Marys Medicine

Be on the Giving End of Mercy
New York Mission of Mercy is opportunity to make a difference and show you care. access to care is a big problem in the united and care to those in need. mid-level providers could states. many people go without needed dental care provide palliative care until the patient can secure for a variety of reasons. there are no dentists in treatment with a dentist.
their area who accept their insurance. they don't another way the dental profession has tried to understand the importance of good dental health address this situation is through the mission of to their overall health. they are on medicaid and mercy, or, mOm. begun in 2000 by america's the dentists around them do not accept medicaid Dentists Care Foundation, mOm events provide patients. they live in an undesirable area. they free dental care to under-served patients. so far, can't afford care. and the list goes on. mOm has furnished over $50 million in free dental What can we do to ameliorate this crisis? We all care. this is an extensive undertaking, as people have established our practices in areas where we line up hours in advance of the event for the chance want to live, for better or for worse. We can't just at treatment. each state participating in mOm has uproot our practices and take them to areas where its own rules and regulations as to what can be dentists are in short supply to meet the need for care. accomplished during that state's mission. However, We may be able to accept medicaid patients, but that most provide cleanings and oral hygiene instruc- is an economic model that is fraught with danger. tion, restorations and extractions. some even pro- We could donate our time at a local charitable dental vide endodontic services. clinic. New graduates could be lured to areas where On June 13 and 14, 2014, NYsDa and the shortages exist through economic incentives ranging New York state Dental Foundation will be spon- from low-interest/no-interest loans to student loan soring its own mOm at Hudson Valley Community forgiveness. Collaborative agreements with hygien- College in troy. this will be a massive undertaking ists could be instituted to get oral hygiene instruction and volunteers are needed. this clinic, like others 4 august/september 2013 • the New York state Dental Journal Joel M. Friedman, President
525 E. 68th St., New York, NY 10065 John J. Liang, President Elect
2813 Genesee St., Utica, NY 13501 David J. Miller, Vice President
467 Newbridge Rd., East Meadow, NY 11554 Mark J. Weinberger, Treasurer
78 Southbury Road, Clifton Park, NY 12065 Robert M. Peskin, Speaker of the House
601 Franklin Ave., #225, Garden City, NY 11530 Mark J. Feldman, Executive Director
20 Corporate Woods Blvd., Albany, NY 12211 Steven Gounardes, ADA Trustee
351 87th St., Brooklyn, NY 11209 BOARD OF TRUSTEES P. Deborah Weisfuse, Immediate Past President
12 E. 41st St., #1100, New York, NY 10017 NY – Edward J. Miller Jr
121 E. 60th St., #7A, New York, NY 10022 2 - Craig S. Ratner
7030 Hylan Blvd., Staten Island, NY 10307 3 – Lawrence J. Busino
2 Executive Park Dr., Albany, NY 12203 4 – Frederick W. Wetzel
1556 Union St., Schenectady, NY 12309 5 – William H. Karp
Bldg. 6, 4500 Pewter Lane, Manlius, NY 13104 6 - Scott J. Farrell
39 Leroy St., Binghamton, NY 13905 7 - Robert J. Buhite II
564 E. Ridge Rd., #201, Rochester, NY 14621 8 – Jeffrey A. Baumler
2145 Lancelot Drive, Niagara Falls, NY 14304 9 – Stuart H. Coleton
7 Stone Rd., Chappaqua, NY 10514 N—Michael S. Shreck
1300 Union Turnpike, #201, New Hyde Park, NY 11040 Q – Joseph R. Caruso
40-29 Utopia Pky., Auburndale, NY 11358 S – Paul R. Leary
80 Maple Ave., #206, Smithtown, NY 11787 B - Richard P. Herman
2 Lockwood Lane, New Windsor, NY 12553 COUNCIL CHAIRPERSONS
Lawrence E. Volland
115 Professional Parkway, Lockport, NY 14094 Dental Benefit Programs
Eugene G. Porcelli
601 Franklin Ave., #211, Garden City, NY 11530 Dental Education & Licensure
Rekha C. Gehani
35-40 82nd St., #1F, Jackson Heights, NY 11372 across the country, will provide oral hygiene Dental Health Planning & Hospital Dentistry
Carl H. Tegtmeier
care and instruction, dental restorations and 359 E. Main St., #2C, Mt. Kisco, NY 10549 extractions. the main goal is to alleviate Dental Practice
Bijan Anvar
15 Rocky Rd., Larchmont, NY 10538 pain. Information for establishing a dental Adam A. Edwards
home will also be provided. twenty-three 103 Main St., Altamont, NY 12009 states are official mOm states. three states Governmental Affairs
110-45 Queens Blvd., #108, Forest Hills, NY 11375 are mOm-affiliated states. New York is an Membership & Communications
Maria C. Maranga
official mOm state. 508 Main Rd., PO Box 170, Aquebogue, NY 11931 this is an event where you can make a real Nominations
P. Deborah Weisfuse
12 E. 41st St., #1100, New York, NY 10017 difference in someone's life. reports from other Peer Review & Quality Assurance
Jeffrey M. Galler
mOm events show patients are truly grateful 18 Copper Beech Lane, Lawrence, NY 11559 and appreciative of the care they receive. they Professional Liability Insurance
Roland C. Emmanuele
marvel when they are free from pain and on the 4 Hinchcliffe Dr., Newburgh, NY 12550 road to dental health. but these mOm events also increase awareness among dental profes-sionals of the toll dental disease takes on those Suite 602, 20 Corporate Woods Blvd., Albany, NY 12211 (518) 465-0044 (800) 255-2100 who can't afford treatment. as private practitio- Mark J. Feldman
Executive Director ners, we tend to get lost in our offices, con- Lance Plunkett
cerned with our own little world and the prob- Beth M. Wanek
Associate Executive Director lems we face daily. there is a much bigger world Michael J. Herrmann
Assistant Executive Director Finance-Administration Judith L. Shub
Assistant Executive Director Health Affairs out there and, sometimes, we need a little push Joshua Poupore
Assistant Executive Director Marketing and Communication to get us to see it.
Mary Grates Stoll
the New York state Dental Journal • august/september 2013 5 the New York state mission of mercy is our chance to get out of is an experience he or she will never forget and how glad he or our comfort zones for a few days and help people in need. It is an she was to have taken part in it.
opportunity to see what will truly make a difference in someone's registration for the New York state mission of mercy is now life, someone we may have never met before and, most likely, will open at by the time you read this, I will have not meet again. but someone, who, for just that short time we registered. as an orthodontist, I know I won't be able to treat any interact with and who will appreciate all that we do. someone patients. but I am sure there are many things I will be able to do who may not be able to afford the best dental care, but who needs to contribute to the success of this mission. You can volunteer for our best for that day. as many shifts as you like. there will be two shifts on each of the If New York's mOm is like others around the country, two days. each shift lasts six hours. those may be the most patients will be turned away because the number of people seek- rewarding hours of your dental career.
ing care will exceed the mission's ability to treat them. If it is like this mission will show that the dentists in New York state the other missions, the patients who will be treated will be eter- do care about those in need. It will be a win-win situation for all. nally grateful for the care they receive. search the Internet for so, get involved and make this mission a resounding success. It is stories about other mOms and see for yourself the joy these only through your efforts that this will occur. It's time to take patients express. It is truly astounding that so many people can charge and give back to your community. this is the perfect be helped in such a short period of time.
opportunity for that! but it won't be just the patients who are impacted. every report I have read or heard details the positive influence a mis-sion has on the providers of care as well. each person is touched in his or her own way and says what a rewarding experience it was to have taken part in the mission. each individual reports it NEW YORK STATE MISSION OF MERCY Volunteer Registration is now open The New York State Dental Association (NYSDA) and New York State Dental Foundation (NYSDF), together with national partner Mission of Mercy, are launching the New York State Mission of Mercy (NYSMOM), a free two-day dental clinic to provide oral health services and education to people who, for many reasons, lack access to dental care. Go to for information and to volunteer. SAVE THE DATE Date: June 13 & 14, 2014
Edward F. McDonough Sports Complex
Hudson Valley Community College 6 august/september 2013 • the New York state Dental Journal Photos by Joshua Poupore Lauro Medrano-Saldana thanks the academy for selecting him to receive its Distinguished Chad Gehani accepts PFA Honor Award from Lynne Halik, PFA Region 2 Northeast Service Award.
U.S. Trustee.
Fauchard Academy Honors TwoLauro Medrano-Saldana, Chad Gehani Recognized for Service to Dentistry Lauro medrano-Saldana, D.D.S., a pediatric dentist from brook- tion Team of manipal Dental School in India. He is in private lyn, is the 2013 recipient of the pierre Fauchard Academy Distin- practice in Queens. guished Service Award, presented by the New York Section of the A graduate of government Dental College and Hospital (uni- academy. Dr. medrano-Saldana received his award at the group's versity of bombay), Dr. gehani has been active in efforts to improve annual luncheon in may at the grand Hyatt Hotel in New York the status of foreign-trained dentists. He is a past president of the City. Also honored at the luncheon was Chad p. gehani, an endo- Indian Dental Association; the International College of Dentists, dontist from Queens, who served as president of NYSDA in 2011- New York Section; and the Queens County Dental Society. Cur- 2012. Dr. gehani received the academy's Honor Award. rently, he serves on the NYSDA Council on Awards, is an at-large During the luncheon, which was held in conjunction with member of the empire Dental political Action Committee, a mem- the NYSDA Annual meeting, 14 dentists were inducted as fellows ber of the New York State Dental Foundation board of Trustees and of the academy.
an alternate delegate to the ADA House. In June, he was elected to Dr. medrano-Saldana is an attending in pediatric dentistry at serve as the next ADA Second District Trustee. Lutheran medical Center in brooklyn and in private practice at Dr. gehani completed a two-year dental practice residency at beek- Sunset pediatric Dentistry, also in brooklyn. He is president elect of man Downtown Hospital in New York City and postgraduate work in the Second District Dental Society and Second District Component endodontics at Columbia university College of Dental medicine. Chair, empire Dental political Action Committee. He is a member of the NYSDA House of Delegates and sits on the NYSDA Council New Members Inducted
of governmental Affairs. previously, Dr. medrano-Saldana served The pierre Fauchard Academy seeks to educate dental profession- as president of the puerto rican Dental Association uSA.
als about the latest techniques in dentistry and to foster a shar- As outreach chairman for the greater New York Dental ing of ideas to improve the profession. Amarilis Jacobo, bronx meeting in 2012, Dr. medrano-Saldana helped facilitate the or- County, is section chair. edward Feinberg, Ninth District, is sec- ganization and hosting of an international pierre Fauchard Acad- tion vice chair. This year's inductees include: emy event at the gNYDm. Leonard brenner, Second District; James Fitzgerald, Nassau Dr. medrano-Saldana received bachelor's and doctoral de- County; Joseph giovannone, Fifth District; John guaraglia, Suf- grees from universdad Interamericana de puerto rico and his folk County; Donald Hills, Nassau County; Anthony Ienna, Nas- dental degree and certificates in general and pediatric dentistry sau County; Kerry Lane, Suffolk County; rosa martinez, Ninth from New York university College of Dentistry. District; Fabiola milord, Nassau County; Janice pliszczak, Fifth Dr. gehani is an associate clinical professor of endodontics District; Sari rosenswein, Second District; Christopher Salierno, at NYu, chairman of endodontics at Flushing Hospital medical Suffolk County; Stuart Segelnick, Second District; and Nicholas Center and a consultant member of the International Accredita- Tucci, Nassau County.
The New York State Dental Journal • AuguST/SepTember 2013 25 Meet the Members of the Board
g. Kirk gleason, D.D.s.
as peter Drucker said, "management is doing things right; leader- such as developing a course or coordinating a screening. Finally, ship is doing the right things." there's the volunteer hat, something that plays an increasingly In my own professional and personal experiences, as a board larger role as we move closer to the 2014 mission of mercy. In ad- member and as chairman of the New York state Dental Founda- dition to providing dental treatment, our board members can be tion board of trustees, I've observed that successful boards need expected to assist with fund-raising, promotion, patient manage- to add to this theory how to effectively govern. this includes the ment, even set up and take down. ability to work together collaboratively, to think strategically and Fortunately, the Foundation board comprises a very skilled, to always seek better solutions. very cohesive group. I'd like to take a few moments to acquaint as I write this, we are in the midst of the Foundation's an- you with them. my vice chair is Don Fager, who many of you may nual nominations process. this year's nominations chair, David know in his capacity as CeO of medical Liability mutual Insur- C. schirmer, approaches everything with meticulous attention to ance Company. underneath Don's quiet exterior is a razor-sharp detail. David, working with fellow trustees brian Kennedy, ray mind, expert at getting to the heart of matters. the fact that he's Williams, executive Director Laura Leon and ex officio trustee a mets fan never enters into the equation.
mark Feldman, will review and select trustees who have experi- bob Doherty, former NYsDa president, noted for his come- ence and who have demonstrated qualities that meet the leader- dic prowess, is our treasurer. and while he may joke that he's not ship needs of the Foundation. gone are the days, if they ever qualified, his efforts have helped staff to develop pretty "dead-on" existed, when boards were the figurative happy hunting ground budgets for the last few years. bob's attention to detail is some- for members whose terms of office in other capacities had ended thing to behold, as I can attest, having been with him in compre- and who weren't quite ready to retire. hensive pre-board financial meetings.
Nowadays, board members typically have three hats, while Our secretary, mark Feldman, has himself worn many hats wearing only one at a time. there's the governance hat, which is in organized dentistry. His steady presence helped sustain our worn during our meetings and when we're making decisions re- board during transitions. lated to furthering our mission. then there's the implementation as already mentioned, Dave schirmer commits himself 110% hat, which is donned when a board member accepts an assign- to the various roles he has played, including heading up not just ment to serve on a task force or to help with a specific project, the Nominations Committee, but two of our current task forces. 26 august/september 2013 • the New York state Dental Journal another board member who always seems to find himself on one task force or an-other is mike breault, who masterfully balances whatever assignments we throw his way with the demands of a busy practice. Like Dave and mike, brendan Dowd has had his share of committee and task force work, which he accomplishes with energy and efficiency.
terry thines is our go-to person on educational matters and for coordinating dental screenings at the New York state Fair. another expert at dental screenings is madeline ginzburg, who spearheaded our Harlem Week efforts over the course of two very hot summers. I have no idea how brian Kennedy finds the time and energy to devote to mission of mercy, for which he and mark bauman serve as co-chairs. I think one secret to his success is his military background. We are extremely fortunate to have had two deans of New York state den- tal schools—Ira Lamster, former dean of Columbia university College of Dental medicine, and ray Williams, dean of stony brook university school of Dental medicine—provide thoughtful analysis of the various issues we encounter. For those of you who had the pleasure of attending either or both of the last two Foundations of excellence luncheons, held in conjunction with the annual session of the NYsDa House of Delegates, you have paul Leary to thank. paul has served as chair of this event since 2012 and, undoubtedly, his work has really paid off.
New to the board this year is Lorna Flamer-Caldera, who has already im- pressed us with her quick understanding and thoughtful analysis of the issues we deal with. We are indeed fortunate to have former NYsDa president (and our liaison) Chad gehani return to the fold as a trustee. Chad has helped us with many proj-ects over the years, lending his enthusiasm, not to mention connections. seri-ously, is there anybody Chad doesn't know? Our board is greatly strengthened by the presence and marketing expertise of steve Kess from Henry schein, Inc. steve always has a new idea, and it's usually something none of us had ever considered, but which makes perfect sense.
and this year, at the suggestion of NYsDa Immediate past president p. Deborah Weisfuse, we began inviting an asDa member to participate in our meetings. Keren etzion, who attends stony brook school of Dental medicine, is a true find—keenly intelligent, enthusiastic about the Foundation's mission and full of great ideas. Finally, our director and fellow trustee, Laura Leon, is responsible for achiev- ing the goals within the guidelines established by the board and for overseeing management and operations.
Of course, we are fortunate to have as our NYsDa liaison the associa- tion's current president, Joel Friedman. In the past year, we have benefitted from the support of first, Deborah Weisfuse and now, Joel Friedman. the ties that bind NYsDa and the Foundation have been considerably strengthened by their leadership. these are the people who sit on your Foundation's board of trustees, who maintain trust and credibility with our various constituencies, including our stakeholders and beneficiaries. they are well-informed, honest, diligent and pro-active members of the same team, of which I, too, am proud to be a part. p Dr. Gleason is chairman of the New York State Dental Foundation Board of Trustees. the New York state Dental Journal • august/september 2013 27 Impact of Residency Requirement for Dental LicensureAn Update H. barry Waldman, D.D.s, m.p.H, ph.D.; mary rose truhlar, D.D.s, m.s.
A b s t r A c t
As of 2007, New York State Education Law requires
tion or completion of an approved residency program was recog- successful completion of dental school training and
nized by New York state for licensure in the dental profession.1 Legislation was passed in 2002 modifying New York state ed- completion of an approved dental residency program
ucation Law, section 6604 (subdivision 3 and 4), which allowed for dental licensure. In a transitional period, from
(during 2003-2006) voluntary substitution of the completion of 2003-2006, a dental licensure applicant could select
a commission on Dental Accreditation (cODA) approved dental residency program for the traditional standardized regional clini- the path of an approved residency program or the New
cal examination requirement for dental licensure. "the residency York State-recognized regional standardized clinical
program shall be a postdoctoral clinical dental residency program examination. By contrast, in 2007, the state of Con-
in either general dentistry, or a specialty of dentistry…"2 effective Jan. 1, 2007, the option of completion of a regional standardized necticut adopted and continues to abide by regula-
clinical examination by applicants for dental licensure was elimi- tions that permit licensure by either completion of
nated, thereby requiring all applicants to complete a recognized an approved residency program or passage of the rec-
accredited residency program for licensure.2 ognized regional standardized clinical examination. A
In 2007, the state of connecticut also initiated a change in its dental licensure procedures. under the new regulations, the review of the changing number of dentists licensed
regional standardized clinical examination requirement for li- in these two adjoining Northeastern states under new
censure could be satisfied by completion of a cODA-approved licensure guidelines is considered in terms of the pos-
dental residency program or passage of the clinical test adminis-tered by the American board of Dental examiners (ADeX). this sible relationship to the new licensing process.
includes the North east regional board (Nerb), southern re-gional testing Agency, central regional Dental testing service, or A 2007 report in the NYsDA News detailed a pronounced in- Western regional examining board. (personal communication, crease in the annual number of newly licensed dentists in New s.carragher, connecticut Office of Healthcare practitioner Li- York state during the transitional years 2003-2006, when passage censing and Investigation, september 25, 2012) In addition, the of the North east regional board (Nerb) standardized examina- states of california, minnesota and Washington offer licensure 30 August/september 2013 • the New York state Dental Journal applicants the option of completing an accredited postgraduate Number of Licensed Dentists
education program, at least one year in length, in lieu of a re- gional standardized clinical examination.3 between 1990 and 2012, there was a gradual, irregular increase in the number of people licensed as dentists in New York state, from Rationale for Change
approximately 17,000 to 18,000 (table 1). since 1990, however, In New York state, numerous reasons were cited for eliminating there has been a progressive increase in the number of people li- the traditional clinical examination and mandating the fifth-year censed in the state with an out-of-state primary mailing address, requirement for licensure, including: the necessity of patients in from approximately 1,500 to 2,800 individuals.
the testing process and allegations of unethical patient treatment; During this period, there were limited changes in the den- complaints of examination unfairness; lack of relevance and va- tist-to-population ratio as a consequence of the combination of lidity of the test given the ever-increasing complexity of delivering the gradual increases in both the state overall population and dental services in the rapidly evolving realities for the delivery of the number of licensed dentists.7-9 "New York state, with over care; and the "snapshot" assessment nature of the examination.4,5 80 dentists per 100,000 population, is well above the national "Few would argue today that the current clinical examination has ratio. most regions of the state either meet or exceed the national any connection to contemporary practice or protects the public from substandard Persons Licensed and Registered as Dentists in New York and Connecticut by Residency or Board Examination: 1990-20127-9, Connecticut Office of Licensing Concerns
conflicting views regarding the residency
Total Number of licensed Dentists
New licensed Dentists
pathway to licensure include the following: Connecticut
l "residents practice under the close REquiREmENts foR LiCENsuRE supervision of attending staff and faculty…"4 but "… licensure by com- Mandatory
Residency or
Residency or
Regional board*
pletion of a residency …restricts the new dentist to practice only in New York and a limited number of states that accept this pathway…" since li- censure granted by a residency route is not yet acceptable in the majority of licensing jurisdictions.5 REquiREmENts foR LiCENsuRE l "…how (will the) mission of further education relate to a fair, unbiased Regional
or Residency
or Residency
assessment of critical competency required for licensure?"5 l Will the requirement of an addi- tional year of training and the de- lay of the entrance of dentists into REquiREmENts foR LiCENsuRE practice, thus postponing the indi-vidual's income, limit the number Regional
of dentists who remain in state and thereby worsen access to care issues? In addition, concern is raised wheth- er "…residencies (will) become a ‘dump- ing ground,' allowing schools to absolve themselves of what to do with the bottom of the class?"5 by extension, the question * Includes North East Regional Board, Southern Regional Testing Agency, Central Regional Dental Testing Service, Western Regional Examining Board. may be raised, whether New York state ** North East Regional Board.
now attracts dental school graduates who are unwilling to attempt or who are Notes: Totals include numbers of dentists with primary out-of-state or foreign mailing address. As result of annual influx of recent licensed practitioners, number of dentists varies in different reports based upon time of unable to successfully pass other states' year covered.
clinical examination for licensure. the New York state Dental Journal • August/september 2013 31 ratio of 58 dentists per 100,000 population."9 However, there is numbers of individuals from other jurisdictions who may have con- wide regional variation in the distribution of dentists in the state, sidered the possibility of future practice in the state. many recent ranging from over 106 dentists per 100,000 population on Long graduates complete both the clinical examination (i.e., the ADeX, Island, to 54 and 53 per 100,000 in the upstate, Adirondack and North east regional board examination and the residency, in an ef- catskill regions.10 fort to: 1. maintain their options to practice in other states that may or may not grant a license by reciprocity for those individuals who secured a license by completion of residency; or 2. "moonlight" dur- between 2002 and 2006 (the period prior to institution of an ap- ing the period of the residency. (Note: a license based on a residency proved dental residency program for the clinical component of the is granted upon completion of the full term of the residency, which licensing process), there was a slight increase in the number of li- may last several years, particularly for the various specialties.) censed dentists in the state, from approximately 3,000 to 3,100 in- During the past years, since adoption of the residency pro- dividuals. During the period between 2007 and 2012, the number of grams for licensure in New York state, there has been some de- licensed dentists increased to almost 3,400 individuals, with only a crease in the proportion of graduates from stony brook university moderate increase in the dentist-to-population ratio, from 89 to 94 school of Dental medicine taking regional board clinical examina- dentists per 100,000 population,11 connecticut Office of Licensing (table 1) .
tions for licensure. by contrast, responses from the dental schools of columbia university, university at buffalo, New York univer- New Licensees
sity and the university of connecticut indicate limited changes in the proportion of graduates taking regional examinations. In most years between 1990 and 2000, between approximately 400 and based on new licensee data since institution of the comple- 500 new individuals were licensed annually as dentists in New York tion of a mandatory graduate residency for license in New York state. In the period between 2003 and 2006 (when New York state was state and an elective graduate residency programs for licensure the only state with a Nerb examination or a residency program as a in the state of connecticut, it would appear that the fears have route to licensure), there was a progressive increase in the annual not been borne out that these two states would become either number of newly licensed dentists in the state, with more than 700 new wholesale "dumping grounds" of graduates at the "bottom of the dental licensees each year, reaching 765 individuals in 2006 (table 1). class" from other states or an attraction for other state graduates the comments made in the earlier review, in 2007, on the burgeoning who were unwilling to attempt or who were unable to complete annual numbers of new licensees during this period were that "… it is successfully a clinical examination for licensure. p difficult to determine whether the optional residency route for licensure was a magnet during the 2003-06 period for the state to: 1. become a Queries about this article can be sent to Dr. Waldman at [email protected]. "dumping ground" of graduates at the "bottom of the class";5 or 2. at-tract graduates who were unwilling to attempt or who were unable to Waldman Hb, truhlar mr. tracking newly licensed dentists following passage of residency complete successfully the clinical examination for licensure.1 alternative. NYsDA News 2007(4):14,15.
commencing in 2007 and continuing to 2012—with adop- state education Department. regulations of the commissioner of education relating to the examina-tion and residency program requirements for dental licensure. December 21, 2005. Web site: http:// tion of the mandatory graduate residency program requirement— Accessed June 4, 2007.
the number of new licensees decreased to a level slightly greater American Dental Association. state licensure for us dentists. Web site: http://www.ada.
org/492.aspx Accessed February 1, 2013. than the general level when passing the Nerb examination was Lasky re, shub JL. Dental licensure reaches a crossroads: the rationale and method for required for licensure (table 1).
reform. J Dent educ 2003;67:295-300. maitland rI. the New York state postgraduate fifth-year dental residency as a new licensure path: concerns for public protection. J Dent edu 2003;67:301-310.
Formicola AJ, shub JL, murphy FJ. banning live patients as test subjects on licensing exami- In the years between 2002 and 2006, there were limited changes in nations. J Dent edu 2002;66:605-609.
New York state education Department, Office of the professions. New York state Dental Li- the number of new licensees, between approximately 130 and 150 censes. 2007. Web site: Accessed June 1, 2007. individuals. In the period between 2007 and 2012—after adoption New York state education Department, Office of the professions. New York state Dental Licenses. 2012. Web site: Accessed April 19, 2013.
of the residency program alternative route for licensure—the an- New York state statistical Yearbook: 1993 through 2011. Albany, NY: Nelson A. rockefeller nual number of new licensees increased, reaching almost 250 in Institute of government, 1993 through 2012.
center for Health Workforce studies. A profile of active dentists in New York, 2011. some years (table 1). Nevertheless, during this period, there were limited changes in the dentist-to-population ratio.12,13 dentists_in_ny.pdf Accessed september 28, 2012.
American Dental Association. Distribution of Dentists in the united states by region and state, 2006. chicago: American Dental Association, 2008.
connecticut Department of public Health. population. Web page: the reality is that, to some degree, the greater numbers of new New lib/ecd/dph-population/dph_pop_2007.pdf Accessed september 27, 2012.
13. census bureau. population: connecticut. Web page: York state dental licensees during the transition period prior to the states/09000.html Accessed september 28, 2012.
mandating of an additional year(s) was a reflection of increased 32 August/september 2013 • the New York state Dental Journal Disease Management Dental Management of Parkinson's DiseaseA Case Report preeti Agarwal Katyayan, m.D.S.; manish Khan Katyayan, m.D.S.; babitha Nugala, m.D.S.
A b S T r A c T
Parkinson's disease is an idiopathic, slowly progressive
pD is the second most common neuro-degenerative disorder, af- disorder of the central nervous system characterized by
ter Alzheimer's disease. It affects primarily the elderly. It is esti-mated that about 1% of the population above the age of 65 and resting tremor, muscular rigidity, slow and decreased
about 5% above the age of 80 suffer from pD. In India, with an movement (bradykinesia), and postural instability.
estimated population of more than one billion, more than 700 Oral healthcare providers can expect to be called upon
million people will be above the age of 65 years, of which approx-imately more than 7 million suffer from pD.3 Oral healthcare to care for patients with this progressively debilitat-
providers can expect to be called upon to care for patients with ing disease. To provide competent care to patients with
this progressively debilitating disease. To provide competent care Parkinson's disease, clinicians must understand the
to patients with pD, clinicians must understand the disease, its treatment and its impact on the patient's ability to undergo and disease, its treatment and its impact on the patient's
respond to dental care.2,3,4 ability to undergo and respond to dental care. The suc-
pD symptoms are classified as motor and non-motor (Table 1). cessful prosthodontic management of a 74-year-old
It is a very individual condition, with each person experiencing different symptoms. However, the three cardinal signs of pD are completely edentulous Parkinson's disease patient is
motor-related. They are: presented, with the conclusion that a prosthodontic
l Dyskinesia—tremor or involuntary movement.
l bradykinesia—slow movement.
intervention may contribute to improvement in the
l Akinesia—muscular rigidity.5 quality of life of a Parkinson's disease patient.
Oral Manifestations of Parkinson's Disease
parkinson's disease (pD) is a progressive neurological disorder Oral Motor and Sensorimotor Impairment: In pD, tremor is an caused by the degeneration of dopaminergic neurons in the sub- early sign and generally affects the hands, lips and tongue.7 bra- stantia nigra of the basal ganglia of the brain. With the depletion dykinesia is also a common feature and often involves the oro- of dopamine-producing cells, the parts of the brain that control facial muscles. It has been noted that tremor and rigidity of the movement are unable to function normally.1 orofacial musculature may induce orofacial pain, temporoman- The New York State Dental Journal • AuguST/SepTember 2013 33 dibular joint (TmJ) discomfort, cracked teeth, soft tissue trauma, Burning mouth: burning mouth is reported by up to 24% of pa- displaced restorations, attrition from rumination and ptyalism tients with pD. This represents a five-fold increase when com- (lack of salivary control). At least 75% of patients with pD have pared to similar symptoms reported by the general population.15,16 disordered speech or voice.8 In one study,9 sensorimotor impair- burning mouth syndrome has been associated with vitamin and ment was observed in association with six out of nine orofacial mineral deficiencies, hormonal imbalances, xerostomia, candidal tasks when compared with normal controls. These six tasks in- infections, denture design faults, parafunctional activity and de- cluded jaw proprioception; tactile localization of the tongue, pression. In patients with pD, an additional factor may be treat- gingiva and teeth; target head movement in response to perioral ment with levodopa, which is known to promote parafunctional stimulation; and tracking head movements in response to perio- or purposeless chewing. In one study,17 77% of patients with pD ral feedback.
and 96% of those with burning mouth were taking levodopa. None of these patients had a history of burning mouth prior to Dysphagia: An inability to effectively swallow is reported by as treatment for pD.
many as 50% of patients with pD.10 Tongue and pharyngeal motor deficits result in an inability to form an adequate bolus, Difficulty Wearing Complete Dentures: pD patients have great dif- hesitancy in initiating swallowing and disruption of peristaltic ficulty adjusting to the use of complete dentures.18 The success movement, which can result in silent aspiration. Aspiration may of wearing complete dentures depends, to a large extent, on the contribute to the development of bronchopneumonia, a common wearer's ability to control the dentures with his or her oral mus- cause of death in patients with pD. Slowed swallowing can fur- culature. It also relies on the presence of an adequate amount and ther contribute to ptyalism, which, in turn, can lead to angular quality of saliva. Thick, "ropey" or "frothy" saliva in an abundant cheilosis and further angular irritation by frequent blotting of the quantity has the same detrimental effect on denture retention as lips and mouth.11 does dry mouth. The muscle incoordination, rigid facial muscles and xerostomia of pD conspire to jeopardize denture retention Xerostomia: The incidence of xerostomia among patients with pD and control. This is particularly true in the case of complete upper is reported to be as high as 55% (versus 20% in the general el- and lower dentures and some acrylic partial dentures. For some derly population).12 reduced qualitative and quantitative changes people this will mean they are not able to cope with dentures. in salivary flow are generally related to the parasympatholytic or Other people will require the use of a denture fixative/adhesive to antimuscarinic effects of the many drugs administered to these increase denture retention and denture-wearing confidence.19 patients and not to the pD itself. chronic xerostomia may result in painful (burning) oral soft tissue problems and poor tissue Dental Management of Parkinson's Disease
adaptation to prostheses. The patient may experience difficulties When providing oral healthcare to patients with pD, the goals with mastication, swallowing and speech. The reduced buffering are to develop and implement timely preventive and therapeutic capacity of the saliva also contributes to an increased incidence of strategies that are compatible with the patient's physical, cogni- dental caries, exacerbates periodontal disease and may affect the tive and behavioral ability to undergo and respond to dental care sensitivity of taste buds, contributing to dysgeusia. In addition, and with the patient's social and emotional needs and desires. xerostomia may predispose the patient to esophageal injury and clinicians must exercise empathy, congruence, a positive attitude contribute to nutritional deficiencies and weight loss.13,14 and strive to reach these goals with the same ethical, moral and professional standards of care as may be appropriate in the man-agement of any other patient.
Effects of Parkinson's Disease6 Preventive Strategies
Oral Hygiene Maintenance: rigidity and tremor can contribute
to poor oral hygiene. Dental management plans for patients ‘Mask-like' face (lack of facial expression) Sleep disturbances with pD should include appropriate preventive strategies, which take into consideration the patient's physical and cognitive de- Quiet, monotone voice ficiencies. As the physical and mental condition of the patient deteriorates, the patient may become incapable of carrying out Slurring of speech some of or the entire dental hygiene regimen. In these cases, the education of a family member and/or caregiver is essential. It is Slow reactions and responses important that the patient's caregivers receive appropriate train- Short, shuffling steps and gait instability ing to enable them to understand and implement the preventive 34 AuguST/SepTember 2013 • The New York State Dental Journal plan. Information should be included on the proper positioning with a nailbrush attached by suction cups to a sink. This enables of the patient to safely implement home-care activities; the tech- patients to clean their denture with one hand. The goal of these nique for inserting, removing and caring for prostheses; and the modifications is to allow the patient to maintain self-care as long technique for oral cancer screening. However, caregivers should only perform those oral hygiene procedures that the patient can-not. The need for professional supervision, consisting of frequent Topical Rinses: The use of topical agents, such as chlorhexidine communication with the patient's caregiver, in concert with fre- gluconate, is useful to combat gingivitis and other periodontal quent recall and office-based preventive care, should be stressed.
pathoses that result from plaque accumulation. However, these products require the use of a swish-and-spit technique that may Plaque Removal: It has been reported that even with average dex- be beyond the capabilities of patients with pD. In such cases, a terity, no specific manual toothbrush design has been shown to small spray bottle filled with the therapeutic rinse may be used to be superior for plaque removal.20 gently spray the product on the oral tissues either by the patient In both short-term and long-term studies, electromechanic or the caregiver and the excess suctioned off. When the potential and ultrasonic brushes have been shown to be more effective than for silent aspiration is a concern, a chlorhexidine gel may be ap- conventional brushes in reducing plaque and gingivitis in all age plied with a toothbrush, a sponge applicator or a cotton swab.11 regardless of the toothbrush design (manual, electrome- Fluorides: As previously indicated, the incidence of xerostomia chanic or ultrasonic/electromechanic), care must be taken to in- among patients with pD is reported to be high. Since xerostomia struct the patient and/or caregiver in its proper use to prevent un- can lead to increased caries activity, preventive modalities, such wanted soft-tissue laceration or periodontal tissue trauma. With as dietary analysis, dietary counseling and prophylaxis, should decreasing muscle coordination and increasing motor difficulty, be combined with over-the-counter home fluoride use. A topi- modification of oral hygiene aids such as toothbrush, proxybrush cal fluoride—1% sodium fluoride (NaF)—in the form of a brush- and floss handles may also be recommended. The handles of these on gel is more appropriate than topical solutions, since patients oral hygiene aids may be lengthened or thickened with acrylic, with pD may not be able to adequately swish and expectorate to aluminum foil or a tennis ball. An elastic or velcro handle can minimize ingestion. The use of a topical fluoride gel in a carrier be applied to the handle to facilitate its proper use. patients with is another alternative; however, more patient and caregiver coop- removable prostheses can have their denture brushes replaced eration is required. The application of topical fluorides, including a 5% fluoride varnish, should be part of office-based preventive care. The effec- tiveness of chemoprevention, using both Managing Xerostomia6 chlorhexidine and a fluoride, has been Key Action
demonstrated in patients at high risk for caries and periodontal disease.23 To max- Understand underlying cause Ask GP if alternative medications without xerostomic effects are available.
imize therapeutic efficacy, it is suggested that the chlorhexidine be used first, fol- lowed 50 minutes later by application of Sipping water or other non-sugar-containing drinks throughout day, and have water available at meal the fluoride gel.24 times and at night Rinsing mouth after meals Use of Sialagogues: Qualitative and quan- Using oral moisturiser titative changes in saliva lead to reduced Advise use of a salivary substitute, particularly useful before eating, talking or socializing lubrication; antibacterial, antiviral and antifungal activity; loss of mucosal in- This can be achieved by: Chewing sugar-free/xylitol-containing gum tegrity; loss of buffering capacity; reduced Stimulate salivary flow lavage and cleansing of oral tissues; in- Use of prescribed drugs such as prilocarpine terference with normal remineralization of teeth; and altered digestion, taste and Advise avoidance of: speech. patients with xerostomia whose Avoid anything that increases xerostomia salivary glands can respond to stimula- tion may benefit from simple dietary Prevent caries exacerbation due to xerostomia Instigate rigorous preventive regime tailored to needs measures, such as eating carrots or cel- The New York State Dental Journal • AuguST/SepTember 2013 35 ery, and from chewing sugarless or xylitol-containing gums. Sali- clinicians should also consider that certain medications (haloperi- vary substitutes, oral moisturizers and artificial saliva may provide dol, chlorpromazine, chloridazine, molindone, perphenazine, per- some, if inadequate, relief for xerostomia. However, the prescrip- phenazine and amitriptyline, thiothixene, flufenazine, ciozapine, tion of cholinergic agonists such as pilocarpine hydrochloride and metoclopramide, prochiorperazine, methobenzamide) used pri- cevimeline hydrochloride should be avoided because of an underly- marily to treat psychoses, hallucinations, confusion and gastroin- ing parasympathetic predominance associated with pD.11 testinal problems may worsen the primary features of pD.25 When such drug-related problems are suspected, the patient's primary Managing Xerostomia: Over the past decade, medications used to care physician should be notified (Table 3).
treat patients with pD have greatly improved their quality of life and lengthened their years of independent living. However, these medications, either directly or indirectly, may cause xerostomia, Communication in PD: communication is jeopardized by the nausea, vomiting, constipation, nervousness, agitation, anxiety, "mask-like," expressionless face that robs the individual of much heartburn, confusion, depression, fatigue, loss of sense of smell of his or her nonverbal communication; the monotone, quiet and taste, loss of appetite, anorexia or sleep disruption. Adverse speech that makes a person both difficult to hear and to listen to; drug effects can exacerbate dental caries, periodontal disease and and the slowness of response that can lead to the person being la- chemical erosion of teeth; cause dystonic muscle movements, beled incorrectly as cognitively impaired. Depression or dementia which can result in significant and rapid changes in the occlu- can further erode the ability to communicate. These communica- sion; and further influence food intake, oral hygiene and the pa- tion difficulties can affect the ability to access dental services and tient's self-care ability (Table 2). to voice needs and wants. Drugs Used in Management of Parkinson's Disease25 Class and Drug
Reason Used
Blocks effect of another brain Sedation, urinary retention, 1. Trihexyphenidyl HCl (Artane) transmitter (acetyl 2. Benztropine mesylate (Cogentin) choline) to resemble its levels If choreiform movements, dyski- with dopamine.
nesias, or tremors present, may DOPAMINE PRECURSOR Dyskinesia, fatigue, headache, require sedation techniques to Provides drug that is anxiety, confusion, insomnia, perform dentistry; caution when 2. Carbidopa (Sinemet CR, Madopar CR) metabolized into dopamine orthostatic hypotension getting up from dental chair.
Mimics action of Dopaminergic effects: Caution when getting up from 1. Bromocriptine mesylate (Parlodel) Psychosis (hallucinations, delusions), chair 2. Pramipexole (Mirapex) orthostatic hypotension, dyskinesia, Mirapex adversely reacts with 3. Ropinorole HCl (Requip) CATECHOL-O-TRANSFERASE (COMT) INHIBITOR Used along with levodopa. Potentiate levodopa effects: Caution with use of vasoconstric- 1. Tolcapone (Tasmar) This medication blocks dyskinesia, psychosis, or orthostatic tors. Monitor vital signs during 2. Entacapone (Comtan) enzyme (COMT), to prevent hypotension; nausea and diarrhea, and after administration of first levodopa breakdown in capsule, limit dose to 2 capsules intestine, thus allowing more containing 1:100,000 epineph- levodopa to reach brain. rine (36µg) or less, depend- ing on vital signs and patient response; aspirate to avoid intravascular injection. MONOAMINE OXIDASE B INHIBITOR Prevents metabolism of Dizziness, orthostatic hypotension, Select adrenergic agents (i.e., dopamine within brain.
rine, and tyramine) may cause increased pressor response. However, this does not appear to occur with epinephrine or Has anticholinergic proper- Sedation, urinary retention, periph- ties that enhance dopamine eral edema, nausea, constipation, 36 AuguST/SepTember 2013 • The New York State Dental Journal The parkinson's Disease Society leaflet carries the title "Just a little ptyalism (lack of salivary control), characterized by dribbling and more time," and this is one of the main requirements of people drooling. The patient with a lack of salivary control should be with pD in the dental setting. Sufficient time avoids the sense of positioned in a semi-reclined position (45-degree angle) to avoid rushing, which will only delay communication further. Waiting pooling of the saliva, airway obstruction and/or aspiration. It is for a response is important, as asking the question again may interesting to note that the tendency for a stooped posture when incur a further time lag in response. The use of questions that standing seems to disappear when the patient is reclined slightly, require "yes" or "no" responses can both aid the flow of informa- but many patients with pD object to a fully reclined position. This tion and reduce the time taken to obtain it. The time required reluctance probably relates to their inability to swallow effectively. by some people with pD is best accommodated by the use of a Orthostatic hypotension, related to autonomic dysfunction and salaried dental service.6 a potential adverse drug effect, is often encountered in patients The treatment plan for a patient with pD should be compat- with pD and must be given special consideration at the end of the ible with the patient's physical and cognitive ability to undergo and appointment. The dental chair should be raised slowly, and the respond to dental care. Tremor and rigidity may cause problems get- patient should be allowed adequate time to adjust to the upright ting into and out of the dental chair and interfere with the patient's sitting position before being instructed to rise slowly from the ability to cooperate. To minimize these limitations, patients with pD chair. Orthostatic hypotension and balancing problems or dis- should be seen at a time of day when their medications produce equilibria upon standing should be anticipated to minimize the their maximum effect. The peak efficacy of most antiparkinsonian potential of a fall.11 drugs begins within 60 to 90 minutes of the time of administration. When it is not possible or it is not in the best interest of the patient Prosthetic Considerations: When patients are able to insert, re- to receive treatment in a dental chair, an outpatient surgical suite move and maintain their prostheses, or when caregivers are avail- or a hospital operating room should be chosen to provide for the able to provide these services, removable prostheses are appropri- patient's comfort and safety while allowing for the delivery of the ate to restore function. To minimize problems with adaptation, highest quality dental care. If the patient is confined to a wheelchair, ill-fitting "old friend" prostheses should be modified or improved wide parking spaces and entrance ramps, as well as the removal of when possible. The use of tissue conditioners are recommended other impediments to access of care must be considered.
for functional relines where vertical dimension has to be changed. urinary incontinence and temperature intolerance are com- In some cases, there may be no alternative but to construct a new mon complicating factors in patient management. Shorter ap- prosthesis. patients and caregivers must be informed that success pointments can lessen the possible embarrassment of inconti- with dentures depends to a large degree on appropriate muscle nence; however, at the same time, anticipate that these patients function, which controls and stabilizes the prosthesis during pe- may take longer to comply with instructions and more time may riods of rest and use. The tongue may dislodge the mandibular be required to perform therapeutic procedures. The issue of tem- denture, and facial muscles that are rigid or uncontrollable may perature intolerance can easily be dealt with by simply adjusting prevent a maxillary denture from maintaining a retentive seal. the ambient temperature to patient comfort. clinicians should also even with the best technique, removable prostheses cannot be recognize that while patients with pD have no sensory dysfunction, guaranteed to function properly because of the diminishing adap- they may be slow in responding to nociceptive stimulation, are un- tive skills of patients with pD. If the dental practitioner is pro- able to recoil from pain as quickly as normal patients, and require viding replacement complete dentures for a person with pD, a implementation of appropriate pain control methods.
copy/duplication technique should be used to retain the learned muscle tremor and rigidity affecting the lips, tongue, jaw and muscle control of the familiar dentures. If planning to provide facial muscles can greatly affect the clinician's access to the op- dentures for the first time, the use of overdentures should be con- erating field, compromising the quality of care. This issue may be sidered, as they help to retain proprioception and to maintain minimized with the use of mouth props during treatment. Dys- phagia may further affect the clinical process. It creates a pool- For the person with early pD who requires dentures, con- ing of saliva, prompting the patient to request frequent stops so sideration should be given to the possible role of implants or that he or she can swallow. Loss of sensation from anesthesia can implant-retained overdentures. Although this is an expensive compound swallowing difficulties and increase the risk of aspira- option, it may well be cost-effective in the long term, providing tion. High-volume oral evacuation is a must during most dental the individual with security and helping him or her to preserve procedures. predetermined hand signals for breaks will give the self-esteem and social contacts. As pD progresses, an inability to patient a greater sense of control and comfort.11 narrow the vocal tract contributes to difficulties in pronunciation Positioning the Patient: As pD progresses, muscular rigidity and of consonants, especially "k, g, f, v, s, z.10 before prosthetic re- hypokinesia lead to an open mouth, difficulty swallowing and habilitation is initiated, the potential for such changes in speech The New York State Dental Journal • AuguST/SepTember 2013 37 must be explained to the patient, family members, and/or caregiver to avoid unrealistic expectations.
Case Report
A 45-year-old completely edentulous patient reported to the Department of
prosthodontics for a set of complete dentures. A detailed case history was re-
corded, which revealed that the patient suffered from pD and was on medica-
Figure 1. Preoperative photo.
tion. He also presented with signs and symptoms indicative of the disease, such as mask-like appearance, stare, drooling saliva (Figure 1), gait with rapid, short, shuffling steps and reduced arm swinging. The patient had lost all his teeth due to periodontal disease, which correlated with a history of difficulty in maintaining oral hygiene. Keeping the patient's medical condition in mind, a comprehensive pros- thetic treatment was planned, and the following steps were taken: 1. The patient was given early morning appointments, two to three hours after medication.
2. The patient was asked to be accompanied by a family member, preferably his wife, for psychological comfort.
Figure 2. Peripheral molding.
3. The patient was assisted into and from the dental chair each time he un- derwent treatment.
4. An alginate primary impression was made with warm impression com- pound to reduce patient discomfort.
5. peripheral molding was completed in a single step with a putty consistency of additional silicone (Figure 2) and wash impression with light body con-sistency of the same material (Figure 3). This was done to reduce chairside time and because the material is more patient-friendly than the green stick compound and zinc oxide eugenol paste combination for a final impres-sion. (green stick compound needs to be heated and used in multiple Figure 3. Final impression.
steps; and eugenol paste is an irritant to oral tissues.) 6. before the wash impression, the patient was asked to rinse his mouth with chlorhexidine gluconate because the mucous salivary secretion from the palate can cause voids. rinsing with chlorhexidine gluconate also reduces the likelihood of gagging.
7. The challenge with this patient was the establishment, recording and veri- fication of his maxillomandibular relationship records. While anatomical landmarks, such as paralleling of the residual alveolar ridges, measurements of the face height, phonetics and esthetics, were helpful in establishing an estimated occlusal vertical dimension, his excessive elliptical mandibular movement patterns made jaw verification records quite tenuous. While the Figure 4. Denture with non-anatomic teeth.
needed verification was possible at an individual appointment, it was rarely reproducible at a subsequent one. considerable patience, time and empathy were necessary before a final decision could be made regarding what was judged to be the optimal jaw records for the patient. Jaw relations were re-corded tentatively and transferred onto a mean value articulator. ultimately, a lingualized occlusal scheme was designed in an effort to permit a defini-tive and maximal intercuspal position with a bilateral balance in excursive movements.
8. Non-anatomic teeth (Figure 4) were selected to overcome the problem of a definite centric jaw relation.
9. The neutrocentric concept of complete denture occlusion was adopted and Figure 5. Postoperative photo.
teeth were arranged accordingly.
38 AuguST/SepTember 2013 • The New York State Dental Journal 10. The trial denture was waxed and contoured in harmony with Stuart DA. pathology, Aetiology and pathogenesis. In: playfer Jr, Hindle JV (eds). parkin- the orofacial musculature.
son's Disease in the Older patient. London: Arnold, 2001. pp 11-29.
11. At the try-in appointment, the trial dentures were checked clifford T, Finnerty J. The dental awareness and needs of a parkinson's disease population. for esthetics, phonetics, border extensions, and stability and Jolly De, pauison rb, paulson gW, pike JA. parkinson's disease: a review and recommenda- jaw relations were verified.
tions for dental management. Spec care Dentist 1989:9:74-78.
12. The denture was acrylized with a denture base resin having Fiske J, Hyland K. parkinson's disease and oral care. Dental update 2000;27:58-65.
macphee g. Diagnosis and Differential Diagnosis. In: playfer J r, Hindle J V (eds). parkin- high-impact strength, as the patient's muscle rigidity and son's Disease in the Older patient. London: Arnold, 2001. pp 43-76.
tremors increase the chances of accidental denture fracture.
Dougal A, Fiske J. Access to special care dentistry part 9: special care dentistry services for older people. bDJ 2008;205:421–34.
13. The dentures were inserted in the patient's mouth and neces- Scully c, cawson r. medical problems in Dentistry, 4th ed. butterowrth-Heine London: sary adjustments to the dentures were done (Figure 5). post- Wright, 1998, 362-365.
Steifier m, Hofman S. Disorders of verbal expression in parkinsonism. Adv Neurol insertion instructions were given to the patient. The patient was also given a denture cleaning brush with a handle modi- Diamond Sg, Schneider S, markham cH. Oral sensimotor defects in patients with parkin- fied with acrylic resin that would enable him to have a better son's disease. Adv Neurol 1986;45:335-338.
10. robbins JA, Logemann JA, Kitshner HS. Swallowing and speech production in parkinson's grip when cleaning the denture surfaces. disease. Ann Neurol 1986:19:283-287.
11. Dirks SJ, paunovich eD, Terezhalmy gT, chiodo LK. The patient with parkinson's Disease. Quintessence Int 2003,34:379-393.
12. clifford T, Finnerty J. The dental awareness and needs of a parkinson's disease population. The effects of the combination of edentulism and pD can be dev- 13. Jolly De, pauison rb, paulson gW, pike JA. parkinson's disease: a review and recommenda- astating. Speech can be virtually unintelligible and mandibular tions for dental management. Spec care Dentist 1989:9:74-78.
movement patterns embarrassing. Therefore, in the absence of 14. Fiske, Hyland K. parkinson's disease and oral care. Dental update 2000;27:58-65.
15. Jolly De, pauison rb, paulson gW, pike JA. parkinson's disease: a review and recommenda- robust evidence regarding the possible benefits of routine prost- tions for dental management. Spec care Dentist 1989:9:74-78.
hodontics management, a case should be made for the inclusion 16. Fiske, Hyland K. parkinson's disease and oral care. Dental update 2000;27:58-65.
of preventive dental programs and routine dental care as an inte- 17. clifford TJ, Warsi mJ, burnett cA. Lamey pJ. burning mouth in parkinson's disease suffer- ers. gerodontology 1998:15:73-78 gral part of the regimen of all patients at risk for pD development. 18. Heckmann Sm, Heckmann Jg, Weber Hp. clinical outcomes of three parkinson's dis- The condition is medically mandated, but the dental clinician ease patients treated with mandibular implant overdentures. clin Oral Implants res 2000 Dec;11(6):566-71.
may very well be the first health professional to identify the un- 19. marks L, Hyland K, Fiske J. Oral problems: Speech Diet and Oral care. In: playfer J, Hindle controlled movements that may suggest pD, especially those in- JV. parkinson's Disease in the Older patient. 2nd ed. radcliffe publishing 2008, pp 187.
20. park KK, matis bA, christen Ag. choosing an effective toothbrush. clin prev Dent volving the orofacial complex. A frank discussion with the patient and referral to his or her physician can lead to an early diagnosis 21. Youngblood JJ, Kiiby W, Love JW, Drisko c. effectiveness of a new home plaque-removal instrument in removing subgingival and interproximai plaque: a preliminary in vivo report. and effective management of this movement disorder. Above all, compend contin educ Dent 1985:(suppl 6):S128-S132.
edentulism should be prevented whenever possible.
22. baab DA, Johnson rH, The effect of new electric toothbrush on supragingival plaque and The success of a denture depends, to large extent, on the gingivitis. J periodontol 1989:60:336-341.
23. Keitjens H, Schaeken T, van der Hoeven H. preventive aspects of root caries. Int Dent J wearer's ability to control it with the orofacial musculature (cheek, tongue and lips). Also important is the presence of an adequate 24. Ten cate m, parsh pD. procedures for establishing efficacy of antimicrobial agents for che- motherapeutic caries prevention. J Dent res 1994:73:695-703.
quality and quantity of saliva to act as an adhesive. Adequate den- 25. The National parkinson Foundation. Drugs contraindicated in parkinson's disease. Avail- ture retention and control is threatened by a combination of lack able at Accessed January 7 2003.
of muscle coordination, muscular paralysis or rigidity, and/or xe-rostomia in this group of patients. Denture problems can affect dietary intake, dietary enjoyment, sense of self-worth and social acceptance. providing stable, retentive and aesthetically pleasing dentures can be quite a struggle.
The regimen described above appears to be a useful adjunc- tive treatment in edentulous pD patients and may be considered for patients with diseases similarly affecting motor skills.
proper diagnosis of the challenging predicament of pD, combined
with proper, albeit palliative, prosthodontic management, may be
of inestimable help to such a patient. This particular case history
endorses such an approach. p
Queries about this article can be sent to Dr. Preeti Katyayan at [email protected]. The New York State Dental Journal • AuguST/SepTember 2013 39 restorative Dentistry Restoring Unfavorably Positioned Implants in Anterior Maxilla Case Report Joseph L. rumfola, D.D.s.; sebastiano Andreana, D.D.s., m.s.; Leah colucci, D.D.s.; Yvonne tsay, D.D.s. A b s t r A c t
This article describes a clinical case involving a unique
revealed little has been written or researched on this particular solution to restoring implants placed in an unfavor-
concept. restorability depends upon a multitude of factors, in-cluding: projected or expected longevity of a restoration; avail- able, labial location in the anterior maxilla. Back-
able materials; operator skill; esthetics; and patient expectation. ground information is provided with regard to avoid-
In implant dentistry, factors such as angulation, bone quality, ing compromised situations from the outset, as well
availability of appropriate restorative components, tissue health, occlusal load and maintainability are critical to success. proper as a discussion of issues of restorability, with an em-
planning and surgical execution are paramount to ensuring a re- phasis on dental implants. Different treatment op-
storable implant. the goal should be proper placement to help tions are explored. To complete the case presented, a
ensure that a shortcoming will still meet the standard of care.
custom cast framework resembling traditional veneer
surgical miscues can be the result of incorrect implant selec- tion, number of implants placed, encroachment on vital struc- preparations was selected, with porcelain veneers to
tures, vertical orientation, inadequate intra-arch distance, angu- cover abutment screw access channels.
lation and inadequate spacing.2 In the anterior maxilla, implants are often misangled and bodily positioned to the palatal, since For the patient, the tooth is the gold standard by which they will bone resorption occurs in this direction.3 Angle-corrected abut- compare a replacement prosthesis. And a dental implant is the ments are often necessary because of the orientation of available closest approximation to what the patient lacks. In dentistry, bone for implant placement. they allow for an incisal screw ac- we are faced daily with attempting to satisfy our patients within cess in cement-retained restorations and palatal access for screw- the realm of what is possible, bearing in mind the concept of retained prostheses. With the advent of socket preservation or restorability. thankfully, due to the efforts of leading clinicians, site augmentation techniques, and the use of angle-corrected implant dentistry has evolved such that the final restoration dic- abutments, implants in the anterior maxilla are readily restored.
tates implant placement, and questions of restorability arise in- unfavorably positioned implants can be dealt with in several ways. they can be removed and replaced, surgically repositioned, the concept of restorability is germane to the practicing restored (in a vast array of creative ways), or they can be left un- dentist; however, a search of the literature and of relevant texts restored and buried subgingivally.
40 August/september 2013 • the New York state Dental Journal trephination and removal of integrated implants, followed by Leaving a dental implant unrestored is a difficult decision to make grafting and subsequent replacement, involves at least two addi- and would seem to defeat the purpose of placing it in the first tional surgeries. each surgery visit has a certain degree of morbidity place. there may be times, however, when the risks associated associated with it and the potential for pain, bleeding, swelling, with more surgery or a severely compromised restoration do not infection, failure of implant integration, rejection or loss of graft, outweigh the benefits. For example, a decline in a patient's health and loss of crestal bone.4 One must also take into consideration the status, limited availability, financial limitations or a patient's ac- time and expense involved in this treatment and weigh it against ceptance of interim treatment as a long-term solution might pre- the prospect of having a much more ideal treatment outcome.
clude other treatment options.
One possible option to deal with malpositioned osseointe- creative restorative solutions to unfavorably positioned im- grated implants is the technique defined as distraction osteogen- plants are abundant in the literature. Angled abutments, cAD- esis. Distraction osteogenesis was first reported in orthopedics by cAm custom abutments, preparable abutments and ucLA-type Ilizarov in the late 1980s, and has been used in dentistry to re- cast-to abutments are among the more common solutions when position implants or ankylosed teeth or to increase alveolar crest a prefabricated straight abutment will not be effective. pink por- height.5,6 the basic premise involves intentional separation of a celain or composite and bars used as a substructure are also valu- section of bone, slight movement of the section and subsequent able tools to employ when a case hasn't been properly planned or fixation. New bone will form in between the segment and its did not proceed according to plan.9-11 magne described a planned source as the bone is "stretched." With regard to an unfavor- technique whereby a porcelain veneer was used to restore screw ably positioned implant, an osteotomy can be made around the access in an area with limited interocclusal space.12 All of these block of bone in which it is integrated. the block is then reposi- solutions are not an excuse for improper planning or execution, tioned to create a situation that is more readily restored and then and they each have limitations, but when the benefits outweigh orthodontically or otherwise mechanically fixated.7,8 treatment risks associated with additional surgery, they represent a substan- time and expense may be reduced, but the surgery is more com- tial armamentarium available to the restoring clinician. In fact, plex, and is not without morbidity as well. these solutions have become so common, and diagnostic tools so Mark Your Calendar for
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For more information about this and other Endorsed Programs call: 800-255-2100 the New York state Dental Journal • August/september 2013 41 Figure 1. Anterior retracted view with interim RPD in
Figure 2. Anterior retracted showing position of healing
Figure 3. Side view of working model showing angula-
tion of abutment screw access.
Figure 4. Anterior view of casting on working model.
Figure 5. Anterior view of finished substructure on
Figure 6. Anterior retracted view of seating of substruc-
working model.
precise, we may be experiencing another paradigm shift back to possible, since he would be away for six months during the ap- placing implants in available, native bone.
proaching winter.
A closed tray technique was used to make a fixture level im- Case Report
pression. the goal at this point was to use the resulting model A 67-year-old male patient presented to the Advanced education for diagnostic purposes and to provide the patient with either a in general Dentistry clinic at the university at buffalo school of diagnostic model or, perhaps, even a provisional restoration to Dental medicine for restoration of Nobelreplace straight groovy evaluate. the patient's interim restoration was already estheti- rp implants in sites #8 and #9. A review of his medical history cally compromised and it was possible that he would be accept- found the patient was in very good health, with 81 mg of aspirin ing of a less-than-ideal definitive treatment as well. the working intake daily, his only medication. the patient was also free of any model was the subject of much deliberation. It was decided to known risks factors for implant dentistry, such as smoking and re-appoint the patient for evaluation and to present him with the poor oral hygiene.
treatment options discussed above regarding misplaced implants, the dental history revealed an account of external resorption with removal and replacement as, perhaps, the ideal choice.
on his maxillary central incisors. tooth #9 had been extracted 10 the patient was given the options of removal, grafting years prior, and a ridge preservation procedure was performed. and re-implantation, distraction osteogenesis and attempting A three-unit resin-bonded, fiber-reinforced fixed partial denture restoration. the patient did not consider leaving the implants served as an interim prosthesis for eight years, until tooth #8 was unrestored, because he had been wearing the removable ap- extracted, the socket grafted with DFDbA and a resorbable col- pliance for almost two years and was not satisfied with this lagen barrier membrane placed. the patient was restored with an as a long-term solution. Distraction osteogenesis was given interim maxillary partial denture replacing the central incisors; little consideration because the patient would be leaving town implants were placed the following year.
in two months for an extended time and follow-up wouldn't upon clinical examination, it was apparent that the implants be feasible.
had been placed more labially than what is ideal. the denture removal of the implants would allow for ideal positioning teeth on his interim rpD were set labially to the rest of the arch, at a later time. the patient was willing to go through with this, yet the healing abutments were clearly visible with the prosthesis and his schedule would allow time for removal and grafting, in place (Figures 1, 2). the patient was told that the implant posi- with placement of new implants the following spring, and, it was tion was compromised and that further investigation was neces- hoped, restoration the next fall before the patient's next planned sary to develop a course of treatment. It was at this time that he hiatus out of town for the winter. For the patient, the main draw- expressed his desire to finish the case in as timely a manner as back would be the additional year of treatment.
42 August/september 2013 • the New York state Dental Journal Figure 8. Anterior retracted view of final restoration at
Figure 9. Anterior retracted view of final restoration at
six-month recall.
six-month recall.
Figure 7. Radiograph of framework seated on implants.
Figure 10. Unretracted view of smile at six-month recall.
restoration of the implants was still questionable at this point, replacement if a fracture occurred, but would provide more con- but the patient was eager to proceed in this way. Function was sistency in appearance over the long term. the use of pink por- more important to him than esthetics. And even at his largest celain would allow for final veneers that would appear to have a smile, the patient displayed only the incisal half of his maxillary more ideal length. the use of a pink opaquer to cover the gingival anterior teeth, so a collaborative decision was reached to explore portion of a metal abutment was explored and, given space limi- restorative possibilities. If a suitable solution was not possible, tations, it would not have been possible to build in enough layers then the implants would be removed.
to make it look real. the other options were to have a long crown collaboration of the restorative team led to two possible solu- or to have "root" exposure. this was a moot point for the patient, tions. the implants were not angulated sufficiently to allow for a since he does not naturally display this area and given the techni- palatal screw access, so angle-corrected abutments were ruled out. cian's concerns, pink porcelain would not be used.
the technician made a diagnostic mock-up of a custom substruc- In fabricating the framework, the type of abutments to use ture, which essentially resembled two connected veneer prepara- was also a consideration. One possibility was to use a cAD-cAm tions. It was fabricated using peAK temporary abutments, pattern titanium abutment, which would likely need to be cut back in resin and wax and could be torqued into the implants through the gingival portion and then veneered with titanium-compatible the labial screw access channels. composite resin or porcelain porcelain to make the veneer "preps." the other possibility would veneers would then be cemented to cover the screw access (Figure be to use a ucLA-type cast-to abutment, which could be waxed 3). the alternative option was to fabricate a bar substructure to up and cast, cut back in the gingival area and veneered with por- torque into the implants that would feature additional, palatally celain to form the "preps." this method was chosen, and the pa- located screw channels. these would allow for a definitive restora- tient was appointed for a try-in (Figures 4, 5).
tion to be screwed into place. this option was discounted for two At the try-in, an 810 nm diode laser (Odyssey, Ivoclar Vivadent) reasons: the palatal screw access would be spatially very difficult was used to recontour tissue to allow full seating of the frame- to access; and another microgap could lead to bacterial contami- work (Figure 6). ucLA abutments engage an implant's internal nation and, possibly, a negative odor or taste.
connection and, as such, there was some concern that they would the patient was appointed to present and discuss the treat- need to be adjusted to allow seating of the restoration. the im- ment plan and to make decisions regarding composite or por- pression transfer was accurate, as shown radiographically (Figure celain and the use of pink or tooth-color in the gingival area. 7). proximal contacts were adjusted and verified, and shade selec- composite veneers were presented as an option that would be tion was confirmed. the angle from the long axis of the implant easier to repair chairside, but with the drawback that they might to that of the restoration was measured at less than 20 degrees. lose surface luster over time. porcelain veneers would likely need the patient was informed that a slight enameloplasty of an op- the New York state Dental Journal • August/september 2013 43 posing mandibular incisor might be advantageous to maintain restoring labially misplaced dental implants in the anterior max- even protrusive contact.
illa by using porcelain veneers to cover the screw access channels the final appointment was scheduled before the patient left of a custom-cast subframe. town for the winter. Healing abutments were removed, and the As dental implantology evolves, cases like this one should oc- framework was torqued into place. the emax press veneers (Ivoclar cur less frequently, as great care should be taken to place the im- Vivadent) were tried in with transparent Variolink Veneer try-in (Ivo- plant in a position driven by the final restoration. It is reassuring clar Vivadent) paste, since the veneers exhibited little translucency, to know, however, that there is a great knowledge base within the and the underlying shade was ideal. Fermit (Ivoclar Vivadent), a com- profession should similar circumstances arise in the future. p posite, provisional restorative material was placed into the screw access holes. the patient approved the esthetics of the restora- The authors thank Frank Barnashuk, D.D.S., for his support during the execu- tions, which were subsequently cleaned, silanated and cemented tion of the case, and Christopher Pusateri, D.D.S., Jake J. Kneiert, C.D.T., ZT, and Ken Jones, C.D.T., for their technical input. Queries about this article can with Variolink veneer (Ivoclar Vivadent). the cement was light cured, be sent to Dr. Rumfola at [email protected]. the restorations polished with Astropol polishers (Ivoclar Vivadent), and the occlusion checked and adjusted slightly. the patient left with a pleasing final result in a situation that might have been garber DA. the esthetic dental implant: letting restoration be the guide. J Am Dent Assoc deemed unrestorable (Figures 8-10).
binon pp. treatment planning complications and surgical miscues. J Oral maxillofac surg 2007, suppl 1;65:73-92.
pietrokowski J. the bony residual ridge in man. J prosthet Dent 1975;34:456-462.
this case, with malpositioned implants, presented to our clinic as Hoag pm, Wood DL, Donnenfeld OW, et al. Alveolar crest reduction following full and partial thickness flaps. J periodontol 1972;43:141.
potentially unrestorable. As dental school faculty we are routinely Ilizarov gA. the tension-stress effect on the genesis and growth of tissues: part 1. the influ- asked whether a case is "restorable." In some cases, a theologian ence of stability of fixation and soft-tissue preservation. clin Orthop 1989;238:249-81. Oda t, sawaki Y, ueda m. Alveolar ridge augmentation by distraction osteogenesis using could provide more insight than a dentist, since the answer is titanium implants: an experimental study. Int J Oral maxillofac surg 1999;28:151-156.
often more complex than "yes" or "no." Our literature has very gotta s, sarnachiaro g, tarnow D. Distraction osteogenesis and orthodontic therapy in the treatment of malpositioned osseointegrated implants: A case report. pract proced Aesthet little that explores this concept, and there certainly is no text available to determine what is or is not restorable. there is, how- Werner Zechner, thomas bernhart, Konstantin Zauza, Ales celar, georg Watzek. multidi-mensional osteodistraction for correction of implant malposition in edentulous segments. ever, a great knowledge base among clinicians and technicians clinical Oral Implants research 2001;12(5): 531-538.
within the profession, and case reports can be invaluable in their Kamalakidis s, paniz g, Kang K, Hirayama H. Nonsurgical management of soft tissue defi- ciencies for anterior single implant-supported restorations: a clinical report. J prosthet Dent 2007;97:1-5.
In some respects, this case was "unrestorable." prefabricated Asvanund c, morgano s. restoration of unfavorably positioned implants for a partially parts to restore it don't exist. crown shapes and gingival contours edentulous patient by using an overdenture retained with a milled bar and attachments: a clinical report. J prosthet Dent 2004;91:6-10.
would not allow success for the esthetically demanding patient Hagiwara Y, Nakajima K, tsuge t, mcglumphy e. the use of customized implant frame- and, most importantly, had members of the restorative team not works with gingiva-colored composite resin to restore deficient gingival architecture. J pros-thet Dent 2007;97:112-7.
had some knowledge of how to handle the case, viable implants magne, p, magne m, Jovanovich, sA. An esthetic solution for single-implant restorations – may have been removed.
type III porcelain veneer bonded to a screw-retained custom abutment: a clinical report. J prosthet Dent 2008;99:2-7.
In the end, the case was "restorable." materials were available Holst s, blatz mb, Hegenbarth e, Wichmann m, eitner s. prosthodontic considerations for that could be modified for use. the patient's expectations were predictable single-implant esthetics in the anterior maxilla. J Oral maxillofac surg 2005 primarily related to function. He had stable implants, healthy tis- sept;63(9 supp 2):89-96.
sue and the ability to maintain his prosthesis for a long period of time. reviews are available in the literature like the one pre-sented by Holst et al.,13 which attempt to summarize restorative options for the implant dentist. It remains critical, however, for the clinician to stay well informed, since our ability to "restore" something is constantly changing.
Dental implants are perhaps the closest treatment option for a
patient who just wants "teeth." they must be planned and man-
aged carefully, and they require close communication between
the surgeon, the restoring dentist, the patient and the laboratory
technician. the case presented here demonstrates a method for
44 August/september 2013 • the New York state Dental Journal Providing Oral Health Care to Underserved Population of Pregnant Women Retrospective Review of 320 Patients Treated in Private Practice Setting Steven J. Kerpen, D.m.D., m.p.H.; ronald burakoff, D.m.D., m.p.H.
A b S T r A c T
This article aims to quantify the impact of a novel
should be an integral part of prenatal care. It further suggests that partnership between a fee-for-service private prac-
prenatal care providers encourage oral health exams for all preg-nant women who have not had one in the last six months.
tice and a teaching hospital dental service intended
A novel program was developed in Nassau county, NY, to to provide oral care to an underserved population of
provide access to oral care to an underserved population of preg- pregnant women. Further, it seeks to ascertain the
nant women. It combines the efforts of a private practice, fee-for-service periodontal practice and two teaching hospital dental oral needs of this high-risk and diverse population.
services to deliver oral healthcare to pregnant women enrolled in Data is presented that suggests the dire need for oral
a prenatal care Assistance program (pcAp). care among this pregnant population and the efficacy
The target groups for this program are the prenatal care Assis- of treating these women in a private practice setting.
tance programs at the North Shore/Long Island Jewish Health Sys-tem and South Nassau communities Hospital. These programs are dedicated to decreasing the incidence of poor pregnancy outcomes The 2000 Surgeon general's report, Oral Health in America, in a high-risk population. The pcAp offers comprehensive obstetric called for oral health to be an accepted component of general care and provides prenatal care, employing obstetricians, nurses, health.1 In August 2006, the New York State Department of social workers, nutritionist and a large constellation of support- Health (DOH) published a document entitled, Oral Health care ive staff. The Long Island Jewish Hospital pcAp sees approximately During pregnancy and early childhood—practice guidelines. 1,100 patients each year; the North Shore Hospital at manhasset The DOH guidelines state that improving oral health pre- campus sees 350 patients; and South Nassau communities Hos- vents the many complications of oral disease during pregnancy. pital pcAp sees 600 patients. The patients are a diverse, multicul- It can decrease childhood caries by limiting the transference of tural, at-risk, and often high-risk, group of women and families.
bacteria that cause caries from mother to child. It may reduce ad- The aim of this study was: verse pregnancy outcomes. For many women, it may be the only 1. To ascertain the oral needs of this pcAp population who were time they have dental insurance and, thus, access to care. It is a appointed for dental care.
teachable moment whereby significant lifestyle changes may be 2. To evaluate the efficacy of providing oral care to this popula- initiated. For these reasons, the DOH suggested that oral health tion in a private practice setting. The New York State Dental Journal • AuguST/SepTember 2013 45 Method
1. A prenatal care-periodontal risk Assessment Form was de-
veloped with the help of the DOH Dental bureau.
2. charts of 320 consecutive pcAp patients seen for oral care between April 1, 2008, and October 1, 2008, were reviewed and summarized using the prenatal care-periodontal risk Assessment Form. Results
All women received a full-mouth periodontal examination. prob-
Figure 1.
ing depths were measured at six sites per tooth with a manual probe. Disease status was based on established criteria.2 Figure 1 shows the prevalence of periodontal disease at the initial examination. Only 12.5% presented with gingival health. 39.5% pre-sented with gingivitis. Significantly, 48% of these women had a peri-odontal diagnosis of more advanced forms of periodontal disease.
Figure 2 reveals that only 7% of these patients have had an oral health visit within the last six months. 42% had not seen at dentist for over two years. And 26% have not had an oral care visit for five years or longer.
We evaluated the number of weeks pregnant at the first oral care appointment. While patients presented throughout their pregnancy as they were referred from the prenatal care providers, it is of note Figure 2.
that 37% were referred for oral care examinations during the first trimester of their pregnancy. A significant majority (75%) of women returned for multiple visits for oral care as recommended by the oral care providers. Finally, 17.5% of these patients required emergency referral to a dental clinic for either pain or infection or both.
The DOH has suggested that oral health be an integral component of
prenatal care. A retrospective chart review was performed on 320 con-
secutive patients seen in a novel program in Nassau county dedicated
to meeting the oral care needs of an at-risk population of underserved
pregnant women. The goal of this study was to assess and treat the peri-
odontal needs of this population. Further, it aimed to evaluate the po-
tential of a hospital-based prenatal care Assistance program to refer pa-
tients to a private practice and for that practice to treat these patients.
gingivitis is a common finding among a population of preg- nant women. estimates range from 30% to 70%.3 The wide range of findings may be a result of disparate criteria for diagnosing the disease or because of different study populations. more ad-vanced forms of periodontal disease can be detected in 37% to 46% of women of reproductive age and up to 30% of pregnant women.4 Our review shows that in this population of pregnant women, 87.5% had either gingivitis or more advanced forms of periodontal disease. Significantly, 48% had either mild, moderate or advanced forms of periodontal disease.4 It is estimated that 25% of pregnant women have tooth de- cay. While not specifically evaluated in this review, it is of note that 17.5% of these patients required referral for emergency den- 46 AuguST/SepTember 2013 • The New York State Dental Journal tal care for either pain or swelling or both. The combination of a require further treatment. We believe that this is evidence that high prevalence of periodontal disease, coupled with a significant this population can be motivated to receive oral care and that life- number of women requiring emergency referral, clearly points to style changes can be brought about in a private practice setting. a dire need for oral care for this at-risk population. It has been suggested that there is great difficulty overcoming urban myths regarding dentists providing, and patients seeking, This data shows that the need for oral care is great in this population oral care during pregnancy.5 Our data shows that 37% of patients of pregnant women and that access to oral care services has been were referred and appointed before 14 weeks gestation for oral historically inadequate. Data is presented from a novel program examination and consultation. This data evidences that prenatal that combines the efforts of a private practice in periodontics, an care providers can overcome misconceptions among this popula- Article 28 hospital-based dental program and three hospital-based tion and motivate them to seek oral care at a time in their preg- pcAps. This data suggests that underserved pregnant women can nancy when they may receive the greatest benefit. be successfully motivated by the joint efforts of prenatal and oral The DOH guidelines suggest that prenatal care providers care providers to seek appropriate and timely treatment. p refer pregnant women for an oral examination if they had not seen a dentist in the last six months.4 Our data show that only Queries about this article can be sent to Dr. Kerpen at [email protected]. 7% of this population had oral care within the last six months. Indeed, 25% had not seen a dentist for at least five years. Access to oral care in this population has been inadequate and, therefore, u.S. Department of Health and Human Services. Oral Health in America: A report of the Surgeon general. NIH publication No. 00-4713, rockville, mD: u.S. Department of Health it seems appropriate for all women from pcAp programs in New and Human Services, National Institute of Dental and craniofacial research, may 2000.
York State to be referred for oral examinations. Screening for a gazolla c, ribeiro A, moyses m, Oliveira L, pereira L, Sallum A. evaluation of the incidence of preterm low birth weight in patients undergoing periodontal therapy. J periodontol 2007;78(5):842-848.
disease that has a very high incidence and prevalence is not cost- Levin rp. pregnancy gingivitis. maryland State Dental Assoc 1987;30:27. DeLiefde b. The effective. Scarce dollars should be spent on treatment.
dental care of pregnant women. NZ Dent J 1984;80:41-43.
NYS Department of Health, Oral Health care During pregnancy and early childhood: greater than 75% of these women returned for more then practice guidelines; 2006.
one treatment visit. many who received only one visit did not Samuelson r, guest editorial. grand rounds in Oral-Systemic medicine,2006,1(4):10-13.
The New York State Dental Journal • AuguST/SepTember 2013 47 general dentistry Use of High-Magnification Loupes or Surgical Operating Microscope When Performing Prophylaxes, Scaling or Root Planing Procedures John mamoun, D.m.D.
A b s t r A c t
The use of high-level magnification (6-8x loupes mag-
microscope-level magnification (6-8x or greater), combined with nification, or higher degrees of magnification provid-
head-mounted illumination that is coaxial with the visual axis that the dentist uses to view intraoral surfaces, allows a dentist ed by the surgical operating microscope), combined
to more optimally perform dental prophylaxes procedures com- with head-mounted, coaxial lighting, may improve
pared to using unaided vision and non-coaxial overhead opera- the ability of a dentist or dental hygienist to perform
tory lighting.1-5 prophylaxis or scaling and root planing procedures,
Detection of Hard Calculus Structures or
compared to the performance of these tasks using un-
Soft Inflammatory Subgingival Biofilms
aided vision or entry-level (2.5x) magnification, com-
microscope-level magnification improves a dentist's ability to detect the color contrasts between calculus and normal tooth bined with overhead operatory lighting. A magnified
structure, and to detect microscopic amounts of calculus that are view of the supragingival contours of a tooth surface
located subgingivally near the opening of a periodontal pocket facilitates visualizing the dimensions and curvature of
(Figure 1), or that are protruding like spicules from an aspect of a tooth surface that a dentist is viewing at an angle that is tangent the unseen sub-gingival tooth surfaces, which facili-
to that surface aspect.1 A magnified view of the shape, morphol- tates detection and removal of calculus that is located
ogy and curvature of a tooth allows a dentist to better see how on these subgingival surfaces. Improved calculus re-
calculus that is layered over a tooth surface changes the normal contour of the tooth curvature. moval ability may lead to better periodontal disease
A dentist can use microscopically precise tactile sensitivity to treatment outcomes in dentistry.
determine if there is calculus at any microscopically small point on a subgingival tooth surface. using microscopes, a dentist can the therapeutic value of a dental prophylaxis procedure consists associate a tactile sensation of either "smooth" or "rough" with mainly of the removal of hard calculus precipitates that form any microscopically small point on a tooth surface. A tactile feel- around teeth surfaces and the removal of soft, persistent bio- ing may be associated with a microscopically small point on a films located within periodontal pockets. this article argues that tooth surface that is directly visible, such as a point on suprag- 48 August/september 2013 • the New York state Dental Journal Photos courtesy of Dr. Donato Napoletano ingival tooth structure, or on a non-visible, subgingival surface point, the location of which is inferred based on a magnified view of tooth structure curvatures or on a magnified view of the an-gle and depth of penetration of a cavitron tip into a periodontal pocket.
A dentist using a microscope can detect tiny changes in the shape of the gingiva at different points along a tooth perimeter that are caused by gingival inflammation (Figure 2). the gingiva at various inflamed points along the perimeter of a tooth at the gingiva may be larger in volume, show different colors and show different magnitudes of curvatures, compared to points along the perimeter that are not inflamed. Associated with these inflamed points may be soft subgingival biofilms, microscopic overhangs of amalgam, subgingival crown cement or subgingival calculus. Figure 1. Coaxial y il uminated, magnified view of malposed maxil ary incisors shows
microscopic amounts of calculus at CEJ, periodontal pocket suppuration, and supragingival tooth surface curvature, which aids in making presumptions about subgingival tooth structure Microscope-aided Observation of Tooth
Surface Topography in Performing Prophylaxis
microscope-level magnification provides a dentist with a magni-
fied view of the supragingival tooth surface, the angle in three-
dimensional space of the long axis of the tooth, the dimension of
the perimeter of the tooth at the gingiva, and concavities on the
supragingival clinical crown that indicate the furcations of roots
or subgingival tooth surface concavities. Information about the
dimensions of the shape and curvature of the visible supragingi-
val tooth structure allows a dentist to make intelligent inferences
about the dimensions of the shape and curvature of the non-
visible subgingival tooth structure, and to infer where calculus is
located on these subgingival surfaces (Figure 3).
calculus that precipitates onto subgingival furcation surfaces can cause the normally concave morphology of the furcations seem smooth and contiguous with the rest of the subgingival root Figure 2. Magnification makes it easier to read periodontal probing measurements and to
surface. However, with a microscope, the dentist may observe associate measurement values with microscopical y smal points along tooth perimeter at CEJ. that touching a cavitron tip to this ostensible tooth "surface" re- Increased gingival curvature due to inflammation is more obvious. sults in microscopically small incremental increases in the depth of penetration of the cavitron tip towards the actual subgingival root surface. this increasing depth of penetration shows that this subgingival "tooth surface" is actually subgingival calculus. With a microscope, the dentist observes that as the calculus chips away in response to the cavitron tip force, the cavitron tip traces out, one point at a time, in three-dimensional space, the concave to-pology of the subgingival furcation surface.
A magnified view of the interproximal area between two teeth allows a dentist to better determine the location of the interfaces between tooth structure, gingiva and alveolar bone, and the loca-tions of the contact areas. the dentist can better estimate the di-mension of the contact area in three-dimensional space from the buccal to the lingual direction, and the dimensions of the empty embrasure space between the teeth. When the dentist places a Figure 3. Magnified, coaxially illuminated view of maxillary canine shows calculus at distal
cavitron tip interproximally and subgingivally and feels a hard furcation area and provides information about curvature of furcation surface on which calculus structure, a magnified view of the interproximal allows a dentist is precipitated.
to intelligently presume if this hard structure is calculus, tooth the New York state Dental Journal • August/september 2013 49 structure or alveolar bone, or if the tip is lodged between two in- ensure that it contacts the undercut subgingival tooth surface. terproximal tooth surfaces that form the embrasure space.
this enables a dentist to precisely clean, for example, the mesial subgingival surface of a mesially inclined mandibular molar or Improved Efficiency in Orienting Cavitron Tip
teeth that feature a deep lingual undercut due to the occlusal as- While Removing Calculus
pect of the lingual surface protruding lingually.
microscope-level magnification allows a dentist to more quickly A magnified view of the three-dimensional structure of a and efficiently angle a cavitron tip in three-dimensional space block of calculus allows a dentist to visualize the directions of so that the tip contacts calculus precisely. A cavitron tip may various imaginary axes that pass through the calculus block. the contact a tooth surface point such that the tip is tangential to dentist can use this visual information to align the axis of the the tooth surface, or multiple points on the tip may contact cavitron tip with the axes where the calculus is backed by air and multiple points on the tooth surface simultaneously, or only not by tooth structure, or to touch the cavitron tip at the inter- the tip of the cavitron tip may touch a single point on the tooth face between the calculus and the tooth, which puts the calculus surface. A magnified observation of how the tip contacts a tooth under maximum sheer forces.
surface allows a dentist to evaluate if a particular tip contact re-sults in efficient removal of calculus. Occasionally, a dentist may Advantages of Head-mounted, Coaxial Illumination
observe a microscopic gingival point along the tooth perimeter When performing a prophylaxis, a dentist must view teeth using that is inaccessible to a cavitron tip, even after attempting to ac- multiple viewing angles. For each viewing angle, adequate light- cess this point by angling the tip in a variety of microscopically ing is required. It may be inefficient to use operatory lighting to different ways; this indicates the need to switch to a different illuminate teeth for all of these viewing angles, and some view- shaped tip or to use hand instruments to manually clean this ing angles cannot be illuminated using operatory lighting. Head- point. A dentist can also observe if a tip of a certain length or mounted lighting is coaxial with the axis of the dentist's line of width results in better penetration into the periodontal pocket sight and allows illumination of the entire mouth during the pro- at a specified point on a tooth perimeter compared to a tip of phylaxis procedure.
unlike overhead lighting, coaxial illumination does not cast even if a cavitron tip that is placed into a periodontal pocket shadows on teeth. shadows can obstruct visibility of specific is oriented approximately parallel to the subgingival tooth surface, points along a tooth perimeter at the cemento-enamel junction. it may not be touching calculus; instead, it may only be touching A dentist may not be able to see the following at a shadowed, visu- the gingival tissue on the inner wall of the periodontal pocket ally obstructed perimeter point: microscopic amounts of gingival that is facing the tooth surface. A dentist using a microscope can inflammation; color contrasts between calculus and normal tooth determine at what precise angle and depth of penetration the structure; how calculus changes the morphology of an otherwise cavitron tip contacts the subgingival tooth surface at each point smooth tooth surface; the tooth surface contour at a specific along a tooth perimeter. the dentist can then precisely reproduce point along a tooth perimeter; the angle in three-dimensional this angle and depth of penetration of the tip and keep the tip space of a scaling instrument; if a cavitron tip that is penetrating concentrated on this point until he or she no longer detects mi- a periodontal pocket is actually contacting the subgingival tooth croscopic chips of calculus being ejected from that point on the surface; if the cavitron tip is penetrating more deeply into sub- tooth surface as a result of the cavitron force. gingival tooth surface concavities or furcations as it chips away at A magnified view of the tip of an 11/12 explorer while it is calculus that is coating these concavities or furcations; whether contacting subgingival calculus allows a dentist to observe with or not chips of calculus are being ejected from that point in re- microscopic precision the depth of penetration of the explorer sponse to the cavitron tip; and the specific point on a tooth sur- tip into the periodontal pocket and the angle of contact of the tip face that is associated with a tactile feeling of roughness due to with subgingival calculus. this magnified view allows a dentist to calculus still remaining at that point.
precisely match the angle and depth of penetration of a cavitron coaxial lighting may be particularly useful for illuminating tip with that of the 11/12 explorer for precise targeting of the the buccal surfaces of maxillary posterior teeth; tooth surfaces calculus spicule detected with the explorer. the dentist can also that may be lingually inclined, such as the lingual surfaces of make microscopic changes to the rotation of the cavitron tip and mandibular anterior teeth; and, in general, multiple malposed move the tip superiorly or inferiorly in microscopic increments teeth of multiple emergence profile angles in a patient. coaxial to clean calculus adjacent to the calculus at the initial point of lighting improves illumination of a tooth that appears foreshort- tangential contact on the tooth surface.
ened in the perspective used to view it, improving a dentist's abil- A magnified view of a tooth allows a dentist to detect if the ity to comprehend the dimensions of these teeth.
subgingival tooth structure is undercut relative to the supragin- Also, if a patient is anxious or uncomfortable, the patient gival tooth structure and to angle the cavitron tip accordingly to may curl his or her lips over the teeth to block the cavitron, creat- 50 August/september 2013 • the New York state Dental Journal ing a narrow crevice through which light must pass to illuminate cles that eventually stain. A dentist can use microscopes to de- the tooth surfaces. coaxial lighting penetrates these crevices bet- tect these ledges, often by directly seeing the ledge or other pro- ter than overhead lighting does and also illuminates the lingual trusions or sharp areas on the restorations, and to polish these surfaces of mandibular molars when the posterior aspect of the ledges and remove the stains around the ledges using aluminum tongue blocks overhead light from reaching these surfaces.
oxide composite polishing burs. If the stains still do not come off, which may occur if the composite features a pit or thin crevice, Assessment of Origins of Tooth Stains and
the composite may need to be replaced with another composite How Best to Remove Them
that has a less stain-catching surface topology. stains that are as- using microscopes, a dentist can better analyze the types and sociated with deep pits or soft areas can be caused by dental caries possible causes of a patient's tooth stains. sometimes, stained and would require direct restorations. calculus collects in microscopic pits, corrugations or depressions microscope-level magnification allows a dentist to detect a on a tooth surface. these pits may have to be cleaned tediously, thin, sometimes square-shaped film of yellow discoloration on one point at a time, using a cavitron tip. microscopes facilitate the facial surfaces of incisors, which could be old orthodon- detection of these pitted surfaces and aid in precise smoothing of tic composite bonding material that was not removed when the the surfaces using an aluminum oxide composite polishing bur orthodontic brackets were removed. A metal explorer tip may in a high-speed handpiece. the dentist then moves an explorer leave microscopic dark streaks when rubbed across this material. tip on the surface while viewing the surface with microscopes to Here, the bonding material is abrading the metal and causing verify that the surfaces are smooth and that all such pitting has tiny metal streaks to form on the composite surface. Viewing been removed. At the next recall, the dentist will re-evaluate the the dark streaks with microscope-level magnification shows that tooth surface to see if the surface catches fewer stains overall the material is bonding material. the dentist polishes the bond- and re-polish areas of the surface that still catch stain.
ing away with an aluminum oxide composite polishing bur and stains can also be due to microscopic overhangs and ledges uses microscopes to verify that the bonding material has been on composite restorations that catch and retain organic parti- removed and that the tooth surface is a homogeneous shade.
the New York state Dental Journal • August/september 2013 51 Detection and Polishing of Restoration
Overhangs and Associated Gingival Inflammation
microscope-level magnification facilitates detection of micro-
scopic ledges or spikes of restoration overhangs at the margins
of crowns or buccal composites that facilitate gingival inflamma-
tion. the dentist uses microscopes to aid in precise angling of
polishing burs to polish these overhangs, followed by an explorer
and microscopically precise tactile sensitivity to verify removal of
all overhangs.
Also, a dentist may detect an amalgam overhang by observing microscopic flakes of amalgam overhang being chipped away by the cavitron tip while it is cleaning at the overhang areas. Prophylaxis Procedures around Fixed Partial Dentures
microscope-level magnification improves a dentist's ability to
detect the interface between the tooth root surface and sub-
gingival crown margins that are hidden by gingiva, and to dis-
tinguish the hard sensations of crown margin overhangs from
other hard sensations, such as subgingival calculus, subgingival
tooth structure and excess subgingival crown cement. coaxial
lighting illuminates the junctions between the abutments and
pontics underneath bridges and eliminates shadows that hinder
the ability to distinguish between the metal collars of crowns
and the gingiva and tooth structure inferior to these collars. the
dentist can precisely angle a cavitron tip underneath a bridge
and into the mesial periodontal pocket of a mesially inclined
molar bridge abutment.
microscope-level magnification (6-8x or greater), combined with
head-mounted, coaxial illumination aids, enhances a dentist's
ability to perform prophylaxis procedures by improving a den-
tist's ability to detect hard calculus and soft biofilm structures to
microscopic precision; sense the color contrasts between calculus
and tooth structure; detect the morphological contours of both
supragingival and (unseen) subgingival tooth surfaces; and to
precisely reproduce working end angles that result in progressive
and efficient cleaning of tooth surfaces. p
The author thanks Dr. Donato Napoletano for providing digital photographs for this article. Queries about this article can be sent to Dr. Mamoun at [email protected]. syme se, Fried JL, strassler He. enhanced visualization using magnification systems. J Dent Hyg 1997 Fall;71(5):202-6. sunell s, rucker L. surgical magnification in dental hygiene practice. Int J Dent Hygiene 2004; 2(1):26–35.
mamoun Js. A rationale for the use of high-powered magnification or microscopes in gen-eral dentistry. gen Dent 2009 Jan-Feb;57(1):18-26; quiz 27-8, 95-6.
pencek L. benefits of magnification in dental hygiene practice. J prac Hyg 1997;6:13-15.
Friedman m, mora AF, schmidt r. microscope-assisted precision dentistry. compend con-tin educ Dent 1999 Aug;20(8):723-8, 730-1, 735-6; quiz 737.
52 August/september 2013 • the New York state Dental Journal Cigarette Smoking and the Alveolar Bone around Teeth and Dental Implants Liran Levin, D.m.D.; Ortal Kessler-baruch, D.m.D.
A b S T r A c T
Tobacco is one of the most popular habits among the
nicotina and impaired gingival bleeding.5-7 cigarette smoking ac- general population. Tobacco is also an important risk
counts for half of all periodontal diseases,8 as demonstrated by an increased loss of attachment, development and progression of factor for oral cancer, oral mucosal lesions and peri-
periodontal disease, and increased gingival recession. In addition, odontal diseases. There is substantial evidence sug-
smoking is a potential risk factor for alveolar bone loss.9 gesting that the risk of oral diseases increases with
The number of cigarettes smoked per day is a major risk fac- tor for periodontal diseases, doubling the risk for those in the intensity and duration of tobacco smoking and that
lowest consumption category and increasing it six-fold in the smoking cessation results in risk reduction. In this ar-
subgroup smoking more than 30 cigarettes per day.8 ticle, the influence of cigarette smoking on the perio-
The use of osseointegrated implants as a foundation for the dontium as well as the alveolar bone will be discussed,
prosthetic replacement of missing teeth has become widespread in the last decade.10-12 Owing to the remarkable success of dental highlighting the negative effects on dental implants
implants, there has been growing interest in identifying the fac- and implant-related surgery.
tors associated with implant failure. given the well-documented deleterious effect of smoking on wound healing after tooth extrac- There are an estimated 1.3 billion smokers worldwide, and 4.9 tion and its association with poor quality bone and periodontal million people die from tobacco smoking-related diseases every disease, a negative effect of tobacco use on implant success is to be year (WHO 2005).
expected.13,14 most of the studies report the failure rate of implants Smoking was shown to be a primary risk factor for general in smokers as being more than twice that in nonsmokers.15 health, responsible for many serious diseases: 90% of all lung complications of implants influenced by smoking may cause cancers; 70% of chronic lung diseases; 80% of myocardial infrac- a significantly more marginal bone loss after implant placement, tions before the age of 50; and 39% of chronic ischemic heart increasing the incidence of peri-implantitis and affecting the suc- diseases and strokes.1 cess rates of bone grafts.13,14,16,17 In the dental and oral literature, smoking is reported to have In light of the facts presented, it becomes important to estab- compromised healing after mucogingival surgery2-4 and is associ- lish the effect of smoking on implant-related surgical procedures ated with oral cancer, periodontal disease, leukoplakia, stomatitis (that is, sinus lift procedures, bone grafts and dental implanta- The New York State Dental Journal • AuguST/SepTember 2013 53 tions) and to study the incidence of the complications related to ever, gingivitis does not affect the underlying supporting bony these procedures. These facts will assist health professionals in structures of the teeth and is reversible.28 formulating treatment plans and provide them with important periodontal disease is a chronic microbial infection that trig- information to share with patients who are users of tobacco prod- gers inflammation-mediated loss of the periodontal ligament and ucts so as to obtain informed consent prior to surgery.14 patients alveolar bone that supports the teeth.30 An aggressive form of should be told they are at a greater risk of implant failure if they periodontitis is characterized by a rapid loss of clinical attachment smoke during the initial healing phase following implant inser- and alveolar bone and normally affects young adults. As opposed tion or if they have a significant smoking history.18 to chronic periodontitis, the amount of biofilm and calculus ac-cumulation in aggressive periodontitis subjects is inconsistent Smoking and the Oral Cavity
with the severity and progression of the periodontal destruction. Following lung cancer, the highest relative risks for cancer are These infections are subdivided into localized and generalized cas- observed for the larynx and oral cavity. A recent meta-analysis es, according to the extent of the periodontal destruction.31 reported on 12 studies that estimated oral cancer risk in the u.S., In addition to pathogenic microorganisms in the biofilm, uruguay, Italy, Sweden, India, china, Taiwan and Korea. The genetic and environmental factors, especially tobacco use, con- reported pooled cancer risk estimate was 3.43-times higher in tribute to the cause of periodontal disease. genetic, dermato- smokers compared with nonsmokers.19 Several lines of evidence logical, hematological, granulomatous, immunosuppressive and indicate that oral cancers arise as a result of mutagenic events neoplastic disorders can also have periodontal manifestations.28 causing multiple molecular genetic events in several chromosomes Therefore, the diagnosis of periodontitis requires exclusion of sys- and genes. Two main carcinogens present in tobacco smoke are temic disorders that may severely impair host defenses and lead benzo-pyrine and tobacco smoke-derived nitrosamines.20 Several to premature tooth loss.31 potentially malignant disorders, particularly oral leukoplakia and common forms of periodontal disease have been associated erythroplakia, are known to be more prevalent in smokers, and a with adverse pregnancy outcomes, cardiovascular disease, stroke, proportion of these transforms to cancer over a period of time. pulmonary disease and diabetes, but the causal relations have not The presence of epithelial dysplasia in pre-cancerous lesions been established. prevention and treatment are aimed at control- is a hallmark for cancer development, and several studies from ling the bacterial biofilm and other risk factors, arresting progres- the u.S. and the u.K. have demonstrated significant associations sive disease and restoring lost tooth support.28 with smoking in relation to oral epithelial dysplasia.20 Oral leuko-plakia is the most common pre-cancerous lesion associated with Dental implants are an option for tooth replacement following Among smokers, an increase in plaque accumulation, a high- tooth loss due to caries, periodontal disease or injury. Dental im- er incidence of gingivitis and periodontitis, a higher rate of tooth plants are usually made of titanium screws that are inserted into loss and an increased resorption of the alveolar ridge have been the alveolar bone and function as artificial tooth roots. The suc- found in the oral cavity.13 In addition, smoking has been reported cess of dental implants is critically dependent upon the available to cause brown/black discoloration of teeth,21 dental restorations bone at the implant site. The biocompatibility of the implant itself and dentures;22 alteration in taste and smell;23 association with is determined by both the physical and chemical characteristics of coated tongue (black hairy tongue);24 and impairment and delay the material and particular features of the implant surface, such of wound healing after dento-alveolar surgical procedures, such as the thickness of the oxide layer, microstructure and porosity. as extraction and implantation.25 Furthermore, smokers are more The surface of the dental implant should enhance firm attach- susceptible to oral candidosis.26 ment of the implant to junctional epithelium, soft connective tissue and bone. What is Periodontal Disease?
The most common dental implant material is titanium, Oral health is an essential component of health throughout life. which is resistant to corrosion and has an elasticity modulus Two major oral diseases, dental caries and periodontal diseases, similar to that of bone. Initially, implant surgery induces an acute are both ancient and widespread.27 inflammatory response. This is followed by repair processes, re- The periodontal diseases are highly prevalent and can affect sulting in wound healing.32 While dental treatment offers a high up to 90% of the worldwide population.28 mild forms of peri- success rate, it is not without complications. The complications odontal disease affect 75% of adults in the united States; more associated with implant placement can be classified on a chrono- severe forms affect 20% to 30% of adults.29 gingivitis, the mild- logical basis. They are: est form of periodontal disease, is caused by the bacterial biofilm l early complications—resulting from surgical trauma, inad- (plaque) that accumulates on teeth adjacent to the gingiva. How- equate bone volume, a lack of primary stability, intrabony 54 AuguST/SepTember 2013 • The New York State Dental Journal infection or bacterial contamination of the receptor zone. smoking as well. The proliferation response of T-cells to antigens l Late complications—related to microbiological (peri-implan- is decreased by long-term exposure to cigarette smoking.8 titis) and biomechanical changes and implant fractures (oc- periodontal disease is influenced by genetic factors. There is clusal overload).33 some evidence that tobacco smoking may affect the genetically reported predictors for implant success and failure are gen- determined susceptibility for periodontal diseases.20 Typical signs erally divided into patient-related factors (for example, general of an inflammation, such as changes in gingival color, swelling of patient health, smoking habits, quantity and quality of bone, and the marginal and papillary gingiva, an increase in gingival cervi- oral hygiene maintenance); implant characteristics (for exam- cular fluid flow, as well as bleeding on gentle periodontal probing, ple, dimensions, coating and loading); are caused by alterations of the vascular implant location; and clinician experi- system. The periodontal tissues are very Studies have shown well vascularized. In smokers, the clini- Smoking produces an adverse effect cal signs of inflammation and bleeding that smokers present with on clinical periodontal variables and al- on probing are not as prominent as in veolar bone height and density, acting as greater bone loss, attachment a potential risk factor for alveolar bone The findings of decreased inflam- loss, even at an early age with low to- loss and mean probing mation and reduced gingival cervicu- bacco consumption.9,35 These factors ul- lar fluid volumes in smokers compared timately may cause tooth loss.28 When depth when compared to nonsmokers suggest that smoking the treatment of choice is implantation, impairs gingival blood flow. Although with nonsmokers.9,48 bone volume and density at an implant smokers have significantly higher num- site are critical factors with respect to bers of neutrophils, they have shown surgical protocol and osseointegration.36,37 decreased chemotaxis, phagocytosis and adherence.8 The mechanisms by which smoking compromises wound Smoking and Periodontal Disease
healing are hypothesized as the direct cutaneous vasoconstrictive The periodontal tissues in smokers are continuously exposed to action of nicotine, hemoglobin and blood viscosity, excessive lev- nicotine and its metabolites due to deposition of nicotine on the els of carboxyhemoglobin in blood, compromised polymorpho- root surface. At the same time, cotinine levels (metabolite of nic- nuclear neutrophil (pmN) leukocyte function44,45 and increased otine) are elevated in saliva and gingival cervicular fluid.20 platelet adhesiveness.14 research conducted among young army recruits found a In addition, nicotine may have an effect on cellular protein higher prevalence of aggressive periodontitis among smokers, synthesis and impair gingival fibroblast ability to adhere, thus im- particularly the generalized form of the disease, which agrees with pairing wound healing and/or exacerbating periodontal disease.46 previous reports that found a positive relation between cigarette cigarette smoke could have a cytotoxic effect on human gingival smoking and aggressive periodontitis.38 fibroblasts, which results in capacity loss for adhesion and pro- During cigarette smoking, nearly 4,000 different gases and liferation.47 The consequences of this could be impaired mainte- chemicals are released, among them, nitrogen, carbon monoxide, nance, integrity and remodeling of the oral connective tissue.13 carbon dioxide, ammonia, hydrogen cyanide, benzene, nicotine, Studies have shown that smokers present with greater bone nornicotine, anatabine and anabasine.39 Nicotine, considered the loss, attachment loss and mean probing depth when compared addictive component of cigarette smoke, has been implicated in with nonsmokers.9,48 even after treatment, smokers were found the pathogenesis of numerous diseases.40,41 carbon monoxide has to have a lesser reduction in periodontal depth and lesser clini- a stronger affinity for hemoglobin than oxygen, resulting in dis- cal attachment gain compared to ex-smokers or nonsmokers. In placement of oxygen from the hemoglobin and a lower oxygen a six-year longitudinal study, nonsmokers had approximately a tension in tissues.42 50% higher rate of improvement in probing depth and clinical cigarette smoking is likely to affect the composition of the mi- attachment levels after periodontal therapy than smokers.8 croflora due to a decrease in oxygen tension in the periodontal pock- grossi et al. (1995) showed that smokers present a higher ets and may lead to a selection of anaerobic bacteria.20 The composi- probability of periodontal bone loss when compared with non- tion of bacterial plaque is not altered by smoking, but it has been smokers, showing a ratio of 3.25- and 7.28-times higher for light observed that the host's response to bacterial plaque is disturbed.43 smokers and heavy smokers, respectively.48 Tobacco smoking affects the humoral-mediated and the cell- Smoking might produce an adverse effect on alveolar bone mediated immunity of the host and this may increase suscepti- height and density. In vitro studies have shown decreased pro- bility to periodontal disease. Antibody production is altered by liferation and impaired collagen synthesis in osteoblast-like cells The New York State Dental Journal • AuguST/SepTember 2013 55 exposed to high concentrations of cigarette smoke.49-51 bone loss operations are also common and well-documented procedures and lower basic bone levels may be associated with smoking even done prior to dental implant placement. bain and moy assessed in patients with good oral hygiene.13 the various factors that predispose implants to failure in a group In a study by Levin and Levine, measurements were taken of 540 patients who received 2,194 bränemark implants. The in order to investigate the relationship between smoking and al- most significant factor was smoking.13 veolar bone loss among young healthy adults. The results showed In a retrospective cohort study,57 the risk factors for implant that smokers exhibited significantly lower bone height and den- failure were determined by evaluating a total of 4,680 implants sity values than nonsmokers. Alveolar bone loss was positively placed in 1,140 patients over a 21-year period, from 1982 to 2003. correlated to the reported number of cigarettes smoked per day most of the subjects were followed up over 20 years. Smoking was and number of smoking years.9 The effect of calcium and vitamin found to be a significant predictor of implant failure, with a rela- D supplementation, as measured by increases in urinary calcium/ tive risk of 1.56 most of the failures occurred within the first year, creatinine excretion, was lower in smokers than in nonsmokers.52 with very few failing at a later time. patients who disclosed a his- This may be due to reduced enteric absorption from impaired tory of smoking had a failure rate of 20%. These failure rates were mesenteric blood flow in smokers.53 parathyroid hormone levels higher than the previously reported rates of 6.50% and 11.28% also correlate negatively with smoking.54,55 moreover, smoking is associated with increased concentrations of free radicals, which Implant failure can be classified as either early or late. ear- may contribute to bone resorption.56 There is evidence of smok- ly implant failures occur in the first months following implant ing's impact on bone metabolism, such as an increased secretion placement, while late implant failures occur after loading the im- of the bone resorbing factors pge2 and IL1b.20 plant. most implant failures are identified at or before loading or during the first two years of service. This suggests that interfer- Smoking and Dental Implants
ence with the wound healing process following implant place- The use of endosseous implants has increased over the past de- ment may be an important reason for implant failure.18 Heat, as cade in certain edentulous situations. bone grafts and sinus lift well as toxic byproducts of cigarette smoking, such as nicotine, carbon monoxide and hydrogen cyanide, have been implicated as risk factors for impaired healing13 and, therefore, may con-tribute to early implant loss. Furthermore, cigarette smoking has been implicated in the reduction of bone density and increased peri-implant bone loss, both of which have been associated with late implant failures. consequently, smoking may lower implant survival outcomes even after successful osseointegration has oc-curred.15,18 DeLuca et al. found that smokers had a 1.69-times higher incidence of early implant failures compared to patients who had never smoked or stopped smoking at least one week prior to im-plant surgery. Therefore, it can be deduced that smoking decreases the possibility of successful osseointegration, with the suboptimal healing response that occurs in smokers leading to a higher in-cidence of early implant failure.18 Lambert et al.35 suggested that increased implant failures in smokers are not the result of poor healing or osseointegration, but of exposure of peri-implant tis-sues to tobacco smoke.16 The location of the implant also has a significant effect on failure rate. Implants placed within the maxilla experienced al-most twice the failure rate of those placed in the mandible.14 It has been shown that the maxilla is more prone to the deleterious effect of smoking.58 Implants placed in the anterior mandible had the lowest failure rate of any location.14 Lindquist et al.60,61 compared alveolar marginal bone loss (mbL) around osseointegrated dental implants among smokers and nonsmokers. Among smokers who also had poor oral hy- 56 AuguST/SepTember 2013 • The New York State Dental Journal giene, mbL was nearly three-times as great as that in nonsmok- filled and decayed teeth, and bleeding on probing by smoking history ers.5 The higher marginal bone loss could be partially explained were not significant. prospective observations of 248 women (mean by the findings of Oates et al.62 that demonstrated that pyridino- follow-up time = 6 ± 2 years) and 977 men (mean = 18 ± 7 years) line levels are specifically elevated in the crevicular fluid associ- indicated that individuals who continued to smoke cigarettes had ated with endosseous dental implants of smokers, suggesting that 2.4-fold (men) to 3.5-fold risk (women) of tooth loss compared smoking may affect implant success in part through alterations in with nonsmokers. The rates of tooth loss in men were significantly the levels of bone resorption.16 reduced after they quit smoking cigarettes but remained higher than According to Haas et al.,63 smokers can suffer detrimental ef- those in nonsmokers. men who smoked cigarettes had a 4.5-fold fects around successfully integrated implants, with a significantly increased risk of edentulism; this risk also decreased upon smoking greater bleeding index, greater mean peri-implant pocket depth, cessation. These findings indicate that the risk of tooth loss is greater more frequent peri-implant inflammation and radiographically among cigarette smokers than among nonsmokers. Smoking cessa- greater bone loss.
tion significantly benefits an individual's likelihood of tooth reten-tion, but it may take decades for the individual to return to the rate Smoking and Implant-related Surgeries
of tooth loss observed in nonsmokers.76 The most common bone augmentation procedures for dental im- patients who quit smoking tend to have a reduction in the plants include guided bone regeneration (gbr), sinus lift opera- adverse effects of smoking on implant survival, but the length tion (SLO) and bone grafting. gbr is a common and well-de- of the time after cessation that is necessary for a significant im- scribed procedure for augmentation, with considerable long-term provement has not been sufficiently investigated.14 It was found results. SLO has a predictable outcome as well, with an implant that no statistically significant difference appeared between com- survival rate of over 90% for three to five years.65-69 It is consid- plications and past smoking,75 which indicates that the risk of ered a safe treatment modality, with only minor complications.69 complications can be reduced up to the normal nonsmoker com- The use of autologous bone grafts with dental implants was origi- plication rate when smoking ceases. Numerous smoking cessation nally described by bränemark et al. in 197570 and is now a well- protocols have been proposed to improve the surgical outcome in accepted procedure in oral and maxillofacial rehabilitation.13 smokers.77,78 However, the effect of short-term smoking cessation Smoking adversely affects treatment outcome, as measured upon the risk of complicating tissue and wound healing or other by gains in clinical attachment levels of intra-bony defects treated complications of general surgery is still controversial.13 by regenerative therapy.71 Smokers, after rehabilitation of severely Following a protocol of complete cessation for one week resorbed maxillae with and without bone grafts, have a higher before and eight weeks after initial implant placement surgery, implant failure rate.58,72,73 cigarette smoking is detrimental to bain77 showed that implant failure was significantly lower in the implant osseointegration in grafted maxillary sinuses regardless group that stopped smoking than in those who continued. Fur- of the number of cigarettes consumed.74 thermore, the failure rate was not significantly higher in the group Levin et al. found 23.1% complications following onlay bone that stopped smoking than in nonsmokers over the same period. grafts (Obg) in nonsmokers compared to 50% complications At the very least, smokers should be advised to follow a smoking in smokers. major complications were found in one-third of the cessation protocol, which is a logical step if we accept the fact that operations in smokers, compared to 7.7% in the nonsmokers.13 smoking has a detrimental effect on implant prognosis. There was also a trend of relation between complications and The initial recommendations by bain and moy58,77 suggest past smoking. There was no relation between SLO complications that long periods of abstinence are required. They suggested that and smoking habits, including intra- and postoperative complica- the patient cease smoking at least one week prior to surgery to al- low reversal of the increased levels of platelet adhesion and blood Hwang and Wang31 defined smoking as a relative contraindi- viscosity, as well as the shorter-term effects associated with nico- cation for dental implant placement, together with adolescence, tine. The patient should continue to avoid tobacco for at least aging, osteoporosis, diabetes, etc.16 two months after implant placement, by which time bone heal-ing would have progressed to the osteoblastic phase and early os- seointegration would have been established.14 In a study investigating the rates of tooth loss by smoking status, it was found that current cigarette smokers of either sex had signifi- cantly more missing teeth than never-smokers or former smokers. It is important to improve periodontal monitoring of young Former smokers and pipe or cigar smokers tended to have an inter- smokers and to advise them to discontinue this habit as a preven- mediate number of missing teeth. current male smokers had more tive measure. Dental professionals should be especially prepared teeth with calculus, but the differences in plaque, tooth mobility, to urge their young patients to quit smoking. Additionally, specific The New York State Dental Journal • AuguST/SepTember 2013 57 information regarding the adverse effects of smoking should be Hutton Je, Heath mr, chai JY, et al. Factors related to success and failure rates at 3-year given to medical and dental students. cigarette smoking is con- follow-up in a multicenter study of overdentures supported by brånemark implants. Int J Oral maxillofac Implants 1995;10:33-42.
sidered an important risk factor for periodontal disease occur- cortellini p, Tonetti mS. Long-term tooth survival following regenerative treatment of in- rence and progression. trabony defects. J periodontol 2004;75:672-678.
Zitzmann Nu, Scharer p, marinello cp. Factors influencing the success of gbr. Smoking, In relation to implant surgery, careful explanation of the timing of implant placement, implant location, bone quality and provisional restoration. J harmful effects of smoking and of the patient's responsibilities in clin periodontol 1999;26:673-682. christen Ag. The impact of tobacco use and cessation on oral and dental diseases and the attempt to achieve the best prognosis would ensure the best conditions. Am J med 1992;93:25-31.
obtainable level of compliance; this would also cover the clinician bergstrom J, eliasson S. Noxious effect of cigarette smoking on periodontal health. J peri-odontal res 1987;22:513-517. in the event of implant failure in a noncompliant patient. unfor- Haber J, Wattles J, crowley m, et al. evidence for cigarette smoking as a major risk factor for tunately, while some patients complete the protocol successfully periodontitis. J periodontol 1993;64:16-23.
and stay off smoking for several months, the vast majority return Jacob V, Vellappally S, Smejkalová J. The influence of cigarette smoking on various aspects of periodontal health. Acta medica (Hradec Kralove) 2007;50(1):3-5.
to smoking. It is left to the discretion of the clinician whether to Levin L, Levine J. cigarette smoking and radiographic alveolar bone height and density. N Y undertake implant treatment in high-risk situations. but should State Dent J 2010;76(6):31-5.
10. Levin L. Dealing with dental implant failures. Journal of Applied Oral Science 2008;16:171- the surgeon decide to go ahead, the patient's fully informed con- sent is essential before proceeding. p 11. Levin L, Laviv A, Schwartz-Arad D. Long-term success of implants replacing a single molar. J periodontol 2006a;77:1528-1532.
12. Levin L, Sadet p, grossmann Y. A retrospective evaluation of 1387 single-tooth implants: A Queries about this article can be sent to Dr. Levin at [email protected]. six-year follow up. J periodontol 2006b;77:2080-2083.
13. Levin L, Schwartz-Arad D. The effect of cigarette smoking on dental implants and related surgery. Implant Dent 2005;14(4):357-61.
14. baig mr, rajan m. effects of smoking on the outcome of implant treatment: a literature review. Indian J Dent res 2007;18(4):190-5.
15. Levin L, Ofec r, grossmann Y, Anner r. periodontal disease as a risk for dental implant Strietzel Fp, reichart pA, Kale A, Kulkarni m, Wegner b, Küchler I. Smoking interferes with failure over time: a long-term historical cohort study. J clin periodontol. 2011; 38(8):732- the prognosis of dental implant treatment: a systematic review and meta-analysis. J clin periodontol 2007; 34(6):523-44.
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47. poggi p, rota mT, boratto r. The volatile fraction of cigarette smoke induces alterations in the human gingival fibroblast cytoskeleton. J periodontal res 2002; 37:230-235. The New York State Dental Journal • AuguST/SepTember 2013 59 Gene Therapy in Dentistry A Review H.s. shilpashree, b.D.s., m.D.s.; shriprasad sarapur, b.D.s., m.D.s.
A b s t r A c t
Gene therapy is an emerging field of biomedicine that
ever, in the late 1980s and early 1990s, the concept of gene ther- has commanded considerable scientific and popular at-
apy was being increasingly considered for treatment of a number of acquired diseases.2 In 1995, the first potential impact of gene tention. Genes are specific sequences of bases that en-
therapy on dentistry was described. In 2000, the first report of a code instructions to make proteins. When genes are
fully successful gene therapy treatment—a French study involv- altered so that encoded proteins are unable to carry
ing a severe combined immunodeficiency in young children—was published.3 out their normal functions, genetic disorders can re-
In the past six years, remarkable progress has been made in sult. Gene therapy essentially consists of introducing
the field of gene therapy, including seven areas relevant to dental specific genetic material into target cells to compen-
practice. they are: bone repair; salivary glands; autoimmune dis- sate for abnormal genes or to make a beneficial pro-
ease; pain; DNA vaccinations; keratinocytes; and cancer. While considerable problems remain, thus impeding the routine clini- tein without producing toxic effects on surrounding
cal use of gene transfer, gene therapy will have a pervasive and tissue. Transferred genes can be used for either re-
significant impact on areas of dental practice that are based in parative or pharmacological purposes. Applications
biological science.4 there are two general ways to transfer genes.2 A gene that is of gene therapy to dental and oral problems illustrate
inserted directly into a cell usually does not function. Instead, a the potential impact of this technology on dentistry.
carrier called a vector is used to introduce the therapeutic gene This review provides an update on transfer techniques
into the patient's target cells. the most common vector is a virus that has been genetically altered to carry normal human DNA.4 and clinical implications of gene therapy in dentistry.
Viral vectors typically are highly efficient for gene transfer in vivo, but they can pose a significant safety risk. gene transfer mediated gene therapy typically involves insertion of a functioning gene by viral vectors is referred to as transduction. Nonviral methods, into cells to correct a cellular dysfunction or to provide a new cel- while much safer for the host, at present are relatively inefficient lular function.1 In the mid-1980s, the focus of gene therapy was for gene transfer in vivo. gene transfer mediated by nonviral vec- entirely on treating diseases caused by single-gene defects. How- tors is referred to as transfection.2 60 August/september 2013 • the New York state Dental Journal the major problems hindering gene transfer applications are bio- in the blood stream.8,9 cannulation of the main excretory ducts logical, resulting from limitations in our knowledge of the essen- of major sgs is a fairly simple procedure that is used for contrast tial components involved in the process. these include inadequate radiography (sialograms). this is a very effective delivery method, understanding of virus biology, recombinant vector interactions because virtually all the epithelial cells in sgs are continuous with different cell types and the targeted diseases.5 with the duct system. since sgs in humans are encapsulated or- some of the different types of viruses used as vectors in gene gans, vectors delivered through the ductal system are limited in therapy include:3 reaching other organs or the bloodstream.1 l retroviruses (e.g., HIV)—A class of viruses that can create A variety of genes used for salivary glands are genes-encod- double-stranded DNA copies of their rNA genomes. these ing hormones (growth hormone, insulin),10,11 an antimicrobial copies of the virus's genome can be integrated into the chro- agent (histatin 3, or H3),12 membrane proteins (aquaporin-1 mosomes of host cells. and aquaporin-5),13,14 a transcription factor (e2F-1),15 protease l Adenoviruses—A class of viruses with double-stranded DNA inhibitors (1-antitrypsin and kallistatin),16 a protein-affecting genomes; they cause respiratory, intestinal and eye infections apoptosis (Fas ligand)17 and several nonmammalian "reporter proteins" (ß-galactosidase, chloramphenicol transferase and lu- l Adeno-associated viruses—A class of small, single-stranded DNA viruses that can insert their genetic material at a spe- transferring genes to salivary glands can correct systemic cific site on chromosome 19. single-protein disorders. since 1995, it was demonstrated in rats l Herpes simplex viruses—A class of double-stranded viruses that transgene products could be secreted from salivary glands that can infect a particular cell type, i.e., neurons.
into the bloodstream—in other words, endocrine secretion.21 besides viruses-mediated gene-delivery systems, there are When an adenovirus-encoding human growth hormone, or several nonviral options for gene delivery. the simplest method is hgH, was administered to adult rat salivary glands, serum hgH the direct introduction of therapeutic DNA into target cells. this increased from background levels to 16 nanograms per millili- technique has restricted use, as it requires large amounts of DNA ter, well above the level considered therapeutic in humans: 5 ng/ to bring out the desired effect.
mL.10 Importantly, these hgH levels induced serological respons- Another nonviral approach involves creation of an artificial es indicative of systemic activity (increased insulin-like growth lipid sphere (a liposome) with an aqueous core. this liposome, factor 1, triglycerides and blood urea nitrogen: creatinine ratio). which carries the therapeutic DNA, is capable of transporting the subsequently, this showed that it is efficient clinically that the DNA through the target cell's membrane. therapeutic DNA can direction (whether endocrine or exocrine) of transgene product also be introduced into target cells by chemically linking the DNA secretion must be controllable.22 A research group at NIDcr23 to a molecule that will bind to special cell receptors. Once bound reported that administration of the immunomodulatory drug to these receptors, the therapeutic DNA constructs are engulfed hydroxychloroquine dramatically increases the efficiency of hgH by the cell membrane and passed into the interior of the target endocrine secretion from rat submandibular glands.
cell. this delivery system, however, tends to be less effective than the other options.4 experiments with the introduction of a 47th chromosome sjögren's syndrome (ss) is an autoimmune disease that leads to (an artificial, human techno-chromosome) into target cells are the destruction of salivary gland tissue and a marked reduction being carried out. this chromosome would exist autonomously in salivary flow. ss is characterized by a focal mononuclear cell alongside the standard 46 without affecting functions or causing infiltrate in the salivary and lacrimal glands.24 this chronic in- mutations. It would be a large vector capable of carrying sub- flammation and the consequent secretion of proinflammatory cy- stantial amounts of genetic code and, because of its construction tokines are associated with dry mouth (xerostomia—often with a and autonomy, the body's immune system would not attack it. A marked increase in dental caries) and dry eyes (keratoconjuncti- disadvantage with this potential method is the difficulty in deliv- vitis sicca). the gene transfer application of immune modulation ering such a large molecule into the nucleus of a target cell.3 appears to have potential for treatment of autoimmune diseases. the cellular infiltrates in ss consist mainly of cD4+ cells, Implications of Gene Therapy in Dentistry
which show divergence into t helper 1 and t helper 2, or th1 Salivary Glands and th2 subsets. th1 cells are associated with cell-mediated im- A gene therapy treatment for salivary glands (sg) involves trans- munity, producing cytokines, such as interleukin 2, or IL-2; inter- fer of a new gene via retroductal cannulation of the main excre- ferong or INF-g; and tumor necrosis factora, or tNF-a. th2 cells tory ducts of a major sg. this could lead to the production of a produce IL-4, IL-6 and IL-10 and are associated with humoral im- cellular therapeutic protein6,7 or to a secretion either in saliva or mune responses. the th1 cell subset induces inflammation; th1- the New York state Dental Journal • August/september 2013 61 related cytokines are likely to stimulate cytologic t cell processes in animals. this gene led to the production of fimbrial protein lo- within the gland. th2-related cytokines tend to cause a decrease cally in the salivary gland tissue of mice, with the consequent in inflammation.25 this situation gives rise to a general paradigm production of specific salivary immunoglobulin A and immuno- that has emerged for developing novel protein-based and, more globulin g antibodies and serum Igg antibodies. Although it was recently, gene-based treatments for several autoimmune diseases, not shown in their report, one might expect that the secretory including ss. this strategy, which we use, is that biological fac- IgA secreted in saliva could neutralize P. gingivalis and limit its tors that enhance th2 functions and suppress th1 cells likely ability to participate in plaque formation. Furthermore, any se- will be efficacious for therapy.26 the transfer of genes-encoding creted fimbrial protein in saliva could bind to pellicle components anti-inflammatory cytokines, such as Interleukin -10 (IL10) or and also inhibit the attachment of P. gingivalis to the developing Vasoactive intestinal peptide (VIp), could lead to a decrease in the plaque. Although applications of DNA vaccination are in the ear- expression of proinflammatory cytokines and, thus, protect sgs liest stages of use with oropharyngeal tissues, it seems reasonable and preserve their secretory function.27 to suggest that these approaches will play a role in future strate-gies for preventing periodontal diseases and dental caries.35 Bone Repairstudies by researchers at the university of michigan school of Gene Therapy for Oral Cancer
Dentistry have used ex vivo methods to transfer genes-encoding Gene Addition Therapy bone morphogenetic proteins, or bmps.28,29 bmps are well-es- cancer cells generally demonstrate impaired cell-cycle progres- tablished agents in the induction of both orthotopic and ectopic sion, largely due to mutations and the overexpression of cell-cy- bone formation. In ex vivo studies, researchers accomplish the cle regulators. several genetic alterations have been described in actual gene transfer in a tissue culture environment and then oral cancer, including mutations of p53, the retinoblastoma gene place the transduced cells, carrying the foreign genes, back into (rb1), p16 and p21.36 the most extensively studied mutations in the host. Other recent studies conducted by researchers have used oral cancer are those of p53. since the protein p53 plays a role in mesenchymal stem cell–mediated gene therapy for bone regenera- cell-cycle regulation and in apoptosis, p53 gene transfer was ini- tion. genetically engineered mesenchymal stem cells expressing tially tested in squamous cell carcinoma patients by injecting the bmp-2 induced increased formation of new blood vessels, as well primary or regional tumor with an adenoviral vector-expressing as new bone.30,31 wild-type p53. Adenoviral p53 (Ad-p53) was demonstrated to be A recent investigation by Alden and colleagues32 demonstrat- safe and well tolerated. several randomized studies of adenoviral ed that it is possible to directly deliver the bmp-2 gene in vivo to p53 are underway in patients with squamous cell carcinoma to tissue via an adenoviral vector (vs. using ex vivo cellular re-engi- determine its role as a surgical adjuvant and in combination with neering) and thus achieve healing of mandibular osseous defects. DNA-damaging agents.37 Another group at the university of michigan reported transfer of the platelet-derived growth factor gene to periodontal cells, which Antisense RNA and Ribozymes resulted in DNA synthesis and cellular proliferation.33 gene expression can usually be inhibited by rNA that is comple-mentary to the strand of DNA expressing the gene. this "anti- sense" rNA can prevent the activity of several known oncogenes, gene transfer may be particularly useful for managing chronic including myc, fos and ras, and can inhibit viruses such as HsV-1, and intractable pain.34 several studies in animal models have HpV and HtLV-1.38 shown that viral-mediated transfer of genes-encoding opiate pep- bertrand et al. observed inhibition of tumor growth in xeno- tides to peripheral and central neurons can lead to antinocicep- graft models of oral cancer with systemic administration of egFr tive effects. there is a report also from the university of rochester antisense DNA. the ability of gene-specific, double-stranded rNA in New York showing the feasibility of direct gene delivery to the to trigger the degradation of homologous cellular rNAs is known articular surface of the temporomandibular joint by using feline as rNA interference (rNAi). small, interfering rNAs (sirNAs) immunodeficiency viral vectors, FIV (lacZ). considerably more mediate mrNA degradation in the process of rNAi and have been research is needed before gene transfer can be tested clinically as shown to be potentially more effective than antisense rNA, likely a strategy for chronic pain management. due to enhanced resistance of sirNAs to nuclease degradation.39 DNA Vaccinations DNA vaccination can be done by directly delivering DNA in a the immunologic gene therapy approach to oral cancer involves plasmid vs. the traditional administration of a purified protein or either increasing the immunogenic potential of tumor cells or an attenuated microbe.4 Kawabata and colleagues in 1999 used augmenting the patient's immune response to a tumor. patients plasmid DNA encoding the Porphyromonas gingivalis fimbrial gene with squamous cell carcinoma of the head and neck demonstrate 62 August/september 2013 • the New York state Dental Journal deficient function of several categories of immune cells, including natural killer cells, t-lymphocytes and several cytokines.36 stud-ies in pre-clinical animal models have included administration of interleukin-2 (IL-2)-activated lymphokine-activated killer (LAK) cells, tumor necrosis factor-alpha (tNF-) and immunomodula-tory gene therapy with IL-2, IL-4, interferon-gamma (IFN-), IFN- and granulocyte-macrophage colony-stimulating factor (gm-csF); IL-6 had enhanced killer cell-mediated cytotoxic effects. the feasibility and efficacy of combination non-viral lipid-for-mulated murine interleukin 2 (mIL-2) and polymer-formulated murine interleukin 12 (mIL-12) gene therapy for squamous cell carcinoma have been investigated in pre-clinical models. the use of combined mIL-2 and mIL-12 gene therapy resulted in signifi-cant anti-tumor effects, most likely due to increased activation of cytolytic t-lymphocyte and natural killer cells.40 Suicide Gene Therapy"suicide" gene therapy involves introduction of a gene into a cell that enables a prodrug to be activated into an active cytotoxic drug. the most extensively studied approach utilizes herpes sim-plex virus-thymidine kinase (HsV-tK). this gene encodes a viral enzyme that phosphorylates ganciclovir into a monophosphate form, which is then further phosphorylated by intracellular en-zymes into an active triphosphate compound that terminates DNA synthesis. thus, this system selectively targets actively divid-ing cancer cells.41 Replicating Viruses That Destroy Tumor Cells
A novel approach to gene therapy that has been evaluated exten-
sively in pre-clinical and clinical studies for squamous cell carci-
noma involves a vector that selectively replicates within and lyses
tumor cells. An e1b 55kD gene-deleted adenovirus, ONYX-015
(d11520), has been developed for the treatment of tumors lack-
ing p53 function. since the e1b 55kD gene product is responsible
for p53 binding and inactivation, it has been hypothesized that an
e1b 55kD deletion mutant would be unable to inactivate p53 in
normal cells and would, thus, be unable to replicate efficiently.
In contrast, cancer cells lacking functional p53 (e.g., due to gene mutation) would hypothetically be sensitive to viral repli-cation and subsequent cytopathic effects. Animal studies with ONYX-015 have also suggested that the efficacy of the virus is significantly augmented with the administration of standard chemotherapeutic agents. ONYX-015 can be administered safely via intra-tumoral injection to patients with recurrent/refractory squamous cell carcinoma. However, evidence of only modest an-ti-tumoral activity has been detected when this approach to gene therapy was used alone. In a phase II trial of a combination of intra-tumoral ONYX-015 injection with cisplatin and 5-fluorou-racil in patients with recurrent squamous cell cancer of the head and neck, there were substantial objective responses, including a high proportion of complete responses. by six months, none of the New York state Dental Journal • August/september 2013 63 the responding tumors had progressed, whereas all non-injected barka t, Van der Noen Hm. retrovirus-mediated gene transfer into salivary glands in vivo. tumors treated with chemotherapy alone had progressed. tumor Hum gene ther 1996;7:613–8.
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Hoque At, baccaglini L, baum bJ. Hydroxychloroquine enhances the endocrine secretion of Conclusion
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clayman gL. the current status of gene therapy. semin Onco. 2000; 27(4 suppl 8):39– Voutetakis A, bossie I, KoK mr, Zhang W, Wang J, cotrim Ap, et al. salivary glands as a po- tential gene transfer target for gene therapeutics of some monogenetic endocrine disorders. maeda N, Kawamura t, Hoshino H, Yamada N, blackard J, Kushida s et al. Inhibition of J endocrinology 2005;185:363-72.
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64 August/september 2013 • the New York state Dental Journal Aloe Vera as Cure for Lichen Planusbharati A. patil, b.D.S., m.D.S.; Hebbar pragati bhaskar, b.D.S., m.D.S.; Jyoti S. pol, b.D.S., m.D.S.; Amandeep Sodhi, b.D.S., m.D.S.; Asha V. madhu, b.D.S., m.D.S.
A b S T r A c T
Oral lichen planus is a difficult condition to treat be-
The treatment of lichen planus can be prolonged due to the nature cause of its chronic nature. Various treatment modali-
of the lesion, with periods of waxing and waning of symptoms. The various treatment modalities used so far in ameliorating the symp- ties have resulted in partial regression of symptoms but
toms of OLp include corticosteroid topical and systemic therapy, not a complete cure. Aloe vera, a product with minimal
retinoids, calcineurin inhibitors and ultraviolet phototherapy.3 In adverse effects, can be tried to treat this disorder. A
contrast to the above-mentioned therapies, aloe vera is an entity with minimum documented side effects, most notably, burning 38-year-old male patient diagnosed with lichen planus
sensation, eczema in a few hypersensitive individuals and allergic of the skin and the oral mucosa was suffering from
dermatitis.4 patients with extensive oral and skin involvement can severe pain and a burning sensation intraorally and
be good candidates for the use of aloe vera juice and gel, consider- pruritus of the skin lesions. Considering the extensive
ing the low toxicity profile and varied beneficial effects.
Herein we report a case of papular and reticular OLp with cuta- involvement, an herbal alternative was considered. The
neous involvement treated with aloe vera juice and gel application. patient was prescribed aloe vera juice and gel applica-
tion for two months. At the nine-month follow-up,

Case Report
A 38-year-old male patient visited the department of Oral medicine
the patient was symptom-free and totally cured of the
and radiology with a chief complaint of a burning sensation and intraoral and skin lesions.
pain in the mouth for 15 to 20 days. The patient gave a history of sudden onset of symptoms and difficulty opening his mouth. This Oral lichen planus (OLp) is a common disease affecting approxi- was preceded by the occurrence of multiple small white boils on the mately 1% to 2% of the population. cutaneous lesions develop in inner side of the cheeks and tongue, which gradually turned into approximately 15% of patients with OLp.1 The usual presentation flat white patches. The patient had a habit of smoking three to four is either in the reticular or erosive forms; the papular form is cigarettes a day and consuming alcohol once a week for 20 years. rarely seen. This form presents as multiple, small white pinpoint On general physical examination, two irregularly shaped pur- papules of the oral mucosa approximately 0.5 mm in size.2 plish macules were seen on the left and right clavicular region, the The New York State Dental Journal • AuguST/SepTember 2013 65 Figure 1. Maculopapular lesion
Figure 2. Dif use papular white
behind left ear.
lesion involving right buccal mucosa.
Figure 3. Dif use papular white
Figure 4. White reticular
lesion involving left buccal mucosa.
lace-like pat ern involving ventral surface of tongue and floor of mouth.
skin behind the left ear (Figure 1), and on the extensor surfaces and showed complete healing of the skin and oral lesions and of the hands and feet. The patient reported these lesions to be has remained symptom-free for the subsequent nine months extremely pruritic. Intraoral examination revealed multiple, small (Figures 5, 6, 7, 8).
pinpoint white papules scattered all over the left and right buccal mucosa and sparsely over the tongue (Figures 2, 3, 4) and hard palate. The ventral surface of the tongue presented with reticular, Lichen planus is a chronic inflammatory disorder involving the lace-like white striae, also involving the floor of the mouth. The skin and the oral mucosa. Despite advances in science that have lesions were smooth and tender on palpation.
helped to elaborate the etiopathogenesis of this disorder, no defi- A provisional diagnosis of lichen planus was given, consider- nite cure has been discovered. considering the chronic nature of ing the clinical features exhibited by the patient. An incisional the disease, any treatment used should aim at having minimal biopsy was performed from the left buccal mucosa that confirmed side effects.
the diagnosis. As there was significant, widespread distribution of Of the conventional treatment modalities used for OLp, topi- oral and skin lesions, an herbal option of treatment was explored. cal steroids are considered to be the first choice.5,6 The treatment The patient was advised to take 30 ml of aloe vera juice in the success with midpotency corticosteroids and fluorinated corticos- morning on an empty stomach and at night before bedtime. He teroids has been in the range of 30% to 100%.1 The various side was asked to swish the juice for about one minute in the mouth, effects of short-term systemic steroid therapy include insomnia, then swallow, and to apply the aloe vera gel intraorally to the left diarrhea, psychotic episodes, sodium and water retention, muscu- and right buccal mucosa and ventral surface of the tongue twice lar weakness, increased susceptibility to infection, hypertension, daily for two months. hyperglycemia and adrenal suppression.7 Topical retinoids are an For the initial two weeks, the patient reported no improve- effective alternative treatment modality for OLp, especially when ment in the burning sensation and pain. After this, the patient lichen planus is associated with mild dysplasia.5 The use of sys- reported a slight reduction in the burning sensation. At the temic retinoids is associated with severe side effects and, hence, end of one month, there was complete cessation of the burn- their routine use in the management of OLp is avoided.2 ing sensation and pain, and the lesion showed partial regres- cyclosporine is an immunosuppressant drug and inhibits sion. After obtaining symptomatic relief, the patient discontin- the proliferation and function of T lymphocytes and the release ued the aloe vera treatment and did not return for follow-up of interleukin 1 and 2.6 The primary side effect of use is a tran- at two months. The patient was reviewed after nine months sient burning sensation; the main adverse reaction is renal dys- 66 AuguST/SepTember 2013 • The New York State Dental Journal Figure 5. Complete resolution of
Figure 6. Complete resolution
maculopapular lesion behind left ear.
of papular lesion of right buccal mucosa.
Figure 7. Complete resolution of
Figure 8. Complete resolution of
papular lesion of left buccal mucosa.
reticular lesion on ventral surface of tongue.
function. The main limiting factor for use of cyclosporine is its A randomized controlled trial reported in 1996 on the efficacy of aloe vera extract in a hydrophilic cream in psoriasis vulgaris Tacrolimus is another potent immunosuppressive agent that states that aloe vera was found to be significantly more effective can be used in the management of recalcitrant OLp. However, than a placebo in reducing the psoriatic plaques, with no toxic there is a black box warning by the FDA stating that the use of effects.13 A 1999 systematic review included 10 well-documented this agent can cause an increased risk for the development of clinical trials using aloe vera mono preparations. In summary, it malignancy in psoriasis. Hence, caution should be exercised in its states that aloe vera was effective in reducing blood glucose levels use.3 puVA therapy includes administration of 8- methoxypso- in diabetic patients and in lowering lipid levels in hyperlipidemic ralen and exposure to long wave ultraviolet A light.7 Some of the patients. Topical use was also effective in genital herpes and pso- side effects include nausea, dizziness, headache and paresthesia.8 riasis but not in radiation-induced skin damage or wound heal- A serious drawback is the potential for development of squamous ing.12 A 2005 review of aloe vera suggests its uses in dentistry in treating aphthous ulcers, alveolar osteitis, lichen planus and as a Aloe vera has been in use for the past 2,000 years, with no denture adhesive.11 major adverse events documented.9 It is a plant belonging to the A randomized controlled trial reported in 2008, conducted Lilaceae family.10,11 Among the approximately 400 species only to determine the efficacy of aloe vera gel in the treatment of OLp, two, namely A. barbadensis and A. aborescens, are used commer- suggests that aloe vera gel was significantly more effective than cially.10 The aloe barbadensis comprises two parts: the inner por- a placebo in inducing clinical and symptomatic improvement in tion of the leaves parenchymal tissue; and specialized cells known OLp patients.14 The safety of aloe vera has been unquestioned due as pericyclic tubules. Aloe vera has been found to contain 75 active to the lack of substantial documentation of any major adverse constituents, such as vitamins, minerals, enzymes, sugars, amino reaction. As these products are natural, they are perceived to be acids, etc.12 The proposed actions of aloe vera include moistur- harmless. but as shown by a case series in 2010, three female izing properties, anti-inflammatory, antibacterial, antiviral, anti- patients, aged 55, 62 and 57, were reported to suffer from aloe- fungal, wound healing and pain relief.11 The various conditions induced acute hepatitis.15 The literature on adverse effects has in which aloe vera have been tried and claimed to be effective in- been sparse and anecdotal; hence, the safety of aloe vera needs clude asthma, arthritis, candidiasis, digestive and bowel disorders, to be tested stringently considering the upsurge in herbal supple- skin disorders,12 ulcer-like recurrent aphthae, extraction sites to ments. A trial recently reported in 2011 comparing the efficacy prevent alveolar osteitis, lichen planus,11 etc.
of aloe vera mouthwash with 0.1% triamcinolone acetonide in The New York State Dental Journal • AuguST/SepTember 2013 67 OLp showed healing in 74% of the aloe group patients and 78% epstein Jb, Wan LS, Zhang L. Oral lichen planus: progress in understanding its malignant among the triamcinolone acetonide patients. This study suggests potential and the implications for clinical management. Oral Surg Oral med Oral pathol Oral radiol endod 2003 Jul;96(1):32-7. aloe vera is an effective substitute in the management of OLp.16 mccreary ce, mccartan be. clinical management of oral lichen planus. british Journal of Oral and maxillofacial Surgery 1999 Oct;37(5):338-43. edwards pc, Kelsch r. Oral lichen planus: clinical presentation and management. J can Dent Assoc 2002 Sept;68(8):494-9.
To the best of our knowledge, only one case report so far has Ismail Sb, Kumar SK, Zain rb. Oral lichen planus and lichenoid reactions: etiopatho-genesis, diagnosis, management and malignant transformation. Journal of Oral Science documented the efficacy of aloe vera in the treatment of lichen planus.9 In conclusion, the authors wish to state that alternative Hayes Sm. Lichen planus: report of successful treatment with aloe vera. general Dentistry 1999 may-Jun;47(3):268-72. therapies with evidence of effectiveness in oral lesions should be moghaddasi Sm, Verma SK. Aloe vera, their chemicals composition and applications: a tried and their effects described, as every new case reported pro- review. Int J biol med res. 2011;2(1):466-71.
vides valuable information to the existing literature. p Wynn rL. Aloe vera gel: update for dentistry. general Dentistry 2005 Jan-Feb;53(1):6-9. Vogler bK, ernst e. Aloe vera: a systematic review of its clinical effectiveness. british Journal of general practice 1999 Oct;49(447):823-8. Queries about this article can be sent to Dr. Patil at [email protected]. Syed TA, Ahmad SA, Holt AH, Ahmad SA, Ahmad SH, Afzal m. management of psoriasis with aloe vera extract in a hydrophilic cream: a placebo-controlled, double-blind study. Tropical medicine and International Health 1996 Aug;1(4):505-9.
choonhakarn c, busaracome p, Sripanidkulchai b, Sarakarn p. The efficacy of aloe vera eisen D, carrozzo m, bagan Sebastian JV, Thongprasom K. Number V Oral lichen planus: gel in the treatment of oral lichen planus: a randomized controlled trial. british Journal of clinical features and management. Oral Diseases 2005 Nov;11(6):338-49.
Dermatology 2008 mar;158(3):573-7. epub 2007 Dec 17. mollaoglu N. Oral lichen planus: a review. british Journal Oral and maxillofacial Surgery Yang HN, Kim DJ, Kim Ym, Kim bH, Sohn Km, choi mJ, et al. Aloe-induced toxic hepatitis. J Korean med Sci 2010 mar;25(3):492-5. epub 2010 Feb 17. Al-Hashimi I, Schifter m, Lockhart pb, Wray D, brennan m, migliorati cA et al. Oral lichen mansourian A, momen-Heravi F, Saheb-Jamee m, esfehani m, Khalilzadeh O, momen- planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral beitollahi J. comparison of treatment efficacy of daily use of aloe vera mouthwash with med Oral pathol Oral radiol endod 2007 mar;103 Suppl:S25.e1-12. epub 2007 Jan 29.
triamcinolone acetonide 0.1% on oral lichen planus: a randomized double-blinded clinical reynolds T, Dweck Ac. Aloe vera leaf gel: a review update. Journal of ethnopharmacology trial. American Journal medical Science 2011 Jun 15. [epub ahead of print] 1999 Dec 15;68(1-3):3-37.
68 AuguST/SepTember 2013 • The New York State Dental Journal


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Newsletter 20, 26 november 2015

matters in Newsletter No 20, Ngā mihi nui ki a koutou. Greetings to you all. Kia ora, Namaste, Mingalaba, Sua's dei, Talofa Lava, Malo e Lelei, Kia Orana, Bula Term Dates 2016 Tuesday 2 February - Friday 15 April Monday 2 May - Friday 8 July Monday 25 July - Friday 23 September Monday 10 October - Wednesday 14 Ngā mihi nui ki a koutou.