Interventions for tobacco cessation in the dental setting. A systematic review.

UNLABELLED: Oral health professionals have a unique opportunity to increase tobacco abstinence rates among patients who use tobacco. OBJECTIVE: To assess the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. RESEARCH DESIGN: We searched standard electronic retrieval systems and databases including the specialized registers of the Cochrane Tobacco Addiction Group and the Cochrane Oral Health Group through 2006. Selection criteria included randomised and pseudo-randomised clinical trials assessing tobacco cessation interventions for tobacco users conducted by oral health professionals in the dental office or community setting. The most rigorous abstinence outcome reported with at least six months of follow-up was recorded. Data collection and analysis involved two authors who independently reviewed abstracts for inclusion and abstracted data from included trials. RESULTS: Six clinical trials assessing the efficacy of interventions in dental office or school community settings were included. All studies assessed the efficacy of interventions for smokeless tobacco users, one also included cigarettes smokers, all employed oral exam and behavioral components, and one offered pharmacotherapy. The results showed that interventions conducted by oral health professionals increase tobacco abstinence rates (OR 1.44; 95% CI: 1.16-1.78) at 12 months or longer. Heterogeneity was evident and could not be adequately explained through subgroup or sensitivity analyses. CONCLUSIONS: Available evidence suggests that behavioral interventions for tobacco use conducted by oral health professionals incorporating an oral exam component in the dental office and community setting increase tobacco abstinence rates.

Interventions for tobacco cessation in the dental setting.

BACKGROUND: Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users. OBJECTIVES: This review assesses the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction group Specialized Register (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1982-2004), Healthstar (1975-2004), ERIC (1967-2004), PsycINFO (1984-2004), National Technical Information Service database (NTIS, 1964-2004), Dissertation Abstracts Online (1861-2004), Database of Abstract of Reviews of Effectiveness (DARE, 1995-2004), and Web of Science (1993-2004). SELECTION CRITERIA: We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow up. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus. MAIN RESULTS: Six clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or a school community setting. All studies assessed the efficacy of interventions for smokeless tobacco users, one of which included cigarettes smokers. All studies employed behavioural interventions and only one offered pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling of the studies suggested that interventions conducted by oral health professionals increase tobacco abstinence rates (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.16 to 1.78) at 12 months or longer. Heterogeneity was evident (I(2) = 75%) and could not be adequately explained through subgroup or sensitivity analyses. AUTHORS' CONCLUSIONS: Available evidence suggests that behavioural interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice.

Comparison of impression techniques for a five-implant mandibular model.

Production of an accurate dental cast framework that meets the implant objective of passive fit demands an understanding of potential processing errors. Working casts fabricated from impressions using two different transfer copings, as provided by a leading implant manufacturer, were investigated for differences in accuracy. A five-implant mandibular model was used to produce seven casts by both the indirect and direct transfer coping techniques. Comparison was made by using a dental cast framework fitted to the master cast. Differences in distances measured between each group and the master cast were analyzed to establish differences between methods. For the model used, the direct technique produced more accurate working casts. A concern for potential impression distortion given the specific clinical situation underscores the method of choice.

Comparison of impression techniques for a two-implant 15-degree divergent model.

To consistently provide passively fitting implant superstructures, an understanding of the accuracy and precision of all phases of fabrication and connection is required. The initial phase of fabrication, ie, impression making and cast forming, was investigated in an earlier report for a mandibular five-implant model. The current study evaluates the accuracy of working casts produced from impressions using two different transfer copings in a 15-degree divergent two-implant posterior mandibular model. While the indirect method is less cumbersome to use, it was found to be less accurate in the prior study. The purpose of this study was to see if the direct method is more precise for this clinical situation. A transfer was deemed effective in producing experimental casts if distances between specified points on the cast agreed with the corresponding distances on the master cast. The absolute value of the difference in distances between experimental and master casts was compared for the two techniques (two-sample t tests). No significant differences were noted (P > .05), and the power of the tests ranged from 0.70 to 0.96 against the one-sided hypothesis that the direct method had a smaller mean absolute difference in distance than the indirect method. This suggests no clear advantage in using the direct method in similar clinical situations. Comparison of these findings to other impression accuracy studies is made.

Effects of fabrication, finishing, and polishing procedures on preload in prostheses using conventional "gold' and plastic cylinders.

This study reviews fundamental concepts related to the use of screws and presents data describing the effect of fabrication, finishing, and polishing procedures on as-received preload for implant cylinders. Specifically, this study measured and compared preload produced when using as-received gold cylinders (the reference or gold standard), and cast cylinders produced from premade gold and plastic cylinders in the as-cast condition and following postcast finishing and polishing manipulations. The results reveal that preload in the gold screw-gold cylinder-abutment joint can be affected by the casting process, and that the choice of cylinder type, casting alloy, investment, and finishing/polishing technique may affect the resultant preload as compared to as-received joint conditions. The data from this study indicate that when plastic patterns are used as part of the framework, finishing and polishing of implant cylinder components should provide an increased preload compared to no such manipulations. Also, if maximum preload is desired, the use of premade metal cylinders offers an advantage over plastic patterns in both preload magnitude and precision.

Reverse torque failure of screw-shaped implants in baboons: baseline data for abutment torque application.

Torque failure for endosseous implants has been used as a biomechanical measure of anchorage, though the significance of such data is not known. A practical understanding of the resistance to torque failure of implant-tissue interfaces at stage 2 surgery would help in assigning torque levels for implant abutment-screw fastening. The purpose of this study was to measure torque failure levels of commercially pure (CP) titanium, Ti-6Al-4V, hydroxyapatite-coated (HA-coated) screw-shaped implants placed into the maxillae and mandibles of baboons. Implants identical in size were placed into the edentulous posterior maxillae and mandibles of six female baboons (n = 37 each group) using a standardized surgical protocol. Reverse-torque data were collected at postinsertion time intervals ranging from 3 to 4 months using a counterclockwise torque driver and the data were analyzed (repeated measures ANOVA) for torque differences related to time, biomaterial, and jaw. The HA-coated implants exhibited significantly greater torque-removal values compared to both metallic implants (HA: 186.0 Ncm [50.1]; Ti-6Al-4V: 78.6 Ncm [18.1]; CP Ti 74.0 Ncm [24.4]). Analysis of torque interactions with jaw showed no significant difference; however, the mandible was found to be greater than the maxilla in torque resistance for all groups tested. Understanding the risks in inferring animal data to human application, the clinical implications of these data suggest that the recommended torque level of 35 Ncm for abutment fastening may provide a margin of safety for most implants of similar design and material as used in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Histomorphometric analysis of implant anchorage for 3 types of dental implants following 6 months of healing in baboon jaws.

In an effort to better understand the supporting anatomy for unloaded endosseous dental implants, this study focused on the histomorphometric analysis of 3 different types of implants placed into non-human primate jaws and allowed to heal for 6 months. This report describes data from 24 screw-type dental implants placed in edentulated (2 months healing time) posterior arches of 4 adult female baboons. Three different implants were placed and allowed to heal for 6 months prior to processing for evaluation: commercially pure titanium (n = 8), titanium alloy (n = 8), and titanium plasma-sprayed (n = 8). Circumferential bone-implant interface sampling from 6 regions along the entire length of each implant was obtained for evaluation of percent bone-implant contact (%BIC) and percent bone area (%BA), within 3 mm of the implant. Data were collected (reliability of 1.6% for both parameters) and analyzed by an observer blinded to implant material using IMAGE analysis software for differences between jaws, implant biomaterials, and jaw/biomaterial (analysis of variance, pairwise comparison using least squares method with Bonferroni adjustment). The results indicated that the overall mean %BIC was 55.8 and mean %BA was 48.1. Maxillary and mandibular differences for both parameters were statistically significantly different: %BIC in maxilla 50.8, in mandible 60.8; %BA in maxilla 43.6, in mandible 52.6 (both significant at the P < .05 level). The biomaterial analyses revealed no significant differences between the different implants for %BIC or %BA. The trend observed--that mandibular values were greater than maxillary values for the overall jaw comparisons--was found to be consistent at the jaw/biomaterial level, although the small sample size limited statistical power. These data, along with data from a previous 3-month study, provide insight into baseline supporting anatomy for dental implants.

Reverse-torque failure of screw-shaped implants in baboons after 6 months of healing.

Mechanical testing of the implant-tissue interface has been the focus of numerous investigations concerning the anchorage capacity of implants. The purpose of this study was to measure reverse-torque failure after 6 months of healing for three different biomaterials in the posterior jaws of four adult female baboons. The animals had all of their posterior teeth surgically extracted and, following 10 weeks of healing, 7 implants were placed in each quadrant. The biomaterials included titanium plasma-sprayed surfaces, titanium-aluminum-vanadium surfaces (both 3.8 mm x 10 mm), and a commercially pure titanium surface (3.75 mm x 10 mm). After 6 months, torque data were collected using a counterclockwise computerized torque driver and were analyzed by repeated measures analysis of variance for differences related to biomaterial, jaw, and biomaterial/jaw. Post-hoc Tukey Kramer analysis was also performed for within-group differences (alpha = .05 level). The biomaterial comparison revealed a significant difference between the titanium plasma-sprayed and the combined commercially pure titanium/titanium -aluminum-vanadium groups (analysis of variance, Tukey Kramer, P < .05). The jaw comparison showed no significant difference, although the data suggest that higher forces may be required for mandibular torsional failure. The biomaterial/jaw comparison revealed that jaw differences for the mean values of commercially pure titanium and titanium-aluminum-vanadium implants were greater than jaw differences for mean values of titanium plasma-sprayed implants, although these differences were not statistically significant. Because of the lack of correlation between single-cycle biomechanical tests and clinical performance, it is necessary to be selective in assigning usefulness to data of this type.

Quantitative histomorphometric description of implant anchorage for three types of dental implants following 3 months of healing in baboons.

Important to the understanding of the dynamics associated with dental implant anchorage over time is a knowledge of the supporting anatomy for common endosseous implants prior to being placed into function. This study followed 20 screw-shaped dental implants placed in edentulated (2 months' healing time) posterior jaws of five adult female baboons. Implants made of three biomaterials were placed and allowed to heal for 3 months prior to processing for evaluation. Percentage integration and bone area data from six horizontal sections along the entire length of each implant were collected and analyzed for differences between jaws, implant biomaterials, jaw/biomaterial, and sections of the implants (ANOVA, pairwise comparison using LSM with Bonferroni adjustment). The results indicated that overall mean percentage integration was 46.5 and mean percentage bone area was 39.9. Maxillary and mandibular differences for both parameters were statistically different (integration: maxillary = 38.1%, mandibular = 56.7%; bone area: maxillary = 35.8%, mandibular = 44.9%; both were significant at the P < .05 level). The biomaterial analyses revealed significant differences for percentage integration between the metal implants and the hydroxyapatite-coated implant (commercially pure titanium = 39.1%, titanium-aluminum-vanadium = 40.0%, hydroxyapatite-coated = 61.5%), but no such difference was noted for percentage bone area (commercially pure titanium = 38.8%, titanium-aluminum-vanadium = 38.9%, hydroxyapatite-coated = 42.3%). Discussion of the relative importance of the two parameters highlights the fact that resistance to functional loads requires establishing and then maintaining an adequate volume of bone, which may have a functionally specific structure based on the mechanical properties of the local jaw environment.

X-ray diffraction studies of as-cast high-palladium alloys.

OBJECTIVES: The purpose of this study was to use x-ray diffraction (XRD) to investigate four representative high-palladium alloys in the as-cast condition and obtain new information about the metallurgical phases. METHODS: Two Pd-Cu-Ga alloys and two Pd-Ga alloys were cast into plate-shaped specimens (20 mm x 1.5 mm) which were bench-cooled. Polished and etched specimens were analyzed using two different x-ray diffractometers and CuKa radiation. RESULTS: All four alloys exhibited strong XRD peaks for the face-centered cubic (fcc) palladium solid solution matrix, and variations in the lattice parameter were consistent with alloy compositions. Comparison of the relative peak intensities for the alloys and the pure palladium powder standard indicated that the as-cast microstructures had preferred crystallographic orientation. Because the two Pd-Cu-Ga alloys contained appreciable amounts of near-surface lamellar interdendritic or eutectic constituents, it was possible to determine previously unreported XRD peaks for the Pd2Ga phase in these alloys. Low-intensity peaks in the Pd-Ga alloys were attributed to small amounts of secondary phases observed in the microstructures. SIGNIFICANCE: Knowledge of the metallurgical structures of these high-palladium alloys can be important for interpretation of microstructural observations, mechanical properties, corrosion behavior and clinical performance.

Effect of prosthetic superstructure accuracy on the osteointegrated implant bone interface.

OBJECTIVE: This study evaluated the biologic result of forces induced by a misfitting prosthetic superstructure on implants placed in a New Zealand white rabbit tibia model. STUDY DESIGN: Nine rabbits had two dental implants placed in both right and left proximal tibias. After 6 weeks, one animal was sacrificed for baseline integration data, and the remaining animals had fitting or misfitting prosthetic superstructures attached to the implants for 12 weeks. Implants were evaluated clinically, radiographically, and histomorphometrically at the scanning electron microscopic level. RESULTS: No clinical, radiographic, or histomorphometric evidence exists of integration failure with implants subjected to superstructure strain, although bone remodeling is noted. CONCLUSIONS: Given the limitations of sample size, animal model used, duration of prosthetic superstructure attachment, and loading confounders possible, the study of prosthetic framework misfit must be evaluated with another animal model, such as an intraoral primate model, to determine the relationship between clinical performance and histologic findings.

Successful long-term treatment outcomes in the field of osseointegrated implants: prosthodontic determinants.

PURPOSE: Because existing implant success criteria have not met with widespread use, consensus is needed among professionals working in the field as to what constitutes implant success. This article discusses implant success within the context of prosthesis success, and argues that successful use of implants cannot be judged without prosthesis consideration. RESULTS AND DISCUSSION: A framework for evaluating clinical success of prosthodontic treatment is presented. A context for judging success by presenting related topics that include contrasting process and outcome measures, and consideration of long-term outcomes that have a tangible meaning to the patient (i.e., are patient-based), is argued for. A hierarchy of outcomes is proposed for a better understanding of the relative strengths associated with various outcomes. Emphasis is given to the concept of prosthodontic treatment being prescribed to reduce the patient-specific burden associated with the missing tooth condition. CONCLUSION: The challenge is to define the best applications of dental implants within the broad context of prosthodontic options through demonstrated advantages over more conventional options. A broad understanding of "success" from multiple outcome domains is most likely to give the truest measure for implant application within the context of possible prosthodontic options for all patients.

New high-palladium casting alloys: 1. Overview and initial studies.

High-palladium alloys for metal ceramic restorations, based on the Pd-Cu-Ga and Pd-Ga systems, were introduced to the dental profession during the past decade. These alloys have become increasingly popular because they are much less expensive than the gold-based alloys, and recently marketed high-palladium alloy compositions have excellent mechanical properties. A summary of the important melting and casting considerations for these somewhat technique-sensitive alloys is presented together with an overview of important dental materials science aspects and the results of a dental laboratory survey. A maxillary central incisor coping was chosen as the clinically appropriate specimen shape, and the gas-oxygen torch melting technique was found to produce castings with clinically acceptable levels of marginal sharpness and little evidence of microporosity. The etched as-cast high-palladium alloys exhibited fine-scale multiphase microstructures, and a noteworthy finding was that relative proportions of the microstructural constituents frequently varied for thin versus thick sections of the cast specimens.

Full-arch implant framework casting accuracy: preliminary in vitro observation for in vivo testing.

PURPOSE: Conventional techniques for implant metal framework fabrication produce error of a magnitude that is inconsistent with the passive-fit requirement for osseointegrated implants. To understand the correlation between prosthesis fit and the implant-tissue response, evaluation of the interface tissue reactions to customary levels of fit is required. The purpose of this study is to determine the accuracy of torch casting full arch frameworks using a high palladium alloy and a ringless phosphate-bonded investment technique. MATERIALS AND METHODS: Three different variables were considered relative to casting accuracy effect. The first variable, completeness of mold-fill, compared cast specimens where the entire sprue system was filled as part of the casting and cast specimens without the sprue system filled. The second variable, phosphate-bonded investment special liquid concentrations, compared groups of castings produced from 0%, 12%, 25%, and 50% special liquid. The third variable, investment mold shape, compared casting produced from a conventional ringless mold shape with a modified ringless mold shape where the investment in the same horizontal plane as the pattern was equal in thickness at the internal and external surfaces. Horizontal and vertical distances on the wax pattern and resulting framework were measured using a machinists microscope to determine casting error. Combined vertical and horizontal error was used for comparison between groups (one-way analysis of variance). RESULTS: No significant differences existed among the three groups compared (P > 0.05). The mean error comparison between the complete and incomplete mold-fill groups showed no statistical difference, while the incomplete fill group was found to be more porous. The mean error of all groups (0.130 mm) exceeded the recommended level of fit needed to satisfy the passive fit requirement by more than 10-fold. CONCLUSIONS: These results verify clinical observation and suggest that the use of conventional lost wax casting technique to cast one-piece full arch implant frameworks is both imprecise and inaccurate as judged against the passive fit requirement. The consequences of screw-fastening misfitting prostheses to osseointegrated implants is currently under investigation.

Titanium alloy cylinders in implant framework fabrication: a study of the cylinder-alloy interface.

Titanium alloy has been proposed as a suitable alternative to noble metal alloys in premanufactured metal cylinders for fabricating implant prosthesis frameworks. The interfaces produced by standard lost wax procedures that use titanium and conventional noble metal implant cylinders with both high-fusing (high-palladium) and low-fusing (high-gold) noble metal casting alloys were compared. Elemental analysis by scanning electron microscopy and energy-dispersive spectroscopy (SEM/EDS) of the two titanium cylinders revealed that one commercial product had a composition similar to that for commercially pure titanium and the other had a composition consistent with that for Ti-6Al-4V alloy. The SEM observations and complementary elemental line scans indicated that the interfaces between the titanium cylinders and the two noble metal casting alloys did not meet proposed criteria for acceptable metal-to-metal unions. The interfaces between the noble metal cylinders and noble metal casting alloys did exhibit acceptable unions. The SEM observations and elemental analyses were supported by push-shear test results that showed that the resistance to failure was appreciably greater for interface specimens produced with alloy cast to noble metal cylinders compared with titanium cylinders.

The accuracy of implant verification casts compared with casts produced from a rigid transfer coping technique.

PURPOSE: Prosthodontic techniques for implant-supported prostheses continue to evolve in an effort to facilitate treatment and minimize costs. Because research has shown no impression transfer technique to be without error, some clinicians have attempted to control the fit of prosthetic frameworks by reorienting sections of patterns or frameworks intraorally, fabricating a verification cast, and completing the prosthesis to fit such a cast. One manufacturer has attempted to meet both impression-making and verification-cast objectives by providing metallic impression copings (MICS) with extensions that allow contact between the copings for rigid fixation with acrylic resin before impression making. The purpose of this study was to determine the accuracy of casts produced from the MICS transfer process compared with casts produced from sectioned frameworks, where both techniques used a low-polymerization-shrinkage acrylic resin polymer to rigidly join the sections. MATERIALS AND METHODS: Using stainless steel measurement spheres as a reference point on each implant analog, the distances between analogs on the experimental casts were compared with the distances measured on the master cast. Seven casts were produced for each group and measured with a machinist's microscope at a 4-micron level of precision. RESULTS: The results revealed that the MICS transfer exhibited a mean error of 41 microns, which was significantly less than the verification-cast group mean error of 57 microns (p < .01, Student's t test). CONCLUSIONS: Given these results, clinicians can consider the rigid transfer technique as provided in the MICS transfer to be more accurate than the verification technique as outlined in this study.

Hierarchy of research design used to categorize the "strength of evidence" in answering clinical dental questions.

The purpose of this article is to highlight important features of research design that clinicians can use to determine which articles are useful when attempting to answer clinical questions and determine the best therapy for a particular patient. This article offers a systematic means of categorizing the quality of research reports for clinicians and clinical investigators. A recurring clinical theme of hygiene education is used to exemplify how phrasing the clinical question determines the type of study design that could be used. The article describes the continuum of research reports, and categorizes them by their inherent strengths and weaknesses. The report describes why the research designs in the supreme position of the research hierarchy, are the most valuable to clinicians seeking evidence that defines the best therapy for their patients.

Characterization of noble metal implant cylinders: as-received cylinders and cast interfaces with noble metal alloys.

A common procedure in the fabrication of implant prostheses is the use of premade wrought cylinders in cast frameworks. Although manufacturers outline some precautions in the use of these components, detailed information about the metal interface between cylinders and cast alloys is lacking. This article, following a previous report that compared titanium-based implant cylinders used with two different classes of cast alloys, compares conventional noble metal cylinders from three different manufacturers combined with these two classes of cast noble alloys. Analysis of the as-received cylinders revealed that the implant cylinders as a group are predominantly composed of metals commonly found in noble dental alloys, namely, platinum, palladium, gold, and silver. The interfaces created by casting both high-fusing and low-fusing alloys around the cylinders exhibited a general elemental concentration variability compared with the bulk alloy regions, but continuous concentrations for shared elements suggested alloy-cylinder compatibility. Vickers hardness values, which ranged from 212 to 276 for the as-received cylinders, decreased from 12% to 43% for the various cylinders after casting. This study suggests characteristics of an ideal cast interface that include maintenance of the cylinder and casting alloy microstructures up to the interface, absence of interfacial reaction regions, lack of porosity created by volatilization of components from either alloy or the casting process, and sufficient strength to maintain anticipated loads.

The relationship of Periotest values, biomaterial, and torque to failure in adult baboons.

A quantitative measure of implant stability would be beneficial to decision-making regarding the status of the bone anchorage around an implant. The Periotest device has been reported to provide such a measure, but the in vivo data are incomplete and inconclusive in support of this claim. The purpose of this study was to determine in an in vivo model the relationship between Periotest values (PTV), three different implant biomaterials, and torque to failure. A total of 79 screw-shape implants made of commericially pure titanium, titanium alloy, and HA-coated alloy were evaluated in the posterior maxillary and mandibular quadrants of six female baboons following healing for 3 to 4 months. At uncovering, the implants were tested with the Periotest device and torqued to failure using an electronic torque driver. Analysis of the PTV-biomaterial relationship revealed no significant difference among the implants based on the biomaterial (P = .7453). Analysis of PTV-torque revealed a significant relationship (P = .0117), however, the association between PTV and torque was not strong and does not explain 92% of the variation between the parameters (Pearson correlation .2823, R2 = .08).