the new york state dental journal
Volume81 Number 2
March 2015
16 Follow-Up Problems with Fixed Appliances in Pediatric Dentistry
Timucin Ari, D.D.S., Ph.D.
A poor outcome to fixed appliance treatment is almost guaranteed if patients fail to keep
follow-up appointments. Success depends upon proper patient selection and effective
communication between dentist and patient/parents regarding the importance of regular
checkups. Case reports.
21 Successful Nonsurgical Management of Post-orthodontic
Gingival Enlargement with Intensive Cause-related Periodontal Therapy
TaeHyun Kwon, D.D.S., M.M.Sc.; David M. Kim, D.D.S., D.M.Sc.; Liran Levin, D.M.D.
By targeting the primary etiologic factor, that is, plaque, periodontal health may be restored
without surgery. Reducing the bacterial load gives the biologic natural healing capacity of
the body the opportunity to stabilize the periodontal condition and should be considered as
the first line of intervention. Case report.
Cover: Over-retained appliances pose risks
to oral health. To minimize the danger, practitioners need to be prepared to effectively convey to patients and their parents the need for
oral hygiene, device maintenance and commitment to follow-up appointments.
2 Editorial
Staving off extinction
5 Attorney on Law
Dental togetherness
9 Association Activities
47 General News
52 Component News
64 Read, Learn, Earn
67 Classifieds
70 Index to Advertisers
72 Addendum
Legislative Day
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24 What it Means to be a Doctor
Sensitizing the Dentist and the Student to Professionalism
Ronald I. Maitland, D.M.D.
Professional demeanor and inter-personal behavior play a large part in building patient
trust. Commanding an image of respect is determined largely by ethical and proper
relationships between doctor and patient. How that relationship can unravel is told
through a collection of true image-damaging episodes.
29 Surgical and Prosthetic Management of a Complex Edentulous
Patient for Fabrication of Complete Dentures
Alper Çomut, D.M.D., D.M.Sc.; Tanya Somohano, D.M.D.
Clinical report describes surgical and prosthetic treatment of patient who presented with
epulis fissuratum in the maxilla and severely resorbed alveolar tissue in the mandible.
34 Maxillary Implant-retained Partial Overdenture with Dolder Bar Attachment
Hyeongil Kim, D.D.S., M.S.; Robert J. Buhite, D.D.S.; Edward A. Monaco Jr., D.D.S.
Technique for maintaining maxillary Kennedy III partial removable dental prosthesis design
in patient with non-restorable failing abutments by replacing the abutments with dental
implants is described. Additional retention and support was provided, significantly
increasing patient satisfaction.
38 An Analysis of the Hemophilia of the Royal Families of Europe,
Its Startling Implications and Dentistry’s Role in Treating the Hemophiliac Patient
William James Maloney, D.D.S.; George Raymond, D.D.S.; David Hershkowitz, D.D.S.;
Glenn Rochlen, D.D.S.
Despite being known popularly as “The Royal Disease,” hemophilia affects many people
living in our communities. These patients must receive proper dental treatment and home
care education to prevent possibly life-threatening emergency dental episodes.
42 Effect of Apically Separated Rotary Instruments on
Bacterial Leakage of Obturated Root Canals Using Resilon
Zahed Mohammadi, D.D.S., M.Sc.; Rasoul Yousefi Mashouf, D.D.S., M.Sc.; Hamid Jafarzadeh,
D.D.S., M.Sc.; Ali Heydari, D.D.S., M.Sc.; Sousan Shalavi, D.D.S.
Study was undertaken to determine the effect of a separated rotary instrument on the time
required for bacterial penetration of obturated root canals using Resilon.
editorial
Breathing New Life into
Organized Dentistry
I
If we don’t come up with creative ways to attract the new generation
of dentists, organized dentistry may be a thing of the past.
n January, I attended the installation dinner of
the Eighth District Dental Society. It was a pleasant
evening, during which the officers were sworn in to
lead the society through 2015 and life memberships
were awarded to our fellow dentists who had
reached 65 years of age and been members of the
ADA for 30 consecutive years, or 40 years in total.
As you might imagine, the crowd was a bit “gray,”
much grayer even, I suspect, than when I first
started attending these events. Notably absent were
younger members. The more I thought about this
later, the more alarmed I became. If we can’t attract
young members, our organization is doomed.
Recent statistics show that the largest group of
non-renewing members is people aged 30 to 39
years old, a group made up largely of what are
referred to as “millennials.” I consulted a variety of
online sources, hoping to get a better handle on
who and what millennials are. What follows is
what I gleaned from my research.
Millennials, it appears, are a unique subset of
the population that interacts with the world in a
totally different way than the generations before
them. They think they are special. It’s the way they
were raised. For starts, they were as children the
most wanted. I know every generation feels that
way, but this time it’s true. Their births were
2
MARCH 2015 • The New York State Dental Journal
planned by their parents, who then lavished them
with attention as they were growing up, marking
every milestone in their lives by some type of celebration and praise—which only added to their sense
of entitlement.
Of all the generations before them, the millennials have been the most sheltered. Gone are
the days when you would say goodbye to your
mother in the morning, go off on your bike to
meet your friends, play all day and come back at
suppertime­
—without ever checking in at home.
Millennials grew up in an era of increased safety
concerns, and were rarely left unsupervised. Their
parents continually advocated on their behalf,
solving their conflicts for them, so they would be
spared the unpleasant experience of working out
their own problems.
Despite all this, these are very confident people.
They are motivated and they are goal-oriented. They
have a high level of optimism, and they feel connected to their parents. They are assertive, and they
believe they are right in their views about the world.
They are also team-oriented, more drawn to
group than individual lifestyle. Indeed, they may
sacrifice their own identities to be part of the group.
They don’t believe in hierarchies, and they are more
closely knit than previous generations. And, while
THE NEW YORK STATE DENTAL JOUR­NAL
EDITOR
Kevin J. Hanley, D.D.S.
they are team-oriented, they tend to exhibit this behavior within their own cohort,
not with other generations. This may account for their reluctance to commit to
organized dentistry. They might be willing to try it when they first graduate from
dental school, but then sour on the hierarchal structure of the organization. On
the plus side, they are oriented toward service and volunteerism.
Millennials set high goals for themselves, preferring achievement over personal development. They gravitate toward the fields of math and science, as
opposed to the humanities and the arts favored by baby boomers. It is not
uncommon for them to feel pressured. As they grew up, their schedules were
highly structured. Every hour of every day was filled with specific activities. This
has caused them to struggle with the allocation of free time and with time management in general. And because they feel the need to succeed, they are likely to
take on more than they can handle.
The final millennial trait worth mentioning is the respect they display toward
others­—to the point of not questioning authority. Members of this generation are
very civic minded. They are more conforming than those who came before them.
They also value their parents’ opinions highly. They believe in social rules and align
with their parents on many issues, more so than previous generations.
MANAGING EDITOR
Mary Grates Stoll
ADVERTISING MANAGER
Jeanne DeGuire
ART DIRECTORS
Kathryn Sikule / Ed Stevens
EDITORIAL REVIEW BOARD
Frank C. Barnashuk, D.D.S.
David A. Behrman, D.M.D.
Michael R. Breault, D.D.S.
Ralph H. Epstein, D.D.S.
Daniel H. Flanders, D.D.S.
Joel M. Friedman, D.D.S.
Chester J. Gary, D.D.S., J.D.
G. Kirk Gleason, D.D.S.
John T. Grbic, D.M.D., M.S., MMSc.
Brian T. Kennedy, D.D.S.
Stanley M. Kerpel, D.D.S.
Rising to the Challenge
How do we attract this crop of new professionals to organized dentistry? That is
the $64,000 question. We have to make membership attractive to a generation
of people who are totally different from us. We must think outside the box if we
wish to keep organized dentistry a viable entity in the future.
Millennials are multitaskers. They desire challenges and variety. We need to
find ways to tap into this, as it makes them ideal candidates for membership. And
it starts with recognizing that millennials comprise the most connected generation ever. They have grown up with new technologies and are comfortable using
them. They constantly check social media outlets. If organized dentistry isn’t
relevant on social media channels, they will ignore us. Utilize their knowledge to
get better at the social media aspects of membership.
They are also tech-savvy. We have to make our communications available on
all platforms. We can use our younger members to help us achieve this goal.
They’re looking for work-life balance and flexibility. They don’t want to sacrifice their personal lives for career advancement. They expect a flexible work
environment. They also like to support various causes. We must appeal to their
sense of commitment to the goals of dentistry and organized dentistry. One reason many may have chosen dentistry is the flexibility it affords. We shouldn’t
infringe on their sense of balance as we ask them to become active in organized
dentistry. We will have to rethink the ways we accomplished things in the past.
That may not work with these members.
One aspect of organized dentistry we can use to attract millennials is their
spirit of teamwork. They enjoy collaborating with others and building friendships. We must let them know there will be plenty of opportunities to collaborate
with others and build long-lasting friendships. We all have benefited from these
opportunities and friendships throughout our professional careers. Share this
information with young dentists you know.
Elliott M. Moskowitz, D.D.S., M.Sd
Francis J. Murphy, D.D.S.
Eugene A. Pantera Jr., D.D.S.
Robert M. Peskin, D.D.S.
Georgios Romanos, D.D.S.,
D.M.D., Ph.D., Prof.Dr.med.dent
Robert E. Schifferle, D.D.S., MMSc., Ph.D.
PRINTER
Fort Orange Press, Albany
NYSDJ (ISSN 0028-7571) is published six times a year,
in January, March, April, June/July, August/ September and November, by the New York State Dental Association, 20 Corporate Woods Boulevard, Suite 602,
Albany, NY 12211. In February, May, October and December, subscribers receive the NYSDA News. Periodicals postage paid at Albany, NY. Subscription rates $25
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48106-1346.
The New York State Dental Journal • MARCH 2015
3
ADA Executive Director Kathleen O’Loughlin spoke eloquently to
this at the ADA House of Delegates meeting this past fall in San
Antonio. She said she recognizes the importance of young dentists to the future of the ADA. And she understands that the ADA
must evolve to attract them to the organization. We can no longer operate as we have in the past, she emphasized. To do so will
be the death of our organization.
If you know any young dentists, mentor them. Discuss the
importance of organized dentistry in their professional lives. They
see the world differently than we do. Learn from them, as well.
Keep an open mind. Establish lines of communication. Get them
involved in organized dentistry in any way you can. Adapt what
we do to what they do. If we become irrelevant to them, our
organization will become irrelevant. That would be a disservice to
all the dentists who went before us and to those who will come
after us.
D.D.S.
NOTICE TO MEMBERS
Pursuant to the NYSDA Bylaws, Chapter XV Section 10, the following
proposed Bylaws amendment is being published at least 30 days prior
to the NYSDA Annual Session at which action is to be taken.
Resolution No.
6
Submitted By:
Board of Trustees
Date Submitted:
February 13, 2015
New n
Total Financial Implication:
Amount One-time
Reference Committee n
Amendment o
Direct to House o
$ none
$ none
Amendment to NYSDA Bylaws Regarding EDPAC Contribution
Background statement: The Board of Trustees is aware that political advocacy is at the top of every member survey as a desired benefit of membership. EDPAC supports NYSDA as we advocate for
both our members and the public. Two years ago, EDPAC sought
to provide an increase in the PAC contribution and proposed to
the membership that the contribution should be 15% of members’ dues, which was adopted. The Board appreciates EDPAC’s
understanding of the financial pressures our members face, and
is concerned that the financial pressures impacting EDPAC are
also affecting NYSDA’s ability to effectively serve our members.
Sending $1.50 of every $10 dues increase to the PAC will further
increase an already existing deficit in NYSDA operations. For this
reason, the Board recommends we return to a stated number for
the EDPAC contribution, which can be periodically reviewed and
adjusted by the House of Delegates, rather than a percentage of
the dues. The Board offers the following resolution:
4
Substitute o
MARCH 2015 • The New York State Dental Journal
Amount On-going
$ none
6. Resolved, that Chapter I, Section 20 of the Bylaws of the New
York State Dental Association be amended as follows (new language underscored; deletions stricken through):
C. Dues and Special Assessments. The dues of active members
shall be the amount established annually by the House of Delegates in accordance with the procedure set forth in Chapter III,
Section 130Ad of these Bylaws, due January 1 each year, fifteen
percent (15%) eighty-four dollars ($84.00) of which, shall be
contributed to the Association’s endorsed political action committee unless the member elects to reassign such amount to another approved Association fund as designated on the dues statement.
pediatric dentistry
Follow-Up Problems with
Fixed Appliances in Pediatric Dentistry
Timucin Ari, D.D.S., Ph.D.
ABSTRACT
Fixed appliances are commonly used in managing
early orthodontic problems. Despite their widespread
use, they have the potential to impinge on the soft
tissues, interfere with the eruption of adjacent teeth
and become dislodged or broken. These two case reports present the poor outcomes of fixed appliance
treatments if the patient fails to attend follow-up appointments. A successful outcome of treatment with
fixed appliances depends upon proper patient selection and the communication skills of the dentist to
help patients/parents understand the importance of
regular checkups.
Guidance of eruption and development during the primary and
mixed dentition stage contributes to a stable, functional and esthetically acceptable occlusion in permanent dentition.1-3 Beyond
their involvement in esthetics, eating and speech, primary teeth
play an important role in growth and development until permanent successors erupt.4,5 The premature loss of primary teeth may
lead to undesirable consequences, such as loss of arch length and
16
MARCH 2015 • The New York State Dental Journal
crowding due to the drifting of adjacent teeth.3,5-7 This in turn
may compromise the eruption of succedaneous teeth, which, it
has been suggested, is a main cause of malocclusion.8-11
An effective approach to limiting the negative effects of premature
loss of primary teeth is the use of space maintainers.4,8,12-14 Both fixed
and removable space maintainer designs can be employed, depending upon clinical situations. But the most common space maintainer
used in pediatric dentistry is the fixed band and loop space maintainer.14,15 This design requires little chair time and is less dependent upon
patient cooperation than removable appliances.4,6,15
Another scenario that has been shown to affect dentofacial
growth and development in children is non-nutritive sucking.16,17
Thumb sucking, finger sucking and pacifier use are considered
forms of non-nutritive sucking that may result in development of
an anterior open bite.16,17
Just like space problems, correction of a thumb-sucking habit
can be managed by both removable and fixed appliances. Since
removable appliances have not been found to be effective in producing significant changes, fixed appliances are usually preferred,
due to better patient cooperation.18-20 Among fixed appliances,
the fixed thumb crib appliance has been shown to be an effective
device in stopping thumb sucking.21
Although fixed appliances are commonly used effectively in
both of the clinical situations described, they have the potential
to impinge on soft tissues, interfere with the eruption of adjacent
teeth, become dislodged or broken, and may place patients at a
greater risk of caries and gingival inflammation due to their high
plaque retention.2,6,12,14,22,23 Therefore, proper patient selection
that takes into consideration the level of oral hygiene, the caries
risk and the dental attendance pattern should be weighed before
the decision is made to place a fixed appliance.4,24
Case Report One
A healthy 12-year-old female patient presented as a returning patient for a routine checkup to a pediatric dental clinic within a
university teaching hospital. Her mother was concerned about the
spacing of her anterior teeth and wanted to know whether she
needed orthodontic treatment to improve the aesthetics (Figure 1).
Clinical extraoral examination of the patient presented symmetrical facial proportion with competent lip closure. The temporomandibular joint function was within normal limits, with
no tenderness on palpation of either side. Intraoral examination
revealed healthy soft tissues and no signs of caries. The patient
was in the early permanent dentition stage, with missing upper
lateral incisors and the upper left second premolar. She exhibited
a Class II malocclusion on right and left sides, and the lower midline was 3 mm left of upper midline.
Further intraoral examination revealed two band and loop
space maintainers, the first spanning tooth #30 to tooth #28 (Figure 2) and the second from tooth #16 to tooth #14 (Figure 3). The
loop of the lower band and loop space maintainer had pushed the
mandibular right first premolar mesially and caused the crowding
and midline shift in the anterior region. The maxillary left first
premolar was rotated and tilted distally due to the retained space
maintainer, with the loop now sitting on its occlusal surface. Spacing was present in the upper anterior region, with 2 mm overjet
and 50% overbite. Radiographic examination revealed congenitally
missing upper lateral incisors (#7 and #10) and impaction of the
upper left second premolar (#13) (Figure 4).
Review of her previous records revealed that band and loop
space maintainers had been placed 26 months ago and that despite receiving follow-up appointment reminders, she had never
attended since that time, resulting in the over-retained space
maintainers impacting significantly on her erupting dentition.
The band and loop space maintainers were removed, and the patient was scheduled for follow-up appointments to address her
orthodontic needs (Figure 5).
Case Report Two
A healthy 10-year-old female patient attended a pediatric dental
clinic within a university teaching hospital complaining of pain
from her gums. Extraoral examination revealed a convex profile
with incompetent lip closure. The temporomandibular joint function was within normal limits, with no functional shift during
Figure 1. Frontal view of patient.
Figure 2. Over-retained band and loop from #30 to #28.
Figure 3. Over-retained space maintainer sitting on occlusal surface of #12.
Figure 4. Panorex view of patient.
The New York State Dental Journal • MARCH 2015
17
A
B
Figure 5. Removal of band and loops.
Figure 6. Anterior open bite.
Figure 7. Soft tissue impingement of appliance.
Figure 8. Removal of appliance.
18
MARCH 2015 • The New York State Dental Journal
opening. Intraoral examination indicated late mixed dentition
stage with Class II molar relationship on both sides. An anterior
open-bite was observed; and her clinical records indicated that
a fixed thumb crib appliance had been placed 10 months earlier
to stop a thumb-sucking habit. Despite being informed of the
importance of regular follow-up and several appointments being
scheduled, the family had not attended any appointments since
that date. The mother reported disappointment that the thumbsucking habit had continued during that time.
On clinical examination, gingival trauma and inflammation
were noted on the anterior area of the palatal mucosa, which was
directly attributed to impingement of the crib appliance in this
area (Figure 7). Therefore, the crib appliance was removed. An
alternative strategy without appliance therapy was implemented
using a psychological approach and positive reinforcement. A
contingency contract was made between the child and her parents, simply stating that the child should be rewarded and praised
for not sucking her thumb for a specific time (Figure 8).
Discussion
Fixed space maintainers are commonly used in children because
of their benefit in eliminating compliance problems. The success
rate of various different designs of fixed appliances can vary from
27% to 91.5%.5,12,22,24,26-31 Regardless of the design chosen, this
doesn’t eliminate the need for regular follow-up. With fixed appliances, vigilance is critical. This allows the practitioner to assess
the integrity of the space maintainer and to ensure removal of
the appliance in coordination with eruption of the permanent
successor.12,22,24,26,29
A primary tooth is the ideal space maintainer; this is why
every effort should be made to preserve arch length in both the
primary and mixed dentition. If early loss of a primary tooth is
unavoidable, and nothing is done to preserve the space, the permanent first molars usually move mesially into this space and
eventually a decrease in arch length is observed.4,9,10,25
In case one, following the early extraction of the primary molars, fixed space maintainers were placed to control arch length
and to prevent potential orthodontic problems.1,3,6,14 According
to the patient’s chart, the parents were told of the importance
of regular checkups for both space maintainers and congenitally missing lateral incisors. Despite this explanation, the patient
failed to attend any recall appointments until such a time that the
mother became concerned about her daughter’s esthetic problems. Unfortunately, the consequence of their non-adherence to
the review schedule resulted in the appliance exacerbating her
previous orthodontic problem, resulting in impaction of tooth
#13 and increased crowding in the mandibular anterior region.
In the second case, a fixed thumb crib appliance was placed
to control a thumb-sucking habit. The incidence of soft-tissue
lesions resulting from impingement of fixed appliances has been
reported to be as high as 11%.22,24 Clinical records indicated there
was no problem with the fit of the appliance and that, again,
the parents were informed about care and follow-up regarding
the maintenance of the appliance. Non-adherence to the post
placement review regime resulted in failure of the appliance, most
likely due to biting forces in the anterior region or continued excessive thumb sucking by the patient. The appliance consequently
dislodged superiorly and impinged on the mucosa. This could
have been prevented by simple adjustment or by changing to a
psychological approach far earlier during regular visits.
A successful outcome of treatment with fixed appliances depends upon the parents/caregivers and patients understanding and
complying with advice given related to oral hygiene, device maintenance and commitment to periodical review appointments. Failure
to adhere to any of these components may result in a poor outcome
and potential problems, as illustrated by these two case reports.
Such problems include damage to oral structures, increased duration of treatment or worsening of a malocclusion.
The practitioner must always keep in mind the parents’ level
of understanding regarding the risks involved in placing fixed
appliances in children. Dentists should take care that they use
effective communication methods and choose language appropriate to the literacy levels of the parents32 in order to explain
the importance of regular review. The use of techniques such as
motivational interviewing could also encourage better adherence
to dental attendance regimens to minimize the potential risks to
oral health from over-retained appliances. p
Queries about this article can be sent to Dr. Ari at timucin.ari@schulich.uwo.ca.
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Pedrin F, et al. A prospective study of the treatment effects of a removable appliance with
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Rajab LD. Clinical performance and survival of space maintainers: evaluation over a period
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Timucin Ari, D.D.S., Ph.D., is assistant professor in the Schulich School of
Medicine and Dentistry, Pediatric Dentistry Division, Western University, London,
Ontario, Canada.
Dr. Ari
New NYSDA Insurance Program offers
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20
MARCH 2015 • The New York State Dental Journal
orthodontics
Successful Nonsurgical Management of
Post-orthodontic Gingival Enlargement with
Intensive Cause-related Periodontal Therapy
TaeHyun Kwon, D.D.S., M.M.Sc.; David M. Kim, D.D.S., D.M.Sc.; Liran Levin, D.M.D.
ABSTRACT
Successful nonsurgical management of severe postorthodontic gingival enlargement and erythema in a
24-year-old male is presented. The patient received
an intensive cause-related periodontal therapy, consisting of oral hygiene instruction, scaling and root
planing, and weekly recall visits. At week five, complete resolution of the lesions was achieved. By targeting the primary etiologic factor, i.e., plaque, periodontal health was restored without needing surgical
intervention. Reducing the bacterial load will give the
biologic natural healing capacity of the body the opportunity to stabilize the periodontal condition and,
thus, should be considered as the first line of intervention before a surgical approach is taken.
Periodontal complications might be a concern among patients undergoing orthodontic treatment.1,2 Clinically, patients might present with gingival enlargement, erythema and edema, which may
be accompanied by pain, spontaneous bleeding and esthetic concerns. These lesions may persist after completion of orthodontic
treatment.3-5 Orthodontic appliances such as fixed brackets and
lingual fixed retainers can act as local plaque-retentive factors and,
thus, might cause an environmental shift in microbial flora from
aerobic to predominantly anaerobic strains, including the so-called
“red complex” periodontal pathogens.5-9 This microbial shift is
often accompanied by elevated gingival crevicular fluid flow and
its pro-inflammatory cytokine levels, such as interleukin-1 beta,
transforming growth factor-beta 1.5,6,7 Thus, if untreated, they can
result in irreversible destruction of the periodontium.1,10-12
The purpose of this report is to describe a patient presenting
with post-orthodontic gingival enlargement. Gingival enlargement is a condition that commonly develops during orthodontic treatment.3,7,13,14 Even after debonding, complete resolution is
not often attainable3,13 necessitating surgical intervention, which
may be complex and carry morbidity to patients.3,14,15 In this case
report, an intensive, cause-related periodontal therapy targeting the etiologic factor, i.e., dental plaque, resulted in successful
management of gingival enlargement.
Case Report
Following completion of orthodontic treatment, a 24-year-old male
was referred to Harvard School of Dental Medicine, Division of
Periodontology, for a gingivectomy procedure due to gingival enlargement. The patient was systemically healthy, with no history of
smoking. His oral hygiene was poor. Clinical examination revealed
severe gingival enlargement in the interproximal gingiva around the
maxillary anterior teeth (Figure 1). Furthermore, there was generalized gingival inflammation, as suggested by erythema at the marginal
gingiva (Figure 1). These conditions appeared in the last six months
before completion of orthodontic treatment and debonding. Radio-
The New York State Dental Journal • MARCH 2015
21
Figure 1. Clinical view of periodontal condition at initial presentation.
Significant gingival enlargement was noted in maxillary anterior sextant (blue
arrow). Generalized erythema was noted at marginal gingiva (black arrow).
Generalized hypocalcified lesions were also noted on dentition, which may
further suggest inadequate oral hygiene during orthodontic treatment.
Figure 2. Clinical view of periodontal condition at week two. Persistent
gingival enlargement was noted in maxillary anterior sextant (blue arrow);
however it reduced in size. Complete resolution of marginal gingival erythema
was noted. Patient reported gingival ulceration due to brushing trauma (yellow
arrow), and his brushing technique was reviewed. There was minimal amount
of dental plaque on mandibular right first molar after using plaque disclosing
solution (black arrow). All other areas were clinically free of dental plaque,
which suggests improvement in patient’s home care.
Figure 3. Clinical view of periodontal condition at week three. Further
resolution of gingival enlargement was noted in maxillary anterior sextant (blue
arrow). There was reduced amount of dental plaque on mandibular right first
molar after using plaque disclosing solution (black arrow). All other areas were
clinically free of dental plaque, which suggests adequate patient home care.
Figure 4. Clinical view of periodontal condition at week five. Complete
resolution of gingival enlargement and gingival erythema was noted. Clinically,
healthy gingiva was noted, free of any signs of inflammation. Patient’s home
care was maintained at adequate level.
22
MARCH 2015 • The New York State Dental Journal
graphic examination did not reveal any significant finding. The diagnosis of plaque-induced gingival enlargement was made.10-12
Intensive, cause-related, nonsurgical periodontal therapy was
planned to avoid surgical treatment.16 At the initial treatment visit, the patient’s oral hygiene status was assessed and scored using
a plaque-disclosing tablet. It revealed generalized plaque deposits around the gingival margin and interproximal areas (O’Leary
plaque score >90%).17 A personalized oral hygiene instruction
program of removing dental plaque with a toothbrush and an interproximal toothpick (Stim-U-Dent, Madison, Revive Personal Products
Co., NJ) was provided to the patient. The patient was instructed
to use these aids three times a day. Finally, dental prophylaxis in
conjunction with localized scaling and root planing treatment in
the maxillary anterior sextant was provided to the patient.
Thereafter, the patient was recalled at weeks one, two and
three (Figures 2, 3). At each recall visit, the patient’s home care
was re-assessed, reinforced and scored using a plaque-disclosing
tablet; and the patient was immediately instructed to remove any
residual plaque. Subsequently, supragingival debridement was
performed. At week five, the patient’s periodontal condition was
re-evaluated (Figure 4). Clinical examination revealed complete
resolution of the gingival enlargement and inflammation. Preexisting gingival erythema and edema were no longer present. All
periodontal clinical parameters were within normal limits, without any deep periodontal pocket or bleeding upon probing. No
additional periodontal intervention was necessary.
The patient was scheduled for periodontal maintenance for
every three months. His oral hygiene was excellent, as suggested
by O’Leary plaque score index <5%.17
Discussion
During orthodontic treatment, patients are susceptible to developing gingival or periodontal disease.1 Orthodontic brackets
and wires may make it challenging to physically remove dental
plaque around them and, thus, may act as local plaque-retentive
factors.1-9 Furthermore, Atassi and Awartani2 found that approximately 60% of patients undergoing orthodontic treatment
exhibited poor oral hygiene status. They also reported that 68%
of patients reported not having a dental hygiene visit during their
orthodontic treatment.2 Similarly, Berlin-Broner, et al.18 found
only 52% of patients reported that their orthodontist verified if
they had attended regular checkups by their general dentists.
In comparison, continuous patient motivation by treating clinicians was associated with significant improvement in patients’
gingival health during orthodontic treatment.19 In addition, Zanatta, et al.20 found that orthodontic patients using dental floss regularly exhibited significantly better gingival conditions than those
who did not use floss. Similarly, according to Silvestrini Biavati, et
al.,21 proper toothbrushing during orthodontic treatment was associated with improvement in plaque and gingival indices.
Therefore, establishment of a stringent preventive program among
a general dentist, an orthodontist and a patient is strongly recommended before initiating orthodontic treatment.1 Through this
program, patients should be able to demonstrate that they can
effectively remove plaque using a toothbrush and interproximal
cleaning aid. General dentists, as well as orthodontists, should
also closely monitor patients’ compliance with home care and
their periodontal condition during the active orthodontic treatment phase, with frequent recalls and periodontal prophylaxis.
In case of any emergence or recurrence of severe gingival or periodontal disease, treating clinicians should consider discontinuing
orthodontic treatment until periodontal health is restored.
This case report demonstrates successful management of postorthodontic gingival enlargement and inflammation. By targeting
the primary etiologic factor—dental plaque—with stringent oral hygiene instruction, in combination with frequent supragingival cleaning, the patient’s periodontal health was restored without needing
surgery. Reducing the bacterial load by these means will give the biologic natural healing capacity of the body the opportunity to stabilize
the periodontal condition and, thus, should be considered as the
first line of intervention before the surgical approach is taken.p
Queries about this article can be sent to Dr. Kwon at taehyun_kwon@hsdm.
harvard.edu.
18. Berlin-Broner Y, Levin L, Ashkenazi M. Awareness of orthodontists regarding oral hygiene
performance during active orthodontic treatment. Eur J Paediatr Dent 2012;13(3):187-191.
19. Acharya S, Goyal A, Utreja AK, Mohanty U. Effect of three different motivational techniques
on oral hygiene and gingival health of patients undergoing multibracketed orthodontics.
Angle Orthod 2011;81(5):884-888.
20. Zanatta FB, Moreira CH, Rösing CK. Association between dental floss use and gingival conditions in orthodontic patients. Am J Orthod Dentofacial Orthop 2011;140(6):812-821.
21. Silvestrini Biavati A, Gastaldo L, Dessì M, Silvestrini Biavati F, Migliorati M. Manual orthodontic vs. oscillating-rotating electric toothbrush in orthodontic patients: a randomised
clinical trial. Eur J Paediatr Dent 2010;11(4):200-202.
Dr. Kwon
Dr. Kim
Dr. Levin
TaeHyun Kwon, D.D.S., M.M.Sc., is a clinical instructor, Division of Periodontology, Department
of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA.
David M. Kim, D.D.S., D.M.Sc., is an associate professor, director of postdoctoral periodontology
and director of continuing education, Division of Periodontology, Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA.
Liran Levin, D.M.D., is a professor and head, Division of Periodontology, Faculty of Medicine and
Dentistry, University of Alberta, Canada.
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Levin L, Einy S, Zigdon H, Aizenbud D, Machtei EE. Guidelines for periodontal care and
follow-up during orthodontic treatment in adolescents and young adults. J Appl Oral Sci
2012;20(4):399-403.
Atassi F, Awartani F. Oral hygiene status among orthodontic patients. J Contemp Dent
Pract 2010;11(4):E025-E032.
Barack D, Staffileno H Jr, Sadowsky C. Periodontal complication during orthodontic therapy. A case report. Am J Orthod 1985;88(6):461-465.
Levin L, Samorodnitzky-Naveh GR, Machtei EE. The association of orthodontic treatment
and fixed retainers with gingival health. J Periodontol 2008;79(11):2087-2092.
Naranjo AA, Triviño ML, Jaramillo A, Betancourth M, Botero JE. Changes in the subgingival
microbiota and periodontal parameters before and 3 months after bracket placement. Am J
Orthod Dentofacial Orthop. 2006;130(3):e17-e22.
van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C. Longitudinal changes in microbiology and clinical periodontal parameters after removal of fixed orthodontic appliances.
Eur J Orthod 2011;33(1):15-21.
Gong Y, Lu J, Ding X. Clinical, microbiologic, and immunologic factors of orthodontic treatment-induced gingival enlargement. Am J Orthod Dentofacial Orthop 2011;140(1):58-64.
van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C. Influence of bracket design on
microbial and periodontal parameters in vivo. J Clin Periodontol 2007;34(5):423-431.
Socransky S, Haffajee AD. Cugini MA, Smith C, Kent RL Jr. Microbial complexes in subgingival plaque. J Clin Periodontol 1998;25(2):134-144.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1-6.
Marriotti A. Dental plaque-induced gingival disease. Ann Periodontol 1999;4(1):7-17.
American Academy of Periodontology. Consensus report: Dental plaque-induced gingival
diseases. Ann Periodontol 1999;4(1):18.
Kouraki E, Bissada NF, Palomo JM, Ficara AJ. Gingival enlargement and resolution during
and after orthodontic treatment. N Y State Dent J 2005;71(4):34-37.
Gama SK, De Araújo TM, Pozza DH, Pinheiro AL. Use of the CO(2) laser on orthodontic
patients suffering from gingival hyperplasia. Photomed Laser Surg 2007;25(3):214-219.
Fornaini C, Rocca JP, Bertrand MF, Merigo E, Nammour S, Vescovi P. Nd:YAG and diode
laser in the surgical management of soft tissues related to orthodontic treatment. Photomed
Laser Surg 2007;25(5):381-392.
Kwon T, Levin L. Cause-related therapy: a review and suggested guidelines. Quintessence
Int. 2014;45(7):585-591.
O’Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43(1):38.
The New York State Dental Journal • MARCH 2015
23
professional ethics
What it Means to be a Doctor
Sensitizing the Dentist and the Student to Professionalism
Ronald I. Maitland, D.M.D.
ABSTRACT
Professional demeanor and the inter-personal behavior of the dentist play a large part in building the trust
patients measure as they gain confidence in their choice
of practitioner. Most of the time, patients experience
comfort through the competent, compassionate care
of a genuinely respected provider. That important image is determined by the ethical and proper relationships every patient encounters. The following discussion brings to the forefront image-damaging episodes
that have occurred as a result of unwise or unthinking
circumstances playing out not only in the office, but in
the community and in private life as well. Can a professional shield the public from disappointing legal,
unprofessional entanglements that could cast doubt
on the good judgment and safety expected of the doctor? What effects on a practice may be seen?
Almost all dentists know that there is a code of ethics and decorum for professionalism. Governmentally, state dental boards
are legally constituted to uphold the health, safety and welfare of
the public. The boards are sensitive to the aberrant, unlawful or
potentially dangerous behavior of their licensees. Any activity that
puts the public at risk or that brings into question the competent
and safe delivery of health care is investigated, and prosecuted
where warranted.
24
MARCH 2015 • The New York State Dental Journal
Over many years, state agencies, through their professional boards, have
encountered very few licensees who are aware that they can also be
charged with out-of-office-related infractions. There is no appreciation,
first, that the licensing agency has the authority over and an intense
interest in the private-life misdeeds of professionals, even though, often,
these misdeeds have little or no connection to the practice of dentistry.
Second, and perhaps more important, dentists often construct
an artificial shield separating their private life from their practice
life, failing to realize how questionable behavior affects their career.
Third, in many cases, such as criminal activity and/or abuse
and impairment issues, there exists a kind of double jeopardy, as after the civil or criminal governmental disciplinary system in court
is enforced, the state professional board can revisit the episode and
mete out its own professional misconduct sanctions, including the
possibility of additional fines, suspension of license, mandated behavior modification therapy and, even, revocation of license.
Ill behavior is certainly not a rarity and can be episodic in anyone’s life by design or through ignorance, although the average dentist has no idea how frequently these troubling issues arise among
professionals. News outlets are filled with it daily for consumption
by the general population, but the expectation that the doctor, while
as many proffer is human and can err the same as anyone else, has
a higher calling, a more stringent ethical duty and is educated to act
with respectful restraint far beyond the lay population.
Certainly, doctors can and should enjoy life, play vigorously
and party. All that is enrobing them is the need to be circumspect,
lawful, to refrain from excess that might invite criticism, and to
avoid being labeled for poor judgment and losing the public’s
trust and confidence. Both the public and the state expect a different standard for a professional’s behavior.
What it Means to be a Professional
Let us discuss professionalism, duty to self, to the community and
to the profession that is the basis of this public expectation.
The title “doctor” is a powerful label. It imparts special status
based upon, among other characteristics, the individual’s tested
intellect, educational achievement, high level of practical training, expertise, wisdom and trustworthiness. The word means
“teacher.” To maintain this special status, each doctor must adhere to the pillars of what a professional embodies—for example,
competent skill, academic and behavioral honesty, financial responsibility, fairness, respect and compassion to all, reliability
and actions worthy of public trust.
One’s demeanor and behavior outside of the practice have
tremendous influence on the doctor’s reputation and respect in
the community. More importantly, behavioral misadventures
may have serious repercussions on the professional’s practice and
licensure, and the special status of the profession as a whole.
Deviating from professional
qualities may be indicative of an
absence of moral character. During dental practice, disregard for
patient welfare (often motivated by
financial gain), for example, and
unfortunate expedient shortcuts in
service that result in outcomes falling below the standard of care can
irreparably damage trust and professional respect. When ethics are
cast aside, undue commercialism
and disingenuous treatment ensues.
Truthfulness decreases. Integrity is lost.
What is the effect of such amorality? In academic circles,
cheating not only marks the character, morality and lifestyle of
the individual, it becomes an addiction. Each act of dishonesty,
without immediate recriminations, builds a comfort level that
encourages repeat behavior. With students, it shortchanges their
own educational experience and subverts the values of an inquisitive scientific mind. Disregarding evidence-based support for
modern practice and allowing excessive anecdotal distraction also
challenges the scientific basis for competent care. The unprofessional student or doctor becomes dependent upon the perceived
success of the deceit.
Bankrupt of professional practice standards, the practitioner
becomes a harbinger of future professional irresponsibility and,
even worse, amasses a dossier of credentials that falsely speak of
an education worthy of licensure. Credentials are based in trust;
they certify a minimum level of competence. Tainted credentials
become a subterfuge and undermine the public’s expectation.
Copying the written work and ideas of others and claiming
them as your own, falsifying data, generating dishonest records
and altering scientific research results are only a few examples
of academic dishonesty. Certification that one has trained his or
her mind and hands to a requisite level of competency but in
reality has been abbreviated is (by the nature of circumvention)
a false achievement, a disingenuous pursuit and a tragedy in the
making. Dishonesty at all levels hurts the entire profession, the
unsuspecting public and the perpetrator as well. A doctor who has
earned respect is looked up to with great confidence. Once that
respect is questioned, one’s reputation is greatly impaired.
That reputation is not generated and upheld just in the dental
office. A dentist is always in the public eye. Dental students, upon
entry into school, are considered to be members of the profession
too; they should conduct themselves according to the expectations
for a fully licensed professional. A doctor’s behavior and lifestyle,
because of the special status that society grants him or her, is under
constant, critical view. Students assume a professional role and the
dictates of public trust that accompany their entry into dentistry.
This responsibilty begins as soon as
they commence navigation through
the educational process. Sensitivity to this new professional role is
an important part of the student’s
educational process. Arrogance, academic dishonesty, illegal and ill behavior, all can become the subject of
professional inquiry in school honor
code enforcement, as well as in legal
and public arenas. Embarrassing acts
stemming from a lack of good sense,
amorality and/or immorality certainly denigrate both the new and seasoned professional’s image
among colleagues and the community.
Social indiscretions and sophomoric episodes acted out in
public, as well as misdemeanors and felony criminal convictions
that become known, can be devastating to the community’s trust
and respect of the individual as a professional. Adverse publicity, as
a result of indiscretion or illegality, hurts the individual, the school
where applicable, the practice and the entire dental profession.
Principles of ethics and professional behavior in the dental
office are addressed in dental school. Often, they are revisited in
practice management discussions during and after commencement of practice. Some management advisors, however, promote
business rubrics in an effort to enhance commercial success without much regard for professional ethics and demeanor. Walking a
tight line, or crossing over the threshold of professional ethics, is
often more avarice than good business sense and, therefore, will
also cross the propriety of good business ethics and the pragmatics of profit and sustainability.
State licensing boards, through practice acts and national,
state and local membership dental associations, and through the
The New York State Dental Journal • MARCH 2015
25
articulation of ethical principles and professional codes of conduct,
spell out unacceptable professional behavior with applicable enforcement regimens. There are lapses in display of good character,
episodes of untrustworthy behavior and demonstrations of poor
self-control, however, that occasionally contribute to denigration
of the special status that a professional enjoys in the community.
Many of these indiscretions, or more serious departures, are
not involved with actual dental care and practice issues. These,
too, are not insulated from community scrutiny and can have a
significant influence on public trust and respect. Indeed, practices
have been ruined by a professional who displays adverse behavior that would be unacceptable in any setting. In the interest of
the duty to uphold public protection, state boards are, therefore,
leveling misconduct proceedings against practitioners who have
demonstrated a lack of self-control or questionable, unstable behavior. Just being accused, even though later exonerated of any
wrongdoing, may be solace to the accused doctor, but the damage to the professional and the profession remains. The original
report still leaves questions in the
minds of patients, friends and colleagues. Such reputational damage,
deserved or not, is difficult to repair.
The following examples of ill behavior may appear extreme, and they
certainly represent noxious behavior
by anyone, not just professionals.
However, when the doctor’s judgment lapses fall to these levels, it is
surmised that one’s self control, mental abilities and professional decisionmaking are questionable, to the point
of compromised patient care. Dentists are human, and can succumb
to the pressures of daily life as anyone else can, but their actions
are subject to higher scrutiny; a higher expectation of judgment,
decision-making and trust; and a much higher standard for respect.
Misconduct #1: Road Rage
J.M., D.D.S., age 34, while driving home from work on the interstate, was abruptly cut off and forced off the road by another
speeding and weaving vehicle. Enraged, J.M. re-entered the highway and chased after the offender. Overtaking the other vehicle,
he engaged the driver with gestures and shouted epithets. Both
drivers pulled off to the shoulder and got into a fist fight on the
side of the highway. The doctor, who was getting the worst of this
entanglement, took a baseball bat from the back of his car and
assaulted the other driver, opening up a serious head wound and
severely damaging his auto.
The police and an ambulance arrived. The doctor was put
into handcuffs and taken into custody. The charges were reckless endangerment, road rage, property damage, and assault and
battery (with a deadly weapon). The conviction was reported
26
MARCH 2015 • The New York State Dental Journal
widely in the local media. Imprisonment was waived in a plea
bargain. In addition to the felony record, the fines, the mandatory program of anger management and probation, the doctor’s
insurance company refused to defend the personal liability action
against J.M. taken by the other driver. Also, the state dental board
later convicted him of professional misconduct and imposed appropriate discipline, a hefty fine and suspended his dental license
until satisfactory completion of an anger management program.
(Suspension of license can also cause a doctor to be dropped from
a number of third-party payment panels.)
In many jurisdictions, suspension or loss of one’s dental license
can be a significant economic loss. As a non-licensee, the dentist can
no longer own or operate a practice, nor practice in any way. This is
not a matter that can be addressed by just taking a vacation while
a colleague covers the practice. The legal entity, the practice, must
close or be transferred. The legal aspects of this kind of disciplinary
action are complex, extremely costly and can be devastating.
In this and the cases that follow, dentists who may be licensed in more than one state are
also subject to professional misconduct proceedings in each state in
which a license is held. The act(s)
committed, which resulted in a conviction in the original primary state
board disciplinary case, if considered a violation within the regulations of another state, may be prosecuted over again, with additional
discipline handed out in each of
those states.
Misconduct #2: Assault
P.J., D.M.D., who practiced orthodontics in a small town, was in
the grandstands at his son’s Little League championship game. His
son, at bat, hit a ball to deep shortstop territory, but was called
out by the umpire in a close play at first base. Enraged at the call,
believing his son to have beaten the throw, P.J. jumped out of the
stands and ran to first base and assaulted the umpire. He had to
be restrained and escorted from the field, all in full view of a large
number of parents, youngsters, patients and potential patients. The
newspaper headline screamed, “Dentist Goes Berserk.” Suitable
repercussions ensued, legally and professionally, including state
board insistence on supervised counseling, probation and a fine.
Misconduct #3: Alcohol Abuse
R.R., D.D.S., a long-time member of his local country club, was
attending the wedding of his patient’s daughter at the club. At the
end of the evening, he and his wife went to the coat check room
to retrieve their coats. The young female attendant couldn’t locate
his wife’s fur coat. Dr. R. got very agitated and started to verbally
abuse the young attendant. He obviously had had a lot to drink.
The entire club was privy to this episode. In fact, the coat had
been taken by mistake and was returned the next day.
Dr. R’s run for president of the club was woefully unsuccessful
several months later, and his practice suffered significant damage.
His staff was concerned about his use of alcohol—and not just at
evening social functions. They had observed he was coming to the
office impaired. They called a dental colleague of R.R. to ask if he
might suggest to their employer that he enter a substance abuse
program. The state board decided to honor his voluntary enrollment into an approved substance abuse program, which monitored
the enrollee’s compliance. The state then exacted a short-term
temporary license suspension, with no charges against R.R., based
upon his compliance. A state action could have been initiated if the
doctor had denied his alcohol abuse, however, which would have
stimulated a formal charge resulting in far more legal ramifications, longer license suspensions and further practice interruption.
While R.R.'s difficulties stemmed from alcohol abuse, numerous other cases can be found related to abuse of and addiction to
drugs and recreational substances.
Misconduct #4: Shoplifting
G.F. D.D.S., a successful dentist, was
arrested and prosecuted for shoplifting. He could easily have paid for the
stolen articles, which he didn’t even
need. He was released with a bench
warrant/misdemeanor, 100 hours
of public service and was required to
prove that he was in therapy. News
of his arrest traveled through the
small town and an article appeared
prominently in the local newspaper that was of no benefit to his
practice. The state board opened an inquiry to investigate impairment, i.e. substance abuse, and/or physical or mental deficit.
Misconduct #5: Fraud
H.S., D.D.S., was getting numerous calls about this headline:
“Bank Sues Doctor Over Building Sale Fraud.” Dr. S. and two
other partners were involved in the sale of a building that they
jointly owned. That sale was now being investigated by the district attorney for false documents and dishonest disclosures. Further investigation revealed tax evasion and unpaid tax liens that
had not been divulged. The headline created a significant change
in the character and busyness of the doctor’s practice. Criminal
charges ensued, with federal and state liens and IRS seizures of
other properties and bank accounts.
When a licensee is convicted of a felony, the state board prosecutes secondarily, after the district attorney and the federal and
state tax courts. Fraud of any kind, within the conduct of business of the practice or outside dealings, is considered professional
misconduct.
Misconduct #6: Bearing False Witness
Dr. J.M. and his wife, Dr. M.M., are both dentists. They have a
12-year-old daughter. The doctors practice separately. The couple
is in the midst of a bitter divorce. The rancor and fighting have
become quite public, including M.M.’s accusation that J.M. is
sexually abusing their daughter. Their story is played out in the
media. When the smoke settles, J.M. proves unequivocally that
M.M.’s accusations are lies, but the facts are too late. After many
months of expensive legal entanglement, J.M. has to move out of
state and start building a practice again.
J.M. does prevail in his civil lawsuit for defamation. The state,
furthermore takes criminal action against M.M. for filing a false
and malicious complaint, perjury and aggravated defamation. She
serves one month in prison, has her dental license suspended for
six months, receives a $10,000 fine and has to make substantial
restitution to J.M.
This is a professional and personal tragedy in so many ways,
but it is also a public relations nightmare for dentistry.
Misconduct #7: Drunk Driving
S.D., D.D.S., while driving home
from an evening dinner party, was
stopped at a police sobriety checkpoint and asked to step out of the
car. Subsequent evaluations ended
up with his arrest for driving while
intoxicated, DWI. His attorney, based
on the blood alcohol level being
just over the legal limit and this being a first offense, was able to plea
bargain the offense to driving while
impaired, a misdemeanor rather than a felony. S.D. paid the $500
fine, but still needed to attend an alcohol abuse program in order
to regain his suspended driver’s license.
Six months later, he was stopped again at another routine
checkpoint and arrested for DWI, this time with a significantly higher blood level, in fact, twice the legal limit. He was remanded to jail
for the night and was convicted of driving while intoxicated. He was
hit with a mandatory $5,000 fine, his driver’s license was suspended
for no less than one year, predicated on completing the DMV driver
safety course and his substance abuse rehabilitation. Since this conviction, states have significantly upgraded and increased penalties
for DWI.10 Auto insurance, if available, will charge prohibitive rates.
Subsequently, the state board for dentistry suspended his dental license for at least four months and until he satisfactorily completed
the mandated rehabilitation program. Many patients, unable to
schedule appointments, delved into the facts, which are a matter of
public record, and departed from the practice.
State boards are very sensitive to the lack of responsibility
and judgment of a professional who will drive under the influence of alcohol or drugs and threaten the safety and lives of oth-
The New York State Dental Journal • MARCH 2015
27
ers. Boards also feel that an educated professional who shows
evidence of the absence of an appropriate degree of good sense
and control relating to physical and mental impairment may also
practice dentistry while impaired.
Misconduct #8: Impersonating an Officer
B.C., D.D.S., while driving his car on the expressway, was pulled
over by the highway patrol. The trooper asked for the doctor’s license and registration. The doctor produced a badge issued by a
nearby police department. The officer asked the doctor where he
worked. B.C. said he was “on the job.” His story sounded suspicious to the officer, who returned to his police car and radioed for
ID corroboration. This inquiry identified the badge as having been
issued to a retired member of the department. The doctor was taken
into custody in handcuffs and charged with impersonating a police
officer, a Class D felony. The criminal action was plea bargained to
a Class E felony, the doctor was fined $5,000 and placed on probation for one year. The traffic summons was enforced as well in
town court. And a state board disciplinary action was leveled at the
doctor consisting of probation and an additional, substantial fine.
Professional Decorum In and Out of the Office
These scenarios are only a handful of examples of dentists breach-
ing the public trust through their misdeeds in private, out-of-theoffice, or civil/community-related matters. Criminal indictments,
business and financial irregularities, drug-related offenses, sexual
offenses, public indecency, questionable morality associated with
adulterous interpersonal relationships, deviant behavior and other kinds of abuse are all open to secondary state board scrutiny.
Degradation of the special status that is afforded those wearing
the robe of a “doctor” also ensues. The dentist, once separated
from direct doctor/patient relationships and in-office encounters
and treatment concerns, segues into personal human behavior
and private life. Many believe that this crosses into a distinctly
separate role governed by different ethics and different standards.
As one becomes aware of the pitfalls of deviancy and public displays of ill behavior, however, it should become abundantly clear
that any mistake in professional behavior separate from private
activity can have career changing outcomes.
The professional must be aware that the ethics and professionalism of dental practice is but a part of the decorum and
behavior that dentists should consider in guiding their daily lives,
in and outside the office. So much of the success of a professional
lies in the trust and respect earned in the delivery of compassionate, competent and concerned care, as well as in assuming an
exemplary, trustworthy, respected lifestyle in the community. p
Queries about this article can be sent to Dr. Maitland at rimdmd@earthlink.net.
REFERENCES
1.
Schon DA. The Reflective Practitioner: How Professionals Think in Action. Ashgate Pub.
Ltd., 2009.
2.
Schon DA. Educating the Reflective Practitioner. Jossey-Bass Inc., 1987.
3.
Maitland RI. Disturbing trends in dental education. J Esthetic and Restorative Dent 2006;
18(6):307-9.
4.
Masella RS. Renewing professionalism in dental education: overcoming the market environment. J Dent Educ 2007;71(2):205-216.
5.
Fisher AK. The indoctrination of dental students with a professional attitude. J Dent Educ
1960; 24(1):38-41.
6.
Bertolami CN. Why our ethics curricula don’t work. J Dent Educ 2004;68(4):414-25.
7.
Parrish JR. Professional conduct in dental school and after. J Dent Educ 1968;32(3);326-9.
8.
Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005
353(25):2673-82.
9.
O’Toole TP, Kathuria N, Mishra M, Schukart, D. Teaching professionalism within a community context: perspectives from a national demonstration project. Acad Med 2005;
80(4):339-43.
10. New York State DWI Penalty Update: Jail time, longer suspensions, much larger fines and
felony convictions are posted. Aggravated DWI, failure to submit to chemical tests (blood
or breathalyzer), use of ignition interlock devices are discussed IID’s) and similar penalties
for driving while ability impaired (DWAI). See NYS DWI.com.
Ronald I. Maitland, D.M.D., is full-time assistant clinical professor at New
York University College of Dentistry, New York, NY, a member of the NYU College of Dentistry’s Academy of Distinguished Educators, visiting professor, Tufts
University School of Dental Medicine and a member (extended) and former
chair of the New York State Board for Dentistry. The comments of the author
Dr. Maitland
are his own and not an official voice of the Board for Dentistry nor the New York
State Department of Education. Cases cited as examples have had the initials
of the persons involved fabricated to advance anonymity. They depict events that have taken place in
several different states. Such cases, however, are a matter of public record.
28
MARCH 2015 • The New York State Dental Journal
prosthodontics
Surgical and Prosthetic Management
of a Complex Edentulous Patient for
Fabrication of Complete Dentures
A. Alper Çomut, D.M.D., D.M.Sc.; Tanya Somohano, D.M.D.
ABSTRACT
Fabrication of well-fitting complete dentures becomes
a challenge in the presence of epulis fissuratum in
the maxilla or severely resorbed alveolar tissue in the
mandible. This clinical report describes the surgical
and prosthetic treatment of a patient who presented
with both problems. The neutral zone technique was
used to improve the stability of the mandibular complete denture. Both dentures were fabricated prior to
surgical excision of the epulis fissuratum and inserted
immediately following the surgery.
According to the American College of Prosthodontics, more than
35 million Americans are currently edentulous. Ninety percent of
this edentulous population wears complete dentures, and about
15% receive a new complete denture each year.1
Dental implants provide an opportunity for edentulous patients to have either fixed or removable implant-supported prostheses and, therefore, improve retention and stability problems
associated with complete dentures. Today, the standard of care
for the edentulous mandible is the addition of two implants and
fabrication of an overdenture.2
For edentulous patients who will have an implant-supported
fixed dental prosthesis as a definitive restoration, the initial phase
involves a complete denture fabrication as an interim prosthesis.
A proper complete denture fabrication for these patients is important for many reasons, including the patient’s comfort at the
transitional stage. The average time the patient will wear the denture ranges from 12 to 18 months before the surgical and healing
phases are completed.
A second reason is to determine if and where bone augmentation procedures will be required by duplicating the complete
denture as a radiographic/surgical guide. A third reason is to
guide the surgeon in proper placement of implants using the radiographic/surgical guide. And, lastly, to provide the dental technician with information about esthetics and position of the teeth
for the definitive implant-supported fixed prosthesis.3
Granting that implants offer many advantages to the edentulous population, complete dentures still represent the prosthesis
of choice as a definitive prosthesis for many patients due to anatomic restrictions, objection to surgical interventions or financial
limitations. As a result, complete dentures remain very important
in today’s dentistry, since they are used as either a definitive or
transitional prosthesis.
Fabrication of a well-fitting complete denture requires adequate extension with positive contact of the soft peripheral
tissues and bony anatomic structures for support.4 Problems or
limitations can be encountered with soft tissues, hard tissues or a
combination of both.
When referring to the soft tissues, a clinician can encounter inflammatory responses, hyperplasias, chemical burns, white
lesions, ulcerative lesions, mechanical irritations or malignan-
The New York State Dental Journal • MARCH 2015
29
Figure 3. Panoramic radiograph showing maxillary and
mandibular ridge resorption.
Figure 1. Clinical view of maxilla and epulis fissuratum.
Figure 2. Clinical view of severely resorbed mandible.
Figure 4. Modified mandibular base plate prior to recording
neutral zone.
Figure 5. Neutral zone formed using Coe-Soft.
cies.5 One of the hyperplasias, epulis fissuratum, is defined as a
tumor-like hyperplasia of fibrous connective tissue that develops
in association with the flange of an ill-fitting complete or partial
denture.6 The lesion forms as a pathological response to chronic
irritation. The most common complications for the patient are
pain and discomfort. Another complication is extension of the
lesion to a point where it compromises the retention and stability
of a denture.
Various treatments for this type of lesion have been described,
including surgical excision, a more conservative approach such as
soft relining of the existing denture or a combination of both.7
The conservative method is based on the belief that the soft relining material may facilitate shrinkage of the fibrous tissue mass.
The decision for surgical excision depends upon the amount of redundant tissue, its location and a patient’s acceptance of surgery.
Once the surgical intervention is decided upon, two approaches
can be taken in terms of the timing for the new denture fabrication—either prior or after the surgery. The advantages of fabrication prior to surgery are that the denture can be used as an aid
for healing following excision and the patient does not have to
be without the prosthesis for a long time. Its main disadvantage
is the potential need for reline procedures if the tissue changes
drastically following surgery.8
As with the soft tissues, certain limitations can arise when
evaluating the hard tissues for support in complete denture fabrication. The presence of unerupted teeth, large bony maxillary
tuberosities, severe residual ridge undercuts and exostosis may
30
MARCH 2015 • The New York State Dental Journal
Figure 6. Index of neutral zone on mandibular master cast.
require pre-prosthetic surgery.9 On the opposite end of the treatment spectrum, lack of bone or severe alveolar ridge resorption
can also be a problem. This becomes a bigger concern in the mandibular arch because the surface area is less than that in the maxilla and muscles of the tongue, cheeks and lips can dislodge them.
To aid in the retention and stability of a complete denture, the
neutral zone technique can be utilized.
The neutral zone, first introduced in the 1950s by Wilford
Fish and Russell Tench, is described as the area in the potential
denture space where the forces of the tongue pressing outward are
neutralized by forces of the cheeks and lips pressing inward.10,11,12
The neutral zone is captured by a patient’s functional movements
and transferred to the laboratory to guide artificial tooth setup.
This patient report describes management of an edentulous
patient who presented with both complications, a large epulis fissuratum in the maxilla and severe alveolar ridge resorption in the
mandible. It explains surgical and prosthetic treatments provided.
Clinical Report
A 92-year-old Hispanic woman presented to the Advanced Education Program in Prosthodontics at the New York University
College of Dentistry with a chief complaint of ill-fitting maxillary complete denture and missing mandibular complete denture.
Medical history revealed high blood pressure and severe arthritis.
Medical consultation and clearance for dental surgery were obtained prior to any procedure. Dental history revealed no dental
visit for the last 10 years. Clinical examination of the residual
Figure 7. Artificial tooth arrangement following neutral zone
index.
Figure 8. Intraoral view of artificial tooth arrangement with
presence of epulis fissuratum.
Figure 9A. Mandibular anterior teeth in relation to
mandibular lips.
Figure 9B. Mandibular posterior teeth in relation to tongue
and cheeks.
Figure 10. Surgical excision of epulis fissuratum.
Figure 11. Clinical view of maxilla following surgery.
ridge morphology in the maxilla showed the presence of an epulis
fissuratum, 40 mm x 25 mm x 15 mm in size, in the patient’s left
vestibule, extending labially and buccally (Figure 1). The residual
ridge morphology of the mandible was evaluated radiographically
and clinically, and revealed severe alveolar ridge resorption and
loss of bone volume (Figures 2 and 3). According to the Prosthodontic Diagnostic Index, this patient was classified as a Class IV,
the most challenging edentulous condition.13
Challenges in treatment planning involved determining the
sequence of treatment and how to improve the outcome, having
both alveolar ridges compromised by severe resorption and the
presence of hypertrophic tissue. The treatment plan chosen, based
upon the patient’s finances and viable options, was fabrication
of maxillary and mandibular removable complete dentures. The
determination was made to utilize the neutral zone technique for
the fabrication of the mandibular complete denture to maximize
the stability.
Consultation with the oral and maxillofacial surgeons was
done prior to the start of treatment; the recommendation for
surgical excision of the epulis fissuratum and hemostasis control
with CO2 laser treatment was made.14 It was decided to fabricate the maxillary complete denture prior to surgery to shorten
the treatment time, provide assistance in the healing process and
minimize the probability of further surgical revisions.
Fabrication of the maxillary immediate complete denture
and the mandibular complete denture was initiated by making
preliminary irreversible hydrocolloid impressions (Jeltrate Fast Set;
Dentsply Caulk, Milford, DE) of both edentulous arches using stock
metal edentulous trays. The impressions were poured in Type III
stone (Microstone; Whipmix, Louisville, KY). Custom trays were fabricated with Triad Original Blue material (Triad; Dentsply Caulk,
Milford, DE), adjusted intraorally. Border molding was done with
modeling plastic impression compound (Impression Compound; Kerr
Corp., Orange, CA). Final impressions with light body rubber base
impression material (Permlastic Light Body; Kerr Corp., Orange, CA)
were made and the master casts poured in Type III dental stone
(Microstone). Occlusal rims were fabricated with Triad base plate
material and baseplate wax (TruWax; Denstply Prosthetics, York, PA)
following averages for height and width. The maxillary occlusal
plane was adjusted intraorally following inter-pupillary and alatragus lines as references; then a face-bow transfer was made. The
mandibular occlusal rim was adjusted and the vertical dimension
of occlusion evaluated using the rest position, esthetics and phonetics.15 Centric relation record followed using bilateral manipulation and Blu-Bite (Blu-Bite; Henry Schein, Melville, NY) recording
material. Mounting was completed in a semi-adjustable articulator (Hanau Wide-Vue; Whipmix Corp., Louisville, KY).
In order to proceed with the neutral zone technique, the
mandibular occlusal rim was adjusted by removing the majority of the baseplate wax, leaving 1 cm at both posterior ends
to maintain vertical dimension of occlusion. An orthodontic
wire (Permachrome Resilient OrthoForm; 3M Unitek, Monrovia, CA) was
bent and added to the baseplate with sticky wax (Sticky Wax; Kerr
Corp., Orange, CA) as a retentive element. Both maxillary occlu-
The New York State Dental Journal • MARCH 2015
31
The treatment plan chosen, based
upon the patient’s finances and viable
options, was fabrication of maxillary
Figure 12. Insertion of complete dentures after surgery.
and mandibular removable complete
dentures.
sal rim and modified mandibular base plate were transferred to
the mouth (Figure 4). The neutral zone was captured by adding
Coe-Soft material (Coe-Soft; GC America Inc., Alsip, IL) to the mandibular base plate. To record neuromuscular functional movements via Coe-Soft, the patient was instructed to lick her upper
and lower lips from side to side, extend the tongue all the way
forward, swallow and pucker lips like for a kiss. After the neutral
zone was formed in the mouth (Figure 5), the base plates were
transferred to the laboratory.
The mandibular base plate with Coe-Soft was indexed on the
mandibular master cast as a guide of the neutral zone area (Fig-
32
MARCH 2015 • The New York State Dental Journal
ure 6). The Coe-Soft was then removed, replaced by wax, and the
artificial tooth arrangement was completed, guided by the index
(Figure 7). The completed artificial tooth arrangements on the
respective record bases were placed intraorally (Figure 8), and the
mandibular record base was evaluated for stability (Figures 9A
and B). Festooning of the polished surfaces of the denture was
completed, taking into consideration the indexes. The posterior
palatal seal was recorded and prepared into the maxillary master
cast. The dentures were processed using the SR Ivocap System (SR
Ivocap System Ivoclar Vivadent, Inc., NY) and polished for insertion
following surgery.
At the time of the surgical excision of the epulis fissuratum,
the patient was anesthetized with three carpules of lidocaine
2% and 1/100,000 epinephrine (Lidocaine HCl 2% with Epinephrine;
Henry Schein, Melville, NY). An incision was made surrounding the
excess tissue while pulling with a hemostat (Figure 10). The laser was used simultaneously and at the end of the excision to
control areas of bleeding. Three chromic-gut sutures were placed
in areas where coagulation could not be obtained (Figure 11).
Post-operatory instructions and prescriptions for antibiotics
and pain control medication for seven days were given to the
patient. The new complete dentures were inserted at that time
(Figure 12).
The patient was instructed not to remove the dentures and
to return for a 24-hour follow-up visit. At the 24-hour followup visit, the dentures were removed and inspected; pressureindicating paste (Pressure Indicating Paste; Mizzy Inc., Cherry Hill, NJ)
was used to evaluate the proper fit of the intaglio surface, and
areas of excessive pressure were eliminated. The patient returned
for a one-week follow-up and sore spots were adjusted. At the
two-week follow-up, healing was almost complete and no surgical revisions were recommended. Final occlusal adjustments
were made. The patient was very satisfied with the stability of the
mandibular denture and overall treatment outcome. A follow-up
protocol of 3, 6 and 12 months was established.
Summary
This clinical report describes the treatment of a completely edentulous patient with severe resorption in the mandible and a large
epulis fissuratum in the maxilla. The treatment rendered was fabrication of a maxillary complete denture prior to surgical excision
of the epulis fissuratum and a mandibular complete denture using a neutral zone technique. The advantage of the neutral zone
technique is improvement of stability with the understanding
that complete dentures must function in the oral cavity in harmony with the neuromuscular system. p
Queries about this article can be sent to Dr. Çomut at alpercomut@nyu.edu.
REFERENCES
1. Felton D, Cooper L, Duqum I, Minsley G, Guckes A, Haug S, et al. Evidence-based guidelines for the care and maintenance of complete dentures. A publication of the American
College of Prosthodontists. J Am Dent Assoc 2011;142:1S-20S.
2. Das KP, Jahangiri L, Katz RV. The first-choice standard of care for an edentulous mandible.
A Delphi method survey of academic prosthodontists in the United States. J Am Dent Assoc
2012;143:881-889.
3. Zitzmann, NU, Marinello CP. Treatment plan for restoring the edentulous maxilla with
implant-supported restorations: removable overdenture versus fixed partial denture design.
J Prosthet Dent 1999;82:188-196.
4. Jacobson TE, Krol AJ. A contemporary review of the factors involved in complete dentures.
Part III: Support. J Prosthet Dent 1983; 49:306-313.
5.
Jones PM. Complete dentures and the associated soft tissues. J Prosthet Dent 1976; 36:136149.
6. Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & Maxillofacial Pathology. 2nd
ed. Philadelphia: W.B. Saunders. pp. 440–442.
7. Thomas GA. Denture-induced fibrous inflammatory hyperplasia. Australian Prosthodontic
Journal 1993:49-53.
8. Seals RR, Kuebker WA, Stewart KL. Immediate complete dentures. Dent Clin North Am
1996;40:151-167.
9. Lynde TA, Unger JW. Preparation of the denture-bearing area: an essential component of
successful complete denture treatment. Quintessence Int 1996;26:689-695.
10. Beresin VE, Schiesser FJ. The neutral zone in complete dentures. J Prosthet Dent 2006;
95:93-100.
11. Fahmy FM, Kharat DU. A study of the importance of the neutral zone in complete dentures.
J Prosthet Dent 1990;64:469-62.
12. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical concepts to
modern application. J Prosthet Dent 2009;101:405-412.
13. McGarry TJ, Nimmo AS, James F, Ahlstrom RH, Smith CR, Koumjian JH. Classification
system for complete edentulism. J Prosthodont 1999;8:27-39.
14. Iseri U, Özçakır-Tomruk C, Gürsoy-Mert H. Treatment of epulis fissuratum with CO2 laser
and prosthetic rehabilitation in patients with vesiculobullous disease. Photomedicine and
Laser Surgery 2009;27:675-681.
15. Turrell AJW. Clinical assessment of vertical dimension. J Prosthet Dent 2006;96:79-83.
A. Alper Çomut, D.M.D., D.M.Sc., is clinical assistant professor, Department of Prosthodontics, New York University College of Dentistry, New York,
NY.
Dr. Çomut
Tanya Somohano, D.M.D., is a resident in the Jonathan and Maxine
Ferencz Advanced Education Program in Prosthodontics, New York University
College of Dentistry, New York, NY.
The New York State Dental Journal • MARCH 2015
33
restorative dentistry
Maxillary Implant-retained Partial
Overdenture with Dolder Bar Attachment
A Clinical Report
Hyeongil Kim, D.D.S., M.S.; Robert J. Buhite, D.D.S.; Edward A. Monaco Jr., D.D.S.
ABSTRACT
This article describes a technique for maintaining a
maxillary Kennedy III partial removable dental prosthesis design in a patient who had non-restorable failing abutments by replacing the abutments with dental implants. Two implants were placed immediately
after extraction of the abutment teeth in the anterior
maxilla. After the implants were fully integrated, a
Dolder bar attachment was fitted onto the implants.
A new maxillary partial removable dental prosthesis
was fabricated using the implants and the remaining
natural teeth as abutments to restore function and
esthetics. With the aid of dental implants, this Kennedy III maxillary removable dental prosthesis design could provide additional retention and support
by promoting cross-arch stability and tissue, implant
and tooth support. The patient’s satisfaction was significantly increased.
The efficacy of the implant-supported/retained overdenture is
apparent in a completely edentulous patient, and has been well
documented.1-4 When it comes to treating partial edentulism,
there are several treatment options, such as conventional partial
fixed dental prostheses, partial removable dental prostheses and
implant-supported fixed prostheses.5,6 However, the benefits of
incorporation of dental implants into partial removable dental
34
MARCH 2015 • The New York State Dental Journal
prostheses for a compromised dentition and severely resorbed
alveolar ridges are also shown in the dental literature.7-12 An invitro study indicated that an implant placed in the distal edentulous ridge prevented the displacement of distal extension partial
prostheses and decreased the pressure on soft tissues.13
Most clinical reports about the implant-retained partial removable dental prosthesis described an approach to incorporate
the dental implant into the removable dental prostheses to convert Kennedy Class I or II to Kennedy Class III removable partial
design in the maxilla and the mandible.14-17 This treatment modality can also be a compromise, allowing patients who are not
suited to a complex treatment to easily reach prosthetic goals.
Kaufmann, et al. indicated that this option may be used to rescue
hopeless abutments for the existing partial dentures.19 Bortolini,
et al. also suggested that this can constitute an interim treatment
option while dentists and patients make decisions about the extraction of minimally compromised teeth and can later be transformed into a complete implant-supported overdenture.20
However, there have been a few studies of its long-term success. Objections to such a treatment modality are that there are
fewer evidence-based articles to support this option and that implants are mostly single standing, not rigidly splinted. In a longterm retrospective analysis, Bortolini, et al.19 reported that overall
survival rates of implants and the implant-retained partial denture for both the maxilla and mandible were 93.75% and 100%,
respectively, for an eight-year period.
Grossman, et al.10 also reported that an overall implant
survival rate of 95.5% was observed with improved masticatory function and esthetics in their 31-mean follow-up study.
Kaufmann, et al.19 followed for up to eight years to analyze pros-
Figure 1. Pre-treatment maxillary arch
without prosthesis. Note central incisor lost
intracoronal attachment.
Figure 2. Surgical template adaptation over
extraction sites without flap elevation.
Figure 3. Radiograph after implant placement.
Figure 4. Dolder bar-custom abutment
assembly on maxillary final cast and laboratory silicone putty index of trial denture.
Figure 5. Brazed Dolder bar assembly with
retentive sleeves and spacers.
Figure 6. Framework for removable partial
prosthesis.
Figure 7. Maxillary occlusal view with
definitive prosthesis.
Figure 8. Facial view of definitive
prostheses.
thetic maintenance in partially edentulous patients with removable prostheses supported by teeth and strategic implants. They
summarized that overall, 3 maxillary implants were lost out of
93 implants, and the placement of a few implants allowed for
maintaining a compromised residual dentition. They also addressed technical problems, such as complications related to
anchorage types, mechanical failures of the dentures and prosthesis-related adjustments.
In another retrospective study of an average 2.57-year observation of clinical applications of dental implants on distal
extension removable prostheses, Mitrani, et al.7 reported increased patient satisfaction with a minimal radiographic bone
loss. Wesmeijer, et al.20 concluded that the implant-assisted
mandibular bilateral distal extension removable partial denture
was a preferable treatment option over the conventional mandibular bilateral removable partial denture in their three-year
prospective study. This implant-assisted partial removable dental prosthesis has many advantages, including preservation of
the proprioception of teeth and alveolar bone, improved stability of the partial denture framework that allows a mechanically
favorable design with excellent esthetics and a cost-effective
treatment modality.11,21
Most articles have described how to incorporate the dental
implant into removable denture designs by placing dental implants in the distal extension areas to distribute adverse forces.
This article describes the fabrication of an implant-retained maxillary partial overdenture in a unique way by placing two strategically located implants to replace unrestorable root-coping
abutments in the anterior ridge with the aid of the Dolder bar
attachments and natural posterior abutments.
Clinical Report
A 74-year-old man presented with an ill-fitting maxillary partial
overdenture and a mandibular Kennedy Class I partial removable
dental prosthesis. Evaluation of the existing prosthesis revealed
deformed plastic components of the Zaag attachment (Zaag; Preat,
Santa Ynez, CA) and a broken retentive clasp of the maxillary prosthesis. Severe wear was apparent on the occlusal surfaces of the
denture teeth opposing the natural dentition. Overall, stability
and retention of the prosthesis was very poor. Recurrent caries
was seen on both maxillary anterior abutment teeth. One of the
intra-radicular attachments (Zaag; Preat) was lost. The maxillary
anterior palatal mucosa demonstrated mild denture stomatitis
due to the ill-fitting prosthesis. A palatal torus, 11 mm in width
and 16 mm in length, was present on the hard palate. The posterior complete cast crowns were clinically acceptable, as abutments
were presented with no recurrent caries (Figure 1).
The treatment plan selected by the patient included extraction of the maxillary anterior abutment teeth, followed by immediate implant placement, and an implant-retained maxillary
partial overdenture together with a mandibular bilateral distal
extension removable partial denture. The resilient type of Dolder
bar attachment (Dolder bar; Preat, Santa Ynez, CA) was selected for
the retention and the stress distribution by splinting the implants.
This attachment system allows rotation and vertical movement of
the prosthesis, and is relatively easy to make parallel to the path
of insertion. The patient declined alternative options, including a
complete RDP and removal of the palatal torus, or an implantsupported fixed or removable dental prosthesis. The patient was
taking digoxin and atenolol for irregular heartbeat, and baby aspirin (81 mg) for stroke prevention; otherwise, he was a healthy
The New York State Dental Journal • MARCH 2015
35
individual. Medical clearance was obtained from his physician for
implant placement procedures aimed at improving retention and
stability of the maxillary partial prosthesis.
Preliminary impressions were made for diagnostic casts and
trial dentures using irreversible hydrocolloid (Jeltrate; Dentsply
Caulk, Milford, DE). The occlusal vertical dimension of the patient
was determined clinically using the trial bases (Triad; Dentsply Trubyte, York, PA). Casts were mounted in a semi-adjustable articulator (Denar Combi, Whip Mix Corp., Ft. Collins, CO) using a facebow (Slidematic face-bow; Denar, Whip Mix Corp., Ft. Collins, CO) and
centric relation record (Blue-mousse; Parkell, Edgewood, NY). Denture
teeth (SR Ortholingual DCL; Ivoclar Vivadent, Amherst, NY) were arranged with lingualized occlusion concept on trial dentures. Trial
dentures were placed in the patient’s mouth and evaluated clinically. The diagnostic trial denture was duplicated to fabricate a
clear acrylic radiographic template using laboratory silicone putty
(Lab-Putty; Coltene/Whaledent, Cuyahoga Falls, OH) and a denture processing flask (Hanau Varsity Flask, Fort Collins, CO). The position and
direction of the implants were confirmed by a cone beam imaging
system (i-CAT; Imaging Sciences Intl, Hatfield, PA).
The maxillary anterior teeth were extracted atraumatically
using periotomes, followed immediately by implant placement
in the extracted sockets (Figure 2). Surgical templates with drill
guides (Brass tubing; KS Engineering, Chicago, IL) were used to facilitate precise drilling. Two internal-platform, tapered endosseous
implants (4.3 × 10 mm, NobelReplace; Nobel Biocare, Yorba Linda, CA)
were placed with a flapless technique and torqued to 35 Ncm. At
the same time, cover screws (Nobel Biocare) were placed into the
implants. A maximum of 1 mm gap between the implant and
surrounding socket was noticed, but grafting procedures were not
indicated (Figure 3), according to Paolantonio, et al.22 Primary
closure of the surgical sites was achieved.
It was noticed two weeks after the implant placement that
the cover screws were partially exposed. The two cover screws were
replaced with two healing abutments (Nobel Biocare) after the implants were uncovered with a soft-tissue punch (Biopsy punch 4 mm;
Miltex Inc, York, PA). The implants were allowed to heal for eight
weeks. An anterior acrylic resin base of the existing prosthesis was
relieved to eliminate the occlusal loading on the implant during
the healing time and returned to the patient.
A custom impression tray (Triad; Dentsply, Trubyte) was border molded with a modeling plastic impression compound (Compound Stick; Kerr Corp., Orange, CA). An implant level impression of
the maxillary arch was made to fabricate custom gold abutments
(GoldAdapt; Nobel Biocare) after the healing of soft and hard tissues was completed. Waxed custom gold abutments were invested
(Fujivest II; GC Corp., Alsip, IL) and cast using a gold alloy (Harmony
Hard; Au 74.0, Pd 3.8, Ag 12.0, Cu 9.0, Zn <1.0, In < 1.0, Ir < 1.0 %,
Ivoclar Vivadent). Dolder bars were assembled on the custom gold
abutments using an autopolymerizing acrylic resin (Pattern Resin
LS; GC Corp.) (Figure 4).
36
MARCH 2015 • The New York State Dental Journal
After the position of the bars was assessed using a surveyor (Ney
Surveyor; Dentsply CA, Woodbridge, ON, Canada) and a silicone putty
(Sil-Tech Plus; Ivoclar Vivadent) template of the trial denture, the
Dolder bar assembly was invested with a solder investment (Soldervest; GC Corp.) and brazed (Figure 5) in a heat-assisted microwave oven (ThermWave; EPL Ceramic Materials LLC, Youngstown, NY)
with a solder (.585 Fine Solder; Au 58.5, Ag 16.0, Cu 18, Ga 7.2, Zn
<1.0%, Ivoclar Vivadent). After clinical verification of the fit of the
Dolder bar assembly was assessed to be satisfactory, a new implant level impression was made to pick up the Dolder bar assembly intraorally using an open tray and vinyl polysiloxane material (Aquasil Ultra; Dentsply Caulk). The new maxillary definitive
cast with Dolder bar assembly was sent to a dental laboratory for
the fabrication of the metal framework using a base metal alloy
(Wironium; Co 63, Cr 29.53, Mo 5, Si, Mn, Fe, N each < 2, C max. 0.17,
BEGO, Lincoln, RI) (Figure 6).
After the clinical trial of the maxillary metal framework, the
maxillary trial wax denture was completed, flasked and processed
using heat polymerized acrylic resin (SR Ivocap, Ivoclar Vivadent).
Denture bases were adjusted with a pressure-indicating paste (Detail Pressure Indicating Paste; Pfingst & Co., Inc., South Plainfield, NJ) accordingly to relieve pressure during the clinical trial placement.
The removable dental prosthesis was remounted in the articulator
to adjust occlusal interferences. The removable dental prostheses
were finished and polished for final placement (Figures 7, 8).
The patient was advised to maintain a prescribed schedule for
the periodic recall evaluation, including oral hygiene and prosthodontic maintenance. The patient has been followed for six years
since completion of his treatment. The prosthetic complication of
the maxillary RDP during the recall examination included wear of
the anterior denture teeth and replacement of a broken denture
tooth opposing the natural teeth. The patient was highly satisfied
with the improved esthetics and function of the prosthesis.
Summary
The authors replaced the existing natural abutments of the
overdenture with dental implants immediately after extraction.
Because there was the minimum gap between the implant and
surrounding socket, the same osseointegration was expected in
immediate placement as placed in mature bone.22 The existing
prosthesis was relieved to eliminate the occlusal loading on the
implant during the eight-week healing time.
For the retention of implant-assisted partial dental prostheses, several attachment systems have been used, such as the ERA
system,15,16 healing cap,10,14 bar system,11 Locator attachment13,17,18
and ball attachments.8,9,11,19,20,21 Although there is no advantage to
selecting the splinted bar attachment over unsplinted abutments
in mandibular overdentures in terms of retention and implant survival rates,23,24 the splinted bar device seems to be more retentive
and require less maintenance than the unsplinted attachment in
patients with severe resorption of the alveolar ridge.25
The Dolder bar system (Large resilient; Sterngold, Attleboro, MA) used
in this report consists of the oval-shaped metal bar, the retentive
metal sleeve and a spacer for the acrylic processing. The precision bar attachment provides retention of the prosthesis as well as
anterior-posterior rotational movement. The space used in denture processing allows settlement of the denture base, resulting in
maximum mucosal support. Overall, it combines excellent retention and minimal wear of the attachment system.
This article presents a simplified treatment modality in which
a limited number of strategically placed implants serve to improve
an otherwise unfavorable function. Without the option of two
dental implants placed in the anterior maxilla, the patient would
have received a maxillary removable complete denture with unfavorable anterior alveolar ridge occluding the mandibular bilateral
distal extension removable partial denture. With this method, it
was possible to maintain the existing Kennedy Class III condition
by strategically placing dental implants, which led to increased
patient satisfaction. p
Queries about this article can be sent to Dr. Kim at hik@buffalo.edu.
20.
21.
22.
23.
24.
25.
Bortolini S, Natali A, Franchi M, et al. Implant-retained removable partial dentures: an
8-year retrospective study. J Prosthodont 2011;20:168-72.
Wesmeijer D, Tawse-Smith A, Payne AGT. Multicentre prospective evaluation of implantassisted mandibular bilateral distal extension removable partial dentures: patient satisfaction. Clin Oral Imp Res 2013;24:20-27.
Paolantonio M, Dolci M, Scarano A, et al. Immediate implantation in fresh extraction
sockets. A controlled clinical and histological study in man. J Periodontol 2001;72:1560-71.
Naert I, Alsaadi G, van Steenberghe D, et al. A 10-year randomized clinical trial on the
influence of splinted and unsplinted oral implants retaining mandibular overdentures: Periimplant outcome. Int J Oral Maxillofac Implants 2004;19:695-702.
Van Kampen F, Cune M, van der Bilt A, et al. Retention and postinsertion maintenance of
bar-clip, ball and magnet attachments in mandibular implant overdenture treatment: an in
vivo comparison after 3 months of function. Clin Oral Imp Res 2003;14:720-26.
Mericske-Stern R. Clinical evaluation of overdenture restorations supported by osseointegrated titanium implants: a retrospective study. Int J Oral Maxillofac Implants 1990;5:375-83.
Dr. Kim
Dr. Buhite
Hyeongil Kim, D.D.S., M.S., is assistant professor, Department of Restorative Dentistry, University at Buffalo.
Robert J. Buhite, D.D.S., is associate professor, Department of Restorative Dentistry, University at Buffalo.
REFERENCES
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2.
3.
4.
5.
6.
7.
8.
9.
10.
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13.
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17.
18.
19.
Feine JS, et al. The McGill consensus statement on overdentures. Int J Prosthodont
2002;15:413-14.
Mericske-Stern R. Treatment outcomes with implant-supported overdentures; Clinical considerations. J Prosthet Dent 1998;79:66-73.
Quirynen M, Alsaadi G, Pauwels M, et al: Microbiological and clinical outcomes and patient satisfaction of two treatment options in the edentulous lower jaw after 10 years of
function. Clin Oral Imp Res 2005;16:277-87.
Doundoulakis JH, Eckert SE, Lindquist CC, et al. The implant-supported overdenture as an
alternative to the complete mandibular denture. J Am Dent Assoc 2003;134:1455-1458.
Charyeva OO, Altynbekov KD, Nysanova BZ. Kennedy classification and treatment options:
a study of partially edentulous patients being treated in a specialized prosthetic clinic. J
Prosthodont 2012;21:177-80.
Krennmair G, Seemann R, Weinlander M, et al. Implant-prosthodontic rehabilitation of
anterior partial edentulism: a clinical review. Int J Oral Maxillofac Imp 2011;26:1043-50.
Mitrani R, Brudvik JS, Phillips KM. Posterior implants for distal extension removable prostheses: a retrospective study. Int J Periodontics Restorative Dent 2003;23:353-9.
Kuzmanovic DV, Payne AG, Purton DG. Distal implants to modify the Kennedy classification of a removable partial denture: a clinical report. J Prosthet Dent 2004;92:8-11.
Jacob RF, King GE. Partial denture framework design for bone-grafted mandibles restored
with osseointegrated implants. J Prosthodont 1995;4:6-10.
Grossmann Y, Levin L, Sadan A. A retrospective case series of implants used to restore partially edentulous patients with implant-supported removable partial dentures: 31-month
mean follow-up results. Quintessence Int 2008;39:665-71.
Mijiritsky E. Ormianer Z, Klinger A, et al. Use of dental implants to improve unfavorable
removable partial denture design. Compend Contin Educ Dent 2005;26:744-50.
Shahmiri RA, Atieh MA. Review article. Mandibular Kennedy Class I implant-tooth-born
removable partial denture: a systemic review. J Oral Rehab 2010;37:225-234.
Chikunov I, Doan P, Vahidi F. Implant-retained partial overdenture with resilient attachments. J Prosthodont 2008;17:141-8.
Ohkubo C, Kurihara D, Shimpo H, et al. Effect of implant support on distal extension
removable partial dentures: in vitro assessment. J Oral Rehabilitation 2007;34:52-56.
Uludag B, Celik G. Fabrication of a maxillary-supported removable partial denture: a case
report. J Prosthet Dent 2006;95:19-21.
Giffin K. Solving the distal extension removable partial denture base movement dilemma: a
clinical report. J Prosthet Dent 1996;76:347-9.
Liu R, Kaleinikove Z, Holloway J, et al. Conversion of a partial removable dental prosthesis
from Kennedy Class II to Class III using a dental implant and semiprecision attachments. J
Prosthodont 2012;21:48-51.
Turkyilmaz I. Use of distal implants to support and increase retention of a removable partial
denture: a case report. J Can Dent Assoc 2009;75:655-58.
Kaufmann R, Friedli M, Hug S, et al. Removable dentures with implant support in strategic
positions followed for up to 8 years. Int J Prosthodont 2009;22:233-241.
Edward A. Monaco Jr., D.D.S., is assistant professor, Department of Restorative Dentistry,
University at Buffalo.
The New York State Dental Journal • MARCH 2015
37
disease management
An Analysis of the Hemophilia of the Royal Families
of Europe, Its Startling Implications and Dentistry’s
Role in Treating the Hemophiliac Patient
William James Maloney, D.D.S.; George Raymond, D.D.S.; David Hershkowitz, D.D.S.;
Glenn Rochlen, D.D.S.
ABSTRACT
Hemophilia is an inherited x-linked recessive disorder. It is known popularly as “The Royal Disease,” as
it has affected many of the royal families of Europe by
virtue of Queen Victoria being a carrier for the gene
and, subsequently, passing it on to her offspring. They,
in turn, married and had children with other royal
families of Europe. Hemophilia is certainly not limited to royalty. There are many hemophiliacs living in
our communities, and they must receive both proper
dental home-care education and dental treatment in
order to prevent possibly life-threatening emergency
dental episodes. Individuals with hemophilia pose different management issues to the dental professional.
The various precautions and modifications that must
be taken in order to ensure the safe delivery of dental
care to hemophiliac dental patients are discussed.
38
MARCH 2015 • The New York State Dental Journal
Certain disorders patients possess require various precautions
and, possibly, modifications to the usual course of delivery
of dental care. Hemophilia is one such entity. Virtually all
aspects of dentistry—from the prescribing of oral analgesics to
the possible need for factor replacement therapy prior to certain oral surgery procedures—necessitate that prudent measures be taken for the hemophiliac patient. A comprehensive
understanding of all necessary precautions must be achieved
prior to commencing any dental procedure, even an oral examination, on a hemophiliac patient.
Hemophilia is an x-linked recessive disorder. There are two
types of the disease—Type A and the more severe and rarer Type B.
A daughter who inherits the gene for hemophilia from her father
becomes an obligate carrier. Only in the rarest of instances does
a female manifest clinical signs of the disease. This would occur
when her father is a hemophiliac, her mother is a carrier and she
inherits the mother’s x chromosome, which carries the genetic
defect for hemophilia.
The genetic inheritance pattern of hemophilia played an immense role in shaping the history and political landscape of Europe in the 19th and 20th centuries. Queen Victoria of Great
Britain was a carrier and passed the gene for hemophilia down to
her offspring, who married into the other royal families of Europe.
It would be reasonable to predict that Victoria’s father (and her
other male ancestors) would have exhibited signs of hemophilia,
but none were ever observed. To explain this apparent genetic impossibility, certain individuals have argued for the possibility of a
spontaneous genetic mutation in the sperm of Victoria’s father
at the moment of Victoria’s conception. While this theory is not
impossible, it is extremely unlikely. A more plausible explanation
was that Victoria’s biological father is not Edward, Duke of Kent,
thus making Victoria’s birth illegitimate and, consequently, setting off an illegitimate succession to the English throne by her
son Edward VII.
Hemophilia
Hemophilia is a rare hereditary bleeding disorder in which the
blood does not clot in a normal manner at the site of a wound
or injury. There are two main types of inherited hemophilia:
Type A and Type B (Christmas disease). There is a deficiency
of Factor VIII in Type A, while there is a deficiency in Factor IX in Type B.1 The gene for hemophilia is located on the
x chromosome. They are clinically similar x-linked recessive
disorders.2 Hemophilia is almost always found exclusively in
males, while females can be carriers and pass it down to their
offspring.3 There is also a non-inherited hemophilia whereby
the body starts to attack and destroy its own clotting factors.
This type is very rare.3
The incidence of Type A is 1/5,000 live male births; the incidence of Type B is 1/300,000 live male births.4 Individuals with
hemophilia A demonstrate bleeding tendencies that are not always predicted by their Factor VIII level. It has been suggested that
bleeding in hemophilia is due not only to defective prothrombin
activation, but also to aberrant fibrinolysis.
Hemophilia may lead to joint swelling, which can bring
on damage or swelling in the muscle, as well as bleeding in
the head and sometimes in the brain that can lead to brain
damage, damage to other organs and death, which can occur
if bleeding cannot be stopped or if bleeding occurs in a vital
organ.5 These recurrent joint bleeds, which inevitably lead to
disabling arthropathy, were the hallmark of the disease before the 1970s, when plasma fractions containing Factor VIII
or Factor IX were still not available. At that time, mortality
for bleeding was markedly high and the life expectancy of
persons with hemophilia was lower than that of the general
population. 6-8
Currently, there are 141 federally funded treatment centers
and programs across the United States that provide comprehensive care for the individual and his family. As a result, individuals
with bleeding disorders have become more independent and productive, with an improved quality of life.9
The Royal Disease
England’s Queen Victoria (1819-1901) was a carrier of the gene
for hemophilia and, eventually, passed it down to the royal families of Germany, Russia and Spain.10,11 Prince Leopold was born
on April 7, 1853. His birth marked the first instance of hemophilia in the British royal family. Leopold was Queen Victoria
and Prince Albert of Saxe-Coburg and Gotha’s eighth child and
fourth son. Prior to Leopold, there was no known occurrence of
hemophilia in the royal family. This is extremely important, as
one must conclude that the mutation occurred as an extremely
rare de novo point mutation in the sperm of Queen Victoria’s father, Edward Augustus, Duke of Kent.12 Otherwise, the only other
scientific explanation as to the origin of Victoria’s recessive trait
is that Queen Victoria’s birth was of an illegitimate nature. The
Royal Society of Medicine has investigated 17 generations of the
family on Queen Victoria’s mother’s side. It could not find anyone with hemophilia.13
The first written allusion to the hemophilia of the British
royal family was in the British Medical Journal of February 8,
1868. It stated that His Royal Highness Prince Leopold, “who had
previously been in full health and activity, has been suffering during the last week from severe accidental haemorrhage. The Prince
was reduced to a state of extreme and dangerous exhaustion by
the loss of blood, but has since greatly recovered and has regained
his strength.”14
Leopold was the only son of Victoria to suffer from hemophilia. However, Victoria’s youngest child, Beatrice, gave birth to
Eugenie, who was a carrier and later married King Alonso XIII of
Spain.15 The couple had five sons. Four out of the five suffered
from hemophilia. The Spanish royal family was discredited, as it
disinherited the legacy of heirs on medical grounds.16,17
Alice, Queen Victoria’s third child, passed hemophilia to the
German and Russian imperial families. Alice had two daughters,
Irene and Alix. Irene married Prince Henry of Prussia, her first
cousin. The couple had two hemophiliac sons. Alix married Tsar
Nikolas II of the Russian imperial family. Their fifth child was,
finally, the long-awaited son, Alexis, heir to the Russian throne.
It was apparent from a very early age that Alexis suffered from
hemophilia. His father is said to have become preoccupied with
Alexis’s illness and let the affairs of the state deteriorate. The
family turned to a spiritualist, Rasputin, who seemed to be able
to relieve the boy’s suffering. The grateful family gave Rasputin
unlimited trust. These factors are believed to have led to the Russian Revolution and the eventual execution of the entire Russian
royal family.15
Dental Treatment of the Hemophiliac Patient
Although there are no inherent differences in the oral health of
an individual with hemophilia and that of an average individual,
it is imperative that meticulous oral hygiene be practiced in he-
The New York State Dental Journal • MARCH 2015
39
Periodontics play an important role in the oral health of the hemophiliac, as
hyperemic gingiva contribute to both spontaneous and induced gingival bleeding
and because periodontitis is a leading cause of tooth morbidity, which would lead
to the need for an extraction.10,37
mophiliacs in light of the many potential problems associated
with oral surgery.13 Thus, the dentist plays an extremely vital role
in the overall well-being of the hemophiliac.15
There are certain necessary precautions to be taken when
performing restorative dental procedures, including crown and
bridge procedures, in order to decrease the potential for serious
hemorrhage. Isolation with a rubber dam is of utmost importance. It provides retraction of the gingiva, improved visibility,
and minimizes the potential for laceration of the buccal mucosa
and lips.13 Care must be taken with cotton rolls, high-speed suction tips and saliva ejectors. High-speed suction, as well as saliva
ejectors, may cause hematomas.11 Saliva ejectors should be placed
on top of gauze on the floor of the mouth,11,16-18 and cotton rolls
should be wet prior to placing in the mouth to avoid mucosal
bleeding.11
A thorough clinical and radiographic examination needs to
be conducted prior to any oral surgery procedure. No more than
two teeth should be extracted at the first appointment if multiple
extractions are required. This is to ensure that hemostasis can be
achieved.19 All hemophiliac patients must be observed after extractions for a prolonged period of time, which can range from a few
hours to supervision overnight in a hospital for individuals with a
history of prolonged bleeding despite hemostatic coverage.15,19
There are generally no contraindications for performing endodontic treatment on a hemophiliac patient,20 and it is preferable to perform a pulpotomy or a pulpectomy rather than extractions.16,21-24 However, on a vital tooth, instrumentation and
obturation should never go beyond the apical region.25 In nonvital teeth, the treatment should always be at least 2 mm to 3 mm
short of the radiographic apex.19 Performing periradicular surgery
on a hemophiliac poses unique problems for the endodontist,
who must maintain hemostasis in the operating field. There are
various tests that need to be conducted prior to surgery. They include tests for bleeding time, clotting time, reptilase time, partial
thromboplastin time, activated partial thromboplastin time and
prothrombin time.26
Intravenous coagulation treatment is required only when an
inferior dental nerve block or lingual infiltration is required.30
It has been demonstrated27 that the use of intraligamentary
anesthesia during certain restorative procedures might eliminate
40
MARCH 2015 • The New York State Dental Journal
the need for factor replacement. The practitioner should prescribe
pain relievers other than NSAIDs or aspirin, as they decrease the
ability of the blood to clot.29
Orthodontic appliances, both fixed and removable, may be
used on the hemophiliac patient.28 Extra effort should be made to
prevent injury to the gingiva during the fitting of such appliances.
It is imperative that pediatric patients with hemophilia be
placed on frequent recall programs and have proper oral hygiene
reinforced on a continuing basis. It has been demonstrated30 that
children with hemophilia A have significantly higher gingival index and DMF(T)-DMF(DS) scores than matched healthy control
subjects.
Removable prosthodontics are unlikely to pose problems
for patients with inhibitors.31 However, trays should be removed
carefully from the mouth when making impressions for removable prostheses.
Minor, uncomplicated oral surgeries in hemophilia patients
can be performed by a general dentist or an oral surgeon with
the close assistance of a hematologist. However, a hemophilia
treatment center is the preferred site of any major oral surgeries performed on a hemophilia patient, with antibodies administered to counteract coagulation agents.31 Individuals with mild
hemophilia A (Factor VIII > 5%) may have minor surgery with
desmopressin (DDAVP) cover.32 Fibrin glue used locally and
swish-and-swallow rinses of tranexamic acid before and after extractions help control bleeding.32 Factor replacement is necessary
for individuals with severe hemophilia.32
Preventive dentistry is essential for the hemophiliac patient.
Hemophiliac patients have been shown to be more susceptible to
dental caries and periodontal disease than non-hemophiliacs.33,34
It is essential that individuals with hemophilia be instructed in
ways in which to reduce their risk factors for dental disease. This
includes practicing good oral hygiene, avoiding smoking, using
fluoride, reducing the frequency and amount of sugars in the diet,
and having regular dental examinations.35 The application of fissure sealants to the occlusal surfaces of posterior teeth can aid in
decreasing the incidence of dental caries.36
Periodontics play an important role in the oral health of the
hemophiliac, as hyperemic gingiva contribute to both spontaneous and induced gingival bleeding and because periodontitis is a
leading cause of tooth morbidity, which would lead to the need
for an extraction.10,37 Patients with pocket depths up to 4 mm
have a sound prognosis and should be capable of being maintained on a home-care program.35 It is unlikely that routine scaling and polishing will cause prolonged bleeding for patients with
mild conditions. This includes the use of ultrasonic scaling.21 Factor replacement therapy is necessary before scaling when treating
severe hemophiliacs.32
Conclusion
Dentists play an immense and vital role in the overall health care
of individuals with hemophilia. Hemophilia itself has played a
crucial role in 19th and 20th century world history. Whether performing a seemingly routine restorative procedure or evaluating
the need for extraction of a symptomatic third molar, the dentist
must be intimately familiar with all necessary precautions and
modifications to ensure the safety and well-being of the hemophiliac patient. p
Queries about this article can be sent to Dr. Maloney at wjm10@nyu.edu.
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22. Kumar NJ, Kumar A, Varadarajan, Sharma N. Endodontics for the haemophiliac, a multidisciplinary perspective. J Conservative Dentistry 2007;10(2):59-63.
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Dr. Maloney
Dr. Raymond
Dr. Hershkowitz
William J. Maloney, D.D.S., is a clinical associate professor in the Department of Cariology and
Comprehensive Care at New York University, New York, NY.
George Raymond, D.D.S., is a clinical instructor in the Department of Cariology and Comprehensive Care, New York University, New York, NY.
David Hershkowitz, D.D.S., is clinical assistant professor and associate chair, Department of
Cariology and Comprehensive Care, New York University, New York, NY.
Glenn Rochlen, D.D.S., is a clinical assistant professor in the Department of Cariology and
Comprehensive Care at New York University, New York, NY.
The New York State Dental Journal • MARCH 2015
41
endodontic research
Effect of Apically Separated Rotary
Instruments on Bacterial Leakage of
Obturated Root Canals using Resilon
Zahed Mohammadi, D.D.S., M.Sc.; Rasoul Yousefi Mashouf, D.D.S., M.Sc.;
Hamid Jafarzadeh, D.D.S., M.Sc.; Ali Heydari, D.D.S., M.Sc.; Sousan Shalavi, D.D.S.
ABSTRACT
The purpose of this study was to determine the effect
between experimental groups was observed. However,
of a separated rotary instrument on the time required
differences between experimental groups and control
for bacterial penetration of obturated root canals us-
groups were statistically significant.
ing Resilon. Eighty-four extracted human maxillary
premolars with single canals were used in this study.
Group 1 consisted of teeth obturated with gutta-percha and AH-26 sealer (n=15); Group 2 consisted of
teeth obturated similarly to Group 1 but without a
separated file; Group 3 consisted of teeth obturated
with Resilon and Epiphany sealer (n=15); and Group
4 consisted of teeth obturated similarly to Group 3
but without a separated file. Six teeth were used as
positive controls, and six teeth were used as negative
controls for each experimental group. Negative controls were obturated similarly to experimental teeth.
On the other hand, positive controls were obturated
with gutta-percha or Resilon without sealer. A suspension of Enterococcus faecalis was placed in the access chamber daily, and penetration was determined
when turbidity was noted in the culture broth during a three-month period. No significant difference
42
MARCH 2015 • The New York State Dental Journal
Separation of instruments is an unfortunate sequela of endodontic instrumentation. Reasons include improper use of the
instrument, overuse of the instrument, microcracks inherent in
the new instrument, and curved or calcified canals. When instrument separation occurs, the clinician has the choice of leaving
the instrument in the canal or attempting to remove it, either
surgically or nonsurgically.1
Nickel-titanium (Ni-Ti) instruments seem to fracture most
commonly in the apical region of the root canals,2 which often
renders orthograde removal ineffective.3 A fractured rotary Ni-Ti
instrument retained in a root canal has no adverse influence on
the prognosis of nonsurgical root canal treatment and retreatment if endodontic therapy and final coronal restoration are performed to a high technical standard.2,4
Torabinejad and Lemon5 suggested that the prognosis is best
when separation of a large instrument occurs in the later stages of
canal instrumentation close to the working length. The prognosis
is poor for teeth with undebrided canals in which a small instrument is separated short of the apex or beyond the apical foramen
early in instrumentation because the prognosis depends upon the
extent of undebrided infected canal space apical to the separated
instrument. Furthermore, the presence of preoperative periapical
radiolucency is clinically more significant as a negative prognostic
indicator than the fractured Ni-Ti instrument itself.2,6
Resilon (Epiphany, Pentron Clinical Technologies, Wallingford, CT;
RealSeal, SybronEndo, Orange, CA) is a thermoplastic synthetic polymer-based root canal filling material. Based on polymers of polyester, Resilon contains bioactive glass and radiopaque fillers. It
performs like gutta-percha, has the same handling properties,
and for retreatment purposes may be softened with heat or dissolved with solvents like chloroform. Similar to gutta-percha,
there are master cones in all ISO sizes and accessory cones in
different sizes. The sealer, Epiphany Root Canal Sealant, is a dual
curable dental resin composite sealer.7
The sealing ability of canals containing a separated instrument and obturated with Resilon/Epiphany has yet to be assessed.
Therefore, the purpose of the present study was to determine the
effect of apically fractured rotary instruments on the time of
bacterial penetration of obturated root canals with Resilon and
Epiphany sealer.
Materials and Methods
Eighty-four extracted human maxillary premolars were used in
this study. All of the teeth were caries-free and contained either
minimal or no coronal restoration. The teeth all possessed fully
formed apices. The teeth had been stored in 0.05% sodium hypochlorite and were kept moist throughout the experiment. The
teeth were radiographed both from the buccal and proximal directions to ensure one straight canal.
The crown of each tooth was removed using a rotary diamond saw at 1000 rpm (Isomet Plus precision saw, Buehler, IL) under
water-cooling in such a manner that a 16 mm root was obtained.
Working length was determined by subtracting 1 mm from the
canal length. All of the canals were flared coronally with #2 to #4
Gates-Glidden drills (Dentsply, Maillefer, Switzerland), and the apical
canal was instrumented using M-two rotary files. The canal was
flushed with 2 ml of 2.6% sodium hypochlorite (Sigma Chemicals
Co., St. Louis, MO) between every instrument, and apical patency
was maintained with a #10 file throughout the instrumentation.
Furthermore, 5 ml of 17% EDTA (pH 7.2) rinses were used during
and after instrumentation to remove the smear layer and decrease
coronal leakage.8 The teeth were divided into two experimental
groups of 15 teeth each. Six teeth were used as negative and six
teeth were used as positive controls for each experimental group.
Group 1: Teeth were obturated with gutta-percha (AriaDent,
Tehran, Iran) and AH-26 sealer (Dentsply, Darmstadt, Germany) (n=15).
Group 2: Each tooth contained a 3 mm piece of broken FlexMaster file (#30 with 0.04 taper) and was obturated with gutta-
The New York State Dental Journal • MARCH 2015
43
percha (AriaDent, Tehran, Iran) and AH-26 sealer (Dentsply, Darmstadt, Germany) (n =15).
Group 3: Teeth were obturated with Resilon (Epiphany, Pentron
Clinical Technologies, Wallingford, CT) and Epiphany sealer (RealSeal,
SybronEndo, Orange, CA) (n =15).
Group 4: Each tooth contained a 3 mm piece of broken FlexMaster file (#30 with 0.04 taper) and was obturated with Resilon
(Epiphany, Pentron Clinical Technologies, Wallingford, CT) and Epiphany
sealer (RealSeal, SybronEndo, Orange, CA) (n =15).
Six teeth were used as positive controls and six teeth were used as
negative controls for each experimental group. Negative controls were
obturated similarly to experimental teeth. On the other hand, positive
controls were obturated with gutta-percha or Resilon without sealer.
All the areas of root surfaces of the experimental samples and positive
controls were covered with two layers of nail varnish except for the
apical foramen. The negative control teeth were completely covered
with two layers of nail varnish, including the apical foramen.
All teeth in the gutta-percha groups were obturated using the
lateral compaction technique. All teeth in the Resilon groups were
obturated in the following manner. A self-etch primer (Epiphany
Primer; Pentron Clinical Technologies) was placed into the canal with
a thin needle. Excess primer was then removed with paper points
(Patterson Dental Supply, Inc., St. Paul, MN). Roots were filled with a
lateral compaction of Resilon and Epiphany sealer. A sterile technique was used for obturation of all teeth. A heated plugger was
used to remove excess filling material. After obturation, the coronal 2 mm of the canal was light-cured for 40 seconds.
Teeth were stored in gauze that was dampened with storage
medium (Tryptic Soy Broth), enclosed in sealed tubes and placed in
an incubator for 14 days at 37˚C to allow the sealer to set. The microbial leakage model consisted of an upper and a lower chamber.
Five ml of culture medium was placed in 40 individual test tubes.
Each tooth was placed into the test tube so that at least 2 mm of
each tooth’s apex was within the Tryptic Soy Broth. The chamber
of each tooth was filled with a suspension of Enterococcus faecalis
on day 0. A fresh bacterial suspension of E. faecalis, which was
prepared daily, was added to the upper chamber of each sample
until the chamber was nearly full. This procedure was performed
every day throughout the experiment. Penetration of the root canal was recorded when turbidity was noted in the broth. Cultures
were checked daily until the final test system became positive at
day 90. Data were analyzed using the Fisher exact test.
Results
Control groups behaved as expected. Turbidity was noted on day
one for all of the positive controls. The culture medium of the
negative controls showed no turbidity over the 90-day course of
the experiment, thus confirming the methodology.
Among the experimental groups, Group 3 showed the least
amount of leakage (33.3%). The amount of leakage in other ex-
44
MARCH 2015 • The New York State Dental Journal
perimental groups was as follows, in ascending order: Group 4<
Group 1< Group 2. The differences between experimental groups
were not statistically significant.
Furthermore, results showed that the least and greatest
amounts of additive risk of microleakage were associated with
groups 1 and 4, respectively.
Irrespective of the type of root filling material, the incidence
of leakage in the groups with and without a fractured file was
40% and 50%, respectively. In addition, irrespective of the presence or absence of a fractured file, the incidence of leakage in the
Resilon and gutta-percha groups was 36.7% and 53.3%, respectively (Table 1).
Discussion
The use of bacteria to assess leakage (mainly coronal) is considered to be of greater clinical and biological relevance than the dye
penetration method. Many different strains of bacteria have been
used to assess marginal leakage.9,10
E. faecalis is also a normal inhabitant of the oral cavity. E. faecalis
is found in 4% to 40% of primary endodontic infections. However,
its frequency in persistent periradicular lesions has been shown to be
nine-times higher. The prevalence of E. faecalis in root-filled teeth with
periradicular lesions using culturing and polymerase chain reaction
(PCR) methods is 24% to 70% and 67% to 77%, respectively.11
In the present study, the presence of turbidity indicated full
bacterial penetration through the root canal of the teeth. The results of the positive and negative control groups confirmed the
methodology. All positive control teeth showed turbidity by day
one. On the other hand, none of the negative controls showed
turbidity after 90 days. Statistical analysis demonstrated that
there was no significant difference between experimental groups.
However, teeth obturated with Resilon without separated instruments showed less bacterial leakages compared to other groups.
TABLE 1
Results of Study
Group
Number
No leakage
Leakage
P.Value
Guttapercha/
sealer
15
8
(53.3%)
7
(46.7%)
0.358
Guttapercha/
sealer
+Fractured
file
15
6
(40%)
9
(60%)
0.358
Resilon/
Epiphany
15
10
(66.7%)
5
(33.3%)
0.500
Resilon/
Epiphany
+Fractured
file
15
9
(60%)
6
(40%)
0.500
In a study to determine the effect of separated instruments on the
time required for bacterial penetration of obturated root canals with
gutta-percha and EWT sealer, Saunders, et al.12 found that the separated instrument itself did not play a significant role in the sealing
ability of the obturation material, which is in agreement with the
findings of the present study. Mohammadi and Khademi4 evaluated
the effect of apically-fractured K3 rotary files on the time required
for bacterial penetration of obturated root canals with gutta-percha
and AH-26 sealer using lateral compaction technique. Their findings
showed that a separated K3 file had no adverse effect on the sealing
ability of obturation material, which is in agreement with the present findings.
Resilon, a thermoplastic synthetic polymer-based root canal
filling material, contains bioactive glass, bismuth oxychloride and
barium sulfate. The overall filler content is approximately 65% by
weight. Epiphany is a dual-curable dental resin composite sealer. The
resin matrix is a mixture of BisGMA, ethoxylated BisGMA, UDMA
and hydrophilic difunctional methacrylates. It contains fillers of calcium hydroxide, barium sulfate, barium glass and silica. The total
filler content in the sealer is approximately 70% by weight. Forty
seconds of light will cure the coronal 2 mm of the canal, whereas
the entire filling will self-cure in approximately 15 to 30 minutes.13
Seventeen percent EDTA was used during and after instrumentation
to remove the smear layer and decrease coronal leakage.8 The adherence of the sealer to the dentin walls is a function of smear layer
removal. High bond strength cannot be achieved unless the smear
layer is removed.7 In addition to EDTA, Epiphany primer was applied
to the dentin walls of the root canals that were to be filled with Resilon. Epiphany primer is a self-etch primer that contains sulfonic acid
terminated functional monomer, HEMA, water and polymerization
initiator. The preparation of the dentin through these chemical
agents may prevent shrinkage of the resin filling away from dentin
wall and aid in sealing the roots filled with Resilon.7
The better sealing ability of Resilon may be attributed to the
“monoblock,” which is created by the Resilon filling closely adapting
to the Epiphany sealer and, in turn, the Epiphany sealer adhering to
the dentin walls.7 A number of studies have compared the sealing
ability of Resilon and gutta-percha. Shipper, et al.7,14 found that the
sealing ability of Resilon was significantly superior to gutta-percha.
In an in vivo study, they confirmed the superior coronal sealing ability of Resilon compared to gutta-percha and AH-26 sealer.15
Bodrumlu and Tunga16 compared the coronal sealing ability of Resilon/Epiphany to that of gutta-percha/ AH-26 and
gutta-percha/AH-Plus. Their findings demonstrated the su-
The New York State Dental Journal • MARCH 2015
45
perior sealing ability of Resilon/Epiphany. The better sealing
ability of Resilon compared to gutta-percha in the presence or
absence of a separated instrument was shown in the present
study as well.
Another important factor that may influence the leakage of
obdurate root canals containing separated files is the type or, more
accurately, the cross section of the file.17 Altundasar, et al.17 investigated the sealing properties of two different obturation systems
(cold lateral compaction and thermoplasticized gutta-percha)
applied over different apically fractured rotary Ni-Ti files (ProFile
and ProTaper) using a fluid transport model. Their findings showed
that roots with a retained ProFile fragment showed significantly greater leakage than those filled without ProFile fragments,
whereas significantly less microleakage was observed in the presence of fractured ProTaper instruments than their nonfractured
versions. They attributed these findings to the differences in the
cross-section design of these two systems.17 The cross sections of
ProFile instruments have U-shaped grooves with radial lands and
a central core, whereas the cross sections of ProTaper files, which
have rather superficial grooves, show a modified triangular shape
with sharp cutting edges and no radial land. K3 files, like ProFile,
have radial land and triple U-shaped grooves.18
Despite this similarity in the cross sections of ProFile and K3
rotary files, in the present study, apically fractured K3 files had no
significant adverse effect on the sealing of obturated root canals.
This can be attributed to the root filling material (gutta-percha
and AH-Plus sealer versus Resilon and Epiphany sealer).
Considering the fact that root canal anatomy is quite variable and is not completely round like the separated instrument,
as well as the fact that the separated instrument is fluted, it
would be unlikely to completely obturate the root canal space by
itself.4,12 However, the real determinant for evaluating the effect
of separated instruments on the prognosis of endodontic treatment and retreatment lies in clinical studies. The classic Washington study19 showed that treatment outcome was unaffected
by a retained fractured instrument. Spili, et al.2 investigated the
influence of retained fractured rotary Ni-Ti instruments on the
prognosis of endodontic treatment. From a pool of 8,460 cases,
the authors conducted a case control study of 146 teeth with a retained fractured instrument (plus 146 controls), for which clinical and radiographic follow-up for at least one year was available.
The overall healing rates were very high both for cases with a fractured instrument (91.8%) and for the matched controls (94.5%),
but with no statistically significant difference. However, it seems
that the most important factor influencing the outcome of endodontic treatment of teeth containing fractured files is the presence of a preoperative periapical lesion.
Based on the results of the present study, the separated instrument itself does not play a significant role in the sealing ability of
the obturation material. Extrapolation of the results of this in vitro
study to clinical situations must be done with caution because the
46
MARCH 2015 • The New York State Dental Journal
vitality status of the pulp as well as how much undebrided and unobturated canal apical to and including the instrument remains. p
Queries about this article can be sent to Dr. Mohammadi at zahed_mohammadi@yahoo.com.
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Shipper G, Teixeira FB, Arnold RR, Trope M. Periapical inflammation after coronal microbial inoculation of dog roots filled with gutta-percha or Resilon. J Endod 2005;31:91-6.
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Altundasar E, Sahin C, Ozcelik B, Cehreli ZC. Sealing properties of different obturation
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Dr. Mohammadi
Dr. Jafarzadeh
Zahed Mohammadi, D.D.S., M.Sc., is a member of the Department of Endodontics, School of
Dentistry, Hamedan University of Medical Sciences, Hamedan, Iran, and is affiliated with the Iranian
Center for Endodontic Research (ICER), Shahid Beheshti University of Medical Sciences, also in Tehran.
Rasoul Yousefi Mashouf, D.D.S., M.Sc., is a member of the Department of Bacteriology,
School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran.
Hamid Jafarzadeh, D.D.S., M.Sc., is affiliated with the Dental Research Center, Department of
Endodontics, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
Ali Heydari, D.D.S., M.Sc., is a member of the Department of Endodontics, School of Dentistry,
Hamedan University of Medical Sciences, Hamedan, Iran.
Sousan Shalavi, D.D.S., is a general dental practitioner in Hamedan, Iran.