Relationships among Cortisol, Perceived Stress, and Dental Caries Experience in Adolescents and Young Adults.

INTRODUCTION: Stress can impact mental and physical health, especially during adolescence and young adulthood, but the extent of its contribution to dental caries is poorly understood. The present study assessed the association between perceived stress, cortisol levels (in hair and saliva), and overall caries experience of adolescents and young adults aged 15-25 years. METHODS: Hair and saliva samples were obtained from 93 participants free of periodontal disease. Cortisol in hair and saliva was determined using a competitive enzyme-linked immunosorbent assay. Participants completed a perceived stress questionnaire and underwent full-mouth oral examination by a calibrated examiner. Dental caries experience was based on the decayed, missing, and filled teeth (DMFT) index. Sociodemographic variables were also recorded. RESULTS: There were significantly higher hair cortisol levels and perceived stress scale (PSS) scores in individuals with dental caries experience (DMFT≥1) than in those without (DMFT = 0). However, there was no significant difference in salivary cortisol concentration. A binary logistic regression revealed that higher hair cortisol levels and greater scores on the perceived stress scale were associated with increased odds of having experienced dental caries. In contrast, no significant association was found between salivary cortisol concentration and dental caries. Using multivariable regression models, caries experience was found to be significantly associated with both hair cortisol levels and PSS scores. These associations remained statistically significant even after adjusting for sociodemographic variables. CONCLUSION: Hair cortisol levels and perceived stress have a significant association with dental caries experience, whereas salivary cortisol concentrations do not.

Friction and archwire engagement in contemporary self-ligating appliance systems : An in vitro comparison.

PURPOSE: The aim of this study was to compare classical friction (FR) in passive self-ligating brackets (P-SLBs), active self-ligating brackets (A-SLBs) and a traditional twin bracket, in vitro, and to identify the point of initiation of bracket-archwire engagement. METHODS: Nine bracket systems of 0.022 in slot size were FR tested: 5 P­SLB systems; 4 A­SLB systems; and a control group of twin brackets with elastomeric ligatures. Single upper right central incisor brackets were mounted on a custom metal fixture for testing. Straight sections of various round and rectangular nickel-titanium (NiTi) archwires (0.016, 0.018, 0.018â€¯× 0.018, 0.020â€¯× 0.020, 0.016â€¯× 0.022, 0.017â€¯× 0.025, 0.019â€¯× 0.025, and 0.021â€¯× 0.025 in) were ligated to the bracket and peak static FR (cN) was measured with an Instron Universal Testing Machine. Ten unique tests each utilizing a new bracket and new archwire were conducted for each group in the dry state. RESULTS: FR was significantly different between control, P­SLB and A­SLB systems (P < 0.001). P­SLB groups displayed no significant differences in FR between each other, regardless of archwire size. A­SLB groups did exhibit significant differences in FR between each other depending on both the bracket system and archwire size. Each A­SLB system tested possessed a distinctly different pattern of initiation of bracket-archwire engagement. CONCLUSIONS: FR between the archwire and bracket slot differs between P­SLB and A­SLB systems, with a distinct pattern of FR and bracket-archwire engagement for each A­SLB system. Understanding the different bracket-wire interactions of SLB systems should help orthodontic clinicians to plan effective and efficient biomechanics with the bracket system of their choice.

Evaluation of Facial Profile Esthetics After Maxillomandibular Advancement Surgery for the Treatment of Obstructive Sleep Apnea.

PURPOSE: Maxillomandibuar advancement (MMA) surgery has been shown to be a successful treatment for obstructive sleep apnea (OSA), but concerns still exist regarding esthetic outcomes due to the large advancements involved. The objective of this study was to evaluate facial profile changes in patients who underwent MMA surgery for OSA by utilizing panels of external evaluators. METHODS: Pre- and posttreatment silhouettes of 21 patients (10 females, 11 males; mean age 43.2 [±11.5] years), who underwent MMA surgery for OSA, were generated from profile photographs. Utilizing survey software, the individual silhouettes were shown in random order to surgeons, orthodontists and laypeople, who assessed the esthetics of each via a sliding visual analogue scale (0 to 10). RESULTS: For all evaluators combined, postsurgical esthetic scores were significantly improved in 19 of 21 patients (P < .001). Ninety-five percent of evaluators judged the changes after surgery as positive or neutral. There was a mean increase in postsurgical esthetic scores of 1.9 [±1.9], which was moderately correlated with AHI changes (r = 0.48, P < .05). Mean esthetic score changes were significantly different between evaluator groups for 12 of 21 patients (P < .05), with surgeons and orthodontists reporting more positive change than laypeople. CONCLUSIONS: Overall, MMA surgery for the treatment of OSA does not have a negative impact on facial profile esthetics, with external evaluators judging the changes as favorable in the majority of patients assessed.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions.

BACKGROUND: The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions. METHODS: Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined. RESULTS: DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria. CONCLUSION: The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions.

BACKGROUND: The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales. METHODS: Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity. RESULTS: 1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores. CONCLUSION: The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Establishing content validity of an orthodontic subset of the FACE-Q Craniofacial Module in children and young adults with malocclusion.

OBJECTIVE: The FACE-Q Craniofacial Module for children and young adults is a patient-reported outcome measure (PROM) designed to measure outcomes for patients aged 8 to 29 years with facial conditions. The aim of this study was to establish content validity of a relevant subset of the module for its use in orthodontic patients with malocclusion. SETTING AND SAMPLE POPULATION: Experts in orthodontics were emailed and invited to provide feedback through a Research Electronic Data Capture survey. Patient feedback was obtained through cognitive interviews with patients aged 8 to 29 years recruited from a university-based orthodontic clinic in Canada. MATERIALS AND METHODS: Expert opinion and patient interviews were used to obtain feedback on the content of 4 appearance (face, smile, teeth and jaws) and 1 function (eating and drinking) scales hypothesized to be relevant to orthodontic malocclusions, and to elicit new concepts. Interviews were audio-recorded, transcribed, and coded using a line-by-line approach. RESULTS: Twenty-one experts and 15 patients participated. Expert feedback led us to drop 9, retain 40, revise 4 and add 16 new items. At the conclusion of cognitive interviews no items were dropped, 55 were retained, 5 were revised and 8 new items were added. The final set of 68 items demonstrated content validity for orthodontic patients. CONCLUSION: Expert feedback and cognitive interviews enabled us to revise and refine 5 scales as part of the FACE-Q Craniofacial Module for use in orthodontic patients. These scales were included in the internationalfield-test of the FACE-Q Craniofacial Module.

Evaluation of masticatory muscle response to clear aligner therapy using ambulatory electromyographic recording.

INTRODUCTION: Patients undergoing clear aligner therapy (CAT) report muscle tenderness and produce wear facets on their aligner trays. However, little is known about the masticatory muscle response to clear aligners. Here, we measured the activity of the masseter during CAT using ambulatory electromyography. We also explored whether psychological traits modulate the masticatory muscle response to CAT. METHODS: Using portable data loggers, we recorded the electromyographic (EMG) activity in the right masseter muscle of 17 healthy adults without temporomandibular disorder (16 females, 1 male; mean age ± standard deviation, 35.3 ± 17.6 years) commencing treatment with CAT over 4 weeks, under the following conditions: week 1 without aligners (baseline), week 2 with a passive aligner (dummy), week 3 with their first active aligner (active1), and week 4 with their second active aligner (active2). We used a mixed-effect model to test differences in EMG activity over the 4-weeks and a general linear model to test the effect of psychological traits on EMG activity. RESULTS: The EMG activity of the masseter increased significantly with aligners compared with baseline. The largest relative increase in EMG activity was seen during the dummy (152%; P <0.001) and active1 (155%; P <0.001) stages. During active2, the activity of the masseter decreased significantly toward baseline levels. Participants' trait anxiety was positively associated with increases in EMG activity (P = 0.027). CONCLUSIONS: CAT is associated with a transient increase in masticatory muscle activity, possibly because of an increase in wake-time parafunctional tooth clenching. Temporomandibular disorder-free patients adapt well to CAT as the masticatory muscle activity decreases toward baseline levels after 2 weeks.

Impact of clear aligner therapy on tooth pain and masticatory muscle soreness.

BACKGROUND: Clinical findings suggest that orthodontic treatment with clear aligners (clear aligner therapy/CAT) may cause masticatory muscle soreness in some patients. OBJECTIVE: This multi-site prospective study investigated tooth pain and masticatory muscle soreness and tenderness in patients undergoing CAT and explored whether psychological traits affected these outcomes. METHODS: Twenty-seven adults (22F, 5M; mean age ± SD=35.3 ± 17.6 years) about to start CAT were recruited at three clinics. During CAT, they reported on 100-mm visual analogue scales their tooth pain, masticatory muscle soreness and stress three times per day over 4 weeks (week 1 = baseline; week 2 = dummy aligner; week 3 = first active aligner; week 4 = second active aligner). Pressure pain thresholds (PPTs) were measured at the masseter and temporalis at baseline and after week 4. Mixed models were used to evaluate the outcome measures over time. RESULTS: Clear aligner therapy caused mild tooth pain, which was greater with the passive than the first and second active aligners (both P < .001). Mild and clinically not relevant masticatory muscle soreness was produced by all aligners (all P < .05), with the first active aligner producing less soreness than the dummy aligner (P < .001). PPTs did not change significantly after 4 weeks. Both tooth pain and masticatory muscle soreness were affected by stress and trait anxiety, whilst muscle soreness was affected also by oral behaviours. CONCLUSIONS: In the short term, CAT produces tooth pain and masticatory muscle soreness of limited significance. Frequent oral behaviours are related to increased masticatory muscle soreness during CAT. The medium- and long-term effects of CAT should be further explored.

A novel technique for measurement of orthodontic mini-implant stability using the Osstell ISQ device.

OBJECTIVES: To develop and validate a method for application of the Osstell ISQ device in the assessment of mini-implant stability. MATERIALS AND METHODS: An adaptor was developed for attachment of Osstell's SmartPeg onto a variety of orthodontic mini-implants. For validation of the adaptor, Benefit mini-implants were inserted into bone blocks that mimicked different stability conditions. The Osstell device was used to assess mini-implant stability with the adaptor (test measurement) and conventional SmartPeg attachment (gold-standard measurement). Implant stability quotient (ISQ) values were assessed for agreement, repeatability, and reproducibility. RESULTS: Strong positive correlations were found between ISQ values obtained using the novel adaptor and the conventional attachment. Repeatability and reproducibility of ISQ values with the adaptor were similar to those obtained with the conventional attachment. CONCLUSIONS: A method was developed and validated to assess the stability of orthodontic mini-implants using the Osstell system. The novel mini-implant adaptor provided repeatable and reproducible measurements of mini-implant stability, which agreed with those obtained using a conventional SmartPeg attachment. This adaptor permits noninvasive stability assessment of various designs of mini-implants, most of which are incompatible with the conventional SmartPeg attachment.

In-vitro comparison of different palatal sites for orthodontic miniscrew insertion: Effect of bone quality and quantity on primary stability.

INTRODUCTION: This experiment was undertaken to assess the primary stability of orthodontic miniscrews inserted at different sites in human cadaveric palatal bone for temporary skeletal anchorage, and to determine the effect of bone quality and quantity on their primary stability using microcomputed tomography imaging. METHODS: A total of 10 cadaveric maxillary hard palates were used for insertion of 130 orthodontic miniscrews (VectorTAS; Ormco, Orange, Calif; length, 6 mm; diameter, 1.4 mm). Upon insertion, maximal insertion torque (IT) was recorded. Imaging (microcomputed tomography) was performed before and after insertion for assessment of bone quality and quantity parameters (bone mineral density [BMD], bone thickness [BT], and length of screw engagement [LSE]). Differences in each parameter were assessed at the various insertion sites. Correlations between IT and measurements of BMD, BT, and LSE were evaluated. RESULTS: Significant differences (P < 0.001) were found among insertion sites for IT, BT, and LSE, but not for BMD (P = 0.004). Correlations were found between IT and BMD (rs = 0.42; P < 0.001), IT and BT (rs = 0.58; P < 0.001), and IT and LSE (rs = 0.58; P < 0.001). Most perforations of miniscrews into the nasal cavity occurred posterior to the permanent second premolars. CONCLUSIONS: The primary stability of orthodontic miniscrews in the palate is affected by bone quality and quantity, with higher primary stability obtained anterior to the second premolars and parasagittally at the level of the permanent first molars.

A Comparison of the Mechanical Measures Used for Assessing Orthodontic Mini-Implant Stability.

PURPOSE: Mechanical loosening remains a common complication associated with mini-implant failure. The purpose of this study was to compare common mechanical measures of mini-implant stability to determine their association and reliability. MATERIALS AND METHODS: Ninety self-drilling orthodontic mini-implants from 6 manufacturers were inserted into artificial bone blocks. Insertion torques (ITs) and Periotest values (PVs) were measured. Subsequently, mini-implants underwent pull-out testing for measures of pull-out load (POL) and screw displacement (ScrD). Stability measurements were compared using one-way ANOVA, associations among them were assessed using correlation analyses, and reliability was evaluated using coefficients of variation (COVs). RESULTS: Variations in stability of mini-implants were found, specific to the mechanical measure used for assessment (P < 0.05). The strongest correlations were found between IT and PV (r = -0.68) and between IT and POL (r = 0.66). Overall, PV showed the greatest variability (COV: 11%-100%) compared with IT (≤11%), POL (≤4%), and ScrD (≤19%). CONCLUSIONS: IT, PV, and POLs only agreed moderately in their assessment of mini-implant stability, and Periotest showed the least reliability in predicting mini-implant stability. As such, independent and interchangeable use of these stability measures should be avoided.

Insertion Torques of Self-Drilling Mini-Implants in Simulated Mandibular Bone: Assessment of Potential for Implant Fracture.

PURPOSE: Fracture of orthodontic mini-implants during insertion is a limiting factor for their clinical success. The purpose of this study was to determine the fracture potential of commonly used self-drilling orthodontic mini-implants when placed into simulated thick, dense mandibular bone. MATERIALS AND METHODS: Six mini-implant systems were assessed for the potential for fracture (Aarhus, Medicon; Dual-Top, Jeil Medical; OrthoEasy, Forestadent; tomas-pin, Dentaurum; Unitek, 3M; and VectorTAS, Ormco). First, mini-implants were inserted manually, without predrilling, into bone substitutes (Sawbones) with a 3-mm-thick, dense (1.64 g/cm(3)) cortical layer. A custom-made insertion device was used for placement of mini-implants. A sixaxis force/torque transducer was secured at the base of the bone blocks to measure the maximum torque experienced during insertion. Measured insertion torques were compared with previously reported fracture torques, yielding a torque ratio (insertion torque as a percentage of fracture torque), which was used as an indicator of the potential for mini-implant fracture. Mini-implants that experienced torque ratios ≥ 75% upon insertion underwent further testing, following the manufacturer's recommendations for predrilling in thick, dense bone conditions. RESULTS: Significant differences in torque ratios were found among all mini-implants, except between OrthoEasy and Dual-Top, and OrthoEasy and VectorTAS. Overall, Aarhus had the highest torque ratio (91% ± 3%), with Unitek showing the lowest ratio (37% ± 3%). Aarhus and tomas-pin mini-implants displayed torque ratios ≥ 75% and experienced fracture upon insertion. When the manufacturer's specific predrilling recommendations were followed, no changes in torque ratio were found for Aarhus and tomas-pin. However, while Aarhus continued to fracture upon insertion, all tomas-pin mini-implants were inserted fully without fracture following predrilling. CONCLUSION: These findings support the safe use of Unitek, VectorTAS, Dual-Top, and OrthoEasy self-drilling mini-implants in areas of 3-mm-thick, 1.64 g/cm(3) dense cortical bone without predrilling. Following predrilling, fractures did not occur with tomas-pin. For implants that continued to fracture after predrilling, other strategies may be required, such as the use of larger-diameter mini-implants in thick, dense bone conditions.

Fracture resistance of commonly used self-drilling orthodontic mini-implants.

OBJECTIVE: To investigate the fracture resistance of six commonly used self-drilling orthodontic mini-implants by comparing their respective fracture torques during insertion. MATERIALS AND METHODS: Ninety self-drilling mini-implants from six manufacturers (Aarhus, Dual-Top, OrthoEasy, Tomas-pin, Unitek, and VectorTAS), with diameters ranging from 1.4 to 1.8 mm, were inserted into acrylic blocks using a custom-made insertion device. Insertion torques were measured using a 6-degree-of-freedom load cell fixed to the base of the acrylic blocks, and peak torques experienced at the time of fracture for each of the mini-implants were recorded. One-way analysis of variance (α  =  .05) was used to compare the fracture torques among the six different groups. RESULTS: Statistical analysis revealed significant differences (P < .05) in the peak fracture torques among mini-implant groups. Mean fracture torques ranked as follows: Unitek (72 Ncm) > Tomas-pin (36 Ncm) > Dual-Top (32 Ncm) ≈ VectorTAS (31 Ncm) > OrthoEasy (28 Ncm) > Aarhus (25 Ncm), with significant differences found between all manufacturers, except for Dual-Top and VectorTAS. CONCLUSIONS: Mini-implants tested showed a wide range of torque at fracture depending on the manufacturer, with only a weak correlation between mini-implant diameter and fracture resistance. This torque should be considered at the time of mini-implant insertion to minimize the risk of implant fracture, especially in areas of high-density bone without predrilling.