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About P&W | EViDENT is a group of young dentists that focus on lecturing ideas and innovation to others. In order for a better communication, we use digital works to explain the concepts. Most importantly we not only target the dentists as audience, but also the patients too. We are also proceeding the philosophy of evidence-based dentistry, especially in fields of periodontics, prosthodontics and dental implantology. The team was planned over a year (2014-2015) and collected data of needs from undergraduate dental students and dentists with clinical experience. We share our ideas, our studies, great articles, information of all kinds of dental courses for every dentists and students to get the latest news and discuss for our own protocols. E7 dental e-publishing is one of the online/ paperwork of P&W | EViDENT. The publication contains 7 topics per volume in different aspects of dentistry. It is more like a magazine with both dental research and the enjoyment of living. Including topics of lecturing, practical sessions, photos galleries, lifestyle sharing and etc. It is designed for dentists to have a brand new thinking in the academic field. Authors could be from anywhere! E7 epub. is an open sharing work which everyone could subscribe and we are happy to have more and more dentists, professors, students and etc. to join us. We are more than welcome to hear your work experiences, knowledge and ideas, and encourage you to share with no limitation. Lastly, we welcome any kind of suggestions which will help us improve. Team P&W | EViDENT

From Chairman

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In our constantly changing world, our team

Autumn is always an amazing season, the

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Contents • About_________________________________________1 • Calendar (dental events) _________________________ 3 • A Retrospective Comparison Study of Pulpectomy Prevlaence between Male and Female in Children _____ 5

• Clinical Report: Tooth Extraction of Unsupported Cantilever Prosthesis ___________________________11

• The Use of Semi-precision Attachments in Removable Prosthodontics Part:1 ___________________________15

• How to: Set a Simple Dental Studio at Home_________21 • Is Esthetics the Trend for Adult to Receive Orthodontic Treatment? ___________________________________23

• Porphyromonas Gingivalis _______________________28 • Intermediate Implants Prosthodontics Course by MPI X P&W | EViDENT _______________________________33

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A Retrospective Comparison Study of Pulpectomy Prevalence between Male and Female in Children Rianna Xia Patel, Houmayraa Dilmahomed, Ya-Hui Chuang, Wei-Hua Chen keywords: children, epidemiology, gesden, paediatrics, pulpectomy

Introduction The primary goal for pulp therapy in primary dentition is to maintain the function and integrity of the teeth.1 Furthermore it allows proper eruption of permanent dentition by maintaining space in the dental arch.1 There are different pulp treatments in primary dentition, including application of protective liner, indirect pulp treatment, direct pulp capping, pulpotomy and pulpectomy. These treatments differ by the status of the pulp, whenever it is vital or non-vital.1 According to the American Academy of Pediatric Dentistry (AAPD) a pulpectomy is done in primary teeth that are non-vital and diagnosed with irreversible pulpitis or necrotic pulp. 1 Pulpectomy involves the complete removal of pulp tissue from both the pulp chamber and the root canal.2 This cleaning intends to remove all bacteria in the pulp and thereby resolve the infection causing the pain.2 The root canals are cleaned by hand or rotatory files and disinfected by irrigants.2 Then the canals are obturated by filling material that seals the tooth from infection and micro leakage.2 However, in severe cases where there are very deep caries or extensive root resorption, pulpectomy is contraindicated, an extraction may be unavoidable.2 Dental treatment in young children can be challenging for many clinicians. Especially when long procedures are required, such as a pulpectomy. There is a fear of damaging the underlying permanent teeth, difficulty in shaping, cleaning and filling in resorbing roots or open apices. Hence, many clinicians have negative attitudes towards performing 0 78

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pulpectomy in primary teeth. Therefore there are many clinicians that prefer to simply extract the deciduous dentition to avoid all these anatomical problems.3 According to Keyes diagram (Figure 1) by Paul Keyes, 4 caries is the result of a combination of three factors, each of which is of equal importance: the host, diet and microflora. However, the component of time adds complexity to this concept. The host factors include several other parameters, these being: composition and flow rate of saliva, immunological components, oral hygiene habits, socioeconomic background and the importance of dental healthcare provision, both to the patient and their family.

28I8C 7 4: 4

Moreover, the frequency and form (retentive versus non retentive substrates) of dietary intake will also affect caries incidence. This is of great importance particularly in children due to their high consumption of sugary foods and poor habits. Nursing bottle syndrome also

plays an imperative role in the initiation and progression of caries. The presence of Streptococcus mutans and Lactobacillus has been demonstrated to be crucial for the appearance of caries. Genetics has also thought to have an effect on caries incidence, however, the extent to which it does is unknown. Caries is a multifactorial process and each of its risk factors are linked. Reducing its incidence is not as simple as controlling one specific factor, all need to be taken into account by both the clinician and patient. Pulpectomies are a result of caries progression which could be due to the negligence of various factors. Predominantly, failure of compliance and coordination between the patient and dentist is to blame. Albeit, it is not solely this that determines the worsening of caries, factors such as poor diet, success of previous treatment and both the parent’s and child’s behaviour towards dental healthcare are also of great value. Studies have been conducted to prove gender to be one of the risk factors of caries. When dental caries rates are reported by sex, females are typically found to exhibit higher prevalence rates than males. This finding is generally true for different cultures with different subsistence systems and for a wide range of chronological periods. Shaffer and Leslie discovered that child caries incidence in males compared to females differed according to the age group.5 This study showed that the younger age groups (1-5 and 6-11 years old) showed a lower caries rate and DMFT (Decayed, Missing, Filled Teeth) score for girls. However, these figures plateaued in the 12-17 age group and then inversed in adults. Ferraro and Vieira et al. concurred with Shaffer and Leslie et al, concluding that adult females have a higher prevalence of caries than adults’ males. However, in the literature, no studies have yet determined whether pulpectomy prevalence in children was dependent on the patient being male or female. Therefore this study is innovative in the way that it will be the first to

investigate this relationship and caries progression as opposed to caries itself. Based on previous research in this field, we can suspect that there will be a higher pulpectomy prevalence in males as compared to females, in children. Risk factors play a key role in prevention, understanding and diagnosing of this particular disease, as it identifies individuals at risk. The purpose of this study was to determine whether gender difference affects the prevalence of pulpectomies in children from different age ranges. Materials and Methods Study Population In this descriptive, retrospective study, the participants were selected from the clinical database of Universidad CEU Cardenal Herrera, Valencia, Spain. The clinical management software used was Gesden (softeware sanitario, Henry ScheinⓇ). The required information was selected by the process of filtering according to age and pulpectomies performed by the university’s students and professors during a ten year period (2004-2014). Originally, 69 patients were found to match these criteria, however, after applying both the exclusion and inclusion criteria, 56 patients were left, 35 males and 21 females. Inclusion and Exclusion Criteria The inclusion and exclusion criteria are listed in Table 1. Ethical Considerations Non-identifying patient information was accessed, thereby protecting patients confidentiality. Filtering Technique Although the target age range was from 2-13 years old due to the requirement of solely deciduous teeth, the database was filtered using a wider age range of 0-18 years. This was done to compensate for the 10 year time period chosen. In the Gesden system, 0 78

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previous treatments done by another clinician, treatments to be done and treatments done at the CEU clinic are highlighted green, red and blue respectively. Only the information in blue was selected.

Inclusion Criteria •

2-13 years old at time of pulpectomy

Data Analysis This study used a t-test, and thereby a pvalue to analyse the statistical significance of the results corrected. Differences were acknowledged as significant when the probability was found to be less than 0.05. Results

treatment

Males Females

•

Both sexes

•

Deciduous dentition

Exclusion Criteria •

Pulpectomies performed in other clinics

•

Children with systemic diseases and/or

Both

Mean Age

5.1

Mean Visit

17.2

18.7

17.7

Mean Pulpectomy

1.4

1.2

1.3

84 4:8 C 4 7 AE A86 4 8C 98 4 8C 4 7 5 ; :8 78 C

I E 58

physical or developmental disorders

Number

Reason: alters oral health, manual dexterity and immunity •

Gender and Age

Orthodontic patients

Reason: oral hygiene is affected (hard to reach/clean areas) Pulpectomies due to trauma 1 6 EC

4 7 0 6 EC

8 4

From the data collected, there are quite noticeably more males (62.5%) presenting with pulpectomies compared to females (37.5%). (Table 2) The graph shows a general decrease in the number of pulpectomies with a simultaneous increase of age for both sexes. However, the number of pulpectomies found in the male category at each age presented was

No. of Pulpectomies

R² = 0.6599 7

R² = 0.4102 Males Females

Age . : 4A; C; 0 78

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: ;8 A 8 4 8 68 9 AE A86

I 5I 4:8

4 8C 4 7 98 4 8C

2 Odds ratio

1.5 1 0.5 0 Mandible vs Maxilla . : 4A; C; A C8 4 74 8

: ;8 77C 4 88 ;

Posterior vs Anterior

9 AE A86

consistently greater than that of females. In the younger years, this difference is more evident, and slowly closes up towards the older ages. At one year of age, this difference is seen to be four, which decreases to less than one at ten years of age. These statistics are most visibly seen through the line of best fit. Taking a look at the original data line, the R2 value for the males is much higher (0.66) than the same value for the females. (0.41) (Figure 2) Mandible vs. Maxilla The results regarding the location of the pulpectomies presented even numbers in the upper and lower arches of males, 25. However, for the females, there was a distinguishable difference between the two, with the maxilla having considerably more pulpectomies, 18, than that of the mandible, 9. The ratio for mandibular to maxillary pulpectomies in males was 1, compared to 0.5 in females. Males are two times more likely to have a pulpectomy in the mandible as compared to females. (Figure 3) Posterior vs. Anterior There were differences between the two locations for both genders. In males, the results showed the presence of 38 pulpectomies in the posterior region compared to 12 in the anterior. For females, there were also more pulpectomies posteriorly, 18, than anteriorly, 9. The ratio for posterior to anterior teeth in males was 3.2, as compared to 2 in females. Males are 1.6 times more likely to

I A 8 4 8 68 58

4 758 4 7

4 4 7

have a pulpectomy in the posterior region than females. (Figure 3) Discussion This is the first retrospective descriptive study to enquire into the potential correlation between gender and pulpectomy prevalence. It was carried out in order to implement improved treatment strategies in children regarding oral health measures, as well as preventive programs in the general population. Age and location were taken into account to improve the chances of success of future therapeutic actions. In the current study, it was evident that males had a substantially higher prevalence of pulpectomies as compared to females, 67 percent greater as extrapolated from the results. This is in accordance with Shaffer and Leslie research,5 and Saravanan.6 In the present study, it can be observed that in the younger ages from 2-4, males showed a significantly higher prevalence of pulpectomies as compared to females. The study from Shaffer and Leslie showed that children from the age ranges 1-5 and 6-11 presented a significantly higher prevalence of caries in males as compared to females.5 Children aged 12-17 indicated similar caries indices. In adults, the trend was reversed, as women showed to have more caries than males. It can be suspect that if the present study had been continued into the teenage years, it would have followed a similar trend to that 0 78

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presented by Shaffer and Leslie which is to say from puberty;5 these results become equal to one another and then reverse. This could be attributed to the hormone rises in both sexes.7 Regarding the location of the pulpectomies, it has been noted that the upper arch has a higher pulpectomy number as compared to the lower. It can be suspected that there are several factors attributing to both mechanical cleaning and self-cleansing of this area.3 For example, the mandible can be more easily seen in the mirror during tooth brushing which can hugely favour oral hygiene habits, particularly in young children who rely on this concept the most.3,8 In addition, regarding manual dexterity, and once again particularly in young children, the maxilla presents harder to reach areas than the mandible.3 Lastly, with supervised tooth brushing, a parent is more likely to notice dental abnormalities such as decays or missing teeth in the lower arch. Oral clearance also helps significantly reduce bacterial load in the mandible, with utmost importance placed on the tongue, and the inferior placement of the major salivary glands. 8

Finally, it can be noticed that location, meaning posterior teeth vs. anterior teeth had a higher impact than did the upper arch vs. lower arch. In both genders, posterior teeth had a noticeably higher pulpectomy prevalence than did the anterior. This could be a result of a few reasons, but most importantly due to the fact that posterior regions and particularly in children are challenging to reach. Also, the inferior anterior teeth are protected by the tongue and also are the location of the salivary glands.8 In addition, it can be noticed that younger age groups are more affected by the appearance of pulpectomies. This could be explained by the fact that children in the age range between 2 to 4 years old rely on parental supervision in cleaning. Depending on parentsâ&#x20AC;&#x2122; knowledge and value of oral hygiene, available time with their child, and the childâ&#x20AC;&#x2122;s compliance, oral health consequences could be greatly altered. 3,9

0 78

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There are several limitations that are apparent in this study. The prime objective of the study was to identify sex bias and pulpectomy prevalence. However, due to a lack of resources and information, factors such as socioeconomic background, ethnicity, household income and education level of the parents of the selected children could not be taken into account.3,9,10 Parameters such as these would have been of great use in eliminating bias and confounding factors, as well as sources of error. Albeit, individually, other authors have researched such factors which completes this current study. 3,9,10 Furthermore, oral hygiene habits of the selected patients, along with dietary intake were not considered, thereby hugely skewing the data. The following would need to be heavily taken into account in further research. Conclusion This investigation was primarily set out to address whether or not the prevalence of pulpectomies was related to gender. It was found that the results ran in concurrence with our original hypothesis stating that males would be more prone to having pulpectomies and concordantly affecting the younger age group. This study was of imperative importance in terms of identifying a preventive strategy and healthcare treatment plan on both an individual and population level. The results presented are a strong indication of the discrepancies in oral hygiene between the genders, edging us towards further research to identity the etiological factors of such disparities, and to therefore implicate and shift preventive measures more importantly towards males. Specifically, more thorough research into sex bias and oral hygiene habits as well as dmft (DMF Index for children) scoring could string together the results with more definitive reasoning, thereby eliminating potential errors.

Reference 1. Clinical Affairs Committee - Pulp Therapy Subcommittee, Guideline on Pulp Therapy for Primary and Immature Permanent

Te e t h , A A P D R e f e r e n c e M a n u a l , 37;6:15/16:244-252 2. Ahmed HM, Pulpectomy Procedures in Primary Molar Teeth, Eur J Gen Dent 2014;3:3-10 3. ML Mattila et al., Will The Role of Family Influence Dental Caries Among Sevenyear-old Children?, Acta Odontol Scand., 2005;63(2):73-84 4. Keyes PH, Research in Dental Caries, JADA, 1968;76:1357-1373 5. Shaffer JR, Leslie EJ, Feingold E, Govil M, McNeil DW, Crout RJ et al. Caries Experience Differs between Females and Males across Age Groups in Northern Appalachia, Int J Dent., 2015;2015:938213 6. Saravanan S, Madivanan I, Subashini B, Felix JW, Prevalence Pattern of Dental Caries in the Primary Dentition among School Children, Indian J Dent Res., 2005 Oct-Dec;16(4):140-6 7. Ferraro M, Vieira AR, Explaining Gender Differences in Caries: A Multifactorial Approach to a Multifactorial Disease, I n t e r n a t i o n a l J o u r n a l o f D e n t i s t r y, 2010;2010:1-5 8. Demirci M, Tuncer S, Yuceokur AA, Prevalence of Caries on Individual Tooth Surfaces and Its Distribution by Age and Gender in University Clinic Patients, Eur j Dent., 2010 Jul;4(3):270-279 9. Al-Hosan E, Rugg-Gunn A, Combination of Low Parental Educational Attainment and High Parental Income Related to High Caries Experience in Pre-School Children in Abu Dhabi, Community Dent Oral Epidemiol., 1998 Feb;26(1):31-6 10. Peres M, Peres K, de Barros A, Victora C. The Relation Between Family S o c i o e c o n o m i c Tr a j e c t o r i e s f r o m Childhood to Adolescence and Dental Caries and Associated Oral Behaviours, J Epidemiol Community Health, 2007 Feb; 61(2):141-145 11. A l - H o s a n i E , R u g g - G u n n A J , T h e Relationship between Diet and Dental Caries in 2 and 4 Year Old Children in the Emirate of Abu Dhabi, Saudi Dent J , 2000;12(3):149-155. 12. Saxena A, Chaudhary C, Pandey P, Reddy N, Rao V. Estimation of Salivary Flow

Rate, pH, Buffer Capacity, Calcium, Total Protein Content and Total Antioxidant Capacity in Relation to Dental Caries Severity, Age and Gender, Contemp Clin Dent., 2015 Mar; 6(Suppl 1):S65-S71 13. Fung MHT, Wong MCM, Lo ECM, Chu CH. Early Childhood Caries: A Literature Review. Oral Hyg Health, 2013;1:1 14. Borutta A, Wagner M, Kneist S, Early Childhood Caries: A Multi-Factorial Disease., OHDMBSC, 2010;9(1):32-38

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Clinical Report: Tooth Extraction of Unsupported Cantilever Prosthesis Chen-Che Hung, DDS. keywords: biomechanics, cantilever, dental bridge, mastication, prosthesis, prosthodontics *the article is also available on perio.prostho.cc.wordpress.com

Introduction

Clinical Review

Problems combining both periodontics and prosthodontics and highlighted in today’s dentistry. Causes would be the wrong prosthesis design, which has effected the damage of the surrounding tissues. One of these would be the affects due to the application of the cantilever prosthesis.

64 years old male patient was referred to prosthodontics apartment for a new partial denture of the lower mandibular jaw. The right posterior region remained an unsupportive prosthesis which should be extracted. The “bridge” as he remembered, is a connection from 4.5 till 4.8. Nevertheless, it is a cantilever from 4.5 till “4.9”, which with an extra pontic to compromise the occlusion status. From the radiograph, there was a moderate horizontal bone loss on prosthesis area, and the keratinized gingiva was lost according to the intra-oral examination. The patient felt a bit pain during the mastication and had been biting with the opposite side, which making the 3rd quadrant with even more bone loss comparing to the 4th quadrant. Furcation involvement was found on 3.6 and at least 4mm of the lost of the bone was found.

Cantilever prosthesis (cantilever fixed partial denture) is defined as a fixed restoration which has one or more abutments at one end while the other end is unsupported. 1 Despite negative arguments, the cantilever prosthesis has been used extensively by the clinicians1 because of favourable preparation. If one abutment tooth is used, there is no need to make preparations parallel to each other; if two or more abutment teeth are used, they are adjacent to each other, so it is easier to make the preparations parallel.2 However, with small bridges the length of span is limited to one Pontic because of the leverage forces on the abutment teeth. Also, occlusal forces on the pontic of small posterior bridges encourage tilting of the abutment tooth, leading the chances of losing the fixture.2 For many cases, it is a compromising treatment due to the remaining teeth position. It is a challenge to define how long the cantilever prothesis should be. Lack of the evidence and with multiple factors, results are shown to be as minimum as possible.3 If there is a long extension or posterior region with high occlusal loading, multiple abutments are advised.3, 4 . 3 ;

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- ; 20 03

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The cantilever was extracted on 4th quadrant and Sc/Rp was applied on 3rd quadrant for the better oral hygiene control. Periodontitis symptoms was significant due to the poor oral

hygiene care and the tooth crowding. Oral care education was advised before the application of removable partial denture. Further periodontal therapy was scheduled.

Discussion Failure of cantilever prosthesis could be concluded into several reasons. 1. Occlusal Loading The cantilever prosthesis should be able to bear the force from the mastication. Since there was only one root supporting the prosthesis, (clinical case) the prosthesis would be effected and with several chances of movements. According to Law of the lever, the rotation of the prosthesis was sufficient, which may lead to the possibilities of root fracture or adjacent bone (tooth) leakage. (In this case, the lost of periodontium/ PDL was found)

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2. Design of Prosthesis Cantilever design without an easy pathway for the patients to achieve oral hygiene may cause food sticking, and the chances of creating a gap for dental calculus, which may causes xerostomia, malocclusion and etc. 3. Periodontal Problems (combination)

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From those 2 reasons above, the force pressure may effect moderate bone loss and the lost of the soft tissues. As the clinical session, with the necessary of tooth extraction,

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the cantilever prosthesis was removed to maintain the oral health. Clinicians should discussed with the patients for the suitable treatment. The outcomes may effect the further procedures. Although long cantilever prosthesis is not recommended, the normal cantilever for anterior region still is a compromised selection. Single pontic is a solution for a temporary missing in paediatrics as well. After all, the oral hygiene is important to reveal a high survival rate for these kind of prosthesis design. Acknowledgment Case records were done in private clinic of Universidad CEU Cardenal Herrera. Advised by Department of Prosthodontics. Reference 1. Sharma A Rahul GR, Poduval ST, Shetty K, Assessment of Various Factors for Feasibility of Fixed Cantilever Bridge: A Review Study, ISRN Dentistry, 2012;1-7 2. Smith B, Howe L, Planning and Making Crowns and Bridges, 4ed., Informa Healthcare, 206 3. Randow K, Glantz P, On Cantilever Loading of Vital and Non-vital Teeth - An Experimental Clinical Study, ACTA ODONTOL SCAND 1986;44:271-277 4. Shillingburg Jr HT, Hobo S, Jacobi R, Brackett SE, Fundamentals of Fixed Prosthodontics, 3ed., Quintessence, 102

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Vincent van Gogh, Amandelbloesem, Canvas, 1890 Van Gogh Museum, Amsterdam

The word of the Lord came to me: “What do you see, Jeremiah?” “I see the branch of an almond tree,” I replied. The Lord said to me, “You have seen correctly, for I am watching to see that my word is fulfilled.” (Jeremiah 1:11-12)

Christian Love Art Project Classic Art with Passages from Bible public domain

The Use of Semi-precision Attachments in Removable Prosthodontics Part 1: Classification & Survival Rate Hing-Ger Lau, DDS. keywords: precision attachment, semi-precision attachment, prosthesis, prosthodontics *the article is modified to adjust for the template. *Original copy could be found in Dentistry Degree Project of Universidad CEU Cardenal Herrera.

Introduction The academy of Denture Prosthetics defines an attachment as a retainer, used in fixed and removable partial denture (RPD) construction, consisting of a metal receptacle and a closely fitting part. Precision or semi-precision attachment denture has been considered as the highest form of partial denture therapy in functional and esthetic term. Attachment use was first introduced in early 20th century by Dr. Herman Chay. The use of attachment in restoring partially edentulous area is the art of combining the advantage of both fixed and r e m o v a b l e p r o s t h o d o n t i c s t o g e t h e r. Attachments have better properties than conventional clasps in terms of esthetics, durability, and retention.1 However, the cost of fabricating attachments is much higher than clasps and the construction of attachment partial denture is also more technically demanding. Attachments can be considered as an alternative treatment to telescopic procedure to anchor partial dentures to the residual dentition.

retaining overdentures. Attachments can also be classified as resilient or rigid depending on the range of movement to be tolerated. Classification of Attachments There are basically 3 ways to classify attachments. Precision and Semi-precision Attachment The first way of classification is based upon their mode of manufacture and their precise tolerances. Attachments can be either precise or semi-precise. Traditional precision attachments have prefabricated, machined components with precisely manufactured metal-to-metal parts that have close tolerances. On the other hand, semi-precision attachments, due to the nature of their fabrication, are less precise in their tolerances and are manufactured from patterns made from direct casting with either wax, nylon, or plastic, or they may be hand waxed by a dental laboratory technician. Their method of fabrication subjects them to inconsistencies.2 Intracoronal and Extracoronal Attachment

There are four main types of attachment according to its design, which are intracoronal, extracoronal, stud type, and bar type attachments. Intracoronal and extracoronal ones are used in either distal extension area or bounded saddle area of removable partial dentures. Stud type attachment can be used in overdentures or in removable ones where there is insufficient interocclusal space. And bar type attachment are mainly used in 0

- ,

If the matrix part of a semiprecision or precision attachment is located within the contours of the abutment crown and the patrix on the prosthesis, it is classified as intracoronal. And if the patrix part of the attachment is located outside the contours of the abutment tooth and the matrix within the prosthesis it is categorized as extracoronal.2

Rigid and Resilient Attachment Depending on whether the attachments allow for movement of their component parts, they are also classified as rigid or resilient. Rigid attachments provide little or no movement of their parts during function, and resilient attachments are designed to provide a defined amount and direction of movement of the partial denture relative to the attachment, in theory permitting controlled movement of the denture base tissue-ward while minimizing the amount of unfavorable stress transfer to the abutment tooth. These types of attachments are considered “stress breakers” or “stress directors.” Resilient attachments are designed to provide either hingelike movement or rotary movement depending on their design. Most intracoronal attachments are rigid attachments, and extracoronal attachments are usually resilient.2 Staubli has further categorized rigid and resilient attachments into six classifications. The higher the classification is, the greater degree of resiliency the attachment has. (Table 1) Class 1a

Solid, rigid, non-resilient

Class 1b

Solid, rigid, lockable with U-pin

Class 2

Vertical resilient

Class 3

Hinge resilient

Class 4

Vertical and hinge resilient

Class 5

Rotational and vertical resilient

Class 6

Universal, Omniplanar

removal. Parallel sided walls provide frictional retention and bracing by transmission of horizontal forces. (Figure 1) Occasionally, the addition of extra retentive elements to the precision attachment increases the retention. This type of construction rigidly connects the RPD to the abutment tooth, and allows no freedom of movement between the tooth and the RPD, which is of particular importance in a tooth tissue-supported type of RPD. This rigid connection often leads to damage to the abutment tooth and its supporting structures.4,6

12 29959 8 5 2 237:5;

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538 8 ;

Semi-precision Attachments

Precision Attachments

A semi-precision attachment, different from a precision attachment, has male and female components that are not as tightly fitted together as a precision attachment does. It consists of a custom-made deep rest of variable outline and form, which can be individually tailored to the patient’s particular needs. The semi-precision attachment is a strong candidate for RPD construction with distal extension saddle for its ability to tolerate a certain amount of movement during functioning.

Precision attachments have prefabricated, machined components with precisely manufactured metal-to-metal parts with close tolerances, usually within 0.01 mm.4,5 The general design of a precision attachment includes a rest and a rest seat, which allow movement only along the path of insertion and

Support, retention, and stability should be considered when designing any RPD connector. Stability and retention are obtained by the deep rest design: Bracing by lateral force transmission by the side walls and support imparted by the gingival floor, which is placed as close as possible to the gingival

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margin, thus reducing the lever effect on the abutment tooth. The retention is imparted by a retentive clasp arm or a nylon sleeve incorporated within the female component. Advantages and Disadvantages of Semiprecision Attachments According to study done by Rantanen, Wetherall and Smales, Feinberg et al., comparing with conventional clasps, semiprecision attachments have longer survival rate of more than 15 years of life. They are also a lot more retentive and esthetic than conventional clasps. Lower rate of caries (8%) comparing to claspsâ&#x20AC;&#x2122; (50%) is shown in their s t u d y. H i g h e r p e r c e n t a g e o f p a t i e n t compliance and better chewing efficiency is also shown comparing to clasps. And one of the most important advantages of the use of attachments is that the point of force application to the tooth is more apical than for occlusal or incisal rests, thus shortening the lever arm and decreasing torquing forces. (Figure 2)

whenever a conventional clasp can be used, it is the retainer of choice. 5 The use of attachments required additional expense to the patient, for both the crowns or resin-bonded retainers on the abutment teeth as well as the attachments themselves. Poor dental motivation and manual dexterity of the patient may result in earlier failure than with the use of conventional clasping. Repairs or alterations are difficult or impossible with some attachments. Intracoronal Semi-precision Attachments Intracoronal attachments are totally incorporated into the cast crown of the tooth. The advantage is that the forces exerted by the prosthesis are applied more closely to the long axis of the tooth and having a more desirable resistance to vertical and lateral forces. (Figure 2) 5 This way, the cantilever effect of a distally extended saddle would be less and therefore there would be less torque on the abutment teeth. Intracoronal attachments are non-resilient and may require double abutting or splinting of the adjacent teeth. This form of attachment offers indirect retention and a more precise path of placement.

Fig 2 The one on the left is the torquing force generated by the occlusal rest of a conventional RPD, and the one on the right is generated by the intracoronal attachment. As we can see, xâ&#x20AC;&#x2122; is shorter than x, which means the force exerted by the attachment is applied more closely to the long axis of the tooth than which by an occlusal rest. Also, the force is applied more apically and closer to the center of rotation. Therefore, less unwanted movement caused by the torque and non-axial loading there would

be.5

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Fig 3 Example of an intracoronal attachment. A crown was prepared on the 1.6. And metal-ceramic crown with an intracoronal attachment on the mesial side is placed.

Extracoronal Semi-precision Attachments Extracoronal attachments are situated external to the developed contour of the crown. The majority of extracoronal attachments have resilient attributes. Attachment alignment is not as critical in highly

resilient extracoronal attachments due to the omniplanar motion possible. This creates the advantage of multiple paths of placement for the prosthesis. Patients with biomechanical limitations not withstanding a rigid attachment apparatus or anatomic limitations precluding a finite path of placement are strong candidates for resilient attachments. Because mucosa is more readily displaced than natural teeth, many extracoronal attachments are designed to allow a certain degree of movement between the components, which means theyâ&#x20AC;&#x2122;re stressbreaking or more resilient.7 However, the vertical denture movements exceeding 0.3 mm are likely to damage the distal mucosa. Extracoronal attachments transmit vertical loads away from the long axes of the abutment teeth, a drawback overcome by splinted abutments and a well-constructed denture.7 Rehabilitation of partially edentulous arch can be challenging when it is a distal extension situation classified as Kennedyâ&#x20AC;&#x2122;s class I and class II. In such condition, a fixed partial denture cannot be fabricated because of missing distal abutment. Dental implant is a possible treatment, however, due to economic reason or insufficiency of mandibular bone, sometimes itâ&#x20AC;&#x2122;s not the most adequate treatment option. Therefore in such situations, a removable partial denture is largely preferred. RPDs are made retentive by the use of retainers and precision attachments. To restore distal extension area, extracoronal attachments are preferred over intracoronal ones.3,4,8,9 The stress-control on abutment is

Fig 4 Example of extracoronal attachment used in distal extension saddle area. The mesial rest seats and the lingual bracing arm provide indirect retention, support, anteroposterior stability, and mediolateral stability.

an essential factor for the success of distal extension cast partial denture. Rigid Semi-precision Attachments Rigid attachments provide all of the necessary functions of a direct retainer. Rigid attachments allow very little or no movement between the patrix and matrix. They are usually used in restoring Kennedy Class III bounded saddle area or other Kennedy modification area and are usually not used in distal extension saddle area. The great amount of torque generated by occlusal load when used in distal extension saddle area makes the abutment tooth rotate and the shearing force caused by the occlusal load would also debond the cement between the cast crown and the abutment tooth.3,6 Resilient Semi-precision Attachments Resilient attachments provide a defined amount and direction of movement of their component parts, permitting movement of the denture base toward the tissue under function, while theoretically minimizing the amount of force being transferred to the abutment teeth. Therefore, resilient attachments are considered stress-breakers. Resilient attachments may provide a hinged motion, allowing movement along one plane, or a rotary motion, allowing movement along many planes. Extracoronal attachments are usually more resilient.5 For the resilient attachments to maintain their ability to move freely in all planes without binding or torquing the teeth, the connection between the components of the resilient attachments must be the only contact between the removable partial denture and the teeth.5 When this premise is followed, the removable partial denture derives little more than retention from the abutment teeth, while support, bracing, and stability are derived primarily from the residual ridge. Therefore, some believe that additional components must be incorporated into the removable partial denture design to provide the necessary 0

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functions of a direct and follow sound principles of prosthodontics.5 Specially designed rests and guiding planes on surveyed crowns contacted by the major connector may be used to supply support and bracing for the prosthesis. The rests and guiding planes also provide the positive relationship between the rigid framework and the relationship of the denture base to the residual ridge. Unfortunately, when this feature is incorporated, the movement of the prosthesis is more restricted but proponents feel that the benefits of such a design outweigh some loss of movement of the prosthesis.5 Survival Rate Study done by David R. Burns and John E. Ward have shown attachments’ average survival rate of 83.35% for 5 years, of 67.3% for up to 15 year, and 50% when extrapolated to 20 years.5,9 A low survival rate of 70% after 5 years refers partially to non-splinted abutment teeth, which created a lack uniformity in the bilaterally retained RPD. Nonsplinted abutment teeth with a RPD design without reciprocation elements in patients with a reduced vertical dimension may put this type of restoration at risk for failures.10 Some clinical studies of rigid precision attachmentretained removable dental prostheses report good results with 80% of prostheses functioning properly after a 3-year period, other studies observed failure rates of 35% to 40% after 5 years and only a 30.1% clinical survival rate after 8 years.11,12 Acknowledgment Articles reviews and clinical photos were provided by Dr. Alastair Edwin Dent, DDS, MS, Department of Prosthodontics CEU Cadernal Herrera. Reference 1. James S. Brudivik. Advanced Removable Partial Dentures. Quintessence Publishing Co, Inc 0

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2. Robert P. Semiprecision attachmentretained removable partial dentures. QDT 1994:137-144 3. Sumit Makkar, Anuj Chhabra, Amit Khare. Attachment Retained Removable Partial Denture: A Case Report. Int. Journal of Clinical Dental Science 4. Z. Ben-Ur, I. Aviv, C. Gorfil, R. Himmel. The semiprecision connector design for distal extension removable partial dentures. Quintessence International Volume 19, Number 12/1988 5. D.R. Burns, J.E. Ward. “Review of attachments for removable partial denture design: 1. Classification and selection,” The International Journal of Prosthodontics, vol. 3, no.1, pp. 98-102, 1990. 6. Mu YD, Fan YB, Yang XM. Clinical study on the abutment periodontal condition with extracoronal attachment denture. Hua Xi Kou Qiang Yi Xue Za Zhi. 2008 Aug;26(4): 371-3 7. H W Preiskel. Precision attachments for partially dentate mouth. Annals of the Royal College of Surgeons of England (1974) vol 55 8. Naveen Gupta, Abhilasha Bhasin, Parul Gupta, and Pankaj Malhotra. Case Report: Combined Prosthesis with Extracoronal Castable Precision Attachments. Hindawi Publishing Corporation, Case Reports in Dentistry Volume 2013, Article ID 282617, 4 pages http://dx.doi.org/ 10.1155/2013/282617 9. D.R. Burns, J.E. Ward. “A review of attachments for removable partial denture design: part 2. Treatment planning and attachment selection,” The international Journal of Prosthodontics, vol. 3, no.2, pp. 169-174, 1990 10. Johannes S, Manfred W, Stephan R, Jorg H, Stefan H. Five-year clinical follow-up of prefabricated precision attachments: A comparison of uni- and bilateral removable dental prostheses. Quintessence Int 2011;42:413-418 11. Zajc D, Wichmann M, Reich S, Eitner S. A prefabricated pacision attachment: 3 years of experience with the Swiss Mini-SG

system. A prospective clinical study. Int J Prosthodont 2007;20:432-434 12. Studer SP, Mader C, Stahel W, Scharer P. A retrospective study of combined fixedremovable reconstructions with their analysis of failures. J Oral Rehabil 1998;25:513-526

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How to: Set a Simple Dental Studio at Home P&W | EViDENT keywords: dentistry, digital, photography, studio, video recording Introduction Since the coming of the digital technology era, more and more dental treatment planning, dental education are using tons of photos, videos and etc. to show the dentists and the patients to simulate the thoughts and the ideas. By using these medias, sharing your philosophy would be easier via Facebook and Youtube. And with the discussion online, the reaching to the next level could be achieved. Unlike the clinicians, dental students sometimes have the difficulty to access a studio for doing projects and works. And of course, not many of the labs have the equipments satisfy for the work you have in your mind. To have everything is prepared, a simple dental studio could be easily set up at your home for practicing lecturing or any educational video recording. A Table, A Chair, and A Lots of Lights

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Tables and chairs are easy to get at home. Plastic bags, or any blanket could be used to cover the table for better recording quality (same background), and protect the surface of the table. Chairs with adjustable height mode are advised to have the better angle when operating the models or any hands-on. Last but not least, the lights. It is important to have multiple lights sources, using lamps from different corners to prevent the possibilities of shadows while taking photos. (Figure 1) Sunlights from windows are a great choice to support the photo shots have the correct measurement of the chroma and values.

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Sterilization, A Pre-preparation The instruments for the practicing should be sterile even though it is a hands-on only. Gloves and related materials are necessary to prepare for any circumstances. Since the practice and the works are doing at home, the sterilization is done before in the clinic, and bring the packages home. After the practice, brush the instruments with detergent and seal in the new package. Blades and medical wastes have to store in containers and bring to the clinic soon to deal with them with restricted control.

Webcam, for the Better Solution Most of the dental videos have the problem of stability. It is recommended to have a webcam and a small tripod to hold it on your desk. (Figure 2) Most of the webcams nowadays have 1080HD for video recording and zoom in function. To have the better quality, focus mode should be controlled manually before the recording, preventing the autofocus switched the objects when practicing. Sounds of explanation could be recorded together or separated for more details. Your Editing Could Be Done Easily There are a lot of computer software to adjust your photos and videos after the shooting. The highlighting of the purposes could be done

by cropping photos and trimming videos. (Figure 3) It is suggested not to edit too much for the â&#x20AC;&#x153;realâ&#x20AC;? situation. Colours should be monitored carefully. Using grey colour papers to take samples could demonstrate the possibilities of the later shots. It is always to have the flash on for great photos not to blur too much. Start Your Sharing Sharing your knowledge using photos and videos is a great way to have your own documentation. Using references of articles is an option to backup the studying and the results. (Figure 4) In case of more future practices, the comparison of studies could be used to enlarge the dental resources, and creating your own electronic dental library.

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Is Esthetics the Trend for Adult to Receive Orthodontic Treatment? Kai-Wen Ko, Po-Sheng Hsueh, Yueh-Ling Lee keywords: descriptive, esthetics, malocclusion, orthodontics, treatment planning Introduction It is obvious that more and more people are receiving orthodontic treatment nowadays no matter what their age are. You might hear that people around us saying “ Hey, I want to receive an orthodontic treatment! ”, “ Don't you think that I look better if my incisors are more backwards? ” Are you curious about the main reason why they want to have orthodontic treatment? It seems that they looked no difference from the others. When you ask them why they want to be treated? The answers always comes up with “ I want to have better appearance. ” This might ring the bell that people pay more attention on their aspect. Therefore, orthodontic treatment provides an option to improve the facial appearance. Sometimes it is offer with the plastic surgery, which considered as a non-invasive treatment and the therapeutic effect is quite significant to make better facial esthetics. Orthodontics treatment is the branch of dentistry, which corrects the relationship between teeth and jaws that are positioned inadequately. Askew teeth that are not well fitted are harder to clean and it leads to early lose of the teeth due to the decay and periodontal disease. Another problem is that the teeth would suffer form the improper bite force when functioning, in this case it could cause headaches or temporal mandibular joint disorder or more sever to effect the neck, shoulder and back pain.1 As we know that the teeth are closely related to the facial bones and the soft tissues, therefore when providing the orthodontic treatment, not only the movement of teeth is seen but also the adjustment of the facial bone could be . 45

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observed. When mentioning the soft tissue, orthodontics could help to take care the longterm health of the teeth, gingiva status, and the temporal mandibular joint under a carefully supervision.2 The orthodontic treatment usually addressed in the patients who have malocclusion, need maintaining spaces for permanent teeth eruption, and expand maxillary and mandibular arches for solving crowded dentition during the growth of the children. Basically, the best time for performing this kind of treatment would be childhood or adolescent, whereas the adults could also receive orthodontic treatment and more and more cases are seen.3 Study shows that orthodontic treatment in adults might or might not differ from the one which perform in adolescents. Whereas when there is some difference it would depends on several factors, such as the severity of the malocclusion, the quantity of the restorations, whether presenting previous trauma or abrasion of teeth, susceptibility to periodontal disease, and temporal mandibular disorders.4 However, in adult patients, esthetics would be the main concern for them. Reports indicates that there is a 34% greater in performing orthodontic treatment due to the demand of improving the appearance.5 In this case, how to restore a good looking smile are important for adults. In order to meet the needs, some progress has been made by the dentists: the evolution time, the requirement of materials, which used in orthodontic treatment and the technique. In our study, we are interesting to know that why people aged from 18 to 65 are willing to

have the orthodontic treatment. Due to the previous study we assume that esthetic is the key for adults to ask for orthodontic treatment.

visit and didn't come for clinic diagnosis and treatment were excluded from our study. Data Analysis

Materials and Methods Statistic analysis was performed using the software Microsoft Office Excel.

There are 78 patients selected from the age group of 18 to 65 years old at Universidad Cardenal Herrera CEU university Dental clinic in Valencia in Spain during 2010 to 2014. Patients who came to our university clinic for orthodontic consult or search for treatment.

Results Our study consisted of 49 patients who received orthodontic treatment in CEU in a three-month period. There are 22 males and 27 females as shown in the figure. (Figure 1)

Inclusion Criteria Patients were selected using the Gesden

According to Figure 1, most of the people who asked for orthodontic treatment are those from 26 to 35 years old followed by the people from 46 to 55 years old. It is seen that the people who received orthodontic treatment from 18 to 25 years old are nearly a half time less than those from 26 to 35 age group, and this correlation also appears between 56 to 64 and 46 to 55 age groups. Nevertheless, it is interesting to mention that those from 18 to 25 age group are two times more likely to receive orthodontic treatment than those over 65 years old; however, people who aged from 46 to 55 are three times less likely to receive orthodontic treatment than those from 36 to 45 age group.

(softeware sanitario, Henry Scheinâ&#x201C;&#x2021;) with the filter of orthodontic treatment, having birth date from 01/01/1931 to 31/12/1992 and receiving the treatment between 01/01/2010 and 31/12/2014. Patients who came to our university to look for orthodontic treatment were collected and we divided their motivation of the treatment into four groups: Esthetic, Malocclusion, Space creation such as implant, and Fixation for periodontal disease. Exclusion Criteria According to our selected criteria, patients who aged more than 65 and less than 18 years old, and patients who came for their first

Number of People

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We see the number of women who received orthodontic treatment are two times greater than the number of man who received orthodontic treatment in both 36 to 45 and 18 to 25 age groups; whereas in the age group 46 to 55, the number of women who received orthodontic treatment are four times less than the number of man who received orthodontic treatment. It is worth to mention that in nearly all age groups, the number of people who received orthodontic treatment is greater in women except for 46 to 55 and 56 to 64 age groups. According to the pie chart (Figure 3), esthetic comes at the first place following by perio fixation. It is seen that esthetic factor is six times (78%) greater than perio fixation (12%); whereas periodontal fixation is two times more than space creation (6%). It is worth to mention that malocclusion (4%) is two thirds less than space creation and one third less than periodontal fixation. Discussion Orthodontic treatment is thought to be a solution of providing perio fixation when the tooth is in moderate mobility,6 creating spaces for prosthetics restorations such as implants 7 and correcting malocclusion which causing the difficulty of oral hygiene maintenance or - ,

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Percentage of Treatment Goal

Esthetic Space Creation Perio Fixation Malocclusal 0 5 79 5 9 5 5 9 7 ; 9 19 6 5 1 95

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leading to severe trauma in the dentition during a long period of time. However, it is interesting to find out in our study that most people who looked for orthodontic treatment are due to the esthetic concerns (78%). Our outcome of study is similar with the article following.8 Why does esthetics come at the first place among other reasons for people to have the orthodontic treatment? Nowadays, people pay more attention on the way they smile. “ I want to have eight upper teeth showing when I smile ”, “ I want to have a brighter and whiter teeth”, “ Why aren’t my incisors symmetric, I want them to look the same! ”, “ I don’t want a gummy smile! ”, “ I don’t want my lower incisors to be seen when I smile”, “ I want to have a charming smile like those movie stars! ” You may hear people complaining these sorts of things everyday. Is it so important to have a harmonious appearance? Few reports review that having

good appearance has some correlation with social interaction,9 for example, people are more willing to make friends with those look nicer, having more confident or the success rate might be higher, although it is not scientifically evidence. Furthermore, some psychologists say that during the interview, those candidates who look prettier have more possibility to be employed! Therefore in our result there were more female came to clinic than men, and the average age of female is younger than men. This result shows female who care about their face appearance more than men. Furthermore, our results also point out that those patient who received orthodontic treatment not for esthetic concern are those over 45 years. This tell us that probably people over 45 years old care less of their appearance whereas young adults care more. In spite of some orthodontics mention that the orthodontic treatment provides in childhood not only could prevent the malocclusion but also lead to an esthetic appearance. ref It is because the teeth development in early ages has an intimate relationship with facial bony growth and soft tissue growth, therefore, both of them could affect the dentition alignment also the smile line. In this case, the nonesthetics appearance could be avoided by receiving the orthodontic treatment in growing ages. However, in adults, orthodontic treatment is more concerning about teeth alignment when we are talking about the esthetics. In the pursuance of better appearance, a perfect alignment dentition is insufficient. The most important thing is to maintain a good oral hygiene! Conclusion Overall, more and more people pay their attention on their smile, which effect the facial appearance, especially people who are in the prime of life. Those who are not satisfying their appearance could go for orthodontic treatment to make a better, harmony smile and looks.

Although esthetics is the main trend for adults to have this treatment done, we still could not ignore the original needs of orthodontic treatment such as: mobility periodontal fixture, space creator and malocclusion corrector. In other words, orthodontic treatment is not only a treatment for teeth alignment to provide good appearance but also a solution for further treatment. Reference 1. Colgate-Palmolive, What Is Orthodontics?, C o l g a t e O r a l C a r e C e n t e r, h t t p : / / www.colgate.com/en/us/oc/oral-health/life-stages/ teen-oral-care/article/what-is-orthodontics

2. B r i t i s h D e n t a l H e a l t h F o u n d a t i o n , Orthodontic Treatment, British Dental Health Foundation, https:// w w w. d e n t a l h e a l t h . o r g / t e l l - m e - a b o u t / t o p i c / orthodontics/orthodontic-treatment

3. Carneiro CB, Moresca R, Petrelli NE, Evaluation of Level of Satisfaction in Orthodontic Patients Considering Professional Performance, Dental Press J Orthod., 2010 Nov-Dec;15(6):56:e1-12 4. Filho LC, Aranha MFB, Ozawa TO, Cavassan A, Orthodontic Treatment in Adults: Restoring Smile Esthetics, Dental Press J Orthod., 2012 Sept-Oct;17(5): 53-63 5. DentistryIQ Editors, Study Finds a 34% Rise in Dentists Performing Orthodontic Tre atme n ts, De n ti stry i Q, http:// www.dentistryiq.com/articles/2013/10/study-findsa-34-rise-in-dentists-performing-orthodontictreatments.html

6. Braun JI, Orthodontics for the Older Adult, Dear Doctor Dentistry & Oral Health, http:// www.deardoctor.com/inside-the-magazine/issue-21/ orthodontics-for-the-older-adult/

7. Rose TP, Jivraj S, Chee W, The Role of Orthodontics in Implant Dentistry, British Dental Journal, 2006;201:753-764 8. Margolis MJ, Esthetic Considerations in Orthodontic Treatment of Adults, Dent Clin North Am, 1997;41(1):29-48 9. Philips C, Beal KN, Self-concept and the Perception of Facial Appearance in Children and Adolescents Seeking Orthodontic Treatment, Angle Orthod., 2009 Jan;79(1):12-6 . 45

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Porphyromonas Gingivalis - The Bacteria of Periodontitis Chen-Che Hung, DDS. keywords: bacteria, biofilm, gingivitis, microbiology, periodontics, periodontitis, porphyromonas gingivalis Introduction Periodontal disease is considered as an gum infection of the tissues that surround and support your teeth. It is an inflammatory-based infection with progressive destruction of the periodontal ligament (PDL) and alveolar bone, leading to tooth loss. Gum infection starts from initial phase, gingivitis, with swelling and redness, moderate phase including bone loss, which is the significant sign, of periodontitis in adult. The severe phase with would be serious periodontitis and chances of losing the teeth. In the mouth, the teeth provide hard, nonshedding surfaces for the development of extensive bacterial deposits. With the accumulation of the bacteria, over 300 species

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have been isolated and characterized in these deposits, it is still not possible to identify all the species present.1 The deposits of the bacteria have been termed as dental plaque, forming a bacterial environment, the biofilm. Individual studying by Loe H et al.2 found out if 5 days without oral hygiene, the oral cavity would suffer the increase of the plaque and forming gingivitis in 15 days. However, with the toothbrushing afterwards, the inflammation signs disappear. The summary is, gingivitis is produced by plaque and is reversible. In 1975, Lindhe et al.3 induce periodontitis in dogs and observe that gingivitis does not transform to periodontitis immediately. Second, the periodontal disease can affect single tooth

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or multiple teeth. and last, the plaque is not the absolute problem to the patients, is the bacteria inside the oral environment. Periodontitis could be in 2 types. Aggressive and Chronic. Aggressive periodontitis is a highly destructive form of periodontal disease that occurs in patients who are otherwise healthy. Common features include rapid loss of tissue and bone and may occur in some areas of the mouth, or in the entire mouth. Chronic periodontitis can lead to the loss of tissue and bone that support the teeth and it may become more severe over time.(Figure 1) Microbial Etiology of Periodontal Disease The main etiological factor is oral biofilm with microorganisms. The search for the pathogens of periodontal diseases has been underway for more than 100 years, and continues up today. The currently recognized key Gram-negative periodontopathogens include: Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus, Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, Capnocytophaga species, and Campylobacter rectus.All bacteria in the periodontal pocket could damage periodontal tissues, and good knowledge of these as well as an adequate treatment could be helpful in treatment of this disease. A full understanding of the microbial factors, their pathogenicity as well as host factors are of the essential importance for pathogenesis of periodontal disease. In this way, it could be possible to treat the periodontal patients adequately.1 The microorganisms could produce disease directly, by invasion on the tissues, or indirectly by bacterial enzymes and toxins. In order to be a periodontal pathogen, a microorganism is must have the following: - The organism must occur at higher numbers in disease-active sites than at diseaseinactive sites. - Elimination of the organism should arrest disease progression. - The organism should possess virulence factors relevant to the disease process.

- The organism should elicit a humoral or cellular immune response. - Animal pathogenicity testing should infer disease potential. Oral Biofilms (Microbial Complexes) Dental plaque biofilm is the community comprises bacterial micro-colonies, an extracellular slime layer, fluid channels, and a primitive communication system. Bacteria are the primary etiologic agents in periodontal disease.4 The association of bacteria is not random; there are specific associations among bacterial species. Depending on the phases of the plaque formation, there are pellicle formation, attachment, young supragingival plaque, aged supragingival plaque, and subgingival plaque formation. Also, bacterial species are also different depending on early or late colonizations, there are different microbial complexes as following, (Figure 2) Early colonizers

- Blue complex: Actonomyces species. - Yellow complex: members of genus Streptococcus.

- Green complex: Capnocytaphaga species, A. actinomycetemcomitans serotype A, E. corrodens and Campylobacter consisus. - Purple complex: V. parvula and Actinomyces odontolyticus. Late colonizers (major etiologic agents of periodontal disease Gram-negative)

- Orange complex: Campylobacter gracilis, C. rectus, C. showae, E. nodatum, F. nucleatum subspecies, F. periodonticum, P. micros, P. intermedia, P. nigrescens and S. constellatus. - Red complex: B. forsythus, P. gingivalis and T. denticola. The microorganisms affect the habitat and the habitat affects the microorganisms too. With different groups of the bacteria, there are some signs to identify the etiology.

subgingival layer that replaces the existing gram-positive, facultative bacteria with gramnegative anaerobic bacteria, eliciting an inflammatory response that results in the gums detaching from the teeth. Virulence Factor

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For example, the prevalence and counts of periodontal disease increased when we have more bacteria in orange and red complexes, which the local environment such as the length of the probing depth increased, gingival inflammation (BOP) and suppuration could be found. P. gingivalis, the Red Complex Porphyromonas gingivalis is a non-motile, Gram-negative, rod-shaped, asaccharolytic, anaerobic pathogenic coccobacillus bacterium. (Figure 3) Consider as â&#x20AC;&#x153;black-pigmented bacteroidesâ&#x20AC;? because of black colonies formation on blood agar. It is aerotolerant which helps the transmission of the organism between individuals and initial survival in the oral cavity. It is one of the common pathogens in early onset periodontitis. This microbe works with other bacteria to create a biofilm in the

P. gingivalis plays an important role in the progression of periodontal disease and the destruction of tissue and bone. It can be attributed to the multiple virulence factors that contribute to its defence and destruction against epithelial cells. An important form of evasion for P. gingivalis is its capsule, which prevents phagocytosis. The presence of fimbriae surrounding the bacteria allows for adhesion to the epithelial cells promoting colonization.(Figure 4) Important virulence factors for P. gingivalis are the proteases, which have the ability to disrupt complement activity, degrade immunoglobulins, cleave matrix proteins, and inhibit iron transport. Animal studies have shown a reduction in virulence when proteases are inactivated. Other virulent factors include endotoxin, collagenase, phospholipase A, hemolysin, and fibrolysin. It has the capacity to invade junctional epithelium and subgingival tissues too.6

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The bacteria, P. gingivalis, in addition to others causes gingivitis as well as periodontitis. Gingivitis is "A disorder involving -

inflammation of the gums; may affect surrounding and supporting structures of the teeth.” periodontitis is "inflammatory reaction of the tissues surrounding a tooth (periodontium), usually resulting from the extension of gingival inflammation into the periodontium.” P. gingivalis expresses proteolytic enzymes which regulate the protein function in the body. 7 These enzymes are usually utilized for Cysteine and Arginine metabolism. However, here they affect the link between the tooth and the bone, thus ultimately separating the two from one another, which causes the taking apart of the tooth from jaw. Symptoms including, swelling, redness and the pain of the gum tissue, bad breath, destruction of the oral mucosa, losing the structures and the fail of supporting teeth. Besides periodontal disease, P. gingivalis has been linked to rheumatoid arthritis. P. gingivalis contains the enzyme peptidylarginine deiminase (PAD), which is involved in citrullination. Patients with rheumatoid arthritis have an increased incidence of periodontal disease and antibodies against the bacterium are significantly more common in these patients. Also, the pathology might include the upper gastrointestinal tract, respiratory tract, and in colon. Invasion into gingival tissues P. gingivalis has many ways of evading host immune responses which affects its virulence. P. gingivalis does this by using a combination of gingipain proteases, a capsular polysaccharide, induction of host cell proliferation and the cleavage of chemokines responsible for neutrophil recruitment. Ultrastructural study demonstrated bacterial invasion in the apical gingiva of patients suffering from advanced chronic periodontitis. In disease legions, the barrier (periodontal pocket) is insufficient to prevent plaque bacterial invasion of the pocket walls, and subgingival plaque bacteria including P. gingivalis penetrate gingival epithelium. The -

bacterial penetration and access to the connective tissue is augmented by enlargement of the intercellular spaces of the junctional epithelium caused by destruction of intercellular junctions.8 Treatment Treatment for periodontal disease should always start from the basic phase, which is scaling and root planning the teeth. (Sc/Rp) It is hard to eliminate all the biofilm simply taking medication or brush with normal toothbrushes, which providing supragingival cleaning only. Scaling and root planning is essential in every periodontal therapy. By using ultrasonic devices first to remove the supragingival plaque and calculus.(Figure 5) Afterward, apply the plaque removal instruments, such as curettes and sickles to clean more subgingivally. The curettes is inserted with the face of the blade parallel to the root surface and with a light contact. Once the blade achieve to the base of the pocket, the starting point, the instrument is turned into cutting position Then, the blade cuts and moves to the coronal direction. Beginning removing the calculus, the biofilm and etc. It’s hard and almost impossible to removal all the bacteria, but the curettes should always insert till the bottom of the pocket to try to eliminate as much as possible. If the cleaning is not efficiency due to the “blind” of the vision, we should always suggest the patients to take periodontal surgery.

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Medication is provided as post-cleaning treatment and maintenance. Antibiotics have different spectrums and affect microbes in different manners. Amoxicillin is a broadspectrum penicillin in the beta-lactam family. Beta-lactam antibiotics’ mechanism of action is inhibition of cell wall synthesis. Amoxicillin is drug of choice for Viridens group Streptococci, E. corrodens, F. nucleatum, non-betalactamase Prevotella, and Porphyromonas spp.. The other choice of the medication would be Metronidazole, which is a bacteriocidal nitroimazole. The mechanism of action is that the active moiety damages bacterial and protazoal DNA, leading to cell death. Metronidazole is effective against obligate anerobes such as Porphyromonas spp., Prevotella spp., Bacteroides spp., Fusobacterium spp., and Clostridium spp.. Clindamyacin is a lincosamide antibiotic, which is another choice for the treatment. It is a bacteriostatic antibiotic that has a mechanism of action that binds to the 23s subunit of the 50s ribosome that prevents bacterial protein synthesis. It is effective against many grampositive and gram-negative anaerobic and facultative anaerobic bacteria, including Prevotella, Porphyromonas, Eubacteria, and Streptococci spp..8 Conclusion Periodontal disease is very common not only in elderly but also in adults and some children. it is consider that more than 70% of the population in the world have chances suffering in this problem. Although it is not a systemic disease, we should still focus on the treatment and prevention. P. gingivalis, as one of the bacteria in severe periodontitis, it is very important to clarify this bacteria and eliminate for the better consequences. Treatment plans for the patients with periodontal disease should also include if he/ she has any systemic problems such as diabetes for better prognosis and “target down” the major bacteria for the better procedures and medication. Oral hygiene is indicated and should be well educated to the society to prevent the periodontitis, which P. gingivalis is mostly found. The role of P. gingivalis as a community

activist in periodontitis is seen in specific pathogen free (SPF) mouse models of periodontal infections. In these models P. gingivalis inoculation causes significant bone loss which is a significant characteristic of the disease. In contrast, germ free (GF) mice inoculated with a P. gingivalis mono infection causes no bone loss indicating that P. gingivalis alone cannot induce periodontitis.9 Studies recently are focusing on the fimbriae, specifically finding ways to inhibit the minor fimbriae production as that would prevent the formation of a biofilm on the tooth. After all, prevention is always better than cure. Reference 1. Lindhe J, Clinical Periodontology and I m p l a n t D e n t i s t r y, 5 e d . , B l a c k w e l l Munksgaard 2. Jöe H, Etiology and Prevention of Periodontal Diseases, Rev Odontol Ecuat, 1975;20(66):1-8 3. Lindhe J, Hamp S, Löe H, Plaque Induced Periodontal Disease in Beagle Dogs, J Periodontal Res., 1975;10(5):243-255 4. N i e l d - G e h r i g J S , F o u n d a t i o n s o f Periodontics for the Dental Hygienist, Lippincott Williams & Wilkins 5. Porphyromonas Gingivalis W83, Bacmap Genome Atlas, http:// bacmap.wishartlab.com/organisms/ 66#biography 6. Kimura S, Ohara-Nemoto Y, Shimoyama Y, Ishikawa T, Sasaki M, Pathogenic Factors of P. gingivalis and the Host Defense Mechanisms, Pathogenesis and Treatment of Periodontitis, InTechOpen, 2012;Jan(20) 7. Porphyromonas gingivalis, microbe wiki http://microbewiki.kenyon.edu/index.php/ Porphyromonas_gingivalis 8. Baffin M, Systemic Antibiotics in the Treatment of Periodontal Disease, Surgical-Restorative Resource, 2011 9. Hajishengallis G et al., A Low-Abundance Biofilm Species Orchestrates Inflammatory Periodontal Disease through the Commensal Microbiota and the Complement Pathway, Cell Host Microbe. 2011;17:10(5):497-506 -

Intermediate Implants Prosthodontics Course by MPI X P&W | EViDENT P&W | EViDENT keywords: dental implants, hands-on, keynote lecturing, mpi, prosthodontics In 2014, P&W I EViDENT Team and MPI by Dr. Fernando Rojas-Vizcaya organized the 1st intermediate implants prosthodontics course for undergraduate dentistry students, for understanding the basis of dental implants and established demonstration via hands-on workshop with support from BoneModels and Dentsply Implants. P&W | EViDENT Team introduce the basis of the dental implants and the theoretical terms of the knowledge. Dr. Fernando Rojas-Vizcaya carries the topics and leads to the intermediate level of the oral implantology. The course has included a live surgery in the morning session for the participants to familiar the real situation in the operating room. Continue to the afternoon, hands-on workshop has the exactly same diagnosis of the patient. With the custom-made BoneModels, all kinds of the treatment planning and the preparing are possible!! Of course, we are preparing for more kinds of programs with these international partnership in the academic field!

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for further upcoming courses, please contact us!

Contact: P&W | EViDENT: evident.academic@gmail.com | www.perioprosthocc.wordpress.com MPI: arantxa@prosthodontics.es | www.prosthodontics.es Fernando Rojas-Vizcaya, DDS, MS Prosthodontist & Oral Surgeon

with the support of Implant Prosthodontic Program

UNC DENTISTRY

Department of Prosthodontics

With the support of

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