Evaluation of an advanced oral hygiene regimen on maternity outcomes in a randomized multicenter clinical trial (Oral Hygiene and Maternity Outcomes Multicenter Study).

BACKGROUND: During pregnancy, dental plaque-induced gingivitis prevalence and subsequent risk of periodontal disease increases substantially, as a consequence of both inadequate oral hygiene and changes in sex steroid hormone levels. Although maternal periodontal disease has been associated with adverse pregnancy outcomes, including spontaneous preterm birth, previous clinical trials involving mechanical debridement (eg, scaling and root planing) to remove plaque biofilm have not yielded decreased rates of preterm birth. OBJECTIVE: We hypothesized that an advanced oral hygiene program, including an antibacterial regimen coupled with a power toothbrush and hygiene instruction, may improve the periodontal milieu and reduce the rate of spontaneous preterm birth. Therefore, we conducted a clinical trial of obstetrical patients with moderate-to-severe gingivitis who were randomized to an advanced oral hygiene program vs usual oral hygiene care, and the primary obstetrical outcome compared between the treatment groups was gestational age at delivery. STUDY DESIGN: Obstetrical patients with singleton pregnancies between 8 and 24 weeks' gestation were screened by trained dentists at 2 clinical sites for moderate-to-severe gingivitis (>30 intraoral sites with gingival bleeding on probing). Eligible participants were randomized to an advanced oral hygiene regimen, including antibacterial mouth wash, dental floss, antibacterial toothpaste, a power toothbrush, and intensive oral hygiene education vs standard oral home care instructions and regimen. The primary obstetrical outcome assessed was gestational age at delivery. The overall primary (dental) outcomes were gingival index, bleeding sites, and pocket depth (reported elsewhere). Secondary obstetrical outcomes included birthweight and incidence of preterm birth at <37 weeks' gestation. Regression models were utilized and included factors such as treatment group, gestational age at enrollment, preterm birth history, and potential markers of health disparities (ie, education, employment status). RESULTS: A total of 817 obstetrical patients underwent dental screening at the 2 sites, 789 were identified with moderate-to-severe gingivitis, 746 were randomized, and birth outcomes were available for 613 of the study participants. The gestational age at delivery was 2 days earlier in the control group (P=.040), but the clinical significance of this finding was limited (39.13 vs 38.85 weeks). Overall rates of spontaneous preterm birth <37 weeks and <34 weeks were not statistically different between the 2 treatment groups (7.0% advanced oral hygiene regimen vs 10.3% controls, OR=1.63 (0.90-3.00), P=.11; and 2.3% vs 3.9%, OR=1.88 (0.71-4.98), P=.20, respectively). However, we observed lower rates of spontaneous preterm birth among unemployed participants with less favorable socioeconomic status (4.7% advanced oral hygiene regimen vs 16.0% controls, OR=4.04 (1.34-15.12), P=.01). CONCLUSION: An advanced oral hygiene program may reduce the risk of spontaneous preterm birth among pregnant patients with moderate-to-severe gingivitis and health disparities. This is the same group that may be at highest risk of poor dental hygiene and preterm birth.

A Randomized Controlled Clinical Trial of Prenatal Oral Hygiene Education in Pregnancy-Associated Gingivitis.

INTRODUCTION: Research shows there is a significant increase in gingival inflammation during pregnancy. This study was conducted to determine if an oral health intervention (OHI), including oral hygiene education delivered by nurse-led staff and an advanced over-the-counter (OTC) oral home care regimen, improved gingival inflammation in pregnant women with moderate-to-severe gingivitis compared with a standard oral hygiene control group. METHODS: This was a multicenter, randomized, controlled, single-masked, parallel group clinical trial conducted in obstetrics clinics of 2 medical centers. A total of 750 pregnant women between 8 and 24 weeks of pregnancy with at least 20 natural teeth and moderate-to-severe gingivitis (>30 intraoral bleeding sites) were enrolled. Participants were randomized to either the OHI group, which included oral hygiene instructions supplemented with an educational video and advanced OTC antibacterial/mechanical oral hygiene products, or the control group receiving oral hygiene instructions and standard products. Both groups received oral hygiene instructions from nurse-led staff. Experienced, masked examiners measured whole mouth gingival index (GI) and periodontal probing depths (PDs) at baseline and months 1, 2, and 3. RESULTS: Participants enrolled in this study presented with moderate-to-severe gingivitis at baseline. Both the OHI and control groups exhibited significant reductions in GI (P < .001) and PD (P < .03) from baseline that persisted throughout the study period. The OHI group exhibited modest, yet statistically greater, reductions in GI (P ≤ .044) compared with the control at all time points. The reduction in PD directionally favored the OHI group, but between-group differences were small (<0.03 mm) and not statistically significant (P > .18). DISCUSSION: Significant gingivitis was prevalent among participants in this study and identifies an opportunity to improve gingival health during pregnancy by providing oral health education during the course of prenatal care when coupled with an advanced OTC oral hygiene regimen.

Accurate gingival segmentation from 3D images with artificial intelligence: an animal pilot study.

BACKGROUND: Gingival phenotype plays an important role in dental diagnosis and treatment planning. Traditionally, determining the gingival phenotype is done by manual probing of the gingival soft tissues, an invasive and time-consuming procedure. This study aims to evaluate the feasibility and accuracy of an alternatively novel, non-invasive technology based on the precise 3-dimension (3D) soft tissue reconstruction from intraoral scanning and cone beam computed tomography (CBCT) to predict the gingival biotype. METHODS: As a proof-of-concept, Yorkshire pig mandibles were scanned, and the CBCT data were fed into a deep-learning model to reconstruct the teeth and surrounding bone structure in 3D. By overlaying the CBCT scan with the intraoral scans, an accurate superposition was created and used for virtual measurements of the soft tissue thickness. Meanwhile, gingival thicknesses were also measured by a periodontal probe and digital caliper on the buccal and lingual sides at 3 mm apical to the gingival margin of the posterior teeth and compared with the virtual assessment at the same location. The data obtained from virtual and clinical measurements were compared by Wilcoxon matched-pairs signed-rank analysis, while their correlation was determined by Pearson's r value. The Mann-Whitney U test was used for intergroup comparisons of the amount of difference. RESULTS: Among 108 investigated locations, the clinical and virtual measurements are strongly positively correlated (r = 0.9656, P < 0.0001), and only clinically insignificant differences (0.066 ± 0.223 mm) were observed between the two assessments. There is no difference in the agreement between the virtual and clinical measurements on sexually matured samples (0.087 ± 0.240 mm) and pre-pubertal samples (0.033 ± 0.195 mm). Noticeably, there is a greater agreement between the virtual and clinical measurements at the buccal sites (0.019 ± 0.233 mm) than at the lingual sites (0.116 ± 0.215 mm). CONCLUSION: In summary, the artificial intelligence-based virtual measurement proposed in this work provides an innovative technique potentially for accurately measuring soft tissue thickness using clinical routine 3D imaging systems, which will aid clinicians in generating a more comprehensive diagnosis with less invasive procedures and, in turn, optimize the treatment plans with more predictable outcomes.

Impact of Frontier Development of Alveolar Bone Grafting on Orthodontic Tooth Movement.

Sufficient alveolar bone is a safeguard for achieving desired outcomes in orthodontic treatment. Moving a tooth into an alveolar bony defect may result in a periodontal defect or worse-tooth loss. Therefore, when facing a pathologic situation such as periodontal bone loss, alveolar clefts, long-term tooth loss, trauma, and thin phenotype, bone grafting is often necessary to augment bone for orthodontic treatment purposes. Currently, diverse bone grafts are used in clinical practice, but no single grafting material shows absolutely superior results over the others. All available materials demonstrate pros and cons, most notably donor morbidity and adverse effects on orthodontic treatment. Here, we review newly developed graft materials that are still in the pre-clinical stage, as well as new combinations of existing materials, by highlighting their effects on alveolar bone regeneration and orthodontic tooth movement. In addition, novel manufacturing techniques, such as bioprinting, will be discussed. This mini-review article will provide state-of-the-art information to assist clinicians in selecting grafting material(s) that enhance alveolar bone augmentation while avoiding unfavorable side effects during orthodontic treatment.

En-Mass Retraction of Maxillary Anterior Teeth with Severe Proclination and Root Resorption-A Case Report.

Molar distalization has been a validated method to correct dental sagittal relationships and create space to relieve mild to moderate crowding. In the current case report, an adult female patient had a mild skeletal Class III relationship and dental Class III molar relationship. Four premolars and one lower incisor were extracted during the previous two rounds of orthodontic treatments, and the maxillary anterior teeth were left with severe proclination and root resorption. Limited by the available teeth, extraction was not an option for her. Thus, molar distalization with TADs was the best option used in the treatment to address her chief complaint. In addition, a proper bite opening was performed to eliminate occlusion trauma. Utilizing the mid-palatal TADs, the maxillary central incisors were retracted 7.9 mm and retroclined 33 degrees, and the molar distalization was achieved as much as 8 mm. The cross-section slices of CBCT images confirmed the proper retraction of maxillary incisors and well-positioned roots in the alveolar bone. Moreover, the root resorption was not worsened from the treatment. Clinically, the maxillary anterior teeth were preserved esthetically and functionally. This case report illustrates that with proper diagnosis and treatment mechanics, significant tooth movement can be achieved even on extremely proclined maxillary incisors with severe root resorption.

Maxillary protraction and vertical control utilizing skeletal anchorage for midfacial-maxillary deficiency.

INTRODUCTION: The efficacy and efficiency of early treatment of skeletal Class III patients with facemask therapy are well-documented; however, very few cases for adolescents or adults were reported. OBJECTIVE: The aim of this case report was to demonstrate skeletal and dental correction of a post-pubertal-growth-spurt patient whose malocclusion consisted of a skeletal Class III with slight transverse deficiency, a high mandibular plane angle, and a retrusive maxillary complex. CASE REPORT: A 13-year-5-months old Hispanic female was diagnosed as a retrognathic maxilla and mandible, a high mandibular plane angle, open bite pattern, a bilateral Angle Class I molar relationship with an anterior crossbite on the maxillary lateral incisors. A TAD-supported Haas rapid palatal expander was utilized for maxillary protraction combined with a facemask, vertical control, and maxillary molar distalization with fixed appliance. RESULTS: The total treatment time was 26 months. An improved facial profile with maxillary lip support and more prominent cheeks was established. Adequate vertical control prevented a change in the mandibular plane angle even though facemask treatment can increase the vertical dimension. After the 18-month retention, excellent stability of the treatment results was shown. CONCLUSION: With skeletal anchorage and facemask treatment, orthodontists have the ability of expanding and protracting the maxilla without tipping maxillary molars buccally and without the risk of unfavorable periodontal consequences. A TAD-supported Haas rapid palatal expander allowed to control the vertical dimension and distalize molars, while minimizing undesired consequences.

The Reliability of Two- and Three-Dimensional Cephalometric Measurements: A CBCT Study.

Cephalometry is a standard diagnostic tool in orthodontic and orthognathic surgery fields. However, built-in magnification from the cephalometric machine produces double images from left- and right-side craniofacial structures on the film, which poses difficulty for accurate cephalometric tracing and measurements. The cone-beam computed tomography (CBCT) images not only allow three-dimensional (3D) analysis, but also enable the extraction of two-dimensional (2D) images without magnification. To evaluate the most reliable cephalometric analysis method, we extracted 2D lateral cephalometric images with and without magnification from twenty full-cranium CBCT datasets; images were extracted with magnification to mimic traditional lateral cephalograms. Cephalometric tracings were performed on the two types of extracted 2D lateral cephalograms and on the reconstructed 3D full cranium images by two examiners. The intra- and inter-examiner intraclass correlation coefficients (ICC) were compared between linear and angular parameters, as well as between CBCT datasets of adults and children. Our results showed that overall, tracing on 2D cephalometric images without magnification increased intra- and inter-examiner reliability, while 3D tracing reduced inter-examiner reliability. Angular parameters and children's images had the lowest inter- and intra-examiner ICCs compared with adult samples and linear parameters. In summary, using lateral cephalograms extracted from CBCT without magnification for tracing/analysis increased reliability. Special attention is needed when analyzing young patients' images and measuring angular parameters.

Genes and Pathways Associated with Skeletal Sagittal Malocclusions: A Systematic Review.

Skeletal class II and III malocclusions are craniofacial disorders that negatively impact people's quality of life worldwide. Unfortunately, the growth patterns of skeletal malocclusions and their clinical correction prognoses are difficult to predict largely due to lack of knowledge of their precise etiology. Inspired by the strong inheritance pattern of a specific type of skeletal malocclusion, previous genome-wide association studies (GWAS) were reanalyzed, resulting in the identification of 19 skeletal class II malocclusion-associated and 53 skeletal class III malocclusion-associated genes. Functional enrichment of these genes created a signal pathway atlas in which most of the genes were associated with bone and cartilage growth and development, as expected, while some were characterized by functions related to skeletal muscle maturation and construction. Interestingly, several genes and enriched pathways are involved in both skeletal class II and III malocclusions, indicating the key regulatory effects of these genes and pathways in craniofacial development. There is no doubt that further investigation is necessary to validate these recognized genes' and pathways' specific function(s) related to maxillary and mandibular development. In summary, this systematic review provides initial insight on developing novel gene-based treatment strategies for skeletal malocclusions and paves the path for precision medicine where dental care providers can make an accurate prediction of the craniofacial growth of an individual patient based on his/her genetic profile.

Imaging in Orthodontics.

Imaging in orthodontics has evolved from cephalometric and extraoral films, manual cephalometric tracings, to digital imaging and intraoral scanners. Software-assisted cephalometric tracings and three-dimensional image analysis have become routine in orthodontic diagnosis and treatment planning. Determination of biologic boundaries of orthodontic treatment and evaluation of temporomandibular joints and airway became part of orthodontic assessment. Use of advanced imaging and software to digitally plan the orthognathic surgery and accurately predict a successful outcome are now integral to orthodontic practice. This article discusses radiographic methods used in cephalometric analysis and craniofacial growth and development for a predictable orthodontic assessment and treatment planning.

A cone-beam computed tomographic evaluation of alveolar bone dimensional changes and the periodontal limits of mandibular incisor advancement in skeletal Class II patients.

OBJECTIVES: To evaluate the presence of dehiscences and changes in alveolar bone height and width in the area of the mandibular central incisors pre- and post-orthodontic treatment. MATERIALS AND METHODS: In 60 skeletal Class II patients, cone-beam computed tomographic (CBCT) images were obtained and the patients were divided into four groups based on the presence of dehiscences at pre- and post-orthodontic treatment. The alveolar bone height and width were measured on CBCT in cross section along the long axis of the teeth. Lateral cephalograms were analyzed. RESULTS: The changes in L1-NB and IMPA appeared to be correlated with vertical bone loss and dehiscence. Alveolar bone height appeared to follow a segmented relationship with these two variables, with changes below a threshold (L1-NB = 0.71 mm, IMPA = 3.02°) having relatively minimal or no effect on bone loss but with changes beyond the threshold correlated with extensive bone loss. Similarly, increases in L1-NB or IMPA correlated with decreases in alveolar bone width (L1-NB: -0.25 mm/mm, IMPA: -0.07 mm/°) and increased the probability of developing dehiscences, with an estimated 50% probability of vertical bone loss at a L1-NB change of 2.00 mm or, equivalently, an IMPA change of 8.02° was estimated. CONCLUSIONS: When treating skeletal Class II patients, the limits of incisor proclination/protraction are less than previously thought. To prevent undesired periodontal outcomes, careful three-dimensional diagnosis is advisable. Furthermore, when excessive protrusion and/or proclination is planned, additional treatment modalities, including orthognathic surgery, tooth extraction, and corticotomy with bone graft, should be considered.

Association of a common genetic factor, PTGER3, with outcome of periodontal therapy and preterm birth.

BACKGROUND: Clinical evidence suggests an association between preterm birth and periodontal disease. This study explores whether specific genetic polymorphisms are associated with success of periodontal therapy in pregnant women with periodontal disease and, further, whether any of these same polymorphisms are also associated with spontaneous preterm birth (sPTB). METHODS: One hundred sixty high-risk pregnant women (6 to 20 weeks of gestation) with periodontal disease (≥ 3 sites with attachment loss ≥ 4 mm) were studied. All women received scaling and root planing plus oral hygiene instruction. Periodontal examinations were performed before treatment and 20 weeks later. Participants were classified according to two study outcomes: 1) success or failure of periodontal treatment; and 2) presence or absence of sPTB. Maternal DNA samples from mucosal swabs were characterized using a 1536-SNP (single-nucleotide polymorphism) custom polymerase chain reaction chip. A probabilistic model of each dichotomous outcome, derived using a stepwise Bayesian procedure, was compared to respective null hypotheses on the basis of Monte Carlo simulations and significance estimates obtained using three measures (z-test, Welch t-test, and probability convolution). The models were further confirmed by logistic regression analyses. RESULTS: The models revealed a significant relation between a specific polymorphism of prostaglandin E receptor 3 (a gene associated with inflammatory response) and both periodontal treatment failure (odds ratio 11.09, P <0.0002) and sPTB (odds ratio 6.89, P < 0.0032). CONCLUSIONS: These results demonstrate that the risk of unsuccessful periodontal treatment is associated with tag SNPs in specific genes that regulate the inflammatory response, one of which is also associated with sPTB.

Friction between various self-ligating brackets and archwire couples during sliding mechanics.

INTRODUCTION: The aim of this study was to evaluate the frictional resistance between active and passive self-ligating brackets and 0.019 × 0.025-in stainless steel archwire during sliding mechanics by using an orthodontic sliding simulation device. METHODS: Maxillary right first premolar active self-ligating brackets In-Ovation R, In-Ovation C (both, GAC International, Bohemia, NY), and SPEED (Strite Industries, Cambridge, Ontario, Canada), and passive self-ligating brackets SmartClip (3M Unitek, Monrovia, Calif), Synergy R (Rocky Mountain Orthodontics, Denver, Colo), and Damon 3mx (Ormco, Orange, Calif) with 0.022-in slots were used. Frictional force was measured by using an orthodontic sliding simulation device attached to a universal testing machine. Each bracket-archwire combination was tested 30 times at 0° angulation relative to the sliding direction. Statistical comparisons were performed with 1-way analysis of variance (ANOVA) followed by Dunn multiple comparisons. The level of statistical significance was set at P <0.05. RESULTS: The Damon 3mx brackets had significantly the lowest mean static frictional force (8.6 g). The highest mean static frictional force was shown by the SPEED brackets (83.1 g). The other brackets were ranked as follows, from highest to lowest, In-Ovation R, In-Ovation C, SmartClip, and Synergy R. The mean static frictional forces were all statistically different. The ranking of the kinetic frictional forces of bracket-archwire combinations was the same as that for static frictional forces. All bracket-archwire combinations showed significantly different kinetic frictional forces except SmartClip and In-Ovation C, which were not significantly different from each other. CONCLUSIONS: Passive self-ligating brackets have lower static and kinetic frictional resistance than do active self-ligating brackets with 0.019 × 0.025-in stainless steel wire.