[Mental disorders in the dental practice. Substance use disorders]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Middelgerelateerde stoornissen.

When addictive substances are used excessively and a person continues to use them despite the fact this causes problems, this is called substance use disorder. Despite the large scale of the problem, it occurs largely invisibly. However, it has many negative consequences for physical and psychological health, the surroundings (including family, friends, work) and society. Genetic and environmental factors play a role in the origin and continuation of substance use disorders. In many cases, these disorders affect oral health, personal care and treatability. Oral healthcare professionals can play an important role in identifying substance use disorders, in encouraging those with problematic substance use to seek professional help and as an essential step in treatment and recovery.

[To sedate or to confront? Sedation in adult dental treatment]. / Sederen of confronteren? Sedatie bij de tandheelkundige behandeling van volwassenen.

When patients are unable to undergo diagnostics or treatments for various reasons, sedation can be applied. A psychological approach and/or non-pharmacological sedation is preferred. When this is not possible, pharmacological sedation may be considered. In principle, the level of sedation applied, will be no deeper than is necessary for the patient to undergo the treatment and for the practitioner to be able to perform the treatment. Sedation is aimed at reducing agitation, anxiety, and/or lowering consciousness. However, it is not a pain treatment. Pain treatment will therefore always require adequate local anaesthesia. This article highlights the different levels of sedation, areas of indication, and sedatives used in dentistry. The application of pharmacological sedation will always have to be considered for each individual situation, within a total treatment plan that is aimed at lastingly increasing treatability.

[Mental disorders in a dental practice. Patients with mental disorders in the dental practice - an introduction]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Patiënten met psychische aandoeningen in de tandartspraktijk ­ een inleiding.

Given the high prevalence of mental disorders and the consequences that sometimes arise from this for oral health or the treatability of the patient, it is important for oral care professionals to have some basic knowledge of these disorders. This introductory article examines mental disorders in general, their classification according to the most widely used manual of mental disorders (the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5) and some relevant differences in classification and designation from the previous edition of the DSM.

[Mental disorders in the dental practice. Patients with body dysmorphic disorder]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Patiënten met een morfodysfore stoornis.

Oral healthcare professionals are frequently consulted by patients who are dissatisfied with their teeth and/or facial looks. Sometimes, this dissatisfaction takes a pathological form. When someone is preoccupied with a (supposed) abnormality barely or not visible to others, performs certain actions in response to the concerns about their appearance and experiences significant suffering, this may be a case of body dysmorphic disorder. Its prevalence is 0.7-2.4% in the general population, but significantly higher in clinics where cosmetic or orthognathic procedures are performed (10-15%). Procedures aimed at improving the abnormality experienced by the patient rarely lead to a reduction of the symptoms, but more often result in more dissatisfaction and complaints towards the practitioner. It is difficult for practitioners to recognise this condition. An overview of characteristics, co-morbidity and consequences of body dysmorphic disorder for oral health and treatment will result in increased awareness of this condition among oral care providers.

[Series: Communication in the dental practice. Dealing with anxiety in the dental office]. / Serie: Communicatie in de tandartspraktijk. Omgaan met angst in de tandartspraktijk.

Dentists frequently have to deal with anxious children and adults. Whether these patients can be treated successfully in a regular dental office depends on the type of fear and its severity. Proper diagnostic procedures are therefore paramount. This article gives an overview of how dental fear develops, is sustained, and can be treated. It elaborates on the communication skills important in reducing anxiety and preventing children from developing dental fear.

[Dental treatment of fearful children: subjection, denyal or -guidance?] / Tandheelkundige behandeling van angstige kinderen: belijden, vermijden of begeleiden?

Dental treatment anxiety is a common fear among children. The dental health care provider is faced with difficult dilemmas about ensuring good oral health for these children in general daily practice. The indicated treatment usually exceeds the capacity of the frightened child, but when treatment is not performed, the child is at risk of serious general health problems and its quality of life could diminish. This article provides an overview of the aetiology of dental treatment anxiety in children. In addition, the dental practitioner is provided with insight into the possibilities that allow him/her to enhance the treatability of the child and reduce anxiety to such an extent that the indicated dental care can be provided. Psychotherapy and cognitive-behavioural techniques, as well as pharmacological therapies, are currently considered the most acceptable and successful treatments for anxiety and phobia. The dental care provider will have to determine a well-motivated and carefully considered course of treatment, always keeping in mind the individual context of the child.

Gagging Problem Assessment: a re-evaluation.

The Gagging Problem Assessment (GPA) is an instrument to evaluate dental gagging. Although the GPA seemed to be reliable and valid in a pilot study, a replication study with more subjects was needed. Based on the pilot study, the number of items was reduced, resulting in the revised version of the GPA (GPA-R). The aims of this study were to replicate the reliability of the GPA-R and to investigate the correlation between dental gagging and general anxiety. Dental gagging patients (n = 59) were compared with a control group (n = 17) at t0 and 3 weeks later. The 'gagging group' also filled in the SCL-90 anxiety scale. Gagging-specific homogenous domains and internal consistency were determined. Stability and distinguishing capacity of the GPA-R were assessed. SCL-90-Anxiety scores were compared with standard values in a non-clinical population. The GPA-R patient part was able to reliably discriminate between the absence or the presence of dental gagging. However, the reliability of the GPA-R-dentist part was insufficient. The GPA-R seems to be sensitive to subtle differences in acts of the dentists. To overcome these problems, more detailed and explicit instructions on how to use the GPA-R should be formulated and more specific gagging stimuli should be included. The 'gagging group' reported 'fear of choking' significantly more often than the control group (P = 0·008). This finding might be important for the treatment of dental gagging. Considering the outcome of our study, development of a new diagnostic gagging tool needs another approach that focuses on gagging severity.

[Administration of intravenous sedation with midazolam by dentists is unsafe]. / Toediening van intraveneuze sedatie met midazolam door tandarts is onveilig.

In the December issue of the Nederlands Tijdschrift voor Tandheelkunde (Dutch Journal of Dentistry) in 2014, an article was devoted to the use of light sedation with midazolam by dentists. A number of dentists who are active in the area of Special Dentistry (anxiety management, care of the disabled) and a anesthesiologist offer a response to the article and argue that the administration of intravenous sedation with midazolam by dentists is unsafe.

Matrix metalloproteinase inhibitors reduce collagen gel contraction and alpha-smooth muscle actin expression by periodontal ligament cells.

BACKGROUND AND OBJECTIVE: Orthodontic tooth movement requires remodeling of the periodontal tissues. The matrix metalloproteinases (MMPs) degrade the extracellular matrix components of the periodontal ligament, while the tissue inhibitors of metalloproteinases (TIMPs) control their activity. Synthetic MMP inhibitors have been developed to inhibit MMP activity. In this study, periodontal ligament cells in contracting collagen gels served as a model for enhanced periodontal remodeling. The effect of MMP inhibitors on gel contraction and on MMP and TIMP expression was analyzed. MATERIAL AND METHODS: Human periodontal ligament cells were cultured in three-dimensional collagen gels and incubated with the MMP inhibitors BB94, CMT-3, doxycycline and Ilomastat. Gel contraction was determined using consecutive photographs. The relative amounts of MMPs and TIMPs were analyzed using substrate zymography and mRNA expression using quantitative polyermase chain reaction. RESULTS: All MMP inhibitors reduced MMP activity to about 20% of the control activity. They all reduced contraction, but CMT-3 and doxycycline had the strongest effect. These inhibitors also reduced MMP-2, MMP-3 and alpha-smooth muscle actin mRNA expression. The expression of MMP-1 mRNA seemed to be increased by CMT-3. No effects were found on the amounts of MMPs and TIMPs. CONCLUSION: Synthetic MMP inhibitors strongly reduced gel contraction by periodontal ligament cells. This was primarily caused by an inhibitory effect on MMP activity, which reduces matrix remodeling. In addition, alpha-smooth muscle actin expression was reduced by CMT-3 and doxycycline, which limits the contractile activity of the fibroblasts.

Matrix metalloproteinases and tissue inhibitors of metalloproteinases in gingival crevicular fluid during orthodontic tooth movement.

Orthodontic tooth movement requires extensive re-modelling of the periodontium. Matrix metalloproteinases (MMPs) degrade the extracellular matrix during re-modelling, while their activity is regulated by the tissue inhibitors of metalloproteinases (TIMPs). The aim of this study was to investigate differences in MMP and TIMP levels in the gingival crevicular fluid (GCF) at the resorption and apposition sides of orthodontically moved teeth, and to compare these with control teeth. GCF samples were collected from eight orthodontic patients wearing fixed appliances with superelastic nickel-titanium coil springs. The samples were analysed by gelatin zymography, which allows detection of both active and latent MMPs, and reverse zymography for analysis of TIMPs. Western blotting was performed to confirm the identity of MMPs. The data were analysed using either the one-way analysis of variance or the Kruskal-Wallis test. In general, higher levels of MMPs and TIMPs were found at both the resorption and apposition sides compared with the control teeth. Remarkably, partially active MMP-1 was found in GCF from both the resorption and the apposition side but was barely present at the control teeth. TIMP-1 was strongly increased at the apposition side. Gelatinases were mainly present at the resorption side, while gelatinolytic fragments were exclusively detected at the apposition side. MMP-9, which is known to be involved in bone degradation, and a 48 kDa gelatinase were increased at the resorption side. The small increase in TIMP-1 at the resorption side might stimulate bone resorption, whereas the large increase at the apposition side reduces bone resorption. The analysis of MMPs and TIMPs may contribute to the improvement of orthodontic treatment regimens.

Relaxin stimulates MMP-2 and alpha-smooth muscle actin expression by human periodontal ligament cells.

The main cells in the periodontal ligament (PDL) are the fibroblasts, which play an important role in periodontal remodelling. Matrix metalloproteinases (MMPs) are largely responsible for the degradation of extracellular matrix proteins in the PDL. Previous studies have indicated that MMP production can be stimulated by the hormone relaxin. This hormone facilitates delivery by softening the connective tissues of the reproductive tract, and it prepares the mammary gland for lactation. Periodontal remodelling takes place during orthodontic tooth movement, which might be enhanced by relaxin. Therefore, we investigated the effects of relaxin on gelatinase expression of human PDL cells. Cultures of human PDL cells were incubated with relaxin. Gelatinase (MMP-2 and -9) expression, alpha-smooth muscle actin expression (alpha-SMA), total MMP activity and DNA content were measured. Both proMMP-2 and active MMP-2 was identified in the cultures. There was a clear trend showing a dose-dependent increase of MMP-2 production, which was significant at 250 ng/ml. Total MMP activity was not affected. A stimulation of alpha-SMA expression was found at 50 ng/ml. The results indicate that relaxin activates human PDL cells by the stimulation of MMP-2 and alpha-smooth muscle actin.

CMT-3 inhibits orthodontic tooth displacement in the rat.

OBJECTIVE: Orthodontic tooth movement requires extensive remodeling of the periodontal ligament (PDL) and the alveolar bone. Osteoclasts resorb bone, allowing teeth to migrate in the direction of the force. Matrix metalloproteinases (MMPs) are able to degrade the extracellular matrix of the periodontal tissues. Chemically modified tetracyclines (CMTs) can inhibit MMPs, but lack antimicrobial activity. We hypothesize that CMT-3 will decrease the rate of orthodontic tooth movement in the rat. DESIGN: Eighteen Wistar rats received a standardized orthodontic appliance at one side of the maxilla. During 14 days, three groups of six rats received a daily dose of 0, 6 or 30mg/kg CMT-3, and tooth displacement was measured. Thereafter, osteoclasts were counted on histological sections using an ED-1 staining. Multi- and mononuclear ED-1-positive cells in the PDL were also counted. In addition, sections were stained for MMP-9. RESULTS: CMT-3 significantly inhibited tooth movement (p=0.03) and also decreased the number of osteoclasts at the compression sides in the 30mg/kg group (p<0.05). Significantly more mono- than multinuclear ED-1-positive cells were present in the PDL, but no significant differences were found between the dosage groups. Osteoclasts in the 30mg/kg group seemed to contain less MMP-9 than in the control. CONCLUSIONS: CMT-3 inhibits tooth movement in the rat, probably by reducing the number of osteoclasts at the compression side. This might be due to induction of apoptosis in activated osteoclasts or reduced osteoclast migration. Reduced MMP activity by CMT-3 might also directly inhibit degradation of the organic bone matrix.

Chemically modified tetracyclines stimulate matrix metalloproteinase-2 production by periodontal ligament cells.

BACKGROUND AND OBJECTIVE: The purpose of this study was to investigate the effects of chemically modified tetracyclines (CMTs) on the production of gelatinases [matrix metalloproteinase (MMP)-2 and -9] by human periodontal ligament (PDL) cells, and on the activity of recombinant gelatinases. MATERIAL AND METHODS: Human PDL cells were cultured with CMT-1, -3, -5, -7 or -8 in concentrations of 0, 1, 5, 10, 20, 50, 100, 200 and 500 microm. Gelatin zymography was used to determine MMP-2 and -9 production of the cells. The amount of DNA present in the cultures was analyzed using a fluorescent assay. The cytotoxicity of the CMTs was also determined. Recombinant human MMP-2 and -9 were incubated with the CMTs (0-500 microm) and their activity was analyzed using an internally quenched fluorogenic substrate. RESULTS: MMP-2 production was stimulated up to sevenfold by CMT-1, -3, -7 and -8 at low concentrations (10-200 microm). No significant amounts of MMP-9 were produced. In contrast, MMP-2 and -9 activity was reduced by approximately 10-40-fold at higher concentrations (200-500 microm). CMT-5 had no effect on the production or on the activity of MMP-2 and -9. Only CMT-3 and -8 had cytotoxic effects on the PDL cells at the highest concentrations. CONCLUSION: Surprisingly, CMTs are able to stimulate MMP-2 production at relatively low concentrations. However, at higher concentrations they exert a much stronger inhibitory effect on gelatinase activity. A possible stimulatory effect of CMTs on MMP production should be considered in their clinical use.