left unmanaged. The characteristic desquamative blistering lesion and the appearance of skin and other mucosal lesions represent advanced stages of PV. In order to prevent morbidity and reduce mortality, early recognition and therapeutic intervention are essential. Since PV has an initial oral manifestation, dentists are in an ideal position to make an early diagnosis,therefore the need to biopsy all suspicious lesions in the oral cavity that may resemble PV. ■ REFERENCES 1. Weinberg MA, Insler MS, Campen RB. Mucocutaneous features of autoimmune blistering diseases. Oral Surg Oral Med Oral Path Oral Radiol Endod 1997;84:517-34. 2. Scully C, Challacombe SJ. Pemphigus vulgaris: update on etiopathogenesis, oral manifestations and management. Crit Rev Oral Biol Med 2002;13:397-408. 3. Stoopler ET, Sollecito TP, DeRossi SS. Desquamative gingivitis: early presenting symptoms mucocutaneous disease. Quint Int 2003;34:582-586. 4. Robinson NA, Yeo JF, Lee YS. Oral pemphigus vulgaris: a case report and literature update. Ann Acad Med Singapore 2004;33:63-68. 5. Ben Lagha N, Poulesquen V, Roujeau JC,Alantar A, Maman L. Pemphigus vulgaris: a case based update. J Can Dent Assoc 2005 Oct;71:667-72. 6. Mahajan VK, Sharma NL, Sharma RC, Garg G. Twelve-year clinico-therapeutic experience in pemphigus: a retrospective study of 54 cases. Int J Dermatol 2005 Oct; 44:821-8277. 7. Yeh SW, Sami N, Ahmed R. Treatment of pemphigus vulgaris: current and emerging options. Am J Clin Dermatol 2005;6;327-242. 8. Fellner MJ, Sapadin AN. Current therapy of pemphigus vulgaris. Mt. Sinai J Med 2001; 68:268-78. 9. Thivolet J, Jablonska S. Bullous disorders: from histology to molecular biology. Clin Dermatol 2001;19:538-543. 10. Berger BW, Maler HS, Kantor I. Pemphigus vulgaris in 3 ½-year-old baby.Arch Dermatol 1973;107:433-434. 11. Amagai M. Desmoglein as a target in autoimmunity and infection. J Am Acad Dermatol 2003;48:244-252. 12. Ahmed AR, Mohimen A, Yunis EJ, Mirza NM, Kumar V, Beutner EH, Alper CA. Linkage of pemphigus vulgaris antibody to the major histocompatibility complex in healthy relatives of patients. J Exp Med 1993; 177:419-24. 13. Kaplan RP, Potter TS, Fox JN. Drug-induced pemphigus related to angiotensin-converting enzyme inhibitors. J Am Acad Dermatol 1992; 26:364-645. 14. Korman NJ, Eyre RW, Zone J, Stanley JR. Drug-induced pemphigus: autoantibodies directed against the pemphigus antigen complexes are present in penicillamine and captopril-induced pemphigus. J Invest Dermatol 1991; 96:273-6. 15. Siegel MA, Balciunas BA, Kelly M, Serio FG. Diagnosis and management of commonly occurring oral vesiculoerosive disorders. Cutis 1991;47:39-43. 16. Hashimoto K, Lever WE An electron microscopic study of pemphigus vulgaris of the mouth and skin with special reference to the intercellular cement. J Invest Dermatol 1967; 48:540-52. 17. Jordon RE. Direct immunofluorescent studies of pemphigus and bullous pemphigoid. Arch Dermatol 1971; 103:486-90. 18. Kim YH,Geoghegan WD,Jordon RE.Pemphigus immunoglobulin G subclass autoantibodies: studies of reactivity with cultured human keratinocytes. J Lab Clin Med 1990;115:324-31. 19. Lever WF,White H. Treatment of pemphigus with corticosteroids: results obtained in 46 patients over a period of 11 years. Arch Dermatol 1963;87:12-26. 20. Ahmed AR, Dahl MV. Consensus statement on the use of intravenous immunoglobulin therapy in the treatment of autoimmune mucocutaneous blistering diseases. Arch Dermatol 2003;139:1051-1059.
Clinical and Radiographic Evaluation of Root Perforation Repair Using MTA Jamileh Ghoddusi, D.D.S., M.Sc.; Azadeh Sanaan, D.D.S.; Fatemeh Shahrami, D.D.S., M.Sc. Abstract An accident that can occur during endodontic treatment is perforation, which adversely affects the prognosis of the teeth. A restorative material should be easy to use, nonresorbable, biocompatible, esthetically pleasing, and should provide a complete seal. Mineral trioxide aggregate (MTA) is a relatively new material that is being used successfully to repair perforation. The purpose of this study was to perform a clinical and radiographical evaluation of the success rate of root perforation repairs using mineral trioxide aggregate. Based upon the results of this study, MTA is a suitable material for root perforation repair and can be used confidently.
ONE OF THE EVENTS that occurs during endodontic treatment is strip and forcal perforation. Ingle1 showed that the second greatest reason for treatment failure was related to root perforation. However, these operative errors accounted for only 9.62% of the unsuccessful cases. According to Seltzer’s study,2 if the perforated region can be closed quickly, so that infection and packing do not intervene, there 46 NYSDJ • APRIL 2007
is a chance for regeneration of the periodontium everywhere except over the perforated region. Therefore, a material with appropriate seal ability with no cytotoxic effect should be considered. Variables affecting the long-term prognosis of perforations include location of the defect relative to the crestal bone; length of the root trunk; accessibility for repair; size of the defect; presence or absence of a periodontal communication to the defect; time lapse between perforation and repair; the sealing ability of the restorative material; and subjective factors, such as technical competence of the dentist and the attitude and oral hygiene of the patient.3,4 Balla5 and Eldeeb6 explained that inflammation in the perforated area may be due to the inadequate sealing ability of the repair materials. A restorative material should be easy to use, nonresorbable, biocompatible, esthetically pleasing, and should provide a complete seal.7 Perforation defects may be repaired by nonsurgical or surgical techniques.8 Surgical alternatives are hemisection, bicuspidization, root amputation and intentional replantation. The materials commonly employed to repair perforations include: cavit,9 zinc oxide eugenol (ZOE),3 amalgam,6 super-EBA,10 tricalcium phosphate,11 calcium hydroxide,12 gutta-percha,13 IRM14 and glass ionomer.15 Mineral trioxide aggregate (MTA) is a material that was introduced in 1993.14,16 It is a hydrophilic powder that sets when in contact with moisture.
In 1993, Lee et al14 tested amalgam, IRM and MTA for repair of experimentally created root perforations. The result showed that the MTA had significantly less leakage than IRM or amalgam. In 1995, Torabinejad et al17 investigated the marginal adaptation of MTA as a root-end filling material compared with super-EBA and IRM. Statistical analysis of data comparing gap sizes between the root-end filling materials and their surrounding dentin shows that MTA had better adaptation than super-EBA and IRM. In 1995, another study was done by Torabinejad et al.8 They compared the antibacterial effects of amalgam, ZOE, super-EBA and MTA on facultative bacteria and seven strict anaerobic bacteria. Results showed that amalgam had no antibacterial effect against any of the bacteria tested in this study. MTA had an antibacterial effect on some of the facultative bacteria and no effect on any of the strict anaerobic bacteria. ZOE and super-EBA pastes had some antibacterial effects on both types of bacteria tested. In 1997, Torabinejad et al19 examined the periradicular tissue response of monkeys to MTA and amalgam as root-end fillings.The results showed no periradicular inflammation adjacent to five of six root ends filled with MTA; also, five of six root ends filled with MTA had a complete layer of cementum over the filling. In contrast, all root ends filled with amalgam showed periradicular inflammation, and cementum had not formed over the root-end filling material, although it was present over the cut root end. Based on these results, MTA was recommended as a root-end filling material. In 1998, Sluyk et al20 evaluated the setting properties and retention characteristics of MTA when used as a forcation perforation repair material. The results showed that MTA resisted displacement at 72 h to a significantly greater level than at 24 h. When slight displacement occurred at 24 h, the material demonstrated the ability to re-establish resistance to dislodgement from the dentin wall. The presence of some moisture in the perforation during placement was advantageous in aiding adaptation of MTA to the walls of the perforation, but there was no significant difference in MTA retention when a wet or dry cotton pellet was placed in the pulp chamber during the setting time. In 1999, Schwartz et al21 presented five cases in which MTA was used to manage clinical problems. These included vertical root fracture, apexification, perforation repair and repair of a restorative defect. In each case, MTA allowed bone healing and elimination of clinical symptoms. It allowed the overgrowth of cementum and periodontal ligament. Because of these results, MTA may be an ideal material for certain endodontic procedures. In 2001, Holland et al22 observed the healing process of intentional lateral root perforation repaired with MTA. Results showed no inflammation and deposition of cementum over MTA in the majority of the specimens. In the 180-day period, sealapex control groups exhibited chronic inflammation in all the specimens and slight deposition of cementum over the material in only three cases of 48 teeth. In conclusion, MTA exhibited better results than the control group.
In 2001 Roda,23 in 2002 Joffe,24 and in 2003 Hembrough et al25 evaluated the clinical success rate of root perforation repair using MTA. Results showed that MTA sealed the perforation region successfully. In 2004, the clinical success rate of MTA was evaluated by Main et al.26 They showed that it provides an effective seal perforation for teeth that would otherwise be compromised. The purpose of the study described here was to ascertain a clinical and radiographical evaluation of the success rate of root perforations using MTA. Method and Materials
In this clinical trial study, the subjects were people who were referred to Mashad Dental School with the primary diagnosis of perforation. After clinical and radiographical examination, the including criteria were: presence of forcal or strip perforation; location of the perforation under the alveolar crest; absence of a large perforation; no periodontal disease; and presence of mechanical perforation. Finally,28 patients were selected. The results of the examination were collected from evaluation forms. The treatment was done in either one or two steps. The teeth that had been perforated for one week or less were treated by the one-step treatment, using MTA (Pro Root, Dentsply, Tulsa, OK). Teeth that had been perforated for more than one week were treated with a two-step treatment; the first step consisted of using calcium hydroxide, and in the second step, MTA was used. After treatment in both groups, a wet cotton pellet was placed over the MTA, and the teeth were restored. The treated teeth were followed up after 6 to12 months. These teeth were evaluated clinically and radiographically to examine the healing process. Three radiographs were examined for each tooth. The first radiograph was the preoperative film, exposed before repair of the perforation defect. The second radiograph was the film exposed immediately after repair of the perforation. The third radiograph was the follow-up film taken at least six months after the repair procedure. The results were recorded noting the presence or absence of a periradicular lesion.A lesion was defined as any radiolucency adjacent to the repair site that exceeded double the width of a normal periodontal ligament space. All 28 cases were also clinically evaluated to determine the presence or absence of a periodontal defect in the area of the perforation. Periodontal pocket measurements were noted from the follow-up examination. All evaluations were done by two endodontists. Finally, according to the negative or positive response to the treatment, the teeth were categorized into three groups as follows: 1. Successful. The periapical or forcal radiolucency was eliminated or became smaller and the clinical signs were eliminated. 2. Unsuccessful. The periapical or forcal radiolucency became larger or remained unchanged and the clinical signs were not eliminated. NYSDJ • APRIL 2007 47
Figure 1. Radiograph before treatment shows radiolucent lesion in furcation.
Figure 2. Radiograph after treatment.
Figure 3. Radiograph one year after treatment shows healing.
3. Non-defined. The clinical signs were eliminated but the periapical or forcal radiolucency remained unchanged.
TABLE1 Frequency of Radiographic Sign After Treatment Frequency
Results
Radiography Normal
Number
Percent
3
10.7
Widening of PDL
6
21.4
Radiolucency
18
64.3
Undetectable
1
3.6
Graph 1: Frequency of Sign and Symptom Before Treatment
50 40 30
This study was descriptive. The rate of abundance of each group was described by the graphs. In this study, the patients were arranged into four groups. The majority of cases fell in the 20-to29-age group. The teeth, based on their type, were categorized in six groups of upper and lower incisors, premolars and molars. According to the radiographical signs before treatment, 64.3% of the subjects had radiolucency before treatment, 10.7% were normal, and 21.4% had widening of PDL. The clinical signs before treatment are charted in Graph 1. The postoperative radiographic condition after the 6- to 12-month follow-up period is summarized in Table 1, which shows that 82.1% of cases were repaired. In all cases, the clinical signs and symptoms were eliminated. According to Graph 2, 92.9% of cases were placed in the successful group. Figures 1-3 demonstrate preoperative, postoperative and follow-up radiographs of one of the treated cases.
20 Discussion
10 0
Normal
Pain & Swelling & Fistol
Pain
Graph 2: Frequency of Response to Treatment
100 80 60 40 20 0
Successful
48 NYSDJ • APRIL 2007
Unsuccessful
Undetectable
Root perforation is an undesirable accident that can occur at any stage of root canal therapy. It includes apical, forcal and strip perforation. Much research has been done on the sealing materials used on perforations.The factors affecting the repair process include the location of the perforation,the time lapse before obturation of the perforation,and the sealing ability and biocompatibility of the repair materials.3 Many materials have been used to repair perforations, such as IRM,14 ZOE,3 cavit,9 amalgam,6 calcium hydroxide,12 super-EBA10 and glass ionomer.15 The last recommended material was MTA, which was first used in 1993.14,16 There have been more animal and in vitro investigations of MTA than human studies of this material. The cervical or forcal perforations, because of their oral communication, had the worse prognosis in comparison with apical or middle root perforations.3 The main reason to control perforations is to limit the inflammatory process and to promote PDL attachment. Each material or technique has its own characteristic that should be considered in clinical use. Based upon the many investigations of perforation repair that have been done, MTA was introduced as a suitable material. The results of this study, in comparison with the results of other investigations, showed a remarkable increase in positive prognosis in perforated teeth that were repaired with MTA.
In our study, 28 teeth in different patients that had had forcal or strip perforation were selected. Of these 28 teeth, 26 cases in which clinical signs and symptoms that appeared before treatment were eliminated completely and the radiolucency was smaller or repaired completely were defined as successful. One case had failure in treatment. In this case, there were no clinical signs or symptoms before and after treatment, but the radiolucent area became larger. In fact, it seems that the case selection was wrong because the perforation area in this tooth was so large.Also, one tooth was considered to be a non-defined case because of the superimposition of anatomic landmarks on the perforation region.As a result, we could not investigate this area. Finally, this study showed that MTA is a very suitable material for root perforation repair and increases the root prognosis significantly. In 1995, Pitt Ford et al27 examined MTA as a perforation repair material. In this animal study, MTA was compared with amalgam, and the results showed MTA was a suitable material for repair of root perforations. In 1998, Nakata et al28 evaluated the ability of MTA and amalgam to seal forcal perforations in extracted human molars using an anaerobic bacterial leakage model. The results showed that MTA was significantly better than amalgam in preventing leakage of F. nucleatum in forcal perforations repair. In 2001, Holland et al22 observed the healing process of intentional lateral root perforation repaired with MTA. It was an animal study and the results introduced MTA as a suitable perforation repair material, too. In 2002,Weldon et al29 longitudinally compared the ability of MTA and super-EBA to seal forcation perforation. This study was done on extracted human teeth. In this study, MTA sealed perforations very well. In 2004, Main et al26 evaluated the clinical success rate of MTA in root perforation repairs. In this study, 16 cases were examined. Five were cases of lateral perforation; five were cases of strip perforation; three were cases of forcal perforation; and three were cases of apical perforation. In Main’s study, like our study, the teeth had no periodontal disease. Nine cases had radiolucency and seven cases had no lesion before treatment.Finally,after the follow-up period,all cases showed no lesion in the perforation area. In fact, this study showed the suitability of MTA in sealing root perforations, too. In 2005, Bargholz30 suggested a resorbable collagen material for root perforation repairs. The author claimed that the matrix reconstructed the outer root shape and facilitated the MTA adaptation. Conclusion and Suggestions
The results of this study showed that MTA is a suitable material for root perforation repair and can be used confidently. Therefore, the prognosis of the perforated teeth that were repaired with MTA increases significantly. The case selection for perforations repair is important. The location and size of the perforation, the tooth situation, the existence or absence of periodontal disease and accessibility to the perforation area are very important in case selection. Finally, further histological investigations with longer follow-up periods seem to be necessary. ■
REFERENCES 1. Ingle JI.A standardized endodontic technique utilizing newly designed instruments and filling materials. Oral Surg Oral Med Oral Pathol 1961Jan;14:83-91. 2. Seltzer S, Sinai I, August D. Periodontal effects of root perforation before and during endodontic procedures. J Dent Res 1970 Mar. Apr; 49(2): 332-9. 3. Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surg Oral Med Oral Pathol. 1962;15:603-12. 4. Lemon RR. Nonsurgical repair of perforation defects: Internal matrix concept. Dent Clin North Am. 1992;36:448. 5. Torabinejad M, Lemon RR. Procedural Accidents. In Torabinejad M, Walton RE. Principles and Practice of Endodontics. Third Edition. Philadelphia: WB Saunders Co. 2002;Ch18,P:314. 6. Eldeeb ME, Eldeeb M, Tabibi A, Jensen JR. An evaluation of the use of amalgam, cavit and calcium hydroxide in the repair of furcal perforations. J Endod. 1982Oct; 8(10): 459-66. 7. Ruddle CJ. Nonsurgical endodontic retreatment. In Cohen S, Burns RC. Pathway of the Pulp. Eight editions. St. Louis: Mosby. 2002;Ch:25,P:919-23. 8. Alhadainy HA. Root perforations: a review of literature. Oral Surg Oral Med Oral Pathol. 1994 Sep; 78(3):368-74. 9. Harris WE. Simplified method of treatment for endodontic perforations. J Endod 1976 May; 2(5):126-34. 10. Oynick J, Oynick T. Treatment of endodontic perforations. J Endod 1985 Apr;11(4):191-2. 11. Himel VT, Brady J, Weir J. Evaluation of repair of mechanical perforations of the pulp chamber floor using biodegradable tricalcium phosphate or calcium hydroxide. J Endod 1985;11:161-5. 12. Frank A,Weine FS. Nonsurgical therapy for the perforative defect of internal resorption. J Am Dent Assoc. 1973Oct;87(4):863-8. 13. Stomberg T, Hasselgran G, Bergstedt H. Endodontic treatment of traumatic root perforations in man: a clinical and roentgenological follow up study. Sven tandlak Tid Skr. 1972;65:457-66. 14. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993 Nov;19(11):541-4. 15. Salman MA, Quinn F, Dermody J, Hussey D, Claffey N. Histological evaluation of repair using a bioresorable membrane beneath a resin-modified glass ionomer after mechanical furcation perforation in dog’s teeth. J Endod 1999Mar;25(3):181-6. 16. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root-end filling material. J Endod 1995Dec;19(12):591-5. 17. Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod 1995Jun;21(6):295-9. 18. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some rootend filling materials. J Endod 1995Aug;21(8):403-6. 19. Torabinejad M, Pitt Ford TR, Mckendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod 1997Apr;23(4):225-8. 20. Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation perforation repair material. J Endod 1998Nov;24(11):768-71. 21. Schwartz RS, Mauger M, Clement DJ, Walker WA III. Mineral trioxide aggregate: a new material for endodontics. J Am Dent Assoc 1999Jul;130(7):967-75. 22. Holland R, Filho JA, De Souza V, Nery MJ, Bernabe PF, Junior ED. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001 Apr;27(4):281-4. 23. Roda RS. Root perforation repair: surgical and nonsurgical management. Prac Proced Aesthet Dent 2001Aug;13(6):467-72. 24. Joffe E. Use of mineral trioxide aggregate (MTA) in root repairs: clinical cases. NYSDJ 2002Jun-Jul;68(6):34-6. 25. Hembrough MW, Meares WA, Cohen J, Steiman HR. Nonsurgical post perforations repair with mineral trioxide aggregate: a case report. J Mich Dent Assoc 2003Mar;85(3):36-8. 26. Main C, Mirzagan N, Shabahang Sh, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod 2004Feb;30(2):80-3. 27. Pitt Ford TR, Torabinejad M, Hong CV, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol 1995;79(6):756-63. 28. Nakata TT, Bea KS, Baumgartner JC. Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod 1998Mar; 24(3):184-6. 29. Weldon JK, Pashley DH, Loushine RJ, Weller RN, Kimbrough WF. Sealing ability of mineral trioxide aggregate and super-EBA when used as furcation repair materials: a longitudinal study. J Endod 2002Jun;28(6):467-70. 30. Bargholz C. Perforation repair with mineral trioxide aggregate: a modified matrix concept. Int Endod J 2005Jun;38(1):59-69.
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