general dentistry

Peer-Reviewed Journal of the Academy of General Dentistry

GENERAL DENTISTRY May/June 2011 ~ Volume 59 Number 3

PROSTHODONTICS Q ORAL DIAGNOSIS OCCLUSAL ADJUSTMENT/THERAPY PERIODONTICS Q DENTAL MATERIALS PEDIATRIC DENTISTRY Q WWW.AGD.ORG

CONTENTS Departments 166

Editorial Listen to your heart

168

Pharmacology The sugar-loaded fentanyl lollipop (Actiq) and the risk for tooth decay

172

Restorative Dentistry Educating and motivating patients for restorative dentistry

176

Prosthodontics Full-mouth rehabilitation using both fixed and removable implant restorations

234

Oral Diagnosis Compressible tumor of the buccal mucosa and Painful lesion in the floor of the mouth

236

Answers Oral Diagnosis and Self-Instruction exercises No. 258, 259, 260, 261, 262, and 263

Clinical articles 180

Periodontics Benefits of additional courses of systemic azithromycin in periodontal therapy Edgar Schmidt, DDS, MS Walter Loesche, DMD, PhD

190

Removable Prosthodontics Improving the esthetic replacement of missing anterior teeth: Interaction between periodontics and a rotational path removable partial denture Leticia Machado Goncalves, DDS Bruno Braga Benatti, DDS, MS, PhD

196

Jose Ribamar Sabino Bezerra-Junior, DDS Ivone Lima Santana, DDS, MS, PhD

Occlusal Adjustment/Therapy Nonsurgical correction of Class III malocclusions: A new approach to treating late adolescents and adults Robert J. Kanas, DDS Scott J. Kanas

207

Niko Kaciroti, PhD

Leonard Carapezza, DMD

Fixed Prosthodontics The use of a porcelain repair technique to improve the plane of occlusion of an existing restoration Nancy Jacobson, DMD

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Maria Barrera Hagen, DDS

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Coming Next Issue In the July/August issue of General Dentistry UÊ Current status of potential bisphenol toxicity in dentistry UÊ Implant-retained dentures for full-arch rehabilitation: A case report comparing fixed and removable restorations UÊ Influence of conditioning time on bond strength— An evaluation of selfetching adhesive systems In the June issue of AGD Impact UÊ œÛiÀÊÃ̜ÀÞ\ÊHITECH, HIPAA, and EHR: What you need to know UÊÊ œœÃ̈˜}ÊV>ÃiÊ>VVi«Ì>˜Vi

210

Oral Diagnosis Burning mouth syndrome: A challenge for dental practitioners and patients Gary D. Klasser, DMD Dana Villines, MA

224

Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCSE Robert Utsman, DDS

Dental Materials Degree of microleakage of a self-etch sealant Frederick A. Conner, DDS Joseph A. Bartoloni, DMD, MPH, ABGD

230

Kraig S. Vandewalle, DDS, MS, MAGD, ABGD

Pediatric Dentistry One-year clinical evaluation of oral rehabilitation after the loss of multiple primary teeth Patricia Almada Sacramento, DDS, MS, Aline Rogeria Freire de Castilho, DDS, MS Fernanda Frasseto, DDS Maria Beatriz Duarte Gaviao, DDS, MS, PhD Marines Nobre-dos-Santos, DDS, MS, PhD Regina Maria Puppin Rontani, DDS, MS, PhD

e87

Oral and Maxillofacial Surgery Alveolar ridge augmentation—A case series M.L.V. Prabhuji, MDS B.V. Karthikeyan, MDS, DNB

e96

S.S. Madhu Preetha, MDS R. Shobha, MDS

Dental Materials Shear bond strength of two adhesive systems bonded to Er:YAG laser-prepared dentin Marta Proto da Silva, DDS, MSD Marcos Oliveira Barceleiro, DDS, MSD, PhD Katia Regina Hostilio Cervantes Dias, DDS, MSD, PhD Fatima Zanin, DDS, MSD, PhD

e101 Endodontics Treatment of inflammatory external root resorption resulting from dental avulsion and pulp necrosis: Clinical case report Rodrigo Sanches Cunha, DDS, MSc, PhD Flavia Casale Abe, DDS, MSc Roberta Aranha Araujo, DDS, MSc Eduardo Rodrigues Fregnani, DDS, MSc, PhD Carlos Eduardo da Silveira Bueno, DDS, MSc, PhD

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e105 Implants Immediate provisional restoration of an implant placed in a fresh primary maxillary canine extraction socket: A case report Ilser Turkyilmaz, DDS, PhD

Vladimir Shapiro, DDS, MS

e110 Caries Detection and Prevention Efficacy of antiplaque mouthwashes: A five-day clinical trial Muhammad Wasif Haq, BDS Syed Hammad Ahsan, MSc

Mehwish Batool, BDS Gaurav Sharma

e116 Esthetic Dentistry The effect of repeated firings on the color of feldspathic ceramics Gloria Beatriz de Azevedo Cubas, DDS, MSc Silvia Terra Fontes, DDS, MSc

self CDE 2 HOURS instruction CREDIT

Continuing Dental Education (CDE) Opportunities Earn two hours of CDE credit by signing up for and completing these exercises based on various subjects. 188

Self-Instruction Exercise No. 282 Periodontics

205

Self-Instruction Exercise No. 283 Occlusal Adjustment/ Therapy

221

Self-Instruction Exercise No. 284 Oral Diagnosis

Guilherme Briao Camacho, DDS, MSc, PhD Tatiana Pereira-Cenci, DDS, MSc, PhD

e121 Oral Diagnosis Sclerotherapy followed by surgery for the treatment of oral hemangioma: A report of two cases Fernanda Viviane Mariano, DDS Ricardo Della Coletta, DDS, PhD

Pablo Agustin Vargas, DDS, PhD Marcio Ajudarte Lopes, DDS, PhD

e126 Tobacco Cessation Tobacco cessation efforts in dentistry: A rural state study Susan Morgan, DDS, MAGD Emma Hunter

Elizabeth Gonzalez Kwang Ho Ha

Instructions for Authors For an electronic copy of General Dentistry’s Instructions for Authors, please visit the journal’s website at www.agd.org/ publications/GD/AuthorInfo.

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Editor Roger D. Winland, DDS, MS, MAGD Associate Editor Peter G. Sturm, DDS, MAGD Director, Communications Cathy McNamara Fitzgerald Managing Editor Chris Zayner Specialist, Communications Cassandra Bannon Circulation Coordinator Salithia Graham Manager, Production/Design Timothy J. Henney Associate Designer Jason Thomas Publications Review Council Norman D. Magnuson, DDS, FAGD, Chair William E. Chesser, DMD, MAGD Jon L. Hardinger, DDS, MAGD Advertising M.J. Mrvica Associates 2 West Taunton Ave. Berlin, NJ 08009 856.768.9360 [email protected]

General Dentistry

Email: [email protected] Fax: 312.335.3442 Back Issues and Change of Address Members, call 888.AGD.DENT (toll-free) and ask for a Member Services representative. Nonmembers, call Salithia Graham (ext. 4097). Mailing Lists For more information about ordering AGD mailing lists, call Cassie Vanderbeek (ext. 4962). Reprints To order reprints of any article in General Dentistry, contact Rhonda Brown at Foster Printing Company (866.879.9144, ext. 194) or email your request to [email protected]. All materials subject to copying and appearing in General Dentistry may be photocopied for the noncommercial purposes of scientific or educational advancement. Reproduction of any portion of General Dentistry for commercial purposes is strictly prohibited unless the publisher’s written permission is obtained. Disclaimer The AGD does not necessarily endorse opinions or statements contained in essays or editorials published in General Dentistry. The publication of advertisements in General Dentistry does not indicate endorsement for products and services. AGD approval for continuing education courses or course sponsors will be clearly stated. This online edition contains hyperlinks or references to other sites on the World Wide Web. These links are provided for your convenience only. As soon as you use these links, you leave this publication. The linked sites are not under the control of the Academy of General Dentistry (AGD); therefore, the AGD is not responsible for the contents or for any form of transmission received from any linked website or reference linked to or from this publication. The AGD disclaims all warranties, expressed or implied, and accepts no responsibility for the quality, nature, accuracy, reliability, or validity of any content on any linked website. Links from this publication to any other website do not mean that the AGD approves, endorses, or recommends that website.

General Dentistry (ISSN 0363-6771) is published bimonthly (every other month) by the AGD, 211 E. Chicago Ave., Suite 900, Chicago, IL 60611-1999. AGD members receive General Dentistry as part of membership.

Academy of General Dentistry Corporate Sponsors

The nonmember individual subscription rate for General Dentistry is $100 for the print version, $100 for the online version, and $175 for print and online versions; the nonmember institution rate is $300 (add $20 for Canada and $50 for outside the U.S. and Canada). Single copies of General Dentistry are available to nonmember individuals for $15 and nonmember institutions for $18 (add $3 for orders outside the U.S.). © Copyright 2011 by the Academy of General Dentistry. All rights reserved. Academy of General Dentistry Advancing the value and excellence of general dentistry 211 East Chicago Ave., Suite 900, Chicago, IL 60611-1999, USA Monday through Friday, 8:30 a.m. to 5:30 p.m., Central Time Telephone: 888.AGD.DENT (888.243.3368) (toll-free) or 312.440.4300 www.agd.org

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Advisory Board Dental Materials

Oral and Maxillofacial Pathology

Pain Management

is in general practice in Bellevue, Washington. He is a visiting faculty member of the Pankey Institute and the Pride Institute and is a Diplomate of the American Board of Dental Sleep Medicine.

certified oral and maxillofacial pathologist at Virginia Commonwealth University in Richmond. He currently is a professor of oral and maxillofacial pathology and maintains a private practice in oral medicine and oral pathology.

University School of Dentistry and a professor in the Department of Orthodontics at LSUSD.

Dental Public Health

Oral and Maxillofacial Radiology

Steve Carstensen, DDS, FAGD,

Larry Williams, DDS, ABGD, MAGD, is a Captain in the United States Navy Dental Corps, currently stationed at the Great Lakes Naval Training Center as a member of the Great Lakes Naval Health Clinic. Dr. Williams is the Public Health Emergency Officer for the 16 states of the Navy Region MidWest and for the Naval Health Clinic. He also serves as the co-chair of the Navy’s Tobacco Cessation Action Team and as a member of the Department of Defense Alcohol and Tobacco Advisory Council. He also teaches for the Dental Hygiene program at the College of Lake County and as an assistant clinical professor for the Rosalind Franklin University for Medicine and Science.

Esthetic Dentistry

Wynn H. Okuda, DMD, is Past National President (2002–03) and a board-accredited member of the American Academy of Cosmetic Dentistry (AACD). He also is on the Advisory Board of Best Dentists in America and on the Executive Council of the International Federation of Esthetic Dentistry (IFED). He practices cosmetic, implant, and restorative dentistry at the Dental Day Spa of Hawaii in Honolulu.

Endodontics

John Svirsky, DDS, MEd, is a board-

general dentist in Utah who performs oral surgery exclusively. He lectures extensively on oral surgery in general practice and has made articles, books, and video presentations available to general practitioners.

Pharmacology

Oral Medicine

Prosthodontics

Sook-Bin Woo, DMD, MMSc,

Daniel E. Myers, DDS, MS, is a

member of the Oral Diagnosis Department, Dental Associates of Wisconsin, Ltd. in Wauwatosa.

is assistant professor of Oral Medicine, Infection and Immunity at Harvard School of Dental Medicine. She is board-certified in Oral and Maxillofacial Pathology and Oral Medicine and practices both specialities in the Boston/ Cambridge area in Massachusetts.

Dental Service, at VA Salt Lake City Health Care System and Clinical Assistant Professor, University of Utah in Salt Lake City.

P. Emile Rossouw, BSc, BChD, BChD(Child-Dent), MChD (Ortho), PhD, is professor and chairman

is a general dentist who practices in New Jersey. He is a Diplomate of both the American Board of Oral Implantology/Implant Dentistry and the International Congress of Oral Implantologists, and a Fellow of the American Academy of Implant Dentistry.

Sebastian Ciancio, DDS, is Distinguished Service Professor and Chair, Department of Periodontics and Endodontics, Adjunct Professor of Pharmacology, and Director of the Center for Dental Studies at the University at Buffalo, State University of New York.

Karl Koerner, DDS, FAGD, is a

Geriatric Dentistry

Wesley Blakeslee, DMD, FAGD,

Periodontics

Oral and Maxillofacial Surgery

is Past President, International Association for Orthodontics; a Fellow of the American Academy of Craniofacial Pain; and a member of the American Academy of Dental Sleep Medicine. He maintains a general practice in Mt. Holly, New Jersey.

Implantology

of the American Board of Pediatric Dentistry, has authored numerous articles in the dental literature, and has been recognized as a leader in continuing education. She maintains a private practice in Allison Park, Pennsylvania.

has been a professor of oral and maxillofacial radiology in the Department of Oral Diagnosis, Medicine, Radiology, at the Louisiana State University School of Dentistry in New Orleans since 1975. He was named a Fellow in the American Academy of Oral and Maxillofacial Radiology in 1978 and was board-certified by the American Board of Oral and Maxillofacial Radiology in 1981.

Orthodontics

Lea Erickson, DDS, MSPH, is Chief,

Pediatrics

Jane Soxman, DDS, is a Diplomate

Kavas Thunthy, BDS, MS, MEd,

Stephen Cohen, DDS, is one of the

foremost endodontic clinicians in the country and lectures worldwide on endodontics. A board-certified endodontist, Dr. Cohen specializes exclusively in the diagnosis and treatment of endodontic infections.

Henry A. Gremillion, DDS, MAGD, is dean of the Louisiana State

Yosh Jefferson, DMD, FAGD,

Joseph Massad, DDS, is currently the Director of Removable Prosthodontics at the Scottsdale Center for Dentistry in Arizona. He is adjunct faculty at Tufts University School of Dental Medicine in Boston and the University of Texas Dental School at San Antonio. Jack Piermatti, DMD, is a Diplomate of the American Board of Prosthodontics, the American Board of Oral Implantology, and the International Congress of Oral Implantologists. He is a board-certified prosthodontist in private practice in Voorhees, New Jersey.

of the Department of Orthodontics, University of North Carolina at Chapel Hill School of Dentistry. He has published and lectured on clinical orthodontic research nationally and internationally. He maintains a part-time clinical practice in addition to his academic responsibilities.

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Editorial

Listen to your heart

W

hen I reach the end beginning to understand that there is more to life than of my life, I want simply having more, and you recognize that an endless to know that I did cycle of blind achievement and acquisition will not all I could with what I had. lead to true fulfillment. I don’t want to look back on Intellectually, you know that life is much too short to a life of unrealized dreams; I spend it doing something you don’t truly enjoy. You unwant to know that I had the derstand that the days that really count are the ones you courage to be who I truly experience with your heart. You are ready to resurrect old was and that I made every hopes and longings and express your true self. effort to fulfill my potential. It’s important to understand the difference between We all have an inborn urge true success and your ego’s need for recognition and to find meaning in life: glory. The process of chasing your dreams should be We know that there must be more to life than merely rewarding on its own terms—it’s the journey that existing and that there is a better way of measuring our matters, not the destination. And it isn’t what we get success than calculating how on that journey that makes much we have acquired. us successful, it’s what we If you could do anything become. It can be incredThe process of chasing you wanted to do, what ibly liberating to create your would it be? What do you own definition of success, to your dreams should be want to do, and who do you finally figure out what it is want to be? you want out of life. What rewarding on its own terms— It was Socrates who said are the longings of your that the unexamined life is heart? You can hear that it’s the journey that matters, not worth living. To find voice if you stand still long the satisfaction each of us so enough to listen for it. not the destination. desperately seeks, we have As some of you know, my to go beyond indulging our passion is hunting, which immediate desires. It’s easy is why my wife Debra and to become completely engrossed with ourselves and end I have made 17 trips to Africa. Each of those trips has up leading self-centered lives, and it’s even easier to yield created fantastic memories that we will treasure all of our to societal pressures that make us obsessed with our lives. I urge you to find a way of living that will allow possessions, our climb to the top, our appearance, and you to fulfill your dreams, or at least to pursue them. the size of our bank account. But whenever we measure Commit to creating a life of your own without worrying our lives by what we have, we always find that it isn’t about what other people think. The greatest tragedy in enough, because there never is enough. life is never having the courage to act on your longings What happens when your life turns out the way you and create the life you want. thought you wanted and yet something still doesn’t feel right? You’ve made it to the top of the mountain, but the view isn’t quite as thrilling as you imagined it would be. You’ve finally reaped the fruits of your labors only to find them less sweet than you expected. Roger D. Winland, DDS, MS, MAGD You are still dissatisfied and searching. Maybe you are Editor COMMENT

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Pharmacology

The sugar-loaded fentanyl lollipop (Actiq) and the risk for tooth decay Richard L. Wynn, PhD

A

ctiq (Cephalon, Inc.) is the brand name of the lollipop dose form of fentanyl citrate, one of the most potent opioid pain relievers available legally.1 It is being used to manage cancer pain and other various chronic (non-cancer) pain syndromes. Because of its high sugar content and mode of delivery through dissolution in the mouth, this product offers optimal conditions for causing tooth decay. A published case report and manufacturer’s labeling relative to tooth decay has prompted concerns about the use of Actiq and its potential for causing dental problems.1,2 Actiq is a solid formulation of fentanyl citrate on a plastic stick that dissolves slowly in the mouth for absorption across the buccal mucosa. It is also available as a generic product known as oral transmucosal fentanyl citrate (OTFC).3 This lollipop form of fentanyl is one of five prescription dosage forms of the opiate, the others being fentanyl solution for intravenous injection (no brand name), a film for buccal application (Onsolis), an effervescent lozenge (Fentora), and a transdermal patch (Duragesic).3 All dose forms of fentanyl citrate are listed as Schedule II controlled substances under the Federal Controlled Substances Act. One Actiq or OTFC lollipop contains 2 g of sugar in a raspberry-flavored additive. It is available in six different strengths of fentanyl citrate: 200, 400, 600, 800, 1,200, and 1,600 mcg. Each strength is packaged in boxes of 30 lollipops. Given that fentanyl is approximately 100 times more potent than morphine or oxycodone, the 1,600 mcg strength (1.6 mg) would be equivalent to taking 160 mg of morphine or oxycodone. As a result of the repetitive fentanyl dosing using a dose form of high sugar content, Actiq use could cause significant dental problems. Oral adverse reactions reported in clinical trials have included caries, gum hemorrhage, mouth ulceration, oral moniliasis, dry mouth, and cheilitis.1 Because of the high sugar content, frequent consumption could increase the risk of dental decay. The occurrence of dry mouth caused by fentanyl could add to that risk.

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Case report and dental concerns Gee et al enrolled a 48-year-old man with chronic generalized pain of eight years’ duration in a rehabilitation program.2 The patient had been treated with OTFC for more than three years and during that time developed extensive dental caries, decay, and tooth loss. He was first prescribed OTFC (400 mcg PRN) in November 2002. Dosing increased through June 2004 to a maximum of 600 mcg four times daily. The patient reported annual dental prophylaxis and minimal carious history. Prior records were not available for review. A dental examination in March 2004 identified multiple infected, nonrestorable teeth. By June 2004, he had undergone extraction of 11 teeth; extraction of all remaining teeth was recommended in May 2005. The authors proposed that the sugar content of OTFC was causally related to the patient’s advanced decay. They suggested that further studies were warranted to discern a correlation, if any, between the use of OTFC in the management of chronic pain and dental disease. Postmarketing reports of dental decay have been received from patients taking Actiq.1 In some of these patients, dental decay occurred despite reported routine oral hygiene. Since patients are taking Actiq “as needed” for pain, any given patient could be taking significant numbers of lollipops each day and month, meaning that the risk of dental decay and other dental problems will always be present, which presents a challenge in the proper dental management of lollipop users. Product labeling has indicated that patients using Actiq should consult their dentist to ensure appropriate oral hygiene in order to minimize the risk of dental decay.1 Attempts were made to develop a sugar-free form of Actiq, but studies were halted in favor of the marketing of Fentora, which is the brand name of an effervescent buccal fentanyl tablet having a similar use as the lollipop version.4 It is not known at this time what the sugar content is, if any, in the Fentora dose form. However, the assumption is that it will cause dry mouth because of the fentanyl component.

More information about Actiq Actiq gained FDA approval for the management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy, such as the fentanyl transdermal patch, morphine, or oxycodone, for their underlying persistent cancer pain.4 Actiq achieved off-label status as a powerful pain reliever, 80–100 times more potent than morphine, and was used to treat migraine headaches, severe back pain, cluster headaches, bone pain, arthritis, neuropathies, and other situations of severe chronic non-cancer pain.3 It can legally be prescribed for off-label use but cannot be marketed as such. As many as 80% of the prescriptions for Actiq each year are written for off-label use for sufferers of chronic non-cancer pain. Dosage forms and dosing

When the lollipop is placed in the buccal mucosal area, fentanyl is immediately absorbed and rapidly passes into the central nervous system, reaching a peak blood level within 20 minutes. Normally, 25% of the drug is taken up through the oral mucosa, while the remainder is swallowed and absorbed through the gastrointestinal tract. Two-thirds of the swallowed fentanyl is metabolized in the liver to inactive compounds, leaving only one-third of the swallowed fentanyl available for pain relief. For this reason, the drug is much more effective when absorbed through the oral mucosa. It also is most effective when consumed in exactly 15 minutes, as the optimal amount of the drug will be quickly absorbed through the mucosa into the bloodstream.3 Patients taking Actiq for severe pain are warned not to take more than 120 doses (lollipops) per month. It has been reported that some patients with severe chronic pain may be taking up to 300 doses per month.5 Actiq and migraine

A case series by Landy reported 20 patients with recurrent acute refractory migraine headaches who had been referred to the headache clinic.6 These patients were prescribed OTFC 400 mcg as rescue treatment for moderate to severe migraine headache pain as outpatients. They were instructed to self-administer the drug at home and complete a diary recording pain intensity (0 = no pain; 10 = worst pain imaginable) before taking the drug and 15, 30, 60, and 120 minutes afterward. They also recorded their satisfaction with the effectiveness of OTFC at 120 minutes, ranging from “very dissatisfied” through “very satisfied,” and to list any adverse events. Eighteen patients (13 female) experienced a migraine attack and self-administered OTFC. The drug treated

migraine episodes successfully in all 18 patients. OTFC rapidly reduced pain intensity, providing significant improvement within 15 minutes that increased progressively at 30, 60, and 120 minutes. Mean pain intensity declined significantly, from 8.83 pretreatment to 2.23 at 120 minutes, an average reduction of 75%. Patients satisfaction ratings with OTFC were overwhelmingly positive, with 94% being satisfied and more than half (56%) being “very satisfied.” Three patients experienced nausea, two experienced somnolence, and one each experienced itching, vomiting, and dry mouth. The Landy study concluded that OTFC rapidly and significantly relieved acute migraine pain in outpatients and was associated with a high patient satisfaction rating. OTFC could be effective for outpatient treatment of acute, refractory migraine headache pain.6 Actiq and decrease in emergency room visits

Tennant et al proposed that self-treatment with OTFC use could prevent emergency room visits.5 They stated that emergency room visits by chronic pain patients who experience pain flare-ups pose an expensive public health problem. To determine if OTFC was effective and safe for at-home treatment of emergency pain flares, 90 chronic pain patients with a variety of painful conditions were treated with a long-acting opioid consisting of either the fentanyl skin patch, methadone, or a sustained-release oxycodone or morphine. Additionally, all patients used a short-acting oral opioid, suppository, or injectable opioid for self-treatment of emergency pain flares. All patients were given OTFC to alternatively substitute for their current opioid to self-treat these emergency pain flares. Patients were surveyed after three or more months of OTFC use, and 86 (95.6%) believed that they could safely and effectively treat their emergency pain flares with OTFC. Seventy-one patients (78.8%) believed that OTFC had prevented the necessity to visit an emergency room or enter a hospital for pain control. Forty-five patients (50.0%) had collectively used OTFC for 375 months; they specifically estimated that, based on previous experience, they avoided 474 emergency room and 220 hospital admissions during that period. There were no emergency visits in the entire group during the study period, and 76 (84.4%) preferred OTFC over their current emergency opioid.5 Illicit use

Actiq’s sweet taste and fast-acting effects mean that it has become ripe for diversion to the black market, where the lollipops are sold as “perc-a-pops” or “morphine www.agd.org

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lollipops” (although they do not contain morphine).4 Prescription fentanyl citrate in all its dose forms is diverted to the street via pharmacy theft, fraudulent prescriptions, and illicit distribution by patients. In order to curb misuse, many health insurers have begun to require precertification of the prescribers and/or quantity limits for Actiq prescriptions. It is claimed that only a small proportion of people will abuse Actiq and that the majority of users truly need it and use it legitimately for the relief of chronic pain.

Summary Actiq offers a dose form of a powerful opioid that provides rapid relief of intense pain and is associated with tooth decay. Its high sugar content and repeated use both for breakthrough cancer and non-cancer pain offers optimal conditions for dental problems.

References

1. Prescribing information for Actiq. Available at: http://dailymed.nlm.nih.gov/ dailymed/archives/fdaDrugInfo.cfm?archiveid=10331. Accessed January 6, 2011. 2. Gee SS, Cunningham J, Rome J, Reid K. Dental disease and the use of oral transmucosal fentanyl: A case report. New Orleans: Paper No. 147, American Academy of Pain Medicine’s 23rd annual meeting, February 7-10, 2007. 3. Monograph on fentanyl. In: Drug information handbook for dentistry, ed. 16. Wynn RL, Meiller TF, Crossley HL, editors. Hudson, OH: Lexi-Comp, Inc.; 20102011:715-723. 4. Schulz W. Fentanyl. Chem Engineer News 2005;83:25):66. 5. Tennant F, Hermann L. Self-treatment with oral transmucosal fentanyl citrate to prevent emergency room visits for pain crises: Patient self-reports of efficacy and utility. J Pain Palliat Care Pharmacother 2002;16(3):37-44. 6. Landy SH. Oral transmucosal fentanyl citrate for the treatment of migraine headache pain in outpatients: A case series. Headache 2004;44(8):762-766.

Manufacturers

Cephalon, Inc., Frazer, PA 800.896.5855, www.cephalon.com

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Restorative Dentistry

Educating and motivating patients for restorative dentistry Bruce W. Small, DMD, MAGD

R

estorative dentistry can present a multitude of challenges. Treatment planning, patient management, clinical procedures, specialist interaction, financial arrangements, and case maintenance all must be accomplished in an orderly fashion to provide successful and long-lasting restorative dentistry. The current column will address the all-important matter of educating patients who are in need of restorative dentistry, including how to motivate them to accept the proper treatment.

The first visit The goal during the first visit by a patient in need of restorative dentistry is to perform a comprehensive examination consisting of a full-mouth series of radiographs; complete clinical charting, including the recording of periodontal pockets, mobility,

recession, and furcations; mounted study models; and, most importantly, intra- and extraoral photographs. Getting patients to accept a comprehensive examination can be challenging, depending on whether they are already members of the practice and whether they’ve had any restorative dentistry performed previously. Patients who are already members of the practice should have some degree of trust and confidence in the restorative dentist and staff. A good way of getting these patients to accept the comprehensive examination might be to say something like, “I see some changes in your teeth and it might be a good idea to look at your mouth more thoroughly” or “You need a better diagnosis than I can provide in the five minutes following a hygiene or emergency visit.” If the patient has never had a comprehensive examination, this

Fig. 1. Unattractive smile of a patient seeking restorative dentistry.

Fig. 2. Maxillary occlusal view showing decayed and missing teeth.

Fig. 4. Close-up of mandibular anterior teeth showing advanced wear.

Fig. 5. Intraoral view of suspicious lesions on the inside of the cheek.

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Fig. 3. Mandibular occlusal view.

Fig. 6. Retracted view of the patient’s anterior teeth, showing multiple restorative and esthetic problems.

Fig. 7. Left lateral view of mounted study models.

Fig. 8. Anterior view of a mandibular model showing short teeth and an uneven occlusal plane.

Fig. 9. Lateral view of a study model showing an uneven occlusal plane and wear.

Fig. 10. Anterior view of a completed wax-up.

Fig. 11. Left lateral view of a wax-up.

Fig. 12. Right lateral view of a wax-up.

would be the time to explain the process and to schedule the patient for the next visit. Patients who have been referred by other patients who have had restorative dentistry performed and know of all the steps involved with it are the easiest to convince that a comprehensive examination is necessary. They know that they have a problem; they often are seeking a second opinion; and they have received a positive referral from a friend or relative. This type of patient usually has not had a comprehensive examination but understands the need for it. New patients who have not been referred by anyone but who may have done some research online are treated a little differently than the first two groups. These patients have no relationship with the dentist or staff and consequently have no trust or confidence in them. A trusting relationship must be built among the patient, dentist, and staff prior to beginning any restorative dentistry. This relationship can begin during the initial phone call, continued during the initial visit, and cemented at the consultation visit. Many patients look to the Internet for information, so it is in the best interests of the dentist to have a patient-friendly website. The site should have information about the dentist, including credentials and experience, as well as before and after photographs of recently treated cases.

When patients are in the office for the first time, the entire staff should attempt to see them on time and make them feel as comfortable as possible. The dentist should initiate a conversation to determine each new patient’s dental hopes and concerns. Only then should the comprehensive examination be performed.

Data collection Data collection can occur during the initial visit or at a subsequent appointment. Some dentists use the initial visit to get to know their patients better, while others always take records at the first visit. This approach can vary depending on the circumstances, but the ultimate goal is to perform a comprehensive examination. Detailed records should be taken during the comprehensive examination to help the dentist identify existing problems and to show the patient things that he or she cannot see or might not understand. During the data collection visit, the purpose of each step in every procedure should be explained to the patient. Allowing patients to take an active role in the examination will increase their trust and confidence in the dental team.

Consultation (educational visit) Soon after the data collection visit, a second appointment should be made for a consultation visit (called by some the educational visit). All visits should be educational, but www.agd.org

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Fig. 13. Radiograph showing the mandible with a large interradicular lesion.

Fig. 14. Radiograph showing hopeless teeth.

this one is the primary time for patients to learn about themselves and their options, dental concepts such as canine guidance, and the dentist’s background and training, all in an effort to build trust and confidence. This visit should take place in the most comfortable location for both the dentist and patient to view photographs and other materials. Enough time should be set aside to answer any questions and interruptions should be kept to a minimum. If hygiene patients need to be checked, that can be done before or after the consultation. Photographs are one of the most powerful tools for showing patients their problems and motivating them to consider treatment options (Fig. 1–6). Photographs should be shown to the patient in as large a format as possible, with access to additional images on a computer. Mounted study models can be used to evaluate many factors, including an uneven occlusal plane, short clinical crowns, and lack of anterior and canine guidance. The dentist can educate patients about the occlusal plane, canine guidance, and more by showing them the difference between unaltered models and the pretreatment wax-up (Fig. 7–12). Radiographs should be shown and explained in as much detail as necessary for each individual patient (Fig. 13–16). The ideal occlusion as a restorative goal should be discussed to help the patient understand the benefit of creating a self-protected environment. Improvement in esthetics will become apparent as the patient notices the difference between the models; this can be discussed further if the patient displays an interest.

Fig. 15. Radiograph showing a hopeless mandibular bridge abutment.

Fig. 16. Radiograph showing an impacted maxillary canine.

The author has found that making this visit a “nonthreatening” consultation for the patient will create a better atmosphere for education as well as help to limit stress. A non-threatening consultation is one where a prewritten treatment plan is not handed to the patient but is developed by both the patient and the dentist during the education visit. Sometimes a final plan cannot be determined, particularly if specialty care is required, but at the end of this visit the patient will have learned enough to make more intelligent decisions about his or her teeth.

Discussion Every patient and every dentist are different and there is no perfect formula or script to guarantee that all patients will understand every treatment option and always accept therapy. This column contains suggestions that have been successful for the author and have helped to foster an atmosphere of trust. It goes without saying that once treatment is accepted, the dentist has the ability to deliver the clinical dentistry or refer the patient to a specialist.

Author information Dr. Small is in private practice in Lawrenceville, New Jersey, and is an adjunct professor at the University of Medicine and Dentistry of New Jersey. He is a visiting faculty member of the L.D. Pankey Institute in Key Biscayne, Florida, where he also serves on the Board of Advisors. COMMENT

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Prosthodontics

Full-mouth rehabilitation using both fixed and removable implant restorations Samuel M. Strong, DDS

T

he use of dental implants has become an integral part of restorative treatment planning for many dentists. Some cases now require simultaneously combining surgical and prosthetic expertise with fixed and removable implant restorations. In some cases, a relatively simple application of removable prosthetics can make a significant contribution to successful results for the patient who is unilaterally or bilaterally edentulous in the posterior region of either arch. The following case report illustrates this condition. A 62-year-old woman with a combination of failing dentition, severe occlusal wear, and reduced vertical dimension came to our office with a chief complaint of pain and esthetic concerns regarding tooth No. 7 and extreme mobility with a fixed bridge on teeth No. 18–20 (Fig. 1 and 2). She was afraid of losing all of her teeth and having to use conventional full dentures. A complete dental and medical history review was performed and a full set of radiographs, photographs, and diagnostic casts were procured, with the casts mounted on a semi-adjustable articulator. Consultation with the patient reviewed several treatment options, and it was decided to perform a full-mouth rehabilitation using

both fixed and removable implant restorations. Bilateral sinus lifts and grafts were performed by an oral surgeon to provide sufficient bone volume for maxillary implant placements in sites No. 3 and 14. Tooth No. 7 was extracted and replaced with an interim, or provisional, fixed bridge on teeth No. 6–8. Six months later, implants were placed in sites No. 3, 14, 21, and 28 (Replace 4.3 mm diameter implants, Nobel Biocare USA, LLC). A diagnostic wax-up was fabricated to simulate the desired final crown dimensions. During the three-month implant integration period, most of the remaining natural teeth (No. 5, 6, 8–12, and 22–27) were prepared for crown restorations and provisionalized (Luxatemp, DMG America) (Fig. 3). Evaluation of the patient’s physiologic rest position (where the mandible is positioned when the patient is in repose) versus her occlusal vertical dimension confirmed that opening the vertical dimension with new restorations was appropriate. The patient’s new vertical dimension with the provisionals in place, an anterior increase of 4 mm, was found to be comfortable and usable as a guide for the final restorations. Torque testing of the maxillary implants three months after placement confirmed implant integration and readiness for restoration. Teeth No. 4 and 13 were included in the maxillary implant level

Fig. 1. The patient presented with a failing dentition, including periodontally hopeless tooth No. 7 and a fixed bridge on teeth No. 18–20.

Fig. 2. An overclosed occlusal vertical dimension is evident, requiring alteration in the new restorative treatment plan.

Case report

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Fig. 3. Provisionalization provided an opened occlusal vertical dimension that enhanced the final restorative procedures and was comfortable for the patient.

Fig. 5. Maxillary implant level impression with implant impression copings and replicas.

Fig. 4. Two implants were positioned in the mandible for use as retention for the proposed mandibular RPD.

Fig. 6. Mandibular implant level impression.

Fig. 7. Mandibular master cast with Locator abutments threaded into the implant replicas.

Fig. 8. Processed mandibular RPD snapped into the Locator abutments.

Fig. 9. Mandibular RPD retained with Locator attachments. Note the absence of conventional clasping.

impression for final restorations. Implant level impressions of the mandibular implants were procured for use in the fabrication of an implant-retained removable partial denture (RPD) (Fig. 4–6). Locator abutments of the appropriate height were selected and threaded into the mandibular master cast replicas (Fig. 7). A mandibular framework try-in with teeth set in wax confirmed an accurate fit of the framework and correct occlusion with the maxillary restorations. The mandibular implant-retained RPD was processed and

returned to our office for delivery (Fig. 8). Locator abutments (Zest Anchors) were threaded and torqued into the implants. Locator metal housings and attachments (Zest Anchors) were processed into the RPD base at the laboratory. It should be noted that the mandibular RPD framework included rests on the mesial of tooth No. 21 and lingual of tooth No. 27, but no other clasps or retentive elements were included in the framework (Fig. 9). In order to provide these rests in metal, teeth No. 21 and 27 were fabricated as porcelain-fused-to-gold crowns. www.agd.org

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Fig. 10. Preoperative view of the maxillary arch.

Fig. 11. The completed maxillary arch, with implant crowns on teeth No. 3 and 14, a Procera fixed bridge on teeth No. 6–8, and Procera crowns on the remaining natural teeth.

Fig. 12. Maxillary and mandibular restorations in full occlusion. Note the lack of external clasps on the mandibular RPD.

The entire retention of the mandibular prosthesis was provided by the Locator abutments and attachments. The maxillary implant abutments and Procera crowns (Nobel Biocare USA, LLC) were returned for definitive intraoral cementation. The implants for sites No. 3 and 14 were restored with titanium abutments to which Procera crowns were cemented. The abutments for sites No. 3 and 14 were bolted into the implants, with the retaining screws torqued to the manufacturer’s recommended 35 Ncm. The Procera crowns were cemented with Unicem (3M ESPE), as were the natural tooth-borne crowns on teeth No. 4, 13, and 27 and the Procera zirconia fixed partial denture on teeth No. 6–8. The porcelain-fused-to-metal crown on tooth No. 21 was cemented with Rely-X (3M ESPE). Occlusal view

comparisons of the maxilla before and after treatment are shown in Fig. 10 and 11. Occlusion was adjusted to achieve bilateral balance with canine disclusion during excursive movements by the patient (Fig. 12). Retention was achieved for the mandibular RPD by using blue (3 lb) retention Locator attachments for both mandibular implants. This full-mouth rehabilitation illustrates the use of all-ceramic Procera technology for crown restoration combined with implants for both fixed and removable prostheses. The patient can function as a fully dentate individual with her vertical dimension restored in a comfortable position.

Author information Dr. Strong lectures and publishes on restorative and implant dentistry and is in private general practice in Little Rock, Arkansas.

Manufacturers

DMG America, Englewood, NJ 800.662.6383, www.dmg-america.com Nobel Biocare USA, LLC, Yorba Linda, CA 800.993.8100, www.nobelbiocare.com Zest Anchors, Escondido, CA 800.262.2310, www.zestanchors.com 3M ESPE, St. Paul, MN 800.634.2249, www.3mespe.com

COMMENT

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Periodontics

CDE

2 HOURS CREDIT

Benefits of additional courses of systemic azithromycin in periodontal therapy Edgar Schmidt, DDS, MS

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Niko Kaciroti, PhD

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Walter Loesche, DMD, PhD

The use of systemic antimicrobials such as doxycycline, metronidazole, and azithromycin in conjunction with debridement has achieved results superior to those produced by debridement alone. The purpose of the present study was to determine if previous results could be improved upon by administering repeated doses of azithromycin during the hygiene phase. One hundred patients with moderate to advanced periodontitis were treated with scaling and root planing plus three courses of azithromycin during the hygiene phase. All patients then were re-evaluated and periodontal surgery and/or extractions involving 96 teeth were performed in 32 patients. All patients then entered a maintenance program that lasted up to 192 weeks, with four-month recalls. Clinical parameters were recorded at baseline, at re-evaluation (week 6 after baseline), and at 96 and 192 weeks into maintenance.

T

he American Academy of Periodontology describes periodontal diseases as “serious infections.” This reflects the findings of numerous publications that have associated a limited number of bacterial species with periodontal inflammation. In particular, the overgrowth of a group of specific, Gram-negative, subgingival, anaerobic bacteria—namely, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia—have been shown to be strongly associated with destructive periodontal disease.1-4 Based on the evidence, periodontal disease should be treated as an infection, and indeed, traditional treatments are anti-infective, as they reduce the bacterial load on the teeth by mechanical debridement of all teeth surfaces.5 Antimicrobials are sparsely employed in the treatment of chronic periodontitis, despite the fact that metronidazole, doxycycline, 180

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The results indicated that probing depths, bleeding upon probing, and suppuration were reduced significantly at re-evaluation. In addition, 14 teeth that displayed a Class III mobility at baseline improved to either Class I or Class II. There was no relapse during the maintenance phase. Multivariate analysis after 192 weeks indicated no change in the number of sites that bled upon probing, or had pockets that were 5.0–6.0 mm or *7 mm. Ninety-five percent of the sites that initially bled upon probing did not do so four years post-treatment. The results indicate that three courses of azithromicin in conjunction with root instrumentation during the hygiene phase led to long-lasting beneficial effects on all clinical parameters for at least 192 weeks. Received: July 20, 2010 Accepted: October 29, 2010

and azithromycin have been shown in double-blind studies to achieve results that are statistically and clinically superior to those obtained by debridement alone.6-13 Schmidt and Bretz treated four cases of recurring periodontal abscesses with two or three courses of azithromycin in conjunction with drainage and subgingival instrumentation.14 This led to clinical resolution of the lesion, and a substantial amount of bone growth was noted radiographically, suggesting that the optimal dose schedule for antibiotics in periodontal infections could require repeated dosing. A plausible rationale for the benefits of additional courses of antimicrobials might be an increase in the amount of time needed to inhibit the putative periodontal pathogens so that tissue repair/ regeneration can occur as well as a shift in the flora from one associated with periodontal disease toward

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one compatible with periodontal stability. The authors hypothesized that the dosage of systemic antimicrobials usually tested in periodontal trials is insufficient and that additional courses could improve the results of treatment. To test this hypothesis, the senior author (ES) initiated this study in 1994 with patients who came to his clinic with either moderate or advanced chronic periodontics. He used an antimicrobial protocol in the hygienic phase of treatment, which included tooth debridement, three courses of azithromycin, and surgical procedures as needed. The study would be stopped and analyzed when he had obtained results on 100 patients who had been followed for at least four years, and the study would be aborted if adverse results were observed. This was a demonstration-type study, as a private practice setting was not suitable for a double-blind study design

in which a control group would receive a placebo or fewer courses of azithromicin.

Materials and methods Patients

One hundred twenty-four patients with a diagnosis of moderate or advanced chronic periodontitis were selected from a pool of 272 patients who were admitted to the authors’ clinic between 1994 and 2007. Patients ranged in age from 25–78. Inclusion criteria required at least 20 teeth, with one tooth having at least one furcation with Class II or III involvement; two teeth having at least one site with ≥7.0 mm probing depth; and 12 teeth having at least one site with 5.0–6.0 mm probing depth. Participants were grouped as either Never Smoked, Current Smokers, or Quit Smoking (more than six months prior to being entered into the study). Exclusion criteria included pregnancy, current antibiotic usage and/or having undergone periodontal therapy in the previous four months, a need for prosthetic devices to replace missing teeth, a need for premedication, and any systemic diseases that could affect the progression or treatment of periodontal diseases. There was no Institutional Review Board review of the protocol because the senior author had no academic affiliation; the co-authors became involved in the study during the analysis stage. The clinical procedures followed here have been used by the senior author for 20 years in his private practice. All selected patients signed an informed consent form. Patients were told that most forms of periodontal disease were treatable infections. Further, patients were aware that data from their examination would be used in a research study and that no person would be

identified in any publication. Only those patients who agreed that their data could be used were included in the study. The procedures endorsed by the Helsinki Declaration were followed. The personal identifiers of the patients were rendered in a cryptic form in the file used in the statistical analysis and were never accessed. Patients were charged a lowered fee for their participation in the study. Probing depth (using a Michigan periodontal probe), bleeding upon probing, suppuration (measured at four sites per tooth—mesiobuccal, distobuccal, distolingual, and mesiolingual), furcation involvement, and mobility were recorded during the baseline visit by the same examiner (ES). This examiner was not calibrated for this study but had been calibrated for a previous clinical study.15 Periapical and bitewing radiographs were taken for all teeth using standard procedures.

maxillary left (UL), mandibular left (LL), and mandibular right (LR) quadrants, respectively, were thoroughly instrumented manually (under local anesthesia, if required). No ultrasonic debridement was used. Second and third courses of azithromycin were prescribed on days 7 and 21. On those days, quadrants that were not scheduled to receive thorough mechanical debridement (UL, LL, and LR on day 7; UR, UL, and LR on day 21) were subjected to a limited subgingival instrumentation. The patient was advised to take the first tablet immediately after the appointment. Carious lesions were debrided and temporized with ZOE during the hygiene phase. Restorations were placed after the hygiene phase and prior to the re-evaluation visit. Endodontic treatment was referred to a specialist during the hygiene phase and completed prior to the reevaluation visit, that is, before any periodontal surgery and/or extractions were performed.

Treatment protocol

Re-evaluation visit

On day 0, scaling and root planing were performed on all teeth, but no effort was made to remove all of the calculus deposits. Azithromycin was prescribed and the patient was advised to take the first tablet immediately after the appointment, so that the agent could concentrate in the inflamed gingiva. The authors chose azithromycin due to its dosage schedule (one 500 mg tablet per day for three consecutive days) and its pharmokinetics. Azithromycin is quickly absorbed by the bloodstream and distributed into various tissues (especially inflamed tissues), including the periodontium, where it has been found in higher levels (10x–100x) than in serum.16,17 On days 7, 14, 21, and 28, the teeth in the maxillary right (UR),

All patients were re-evaluated at week 6 (±1 week). Clinical parameters were recorded and, based on these findings, patients either proceeded to the maintenance phase with no surgical needs (n = 68) or to surgery (n = 32). The patients in the surgery group received, as needed, flap surgery to gain access for instrumentation and extraction of molars due to either carious lesions in the furcation area or persistent vertical mobility. These treatments were completed within two months. All patients then started their maintenance program approximately eight weeks after re-evaluation.

Clinical parameters (baseline)

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Maintenance program

Patients were scheduled at fourmonth intervals for visits, during

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Periodontics Benefits of additional courses of systemic azithromycin in periodontal therapy

Table 1. Baseline characteristics of the study population. Demographics

Mean (SD)

Range

Age (years)

50.40 (10.4)

25–78

Women (%)

71

Men (%)

29

Smokers (%) Never

29

Quit

49

Current

22

Periodontal parameters Number of teeth

Sites/ patient Teeth/patient (average (average [SD]) [SD]) 25.4 (2.6)

n/a

Number of teeth with Pockets *7.0 mm

3.0 (1.4)

16.8 (4.6)

Pockets 5.0–6.0 mm

16.8 (3.2)

42.7 (14.0)

Bleeding on probing

22.9 (2.6)

84.7 (10.3)

which all teeth were scaled and cleaned. At weeks 96 (range = 91– 101) and 192 (range = 187–197), all patients were given an examination during which probing depth, furcation involvement, mobility, bleeding upon probing, and suppuration were recorded and periapical and bitewing radiographs were taken for all teeth. Statistics

All data were entered into an Excel spreadsheet. Descriptive statistics, the paired t-test, and multivariate analysis, including repeat measure analysis, were obtained using programs resident in SAS for Windows, release 9.2 (SAS Institute Inc.). Teeth that were extracted because of decay in the furcation area were not included in the baseline data or outcome analysis. 182

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Fig. 1. Bone gain after 96 weeks of maintenance. Left: Teeth at baseline. Right: Teeth after 96 weeks.

Results One hundred twenty-four patients completed the hygiene phase and reported no adverse effects related to the azithromycin. Twenty-four of these patients failed to return for the re-evaluation visit at week 6. These patients lost to follow-up either failed to respond to repeated efforts to contact them, had moved away, or were not interested in further participation in the study; as a result, their data were not included

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in the statistical analysis. It was not possible to determine whether the patients who returned for the reevaluation visit were a self-selected favorable response group compared to the no-shows. One hundred patients (29 men and 71 women, with a mean age of 50.4) returned for the re-evaluation visit and were followed for 192 weeks during the maintenance phase. These 100 patients came to the clinic at baseline with an

Table 2. Effects of serial courses of azithromycin combined with scaling and root planing in moderate to advanced periodontitis on the number of sites per patient (n = 100).* Hygiene phase Clinical parameters

Maintenance phase

Baseline (mean [SD])

Six weeks (mean [SD])

96 weeks (mean [SD])

192 weeks (mean [SD])

42.7 (14.0) †

16.9 (7.0) †

17.5 (7.6)

17.6 (8.7)

12–96

2–21

Probing depth 5.0–6.0 mm Range *7.0 mm Range Bleeding on probing

6.8 (4.6)†

1.8

(1.7) †

3–20

3–45

1.5 (1.4)

1.4 (1.2)

1–21

0–13

0–11

0–6

84.7 (10.3) †

3.9 (1.9) †

3.7 (2.9)

4.0 (3.0)

Range

62–86

1–9

0–12

0–13

Suppuration

1.4 (2.0)

0

0

0

Range

0–7

*Each course represents one tablet of 500 mg daily for three consecutive days at weekly intervals. †Post-treatment values for sites were significantly different from baseline values, paired t-test p < 0.001.

average of 25.4 teeth, of which 16.8 had at least one pocket measuring 5.0–6.0 mm and three had at least one pocket measuring ≥7.0 mm. Bleeding on probing was found in approximately 90% of teeth, for an average of 85 sites per patient (Table 1). One hundred seven teeth had Class II or III furcation involvements; 23 teeth had Class II mobility; 25 teeth had Class III vertical mobility; and 127 teeth exhibited suppuration. Twenty-two percent of the patients were current smokers; 29% had never smoked; and 49% had quit smoking (Table 1). At the reevaluation visit, the number of sites per patient with probing depths measuring 5.0–6.0 mm decreased from 42.7 to 16.9 (a 60% reduction), while the number of sites with probing depths measuring ≥7.0 mm decreased from 6.8 to 1.8 (a 74% reduction). Over 95% of the sites that formerly bled upon probing no longer did so (Table 2). The reduction in probing depth was still evident during the

maintenance phase after 96 and 192 weeks (Table 2). At baseline, 107 teeth had Class II–III furcation involvements; this number dropped to 104 after treatment. This decrease was due to three maxillary molars with three Class II furcation involvements that could not be probed being measured as a Class II furcation at the re-evaluation visit at week 6. No buccal furcation was noted on these teeth. After treatment, eight of the 25 teeth that displayed Class III (vertical) mobility at baseline were in the Class I category and six were in the Class II category. None of these teeth were recommended for surgery and some even demonstrated evidence of significant bone gain when the 96-week radiographs were compared to the baseline radiographs (Fig. 1). Nine of these teeth had received root canal treatment prior to the maintenance phase. Thirteen of the 23 teeth with a Class II mobility converted to Class 0–I mobility. www.agd.org

Suppuration was present on 127 teeth and 142 sites at baseline, but no teeth or sites showed signs of suppuration at the six-week reevaluation (Table 2). Over the next eight weeks, 32 patients received surgical intervention involving 67 teeth that were given flap surgery (25 quadrants) and 29 teeth that were extracted (18 molars [14 in the mandible and four in the maxilla] that had decay in the furcation area and 11 teeth with Class III mobility). All 100 patients began their maintenance phase treatment at week 14. There was no statistical difference in periodontal health during the maintenance phase between patients who received surgery and those who did not, so patients from both groups were combined in the statistical analysis. No surgeries or extractions were performed during the maintenance phase, and there were no changes in the average probing depth measurements during this time period (Table 2). There were 1.8 sites per patient with probing depths

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Periodontics Benefits of additional courses of systemic azithromycin in periodontal therapy

Table 3. The effect of azithromycin treatment on the number of sites with bleeding on probing.

Estimate

Standard error

df

t value

Probability

Intercept

86.36

2.07

95

41.7

ÃÃÊʓ>œVVÕȜ˜ÃÊ>ÃʈÌÊ relates to a patient’s age; UÊÀiۈiÜÊ>˜`Ê՘`iÀÃÌ>˜`Ê«ÀiۈœÕÏÞÊ`iÃVÀˆLi`ÊÃÕÀ}ˆV>Ê>˜`Ê nonsurgical techniques for treatment; and UÊ՘`iÀÃÌ>˜`Ê̅iÊ`iÈ}˜]Ê>««ˆV>̈œ˜]Ê>˜`ÊÕÃiʜvÊ̅ˆÃʘiÜÊ technique for distalizing mandibular molars.

6.

Nonsurgical (camouflage) orthodontics excludes any extractions. Nonsurgical orthopedic correction of a Class III malocclusion has been shown to be an effective treatment protocol in the adult dentition. A. Both statements are true. B. The first statement is true; the second is false. C. The first statement is false; the second is true. D. Both statements are false.

7.

How should a Class III, Type 6 occlusion (bimaxillary protrusion) be treated? A. Extraction of four premolars followed by fixed orthodontic appliances B. Air-rotor stripping and a multi-distalizating appliance (MDA) C. A maxillary molar rotator, an MDA, and Class III elastics D. Mandibular second molar extractions followed by headgear or mini-implants

8.

How were case reports No. 1 and 2 classified? A. Class III, Type 6 B. Class III, Type 5b C. Class III, Type 3a D. Class III, Type 4a

9.

When utilizing the technique presented to treat a Class III case needing arch development and elimination of a posterior crossbite, which appliance would not be appropriate? A. Class III elastics B. MDA C. Maxillary molar rotator D. Nitanium palatal expander (NPE)

1.

A Class III malocclusion is most often the result of A. a dentoalveolar discrepancy. B. a skeletal growth aberration. C. a prognathic maxilla. D. a retrognathic mandible.

2.

What is the most desirable method for treating a Class III malocclusion in the young patient? A. Mandibular molar extraction followed by distalization with mini-implants B. Nonsurgical camouflage orthodontics C. Orthognathic surgery followed by conventional orthodontics D. Nonsurgical orthopedic therapy followed by conventional orthodontics

3.

4.

Patients may be reluctant to undergo orthognathic surgery for all of the following reasons except: A. Surgical procedures are expensive B. There are associated surgical risks C. Surgical results are unpredictable D. Postoperative recovery may be difficult Nonsurgical (camouflage) orthodontic therapy can include all but which of the following? A. Extraction of teeth B. Implant placement C. Rapid palatal expansion D. Transpalatal and interarch anchorage

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205

10.

11.

12.

Control of vertical dimension during tooth movement is an important consideration. Class III malocclusions with skeletal open bites have a more predictable outcome with a nonextraction technique such as distalizing appliances. A. Both statements are true. B. The first statement is true; the second is false. C. The first statement is false; the second is true. D. Both statements are false. Which of the following can result if the patient is noncompliant in wearing the Class III elastics? A. Maxillary molar intrusion B. Tipping of the mandibular molars C. Buccal flaring of the maxillary molars D. Dumping of the mandibular incisors When a patient is noncompliant in wearing the Class III elastics, which of the following should be considered? A. Switch to Class II elastics B. Maxillary molar rotator C. Mini-implants D. Transpalatal anchorage

13.

There are limits to the mandibular MDA distalizing technique. In severe Class III cases, distalization of more than _______ is difficult to achieve. A. 4 mm B. 3 mm C. 2 mm D. 1 mm

14.

The MDA is used until the molars are in a Class I relationship. How many months can this take? A. 10–12 B. 8–9 C. 6–7 D. 4–5

15.

Which combination of appliances is used with the new technique presented? A. NPE, MDA, fixed orthodontic appliances, and Class III elastics B. Fixed orthodontic appliances, headgear, and lingual arch C. Maxillary molar rotator, fixed orthodontic appliances, and mini-implants D. Fixed orthodontic appliances, reverse pull headgear, MDA, and Class III elastics

Answer form and Instructions are on pages 239-240. Answers for this exercise must be received by April 30, 2012. To enroll in Self-Instruction, click here.

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Fixed Prosthodontics

The use of a porcelain repair technique to improve the plane of occlusion of an existing restoration Nancy Jacobson, DMD

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Maria Barrera Hagen, DDS

This article describes the use of an indirect porcelain repair technique to improve the occlusal relationship between a new fixed partial denture and an existing one. Porcelain repair techniques offer a conservative, minimally invasive, and cost-effective

W

hen dentists fail to make a proper diagnosis and create a comprehensive treatment plan, they are doomed to recreate a patient’s malocclusion. When treating a quadrant with a supererupted tooth in one arch, dentists need to recognize that the occlusion of the opposing arch must be addressed as well. If the opposing arch was previously restored with a fixed partial denture (FPD), the only way to improve the occlusion would be to replace the entire restoration. If the restoration is clinically sound, with good marginal integrity and no other defects, porcelain repair techniques can offer another alternative to replacing the entire restoration. The literature reports numerous methods of repairing porcelain fractures on porcelain-fused-to-metal restorations or all-ceramic restorations. There are two techniques, direct and indirect.1-3 The direct technique uses composite resin to replace missing porcelain and is completed directly in the patient’s mouth. The indirect technique prepares the substructure of a fixed restoration for a new onlay/overlay or veneer that is then cemented or bonded onto the fixed restoration. This method is both cost-effective

method of improving the opposing occlusion without replacing an existing restoration. Received: March 16, 2010 Accepted: June 7, 2010

and minimally invasive; it also can correct the opposing occlusion of a new restoration, allowing patients to keep an existing restoration that is otherwise sound. For a three-unit FPD in which only one of the three teeth in the opposing arch is in infraocclusion, improving the occlusal relationship with an overlay on one tooth would result in a cost savings of two-thirds the price of replacing the entire restoration. An 82-year-old man came to the Advanced Education in General Dentistry (AEGD) clinic at the University of Florida College of

Dentistry for comprehensive care. The patient’s chief complaint was that his bridge had fallen out on the maxillary left side and he wanted it recemented. The patient’s medical history was significant for blood clots and he was taking warfarin. The patient’s physician advised taking the patient off warfarin for five days prior to any surgical procedure. Clinical examination revealed teeth No. 12 and 13 to be carious root tips (Fig. 1). Tooth No. 14 measured 5.0 mm of recession with a 3.0 mm pocket (Fig. 2). It also was supererupted above the maxillary plane of occlusion and had distal caries.

Fig. 1. Maxillary arch at initial presentation. Note the carious root tips on teeth No. 12 and 13.

Fig. 2. Recession on tooth No. 14. Supereruption is also evident.

Materials and methods

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Fixed Prosthodontics A porcelain repair technique to improve the plane of occlusion of an existing restoration

Fig. 3. Radiograph of a mandibular bridge on teeth No. 18–20.

Fig. 4. Pontic tooth No. 19 depressed below the plane of occlusion of teeth No. 18 and 20.

Fig. 6. The provisionals are adjusted to a more ideal plane of occlusion.

Fig. 7. Pontic tooth No. 19 is prepared for an overlay.

The mandibular left side had been restored with a three-unit porcelain-fused-to-metal bridge from teeth No. 18–20. Tooth No. 18 had been treated endodontically and obturated with silver points in the mesial roots and with gutta percha in the distal root (Fig. 3). It also was asymptomatic and had no associated lesion. The occlusal surface of the pontic (tooth No. 19) was depressed below the mandibular plane of occlusion to compensate for the supereruption of tooth No. 14 (Fig. 4) The bridge was clinically sound with marginal integrity and no other defects. Teeth No. 1, 3, and 4 had caries recession and moderate to severe periodontal disease. The patient was offered a fixed restoration on implants or a removable partial denture (RPD) to replace his missing teeth. The

patient opted for a fixed restoration set on implants. A treatment plan was formulated to extract teeth No. 1, 3, 4, and 12–14 and to replace teeth No. 3, 4, and 12–14 with implant-supported crowns. The patient stopped warfarin therapy five days prior to implant surgery. Teeth No. 12–14 were extracted and three implants (Nobel Biocare) were placed without flap elevation. The extraction sockets and osteotomies were grafted and covered with CollaTape (Zimmer Dental). After the appropriate six-month waiting period for osseointegration, the implants were uncovered and the restorative phase began. Temporary abutments and provisionals were placed on the implants at sites No. 12–14. The provsionals were placed in occlusion with

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Fig. 5. Provisionals replicate the patient’s preexisting occlusion.

the opposing arch (Fig. 5), then reduced occlusally to a more ideal plane of occlusion (Fig. 6). At the same appointment, the pontic edge of tooth No. 19 was prepared to receive an overlay to improve the plane of occlusion on the patient’s left side (Fig. 7). The preparation of the pontic included removal of the porcelain, which left buccal and facial walls of at least 5.0 mm in height. The margin was prepared as a wide chamfer of at least 1.0 mm circumferentially. Final impressions and a new bite registration were taken. The laboratory fabricated an all-ceramic overlay for pontic tooth No. 19. At the next appointment, the abutments and splinted crowns on teeth No. 12–14 were delivered, as was the Lava overlay (3M ESPE) on tooth No. 19 (Fig. 8 and 9). Maxillary abutments were placed and torqued to 35 Ncm, per the manufacturer’s recommendation. Screw holes were covered with Blu-Mousse (Parkell, Inc.), and the crowns were cemented with Improv (Salvin Dental Specialties). The overlay on pontic tooth No. 19 was etched with hydrofluoric acid, bonded with Clearfil SE Bond (Kuraray Dental), and cemented with Panavia 21 (Kuraray Dental). The occlusal plane was improved,

Author information At the time the patient was treated, Dr. Jacobson was an associate clinical professor, AEGD in General Dentistry program, University of Florida College of Dentistry, Jacksonville, where Dr. Barrera Hagen was a student in the Internationally Educated Dentist Program. Currently, Dr. Jacobson is in private practice in Jacksonville, FL, and Dr. Barrera Hagen is in private practice in Cocoa Beach, FL.

Fig. 8. The overlay for tooth No. 19 and the FPD on teeth No. 12–14 are cemented.

Fig. 9. The corrected plane of occlusion on pontic tooth No. 19.

and the patient’s new restorations did not replicate his pre-existing occlusal relationship.

implant therapy and minimal alteration of an existing fixed prosthesis met the patient’s functional and esthetic goals.

References

Discussion While treatment planning for this patient, the authors were faced with the option of removing or altering the FPD opposing a new restoration. Replacing the maxillary teeth with implants was the only way to replace the patient’s maxillary dentition with a fixed prosthesis. However, even if the patient had received a maxillary RPD as his final restoration, the plane of occlusion of the opposing arch still would have required attention. Replacing the existing three-unit FPD would have cost approximately three times as much as placing an overlay on the pontic tooth. The combination of

Summary Patients sometimes present with challenges created by existing restorations. When placing a new restoration, clinicians have the choice of replicating the existing occlusion or improving it. Porcelain repair techniques offer a conservative, minimally invasive, and cost-effective means of altering the opposing occlusion without replacing an existing fixed restoration.

Disclaimer

1. Critical appraisal. Intraoral repair of fractured ceramic restorations. J Esthet Restor Dent 2009; 21(4):275-284. 2. Galaitsatos AA. An indirect repair technique for fractured metal-ceramic restorations: A clinical report. J Prosthet Dent 2005;93(4):321-323. 3. Mancuso A. Salvaging a porcelain/metal bridge with a bonded porcelain-fused-to-metal overcasting. Gen Dent 2003;51(5):456-457.

Manufacturers

Kuraray Dental, New York, NY 800.879.1676, www.kuraraydental.com Nobel Biocare, Loma Linda, CA 800.993.8100, www.nobelbiocare.com Parkell, Inc., Edgewood, NY 800.243.7446, www.parkell.com Salvin Dental Specialties, Charlotte, NC 800.535.6566, www.salvin.com Zimmer Dental, Carlsbad, CA 800.854.7019, www.zimmerdental.com 3M ESPE, St. Paul, MN 888.364.3577, www.3mespe.com

The authors have no relationship with any manufacturer listed in this article.

COMMENT

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Oral Diagnosis

CDE

2 HOURS CREDIT

Burning mouth syndrome: A challenge for dental practitioners and patients Gary D. Klasser, DMD Robert Utsman, DDS

 Q

Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCSE

A retrospective study was conducted on patients with burning mouth syndrome (BMS) to assess demographics, onset characteristics, temporal behavior (frequency), duration, and progression of oral burning symptoms. Additionally, treatments provided by health practitioners prior to a definitive diagnosis of BMS were analyzed with an overview of current management strategies. The records of 49 adult patients diagnosed with BMS were reviewed. Descriptive statistics and a Pearson correlation with a statistical significance at p < 0.05 were utilized to analyze the data. The majority of patients were mid-life white women who reported a sudden onset of constant oral burning symptoms that increased in intensity. On average, patients reported oral burning symptoms for 41 months (standard deviation = 73.5, range = 2–360 months,

B

urning mouth syndrome (BMS) is characterized by a constant burning sensation in the intraoral mucosal membranes and perioral areas, with an absence of relevant clinical and normal laboratory findings to account for the pain.1-3 Burning oral symptoms can be classified as either primary (essential/idiopathic) BMS, where there is a lack of evidence for any other disease, or secondary BMS, in which oral burning is identified due to clinical abnormalities and systemic and/or psychological conditions. In general, BMS is used to describe primary oral burning. Sensations associated with BMS have been variously described as “burning,” “annoying,” “granular or sandy,” and “dryness and swelling.”2 Frequently, patients are unaware of pain during sleep and upon waking, but the sensations gradually increase in intensity, peaking by late afternoon or early evening; 210

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Dana Villines, MA

median = 20 months), and 38 of the patients received/trialed 71 various interventions (mean = 1.9) prior to receiving a definitive diagnosis for their oral burning symptoms. This study sample shared many characteristics with those reported previously in the literature. The authors found that patients frequently reported delays in receiving a definitive diagnosis with an array of various trialed interventions. For this reason, the authors provide this overview of current management strategies in order to assist dental practitioners in providing appropriate interventions for patients with BMS. Received: June 28, 2010 Accepted: September 7, 2010

also, the pain is often relieved (or at least not aggravated) while eating.1,2 More than two-thirds of patients with BMS also report xerostomia and/or taste alterations, which can be described as the presence of a constant foul, bitter, or metallic taste sensation that can be equally as or more disturbing than the oral burning pain itself.1,4-7 BMS has a reported prevalence of 0.7–5% of the general population, with the variation likely based on the study methodology (survey or clinical assessment) and geographic location.1,8-10 BMS is most commonly reported by middle-aged to elderly women, focused in menopausal and postmenopausal populations.4,6,11-15 BMS typically has both positive (burning pain, dysgeusia, and dysestheia) and negative (taste loss and paresthesia) sensory symptoms, which adds confusion to the diagnosis.16 The pain is most commonly bilateral and symmetrical,

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involving the anterior two-thirds of the tongue (71–78% of cases), followed by the dorsum and lateral borders of the tongue, the anterior aspect of the hard palate, and the labial mucosa of the lips; however, it also can occur in multiple sites.4,5,17,18 The site(s) of pain have not been shown to affect the course of the disorder or the response to treatment.19,20 The cause of BMS is currently unknown. The etiology is presumed to be multifactorial, involving the interaction between biological (neurophysiological mechanisms) and psychological factors.11 A considerable number of local, systemic, and psychologic factors have been found to be related to BMS; however, many of these factors should be considered as conditions important to the differential diagnosis of oral burning, rather than as an etiological factor for BMS. There is increasing consensus that BMS represents an idiopathic

neuropathic pain condition.11,21 However, there is no consensus on the etiology or whether developing BMS can be attributed to a single precipitating event.4,13 Recent evidence has suggested that both central and peripheral neuropathic changes could be active in BMS patients.12,22-28 A recent study by Lauria et al assessed 12 patients diagnosed with BMS for superficial nerve changes with tongue biopsies.12 Compared to control patients, BMS patients demonstrated a significantly lower density of epithelial nerve fibers and subpapillary nerve fibers, with evidence of diffuse axonal derangement.12 The pathogenesis of these small fiber changes is unknown; however, it has been suggested that such changes can cause both the dysguesia and pain experienced by some BMS patients.27,29,30 Another model is based on taste/ pain interactions and hypothesizes that BMS could be the result of taste damage, either to the chorda tympani, with release of inhibition in the glossopharyngeal nerve (taste alterations, alterations in touch and pain), and/or to the trigeminal nerve (changes in touch and pain).31,32 Consistent with this model, taste damage has been found in many BMS patients. Notably, the intensity of the peak oral pain was found to correlate with the density of fungiform papillae, with the greatest density found in patients with BMS who were primarily supertasters (primarily females, who report the bitterest sensation from the intensely bitter compound known as 6-n-propylthiouracil, or PROP testing).32-34 Another proposed theory for BMS involves a cascade of events that occurs in women undergoing menopause who also are experiencing either chronic anxiety or

post-traumatic stress. According to Woda et al, chronic anxiety or posttraumatic stress lead to a dysregulation of the adrenal production of steroids, resulting in a decreased or modified production of precursors for neuroactive steroid synthesis in skin, mucosa, and the nervous system.35 Furthermore, menopausal women, due to alteration in ovarian steroid production, could experience neurodegenerative alterations in small nerve fibers, both peripherally and centrally. The combination of both of these events could lead to BMS symptomatology. In primary BMS, the etiology is unclear, leading to treatment options based on patients’ symptomatology. This often yields unsatisfactory results, whereas in secondary BMS, the appropriate diagnosis and treatment of the underlying condition is provided. Management for BMS can involve the use of cognitive behavioral therapy or psychotherapy, topically applied or centrally acting medications, or combinations of these treatments. Due to the chronic nature of BMS and the complexities associated with it, it is not surprising that health care practitioners have difficulties in recognizing, understanding, diagnosing, and managing this condition and that patients are frustrated in finding a definitive diagnosis and favorable management strategy for their oral burning symptoms. In this study, a group of consecutive BMS patients were retrospectively analyzed with regard to variables related to demographics, onset characteristics, temporal behavior (frequency), and progression of their oral burning symptoms. The authors also assessed the duration, number, and type of treatments provided by health care practitioners www.agd.org

prior to a definitive diagnosis of BMS. This article also provides an overview of current management strategies.

Materials and methods In total, the records of 49 consecutive patients diagnosed with BMS at the faculty dental practice of two of the authors (GDK and JBE) from January 2003 to March 2008 were reviewed. The two clinicians (GDK and JBE) are experienced in diagnosing and managing BMS and limit their practice to oral medicine/ orofacial pain conditions. Diagnostic criteria included all conditions associated with oral burning sensations in the oral mucosa that appear without any detected abnormalities in the absence of any local or systemic diseases or alterations. The specific inclusion criteria were age 18 or older; symptoms of diffuse oral burning pain located on the tongue, hard palate, and/or oral mucosa, associated or unassociated with subjective oral dryness or loss/ alteration of taste or sensation; clinically normal appearing oral mucosa in the described region of the oral burning pain; the presence of a definitive diagnosis of BMS after ruling out other local and systemic factors and laboratory alterations that could be responsible for oral burning pain/sensations; and symptom duration longer than one month, during which pain/ sensations occurred nearly every day. Exclusion criteria included data missing from the chart; the presence of oral mucosal lesions; or the presence of systemic disease that could explain the oral burning pain/sensations. To ensure that patients met the inclusion criteria, they were examined by one of the two clinicians who had experience in oral

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Oral Diagnosis Burning mouth syndrome: A challenge for dental practitioners and patients

Table 1. Study sample demographics. Number of patients ( n = 49)

Demographic variable

Percentage of total patients

Gender Male Female

6

12

43

88

48

98

Ethnicity Caucasian

1

2

Age range (years)

Asian-American

Mean (SD)

Sample size

33–68

56.4 (8.9)

35 of 49 patients*

*Dates of birth were not available in 14 of the dental records reviewed.

Table 2. Treatments prescribed prior to a definitive diagnosis of BMS. Number of treatments prescribed

Percentage of total treatments prescribed

Medication category

Medication type

Salivary stimulants

Topical (rinse, gel, paste) and systemic sialogogues (pilocarpaine, cevimeline)

21

30

Antifungals

Topical (nystatin cream/gel, clotrimazole troches) and systemic (fluconazole)

13

18

Anticonvulsants

Carbamazepine, gabapentin oxcarbazepine

8

11

Anxiolytics

Topical and systemic (clonazepam)

7

10

Topical anesthetics

Topical (xylocaine/lidocaine gel/rinse)

6

8

Other*

Various

Total

16

23

71

100

* Other medication categories include narcotics, corticosteroids, antioxidants, vitamins, minerals, antidepressants, and mechanical approaches, including oral appliances.

medicine/orofacial pain for disorders related to hard and soft oral tissues in addition to organic systemic diseases, with the assistance of hematological screening (blood count and differential, fasting blood glucose, iron, vitamin B complex and folate levels, and thyroid function). When there was a complaint of xerostomia and/or the clinical examination suggested the 212

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presence of dry oral mucosa tissues or lack of salivary flow on manipulation of the salivary glands, sialometry by measuring the weight of stimulated and unstimulated whole saliva was performed and the patient was evaluated for diseases related to salivary gland hypofunction with laboratory testing for autoimmune and connective tissue diseases.

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Demographics, symptom onset characteristics, temporal behavior, and progression of the subjects’ burning symptoms, including the duration, number, and type of treatments provided by other health practitioners prior to a definitive diagnosis of BMS, were collected. Hormonal status of the female patients was not evaluated because hormone replacement therapy in perimenopausal patients with BMS is not supported in causation of BMS.11 All statistical data were analyzed using SPSS 15.0 (IBM). Correlation between the number of months a patient reported experiencing oral burning symptoms and the number of previous treatment methods was performed using a Pearson correlation with statistical significance determined at p < 0.05. The study was approved by the Institutional Review Board of the University of Illinois.

Results The study sample consisted of 49 patients, predominately Caucasian (48 of 49 patients) females, with a female-to-male ratio of approximately 7:1. The average age of the sample was 56.4 (range = 33–68) (Table 1). The majority of patients (76%) reported the onset of their oral burning symptoms to be “sudden” rather than “gradual” (progressive over time; 24%). Additionally, a majority of the sample (80%) described the oral burning symptoms they experienced as “constant” as opposed to “intermittent” (18%) or “other” (2%). When describing the progression of the oral burning since initial onset in terms of intensity, 63% of patients reported increased intensity, 6% reported decreased intensity, and 31% reported no change in intensity. On average, patients reported experiencing oral burning symptoms for 41 months (standard deviation

[SD] = 73.5, range = 2–360 months, median = 20 months) prior to a definitive diagnosis of BMS. A total of 38 patients reported receiving treatment for oral burning symptoms prior to referral with a mean of 1.9 (SD = 1.2) treatments per patient, while 11 reported no treatment for their oral burning symptoms prior to referral. There was no statistically significant correlation between the number of months a patient reported experiencing the oral burning symptoms and the number of previous treatments (r = -0.24, p = 0.15). Previous treatment interventions were categorized according to various medication categories. The five most frequently reported medication categories reported, in descending order, were salivary stimulants, antifungals, anticonvulsants, anxiolytics, and topical anesthetics. Other medication categories were grouped as “Other” due to small cell sizes (