Metal piercing through the tongue and localized loss of attachment: a case report.

The piercing of intraoral structures to accommodate different types of jewelry has increased in popularity in the last few years. The association of an intraoral piercing with localized periodontitis is not well documented in the literature. A 22-year-old male presented to our clinic with a tongue stud placed through the mid-dorsum of his tongue. The inferior sphere was coated with plaque and calculus. Teeth #24 and #25 exhibited 6 mm interproximal probing depth and recession, horizontal radiographic bone loss, and tissue indentations consistent with the shape of the inferior ball of the tongue stud directly on the lingual surfaces of both teeth. The treatment consisted of an adult prophylaxis, flap curettage of the mandibular anterior region, oral hygiene instructions, and removal of the tongue stud. At our follow-up visit, the patient's oral hygiene had improved, he has removed the jewelry, and the attachment loss appears to have stabilized.

A multicenter 12-month evaluation of single-tooth implants restored 3 weeks after 1-stage surgery.

The time-intensive, multi-step process of dental implant therapy limits patient acceptance. This 3-year prospective multicenter study sought to determine the safety of an expedited therapy that consisted of loading unsplinted maxillary anterior single-tooth implants 3 weeks after 1-stage surgical placement, and determination of the peri-implant cortical bone and mucosal responses to the expedited procedure. Fifty-two patients missing 1 or 2 maxilliary anterior teeth were enrolled in a study approved by the Institutional Committee on Human Subjects Research and based on strict inclusion and exclusion criteria. Astra Tech ST implants placed in a 1-stage procedure were restored 3 weeks later with ST abutments and a provisional crown (baseline); 7 to 9 weeks later, a porcelain-fused-to-metal or all-ceramic crown was cemented. Radiographic and clinical examinations were made at baseline and at 6 and 12 months. Implant survival was recorded. Cortical bone responses and peri-implant mucosal responses were evaluated. Fifty-eight implants were placed. During the 3-week period after implant placement, 4 patients were dismissed because of smoking cigarettes (a protocol deviation), and 1 patient was excluded because of deviation in loading time. Of the remaining 53 implants, 2 failed before definitive crown cementation. The resultant 96.2% survival rate was independent of implant length, tooth position, and bone quality/quantity. The mean change in marginal bone level was 0.4 mm at 12 months. The number of surfaces with plaque decreased from 3.4% at baseline to 0.5% at 12 months. The surfaces with inflammation also decreased. A mean gain in papilla length of 0.61 mm occurred, and a gain in buccal gingiva (x = 0.34 mm) was observed. A high success rate with positive tissue responses was achieved for maxillary anterior unsplinted single-tooth implants placed in a 1-stage surgery and restored at 3 weeks. This 2-component system is suited to a single-stage, rapid loading protocol for esthetic single-tooth replacement.

Treatment of edentulism using Astra Tech implants and ball abutments to retain mandibular overdentures.

The goal of this study was to provide evidence to support simplified treatment of mandibular edentulism using denture fabrication and implant placement to circumvent the need for second-stage surgeries or prosthodontic superstructures. A 5-year prospective clinical trial is reported, which involved treatment of mandibular edentulism using the single-stage surgical placement of a TiOblast microthreaded titanium screw implant with immediate replacement of a relieved mandibular overdenture and eventual retention of the overdenture with reduced ball abutments. Fifty-eight patients were treated; 116 implants were placed using a single-stage surgical approach, with a duplicate mandibular denture as the tomographic/surgical template. Mandibular dentures were relieved and relined with a tissue conditioning material and placed immediately after implant surgery. After 3 months, Conical Seal Design ball abutments were placed and attachments were secured in the overdentures by heat-polymerizing laboratory reline methods. Five of the 116 consecutively placed implants failed at 2 to 4 months, providing an immediate implant survival rate of 95.69% at the time of attachment connection. Pain and inflammation were not common to all failures, and infection was not reported in any of the 5 failures. The immediate placement of implants by a single-stage surgical procedure in the parasymphyseal region of the mandible, followed by placement of a relined mandibular denture, results in predictable and asymptomatic healing of implants that display the clinical and radiographic features of osseointegration. Encouraging results at the immediate observation period (attachment connection) must be tempered by the need for prudent and detailed clinical and radiologic evaluation over the 5-year trial period.

The clinical, microbial, and host response characteristics of the failing implant.

The goal of this study was to provide new data regarding levels of inflammatory and growth factor mediators and bacterial pathogens associated with failing implants, as compared to healthy implants. Twenty-one patients with failing implant sites (group 1) and 8 patients with only healthy implants (group 2) were included. Fifteen of the 21 failing implant patients (group 1) also presented with at least one stable nondiseased implant. Plaque samples were examined, using DNA oligonucleotide probes for 40 different microbes. Gingival crevicular fluid samples were collected for the analyses of catabolic bone resorbing agonists prostaglandin E2 (PGE2), interleukin-1 beta (IL-1 beta) and IL-6 and anabolic bone-forming growth factors transforming growth factor beta (TGF-beta) and platelet-derived growth factor (PDGF). Although positive trends were noted, there were no significant differences in any of the microbial, inflammatory, or growth factors mediators comparing failing to stable implants in group 1. This study found greater detection frequencies of P. nigrescens, P. micros, F. nucleatum ss vincentii, and F. nucleatum ss nucleatum, as well as significant elevations in GCF levels of PGE2, IL-1 beta, and PDGF in mouths with failing implant sites as compared to mouths with healthy control implants. Risk appears to be primarily at a patient level and secondarily at a site or implant level from a clinical, microbial (P. micros and P. nigrescens), and biochemical (PGE2 and IL-1 beta) perspective. Furthermore, the counts of P. nigrescens and P. micros were found to correlate with concentrations of PGE2 at a site level.

Mucogingival considerations for the orthodontic patient.

Recession of the gingival margin during or subsequent to orthodontic therapy may occur as either pseudorecession or true recession. Assessment of both predisposing and possible precipitating factors will assist in evaluating the need for surgical intervention. Unfortunately, several parameters cannot be evaluated by objective measures. The clinician must address both objective and subjective criteria. Factors predisposing a site to recession are elucidated by evaluating the anatomy of the area, including the width of keratinized and attached gingiva, the facial-to-lingual dimension of both soft tissue and alveolus, and the position and angulation of the teeth in question. Marginal inflammation must be controlled to define the mucogingival junction necessary for these anatomic evaluations. Precipitating factors relate to the amount of trauma imposed on the marginal tissues. A definition of trauma would vary from direct trauma such as laceration to plaque-derived inflammation. Treatment that affects either trauma or the anatomy could enhance or reduce the potential for recession. Because the situation is dynamic, multiple evaluations are needed. If an area is to be observed, the presence of adequate donor and recipient sites for root coverage grafting techniques should be assessed to determine the potential for successful grafting in the event recession occurs.

Evaluation of the use of orthodontic records to measure the width of keratinized tissue.

Understanding the gingival tissue response in patients undergoing orthodontic treatment requires accurate pretreatment measurements of the width of the attached and keratinized tissue. Even though these may not be routinely recorded, it has been suggested that the orthodontic records can provide an accurate method of assessing the pretreatment keratinized tissue width. This clinical study was conducted to compare measures of the width of the keratinized tissue calculated from intraoral photographs and study models with direct clinical measures. Maxillary and mandibular study models and intraoral photographs were obtained from 33 patients. The width of the keratinized gingiva facial to the mandibular incisors was measured on two occasions to the nearest 0.5 mm. The width of the gingiva was calculated for the same teeth from two measures taken from projected photographic slides and the study models using a modification of Coatoam's technique. The method error was determined to be 0.43 mm for clinical measures and 0.32 mm for the calculated gingival tissue width. The reliability of measurement from orthodontic records was slightly greater than direct clinical measurement, with intraclass correlations of 0.93 and 0.90, respectively. The differences between the averaged clinical measure and averaged calculated measure for each tooth were small and not statistically significant (paired t-test, P = 0.21, 0.66, 0.24, 0.24 for teeth 23 through 26 respectively). The results indicate that carefully taken photographic slides and study models can provide an accurate measure of keratinized tissue width.

Effectiveness of a calculus scaling gel.

This study evaluated the effect of a calculus scaling gel (SofScale) on time and ease of the scaling procedure in a double-blind, split-mouth clinical study of 32 subjects. The Volpe-Manhold calculus index was used to quantify the distribution and amount of calculus deposition on the lingual aspect of the mandibular 6 anterior teeth at baseline. The gel was applied directly to the calculus and subgingivally to the area to be scaled. Pre- and post-treatment gingival and stain indices were taken. Operator and subject questionnaires were completed immediately after treatment to determine ease of the scaling procedure. Results were analyzed with paired t-tests. The time difference in scaling between the product and placebo side was not significant. This study found that SofScale is safe to gingival tissues and does not promote tooth sensitivity. However, this study did not find significant differences in scaling time between product and placebo when using a 2-minute gel contact time.

Closed versus open debridement of facial grade II molar furcations.

Clinical responses of facial grade II molar furcations to closed (C) versus open (O) debridement were evaluated. 25 teeth were treated at baseline (BL) with scaling/root planning (S/RP) and evaluated at 4 months. 12 of the teeth were then treated with open flap debridement and the remaining teeth were treated with further S/RP. Clinical parameters of plaque, gingival inflammation, bleeding on probing, gingival fluid flow, pocket depth and probing attachment level were taken at BL, 4, 7, 10, 13 and 16 months. Pairwise differences were determined between visits and a t-test was applied to differences for C and O. For both treatment groups, the greatest changes in clinical parameters occurred from BL - 4 months. Plaque and gingival inflammation showed a gradual reduction from BL throughout the study for both groups. A reduction in pocket depth from BL - 16 months was noted in both groups (mid-furcal, C = 1.5 mm, O = 1.2 mm; root prominence, C = 1.02 mm, O = 0.84 mm)! There was a gain in probing attachment level in the midfurcal area for the C group (0.6 mm) while the O group lost (-0.46 mm). There were no statistically significant differences found for any clinical parameter between closed and open debridement. The presence of plaque and bleeding at a furcal site had not significant effect on treatment response.

The effects of scaling a titanium implant surface with metal and plastic instruments: an in vitro study.

The surface roughnesses of pure titanium implants were compared with scaling in vitro with curettes of dissimilar composition. Each of 10 transmucosal implant extensions (TIEs) was divided into three experimental surfaces and an untreated control surface. The three experimental surfaces were instrumented with either a titanium-alloy tipped curette, a curette of stainless steel, or a plastic curette. All experimental surfaces received 30 strokes with the designated curette within a 2 mm wide area. Alteration of the surfaces due to instrumentation was evaluated by a helium neon (HeNe) laser and reported as relative specular reflectance (RSR). Scanning electron microscopy (SEM) conformed the quantitative HeNe laser results. A significant decrease in mean RSR (greater roughness) was observed for surfaces treated by metal curettes compared to either untreated control surfaces (P less than 0.01) or surfaces treated by the plastic curette (P less than 0.01). No statistically significant difference was noted between untreated surfaces and those treated by the plastic curette. The titanium-alloy curette produced a significantly lower mean RSR (greater roughness) compared to those surfaces treated by the stainless steel curette (P less than 0.05). In summary, plastic instruments produced an insignificant alteration of the titanium implant surface following instrumentation, while metal instruments significantly altered the titanium surface.

The effects of scaling titanium implant surfaces with metal and plastic instruments on cell attachment.

This study examined the ability of tissue culture fibroblasts to attach and colonize on the surface of pure titanium dental implants following instrumentation of the implant surface with curettes of dissimilar composition. Pure titanium dental implants were scaled with a plastic, titanium-alloy, or stainless steel curette and then immersed in a cell suspension of 3T3 fibroblasts. Counts of attached cells were made at 24 and 72 hours; the implants were then processed for scanning electron microscopy (SEM). At 24 hours, only surfaces scaled with a stainless steel curette showed a significant reduction in number of attached cells relative to untreated control surfaces. At 72 hours, both stainless steel and titanium-alloy curette instrumented surfaces showed significantly fewer attached cells than untreated control surfaces, with the greatest reduction in cell attachment observed on the stainless steel curette instrumented surfaces. SEM observations showed that fibroblasts on stainless steel instrumented surfaces tended to show a somewhat rounded morphology and a relatively reduced degree of spreading: while fibroblasts on untreated control, plastic, or titanium-alloy instrumented surfaces showed a well-spread, polygonal morphology, more typical of fibroblasts in favorable culture conditions. To the extent that such observations of cell attachment and morphology are indicative of in vivo biocompatibility, these findings could have clinical implications for the proper maintenance of titanium dental implants.

Histological evaluation of periodontal probe penetration in untreated facial molar furcations.

The purpose of this investigation was to histologically determine the position of the periodontal probe tip when probing the deepest interradicular pocket depth in grade II and III facial molar furcation sites. Facial furcation pockets (5.8 mm +/- 1.3) were probed with a pressure-sensitive probe set at 50 g pressure. The probe tip was attached to the tooth with an acid etched composite resin. Surgical block biopsies were removed, fixed, decalcified and processed for histological sectioning. Buccolingual serial sections (6 mu) were cut from 9 biopsies and apicocoronal serial sections were cut from 3 biopsies. The sections were histometrically analyzed. The probe tip penetrated the inflamed furcation connective tissue an average depth of 2.1 mm (+/- 0.6). The probe tip was located 0.4 mm (+/- 1.4) apical to the crest of the interradicular bone. The % of inflammatory cell infiltrate in the connective tissue (ICT) around the probe tip was 56% (+/- 15%). There was no correlation between the % of ICT and the depth of probe penetration. This investigation demonstrated that probing of untreated facial molar furcation sites does not measure the attachment level of the interradicular root surfaces, but rather records the depth of probe penetration into the inflamed furcation connective tissue.

Inter-examiner reproducibility of probing pocket depths in molar furcation sites.

This investigation was designed to determine the reproducibility of probing pocket depths in maxillary facial and mandibular facial and lingual grade II and III molar furcation sites. 80 untreated molar teeth with 102 furcation invasions due to periodontitis were probed with a pressure-sensitive periodontal probe by 3 examiners. 8 sites per furcation were measured by each examiner at a single examination. The sequence of examiner probing was rotated in order to evaluate the effect of sequential probing. Tracings were made from radiographs of the inter-root separations in order to classify the interradicular space and to determine the effect of root separation on reproducibility. Data was analyzed by regression analysis. Pearson correlations, intraclass correlations, and the Student-Newman-Keuls test. Analysis indicated a high reproducibility of the maxillary facial and mandibular facial and lingual furcation sites in this untreated adult sample. No effect was due to probing sequence. The mid-root prominences, the line angles, and the internal surface sites of the furcation roots were recordable and reproducible, while the horizontal measurements were not consistently recordable. The reproducibility of the facial and lingual furcation sites that were probed decreased with an increase in probing pocket depth and an increased degree of root separation.

Effects of mandibular orthognathic treatment on mucogingival tissues.

Twenty-four patients receiving comprehensive orthognathic care including genioplasty were studied to evaluate the effect of orthognathic treatment on the mucogingival complex in the mandibular anterior region. Parameters measured prior to and after therapy were: width of keratinized gingiva, width of attached gingiva and gingival recession. A subjective assessment of tissue thickness was accomplished. A statistically significant decrease in width of both keratinized and attached gingiva was noted following orthognathic therapy in the mandibular anterior area. In six of 24 patients, gingival recession was a clinically significant finding. The actual pretreatment width of keratinized and/or attached tissue did not seem to be the critical factor in development of recession. Risk of recession appeared to increase when genioplasty was combined with mandibular advancement and tended to occur at sites in which the keratinized gingiva and underlying bone appeared thin.

Augmentation genioplasty as an adjunct to conservative orthodontic treatment.

Augmentation genioplasty can serve as a valuable adjunct to orthodontic treatment. The borderline extraction patient with a good nasolabial angle, protruding lower incisors and a deficient chin often can be treated better by nonextraction orthodontics followed by advancement of the chin than by any regimen involving orthodontic extraction. Genioplasty also can be used to improve facial esthetics in the patient with a short mandibular ramus in whom mandibular advancement might well lead to unstable results. In some instances, genioplasty may be a way to overcome the appearance of facial asymmetry without requiring jaw surgery which would complicate a pre-existing adequate occlusion. As a relatively straightforward and predictable procedure, augmentation genioplasty should be used more often in conjunction with orthodontic treatment than it has been in the past.

Summary of an International Symposium on phenytoin-induced teratology and gingival pathology.

Phenytoin has been the preferred drug for treating grand mal epilepsy for more than 40 years. The metabolism of this drug, its teratogenic potential, and its role in the pathogenesis of gingival overgrowth are discussed.

Insomnia: often a therapeutic challenge.

Insomnia, a more or less chronic sleep disturbance, is a very common symptom in psychiatric patients but also relatively freguent in the general population to a lesser degree. Two broad types of insomnia may often be distinguished: (1) difficulty falling asleep and frequent wakening, characteristic of anxiety states or obsessive worrying; and (2) early morning wakening, sometimes in a panic, suggestive of endogenous depression. The first group of patients respond well to minor tranquilizers and psychotherapy, whereas the second do well with tricyclic anti-depressants. Many studies in sleep laboratories have declineated the stages and cycles of sleep physiology and pathology, especially the importance of REM or dreaming sleep. The clinician should be cautious in the use of hypnotics like barbiturates which suppress REM sleep and produce a rebound increase on withdrawal, as well as problems of dependence of habituation. Flurazepam and chloral hydrate are considerably safer in this respect. Understanding sleep neurophysiology and biochemistry permits appropriate individual clinical management for both psychiatric patients and medical patients with conditions like peptic ulcer and nocturnal angina pectoris.

Bacteremia after tooth extractions studied with the aid of prereduced anaerobically sterilized culture media.

Both prereduced molten agar and broth and aerobic molten agar and broth were inoculated with blood samples collected from patients with periodontitis, but in otherwise good health, both before and after extraction of two or more teeth. Postoperative blood samples from 23 of 25 patients sampled yielded anaerobic and facultative species. Colony counts from nine samples yielded from less than 1 to over 100 colonies per ml of blood. Organisms detected were species belonging to the genera Bacteroides, Fusobacterium, Peptostreptococcus, Leptotrichia, Propionibacterium, Peptococcus, Veillonella, plus Streptococcus mitis, S. salivarius, vibrio forms, and strains resembling S. mutans. The data indicate that prereduced anaerobically sterilized culture medium with polyanethol sulfonate is effective for detecting anaerobic species in bacteremia and that anaerobic species can be prevalent in bacteremias immediately after tooth extraction in patients with periodontitis.