Exposed root surface: a review of aetiology, management and evidence-based outcomes of treatment

Gingival recession and the associated exposure of root surfaces are a common finding in our patient population. Many factors have been proposed as influencing the development of marginal tissue recession and controversy exists over the concept of an "adequate" zone of attached tissue. We will explore the aetiology of marginal recession and the factors affecting the outcome of treatment of these defects through an evidence-based perspective. A review of currently accepted surgical techniques backed by evidence of success will be presented to familiarize the reader with procedures used to treat exposed root surfaces.     

Using a Delphi panel to survey criteria for successful periodontal therapy in posterior teeth

BACKGROUND: Health care providers have focused on outcome measures to determine the success or failure of treatment. In periodontics, there is no consistent view regarding what outcome measure(s) is(are) important for successful treatment. This study used a Delphi surveying technique to determine which outcome measures were clinically relevant to an expert panel of periodontists. METHODS: The Delphi surveyed 35 periodontists from the United States to determine the level of importance of attachment level, probing depth, furcation involvement, mobility, plaque, inflammation, esthetics, pain, and patient satisfaction following periodontal treatment of posterior teeth in a patient with severe chronic periodontitis. The Delphi panelists were questioned concerning the relative importance of each outcome measure, a minimally acceptable level considered necessary for success for each outcome measure, and the length of time required for these outcome measures to remain stable. RESULTS: Following two rounds of Delphi surveys, the panelists considered the control of pain to be an "extremely important" outcome measure for successful periodontal treatment. Attachment levels, probing depths, plaque levels, degree of inflammation, function, furcation involvement, and patient satisfaction were considered to be "very important" outcomes for successful periodontal treatment. The minimally acceptable reduction in probing depths following 1 year of treatment was 2 mm; whereas up to 1 mm of attachment loss was considered acceptable. The panel found that Glickman grade 2 furcation involvement or Miller degree II mobility would be considered an acceptable outcome for clinical success. Finally, the panel agreed that the 1-year results of treatment should remain stable for a minimum of 5 years. CONCLUSIONS: The Delphi surveying technique proved useful in developing a hierarchy for the relevance of periodontal outcome measures. Absence of pain was the only outcome measure considered to be "extremely important" for successful therapy. Although panelists considered attachment loss, furcation invasions, and mobility as "very important" outcomes, they were willing to accept loss of attachment of up to 1 mm, grade 2 furcation involvement, and degree II mobility following treatment as long as outcomes remained stable for 5 years. These data suggest that minimal standards for success of posterior teeth can be established among periodontal practitioners.     

Aspects of illness behavior in patients with facial pain.

Results of recent studies have suggested that factors other than clinical signs and symptoms have a significant role in determining whether people seek treatment for perceived facial pain and mandibular dysfunction. The concept of "illness behavior" can be used to investigate this problem. Knowledge of a patient's illness behavior patterns helps enable the dentist to understand who seeks care for symptoms of facial pain and mandibular dysfunction; why the care is sought; the meaning of the symptoms to the patient; and the patient's response to treatment.     

Fixed lingual arch appliance for compliance-free unilateral molar distalization in the mandible. Three case studies.

An asymmetrically activated lingual arch appliance enables rapid, unilateral molar distalization in the mandible without active patient compliance. Using the segmented arch technique, the biomechanics involve only the tooth moved, in accordance with the 2-tooth concept, with a large, multi-rooted tooth segment acting as an anchoring unit. The anchorage system requires no maxillary involvement.     

Fifty Years of Interdisciplinary Site Development: Lessons and Guidelines from Periodontal Prosthesis

Abstract: Just as "osseointegration" became synonymous with successful restoration of function in the fully edentulous patient during the 1980s, the term "implant site development" has become intricately associated in the 1990s with the techniques used to achieve esthetic results with implants in the partially edentulous patient. This article explores the roots of the concept of site development within the philosophy and principles of periodontal prosthesis. In addition, the myriad of techniques that are presently collectively referred to as site development are systematically classified into a sequential four-tiered approach that optimizes their efficient application as well as overall success.     

A new perspective on dental malpractice: practice enhancement through risk management

BACKGROUND: Risk management in dentistry has been developed over the years by concentrating on recording treatment in dental records and informing patients of the proposed treatment before treating them. This article advances the concept of risk management through higher involvement of the entire office staff by increasing communication with patients. CONCLUSIONS: By integrating practice management concepts with risk management techniques, dentists can reduce risk management exposure and improve patients' awareness, understanding and follow-through on the treatment of their dental needs. PRACTICE IMPLICATIONS: Practice enhancement through risk management not only improves patient care and reduces risk exposure, but it also brings the dental team together in an effort to improve patient care. In this way, the office will have improved patient acceptance of proposed dental care and an increase in office growth.     

The expanding influence of computed tomography and the application of computer-guided implantology

Implant dentistry is changing. There are currently two types of computed tomogrophy (CT) scanners--multi-slice and cone beam--available to the dental professional. Computed tomography allows for proactive planning among the entire implant team and with the patient, a concept referred to as "collaborative accountability" In addition, CT surgical guidance that enhances accuracy and precision is available to ensure prosthetic outcomes. A logical and progressive approach is outlined that allows each clinician to assess how to embrace this paradigm shift in his or her clinical practice, and provide better and safer patient care.     

Prosthodontic decision making among general dentists in Sweden. II: The choice between fixed and removable partial dentures

PURPOSE: The purpose of this study was to describe how dentists evaluated various items related to a treatment choice between fixed partial dentures (FPD) and removable partial dentures (RPD), and to determine if the differences could be explained by dentist-related variables ("social and demographic attributes," "job situation," and "attitudes"). MATERIALS AND METHODS: Questionnaires were sent to a random sample of 2,059 Swedish general dentists, with a response rate of 76%. In the questionnaire, the choice between FPDs and RPDs in a clinical situation was presented. The dentists were asked to mark on 14-item visual analogue scales the relative importance he or she gave the different items. The items were analyzed through principal components analysis, where a 3-factor solution was obtained; the factors were labeled as "time," "health," and "comfort." The factors were run as dependent variables in multiple regression analyses. RESULTS: Great individual variations were seen, but the differences between groups of dentists were small. The items evaluated as most important were "patient's wish," "condition of possible abutment teeth," and "prognosis for delivered treatment." Male dentists gave significantly greater importance to the "health" factor compared to female dentists. The attitudinal variable "patient information" showed significant associations with all 3 factors in the multivariate models. CONCLUSION: Great individual differences were seen regarding the importance of the various items. In multiple regression models, several independent variables showed significant associations, most interestingly the attitudinal variable "patient information." Low explanatory (R2) values indicate that it is necessary to capture more variables of importance for the prosthodontic decision-making process.     

Prosthodontic decision making among general dentists in Sweden. III: The choice between fixed partial dentures and single implants

PURPOSE: The purpose of this study was to describe how dentists evaluated the importance of various items related to a treatment choice between fixed partial dentures (FPD) and single implants, and to analyze if the differences could be explained by dentist-related variables such as social and demographic attributes, job situation, and attitudes. MATERIALS AND METHODS: Questionnaires were sent to a random sample of 2,059 Swedish general dentists, with a response rate of 76%. In the questionnaire, the choice between an FPD and a single-implant restoration in a clinical situation was presented. Fifteen items were constructed and the dentists were asked to mark on visual analogue scales the relative importance he or she gave the different items. The items were analyzed through principal components analysis, where a three-factor solution was obtained; the factors were labeled as "time," "health," and "comfort." The factors were run as dependent variables in multiple regression analyses. RESULTS: The items evaluated as most important were "prognosis for delivered treatment" and "patient's wish." Large individual differences were seen, but the differences between groups of dentists were small. Male dentists considered the "health" and the "comfort" factors to be more important compared to female dentists. The attitudinal variable "patient information" was significantly associated with the "time" factor and, inversely, with the "comfort" factor. CONCLUSION: Differences between individuals were great, but between groups of dentists the differences were only minor. Multivariately, the attitudinal variable "patient information" showed significant associations with the "time" and the "comfort" factors. Dentist-related variables explained little of the variations. The results further indicated a low personal knowledge concerning implant treatments. Psychologic methods might explain more of the individual differences in prosthodontic decision making, but these are not easily used in a questionnaire study.     

Dentist-patient communication and patient satisfaction in prosthetic dentistry

PURPOSE: Dentist-patient verbal communication dimensions on patient satisfaction were investigated in a prosthodontic context, controlling for the age and gender of patients and dentists and the amount of delivered prosthodontic treatment. Two concepts of satisfaction were defined, one for the single visit (satisfaction with care), and one for the overall result (satisfaction with treatment outcome). MATERIALS AND METHODS: Audio recordings of 61 patients meeting 15 dentists were made in three specialist clinics of prosthetic dentistry. The prosthodontic treatment periods with fixed tooth- or implant-supported prostheses, on average 20 months, were monitored by questionnaires. One visit near the end of each treatment period was audio recorded. The recorded verbal communication was analyzed with the Roter Interaction Analysis System-Dental. RESULTS: Bivariate analysis showed that patients of female dentists were more satisfied in the long-term perspective than patients of male dentists. In logistic multivariate regression models, the verbal communication dimensions "information-dentist horizon" and "information-patient horizon," together with the mouth involvement of the prosthodontics, influenced patient satisfaction with treatment outcome. CONCLUSION: Patients undergoing extensive prosthodontic rehabilitation should be given the opportunity to ask and talk about their dental health, and dentists should minimize their question-asking and orientating behavior during the encounters to help improve patient satisfaction with treatment outcome.     

Tooth loss after active periodontal therapy. 2: tooth-related factors

Objective: To assess tooth‐related factors contributing to tooth loss over a period of 10 years after completion of active periodontal therapy (APT). Material and Methods: All patients who had received APT by the same experienced periodontist, 10 years before beginning the research, were recruited until 100 patients were re‐examined. Examinations included, at the patient level: test for interleukin‐1 polymorphism, compliance to supportive periodontal therapy (SPT), mean plaque scores during SPT; at the tooth level: assessment of baseline bone loss (type, amount), tooth type, furcation status and abutment status. Logistic multilevel regression was performed for statistical analysis. Results: Hundred patients with 2301 teeth at the baseline (completion of APT) were retrospectively examined. One hundred fifty‐five teeth were lost over 10 years after APT. Logistic multilevel regression identified high plaque scores, irregular attendance of SPT and age as patient‐related factors significantly accounting for tooth loss. Tooth‐related factors significantly contributing to tooth loss were baseline bone loss, furcation involvement and use as an abutment tooth. However, in patients with regular SPT, 93% of teeth with 60–80% bone loss at the baseline, survived 10 years. Conclusion: The following tooth‐related risk factors for tooth loss were identified: baseline bone loss, furcation involvement, and use as an abutment tooth.     

Comparative study of clinical manifestation,plain-film radiography,and computed tomographic scan in arteriovenous malformations of the jaws

OBJECTIVE: The purpose of this study was to summarize the clinical manifestation, plain-film radiography, and computed tomographic (CT) scan features of arteriovenous malformations (AVMs) of the jaws on the basis of a series of 12 patients. STUDY DESIGN: This study group comprised twelve patients with AVM of the jaws from February 1996 to February 2001. Seven cases were located in the mandible, and 5 in the maxilla. Both plain-film radiography and CT scan were available for all cases. For the patients with lesions in the mandible, panoramic, posterioanterior, and lateral mandibular views were applied. Waters' position view and panoramic radiography were indicated for AVMs of the maxilla. RESULTS: Each patient with AVM of the maxillary bone had involvement of adjacent soft tissues. Various radiographic signs were noted, including erosion, coarse trabeculae, and apparent lack of any radiographic change, and CT scans featured cystic expansion of alveolar process with broken cortex. The radiographic signs and CT scan features of AVMs in the mandible were related to involvement of surrounding soft tissues. If involvement of the adjacent soft tissues was found, "soap bubble" radiolucency was shown radiographically and osteolytic expansion with perforation of cortex was present on CT scan. In cases without surrounding soft tissue involvement, the various radiographic signs included multilocular or unilocular radiolucency or coarse trabeculae; osteolytic expansions with intact cortex were found on CT scan. CONCLUSION: AVMs of the jaws showed intraosseous osteolytic expansion on CT scan but had variable appearance on plain-film radiographs.     

Caries prevention and reversal based on the caries balance

The science behind caries prevention and reversal is well understood. A recent clinical trial has confirmed that reducing caries risk results in a reduction in dental decay. Dental caries progression or reversal depends upon the balance between demineralization and remineralization and can be visualized for clinical purposes as the "caries balance." This balance is determined by the relative weights of the sums of pathological factors and protective factors. A structured caries risk assessment should be carried out based upon the concept of the caries balance. Following the risk assessment, a treatment plan is devised which leads to the control of dental caries for the patient. The balance between pathological and preventive factors can be swung in the direction of caries intervention and prevention by the active role of the dentist and his/her auxiliary staff.     

Removal of enamel caries with an air abrasion powder

This study compared the efficiency of air abrasion on enamel caries with selective enamel powder (SEP) or with alumina powder and a negative and positive control group. Ninety-three extracted molars with non-cavitated incipient enamel lesions were selected. After embedding the roots in resin, each lesion was sectioned perpendicular to the surface and photographed. Each lesion was classified microscopically as having or not having dentin involvement. The lesions were distributed into four groups with an equal number of enamel caries with or without dentin involvement. Each group was treated differently: Group 1 had SEP abrasion, Group 2 had alumina abrasion, Group 3 had sodium bicarbonate abrasion (negative control) and Group 4 had bur treatment (positive control). The surface was rephotographed after treatment. Superimposition of the photographs identified areas of "correct-excavation," "under-excavation" and "over-excavation." There were no statistical differences between lesions treated with or without dentin involvement for Groups 2 through 4. However, in the SEP group, all measured areas were significantly influenced by dentin involvement. In pairwise comparisons, no statistical differences were found between the alumina and bur groups. The SEP group, however, showed statistically significant differences for each area compared to the alumina group in enamel caries without dentin involvement. SEP performed as well as alumina and bur in lesions with dentin involvement. SEP is different in its ablative properties toward caries with dentin involvement or no dentin involvement. In terms of dental treatment, SEP seems to have a diagnostic potential for enamel lesions before operative intervention in patients with high caries risk.     

A randomized clinical multicentre trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome

OBJECTIVE: Evaluation of effects of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects. MATERIAL AND METHODS: Fifty-one patients were recruited. In the intention-to-treat population 21 patients were allocated into the sequence left treatment with enamel matrix protein derivative (EMD) and right guided tissue regeneration (GTR) and 27 in the sequence left GTR and right EMD. Evaluated patient factors were: smoking, age, gender, hypertension and oral hygiene status. Outcome parameters included change of: (a) horizontal depth of the defect at the deepest point (b) distance from the fornix of the furcation to bone crest of the defect, (c) distance from stent to the bottom of the defect, (d) pocket depth and (e) attachment level at the middle of the furcation. RESULTS: In patients 54 years of age and older, in males, in non-smokers and in patients with "poor" hygiene EMD-treated sites showed a significant higher mean reduction of the parameters d (age), b (gender, hygiene) a (smoking, hygiene) when compared with sites treated with GTR. CONCLUSIONS: These data provided an indication of a possible effect of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects.     

The role of salivary function in modulating chemotherapy-induced oropharyngeal mucositis: a review of the literature

OBJECTIVES: We sought to investigate whether the finding of temporomandibular joint (TMJ)-related pain may be linked to magnetic resonance (MR) imaging findings of TMJ internal derangement and TMJ osteoarthrosis. STUDY DESIGN: The study consisted of 194 consecutive TMJ patients. Criteria for including a patient with a painful TMJ were as follow: report of orofacial pain in the TMJ, with the presence of unilateral or bilateral TMJ pain during palpation, function, and unassisted or assisted mandibular opening. Criteria for including a patient with a nonpainful TMJ were as follow: absence of a TMJ with pain during palpation, function, and unassisted or assisted mandibular opening. Application of the criteria resulted in a study group of 150 patients with unilateral TMJ pain, 10 with bilateral TMJ pain, and 34 without TMJ pain. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement or osteoarthrosis, or both. RESULTS: A comparison of the TMJ-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ internal derangement (P =.002) and TMJ osteoarthrosis (P =.004). Significant increases in risk of pain occurred with "disk displacement without reduction and osteoarthrosis" (P =.000), "disk displacement without reduction and absence of osteoarthrosis" (P =.000), and "disk displacement with reduction and osteoarthrosis" (P =.036). CONCLUSIONS: The results suggest that TMJ-related pain is correlated with TMJ-related MR imaging diagnoses of internal derangement and osteoarthrosis. The data confirm the biological concept of "internal derangement and osteoarthrosis," yet re-emphasize that internal derangement and osteoarthrosis may not be regarded as the unique and dominant factors in the definition of TMJ pain.     

Multiple primary enoral soft tissue manifestations of a Hodgkin lymphoma—case report and literature review

Background

Hodgkin lymphoma (HL) are lymphoproliferative neoplasms, histologically comprising of mononuclear and multinucleated Hodgkin and Reed Sternberg cells (HRS). About 4 % of all lymphatic malignancies of the head and neck are HL. The typical disease presents itself as a nodal lesion. Extranodal, enoral soft tissue involvement by HL is very rare.

Case report

A 73-year-old man with a suspect, ulcerating lesion in the left retromolar region of the mandible was assigned to our hospital. Prior anti-inflammatory therapy has been without success. Subsequently, three biopsies were taken which could only show inflammation. Finally, two biopsies from the left retromolar region and the left inner cheek showed HRS cells with positive expressions of CD15 and CD30 corresponding to a Hodgkin lymphoma. No lymphatic node or bone involvement could be detected. The patient was designated to receive radio-chemotherapy, but died 3 weeks after diagnosis of multiple organ failure. In a literature review, together with this report, nine cases were found concerning primary HL of the oral mucosa. Accordingly, this is the first case of primary multiple extranodal HL in the oral mucosa in absence of lymphatic node involvement.

Discussion

Neither clinical features nor radiological appearances of HL presenting as primary enoral lesions are pathognomonic. Especially when only small biopsy specimens are available, histological diagnosis remains challenging, may lead to a delay in therapy and may result in a significant worse prognosis.     

Subjective outcomes following sural nerve harvest.

PURPOSE: The goal of this study was to assess subjective patient recovery of donor site sensory deficit following sural nerve harvest for trigeminal nerve repair surgery. PATIENTS AND METHODS: A review of 42 consecutive sural nerve graft patient records yielded 26 patients, at least 20 months following sural nerve grafting for trigeminal nerve repair, who participated in a telephone questionnaire survey to assess subjective outcomes. The association between donor site outcome and other factors, including nerve graft recovery, age, gender, pain, cold sensitivity, scar cosmesis and tactile sensitivity, and legal involvement were analyzed, and presurgical and present levels of donor and nerve graft site sensibility were compared. RESULTS: The perceived area of donor site sensory deficit decreased significantly over time. Postoperative donor site pain and cold sensitivity at low levels were reported by few patients, and the majority have completely resolved. Most patients reported no problems with scar cosmesis or pain. There was a moderate agreement between donor site recovery and nerve graft recovery (kappa = 0.32). Few patients reported satisfaction with one site and not the other or complete dissatisfaction with both sites. Other factors such as age, gender, or legal involvement were not found to correlate with satisfaction level. CONCLUSIONS: The use of a questionnaire for subjective assessment of neurosensory recovery following nerve graft repair yields outcomes information that is generally not considered in the traditional clinical patient assessment. The majority of patients tolerate sural nerve harvest without significant donor site morbidity.     

Comparison between patient expectation before and satisfaction after periodontal surgical treatment

BACKGROUND: The purposes of this study were to compare patient expectation before periodontal surgical treatment with their level of satisfaction afterward on the basis of a self-reported questionnaire, and to analyze the relationship between various satisfaction factors and periodontal surgical treatment. METHODS: Information was obtained from 33 patients initially diagnosed with chronic periodontitis. The survey was completed twice by each patient, once before and once after modified Widman flap surgery. RESULTS: The satisfaction scores of items related to patient expectation of treatment outcome decreased significantly following surgery. The patients also expressed great dissatisfaction with items regarding disease prevention such as "desire for knowledge of periodontal disease prevention" and "desire for knowledge of recurrence control methods." However, some items such as "dental pain during treatment," "dental fear of treatment," and "cost of treatment" increased significantly after treatment. The total mean score of general satisfaction before treatment was 2.65, decreasing to 2.60 after treatment. CONCLUSIONS: Among the 5 subscales, any increase in patient satisfaction related to the treatment factors is difficult to achieve, but we should be able to raise the satisfaction level of our patients through improvement of the preventive measure factors.     

Patient safety in general dental practice 2009

In recent years various studies have been published which indicate that adverse events in health care facilities are the result of structural factors. In 2009 a national study was carried out in the Netherlands to gain insight into patient safety in primary care settings, including general dental practices. In 20 randomly selected practices, patient records were investigated and oral care professionals reported, during a period of 2 weeks, adverse events which occurred. For each practice, 2 researchers screened, with the help of a checklist, 50 randomly selected patient records covering a period of 1 year. A total of 8 preventable adverse events were found in the 1000 patient records (0.8%). Anonymous reports made during the 2 weeks of the research period resulted in 7 adverse events. Practically all of the adverse events had to do with diagnostics and treatment and resulted in limited harmful consequences for patients. On the basis of these results, oral care in general dental practice would appear to be safe, but the concept 'patient safety' is not at all or only minimally active among general dental practitioners. Regarding patient safety performance, improvement in the quality of record-keeping would be desirable.