Epilepsi and Dental Procedure

4 NYSDJ • MARCH 2008

EDITORIAL

DENTAL TECHNOLOGY continues to evolve at an unprecedentedrate. A cursory perusal of the content of local, state, national andinternational continuing education programs attests to our percep-tion that there has been a notable surge in relevant scientificadvancements in dentistry over the past few years. At the sametime, the dental clinician’s strong interest in these advances isundeniable. Our ability to replace teeth (implants) as well as ourcapability, in many instances, to improve the specific biologic envi-ronment where these implants will, it is hoped, thrive and remain(site development) could not have been imagined 25 years ago.

The link between oral health and systemic disease states hasbecome more clearly defined. Similarly, stem cell research utilizingundifferentiated cells from human tooth pulp tissue holds thepromise of dramatically improving future dental and medical care.Additionally, we have identified the etiology of dental caries and itstransmissibility mechanisms. And we have developed specific pro-tocols that have shown to be incontrovertibly effective in preventingthis disease.

The problem of limited access to oral health care has receivedconsiderable attention in the past few years. There is growing con-cern that our modern dental technology and exquisite academicand clinical training programs are not benefiting large segments ofthe public. There appear to be reversals in oral health status nation-ally and abroad. Identifying the constellation of complex factorsthat might be contributing to limiting access will be a fundamentalstep in removing current obstacles to oral health care for all. Some

of these areas might include creating incentives for recent dentalschool graduates to relocate either temporarily or permanently tounderserved areas. Incentives should include some form of “loanforgiveness” or monetary consideration in light of the tremendouspersonal debt that dental school graduates typically have. Naturally,such an incentive must also include removing any existing barriersto the freedom of professional movement within the U.S.

Who will be leading this effort to bring the benefits of moderndentistry to a larger segment of our population? It will be the tri-partite dental organization, led by the American Dental Association.It will be the ADA who will visibly and genuinely remain proactivein oral health care access issues as a major stakeholder and whowill not remain on the side lines and, perhaps, on the “coat tails” ofother heath professions.

The ADA will be challenged to find creative paths to conse-quentially partner with academic and research institutions, thedental manufacturing industry, government, the public and indi-vidual dentists, all in an effort to resolve the pressing problem oforal health care access, while, at the same time, protecting the sanc-tity of the dentist/patient relationship.

These are exciting and challenging times for the dental profes-sion and individual dentists. Only through our powerful collectivevoice, the American Dental Association, can we hope to achieve ourenlightened goals.

Progress in DentistryRemarkable paradox. Remarkable challenge.

D.D.S. M.Sd

Letters

NYSDJ • MARCH 2008 5

NYSDAD i r e c t o r y

OFFICERSStephen B. Gold, President 8 Medical Drive, Port Jefferson Station, NY 11776

Michael R. Breault, President Elect 1368 Union St., Schenectady, NY 12308

Robert Doherty, Vice President280 Mamaroneck Ave., White Plains, NY 10605

Richard Andolina, Secretary-Treasurer74 Main St., Hornell, NY 14843

Steven Gounardes, Immediate Past President351 87th St., Brooklyn, NY 11209

Roy E. Lasky, Executive Director20 Corporate Woods Boulevard, Albany, NY 12211

William R. Calnon, ADA Trustee3220 Chili Ave., Rochester, NY 14624

NY County-Lawrence Bailey215 W. 125th St., New York, NY 10027NY County-Matthew J. Neary501 Madison Ave., Fl. 22, New York, NY 10022NY County- Robert B. Raiber630 Fifth Ave., #1869, New York, NY 101112-Craig S. Ratner7030 Hylan Blvd., Staten Island, NY 103072-James J. Sconzo1666 Marine Parkway, Brooklyn, NY 112343-Lawrence J. Busino2 Executive Park Dr., Albany, NY 122033-John P. Essepian180 Old Loudon Rd., Latham,NY 121104-Mark A. Bauman157 Lake Ave., Saratoga Springs, NY 128664-James E. GalatiParkwood Plaza, 1758 Rte. 9, Clifton Park,NY 120655-William H. Karp472 S. Salina St., #222, Syracuse, NY132025-John J. Liang2813 Genessee St., Utica, NY 135016-Robert G. Baker Jr.803-805 Cascadilla St., Ithaca, NY 148506-Scott Farrell39 Leroy St., Binghamton, NY 139057-Robert J. Buhite II1295 Portland Ave., Rochester, NY 146217-Andrew G. Vorrasi2005-A Lyell Ave., Rochester, NY 14606

8- Jeffrey A. Baumler2145 Lancelot Dr., Niagara Falls, NY 143048- Kevin J. Hanley959 Kenmore Ave., Buffalo, NY 14223-31609-Edward Feinberg14 Harwood Ct., Ste. 322, Scarsdale, NY 105839-Malcolm S. Graham170 Maple Ave., White Plains, NY 106019- Neil R. Riesner111 Brook St., 3rd Floor, Scarsdale, NY 10583-5149N- Peter M. Blauzvern366 N. Broadway, Jericho, NY 11753-2032N-David J. Miller467 Newbridge Rd., E. Meadow, NY 11554N-Frank J. Palmaccio2 Bayard Drive, Dix Hills, NY 11746Q-Chad P. Gehani35-49 82nd St., Jackson Heights, NY 11372Q-Robert L. Shpuntoff28 Beverly Rd., Great Neck, NY 11021S-Paul R. Leary80 Maple Ave., #206, Smithtown, NY 11787S-Steven I. SnyderSuffolk Oral Surgery, 264 Union Ave., Holbrook, NY 11741B-Stephen B. Harrison1668 Williamsbridge Rd., Bronx, NY 10461B-Richard P. Herman20 Squadron Blvd., New City, NY 10956

BOARD OF GOVERNORS

Annual MeetingsAlan L. MazerP.O. Box 985, 140 Terryville Rd.Pt. Jefferson Station, NY 11776AwardsWilliam R. Calnon3220 Chili Ave., Rochester, NY 14624Chemical DependencyRobert J. Herzog16 Parker Ave., Buffalo, NY 14214Dental Benefit ProgramsIan M. LernerOne Hanson Pl., #2900Brooklyn, NY 11243-2907 Dental Health Planning/Hospital DentistryRobert A. Seminara281 Benedict Rd., Staten Island, NY 10304Dental PracticeSteven L. Essig33 Main St., Ravena, NY 12143Dental Education & LicensureMadeline S. Ginzburg2600 Netherland Ave., #117Riverdale, NY 10463EthicsKevin A. Henner163 Half Hollow Rd., #1, Deer Park, NY 11729

Governmental AffairsAlan L. MazerP.O. Box 985, 140 Terryville Rd.Pt. Jefferson Station, NY 11776InsuranceRoland C. Emmanuele4 Hinchcliffe Dr.Newburgh, NY 12550Membership &CommunicationsLidia Epel165 N. Village Ave. #102Rockville Center, NY 11570New DentistDavid C. Bray18 Leroy St., Binghamton, NY 13905NominationsSteven Gounardes351 87th St., Brooklyn, NY 11209Peer Review & Quality AssuranceSteven Damelio1794 Penfield Rd.Penfield, NY 14526ReliefAnthony V. Maresca207 Hallock Rd.Stony Brook, NY 11790

COUNCIL CHAIRPERSONSOFFICESuite 60220 Corporate Woods Blvd.Albany, NY 12211(518) 465-0044(800) 255-2100

Roy E. LaskyExecutive DirectorCarla HoganGeneral CounselBeth M. WanekAssociate Executive DirectorMichael J. HerrmannAssistant Executive DirectorFinance-AdministrationJudith L. ShubAssistant Executive DirectorHealth AffairsSandra DiNotoDirectorPublic RelationsMary Grates StollManaging Editor


Address CorrectionDr. Howell Archard was kind enough to for-ward me a copy of the article “CongenitalDiseases and a New York State Regulation”that appeared in the June/July NYSDJ, as wellas his letter in response to the article, whichwas printed in the November Journal. In hisletter, Dr. Archard says X-Linked Hypophos-phatemic Rickets (sometimes still known asVitamin D Resistant Rickets) should be includ-ed in the list of congenital diseases that affectthe teeth as well as the bones.

Dr. Archard mentioned our organization, butthere was an error in the Web site address.Please let people know that the correct Webaddress for The XLH Network is www.xlhnet-work.org. We also have a listserv open to peopleaffected by the condition, as well as to physi-cians and researchers interested in the condi-tion. The listserve is F—HYPDRR. Somehow, thetwo addresses became intertwined.

We greatly appreciate your help in gettingthe information out that at least in New YorkState, medical insurance is responsible fordental treatment that becomes necessary forcongenital diseases such as XLH.

Joan Reed, President XLH Network4562 Stoneledge Lane, Manlius, NY 13104

You Are InvitedNYSDA PRESIDENT’S DINNER DANCE

HONORING PRESIDENT STEPHEN B. GOLD

& THE OFFICERS OF THE ASSOCIATION FOR 2008

SATURDAY, JUNE 7, 2008Cocktails & Hors d’Oeuvres 7:30 - 8:30 p.m.

DINNER 8:30 P.M.

Lombardi’s on the Soundat the Port Jefferson Country

Club at Harbor Hills44 Fairway Drive

Port Jefferson, New York

ATTIRE: BLACK TIE

$95 PER PERSON

RSVP: Beth Wanek, NYSDA


PRIOR TO 1836, Port Jefferson was known as Drowned Meadow,because of the flooding that took place at every high tide in what istoday the village’s business district. Town fathers realized that anallusion to death by water was probably not desirable for a commu-nity of shipbuilders, and, so, the name of the settlement waschanged to Port Jefferson. The new name came easy. It was, after all,a harbor village, and President Thomas Jefferson was reputed to bethe major source of funding for a project to prevent the flooding.

When NYSDA gathers in Port Jefferson, on the north shore ofLong Island, in June for the Semi-Annual Meeting of its Board ofGovernors, they’ll find few remnants from the Drowned Meadowdays, but plenty of reminders, nonetheless, that this is a village withclose ties to the sea and a storied maritime past.

This year’s meeting will take place June 5-8 at the Port JeffersonVillage Center and nearby Danfords on the Sound. The meeting isbeing hosted by the Suffolk County Dental Society, whose past pres-ident, Stephen B. Gold, will be formally installed as NYSDA Presidentat a dinner dance on Saturday, June 7. Standing up with Dr. Gold willbe his fellow officers: President Elect Michael R. Breault; VicePresident Robert J. Doherty; Secretary-Treasurer Richard F.Andolina;and Immediate Past President Steven Gounardes.

The small town of Port Jefferson, for all its colorful history, is adeceptively cosmopolitan community. Located just 56 miles east ofNew York City, it boasts several unique restaurants and shops and agrowing tourism industry, developed around the town’s many nat-ural attractions, museums and historic sites, and special events.

Danfords, which opened in 1986 as an inn, conference centermarina, restaurant and catering facility, is itself a tourist attraction.The site is located along the nationally recognized North ShoreHeritage Trail and was previously occupied by a painter’s studio,blacksmith shop, boxing emporium, social club and ice cream parlor.

The Board of Governors will hold its opening session from 3 to6 p.m., Thursday, June 5. It will continue deliberations on Saturdayduring an all-day session that will begin at 9 a.m. The annual lun-cheon of the New York State chapter of the Pierre FauchardAcademy is also scheduled for Saturday.

Arrangements for the meeting are being coordinated by thisyear’s Annual Meeting Chair Alan L. Mazer. Requests for informa-tion should be made to NYSDA Associate Executive Director BethWanek at (800) 255-2100 or [email protected].

Getting to Know Port JeffersonWeekend on Long Island Filled with Local Attractions

CHAMPAGNE, CHOCOLATE & JEWELRY (Thursday June 5):Ecolin Jewelers, a family-owned jewelry store located across thestreet from Danfords, is opening its doors especially for NYSDA sothat meeting-goers can browse their collection of fine jewelry.While there, enjoy a glass of champagne and a 10% discount off anypurchases made between 4 and 6 p.m. Ecolin represents manyrenowned designers, among them, Lagos, Carrera y Carrera andTacori. Your Host: Ruth Gold. There is no fee for this event.

NYSDA Chooses Seaside Resort as SettingFOR SEMI-ANNUAL MEETING

Port Jefferson. To get you started on your evening, Suffolk CountyDental Society is sponsoring a cocktail reception from 6 to 7 p.m. atDanfords. And save room for dessert. When you get back from din-ner, you are invited to a dessert reception at Danfords. Coffee,sweets and cordials will be served from 9:30 to 11 p.m., courtesy ofMLMIC, which is underwriting the cost of this event. There is nofee for this event.

STONY BROOK MUSEUM TOUR/SHOPPING (Saturday, June 7):The Long Island Museum of American Art, History and Carriagesis a showcase for artifacts depicting everyday life in early America,works of art and nearly 200 historic carriages. It’s Long Island’slargest privately supported museum and is accredited by theAmerican Association of Museums for excellence in exhibitionsand programs. The museum’s permanent collection numbers over40,000 items, dating from the late 18th century to the present. Yourouting will continue with lunch at Pasta Pasta. If after lunch, you’restill not ready to return to the hotel, you will have time to tour thequaint village of Port Jefferson, stopping at its many and diverseshops and boutiques. Visitor’s guides and maps will be provided.It’s just a short walk from the village of Port Jefferson to Danfords.Your Hosts: Lois Mazer, Dr. Robert & Doreen Benton. Suffolk OralSurgery Associates, LLP (Drs. Steven Snyder, Guenter Jonke, JohnGuariglia, Sachin Jamdar and Christopher First) are underwritingthe cost of this event. Fee: $35 per person.

NATURE TRAIL HIKING/PONTOON BOATING (Saturday, June7): The Ward Melville Heritage Organization, a not-for-profit cor-poration was founded to preserve and protect historical and sensi-tive environmental properties in Stony Brook. On this trip, you willspend approximately one hour hiking the trails of the preserve,then board the 35-passenger vessel, the “Discovery,” for a one andone-half hour tour of the organization’s 88-acre wetlands. A natu-ralist from the Stony Brook University Marine Sciences Center willbe on board to describe the wildlife and flora. Bus departs Danfordsat 12:45 p.m. and will return at approximately 5:15 p.m. Wearsneakers or hiking shoes. Your Host: Dr. John Primavera. Fee:$23/Adults; $18/Seniors; $10/Children under 6.

PRESIDENT’S DINNER DANCE (Saturday June 7): Join yourfriends and colleagues at NYSDA’s Annual Dinner Dance as theyhonor the Association’s 2008 President, Stephen B. Gold, his wife,Ruth, and the other officers of NYSDA. This gala event will be heldat Lombardi’s on the Sound at the Port Jefferson Country Club. Theevening begins with cocktails and hors d’oeuvres at 7:30 p.m.Dinner and dancing will follow. Black tie attire. Transportation willbe provided for hotel guests. Fee: $95 per person.

FAREWELL BREAKFAST (Sunday, June 8): Dr. Barry Rifkin andthe office of the dean of Stony Brook University have invited every-one to join them for breakfast at Danfords prior to their departure.A hearty buffet will be available from 7 to 10 a.m.


LOBSTER BAKE (Thursday June 5): The first social gathering ofthe meeting takes place at the Three Village Inn. A short ride fromthe site of the meeting, the Three Village Inn is a charming countryget-away, the crown jewel of historic Stony Brook and site of one ofLong Island’s great restaurants. The night begins with cocktails andhors d’oeuvres at 7 p.m., followed by an authentic Long Island lob-ster bake. Price includes transportation from Danfords, open barand music. Fee: $65 per person.

GOLF TOURNAMENT (Friday June 6): Suffolk County DentalSociety has invited NYSDA guests to play in its annual tournamentat Great Rock Golf Club in Wading River. Great Rock is the newestsemi-private club on Long Island. Golfers of all abilities will enjoythis par-71 course, laid out on 136 acres of mature woodlands,overlooking sprawling vistas. This is a shot-gun, scramble tourna-ment. It will begin at 8 a.m. Transportation will be provided forhotel guests and will depart at 6:30 a.m. Entry fee includes greensfees, cart, Continental breakfast, lunch and prizes. TournamentChairman: Dr. Anthony Maresca. Fee: $195 per person.

LONG ISLAND SOUND FISHING (Friday June 6): Spend themorning with Capt. Desmond O’Sullivan and his crew aboard the“Celtic Quest,” a pristine and comfortable 60-foot party fishingboat. Set sail at 7 a.m. from the town dock, just a short walk fromDanfords. You will return at approximately 1:30 p.m. If you’realready an accomplished fisherperson, this is a chance to sharpenyour skills. If you’re more accustomed to getting your fish from amarket, you’re still welcome to join the party and learn techniques,tactics and what gear to use to catch the big fish. Who knows? Youmay get lucky. No prior fishing or boating experience is necessary.Bring a jacket or sweatshirt and a pair of old sneakers. Priceincludes rods, bait and tackle, gratuity, boxed lunch and beverages.Your Host: Dr. Alan Mazer. Fee: $60 per person.

WINERY TOUR (Friday June 6): Take a scenic ride to the North Forkof Long Island to visit two of the Island’s premiere wineries.Your firststop will be Paumanok Vineyards, a family-owned, 77-acre estate. Itswinery is housed in a renovated turn-of-the-century barn, sur-rounded by an inviting deck that overlooks the vineyards. Lunch fol-lows at the Jamesport Manor Inn, a beautiful reproduction of a 19th-century Victorian house, which specializes in new American cuisine,with Mediterranean and Asian accents. Last stop is a wine tasting atMartha Clara Vineyards, owned and operated by the Entenmannfamily, also known for the baked goods it produces. This is a first-class winery, noted for the knowledge, skill and experience that gointo the wine it produces. The bus will depart Danfords at 9:30 a.m.and will return at approximately 3:15 p.m.Your Hosts: Dr. Kerry Laneand Dr. Thomas Bonomo. Fee: $50 per person.

COCKTAIL & DESSERT RECEPTION (Friday June 6): NYSDA willnot be hosting a dinner function on Friday evening. This will giveyou a chance to enjoy any of the excellent restaurants located in

Modern-day Port Jefferson continues to build on its maritime past.


NEW YORK STATE DENTAL ASSOCIATION2008 SEMI-ANNUAL MEETING

Port Jefferson Village CenterDansfords on the SoundPort Jefferson, New York

June 5 - 8, 2008

THURSDAY, JUNE 5

10 am - 5 pm Registration — Hotel Lobby (Danfords)

12:30 - 3 pm NYSDA Support Services — Boardroom 4 (Danfords)

3 - 6 PM Board of Governors — Port Jefferson Village Center

4 - 6 PM Champagne, Chocolate, Jewelry Reception Ecolin Jeweler’s

7 pm Lobster Bake — Three Village Inn Bus Transportation Provided

FRIDAY, JUNE 6

7 am Fishing Trip depart from Town Dockreturn approx 1:30 pmboxed lunch/beverages

8 am Annual Golf Tournament w/Suffolk County Dental Society —Great Rock Golf Course in Wading River


9:30 am Winery Tour & Lunch

6 - 7 pm Cocktail Reception — Brookhaven Ballroom (Danfords)

9:30 - 11pm Dessert Reception — Brookhaven Ballroom (Danfords)

SATURDAY, JUNE 7


9 am - 5 pm Board of Governors — Port Jefferson Village Center

9:30 am Museum Tour Stony Brook MuseumLunch Shopping in Port Jefferson

12:45 pm Departure for Nature Trail Hiking/Pontoon BoatingReturning at 5:15 p.m.

Noon - 1:30 pm Pierre Fauchard Academy Luncheon — Brookhaven Ballroom (Danfords)

7:30 pm - 12:30 pm President’s Dinner Dance — Lombardi’s on the Sound at Port Jefferson Country ClubCocktail Reception 7:30 - 8:30 pmDinner/Dancing 8:30 pm - MidnightTransportation ProvidedBlack Tie

SUNDAY, JUNE 8

8 - 10 am Farewell Breakfast — Danfords InnCheck-in time — 4 p.m.Check-out time — 11 a.m.


EVENT REGISTRATION

Please register the following individual(s) for the meeting. Please print names as they are to appear on badges. Badges may be picked upat the NYSDA Registration Desk.

# OF TICKETS TOTAL COST

THURSDAY JUNE 5

CHAMPAGNE RECEPTIONNo Charge

LOBSTER BAKE$65 Per Person

FRIDAY JUNE 6

GOLF (complete separate registration)$195 Per Person

FISHING$60 Per Person

WINERY TOUR$50 Per Person

COCKTAIL RECEPTIONNo Charge

DESSERT RECEPTIONNo Charge

SATURDAY JUNE 7

STONY BROOK MUSEUM/SHOPPING$35 Per Person

NATURE TRAIL HIKE/PONTOON BOATING$23 Adults / $18 Seniors / $10 Child Under 6

PRESIDENT’S DINNER DANCE$95 Per Person

SUNDAY JUNE 8

FAREWELL BREAKFASTNo Charge

TOTAL $

Craig Ratner, third from left, receives congratulations on winning Tillis Award forexcellence in dental writing. Well-wishersare, from left, NYSDJ Editor ElliottMoskowitz; Deborah Pasquale, NYSDACouncil Membership & Communications;Steven Gounardes, 2007 NYSDA President.

CRAIG S. RATNER, president of the Second District DentalSociety, is winner of the 2007 Bernard P. Tillis Award for excel-lence in dental writing.

Dr. Ratner was selected to receive the award, presented bythe NYSDA Council on Membership and Communications, for hiseditorial “A Troubling Trip to the Local Elementary School” in theJune/July 2007 SDDS Bulletin. Dr. Ratner is co-editor of theBulletin. He received an inscribed plaque.

The Council on Membership and Communications alsoselected Nassau County Editor Robert D. Kelsch, D.M.D., for anHonorable Mention citation for his untitled editorial about global-ization in the November/December 2006 Bulletin of NCDS. Dr.


Council Selects Craig Ratner to Receive Tillis AwardROBERT KELSCH GETS HONORABLE MENTION

Kelsch is a 1992 graduate of the University of Connecticut Schoolof Dental Medicine. He is an oral pathologist in Rockville Center.

The Tillis Award was established in 1996 to honor the mem-ory of the longtime New York State Dental Journal editor. It rec-ognizes members of the Dental Association who, through theirwriting in The NYSDJ or in any component publication, promotesa positive image of organized dentistry.

Dr. Ratner, a 1992 graduate of New Jersey Dental School, isa general practitioner on Staten Island. He represents the SecondDistrict on the NYSDA Board of Governors and is an alternate del-egate to the ADA. He is past president of the Richmond CountyDental Society. His winning editorial is reproduced here.

A FUNNY THING happened last week. While at my home in NewJersey, I was called by the school nurse to come to my daughter’sschool. My daughter needed allergy drops placed in her eyes. Thisis not the funny part.

As I arrived in the nurse’s office, I noticed another little girlplaying with a loose tooth. She was unsuccessfully attempting tofree it from its gingival jail. She was to the point of tears when Iheard the nurse say, “I’m sorry. I can’t help you. Only a dentist canpull a tooth from your mouth.” Noting the irony, I replied, “I’m adentist. Can I help?” Acknowledging my arrival, the nurse didindeed propose to the young girl that I could help.

The young girl was a little reluctant, but the discomfort she washaving convinced her to let me help. I reached for the nearest tissueand proceeded to do what most parents do for their children all thetime. I painlessly plucked the baby tooth from her mouth with narya yelp or a tear. The nurse provided a piece of gauze for my “patient”to bite on and sent her back to class. I was a hero, right?

On the way home, I was struck by a strange thought. I consideredthat I had just done something wrong. I had actually treated a minorwithout her parents’ consent. Not only that, but I did it in a state inwhich I wasn’t licensed. Now, I knew that I would probably never bearrested for committing these two class B felonies. However, there was

a small part of me that actually worried that this little girl’s parentsmight be some lawsuit-happy Americans who saw this as an opportu-nity to sue me even though I was doing something I thought was inno-cent and good. Of course, I kept telling myself that I was overreacting.

I was upset nonetheless. I wasn’t upset over a potential lawsuit.Rather, I was upset that the thought even crossed my mind. I was upsetthat I live in a society where this was even a consideration. I was upsetthat I let myself get caught in the trap of paranoia.Then,I thought of allthat NYSDA has done over the past five years to fight off the advances ofthe New York State Trial Lawyers Association. It is one of the mostimportant yet unnoticed benefits of our membership,one that we oftenoverlook. We have spent untold time and dollars fighting off theNYSTLA’s legislative efforts to eliminate the statute of limitations and tocreate new categories of wrongful death and non-economic damages.

It is an ongoing battle. How do we convince legislators who arethemselves lawyers to ignore the influences of fellow lawyers? So farwe have, but we need to continue the fight.We need to maintain ourpresence in Albany with numbers and dollars. If our numbers failto show that we significantly represent our profession, or if our lob-bying efforts fail because we lack monetary strength, we are in seri-ous trouble. This is important. I for one don’t want to have to worryabout helping out another young girl with a loose tooth.

A TROUBLING TRIP TO THE LOCAL ELEMENTARY SCHOOLEditorial Craig S. Ratner, D.M.D.


IN THE PAST 39 YEARS, since I graduated from the University atBuffalo School of Dental Medicine, there have been many changesin dental education, especially in its relationship to dental technol-ogy. There have been changes in dental technology as well, includ-ing the number of dental technologists and their education andthe prosthetic options available to dentists and patients. At thesame time, there has been a steady and gradual corporatism ofdental education and dental technology that appears to be irre-versible. Voids in the existing dental delivery system have becomeapparent and require action from both the dental and dental tech-nology communities.

During my predoctoral training, students were given broadexposure to the technical aspects of prosthetic dentistry. They wereexpected to wax, invest and cast gold routinely, and make acrylicveneer bridges under the supervision of dental technicians anddentists, who served on the faculty at UB. Students also set theirown denture teeth and processed acrylic resin for the partial andcomplete dentures provided in the predoctoral clinic. During eachstep, we interacted with real, live dental technicians.

In the late ‘60s, graduating students predominately enteredthe military service. The military maintained a staff of dental tech-nicians who were highly skilled and worked side by side withactive dental officers to fabricate simple and complex dentalrestorations. Retiring military dental technicians opened commer-cial dental laboratories near military bases and were available to

help with the fabrication of the restorations that were provided tomilitary personnel and their families. Other dental techniciansbecame faculty members in dental schools and dental technologyprograms throughout the country following their retirement frommilitary service. Today, first-year dentists spend a fifth year ofeducation in general practice residencies instead of going into mil-itary service.

Getting to Know the TechnologyAs late as the early ‘70s, as an integral part of the educationalprocess, pre- and postgraduate prosthodontic students wererequired to develop a basic level of dental laboratory skill, compe-tence and attention to detail, as well as an understanding of how tofabricate restorations. The goal was to help students establish prin-ciples and learn to recognize standards of excellence for periodon-tal, occlusal and marginal adaptation, and substructure engineer-ing considerations before treating clinical patients or fabricatingprosthetics. Many faculty had either been laboratory techniciansbefore becoming dentists or had developed a high degree of com-petence in dental technology.

In my own postgraduate experience, at Tufts University, one ofmy mentors, Dr. Lloyd Miller, would bring the porcelain-fused-to-metal cases he personally baked to school for us to see. Dentalceramics was in its infancy then. As time went on, postgraduatestudents were required to visit dental laboratories to meet and

Dentistry and Dental Technology What went wrong with what was once a beautiful relationship? Can that old feeling be restored?

Burney M. Croll, D.D.S.

P E R S P E C T I V E S


establish communication with the dental technicians who pro-duced the prosthetics the students would be placing in patients.

Dr. Miller made sure all of his students visited Bob Welch andLou Consoulis, two certified dental technicians at DentalCeramics, Inc., the laboratory that made a significant portion ofthe fixed restorations the postdoctoral students delivered topatients treated in the postgraduate program. And Bob and Loufreely shared their experience and knowledge with us. They addedto our ability to understand the state-of-the-art of dental technol-ogy available at the time and to make sure that new materials metestablished standards of biocompatibility, materials science anddurability. In all, they enhanced our ability to do thoughtful caseplanning and treatment plans. We also learned the fundamentalimportance of careful tooth preparation, readable dies and appro-priate mounting records, all of which enables technicians to per-form to their best standards as well.

Human Element is GoneIf you visit predoctoral programs today, you notice many changes.There has been a gradual virtualization and corporatism of theeducation experience. Students are given DVDs with all of theessential information they need to prepare for the regional dentalexaminations they will take at the end of their predoctoral training.Visits to the library have been replaced by a PDA or notebook com-puter. Mentors are gone, and there is less chance for students todevelop independent curiosity and personal judgment. There isinformation overload, but also a simplification of information andthe development of a market-based mentality. Many predoctoralprograms require that their students keep track of their productionfigures in dollars instead of meeting the unit requirements andquality requirements of the past.

Teachers of predoctoral students lament that there has beena shift in the curriculum, resulting in a reduction in the numberof clock hours required for dental students in the area of prostho-dontics and a virtualization of dental technology. As a result, stu-dents have never performed laboratory procedures, are not ableto properly evaluate a prosthesis returned from the dental labo-ratory, have never met a dental technologist and have no sense ofthe value the dental technologist has in the delivery of dentistry.They are unaware that technologists are being forced to makedecisions about product design that were typically a dentist’sresponsibility.

Adding to the market-based mentality of graduating dentalstudents, many are leaving school with debt between $250,000 and$425,000 in education loans. Now, it’s no longer enough to make aliving. One has to turn a profit. No wonder one of the first thingsthese students do upon graduation is create a Web site to extol theirexcellence in all phases of dentistry—implants, orthodontics, cos-metic dental services—even though they have little actual trainingin these procedures. Preoccupied with meeting their loan pay-ments, recent graduates have shifted emphasis from excellence toproductivity and profitability.

The situation is not much different in postgraduate educationalprograms. In the school where I completed my training, I discov-ered that most if not all of the prosthetics that were delivered topatients were fabricated offshore in Thailand. That effectivelyreduced or eliminated the two-way communication between stu-dents and qualified dental technicians in the area. For manyundergraduate and graduate students, interaction with dentaltechnologists has been reduced to a box, a written prescriptionand a FedEx form. The obvious statement made here by dentalschool administrators is that the personal nature of a collaborationbetween dentistry and dental technology is of no value, nor is itgood for the bottom line.

Gone Forever?The dentist/dental technician interaction within pre- and postdoc-toral programs is not likely to be reinstated in the immediate futurewithout a nationally mandated change in the predoctoral curricu-lum, according to dentists active in dental prosthetic education.Perhaps an educational module explaining dentists’ responsibilitiesupon graduation and the standards that have to be met mustbecome part of predoctoral educational curriculum.

There are similar problems in dental technology. The gradualTaylorization of the commercial dental technology business, thesame philosophy used by Henry Ford to develop his automobileassembly line, has eroded the culture of artistic professionalismthat used to characterize dental technology, turning it into anindustry based upon productivity relying upon an assembly linemodel developed to create a profit. The supply of retiring military-trained dental technologists has declined dramatically. And thenumber of accredited programs in dental technology has steadilydropped since 1990 from 60 to 20. The Department of Labor,Bureau of Labor Statistics, predicts that 11,000 out of the current48,000 dental technicians will leave the profession by 2014. In thattime, the accredited educational system will replenish that numberby only 1,400.

Outsourcing the fabrication of dental prosthetics to offshorelaboratories will not solve this problem and may diminish ourcapacity to correct the manpower shortage by limiting our ability torecruit and sustain a workforce of educated dental technicians witha comprehensive knowledge of dental technology. It has alsobecome a fact of life that dentists are less able to talk directly withthe dental technologists who are fabricating restorations for den-tists’ patients.

Reducing the dental technician to a prescription and a casepan, eliminating the technician from the predoctoral dental educa-tional experience has created a statement that could not be clearer.Public recognition of the essential collaboration that occursbetween dentists and dental technicians is not occurring andshould be addressed. The number of certified dental technicians(CDTs) has been steadily decreasing due to retirement, and thesetechnicians are not being replaced adequately to meet present andfuture needs of their industry and those of dentistry. It is necessary


to acknowledge the professionalism of CDTs who have demonstrateda verifiable level of competence, established through the standard-ized testing and practical examination conducted by a national cer-tification board.

The American Dental Association has firmly established thatdentists have the ultimate responsibility for deciding what isacceptable to be placed in the mouths of their patients and forsafeguarding their patients’ health. In practice, however, dentistsare relying more than ever on dental technologists to make deci-sions about the materials that will be placed in patients’ mouths.Often, these decisions are made without consultation with thedentist. Absent any state or federal mandate, there is no assuranceor effective safeguard that the materials chosen for use in restora-tions fabricated by dental laboratories meet FDA standards, andthe ability to track materials is severely limited.

Bolstering the Image of DentistryThe changes in the de facto responsibilities of dentistry and dentaltechnology deserve consideration by individual dentists, educa-tional programs, state governments and the ADA. Currently, dentallaboratories are not licensed or regulated in New York State. Thereare no minimum standards or training required, no requireddemonstration of a verified level of competence, no license or reg-ulation required for an individual to operate a dental laboratory in

New York State. There is no minimum or required amount of con-tinuing education for dental technologists who are not certifieddental technicians.

CDT’s who have demonstrated a verifiable level of competencemust be recognized for their accomplishments and professionalcommitment. They should be drawn upon to insure that acceptablestandards are met and adhered to. Dentists should document spe-cific materials contained in a manufactured prosthesis, as well asthe country of its origin. Currently, more is known about the E. coliin the hamburger and spinach sold in a supermarket than about thematerials contained in a dental prosthesis. There is no differencebetween contaminated medicines or food and a material used in adental restoration that is potentially damaging to a patient’s health.Each should meet FDA standards and approval and be specified inthe patient’s record for tracking purposes.

In time, the memory of the basis upon which the credibility ofdentists has rested, the collaborative efforts with dental techni-cians, the dedication to the best care possible for the patient’s healthand welfare will fade and so will the prestige and trust that hasserved dentistry so well. There already has been a decline in pro-fessionalism in both dentistry and dental technology, replaced by amore market-based mentality that is coupled with a reduction inthe quality-of-life experience in both areas.

When dentistry becomes tangled in the bottom line, deliveryof mediocre service will accurately define the image of the den-tist. Despite what you may have read in advertisements, noteveryone needs or can afford porcelain laminates or dentalimplants. But the need for conventional dentistry remains at anall-time high. Without highly dedicated and skilled dental tech-nologists available nearby to discuss prosthetic design and deliv-ery with dentists, the collaborative efforts of educated, knowl-edgeable and well-trained dentist/dental technologist teams willdisappear, and this will have an impact on the quality of the oralhealth service provided.

We must be the custodians of our profession and act positive-ly on these issues. To begin addressing these changes in dentistry,modifications in the curriculum for predoctoral dental studentsneed to be made to provide a clear description of the dentist’sresponsibilities and the standards to be met when evaluating pros-thetics to be placed in patients’ mouths. Also, recognition must bemade of CDTs and their continuing education needs, as well as on-the-job training as a group and as responsible individuals who havedemonstrated a verifiable level of competence and are essential col-laborators in the dental practice. Licensure and regulation of dentallaboratories statewide is a further step in the right directiondeserving consideration. ■

Dr. Croll, a New York City prosthodontist, is executive director of the Dental Laboratory Summit, agroup comprising representatives of the dental technology industry, dental and dental technologyformal education programs, manufacturers and suppliers to dentistry and dental technology, theADA, National Association of Dental Technology and publishing industry that is concerned withissues confronting dentistry and dental technology nationally and internationally.

Abstract

What are stem cells? As dentists, why

should we be concerned with stem

cells? How would stem cells change

dental practice? Is it possible to grow

a tooth or TMJ with stem cells? This

article summarizes the latest stem

cell research and development for

dental, oral and craniofacial applica-

tions. Stem cell research and devel-

opment will, over time, transform den-

tal practice in a magnitude far greater

than did amalgam or dental implants.

Metallic alloys, composites and even

titanium implants are not permanent

solutions. In contrast, stem cell tech-

nology will generate native tissue

analogs that are compatible with the

patient’s own.

STEM CELLS CAN BE DEFINED as cellsthat 1. self-replicate and 2. are able to dif-ferentiate into at least two different celltypes. Both conditions must be present fora cell to be called a stem cell. For example,osteoblasts are not stem cells. Althoughosteoblasts differentiate into osteocytes,they typically do not differentiate into othercell types except osteocytes. Osteocytes arenot stem cells; they are end-lineage cellsthat typically neither self-replicate nor dif-ferentiate.

Different Types of Stem CellsEmbryonic stem cells (ES) refer to the cellsof the inner cell mass of the blastocyst dur-ing embryonic development. ES are partic-ularly notable for their two fundamentalproperties: the capacity to differentiate intoany cell type in the body and the ability toself replicate for numerous generations(Lyons and Rao, 2007). One potential dis-advantage of human ES, besides ethicalissues, is precisely their virtually unlimitedproliferation and differentiation capacity(Ryu et al., 2004). The clinically observed

teratoma is an example of ES growing intowrong tissues. To date, little attempt hasbeen made towards the use of ES in dental,oral and craniofacial regeneration.

Amniotic fluid-derived stem cells (AFS)can be isolated from aspirates of amniocen-tesis during genetic screening. An increas-ing number of studies have demonstratedthat AFS have the capacity for remarkableproliferation and differentiation into multi-ple lineages, such as chondrocytes,adipocytes, osteoblasts, myocytes, endothe-lial cells, neuron-like cells and live cells(Barria et al., 2004; Prusa et al., 2004; DeGemmis et al., 2006; De Coppi et al., 2007;Kolambkar et al., 2007; Perin et al., 2007).The potential therapeutic value of AFSremains to be discovered.

Umbilical cord stem cells (UCS) derivefrom the blood of the umbilical cord. Thereis growing interest in their capacity for self-replication and multi-lineage differentia-tion (Laughlin et al. 2001). UCS have beendifferentiated into several cell types, suchas cells of the liver, skeletal muscle, neuraltissue and immune cells (Warnke et al.,


Stem Cells and the Future of Dental CareJeremy J. Mao, D.D.S., Ph.D.


2004; Young et al. 2004). Their high capaci-ty for multi-lineage differentiation is likelyattributed to the possibility that UCS arechronologically closer derivatives ofembryonic stem cells than adult stem cells.Several studies have shown the potential ofUCS in treating cardiac and diabetic dis-eases in mice (Rebel et al. 1996; Tocci et al.2003; Lee et al. 2005). UCS are neitherembryonic stem cells, nor are they viewedas adult stem cells.

Bone marrow-derived mesenchymalstem cells. When bone marrow is aspiratedand cultured, a subset of adherent andmononuclear cells are mesenchymal stemcells (MSCs) (Alhadlaq and Mao, 2004;Marion and Mao, 2006). Bone marrow-derived MSCs can self-replicate and havebeen differentiated, under experimentalconditions, into osteoblasts, chondrocytes,myoblasts, adipocytes and other cell types,such as neuron-like cells, pancreatic isletbeta cells, etc. (Alhadlaq and Mao, 2004;Kim et al., 2006; Marion and Mao, 2006).Bone marrow-derived MSCs are currentlybeing investigated in broad applications,such as cartilage defects in arthritis, bonedefects, adipose tissue grafts, cardiacinfarcts, liver disease and neurologicalregeneration. MSCs are often viewed as ayardstick of adult stem cells.

Tooth-derived stem cells (TS) are isolat-ed from the dental pulp, periodontal liga-ment—including the apical region—andother tooth structures (Gronthos et al.,2000; Shi et al., 2001; Batouli et al., 2003;Miura et al., 2003; Mao et al., 2006).Craniofacial stem cells, including TS, origi-nate from neural crest cells and mesenchy-mal cells during development (Zhang et al.,2006; Takashima et al., 2007). Neural crestcells share the same origin as progenitorcells that form the neural tissue.Conceptually, TS have the potential to dif-ferentiate into neural cell lineages. Indeed,TS from the deciduous tooth have beeninduced to express neural markers such asnestin (Miura et al., 2003). Similarly, bonemarrow-derived stem cells also have been

induced to express neural cell markers(Kim et al., 2006). The expression of neuralmarkers in TS elicits imagination of theirpotential use in neural regeneration, suchas in the treatment of Parkinson’s disease.However, the expression of certain end celllineage markers by stem cells only repre-sents the first of many steps towards thetreatment of a disease. In balance, thepotential of TS in both dental and non-den-tal regeneration should be furtherexplored. TS that have been isolated to date,either from deciduous teeth or permanentteeth, are considered postnatal stem cells oradult stem cells.

Adipose-derived stem cells (AS) aretypically isolated from lipectomy or lipo-suction aspirates.AS have been differentiatedinto adipocytes, chondrocytes, myocytes,neuronal and osteoblast lineages (DeUgarte et al., 2003; Zuk et al., 2002; Peptan et

al., 2006). AS can self-replicate for manypassages without losing the ability to fur-ther differentiate (De Ugarte et al., 2003;Zuk et al., 2002; Gimble et al., 2007). Manybelieve that AS have advantages over otheradult stem cell populations, for adipose tis-sue is abundant in certain individuals,readily accessible and replenishable. How-ever, the ability to reconstitute tissues andorgans by AS versus other adult stem cellshas yet to be comprehensively documented.

Induced pluripotent stem cells (iPS)refer to adult or somatic stem cells thathave been coaxed to behave like embryonicstem cells. Recent reports have shown thatthe transduction of a small number ofgenes or transcription factors, as few asfour, transforms adult fibroblasts into cellsthat proliferate and differentiate into ES-like cells. The four genes are Oct3/4, Sox2,Klf4, and c-Myc in Takahashi et al. (2007),


but Oct4, Sox2, Nanog, and Lin28 in Yu etal. (2007). The biological and politicalimplications of these studies are quite sig-nificant. On the biological front, theinduced human somatic cells or iPS cellshave the capacity to generate a large quan-tity of stem cells as an autologous cellsource that can be used to regeneratepatient-specific tissues. On the politicalfront, iPS cells appear to minimize the needfor human embryonic stem (ES) cells.However, even the authors of these recentreports have cautioned that any carcino-genic potential of iPS should be fully inves-tigated before any commercialization canbe realized.

Stem Cells and Dental, Oral,Craniofacial StructuresStructures of interest to the dental profes-sion include the enamel; dentin; dentalpulp; cementum; periodontal ligament;craniofacial bones; the temporomandibu-lar joint, including bone; fibrocartilage andligaments; skeletal muscles and tendons;skin and subcutaneous soft tissue; and sali-vary gland. Without exception, all thesedental, oral and craniofacial structures areformed by neural crest-derived and/or mes-enchymal cells during native development.

Since cells are the centerpiece of grow-ing tissue or organs, the immediate ques-tion is how to get hold of the cells that gen-erate dental, oral and craniofacial tissues?Among all possible stem cell sources, adultstem cells have a number of advantagesover embryonic stem cells, umbilical cordstem cells and amniotic fluid stem cells forregeneration of many dental, oral and cran-iofacial structures. Adult stem cells arechronologically closer to the target dental,oral and craniofacial structures thanembryonic stem cells, umbilical cord stemcells and amniotic fluid stem cells. Adultstem cells are not subjected to the ethicalcontroversy associated with embryonicstem cells. Adult stem cells can be autolo-gous and isolated from the patient, whereasembryonic stem cells cannot be autolo-gous. It is also impossible for amniotic fluidstem cells or umbilical cord stem cells to beused as autologous cells until these cells arebanked. The risk of immune rejection is

present for non-autologous cells, whereasautologous stem cells are free fromimmune rejection.

Bone marrow-derived, tooth-derivedand adipose-derived stem cells, despiteimportant differences among them, likelybelong to subfamilies of mesenchymalstem cells (Marion and Mao, 2006; Gimbleet al., 2007). Most dental, oral and craniofa-cial structures are connective tissue.During native development, dental, oraland craniofacial connective structures areformed by neural crest-derived and mes-enchymal cells. Postnatally, clusters of mes-enchymal cells continue to reside in vari-ous tissues and are the logical sources ofadult mesenchymal stem cells (Marion andMao, 2006).

MSCs can be isolated from the patientwho needs treatment, and, therefore, theycan be used autologously withoutimmunorejection. MSCs have also beenused allogeneically to heal large defects(Alhadlaq and Mao, 2004; Marion and Mao,2006; Barrilleaux et al., 2006; Prockop,2007). Figure 1 provides experimental datashowing that a single population of mes-enchymal stem cells can differentiate intochondrocytes, osteoblasts and adipocytes(Marion and Mao, 2006). Each of the differ-entiated cell lineages has implications inthe treatment of a corresponding disorder.For example, MSC-derived chondrocytescan be used for reconstruction of orofacialcartilage structures, such as nasal cartilageand the temporomandibular joint. MSC-

Figure 1. A: Human mesenchymal stem cells (MSCs) isolated from anonymous adult human bone marrow donor follow-ing culture expansion (H&E staining). Further enrichment of MSCs can be accomplished by positive selectionusing cell surface markers, including STRO-1, CD133 (prominin, AC133), p75LNGFR (p75, low-affinity nervegrowth factor receptor), CD29, CD44, CD90, CD105, c-kit, SH2 (CD105), SH3, SH4 (CD73), CD71, CD106,CD120a, CD124, and HLA-DR or negative selection (Alhadlaq and Mao, 2004; Marion and Mao, 2006).

B: Chondrocytes derived from human mesenchymal stem cells showing positive staining to Alcian blue.Additional molecular and genetic markers can be used to further characterize MSC-derived chondrocytes(Alhadlaq and Mao, 2004; Marion and Mao, 2006).

C: Osteoblasts derived from human mesenchymal stem cells showing positive von Kossa staining for calciumdeposition (black) and active alkaline phosphatase enzyme (red). Additional molecular and genetic markers canbe used to further characterize MSC-derived chondrocytes (Alhadlaq and Mao, 2004; Marion and Mao, 2006).

D: Adipocytes derived from human mesenchymal stem cells showing positive Oil Red-O staining of intracellularlipids. Additional molecular and genetic markers can be used to further characterize MSC-derived chondro-cytes (Alhadlaq and Mao, 2004; Marion and Mao, 2006).


derived osteoblasts can be used to regener-ate oral and craniofacial bones. MSC-derived myocytes can be used to treat mus-cular dystrophy and facial muscle atrophy.Stem cell-derived adipocytes can be usedto generate soft tissue grafts for facial softtissue reconstruction and augmentation.

Stem Cells and Dental PracticePatients come to the dentist because ofinfections, trauma, congenital anomalies orother diseases, such as orofacial cancer andsalivary gland disorders. Caries and peri-odontal disease remain highly prevalentdisorders among humans. Whereas nativetissue is missing in congenital anomalies,diseases such as caries or tumor resectionresult in tissue defects. For centuries, den-tistry has been devoted to healing defectswith durable materials or the patient’s own(autologous) tissue. But we now realize thatmetallic alloys or synthetic materials arenot permanent solutions (Rahaman andMao, 2005). Amalgam, composites andeven titanium dental implants can fail; andall have limited service time (Rahamanand Mao, 2005).

Why are stem cells better than durableimplants such as titanium dental implants?A short answer to this question is that stemcells lead to the regeneration of teeth withperiodontal ligament that can remodelwith the host.

Why are stem cells superior to autolo-gous tissue grafts? Autologous tissue graft-ing is based on the concept that a diseasedor damaged tissue must be replaced by liketissue that is healthy. Thus, the key draw-back of autologous tissue grafting is donorsite trauma and morbidity. For example, wecurrently harvest healthy bone from thepatient. We might take from the iliac crest,rib bone, chin or retro-molar area for bonegrafting needs in cleft palate, ridge aug-mentation, sinus lifting, and maxillary andmandibular reconstruction.

In contrast, stem cell-based therapeu-tic approaches may circumvent the keydeficiencies of autologous bone grafting(Rahaman and Mao, 2005). Stem cells froma tiny amount of tissue, such as the dentalpulp, can be multiplied or expanded poten-

tially to sufficient numbers for healinglarge, clinically relevant defects. Stem cellscan differentiate into multiple cell lineages,thus providing the possibility that a com-mon (stem) cell source can heal many tis-sues in the same patient, as opposed to theprinciple of harvesting healthy tissue toheal like tissue in association with autolo-gous tissue grafting (Moioli et al., 2007).Stem cells can be seeded in biocompatiblescaffolds in the shape of the anatomicalstructure that is to be replaced (Rahamanand Mao, 2005). Stem cells may elaborateand organize tissues in vivo, especially inthe presence of vasculature. Finally, stemcells may regulate local and systemicimmune reactions of the host in ways thatfavor tissue regeneration.

When will each stem cell-based tech-nology be available for dental and oralsurgery practice? Some of the near-termapplications, such as growth factor deliv-ery, are approved or are being reviewed bythe FDA, whereas others are being investi-gated at various stages of product develop-ment. However, it is impossible to providethe precise timeline of clinical applicationfor a myriad of dental, oral and craniofacialdiseases. Science does not progress linearly,and breakthrough is not always predicted.

Furthermore, the progress of stem cell-based technologies also depends on the reg-ulatory pathways of the FDA in the UnitedStates and equivalent regulatory agencieselsewhere. What can be predicted is thatstem cell-generated tissue analogs will beavailable for clinical use for certain tissuesbefore others.The first wave of this paradigmshift in dental health care is upon us now.The impact of this paradigm shift will even-tually be present in every dental practice.

Physicians and scientists have recommend-ed that umbilical cord stem cells and amni-otic fluid stem cells be banked for potentialapplication in the treatment of trauma andpathological disorders. Our understandingof mesenchymal stem cells in the tissueengineering of dental, oral and craniofacialstructures has advanced tremendously(Krebsbach et al.,1999; Pittenger et al.,1999;Bianco et al., 2001; Alhadlaq and Mao, 2004;Mao et al., 2006; Marion and Mao, 2006).Wehave witnessed tissue engineering of thetooth, temporomandibular joint condyle,cranial sutures, soft tissue grafts, craniofa-cial bone, and other dental, oral and cranio-facial structures in animal models (review:Mao et al., 2006).

With all that we have learned aboutstem cells and tissue engineering of dental,oral and craniofacial structures, we are in aposition to bring awareness to our patientsregarding the proper storage of theirextracted teeth in conditions that will pre-serve craniofacial stem cells, including tooth-derived stem cells. These include, but arenot limited to, extracted wisdom teeth,extracted deciduous teeth, any teeth extract-ed for orthodontic purposes and any non-infected teeth extracted.

Among postnatal tissues that are sourcesof stem cells that are obtainable withoutsubstantial trauma are extracted wisdomteeth, exfoliating or extracted deciduousteeth, teeth extracted for orthodontic treat-ment, trauma or periodontal disease.

Craniofacial stem cells, includingtooth-derived stem cells, have the potential,as do bone marrow-derived stem cells andadipose-derived stem cells, to cure a num-ber of diseases that are relevant to dentistryas well as medicine, among them, diabetes,Parkinson’s disease and cardiac infarct.

Is it Possible to Grow a Toothor TMJ with Stem Cells? As an example of craniofacial regeneration,we have used stem cells in the tissue engineer-ing of a human-shaped temporomandibularjoint using MSCs (Alhadlaq and Mao, 2003;Alhadlaq and Mao, 2005; Marion and Mao,2006; Troken et al., 2007). Given that themandibular condyle consists of two strati-fied layers of cartilaginous and bone tissues,

The progress of stem cell-based

technologies also depends

on the regulatory pathways

of the FDA in the United

States and equivalent

regulatory agencies elsewhere.


MSCs were first differentiated into chondro-genic and osteogenic cells (Alhadlaq andMao, 2003; Alhadlaq et al., 2004). MSC-derived chondrogenic and osteogenic cellswere encapsulated in a biocompatiblehydrogel in two stratified layers molded intothe shape and dimensions of an adulthuman mandibular condyle (Alhadlaq andMao, 2003; Alhadlaq et al., 2004).

Following in vivo implantation inimmunodeficient mice for up to 12 weeks,the retrieved mandibular joint condylesretained the shape and dimensions of thenative condyle. The chondrogenic andosteogenic portions remained in theirrespective layers (Alhadlaq and Mao, 2005).The chondrogenic layer was positivelystained by chrondrogenic marker, safarninO, and contained type II collagen. In theinterface between cartilaginous and osseouslayers, there is a presence of hypertrophicchondrocytes that express type X collagen(Alhadlaq and Mao, 2005). In contrast, onlythe osteogenic markers, such as osteopon-tin and osteonectin, stained the osseouslayer, but not the cartilage layer.

Lastly and most importantly, there wasmutual infiltration of the cartilaginous andosseous components into each other’s terri-tory, which resembles mandibular condyle(Alhadlaq and Mao, 2005). Therefore, theproof of principle has been established toregenerate the human-shaped TMJ condyle.

The tooth is a highly complex struc-ture, with a level of complexity equal to thatof internal organs, from the perspective oftissue engineering. Dental epithelial andmesenchymal cells isolated from rat or pigteeth have been seeded onto biodegradablescaffolds and implanted in immunodefi-cient mice. Several studies have shown thata tooth crown has been formed with differ-ent layers of enamel, dentin and pulp-likestructures (Young et al., 2002; Duailibi etal., 2004; Sumita et al., 2006; Nakao et al.,2007). In vitro-generated tooth germ cellsor stem cells have been transplanted intothe adult tooth socket, leading to the for-mation of a tooth crown or root (Nakao etal., 2007; Sonoyama et al., 2007). Currentefforts are occurring in several diversedirections, such as the use of sophisticatedscaffold materials (Zhang et al., 2005,

Moioli et al., 2007); the use of enricheddental stem cell populations (Laino et al.,2006; Shi et al., 2005; Sonoyama et al., 2006;Yen and Sharpe, 2006); and the use of spe-cific dental epithelial and mesenchymalcell ratios and seeding (Hu et al., 2006;Honda et al., 2007).

Overall, the proof of concept has beenestablished to generate biologically derivedtooth structures from stem cells. Theremaining challenges are along severalfronts, including scale up, accelerated tissuematuration and development of viablecommercialization approaches.

SummaryIn the dental profession, we treat a myriadof trauma, congenital anomalies and dis-eases, including tissue defects resultingfrom dental caries, periodontal bonedefects or facial bone defects. These defectsnot only lead to physical trauma and pain,but they also are detrimental to the psy-chosocial well-being of patients, given thatthe oral cavity and the face are intimatelyinvolved in self identity, communicationand the expression of emotion.

Current treatment approaches utilizethe patient’s own tissues, allogeneic grafts,metallic alloys or synthetic implants. Muchof what we know as dentists is evolving intoa new dentistry in which dental care isdelivered increasingly by biologically basedapproaches. For example, biomolecules willbe used for periodontal regeneration; stemcells will be used in the regeneration ofdentin and/or dental pulp; biologicallyviable scaffolds will be used to replace oro-facial bone and cartilage; the defective sali-vary gland will be partially or completedregenerated (Rahaman and Mao, 2006;Mao et al., 2006; Mao et al., 2007).

The challenge for the dental profes-sional in the anticipated era of stem cellsand tissue engineering is imminent. Whatwould be a dentist’s response when patientsask whether they can get their own stemcells if they have their wisdom teeth banked?What are the odds that tooth stem cells willgrow a new tooth or be used to treat dia-betes? Should I use a growth factor calledPDGF or BMP2 to treat my periodontalbone defects or have a bone graft? Should

my son’s baby teeth be banked for stemcells, and, if so, what are the odds that thesebaby teeth stem cells will cure a bone frac-ture he may get during a soccer game?

The dental professional needs to beprepared to provide continuing educationcourses. Dental schools should consider theaddition of stem cells and tissue engineer-ing courses to the existing curriculum.Several textbooks are now available in thearea of stem cells, tissue engineering andregenerative medicine (e.g. Mao et al.,2007).Without these and similar measures,dental students, postgraduate students anddental practitioners are likely to be ill-pre-pared for the upcoming era of stem cell-based technologies.

Several well-established dental supplycompanies have established, or are estab-lishing, R&D efforts in the area of stem cellsand tissue engineering. Federal fundingagencies, such as the National Institutes ofHealth, have been providing research andtraining grants on a competitive basis tothe external research community in thearea of stem cells, tissue engineering andregenerative medicine, including regenera-tive dental medicine, for over a decade(Wang et al., 2007). Strategies for educa-tion, training, research, development, com-mercialization and practice models need tobe formulated and implemented. ■

Author’s acknowledgement: This article is dedicated tomy teachers during my dental and specialty training,as well as my scientific training, for their intellectualinfluence and education. It is further dedicated to myprevious and current students, residents, postdoctoralfellows and research scientists who have helped me tounderstand stem cells, tissue engineering and knowl-edge in general. The following research grants from theNational Institutes of Health are gratefully acknowl-edged: DE15391, EB002332 and EB006261.

Editor’s Note: Queries about this article can be sent toDr. Mao at [email protected]. Copies of the exten-sive references that accompanied Dr. Mao’s manuscriptare available upon request to The NYSDJ ManagingEditor.

Abstract

The purpose of this study was to evaluate the transverse

strength of denture base resin repaired with autopolymer-

izing resin and metal wire using a metal conditioner, along

with the synergistic effect of a surface preparation for den-

ture base resin. It was found that the use of Co-Cr-Ni wires

air abraded with 50 µm alumina, followed by treatment

with a metal conditioner and dichloromethane for denture

base resin, was the most effective method for repairing

fractured denture base resin.

ACRYLIC DENTURE BASE FRACTURE is an infrequent complica-tion of denture care in clinical practice. Satisfactory repairs must beeasy to make and performed promptly. They must also provide ade-quate repair strength.

Among the reinforcement methods of denture repair reportedto be in use, a common method involves the use of metal wiresembedded with repair resin.1,2 The resin is easy to handle, rapidlypolymerizes and is cost-effective, although its strength is still notsufficient. To gain optimum repair strength, it is essential for a goodbond to exist between the metal wire and the repair resin, as well asbetween the denture base resin and the repair resin.


Use of Metal Conditioneron Reinforcement WiresTO IMPROVE DENTURE REPAIR STRENGTHS

Hiroshi Shimizu, D.D.S., Ph. D.; Nobuaki Mori, D.D.S.; Yutaka Takahashi D.D.S., Ph. D.

The purpose of this study was to evaluate the transversestrength of denture base resin repaired with autopolymerizing resinand metal wire using a metal conditioner3-5 and to look at the syner-gistic effect of a surface preparation6-10 for denture base resin.

Materials and MethodsTable 1 lists the materials used in this study. A total of 60 bar spec-imens (3.0 mm x 10.5 mm x 68.5 mm) of autopolymerizing den-ture base resin were prepared according to manufacturer’s instruc-tions in a pressure-curing unit (SSKJ-50, Shofu, Inc., Kyoto, Japan) at 50degrees C. and 0.39 MPa pressure for 10 minutes. After processing,the specimens were finished with No. 600 silicon-carbide abrasivepaper under running water to final dimensions of 2.5 mm x 10.0mm x 68.0 mm. They were then stored in 37-degree C. distilledwater for one day.

The 50 specimens were cut in half with a band saw under run-ning water, guided by a standardized positional jig. The remaining 10control specimens were not cut. The cut surfaces were made parallelto each other and perpendicular to the long axis of the specimens byabrading with No. 600 silicon-carbide abrasive paper under runningwater. The cut surfaces of the 10 randomly selected specimens wereprepared using dichloromethane for 5 s for use as Group 5.

The parallel halves of the specimens were placed in open-ended stone molds with the same dimensions as the original intactspecimens. The molds were used so that the ends to be repairedcould be fixed 3.0 mm apart, making a bar butt joint gap. This gap

[ ]

was then filled with the autopolymerizing acrylic repair resin. Themixing ratio (powder to liquid) was 2:1 (w/w).

The free-flowing mix was poured into the joint space to allowfor a slight excess, to ensure a complete joint. After processing, therepaired specimens were trimmed a little larger than their originaldimensions. A steel bur (D 0023, Dentsply Maillefer, Ballaigues, Switzerland;

ISO 027) was used under running water to grind a central groove (2.5mm wide, 2.0 mm deep, 25 mm long) parallel to the long axis of thespecimen into which the metal wires could be placed. A round Co-Cr-Ni wire (�=1.0 mm) designed for clasps of removable partialdentures (Sun-cobalt clasp-wire, Dentsply-Sankin, Tokyo, Japan) was cut into20 mm lengths.

The specimens were divided into six groups: 1. without wires; 2.with untreated wires; 3. with wires treated with 50 µm alumina air-abrasion (at a right angle to the surface from 5 mm distance for 10 sat an emission pressure of 0.48 MPa using a grit blaster [Microblaster,

Comco Inc., Burbank, CA]); 4. with wires treated with 50 µm alumina air-abrasion followed by application of a metal conditioner; 5.50 µm alu-mina air-abrasion of the wires, followed by application of metal con-ditioner on specimens whose cut surfaces and groove were preparedwith dichloromethane; and 6. uncut intact group.

After inserting the treated wires, the groove was filled with theautopolymerizing acrylic repair resin as described above except forthe group 6 specimens. After the polymerization process was com-pleted at 23 degrees C., the specimens were abraded under runningwater with No. 600 silicon-carbide abrasive paper to final dimen-sions of 2.5 (±0.03) mm x 10.0 (±0.03) mm x 68.0 mm. The com-pleted specimens were then immersed in 37-degree C. distilledwater for one day.

A three-point bending test was used to determine the trans-verse strength of the test specimens using a screw-driven universaltesting machine (TCM-200, Minebea Co. Ltd., Tokyo, Japan) at a crossheadspeed of 1.0 mm/minute and with 60 mm between the supportsduring loading. A compressive load was applied to the center of therepaired site. The data were analyzed statistically using a one-wayanalysis of variance (ANOVA). The Tukey’s post-hoc comparisontest was applied when appropriate (95% confidence level).

ResultsThe one-way ANOVA and Tukey’s post-hoc comparisons testdemonstrated that there were significant differences in the trans-verse strengths among the groups assessed (p<0.05). Group 5 hadthe greatest transverse strength among the repair groups (p<0.05).There were no significant differences between groups 5 and 6


Figures A & B. Two fracture patterns after three-point bending test. Arrows indi-cate fractures. A: Metal wire holds two pieces of fractured specimens together. B:Specimen separates into two pieces with fracture at end of metal wire.

T A B L E 1Materials Used

Material Product name Manufacturer Batch number

Denture base resin Pour Resin PO Shofu Inc., Kyoto, Japan Powder 079255 Liquid 099201

Repair resin Unifast #3 GC Corp., Tokyo, Japan Powder 140722 Liquid 211022

Surface preparation agent Dichloromethane Nacalai Tesque, Inc., Kyoto, Japan V2P6474

Metal wire Sun-cobalt clasp-wire (�=1.0 mm) Dentsply-Sankin, Tokyo, Japan C60215

Metal conditioner Cesead II Opaque Primer Kuraray Medical Inc., Tokyo, Japan 0036A

T A B L E 2 . Fracture Load of Repaired Autopolymerizing Denture Base Resin Specimens (MPa)

Group Mean SD* Tukey’s grouping

1 24.0 3.1 a

2 46.4 3.3 b

3 57.2 0.1 c

4 61.7 3.0 d

5 69.2 3.3 e

6 71.3 10.3 e

*SD: standard deviation. Identical letters indicate values are not statisticallydifferent (p>0.05).

(p>0.05). The means and standard deviations of the transversestrengths for each group with statistical categories are summarizedin Table 2.

In most of the reinforced specimens, fractures occurred at thedenture base resin/ autopolymerizing repair resin interface, and thewire held the two pieces of fractured specimens in position (FigureA). Two of the 10 specimens in group 5 broke into two pieces withfracture at one end of the wire (Figure B).

DiscussionTable 2 indicates that the use of air-abraded Co-Cr-Ni wire, fol-lowed by treatment using Cesead II Opaque Primer, plus the appli-cation of dichloromethane, was the most effective method amongthe groups tested. These findings point to a synergistic effect of thereinforcement of the metal wire using the metal conditioner and

surface preparation of the denture base resin. Furthermore, the factthat the transverse strength of group 5 was the same as that ofgroup 6 demonstrated that it is possible to restore the denture baseresin’s original intact strength.

A round Co-Cr-Ni wire (�=1.0 mm) designed for the clasps ofremovable partial dentures (Sun-cobalt clasp-wire, Dentsply-Sankin, Tokyo, Japan; 46% cobalt, 20% chromium, 22% nickel, >3% molybdenum, >3% tungsten, and <6% others) (wt %) wasselected as the reinforcement material. It is well known that the 10-methacryloxydecyl dihydrogen phosphate monomer is effective asa functional monomer for bonding base metal alloys.3-5 Cesead IIOpaque Primer contains this monomer.

The influence of the chromium content on the bond strength anddurability of nickel-chromium alloy was evaluated and was shown todecrease the bond strength only slightly between nickel-chromiumalloys with higher chromium content and an adhesive resin containing4-methacryloxyethyl trimellitate anhydride after thermocycling.11 TheCo-Cr-Ni wire selected for this study contains 20% chromium; thus,the results of the study presented here agree with the above findings.

Dichloromethane is an organic and nonpolymerizable solventthat swells the surface and permits diffusion of the polymerizablematerial.6 Preparation using dichloromethane creates surface poreson a conventional acrylic resin tooth. It is recommended that it beapplied to the denture teeth in the ridge-lap area prior to denturebase processing.8 The same morphological change also occurswhen dichloromethane is applied to denture base resin.10 Prepoly-merizing the PMMA pearls in the denture base resin should allowdiffusion of the dichloromethane solvent.

On the other hand, dichloromethane has also been the subjectof recent toxicological and carcinogenesis studies.12,13 Therefore, asafer surface preparation than dichloromethane is desired. Theeffect of ethyl acetate as an alternative to dichloromethane for den-ture base repair was investigated.14

Two of the 10 specimens fractured at one end of the metal wirein group 5 (Figure 1B). Such fractures are occasionally observed inprosthodontic practice, which indicates considerable stress concen-trated around the end of the metal wire.Whether fracture occurs atthe interface between the denture base resin and the autopolymer-izing repair resin near the loading point or at the end of the wiremay depend on many factors, including the wire’s total rigidity;arrangement, including length; and thickness. It may also be relat-ed to the resin’s rigidity and thickness.

When the wire in the bar specimens was sufficiently long, frac-tures at the end of the wire did not occur.1 For most of the maxil-lary complete denture bases repaired using long reinforcing wires,the pattern reported was that of a fracture line that followed themidline at the interface of the repair resin and the denture baseresin. It was initiated from the posterior border and terminated justin front of the wire.3


Further in vitro studies are needed to analyze this mechanism.

ConclusionsThe use of metal wires air-abraded with 50 µm alumina, followedby application of Cesead II Opaque Primer embedded in autopoly-merizing resin and the application of dichloromethane to the den-ture base resin at the same time, is the most effective way to repairfractured denture base resin. ■

The authors gratefully acknowledge the editorial assistance of Mrs. Jeanne Santa Cruz.Queries about this article can be sent to Dr. Shimizu at [email protected].

REFERENCES1. Polyzois GL,Andreopoulos AG, Lagouvardos PE.Acrylic resin denture repair with adhesive

resin and metal wires: effects on strength parameters. J Prosthet Dent 1996;75:381-7.2. Polyzois GL, Tarantili PA, Frangou MJ, Andreopoulos AG. Fracture force, deflection at

fracture, and toughness of repaired denture resin subjected to microwave polymeriza-tion or reinforced with wire or glass fiber. J Prosthet Dent 2001;86:613-9.

3. Yoshida K, Kamada K, Atsuta M. Adhesive primers for bonding cobalt-chromium alloyto resin. J Oral Rehabil 1999;26:475-8.

4. Ohkubo C,Watanabe I, Hosoi T, Okabe T. Shear bond strengths of polymethyl methacry-late to cast titanium and cobalt-chromium frameworks using five metal primers. JProsthet Dent 2000;83:50-7.

5. Shimizu H, Kurtz KS, Tachii Y, Takahashi Y. Use of metal conditioners to improve bondstrengths of autopolymerizing denture base resin to cast Ti-6Al-7Nb and Co-Cr. J Dent2006;34:117-22.

6. Rupp NW, Bowen RL, Paffenbarger GC. Bonding cold-curing denture base acrylic resinto acrylic teeth. J Am Dent Assoc 1971;83:601-6.

7. Shen C, Colaizzi FA, Birns B. Strength of denture repairs as influenced by surface prepa-ration. J Prosthet Dent 1984;52:844-8.

8. Takahashi Y, Chai J, Takahashi T, Habu T. Bond strength of denture teeth to denture baseresins. Int J Prosthodont 2000;13:59-65.

9. Chai J, Takahashi Y, Takahashi T, Habu T. Bonding durability of conventional resinousdenture teeth and highly crosslinked denture teeth to a pour-type denture base resin.International J Prosthodont 2000;13:112-6.

10. Shimizu H, Kurtz KS, Yoshinaga M, Takahashi Y, Habu T. Effect of surface preparationson the repair strength of denture base resin. Int Chinese J Dent 2002;2:126-33.

11. Salonga JP, Matsumura H, Yasuda K, Yamabe Y. Bond strength of adhesive resin to threenickel-chromium alloys with varying chromium content. J Prosthet Dent 1994;72:582-4.

12. Dell LD, Mundt KA, McDonald M, Tritschler JP 2nd, Mundt DJ. Critical review of the epi-demiology literature on the potential cancer risks of methylene chloride. Int Arch OccupEnviron Health 1999;72:429-42.

13. Maronpot RR, Devereux TR, Hegi M, Foley JF, Kanno J, Wiseman R, Anderson MW.Hepatic and pulmonary carcinogenicity of methylene chloride in mice: a search formechanisms. Toxicology 1995;102:73-81.

14. Shimizu H, Ikuyama T, Hayakawa E, Tsue F, Takahashi Y. Effect of surface preparationusing ethyl acetate on the repair strength of denture base resin. Acta Odontol Scand2006;64:159-63.

Abstract

Distraction osteogenesis is an alternative treatment method

for correction of mandibular hypoplasia. This paper out-

lines the use of mandibular distraction in a patient with

mandibular hypoplasia and a history of a mandibular cleft.

MEDIAN CLEFTS of the lower lip and mandible are rare craniofa-cial anomalies.1-3 Couronne, in 1819, was the first person todescribe the condition. The mandible develops from the mandibu-lar process known as Meckel’s cartilage of the first branchial arch.Inferior gnathoschisis, or median mandibular cleft, is a rare mal-formation, compared with the high frequency of maxillary clefts.4,5

The etiology of mandibular clefting proposed in the literatureis the failure of mesodermal penetration into the midline struc-tures of the mandibular portion of the first branchial arch.1,6,7 Thereis a wide variation in the severity of this anomaly, ranging from aminor cleft of the lower lip with a normal tongue and mandible toa complete cleft with loss of the supporting structures of the neckand sternum.5,7 In patients with extensive clefts, herniation of thelung into tissues of the neck have been reported.4

In a rare case of median cleft lip, limb anomalies and a familyhistory of similar malformations have been described.8 The limbanomalies were brachysyndactyly of the hands and feet.


Treatment of a Mandibular Cleft Using Distract ion

Marguerite Grossman, D.D.S.; Stuart Super, D.M.D.

Case ReportOur patient was a 33-year-old male who was born preterm, at 8months, via natural delivery to healthy parents, of a non-consan-guineous marriage, at St. Catherines Hospital in Ontario. His moth-er was 27 years old at the time of his birth. There was no reportedexposure to radiation, consumption of medication or surgical inter-vention during pregnancy. The patient has two younger, healthysiblings, two and seven years his junior.

In 2005, the patient was referred to our office for severemandibular cleft retrognathia. Upon examination, the patient wasnoted to have a convex profile with a retrognathic mandible (Figure1) and severe microstomia. His maximal oral opening was approx-imately 10 mm in diameter. There was severe crowding with poorarch form to the maxilla and extensive scar tissue and several mal-positioned teeth on the mandibular arch. The patient had minimaltongue mobility. His neck was normal; however, the patient wasnoted to have malformed digits on his right hand with significantscar tissue (Figure 2).

The patient had undergone several surgical procedures duringinfancy at the Hospital for Sick Children in Ontario, including sur-gical repair of his cleft lower lip and right hand surgery to separatehis fused digits. In 1986, the patient underwent a cranial graft har-vest to repair his cleft mandible (Figures 3, 4).

In this case report, mandibular distraction was performed togradually lengthen the mandible and expand the muscle and soft

Figure 5. 3-D model with distractor device.

tissue of the patient, who had a severe hypoplastic mandible withsignificant scar tissue as a result of his previous mandibular cleftrepair. The distractors used for this particular case were modified,as discussed below, in an attempt to have better control of forces,considering the large length of distraction.

Surgical TechniqueIn February 2005, surgery was carried out under general anesthe-sia via nasoendotracheal tube/fiberoptic intubation. A Risdon inci-sion was made to access the mandible. Minimal stripping of theperiosteum was performed, thereby preserving the blood supply tothe bone.

A partial osteotomy was created on the buccal plate until visi-ble bleeding was seen. The corticotomy was continued bicorticallyat the superior and inferior borders, taking caution to protect thelingual nerve. Upon completion, the distractor, which was prefabri-cated and adapted to a 3-D model ( Figure 5), was placed along thepatient’s mandible and modified for appropriate fit. The distractorwas rigidly fixed to the mandible with several screws to allow forrepositioning. The appropriate screw holes were placed, and thedistractor was removed to allow completion of the osteotomy witha one-centimeter wide osteotome. The distractor was fixed to themandible using the previously prepared screw holes. The distractorwas activated to ensure movement of the bony segments, and thenthe device was backed down to the zero position. The vector of dis-

Figure 1. Preoperative frontal and profile views. Figure 2. Patient’s hands.

Figure 3. Preoperative panoramic radiograph.

Figure 4. Preoperative lateral cephalogram.


Figure 9. Postoperative lat-eral cephalogram.

Figure 6. Comparison of change in frontal view before and after distraction.

Figure 7. Comparison of change in facial profile before and after distraction.


traction was parallel to the occlusal plane and close to the sagittalplane. The arm of the distractor was placed outside of the woundvia a transcutaneous approach.

A multiple-layered closure was performed. Antibiotics, anal-gesics and a mouth rinse were prescribed for daily use postopera-tively during the following week. A soft diet was advised during thedistraction period.

After a latency period of seven days, the device was activatedat a rate of 1.00 mm/day, performed in two increments—0.5 mm inthe a.m. and 0.5 mm in the p.m.—for 30 days. The patient visitedthe office every few days to assess the progress of the distraction.Results were based on clinical observation, postoperative radi-ographs and postoperative photographs.

The patient’s mandible was elongated successfully, and a satis-factory profile was achieved, with positive soft tissue changes(Figures 6, 7). The patient did not develop sensory disturbances ofthe inferior alveolar nerve, and he was not subjected to pain ateither the distraction site or the TMJs; the distraction period wasnot uncomfortable.

In June 2005, four months after surgery, the transcutaneousactivation arms were removed. The distractor remained in place.Several months later, the remaining metal of the distractors seemedto be irritating the overlying skin. In July 2006, the patient wastaken back to the operating room to eliminate the irritation fromthe metal distactors that remained.

The consolidation period usually ranges from three and sixmonths, allowing for an optimum regenerate to form. Serial radi-ographs were taken to evaluate the progression of the healingregenerate. In this case, consolidation was noted on the left side infour months, and at 11 months on the right side. At the time of thissubmission, there is well-defined bone bilaterally in the distractionsites (Figures 8, 9).

DiscussionDistraction osteogenesis, also known as callostasis, is a techniqueof bone generation and osteosynthesis by distraction of an osseoussegment. Regeneration of bone occurs between the vascularizedbone surfaces that are separated by gradual distraction.9 The tech-nique, which was first described by Codvilla10 in 1905, was writtenabout in the orthopedic literature by Gavril Ilizarov and is some-times called the Ilizarov method.11

Distraction osteogenesis is an alternative treatment methodfor the correction of mandibular hypoplasia. Utilizing distractionosteogenesis forgoes the need for bone grafting and associateddonor site morbidity.12 It provides an opportunity to provide greaterlengthening of the mandible, with potentially greater stability andless relapse compared to conventional surgery.13 Given the signifi-cant retrognathic mandible of this patient with a planned elonga-tion of 30 mm, an osteotomy was performed.

Figure 8. Postoperative panoramic radiograph.


As a bone is lengthened by gradual distraction, the surroundingsoft tissues also elongate, contributing to improved long-term sta-bility.14,16 In this patient, who presented with significant scarredintraoral mucosa, the gradual distraction of the osseous segments,which in turn gradually stretched the soft tissues, resulted in posi-tive results with well-perfused, non-dehisced soft tissue.

Several factors are important to the success of distractionosteogenesis: stability of fixation; displacement of the oseotomy;and the rate and rhythm of distraction.9 While distraction canoccur at rates from 0.5 mm to 2 mm per day, 1 mm per day appearsoptimal9 and was thus used in the treatment of this patient.

A modification in the fabrication of the distractors (KLS Martin,

Tuttlingen, Germany) used on this patient included 2 mm wide x 5 mmlong kleets soldered on both the proximal and distal segments of thedistractors. The kleets were adapted to the vertical osteotomy cut.Upon activation of the distractor arms, the kleets and the distractormoved as a unit. The kleets acted as a backup in the event of screwloosening, thereby allowing the distraction to continue. This modifi-cation has been used in five additional cases, all with good results.

ConclusionUsing distraction osteogenesis in this patient provided a safe and reliablemethod for achieving positive results. The slow lengthening of themandible resulted in osteogenesis and soft-tissue histogenesis,with grad-ual stretching of the mucosa. In addition, the modifications appearedhelpful in providing the distraction to proceed in a predictable fashion.■

The authors acknowledge the generous support and collaboration of KLS-MartinLP in the development of this device. Queries about this article can be sent to Dr.Grossman at [email protected].

REFERENCES1. Fuj ino H, Kyoshoin Y, Katsuki, T. Median cleft of the lower lip, mandible, and tongue

with midline cervical cord: a case report. Cleft Palate Craniofac J 1970,7:679.2. Amaral CM, Cardoso LA, Julio GL, Bueno MA. Median mandibular cleft. J Craniofac Surg

1994,5(5):333.3. Constantinides CG, Cywes S. Complete median cleft of the mandible and aplasia of the

epiglottis. S Afr Med J 1983, 64(8):293.4. Monroe C. Midline cleft of the lower lip, mandible and tongue with flexion contracture

of the neck: case report and review of the literature. Plast Reconstr Surg 1966,38:312.5. Herman T, Siegel M. Special imaging casebook. J of Periodontology 1995,15(2):63.6. Oostrom C,Vermeij -Keers C,Gilbert P,Meulen,J.Median cleft of the lower lip and mandible:case

reports,a new embryologic hypothesis,and subdivision.Plast Reconstr Surg 1996,97(2):313.7. Millard DR, Lehman JA Jr, Deane M, Garst WP. Median cleft of the lower lip and

mandible: case report. Br J Plast Surg 1971,24:391.8. Iregbulem LM. Median cleft of the lower lip. Plast Reconstr Surg 1978,61:787.9. Aronson J. Experimental and clinical experience with distraction osteogenesis. Cleft

Palate Craniofac J 1994,31:473.10. Codvilla A. On the means of lengthening, in lower limbs, the muscles and tissues which

are shortened through deformity. Am J Orthop Surg 1905,2:353.11. Friedman CK, Costantino PD. Use of distraction osteogenesis for maxillary advance-

ment: preliminary results; discussion. J Oral Maxillofac Surg 1994,52:287.12. Walker D. Management of severe mandibular retrognathia in the adult patient using dis-

traction osteogenesis. J Oral Maxillofac Surg 2002,60:1341.13. Li K, Powell N, Riley R, et al. Distraction osteogenesis in adult obstructive sleep apnea

surgery: a preliminary report. J Oral Maxillofac Surg 2002,60:6.

Abstract

The use of interocclusal records with semi-adjustable

articulators has been proposed as an easier alternative to

axiograph. The operator measured the Bennett angle of 30

participants using an axiograph Quick-Axis, an arcon

Whip-Mix and non-arcon Dentatus articulators. Wax and

polyether interocclusal recording materials were used with

both types of articulators. Compared to the reference axio-

graph, the Whip-Mix plus wax combination was the near-

est one and the Dentatus plus polyether was the most sig-

nificantly different combination.

THE HARMONY OF A DENTAL PROSTHESIS with movements ofthe jaw is a crucial step toward structural and functional preserva-tion of teeth and oral tissues and reduction of intraoral adjust-ments. The construction of a dental prosthesis requires use of anarticulator able to closely mimic mandibular movements. Thearticulator’s condylar settings can be calculated by two methods:extraoral tracing devices and eccentric interocclusal records.

Studies that compared extraoral tracing devices in measuringcondylar inclinations to eccentric interocclusal records have consis-tently found that results with the former were more reproducible1

and accurate than with those with the latter. Among the instru-ments available for extraoral tracing, the simplified jaw trackingdevices (Panadent quick analyzer, Whip-Mix quick set recorder,axiograph) are the most practical ones. They record the movementsof the jaw in the sagittal plan only in contrast to the more compli-cated pantograph.


The Bennett AngleClinical Comparison of Different Recording Methods

Paul J. Boulos, D.D.S. Dr.PH.; Salim M. Adib, M.D., Dr.PH.; Levon J. Naltchayan, D.D.S.

Various studies have considered the amplitude2-5 and nature ofthe path of the nonworking condyle in the horizontal plane duringlateral excursion, the so-called Bennett angle, especially when animmediate mandibular lateral translation exists.6-11 Investigationshave shown that the accuracy of the mechanical axiograph com-pared favorably with the electronic version in determining thetransverse hinge axis.12 Compared to magnetic resonance imaging(MRI), the axiograph showed acceptable results in diagnostic pro-cedures.13 However, extraoral devices are sensitive to the operator’sskill14 and require additional expenses for equipment.

The easier eccentric interocclusal records are widely used androutinely suggested in dental textbooks as an alternative to theaxiographs.15 Dos Santos suggested that arcon-type articulatorssimulated jaw movements more closely than non-arcon types.6

However, Gross et al.16 questioned the reproducibility of three arconsemi-adjustable articulators. And Posselt et al.17 praised theDentatus articulator for its reliability. Investigations of recordingmaterials in interocclusal records techniques have indicated thatelastomeric materials, such as polyether or polyvinyl siloxanes,were superior to wax.18 However, at least one group of authors gavecredit to wax over other interocclusal recording materials.19

A clinical trial was conducted to investigate the performance offour methods for measuring Bennett angle (BA), using different com-binations of interocclusal materials and semi-adjustable articulators(arcon and non-arcon).This article reports on their respective perfor-mances compared to an axiograph that was used as a reference.

Materials and MethodsThirty dental school graduates and undergraduates of both sexesand between the ages of 18 and 33 agreed to participate in this clin-ical study. All participants signed an informed consent form. To beeligible, the participants had to have a complete dentition and an

Angle Class I jaw relation and no extractions, artificial crowns orextensive restorations. Participants had to be free of signs andsymptoms of temporomandibular disorders or parafunctions, suchas bruxism. They could not have any centric slide between the cen-tric relation position and the maximum intercuspation position, toensure unbiased measurements.

All participants were subjected to the same set of combinedmeasurements. Their BAs were measured using the Quick-Axisaxiograph (Sintec, East Wakefield, NH). This measurement was consid-ered the standard reference. Their BAs were subsequently mea-sured using interocclusal records on various types of articulators.

ProceduresAn axiograph Quick-Axis (Sintec, East Wakefield, NH) was mounted onthe head and the mandible according to manufacturer’s instruc-tions. The clutch was affixed with quick-setting plaster (Xanthano

Hearaus-Kulzer, Inc. Armonk, NY) on the mandibular anterior teeth. Thestem of the clutch was centered in relation to the sagittal plane. Theincisal edges of the teeth were covered with utility wax (Utility Wax,

Round Strips; Henry Schein Co, Melville, NY) to facilitate removal of theclutch later. Participants were asked to hold the clutch in the cen-tered position until the plaster set. The upper part of the axiographface-bow was secured tightly to the head using the nasal piece, theearpieces and the head band. Special graph papers were fixed onthe flags on both sides of the face. The transverse bar was affixed tothe stem of the clutch. The lateral arm was attached to the trans-verse bar, holding a stylus in the direction of the graph papersmounted on the flags.

Procedures for measuring BA using the axiograph requiredthat the stylus be replaced with a micrometer, which was zeroedwith its tip passively touching the flag at the origin of the axes(Figure 1). The participant was subsequently guided into a contra-lateral excursion of 3 mm until the tip of the micrometer reachedthe first arc (Figure 2).At this point, the micrometer was blocked bya lateral screw. The knob of the micrometer was turned clockwiseuntil it stopped, which enabled measurements to be read to 1/10 ofa mm (Figure 3) and transformed to an angle according to a chartprovided by the manufacturer. Table 1 presents the conversionchart used for this purpose.

The same maneuvers were repeated for the right and left sides.Stone casts using an improved dental stone (Silky-Rock; Whip-Mix

Corp, Louisville, KY) were obtained for each participant using irreversiblehydrocolloid impression material (Jeltrate Dentsply Caulk, Milford, DE) withperforated metallic trays (Coe Stainless Steel Trays; GC America Inc., Alslip, IL).Maxillary casts were mounted respectively on two different semi-adjustable articulators with corresponding face-bow transfers: Whip-Mix #8500 (arcontype) with Whip-Mix Quick Mount (Whip-Mix Corp,

Louisville, KY) or Dentatus AHR (non-arcon type) with Dentatus ear-bow (Dentatus USA, New York, NY), according to manufacturer’s instruc-tions.Mandibular casts were mounted using centric interocclusal waxrecords (Beauty Pink Wax; Moyco Union Broach-Thompson, Montgomeryville, PA).

Eccentric interocclusal records were made in two sets asrequired for lateral right and left excursions. An arithmetical meanwas computed from the two sets for each condylar setting. Lateral


movements were generated by occluding lightly with opposingcanine teeth placed tip to tip. Participants were asked to rehearsethe movements in front of a mirror until they were well performed.A 5 mm displacement was considered acceptable when a tip-to-tiprelation of anterior teeth was not possible or the eccentric displace-ment was not sufficient. Two interocclusal recording materials wereused for the recordings: wax (Aluwax Bite and Impression Wax, waxed cloth

sheets; Aluwax Dental Products Co., Grand Rapids, MI) and polyether (Ramitec

by 3M-ESPE AG, Dental Products, St. Paul, MN).The interocclusal records were used within two hours to avoid

possible wax distortions. The Whip-Mix and Dentatus articulators

Figure 1. Zeroedmicrometer at originof axes in centricrelation position.

Figure 2.Micrometer at endof eccentric lateralmovement. Notedisplacement visi-ble at center ofmicrometer.

Figure 3. Readingof displacement, inaccordance withwhite reference line(i.e., here it is 0.5 mm).

T A B L E 1Conversion Table for Calculation of Bennett Angle

Range of Displacement (mm) Bennett Angle (degrees)

0.20 -0.40 5 °

0.50 -0.70 10°

0.80 – 1.00 15°

1.10 – 1.30 20°

1.40 – 1.60 25°

1.70 – 1.90 30°

*Source: Quick-Axis® instruction booklet (Sintec, East Wakefield, NH)

were programmed to calculate the condylar inclinations, using thelateral eccentric interocclusal records. Angle measurements weresubsequently recorded on the worksheet for every participant.

Plan of AnalysisThe BAs on each side of the jaw for each participant were measured withfour different articulator/material combinations and tabulated. Themean values with their corresponding standard deviations (SD) werecomputed for each combination alone. Every mean value derived fromeach combination was compared separately to the mean reference valueobtained by the axiograph.Differences were tested using the paired t-testand were considered statistically significant with a P-value � 0.05.

The aim of the analysis was to identify the combination mostsimilar to the axiograph (that is, upholding the null hypothesis).That combination is the one with the least significant mean differ-ence (that is, the largest possible P-value) from the mean measuredby the axiograph. This judgment criteria was applied across all one-to-one comparisons presented in this paper. All computations wereconducted with SPSS 11.

ResultsOf the 30 volunteers participating in this trial, 40% were women; theaverage age was 22.5 years (SD= 2.7 years). The mean right lateralcondylar inclination in the group, as measured by the axiograph,


T A B L E 2Comparison of Bennett Angles Using Various Measurement Techniques (N = 30 patients)

Inclination (in degrees)

Axiography Whip-mix + Whip-mix + Dentatus + Dentatus+

Wax Polyether Wax Polyether

Right Condyle

Mean (SD) 12.2 (5.6) 13.5 (6.8) 14.6 (7.5) 13.8 (7.2) 15.7 (6.2)

P-value* reference 0.27 0.09 0.20 <0.01

Left Condyle

Mean (SD) 10 (4) 11.6 (7) 12.3 (8) 13.5 (7.2) 15.8 (7.2)

P-value* reference 0.22 0.13 0.02 <0.01

*Probability that difference in means, as measured by one method compared to reference, is significant one. Test used was paired t-test.


was 12.2 degrees (SD = 5.6). The smallest departure from that valueby the four alternative methods was obtained with the Whip-Mixarticulator with wax (mean: 13.5 degrees; P=0.27). Whip-Mix per-formed less well with polyether (mean: 14.6 degrees, P= 0.09).

The maximum deviation from the axiograph measurementwas obtained by the Dentatus articulator with polyether (mean:15.7 degrees; P<0.01). On the left lateral inclination, the meanangle measured on the axiograph was 10 degrees (SD=4). Thedepartures from that reference value were similar to those found onthe right side. Details are presented in Table 2.

DiscussionThis clinical trial was conducted to evaluate the accuracy of easieralternatives to axiographs in everyday clinical practice. Results pre-sented here suggest that the use of arcon Whip-Mix articulators canreproduce the patient’s condylar movements in the horizontal planebetter than other non-arcon articulators. The use of polyether onnon-arcon articulators resulted in significantly different measure-ments than the axiographs. All other combinations had varyingresults depending on the side of the jaw that was measured.

In this study, the mean BA value of 12.2 degrees, as measured bythe axiograph on the right condyle, was similar to that found byIsaacson et al.2 In that paper, a gnathograph was used to measure amean BA of 12.3 degrees in 36 participants. Curtis et al.3 evaluated 20patients using the pantograph and found 10.2 degrees as an averageBA. The values found in this study and other similar studies aregreater than those found by Beard et al.,4 who evaluated 86 patientswith an electronic pantograph and calculated a mean BA of 5.15degrees. The same can be said for findings from Theusner et al.,5 whoevaluated 49 patients using a modified SAM axiograph and found amean BA of 7.8 degrees in the asymptomatic group. Reasons for thesediscrepancies may be associated with the measurement of the BAafter calculation of the immediate mandibular lateral translation, aswill be explained later.

Mean values of BA found by the interocclusal records on both sidesin this study were generally higher than those found with the axiograph,regardless of the recording material or the type of articulator used. Thisagreed with results reported by Price et al.,11 who compared articulatorsettings from a computerized pantograph and settings from lateral inte-rocclusal records and concluded that the BA evaluated from the interoc-clusal record was higher than that evaluated by the pantograph.

Dos Santos et al.6 observed in 50% of subjects values of BA onarticulators that were greater than the real values. This was alsonoted by Stern et al.7 When they evaluated the BA using interocclusalwax records with and without taking account of the immediatemandibular lateral translation, the value calculated without theimmediate mandibular lateral translation was always higher thanthe BA evaluated with the immediate mandibular lateral translation.

Hobo et al.8 discussed in their study the difference existing incalculating the progressive mandibular lateral translation on thecondyle level and outside the face with an extraoral tracing deviceand concluded that the more laterally the flag was placed outsidethe face, the smaller the progressive mandibular lateral translation

will be and the greater the immediate mandibular lateral transla-tion will result. The BA values calculated from the interocclusalrecord will always be higher, especially in the presence of a lat-erotrusion of the working condyle, as reported to Lundeen et al.9

The lateral movement of the nonworking-side condyle frequent-ly has two components: the immediate mandibular lateral transla-tion and the progressive mandibular lateral translation.10 The imme-diate mandibular lateral translation is expressed in a tenth of a mm,and the progressive mandibular lateral is translated in degrees.

Figure 4, which represents the path of the nonworking-sidecondyle in the horizontal plane during a lateral excursion move-

Figure 4. Path of nonworking-side condyle in horizontal plane during lateralexcursion movement.

OA: Magnitude of move-ment in mm

OB: Trajectory of nonwork-ing-side condyle in horizon-tal plane

OC’: Immediate mandibularlateral translation

��: Bennett angle withoutimmediate mandibular lateraltranslation

��: Bennett angle with immediate mandibular lateral translation


ment, is used to explain the relationship between the BA and theimmediate mandibular lateral translation. The curve OB is thepath from the centric position to the limit of the movement. Theangle � formed by the sagittal plane (OA) and the line OB repre-sent the lateral condylar inclination as calculated with a semi-adjustable articulator without provision of the immediatemandibular lateral translation. The angle �, formed by the sagittalplane (O’C) and the line (O’B), represents the lateral condylar incli-nation after the calculation of the immediate mandibular lateraltranslation (OC’). Thus, it becomes obvious that the angle � willalways be greater than the angle �, regardless of the interocclusalrecording material or the type of the straight line, semi-adjustablearticulator used.

The intercondylar distance is adjustable with the Whip-Mix artic-ulator. This characteristic may explain the better performance in mea-suring the BA compared to the nonadjustable Dentatus articulator.

The performance of wax is in contradiction with some find-ings, suggesting the contrary.18 This discrepancy may be due to thefact that the polyethers might be more accurate in reproducing theincisal and occlusal forms of the teeth than the plaster casts andthat they remain nonrigid after setting. Both of these factors caninterfere with the placement of the plaster casts into the recordingmedium during mounting procedures. This was the point of viewsuggested by Balthazar et al.20

The clinical significance of these results may not be as decisiveas the statistical significance since it’s known that errors in evalu-ating the BA will affect the ridges and groove positions in the work-ing and nonworking sides and, to a lesser extent, the cusp height.These variations were found to range between 0.18 mm and 0.37mm on groove and ridge positions for every 5 degrees of error inestimating the BA.21

Clinically, the restorations constructed on the Whip-Mix articula-tor programmed with lateral interocclusal records will most likely needminor occlusal adjustments in the mouth, especially if the patient hasan acceptable incisal guidance.On the other side,restorations,especial-ly fixed prosthesis constructed on a Dentatus articulator programmedwith polyether interocclusal records, will present more occlusal prema-turities and will subsequently need more intraoral adjustments.

ConclusionsThe values of the Bennett angle recorded from the axiograph werelower than the values recorded from eccentric interocclusal recordson both types of articulators. Among all the combinations of vari-ous articulators and recording materials, the BA values recordedwith the Whip-Mix articulator were the closest to the axiograph onboth sides.

The advantage of the arcon articulators as a valid alternative tothe axiograph has thus been reaffirmed. The poor performance ofthe non-arcon articulators with polyether has also been a consis-tent finding on both sides. The results showed that wax used as an

interocclusal recording material was equal to polyether, in contra-diction with earlier studies. ■

This research was funded by research grant number FMD 30 from Saint-JosephUniversity, office of Vice-President for Research, to the first author. It was performedin memory of our late professor, Dr. Victor O. Lucia, whose remarks to the first authorprompted the need to initiate this study. Queries about this article can be sent to Dr.Boulos at [email protected].

REFERENCES1. Gross M, Nemcovsky C, TabibianY, et al. The effect of three different recording materials

on the reproducibility of condylar guidance registrations in three semi-adjustable artic-ulators. J Oral Rehabil 1998;25(3):204-208.

2. Isaacson D.A clinical study of the Bennett movement. J Prosthet Dent 1958;8(4):641-649.3. Curtis DA. A comparison of lateral interocclusal records to pantographic tracings. J

Prosthet Dent 1989;62(1):23-27.4. Beard CC, Donaldson K, Clayton JA. A comparison of articulator settings to age and sex.

J Prosthet Dent 1986;56(5):551-554.5. Theusner J, Plash O, Curtis DA, et al. Axiographic tracings of temporomandibular joint

movements. J Prosthet Dent 1993;69(2):109-115.6. Dos Santos J Jr., Ash MM. A comparison of the equivalence of jaw and articulator move-

ments. J Prosthet Dent 1988;59(1):36-41.7. Stern N, Hatano Y, Kolling JN, et al. A graphic comparison of mandibular border move-

ments by various articulators. Part I: Methodology. J Prosthet Dent 1988;60(2):194-198.8. Hobo S, Mochizuki S. A kinematic investigation of mandibular movements using an

electronic measuring system. Part I: Development of the measuring system. J ProsthetDent 1983;50(3):368-373.

9. Lundeen TF, Mendoza F. Comparison of two methods for measurements of immediateBennett shift. J Prosthet Dent 1984;51(2):243- 246.

10. Lundeen HC, Wirth CG. Condylar movement patterns engraved in plastic blocks. JProsthet Dent 1973;30(6): 866-875.

11. Price RB, Bannerman RA. A comparison of articulator settings obtained by an electron-ic pantograph and lateral interocclusal recordings. J Prosthet Dent 1988;60(2):159-163.

12. Nagy WW, Smithy TJ, Wirth CG. Accuracy of a predetermined transverse horizontalmandibular axis point. J Prosthet Dent 2002;87(4):387-394.

13. Ozawa S, Tanne K. Diagnostic accuracy of sagittal condylar movement patterns for iden-tifying internal derangement of the temporomandibular joint. J Orofac Pain 1997;11(3):222-231.

14. El–Gheriani AS, Winstanley RB. Graphic tracings of condylar paths and measurementsof condylar angles. J Prosthet Dent 1989;61(1):77-87.

15. Shillingburg HT, Hobo S, Whitsett LD, et al. Interocclusal Records: Fundamentals ofFixed Prosthodontics (3rd Ed.). Chicago: Quintessence 1997:44-45.

16. Gross M, Nemcovsky C, Friedlander LD. Comparative study of three semi-adjustablearticulators. Int J Prosthodont 1990;3(2):135-141.

17. Posselt UP, Franzen G. Registration of the condyle path inclination by intraoral waxrecords: variation in three instruments. J Prosthet Dent 1960;10(3):441-454.

18. Fattore L, Malone WF, Sandrik JL, et al. Clinical evaluation of accuracy of interocclusalsrecording materials. J Prosthet Dent 1984;51(2):152-7.

19. Utz KH, Müller F, Lückerath W, et al. Accuracy of check-bite registration and centriccondylar position. J Oral Rehabil 2002;29(5):458-466.

20. Balthazar Y, Fattore LD, Hart TO, Malone WFP. Interocclusal records. In Malone WFP,Koth DL(Ed): Tylman’s Theory and Practice of Fixed Prosthodontics (8th Ed). St Louis:Ishiyaku EuroAmerica, Inc. 1989:275.

21. Price RB, Kolling JN, Clayton JA. Effects of changes in articulator settings on generatedocclusal tracings. Part I: Condylar inclination and progressive side shift settings. JProsthet Dent 1991;65(2):237-243.


Abstract

This paper is a review of the dental management of

patients with epilepsy. It includes discussion of the effects

anti-epileptic drugs have on dental procedures and

addresses complications and side effects of these drugs.

A clinical case photo is presented to show gingival hyper-

plasia, along with four tables on which common anti-

epileptic medications are enumerated.

THE PURPOSE OF THIS ARTICLE is to review the relationshipbetween epilepsy and dental procedures and provide updated infor-mation on treating dental patients with epilepsy.Epilepsy and its treat-ment may present special issues for patients receiving dental care.Neurologists are often asked to provide medical clearance for patientswith epilepsy who are about to undergo dental procedures. The safetyof dental anesthetics for these patients is an additional concern.

Though the vast majority of epilepsy patients can undergodental procedures without special precautions, dentists shouldknow the patient’s seizure types and be trained in first aid mea-sures should they become necessary. The physician should providethe dentist with detailed information about patients with poorlycontrolled seizures. Anti-epileptic drugs, such as Phenobarbital,Phenytoin, Carbamazepine, and Valproic acid, can affect dental

Epilepsy and Dental Procedures A Review

Charles K.Vorkas, B.A; Manju K.Gopinathan, M.S., D.D.S.; Anuradha Singh, M.D.;Orrin Devinsky, M.D.; Louis M. Lin, B.D.S., D.M.D., Ph.D.; Paul A. Rosenberg, D.D.S.

health. Seizures can cause dental trauma and may occur in aminority of patients, especially those with atonic, tonic and tonic-clonic seizures. Dental prosthetics may pose dangers during someseizures. Good communication between the patient, dentist andneurologist can improve dental care.

Clinical History/Patient ManagementInformation about a patient’s epilepsy should be available to thedentist to improve safety during dental procedures. Dentists oftenrequest information from the neurological health-care provider(neurologist, nurse practitioner, nurse) about potential issues ofconcern. The information the dentist needs differs for patients withwell-controlled and poorly controlled seizures. For patients withwell-controlled epilepsy, the dentist should know:● The patient’s seizure types, clinical features and frequency.● Anti-epileptic drugs the patient is taking.● Seizure-related problems during prior dental procedures

(Table 1).For patients with poorly controlled seizures, the following sup-

plemental information is helpful:● If an aura typically precedes a complex partial or tonic-clonic

seizure.● Compliance with medication(s).● When last blood level was obtained on the current dosage

(trough, peak or random).● Strategies to prevent seizures.


● Factors that provoke seizures.● Emergency protocol for prolonged seizures or clusters (e.g.,

rectal diazepam).Dentists treating patients with active epilepsy should learn

basic first aid for seizures. This information can be found on Websites (epilepsy.com), in books3,9 or from videotapes available fromthe Epilepsy Foundation of America (for example,“How MedicinesWork, Understanding Complex Partial Seizures”; 2003).

The vast majority of epilepsy patients require few precautionsfor dental procedures. If patients are compliant with anti-epilepticdrugs (AEDs) and are seizure-free, both the patient and the dentistcan be reassured. Indeed, following standard protocols for dentaltherapy may prove the safest and most effective strategy. Changes toroutine dental or neurological care can sometimes lead to adverseoutcomes. For patients with uncontrolled seizures, benzodi-azepines (for example, lorazepam 0.5 mg – 1.0 mg) may be given 30to 45 minutes before the procedure, especially if one of the patient’sseizures could pose a danger during the procedure.

The unpredictable nature of seizures makes it difficult toensure freedom from seizures during dental procedures. However,most patients can identify factors that are associated with anincreased risk of seizures. The most common factors are sleepdeprivation, stress, time of menstrual cycle (catamenial epilepsy;premenstrual, menstrual and ovulatory periods), non-compliance,alcohol use and illness.19,29 Thus, patients should rest well and avoidalcohol before procedures. Patients with seizures provoked bystress, especially those who had seizures during prior dental proce-dures, may benefit from a stress-reduction protocol. Patients withcatamenial epilepsy should schedule procedures during low-riskperiods.21

AEDs and Dental ProceduresPatients should take their AEDs as usual before undergoing dentalor other procedures.10 Depending on the individual case and factors(for example, uncontrolled seizures, variable compliance), it mayhelp to confirm therapeutic AED blood levels before major dentalprocedures.17 Patients should be especially vigilant about compli-ance during the days before a dental procedure. There are no clini-cally significant interactions between AEDs and the local anesthet-ics that are commonly used. Common side effects of AEDs relatedto dental procedures are listed in Table 2.

Hemorrhagic ComplicationsValproic acid (VPA) can cause thrombocytopenia and decreaseplatelet aggregation and function in patients with normal plateletcounts.5,24,27,42 The clinical significance of VPA-induced platelet disor-ders in dental procedures remains uncertain. The lack of reports

T A B L E 2Side Effects of Anti-Epileptic Drugs

AED Common Side Effects Relating to Dental Procedures

Carbamazepine ulceration, xerostomia, glossitis and stomatitis

Lamotrigine xerostomia and oral ulcers

Phenobarbital hepatic enzyme induction

(impaired dental health)

Phenytoin gingival hyperplasia

Rarely causes thrombocytopenia, neutropenia,

aplastic anemia, sedation.

hepatic enzyme induction


Primidone hepatic enzyme induction


Valproate Can cause thrombocytopenia and decrease

platelet aggregation and function.

Rarely causes gingival hyperplasia.

CBZ, ESM, LTG, leukopenia

OXC, PB, PHT,

PRM, TPM

and VPA

T A B L E 1Common AEDs and Their doses for Status Epilepticus in Adults

AEDs Dose

Lorazepam 0.1 mg/Kg (3-6 mg maximum dose)

Diazepam 0.3 mg/Kg (10-20 mg maximum dose)

Fosphenytoin 20mg/Kg at 150mg/min

Phenytoin 20mg/Kg at 50mg/min

Phenobarbital 20mg/Kg at 100mg/min

Depacon 15mg/Kg followed by 1mg/Kg/h

Midazolam 0.2 mg /Kg bolus followed by 0.05-0.5 mg/Kg/h

Propofol 1mg/Kg bolus followed by 1-15 mg/Kg/h

Pentobarbital 5-15 mg slowly followed by 0.5-5 mg/Kg/h

Figure 1. Clinically, initial lesion usually begins as painless enlargement of facialand lingual/palatal-free gingival and interdental papillae, where anterior maxillaryand mandibular teeth are involved.

The vast majority of epilepsy patients require

few precautions for dental procedures.


about complications during dental procedures suggests that coagu-lopathy evaluations (for example, bleeding times) are not needed.However, the most recent platelet count should be reviewed before amajor dental procedure.For patients with a history of excessive bleed-ing on VPA, a clotting profile with bleeding time should be consid-ered.14 For patients with thrombocytopenia (<50,000) from VPA or asa rare complication of other AEDs (for example, carbamazepine,phenytoin or felbamate), elective procedures should be postponeduntil the platelet count improves or another AED is substituted.

Oral/Dental Side Effects of AEDsGingival hyperplasia or enlargement is most often a complication ofphenytoin (PHT) (Figure 1), but also results from Phenobarbital(PB)47,51 and, rarely, VPA.2 The free gingival and interdental papillaeon the facial and lingual aspects of maxillary and mandibular ante-rior teeth are involved most frequently and severely.51 PHT is excret-ed in the saliva and promotes fibrous gingival hyperplasia.21,22

Gingival hyperplasia develops in up to 50% of patients within threemonths after taking PHT.34,44 It can occur at any age, but is seen morefrequently in children.23 Males and females are equally affected.41

There is no clear correlation between PHT serum levels andthe severity of gingival hyperplasia.30 Gingival overgrowth usuallyresolves within six months after PHT is discontinued.7

The mechanism underlying the proliferation of connective tis-sues is unknown.50 Poor dental hygiene contributes to hyperplasiabut cannot fully account for lesions. Bacteria-laden plaque canexacerbate gingival lesions, due to inflammation,28 but the role ofplaque in PHT-induced gingival hyperplasia remains controversial.

High-plaque levels correlate with the severity of hyperplasia.30,52

Plaque removal cannot prevent gingival hyperplasia in individuals onPHT.30 Genetic factors may contribute to gingival hyperplasia, sincesome patients with poor oral hygiene on chronic high-dose PHT donot develop gingival hyperplasia.44 Oral hygiene regimens (for exam-ple,brushing,flossing and regular cleanings by a dental hygienist) canhelp prevent or reduce plaque and gingival hyperplasia.1,30

Chlorhexidine and folic acid rinses are recommended by some.45 Oralhygiene should be initiated prior to, or as soon as possible after, thestart of PHT therapy.30 In cases in which hyperplasia is severe, gin-gevectomy may be necessary. When oral hygiene is difficult or gingi-val hyperplasia severe, alternative AEDs should be considered.

CBZ can cause oral complications, including ulceration, xeros-tomia, glossitis and stomatitis.14 Xerostomia is associated with anincreased risk of dental caries and oral candidiasis.46 Lamotrigine(LTG) can also cause xerostomia and oral ulcers. If these conditionspersist, a topical fluoride can be used to help prevent caries.Clinically significant leukopenia from AEDs is rare, but when pre-sent, it may predispose the patient to dental infections.

AED Interaction with Other DrugsInteractions between some commonly prescribed drugs and AEDsare presented in Table 3. Antibiotics that are most often prescribed

T A B L E 3Common Drug Interactions with Anti-epileptic Therapy

Drugs Prescribed Side Effects/Interaction with by DHCP Anti-epileptic Therapy

Antibiotics

Macrolides Erythromycin and troleandomycin are

the most potent inhibitors of CBZ

metabolism.

Clarithromycin, flurithromycin,

josamycin, midecamicin, miocamycin

and roxithromycin are moderate

inhibitors of CBZ metabolism.

Penicillins Benzylpenicillin is more likely to cause

seizures than semi-synthetic penicillins.

Concurrent use of carbenicillin,

piperacillin or ticarcillin may increase

bleeding tendencies.

Antiprotozoal

Metronidazole Can inhibit the metabolism of CBZ.

Concurrent use with CBZ, PHT or PB

may decrease plasma levels of

metronidazole.

Rarely causes xerostomia.

Rarely convulsant.

Narcotic analgesics Dextropropoxyphene can inhibit

metabolism of PHT, CBZ and PB.

Non-steroidal Concurrent use with VPA may

anti-inflammatory drugs exacerbate bleeding problems.

(aspirin, ibuprofen) Can inhibit the metabolism of PHT.

Carbohydrate-based Compromise a ketogenic diet.

toothpaste & antibiotics

T A B L E 4Anesthesia for Epilepsy Patients

Anesthetic Side Effects/Observations

Benzodiazepines Anticonvulsant

Midazolam rarely convulsant during intravenous

use for sedation.

Enflurane Convulsant

Flumazenil Convulsant

Lidocaine Can be used with adrenaline as a local

anesthetic agent.

Methoxitone Convulsant

Nitrous Oxide Anticonvulsant

Reduces risk of stress-induced seizure.

Nitrous Oxide/ Used for conscious sedation in mentally and/or

Oxygen physically handicapped patients.

Visteril Can be used safely in normal therapeutic doses.

DZP

Versed


by dentists may interact with AEDs and potentially cause sideeffects or seizures. For example, some antimicrobials interfere withthe absorption or metabolism of AEDs, resulting in either increasedor decreased plasma AED levels.40 AEDs can also modify the phar-macokinetics of antimicrobials, leading to loss of efficacy or toxic-ity.33 However, these effects are rarely clinically significant.

Epilepsy and AnesthesiaLocal anesthetic agents are usually safe for people with epilepsy.Low doses of lidocaine in dental local anesthetic cartridges are notassociated with seizures,37 although accidental administrationintravenously could potentially provoke a seizure.

AEDs that depress CNS function (for example, benzodiazepinesor barbiturates) increase the depressant effects of anesthetic agents.Patients undergoing conscious sedation must be monitored closely,as they often require lower doses of anesthetic agents. However,patients on chronic benzodiazepines show a tolerance to short-termbenzodiazepine therapy (for example, midazolam).35 Midazolam(MZL) can cause seizures in patients receiving this agent intra-venously for sedation.36 Benzodiazepine receptor antagonists (forexample, flumazenil) can provoke seizures and should be avoided.16

Enzyme-inducing AEDs enhance the metabolism of most benzodi-azepines, reducing their plasma concentration.48

Conversely,VPA can increase the plasma concentration of LZP39

and DZP.11 Because benzodiazepines have a wide therapeutic index,the clinical significance of these interactions is usually small.33

The side effects related to use of anesthetics with epilepsypatients are given in Table 4.

Behavioral ManagementInhalational sedation with nitrous oxide or intravenous sedationwith a benzodiazepine might reduce the risk of a stress-inducedseizure in susceptible patients.14 Behavioral management, com-bined with conscious sedation using nitrous oxide/oxygen, is oftenused for severely mentally and physically handicapped patients.

A small number of these patients cannot be adequately man-aged by this technique alone because of their restricted copingresources and inability to carry out continuous nasal breathing,essential for nitrous oxide administration by nasal mask.32 Electiveprocedures may be delayed if the patient is in a period of increasedseizures or behavioral problems. In some patients, however, gener-al anesthesia is required.

Patients should take their medication throughout the periop-erative period. AEDs should be administered orally with a smallamount of water before general anesthesia.

Trauma, Prosthetic Dentistry,Oral/Maxillofacial Therapy Patients with epilepsy have increased risk of dental trauma.20 Theside effects related to the use of anesthetics with patients withepilepsy are given in Table 4. Falls can complicate atonic, tonic andtonic-clonic seizures, causing soft tissue lacerations, facial fractures,temporomandibular joint subluxation and devitalization, fractures,and subluxation or avulsion of teeth.18,42 Patients with Lennox-Gataut syndrome, who are prone to suffer from multiple seizuretypes associated with falls, are also prone to suffer dental trauma.

Helmets may be used to prevent head trauma, but they oftenfail to provide protection of the mouth and jaw. In a study of 33children who were prescribed helmets for intractable seizures caus-ing falls, helmets did not appear to reduce the risk of facial or scalpinjury: Twenty-one out of thirty-one (68%) injuries occurred whena helmet was worn, while 16 out of 28 (57%) occurred when a hel-met was not worn.8

In a prospective study of multi-handicapped adults withepilepsy, dental injuries accounted for only 5% of seizure-relatedaccidents.31 In a retrospective survey in adult patients, 9.7% report-ed a dental injury during a seizure; in 86% of these cases, the trau-ma caused tooth loss or jaw fracture.6 Some patients who lose teethreceive inadequate prosthodontic treatment.20 For example, signifi-cantly more epilepsy patients have nickel-chrome rather than themore aesthetic metal-ceramic fixed prostheses.20

Fixed prostheses are preferred over removable partial denturesbecause of the danger of seizure-related injuries and aspiration. Ifa removable denture is unavoidable, then a metal base is preferred,


to minimize the chances of fracture.41 Acrylic facings on anteriorcrowns can facilitate future repair should a fracture occur.4,38

Replacement of missing teeth may prevent the tongue from beingcaught in the edentulous spaces during seizures.15

Oral and maxillofacial surgeons treat epilepsy patients regu-larly for routine as well as reconstructive surgery. Patients withvagus nerve stimulator implants should have them turned offbefore surgery.53

ConclusionPatients with well-controlled seizures can be easily treated in rou-tine dental office settings. Such patients are risk category II underthe American Society of Anesthesiologists (ASA) PhysicalClassification System. This is the same risk category as an other-wise healthy patient who is apprehensive, pregnant, has allergies oris over age 60.21

Patients with poorly controlled seizures or poor complianceare ASA risk category III (severe but not incapacitating system dis-ease) or ASA risk category IV (incapacitating disease that is a con-stant threat to life).26 These higher-risk patients may best be treat-ed in specialized care settings.49

■

Queries about this article can be sent to Dr. Devinsky at [email protected].

REFERENCES1. Addy V, McElnay JC, Eyre DG, Campbell N, D’Arcy PF. Risk factors in Phenytoin-induced

hyperplasia. J Periodontol 1983; 54: 373-377.2. Anderson HH, Rapley JW, Williams DR. Gingival overgrowth with valproic acid: a case

report. ASDC J Dent Child 1997;64:294-7.3. Bazil C. Living Well with Epilepsy and Other Seizure Disorders, 1st Ed. New York: Harper

Collins, 2004.4. Braham, RL, Casamassimo PS, Nowak AJ, Psnick WR, Steiberg AD. The dental implica-

tions of epilepsy. Rockville, Md.: U.S. Department of Health Education and Welfare,1977; DHEW publication no. HSA78-5217.

5. British Dental Association, British Medical Association, Royal Pharmaceutical Society ofGreat Britain. Dental Practitioners’ Formulary 1998-2000. London: pp. 210-220.

6. Buck D, Baker GA, Jacoby A, Smith DF, Chadwick DW. Patients’ experiences of injury asa result of epilepsy. Epilepsia 1997;38:439-444.

7. Dahllöf G,Axio E, Modéer T. Regression of phenytoin-induced gingival overgrowth afterwithdrawal of medication. Swed Dent J 1991; (1593): 139-43.

8. Deekollu D, Besag FM,Aylett SE. Seizure-related injuries in a group of young people withepilepsy wearing protective helmets: Incidence, types and circumstances. Seizure2005;14:347-353.

9. Devinsky O. Epilepsy: Patient and Family Guide, 2nd Ed. Philadelphia: FA Davis, 2002.10. Devinsky O, Paraiso JO, Rosenberg A, Nordli Jr DR. Procedures in Patients with Epilepsy

(Chapter 186). In: Engel J Jr, Pedley T (eds): Epilepsy: A Comprehensive Textbook.Philadelphia: Lippincott-Raven, 1997.

11. Dhillon S, Richens A.Valproic acid and diazepam interaction in vivo. Br J Clin Pharmacol1982; 13: 553-60.

12. Epilepsy Foundation of America, Inc. www.epilepsyfoundation.org, 2003.13. Epilepsy Therapy Development Project. www.epilepsy.com, 2005.14. Fiske J. Epilepsy and Oral Care. Dental Update 2002; 29:180-187.15. Friedlander AH, Brill NQ. The dental management of depressed patients. Spec Care Dent

1987; 7:65-6.16. Greenwood M. General medicine and surgery for dental practitioners Part 4:

Neurological disorders. Br Dent J. 2003 Jul 12;195(1):19-25.17. Grisham PL. Clinical Considerations in Dental Patients with Convulsive Disorders. Dent

Clin North Am. 1982 Jan;26(1):123-7.18. Grundy MC, Shaw L, Hamilton DV. An Illustrated Guide to Dental Care for the Medically

Compromised Patient. London: Wolfe Publishing, 1993.19. Herzog AG, Harden CL, Liporace J, Pennell P, Schomer DL, Sperling M, Fowler K, Nikolov

B, Shuman S, Newman M. Frequency of catamenial seizure exacerbation in women withlocalization-related epilepsy. Ann Neurol 2004 Sept;56(3): 431-4.

20. Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommendedcare of patients with epilepsy. J Prosthet Dent. 2005 Feb;93(2):177-82.

21. Kennedy BT, Haller JS. Treatment of the epileptic patient in the dental office. NYSDJ 1998Feb;64(2):26-31.

22. Kimball O. The treatment of epilepsy with sodium diphenyl-hydantoinate. JAMA1939;112: 1244-1245.

23. Klar LA. Gingival hyperplasia during dilantin therapy; a survey of 312 patients. J PubHealth Dent 1973;33(3):180-5.

24. Lackmann GM. Valproic-acid-induced thrombocytopenia and hepatotoxicity: discon-tinuation of treatment? Pharmacology 2004 Feb;70(2): 57-8.

25. Little JA, Falace DA, Miller CS, Rhodus NL. Dental Management of the MedicallyCompromised Patient. 6th Ed. Mosby; 2002; 420-423.

26. Malamed S. Medical Emergencies in the Dental Office. 4th Ed. Mosby; 1993; 42.27. Mallet L, Babin S, Morais JA. Valproic acid-induced hyperammonemia and thrombocy-

topenia in an elderly woman. Ann Pharmacother 2004 Oct; 38(10): 1643-7.28. Marrioti A. Dental Plaque-Induced Gingival Diseases.Annals of Periodontology,Volume

4 Number 1, December 1999,7-17.29. Mattson RH, Fay ML, Sturman JK, et al. The effect of various patterns of alcohol use on

seizures in patients with epilepsy. In: Porter RJ, Mattson RH, Cramer JA, et al., eds.Alcohol and Seizures: Basic Mechanisms and Clinical Concepts. Philadelphia: FA Davis,1990: 233-240.

30. Modéer T, Dahlöff G. Development of phenytoin-induced gingival overgrowth in non-institutionalized epileptic children subjected to different plaque control programs. ActaOdontol Scand 1987; 45(2): 81-5.

31. Nakken KO, Lossius R. Seizure-related injuries in multihandicapped patients with ther-apy-resistant epilepsy. Epilepsia 1993;34:836-840.

32. Oei-Lim VL, Kalkman CJ, Bouvy-Berends EC, Posthumus Meyjes EF, Makkes PC,Vermeulen-Cranch DM, Odoom JA, van Wezel HB, Bovill JG. A comparison of the effectsof popofol and nitrous oxide on the electroencephalogram in epileptic patients duringconscious sedation for dental procedures. Anesthesia and Analgesia 1992;75:708-714.

33. Patsalos PN, Perucca E. Clinically important drug interactions in epilepsy: general fea-tures and interactions between antiepileptic drugs. Lancet Neurol 2003;2:347-56.

34. Prasad VN, Chawla HS, Goyal A, Gauba K, Singhi P. Incidence of phenytoin induced gin-gival overgrowth in epileptic children: a six month evaluation. J Indian Soc Pedod PrevDent 2002;20:73-80.

35. Robb ND, Hargrave SA. Tolerance to intravenous midazolam as a result of oral benzodi-azepine therapy: a potential problem for the provision of conscious sedation in den-tistry. Anesth Pain Control Dent 1993;2:94-97.

36. Robb ND.Epileptic fits under intravenous midazolam sedation.Br Dent J 1996;181:178-179.37. Rood JP. Local anaesthesia and the medically compromised. Dent Update 1991:18:330-334.38. Rucker LM. Prosthetic treatment for the patient with uncontrolled grand mal epileptic

seizures. Spec Care Dentist 1985;5 (5):206-207.39. Samara EE, Granneman RG, Witt GF, Cavanaugh JH. Effect of valproate on the pharma-

cokinetics and pharamcodynamics of lorazepam. J Clin Pharmacology 1997;37:442-50.40. Sander JW, Perucca E. Epilepsy and comorbidity: infections and antimicrobials usage in

relation to epilepsy management. Acta Neurol Scand 2003:108 (Suppl 180):16-22.41. Sanders, Brian J. Managing patients who have seizure disorders; dental and medical

issues. J Amer Dent Assoc Dec 1995;126.42. Scully C, Cawson RA. Medical Problems in Dentistry. 4th Ed. Oxford:Butterworth-

Heinemann, 1998.43. Seymour RA, Smith DG, Turnbull DN. The effects of phenytoin and sodium valproate on

the periodontal health of adult epileptic patients. J Clin Periodontol 1985;12:413-419.44. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug-induced gingival overgrowth.

J Clin Periodontol 2000;27: 217-223.45. Siegel MA, Silverman S, Sollecito TP, eds. Clinician’s Guide to Treatment of Common Oral

Conditions. 5th Ed. Baltimore: American Academy of Oral Medicine 2001:10-11.46. Silverman S. Oral cancer: complications of therapy. Oral Surg Oral Med Oral Path Oral

Radiol Endoton 1999;88:122-126.47. Sinha S, Kamath V, Arunodaya GR, Taly AB. Phenobarbitone induced gingival hyperpla-

sia. J Neurol Neurosurg Psychiatry 2002;73:601.48. Spina E, Perucca E. Clinical significance of pharmacokinetic interactions between

antiepileptic and psychotropic drugs. Epilepsia 2002; 43 (suppl 2): 37-44.49. Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22(3):

26S-39S.50. Stinett E, Rodu B, Grizzle WE. New development in understanding phenytoin-induced

gingival hyperplasia. JADA 1987;114: 814-6.51. Stroopler ET, Sollecito TP, Greenberg MS. Dent Art Rev Test 2003;July-Aug:361-6.52. Thomason JM, Seymour RA, Rawlins MD. Incidence and severity of phenytoin induced

gingival overgrowth in epileptic patients in general medical practice. Community DentOral Epidemio 1992;20:288-91.

53. Turner MD, Glickman RS. Epilepsy in the oral and maxillofacial patient: current thera-py. J Oral and Maxillofac Surg 63:996-1005, 2005.

Abstract

Hemangioma is a proliferating mass of blood vessels. Its

occurrence in gingiva is rare. The diagnosis and treatment

of hemangioma is complex, and any attempt to carry out

biopsy/surgical excision may lead to fatal consequences

due to severe hemorrhage. A rare case of gingival heman-

gioma with port wine nevi of face is reported. The case is

of periodontal interest because the lesion occurred on the

gingiva, a reliable diagnostic approach (Ultrasound

Spectra Doppler Flow) was used and a conservative treat-

ment using a sclerosing agent was employed.

HEMANGIOMA is a common tumor of the head and neck charac-terized by the proliferation of blood vessels. It may involve soft tis-sue and/or bone, and is considered to be a hamartoma rather thana true neoplasm.1 Failure to judge the presence of hemangiomabefore the initiation of surgical therapy (for example, biopsy orextraction) may lead to severe hemorrhage.

Soft-tissue hemangioma is not an unusual tumor in the oralcavity. The most commonly involved site is the tongue, followed bylips, cheek and palate. Hemangioma of gingiva is uncommon.


Gingival Hemangioma with Port Wine Nevi of the Face

A Case Report

Shridhara B. Reddy, M.D.S.; Shiva Prasad, B.M., M.D.S.; Sudhir R. Patil, M.D.S.;Nagaraj B. Kalburgi, M.D.S.; S.S. Vanaki, M.D.S.; R.S. Puranik, M.D.S.

Excess levels of angiogenic factors like basic fibroblast growthfactor (bFGF) and vascular endothelial growth factor (VEGF) ordecreased levels of angiogenesis inhibitors such as gamma-inter-feron, tumor necrosis factor–beta and transforming growth fac-tor–beta may play a role in the etiology of hemangiomas.2

The diagnosis of the hemangioma is made on the basis of clin-ical, radiological/imaging findings, most commonly, angiographyand Doppler sonography.

The treatment of hemangioma is still a matter of debate. Thereare published reports of success with several treatment modalities.The choice of treatment depends on the size and location of thelesion, the age of the patient and anticipated complications.Different treatment modalities include irradiation, injection ofsclerosing agents, cryotherapy, embolization, interferon-a, laser,electrocoagulation and surgery.3

Sclerosing agents such as sodium morrhuate, sodium psylliateand absolute ethanol have been used successfully but produceadverse effects, including pain, allergic reaction and even anaphy-lactic shock.4 Sodium tetradecyl sulphate is considered an idealsclerosing agent and is associated with minimal systemic and localreaction.5

The case presented here is of periodontal interest because thelesion occurred on the gingiva. It was diagnosed using UltrasoundSpectra Doppler Flow and was treated conservatively using a scle-rosing agent.

Case ReportA 30-year-old male patient presented to the Department ofPeriodontics with a solitary, nodular intraoral swelling of the pos-terior maxillary region of one-year duration. The swelling gradual-ly increased in size and interfered with mastication. Historyrevealed occasional bleeding on mastication, which used to subsideon its own. The patient’s hereditary and familial histories were notsignificant.

Intraoral examination revealed a 2.0 cm x 3.0 cm solitary, ses-sile swelling of reddish granular appearance that extended from themesial of tooth #15 to the buccal half of tooth #17. It covered thebuccal, occlusal and palatal aspects of the involved teeth and resem-bled pyogenic granuloma (Figures 1, 2). The lesion was pulsatile,compressible and exhibited signs of emptying on digital pressurewith thrills. On auscultation, clear bruits could be heard. No otherarea of the oral cavity showed the presence of similar swelling.

Moderate stains and calculus with generalized bleeding onprobing were present. Other dental findings included: 1. Grade IImobility in relation to tooth #14 and Grade III mobility withrespect to teeth #15 and #16; 2. teeth #18 and #22 were missing; 3.root stumps in relation to tooth #46. A routine hematological pro-file was within the normal limit.

It was interesting to note that the patient had diffuse port winenevi on the right side of his face. It had been present since birth andwas not connected to the intraoral swelling (Figure 3).

Intraoral periapical radiograph showed the periodontal liga-ment thickening along the roots of pathologically migrated teeth#15 and #16 with the loss of lamina dura. A slight change in thealveolar bone pattern was noted in the interdental bone betweenteeth #15 and #16, which may have been caused by the pressureeffect of the lesion. Overall radiological findings were suggestive oflocalized periodontitis in relation to teeth #15 and #16. A CT scanrevealed no extension of the lesion to underlying structures, likebone and sinus. Nor was the lesion related to the port wine stainpresent extraorally.

Ultrasound sonography showed a diffuse enlarged mass of 2cm x 2 cm in diameter on the right posterior area of the maxilla.Ultrasound Spectral Doppler Flow (Figure 4) imaged a high densi-ty of vessels, suggesting a high vascular nature of the lesion. Withthe help of the Doppler probe, the course of the feeding vessel wasdetected. External carotid angiography was attempted but couldnot be completed because of patient factors.

Given the clinical and imaging findings, the diagnosis of gin-gival hemangioma was rendered to the lesion.

The root stumps were extracted and the carious teeth werefilled. Meticulous oral prophylaxis was performed.After anesthetiz-ing the area, an intralesional sclerosing agent in aliquots of 0.05 ccto 0.1 cc was injected using a 25-gauge needle at multiple sites. Thetotal dose did not exceed 0.7 cc to 0.9 cc. Injections were repeated 8times at 15-day intervals. At each visit, Ultrasound SpectralDoppler Flow was done in the Radiology Department of HSKMedical College in Bagalkot, Karnataka, India. The patient was fol-lowed for six months without evidence of recurrence (Figure 5).


Figure 1. 2 cm x 3 cm ses-sile granular soft tissue massin relation to teeth #15, #16region (buccal view).

Figure 2. Palatal extension oflesion.

Figure 3. Port wine nevi ofright side of face.

Figure 4. Ultrasound SpectralDoppler flow showingincreased vascularity.

Figure 5. Six months postop-erative.


DiscussionHemangiomas are benign lesions with increased numbers of bloodvessels. They are tumor-like malformations composed of seeming-ly disorganized masses of endothelium-lined vessels that are filledwith blood and connected to the main blood vascular system. Theyaffect numerous tissue types (individually or in combination),including the skin, subcutaneous tissue, viscera, muscle, synoviumand bone.2

The case presented here is rare and is of periodontal interestbecause the lesion occurred on the gingiva (Table 1).Positive responseto treatment was evident clinically as shrinkage of the lesion and wasconfirmed through Doppler ultrasound, which revealed decreasedvascularity. It may be analyzed audibly by listening to the intensityand pitch of the sound and may be recorded graphically either as asimple wave form or as a more complete sound spectrum analysis.6

Sclerosing agents have been used for many years to managehemangiomas of the jaws. This is still an acceptable mode of ther-apy in selected cases, either alone or in conjunction with surgicalexcision. Sclerosing agents cause cell death inflammation and fibro-sis. The fibrosis leads to sclerosis of the vessels, which subsequent-ly leads to regression of the lesion.

A sclerosing agent was chosen in this case after consideringthe following clinical aspects:● The surgical excision of the large hemangioma would be extreme-

ly dangerous and fatal due its hemorrhagic complications.● The sessile growth of the lesion over a large area of gingival

and periodontal structures made complete excision of thelesion impossible.Sodium tetradecyl sulphate proved to be a powerful, almost

ideal sclerosing agent. It was associated with minimal local and sys-temic adverse reactions. This agent has been reported to be an idealagent in treating similar lesions.

ConclusionHemangiomas are tumor-like lesions of blood vessels that can pro-liferate in soft tissue. Diagnosis of the lesion and monitoring itsvascularity with Doppler ultrasound consistently yields a goodresult and can save both time and money for the clinician and thepatient. Sodium tetradecyl sulphate has proved to be a powerfuland almost ideal sclerosing agent.

Cautious diagnosis, treatment and monitoring of the heman-gioma can enable the periodontist and general practitioner to dif-ferentiate it from conventional epulides and treat it without a majorsetback. ■

Queries about this article can be sent to Dr. Shiva Prasad at drshivaprasad2000@red-

iffmail.com.

REFERENCES1. Neville BW, Damn DD,Allen CM, Bouquot. Soft tissue tumors. In: Neville BW, Damn DD,

Allen CM, Bouquot (eds). Oral and Maxillofacial Pathology. Philadelphia: WB Saunders1995:467.

2. Rossiter JL, Hendrix RA, Tom CW, Potsic WP. Intramuscular hemangioma of the headand neck. Otolaryngol Head Neck Surg 1993;108:18-26.

3. Bunel K, Steen S-P. Central hemangioma of the mandible. Oral Surg Oral Med OralPathol 1993; 75:565-70.

4. Chin D. Treatment of maxillary hemangioma with a sclerosing agent. Oral Surg 1983;55(3):247-249.

5. Baurmash H, Mandel L. The nonsurgical treatment of hemangioma with sotradecol.Oral Surg Oral Med Oral Pathol 1963;16(7):777-782.

6. Van Doorne L, De Maeseneer M, Stricker C. Br J Oral Maxillofac Surg 2002;40:497-503.

T A B L E 1 . Substantiation of Rarity of Present Case

Criteria Reported Cases Present Case

Arch Mandible Maxilla

Sex Female Male

Location Tongue, lips, cheek, palate Gingiva


Abstract

This investigation evaluated preferred treatment methods

for primary tooth vital pulpotomies. One hundred and thir-

ty surveys were sent to a randomly selected sample of

board-certified pediatric dentists practicing in the United

States. Ninety-two questionnaires were returned, for a 71%

response rate. This yielded a sample group of 92 board-

certified pediatric dentists. The most commonly used

medicament was formocresol. Seventy-three percent

using formocresol said they were not concerned about

adverse side effects of formocresol and formaldehyde.

Sixty-one percent of respondents used formocresol for pri-

mary tooth vital pulpotomies. Twenty-eight percent of

respondents used undiluted, and 33% used diluted. The

results of this survey suggest that the majority of den-

tists who used formocresol were not concerned with any

adverse effects.

Preferred Treatment Methods for Primary Tooth Vital Pulpotomies

A Survey

Richard K. Yoon, D.D.S.; Steven Chussid, D.D.S.; Martin J. Davis, D.D.S.; Karl C. Bruckman

UNTREATED DENTAL CARIES remains a significant problemamong American children.1 The Centers for Disease Control report-ed in August 2005 a caries prevalence among 2 to 5 year olds of28%, which represents an increase of 15.2% over 8 to 10 years.2 Thisfinding of continuing high prevalence is important to young chil-dren and their families since early caries often results in pain, infec-tion and dysfunction. Pharmacotherapeutic approaches, such asvital pulpotomies, facilitate the maintenance of pulpally compro-mised primary teeth, allowing restoration and healthy function.

Efficacy studies on widely used pulp medicaments such asformocresol and ferric sulfate demonstrate overall clinical successrates ranging from 55% to over 90%.3-15 In a survey of primarytooth pulp therapy, as taught in predoctoral pediatric dental pro-grams in the U.S., Primosh concluded that the diluted formulationof formocresol is the preferred technique in a pulpotomy proce-dure.16 Further, pediatric dental textbooks recommend the dilutedformulation.17-19

Hunter, in a 2003 survey of specialists in pediatric dentistrypracticing in the United Kingdom, examined clinician attitudesabout vital pulpotomies in the primary dentition.20 The most wide-ly used medicament was diluted formocresol. Half of the respon-dents expressed concern regarding the formaldehyde incorporationin formocresol.Approximately half of the respondents were consid-ering changing their current technique.20


Our study sought to surveyboard-certified pediatric dentistspracticing in the U.S. to: 1. deter-mine their preferred techniqueand medicament for primarytooth vital pulpotomies; and 2.evaluate any concerns of toxicityregarding their chosen medica-ment.A survey of the members ofthe American Board of PediatricDentistry (ABPD) was used to establish current trends concerningvital pulpotomies in primary teeth. The ABPD is considered a validsample of the members of the American Academy of PediatricDentistry (AAPD) at large.21

MethodsAfter Institutional Review Board approval, a survey containing anexplanatory letter, questions inquiring about preferred techniquesfor primary tooth vital pulpotomies and a prepaid return envelopewas mailed to 130 practicing pediatric dentists certified by theABPD. Respondents were selected randomly by district. Surveyquestions requested information on the following: 1. preferred vitalpulpotomy technique; 2. justification for medicament chosen; and3. concerns regarding possible undesirable side effects of the cho-sen medicament. Responses were analyzed by number of years inpractice and region and were tabulated as frequencies.

T A B L E 1Preferred Medicament Employed in Vital Pulpotomy Technique

Frequency Percent Valid Percent Cumulative Percent

Valid Formocresol (1:5 dilution) 30 32.6 32.6 32.6

Formocresol (full strength) 26 28.3 28.3 60.9

Ferric Sulfate 29 31.5 31.5 92.4

Other* 7 7.6 7.6 100.0

Total 92 100.0 100.0

* Electrosurgery, calcium hydroxide, laser, sodium hypochlorite, mineral trioxide aggregate, no medicament

ResultsOne hundred thirty surveys were mailed out. Ninety-two complet-ed questionnaires were returned, for an acceptable return rate of71%. The distribution of responses was approximately equal fromeach AAPD Trustee District.

Table 1 illustrates respondents’ preferred medicaments.Formocresol was most widely chosen by 61% of the sample, with33% of all respondents having chosen the diluted formulation. Inno particular order, electrosurgery, calcium hydroxide, laser, sodi-um hypochlorite and mineral trioxide aggregate were specified asbeing favored by respondents using “other”techniques or medica-ments. Two respondents said they used no medicament at all.

Eighty-two of the 92 respondents (89% of the sample group)indicated that the medicament they used was one to which they hadbeen introduced as a postdoctoral student. Of these, ninety percentsaid they were not concerned about the adverse side effects of theirchosen medicament. “Other” reasons provided for use of chosenmedicament were “patient safety” and “literature.”

Seventy-six of the 92 respondents (83% of the sample group)said they had no concerns about their preferred topical medica-ment. Of the respondents using formocresol, 73% said they had “noconcerns” (for example, toxicity, mutagenicity and carcinogenicityof formocresol and formaldehyde) about their chosen medicament.

An analysis of responses for association between preferredmedicament by region and number of years in practice yielded nosignificant associations. Respondents using formocresol provided56 free text comments, and several trends seemed to emerge. Theseincluded: a reduction in application time (n = 15); a tendency toblot the cotton pellet dry (n = 35); and a belief that formocresol isstill the “gold standard” and safe if “used properly” (n = 6).

DiscussionThe choice of topical medicaments for fixation and disinfection ofremaining tissue in “vital” pulpotomies remains controversial.Current clinical guidelines from the AAPD find a variety of tech-niques acceptable, among them, formocresol, ferric sulfate or elec-trosurgery.22 Evidence relating to various modes of use offormocresol has been available since the mid-1970s.6,10,14 Therefore,it is not surprising that respondents continue to use variousstrength formulations.

Although the literature notes considerable controversy regard-ing the toxicity, mutagenicity and carcinogenicity of formaldehydeand formocresol,23,24 it is interesting that the majority of pediatric


dentist responding to our survey who use formocresol had no con-cerns about its potential side effects.

From the respondents’ comments, it is clear that many pedi-atric dentists are comfortable with their chosen medicament.Further, the majority of pediatric dentists prefer formocresol andare unconcerned about its potential adverse effects.

ConclusionWithin the limits of this sample, it can be concluded that 61% of pedi-atric dentists in the U.S. continue to use formocresol and that 73% ofthese pediatric dentists are not concerned about side effects. ■

The authors thank Yanping Wang for her assistance with data analysis.Queries about this article can be sent to Dr. Yoon at [email protected].

REFERENCES1. Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life in young chil-

dren. Pediatric Dentistry 1999;21:325-6.2. Centers for Disease Control.Surveillance for Dental Caries, Dental Sealants, Tooth Retention,

Edentulism, and Enamel Fluorosis - United States, 1988-1994 and 1999-2002. Available at:“http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm”.Accessed May 10, 2007.

3. Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. J Dent Child1965;32:13-28.

4. Beaver HA, Kopel HM, Sabes WR. The effect of zinc oxide eugenol cement on a formocre-solized pulp. J Dent Child 1966;33:381-396.

5. Redig DF. Comparison and evaluation of two formocresol pulpotomy techniques utiliz-ing “Buckley’s” formocresol. J Dent Child 1968;35:22-30.

6. Morawa AP, Straffon LH, Han SS, Corpron RE. Clinical evaluation of pulpotomies usingdilute formocresol. J Dent Child 1975;42:360-363.

7. Rolling I, Thylstrup A.A 3-year clinical follow-up study of pulpotomized primary molarstreated with the formocresol technique. Scand J Dent Res 1975;83:47-53.

8. Willard RM. Radiographic changes following formocresol pulpotomy in primarymolars. J Dent Child 1976;43:414-415.

9. Magnusson BO. Therapeutic pulpotomies in primary molars with the formocresol tech-nique. Acta Odontol Scand 1977;36:157-165.

10. Fuks AB, Bimstein E. Clinical evaluation of diluted formocresol pulpotomies in primaryteeth of schoolchildren. Pediatric Dentistry 1981;3:321-324.

11. Verco PJW,Allen KR.Formocresol pulpotomies in primary teeth.J Int Dent Child 1984;15:51-55.12. Landau MJ,Johnson DC.Pulpal response to ferric sulfate in monkeys.J Dent Res 1988;67:215.13. Fei AL, Udin RD, Johnson R.A clinical study of ferric sulfate as a pulpotomy agent in pri-

mary teeth. Pediatric Dentistry 1991;13:327-332.14. Fuks AB, Holan G, Davis JM, Eidelman E. Ferric sulfate versus dilute formocresol in

pulpotomized primary molar: long-term follow up. Pediatric Dentistry 1997;19:327-330.15. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospec-

tive study. Pediatric Dentistry 2000;22:192-199.16. Primosh RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral

pediatric dental programs in the United States. Pediatric Dentistry 1997 19:118-122.17. Mathewson RJ, Primosch RE. Pulp treatment. In: Fundamentals of Pediatric Dentistry,

3rd Ed. Mathewson RJ, Primosch RE. Chicago: Quintessence 1995.18. McDonald RE, Avery DR. Treatment of deep caries, vital pulp exposure, and pulpless

teeth. In: Dentistry for the Child and Adolescent, 7th Ed. St. Louis: CV Mosby Co. 2000.19. Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak A. Pulp therapy for the

primary dentition. In: Pediatric Dentistry Infancy through Adolescence, 2nd Ed.Philadelphia: WB Saunders Co. 1994.

20. Hunter ML, Hunter B. Vital pulpotomy in the primary dentition: attitudes and practicesof specialists in paediatric dentistry practicing in the United Kingdom. Int J PaediatricDent 2003;13:246-250.

21. Davis MJ. Conscious sedation practices in pediatric dentistry: a survey of members ofthe American Board of Pediatric Dentistry College of Diplomates. Pediatric Dentistry1988;10(4);328-9.

22. American Academy of Pediatric Dentistry Reference Manual. Guideline on Pulp Therapyfor Primary and Young Permanent Teeth. Pediatric Dentistry 2006;131.

23. Zarzar PA, Rosenblatt A, Takahashi CS, Takeuchi PL, Costa Jr LA. Formocresol muta-genicity following primary tooth pulp therapy: an in vivo study. J Dent 2003;27:479-85.

24. Davis MJ, Myers R, Switkes MD. Glutaraldehyde: an alternative to formocresol for vitalpulp therapy. J Dent Child 1982;176-180.

Abstract

Peripheral ossifying fibroma (POF) and pyogenic granulo-

ma (PG) belong to the group of “focal reactive over-

growths,” having different histomorphologic representa-

tions. The pathogenesis of POF remains controversial. It

has been observed that POF in some cases may initially

develop as a PG that undergoes subsequent fibrous mat-

uration and calcification. A case of focal reactive gingival

overgrowth with a recurrence is presented. Clinical, radio-

logical and histological examinations were performed and

included a detailed history of the lesions to come up with

the proper diagnosis.

The primary lesion was diagnosed as POF and the

recurrent lesion as PG. The POF might have developed ini-

tially as PG and subsequent maturation led to the ossifi-

cation of the lesion. These two lesions represent the pro-

gressive stages of the same spectrum of pathosis.

PERIPHERAL OSSIFYING FIBROMA (POF)1 is cited under diverseterminologies, like calcifying fibroblastic granuloma, peripheralodontogenic fibroma, peripheral cementifying fibroma, calcifying


Peripheral Ossifying Fibroma and Pyogenic Granuloma

ARE THEY INTERRELATED?

Shiva Prasad, B.M., M.D.S.; Shridhara B. Reddy, M.D.S;Sudhir R. Patil, M.D.S.; Nagaraj B. Kalburgi, M.D.S.; R.S. Puranik, M.D.S.

and ossifying fibroid epulis2,3,4,5 and peripheral fibroma with calcifi-cation.6 The pathogenesis of this lesion remains uncertain.According to one theory, POF develops initially as pyogenic granu-loma (PG), with subsequent fibrous maturation and ossification.7

But this theory is not applicable to all POFs formed. Cells of perios-teum and periodontal ligament7,8 constitute the most likely origin ofmineralized product.

POF is considered reactive in nature rather than neoplasm.9,10

A number of irritational reasons have been given for the develop-ment of POF, namely, microorganisms, masticatory forces, foodlodgment, minor trauma, calculus and iatrogenic factors.

POF typically is a slow-growing lesion that rarely reaches morethan 3 cm in diameter. It occurs exclusively on the gingiva as apedunculated or sessile mass, with color varying from pink toslightly red. It is found most frequently in teenagers and youngadults and has a high recurrence rate of up to 20%.11-14

Case Description and ResultsA 32-year-old female presented to the Department of Periodont-ology for evaluation of a localized gingival enlargement that hadbeen present in the mandibular premolar area for eight months. Ithad gradually increased in size, causing interference with mastica-tion and occasional bleeding. A large (6 cm) pedunculated, firmswelling with surface ulcerations was present in relation to theinterdental area of teeth #33 and #34 with extension to the lingualside (Figure 1), resulting in the migration of adjacent teeth.Considerable deposition of calculus was also noticed.

Excision of the lesion under local anesthesia revealed bone formationbeneath the lesion, evident in the intraoral periapical radiographtaken. The microscopic diagnosis of POF was rendered for theexcised mass. The bone formed in relation to the tumor was removedwith carbide round burs (Nos. 2, 4), followed by esthetic recontour-ing. Scaling and root planing of the teeth adjacent to the lesion wereperformed with curettage of the lesion down to the bone.15

HistopathologyThe initial lesion showed variations from hyperplastic to atrophicepithelium covering dense to edematous fibrous connective tissuewith focal areas of inflammatory infiltrate. Deeper regions revealedextensive large focus of ossification surrounded by proliferatingfibroblast-like cells, suggestive of POF5,7,10 (Figures 2,3).

Recurrent LesionThe patient returned to the department after 25 days with a swelling(Figure 4) of about 3 cms in diameter in the previous location.She hadbeen instructed to return seven days after removal of the initial lesionfor evaluation and oral prophylaxis. The swelling was sessile, soft, redin color, with increased surface ulcerations when compared with theprevious lesion. The swelling extended to the lingual aspect throughthe interdental area, which had a tendency to bleed on slightest provo-cation. The lesion was excised in toto and analyzed histologically.

Microscopic features of the recurrent lesion consisted ofnumerous proliferating capillaries and fibroblasts admixed withabundant inflammatory cells comprising polymorphonuclear neu-trophils, lymphocytes and plasma cells. The overlying epitheliumwas mainly hyperplastic and ulcerated in some areas, confirmingthe diagnosis of PG (Figure 5).

DiscussionThe most important clinical feature of the peripheral ossifying fibroma(POF) described here was its size, which was approximately 6 cmsin diameter. We believe it is one of the largest POFs reported, apartfrom the lesion (9 cm) reported by Chui-Kwan et al.16 POF has arecurrence rate of about 16% to 20%.

Both the POF and the PG were treated with a conservative sur-gical approach of excisional biopsy and esthetic recontouring of thebone formed in relation to the lesion. Evaluation of the recurrentlesion showed a PG with classical histological features. Reasons forrecurrence of the lesion may be as follows:1. Incomplete removal of the initial lesion.2. Local deposits like plaque and calculus might have acted as

stimulating (irritational) factors for the POF to form. Scaling


Figure 3. 45x, H and E stain showing extensive ossification in deeper region.

Figure 2. 10x, H and E stain showing hyperplastic epithelium covering densefibrous connective tissue with ossification.

Figure 1. Clinical photograph showing initial lesion.

The most important clinical feature of the peripheral

ossifying fibroma (POF) described here was its size,

which was approximately 6 cms in diameter.

and root planing of the teeth adjacent to the lesion were done,but because the patient was not cooperative, scaling and rootplaning of other teeth were not possible. The patient returnedto the dental office only after the recurrent lesion appeared anddid not report after excision of the recurrent lesion. Thepatient’s lower socioeconomic status and illiteracy may be whyshe was not cooperative.

3. Surgical trauma while removing the initial lesion might haveinduced formation of the recurrent lesion (PG).The clinical and histopathological features of the initial and

recurrent lesions affirmed the theory that PG and POF may repre-sent progressive stages of the same pathology. Whatever the rea-son for the occurrence of second lesion, the authors continue tobelieve that theory and that PG and POF belong to the same spec-trum of “focal reactive overgrowths.”

The initial lesion might have started as PG; long durationand maturation then led to development of the POF.6 It is a

known/ observed fact that longstanding PG may undergo organi-zation/healing, which is evident histologically with features ofdecreased vascularity, decreased inflammation and focal ossifi-cation. In the recurrent lesion, the duration and persistent irra-tional factors resulted in the development of PG in the subsequentfour weeks.

ConclusionThis case report strengthens the concept that focal reactive lesionslike PG and POF need not be considered as separate clinical enti-ties but, rather, as the progressive stages of the same pathology.The treatment approach remains the same towards all focal reac-tive overgrowths8 (peripheral gingival fibroma, peripheral giant cellgranuloma, pyogenic granuloma or peripheral ossifying fibroma),that is, complete elimination of the lesion and etiological factors. ■

Queries about this article can be sent to Dr.Shiva Prasad at [email protected].

REFERENCES1. Gardner DG. The peripheral odontogenic fibroma: an attempt at clarification. Oral Surg

Oral Med Oral Pathol 1982;54:40-48.2. Buchner A, Calderon S, Ramon Y. Localized hyperplastic lesions of gingiva. A clinico-

pathological study of 302 lesions. J Periodontol 1977;48:101.3. Anderson L, Fejerskov O, Philipsen HP. Calcifying fibroblastic granuloma. Oral Surg

1973;31:196.4. Lee KW. Fibrous epulis and related lesions. Granuloma pyogenicum,“pregnancy” tumor,

fibroepithelial polyp and calcifying fibroblastic granuloma. A clinicopathological study.Periodontics 1968;6:277.

5. Shafer WG, Hine MK, Levy BM, editors. Benign and Malignant Tumors of the OralCavity. A Textbook of Oral Pathology. 4th Ed. Philadelphia:Saunders. 1993:141-142.

6. Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification:report of 376 cases. J Am Dent Assoc 1966;73:1312-1320.

7. Neville, Damm, Allen, Bouquot, editors. Oral and Maxillofacial Pathology. 2nd Ed.Philadelphia: Saunders. 2002:447-453.

8. Hamner JE, Scofield HH, Cornyn J. Benign fibro-osseous lesions of periodontal ligamentorigin. Cancer 1968; 22: 861.

9. Eversole LR, Rovin S. Reactive lesions of gingiva. J Oral Path 1972;1:30-38.10. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva: a clinicopathological study

of 741 cases. J Periodontol 1980;51: 655-661.11. Buchner A, Louis SH. The histomorphologic spectrum of peripheral ossifying fibroma.

Oral Path Oral Med Oral Surg 1987;63: 452-461.12. Kenney JN, Kaugars GE, Abbey LM. Comparison between the peripheral ossifying fibro-

ma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-382.13. Layfield LL, Shoppr TP, Weir JC. A diagnostic survey of biopsied gingival lesions. J Dent

Hyg 1995;69:175-179.14. Zain RB, Fei YJ. Fibrous lesions of the gingiva: a histomorphologic spectrum of periph-

eral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1990;70:466-470.15. John DW, Joseph KW, Russen DH, David AC, Donald AR. Excision and repair of the

peripheral ossifying fibroma: a report of 3 cases. J Periodontol 2001;72:939-944.16. Chui-Kwan P, Po-cheung K, Shou-yee C. Giant peripheral ossifying fibroma of the max-

illa: report of a case. J Oral Maxillofac Surg 1995;53:695-698.


Spectrum of Focal Reactive OvergrowthsTissue irritation

Pyogenic granuloma

Long duration/chronocity?

Fibrous maturation and sclerosis

Ossification

Peripheral ossifying fibroma

Figure 4. Clinical photograph of recurrent lesion with characteristic features ofpyogenic granuloma.

Figure 5. 10x, H and E stain showing hyperplastic-to-ulcerated epithelium cov-ering dense proliferative connective tissue consisting of numerous capillaries andinflammatory cells.


THE 12TH ANNUAL SARATOGA DENTAL CONGRESS will takeplace Thursday and Friday, May 22-23, at the Saratoga City Centerin Saratoga Springs. The conference is sponsored by the FourthDistrict Dental Society.

The program on Thursday offers three nationally knownspeakers. Dr. John Molinari will present “Infection Control Updatefor 2008” and “Update on Vaccine Recommendations.” RobinWright, M.A., will enumerate the “Top Ten Skills for Success inDental Communication.” Patti DiGangi, R.D.H., B.S., will present“It’s All Connected: Oral Health and Whole Body Wellness.”CPR/AED certification programs will be offered in the morningand afternoon.

The program on Friday features Dr. Gerard Kugel, editor ofInside Dentistry. Dr. Kugel’s presentation is entitled “EstheticDentistry Update.” Also, Bethany Valachi, M.S., P.T., CEAS, ofPosturedontics will lead a seminar for the entire staff titled “Neck,

Fourth District Announces Two-Day Dental Conference

Back and Beyond: Preventing Pain for Peak Performance.”CPR/AED certification will again be offered in the morning.

Attendance at the Congress is expected to exceed 1,000 people.There will be over 60 vendors, some of whom will offer conferencespecials. This year’s raffle will feature two grand prizes. Winners’names will be drawn on Friday.

Register early to take advantage of reduced fees. Member den-tists are being asked to pay $195 for one day or $295 for both days.Fees for hygienists and staff are $80 for each day. The chargeincludes a buffet lunch.

Chairman for this year’s Saratoga Dental Congress is FourthDistrict President Richard Dunham. Dr. Dunham can be reached at(518) 584-2128 or [email protected]. For registration infor-mation, visit the Fourth District Web site, www.4thdds.org, or callthe district office at (518) 371-1114. For exhibitor registration, callRobert Sharp at (518) 793-5908.

“The Meeting at the Springs”City Center, Saratoga Springs, NY

Thursday, May 22, 2008◆ Lecture - Infection Control Update for 2008

Dr. John Molinari

◆ Lecture - Top Ten Skills for Success in Dental CommunicationRobin Wright, MA

◆ Lecture - It’s All Connected: Oral Health and Whole Body WellnessPatti DiGangi, RDH, BS

◆ CPR/AED for the Healthcare Professional

Friday, May 23, 2008◆ Lecture - Esthetic Dentistry Update

Dr. Gerard Kugel

◆ Lecture - Neck, Back and Beyond: Preventing Pain for Peak ProductivityBethany Valachi, MS, PT, CEAS, Prosturedontics

◆ CPR/AED for the Healthcare Professional

◆ Raffle

Plus◆ Table Clinics◆ Exhibitions◆ Luncheons◆ Raffles

Sponsored by Fourth District Dental SocietyRegistration 8:00 amExhibits open at 8:00 am

For more information, contactFourth District Dental Society981 Route 146Clifton Park, NY 12065518-371-1114e-mail: [email protected] forms available online:www.4thdds.org

Epilepsi and Dental Procedure

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