Archive for the ‘Dental Specialties’ Category

Using Attachments in Dental Treatment Planning

Friday, November 14th, 2014

By George Bambara, DMD, MS, FACD, FICD

Before I discuss how using dental attachments allowed me to enhance my treatment planning skills, I would like to give credit to one of my dental school professors who recently passed away, Dr William Cinotti; a man and a friend who knew no boundaries and who contributed greatly to my professional development.

Using attachments in dental treatment planning simply requires a knowledge of how attachments are designed to allow the prostheses to move in certain directions, if not all directions. Using attachments does not change how we fabricate our crown and bridge, partial dentures, overdenture and segmented fixed bridgework. We continue to follow all the steps that lead us to creating a successful prosthesis except that attachments are used in the process.

Attachments are rigid or resilient connectors that redirect the forces of occlusion. By being rigid, occlusal forces can be redirected to tooth or implant bearing areas and away from maxillary or mandibular ridges as in the case of partial dentures or overdentures. By using resilient attachments, those same occlusal forces can be redirected to the maxillaiary or mandibular ridges for support since the tooth or implant bearing areas may not be suitable to bear most of the chewing forces.

Segmenting fixed bridges simply means to fabricate a long span fixed bridge into two or more components utilizing a rigid or resilient attachment between the segments. Using attachments in this fashion creates shorter spanning bridgework that is easier to cast and seat while creating a rigid or resilient unit. A resilient unit acts as a stress releaser or stress breaker, depending on the attachment used while a rigid unit can function exactly as a cast fixed bridge with the ability for easier retrieval.

When using attachments, the first things that must be considered is how this newly designed prosthesis will function. Will it be rigid or resilient? Will it be tooth or implant supported or tissue supported? Evaluation of the remaining teeth or implants in terms of number, position and periodontal condition has to considered to determine exactly how much load the teeth, implants or ridges can bear. We need to determine our philosophy on loading teeth, implants and tissue and examine carefully what is on the opposite arch. Then, select the attachment that will suit our treatment planning purposes. Maxillary arches are usually bound down areas with much surface area and firm supportive areas  Here, in many cases, rigid attachments can be used. The mandible, which has less surface area and less supportive areas can benefit from either rigid or resilient attachments depending on the type of prosthesis designed as well as the existing or planned prosthesis for the opposing arch integration.

In consideration of all these factors, attachment dentistry can provide the opportunity to create long lasting prostheses and many happy and satisfied patients.

 

DrGeorgeEBambara-863kbDr. Bambara is on faculty at the Rutgers School of Dental Medicine and holds Fellowships in the American College of Dentists, the International College of Dentists, and the International Academy of Dento-Facial Esthetics. He is an Adjunct Assistant Professor at the College of Staten Island and lectures nationally and internationally on attachment prosthetics.  He has been selected as one of Dentistry Today’s Leaders in Continuing Education for the past seven years. Dr Bambara has published articles on attachment dentistry and has authored a chapter on Precision and Semi-Precision Attachments in the recently published textbook Contemporary Esthetic Dentistry.

 

Forensic Odontology

Monday, March 3rd, 2014

By Dr. Rick Cardoza

cardoza 4

The field of forensic odontology is that area of dentistry concerned with the application of law in both criminal and civil proceedings. There are two disciplines within forensic odontology, postmortem identification and bite mark (pattern injury) analysis.  Forensic odontologists also assist authorities with multiple fatality incidents, age determination based on tooth development, recognition of child abuse/intimate partner violence (IPV) and participate in civil proceedings as an expert witness.                                                    

    

Dental Identification

As forensic dental identification specialists, we are typically the last conventional option for postmortem identification.  DNA is also now utilized but due to its high cost and the extensive time required for analysis, it is used sparingly or when absolutely no other option exists. Other forms of postmortem identification include visual, personal effects, fingerprints, scars, marks, tattoos, and medical radiographs.

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Forensic dental identification has been successful because of the nature of the human dentition.  The enamel is the hardest substance in the body and the only exposed portion of the skeletal system (fig. 1, 2).  Teeth are very resistant to thermal damage, blunt force trauma, and the dentition remains stable during tissue decomposition.  In addition, the dentition is unique to a specific individual.  This includes not only the morphology of the coronal portion of the tooth but the morphology of the roots, pulpal chamber, and their relationship to their surrounding structures (i.e. sinus proximity, mandibular canal proximity, interproximal bony trabecular patterns etc.).  Following the natural dentition, if you add man made dental restorations, the unique combination for any given individual can factor into the millions.

There are numerous important reasons for identifying the deceased.  A legal certification of death is necessary to consummate legal matters such as life insurance, wills, etc.  There are family and personal reasons as well (closure).  In criminal investigations, it is important to establish the identity of the victim in order to proceed with the criminal investigation and to identify the suspect.  In a fire for instance, the bodies are often burned beyond visual recognition (fig. 3).  Personal effects are also destroyed or lost in the fire. Even if the personal effects are recovered they may not be considered reliable due to the typical calamity which surrounds a fire.  A forensic anthropologist will examine the remains of the skeletal system and can then determine age, race and sex of the victim.  Positive identification is best performed by examination of the surviving dentition by the forensic odontologist.  In a fire where the temperatures may be very high (1000°C) even the dental remains may be destroyed.  Crowns may fracture or explode leaving only the roots.  The bone may also be completely consumed leaving only scattered roots with no bony sockets for reference.

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Forensic dental identification is most often accomplished by the comparison of the radiographs of the teeth of the decedent (postmortem) with the dental radiographs obtained from the dentist of the suspected victim (antemortem) (fig. 4, 5).  Ideally the antemortem radiographs furnished should be the original full mouth series.  Often this is not the case.  Children’s radiographs are typically bitewings only unless they have orthodontic records as well.  Often times duplicate radiographs, not the originals, are sent and have been either poorly duplicated and/or are not labeled right and left for orientation.  In addition, the antemortem radiographic image may be of poor quality due to improper operator technique (cone cuts, overlapping interproximals, elongation/foreshortening, etc.) or poor processing (contrast, burned images, etc.).  When poor antemortem radiographs are compared to an ideal postmortem radiograph, the two may not appear consistent. This could seriously hamper the identification effort.

In forensic dental identification, we stress that good quality, properly mounted and labeled original antemortem radiographs be sent for comparison.  In addition, copies of the victim’s dental treatment progress notes should be submitted as well.  This allows the forensic dentist to verify dental treatment that was performed subsequent to the date of the radiographs.

It is important as practicing dentists to keep complete patient records on file and continually update them, including the radiographs.  One of your records may be needed for the purpose of a postmortem dental identification.

Bite Mark Analysis

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The study of bite marks involves the analysis of teeth contacting another object or medium. Thus, bite mark analysis is a type of forensic pattern analysis similar to tool mark analysis.  Unlike dental identification which is a quantitative analysis, bite mark analysis relies on the odontologist’s interpretation of the pattern therefore bite mark analysis is primarily subjective in nature.  It is for this reason that bite mark opinions, though based on scientific methods and principles, can be highly variable based on the individual’s interpretation of the pattern injury resulting in experts often giving different levels of opinion on the same pattern injury.  The consequence we see today is that bite mark analysis has become highly controversial and in the United States there have been twenty four exonerations by DNA testing of individuals after they had been previously charged or convicted where the charges/convictions were based partially on faulty bite mark evidence.

The study of bite mark analysis involves the comparison of the pattern injury or bite mark to the suspect biters dentition.  The classic appearance of a bite mark is two semicircular or ovoid arches that oppose each other with a central ecchymosis (fig. 6).  The bite mark pattern is photographed from multiple angles with a scale present for reference.  In addition, the bite mark is swabbed for possible suspect DNA.  On the biter it is necessary to take full arch dental impressions of both the maxillary and mandibular arches.  In addition, complete dental charting of all the present, missing, and restored teeth including charting anomalies such as fractures, spaces, rotations, etc., wax bites, and intraoral photography.  If the accused suspect biter is in jail then collection of these records will require a court order and the individual has the right to have his attorney present (note: the biter could also be the victim who bit their attacker in self-defense).

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Once all the records are collected on the bite mark and the suspect biter then the odontologist can complete his analysis.  The analysis consists of a comparison of the bite mark photo which has been digitally resized to life size 1:1 proportions to an overlay of the incisal/occlusal edges of the suspect biters teeth.  This is accomplished by creating a digital hollow volume overlay of the dental models by scanning the models, using a flatbed scanner, into the computer (fig 7).  Then with the use of photographic software the incisal edge overlay can be inverted and superimposed onto the bite mark pattern photo for comparison and analysis (fig 8).

Finally, the odontologist will submit his report to the entity that retained him.  In this report the odontologist will list all the steps he took to complete the analysis and formulate an opinion.  The range of opinions include: The Biter (absolute), Probable (more likely than not), Possible (cannot be excluded from suspect biter population), Exclusion (did not make the bite), and Inconclusive (not enough data or poor quality data to formulate an opinion).

In summary, forensic odontology is an exciting field where dental health care professionals can utilize their skill and training in dentistry for a field complete outside of dentistry.  Choosing a career path as a forensic odontologist or forensic dental autopsy technician (the auxiliary’s role in forensic dentistry) should not be viewed as a hobby but in fact a second career in addition to your primary career in the field of dentistry.  The hours can be long and the monetary return low or even non-existent but the personal reward and satisfaction can be great.

 

Cardoza

Dr. Cardoza is a forensic dental consultant for the County of San Diego Office of the Medical Examiner, County of Imperial Office of the Coroner, State of California Department of Justice and is the Director of the California Dental Identification Team (CalDIT).  Dr. Cardoza graduated from Northwestern Dental School in 1985 and maintains a general dental practice in El Cajon, California. Dr. Cardoza is a Fellow of the American Academy of Forensic Sciences and is a Diplomate of the American Board of Forensic Odontology.

 

Dental Implant Concerns Related To Patient’s Health

Monday, July 8th, 2013

Capped Dental Implant Model

By Dr. Don Callan

The goal of dental implants is to provide function, longevity and esthetics for dental patients in an environment that can be maintained with routine oral hygiene procedures. Dental implants are no longer experimental, exotic or rare. Implants are the treatment of choice for an increasing number of people who want the best that dentistry has to offer. Dental implants have proven to be a valuable treatment of choice for replacing missing teeth and have been developed from the anatomy of natural teeth. Dental implants are also subjected to periodontal disease (periodontitis) caused by oral bacteria (periodontal pathogens). Both patients and dentists should be aware of possible complications that can affect the patient’s oral and systemic health when implants are placed, even if excellent esthetic results are achieved. Professional implant maintenance and diligent patient home care are important factors. However, because a portion of the implant is below the gum level (subgingival), patients and clinicians have limited control over hygienic measures to prevent infection. Therefore, implant design is an important factor.

Periodontal pathogens have been linked with increased risk of systemic illness and complications in existing diseases.  Recently, several articles detailing these findings have been published, emphasizing the importance of the association between periodontal disease and systemic health problems.  In fact, recent reports of oral infections have been shown to be associated statistically with mortality. With periodontal disease, millions of oral bacteria are in direct physical contact with gum tissue, which provides an easy portal to the circulatory system.  After entering the bloodstream, periodontal pathogens have been shown to increase the risk of cardiovascular disease, strokes, lung disease, rheumatoid arthritis and may hinder glycemic control in diabetes. Sufficient evidence exists to conclude that both periodontitis and Peri-Implantitis involve the same bacteria. This same inflammatory process can damage healthy tissue and lead to bone loss around the implant.

In addition to optimizing esthetic and functional results, infection (Peri-Implantitis) of gum and bone tissue surrounding the implant is of major concern. These infections have driven many developments in dental implant design and use. Treatment of dental patients is rapidly moving from an approach focused primarily on esthetic and functional concerns toward an approach, which focuses on optimal health as a critical goal. Numerous published studies promote the prevention of oral bacteria harboring around implants as a key outcome in addition to traditional measures of implantation success.

Studies have shown periodontal pathogens surrounding dental implants will contribute to implant infections and is the main cause of implant loss and systemic concerns. Some patients may have significant infection and bone loss with no symptoms and may not pursue adequate follow-up care that would identify those conditions. Researchers have identified specific periodontal pathogens around and within the micro-gap of implant systems as the same seen in periodontal disease. Some implant companies are developing new designs for the elimination of the microgap issue. Therefore, it is important for all implant patients to see the dental professional for routine care and evaluation of the health around the implant.  It is possible for patients who maintain optimum hygiene care to suffer from implant infections if bacteria are harbored within, around, and between implant components.

In summary, the patient, dentist and the implant manufacturer have their respective areas of responsibility to maintain implant success. Infection about dental implants is the number one cause of failure; therefore, the patient must maintain excellent home care procedures of the implant and visit the dental office for routine cleanings. The dentist is responsible for proper surgical procedures and instruction to the patient for home care procedures. The implant manufacturer must be aware of the causes of implant failures in order to change or correct the design of dental implants as needed to promote long-term success. A poor implant design will affect esthetics, function and the ability to allow proper home care as well as professional cleanings of the implant and its restoration. IMPLANT SUCCESS IS A TEAM EFFORT: THE PATIENT, DENTIST AND MOST OF ALL THE MANUFACTURER OF THE IMPLANT.

 

DPCDr. Callan received his B.S., B.A. degree from the University of Arkansas in Business Management and Marketing. He received his D.D.S. degree and a Certificate in Periodontics from the University of Missouri at Kansas City. Dr. Callan maintains a private practice and hospital appointments limited to Periodontics with an emphasis on tissue regeneration and implant dentistry in Little Rock, Arkansas. Dr. Callan has authored 61 publications about dental implants and tissue regeneration. Dr. Callan has presented lectures in the United States and internationally, including the University of Moscow, Russia, China, Japan, UK, Mexico, Canada, Central America, and South America, on various topics including dental implants, Peri-Implantitis, bone regeneration, soft tissue regeneration, implant maintenance, oral and systemic periodontal health, marketing to the dental patient and treatment planning of the edentulous patient.

 

 

 

Look Before You Leap… The Treatment of Snoring and Obstructive Sleep Apnea

Monday, June 3rd, 2013

 By Gail Demko, DMD

Sleep Apnea and CPAP

All medical and dental professionals are looking for ways to offset decreases in reimbursement, often by acquiring new skills that allow expansion into previously untapped patient populations. Many dentists have become interested in providing oral device therapy for patients who snore and or have obstructive sleep apnea. All dentists possess the skills required to fabricate oral devices, we learned them in dental school. We are adept at using many different impression materials, adjusting and modifying multiple types of mouthpieces, can analyze occlusal contacts on complete dentures and have a passing knowledge of clonic bruxism and tonic bruxism (clenching).

The treatment of patients with snoring and obstructive sleep apnea requires not only these basic mechanical skills but an understanding of the overall disease process. This is a medical disease with medical complications and comorbidities. Just as untreated caries will lead to endodontic involvement and possible tooth loss, untreated sleep apnea can lead to hypertension, heart attack, stroke or an increased incidence of various cancers. Dentists are fully in control of treating all outcomes of the carious process but we are not trained to deal with the severe medical outcomes of untreated sleep apnea.

You must understand that we are part of the medical team. We work with physicians to appropriately treat patients with snoring and sleep apnea. Diagnosis of disease, be it snoring or sleep apnea, lies within the arena of medicine, not dentistry (just ask your malpractice insurer). To treat a patient who complains of snoring without appropriate medical consult and medical diagnosis may result in the resolution of snoring without control of the underlying sleep apnea. This patient could go on to suffer heart failure, have a motor vehicle accident or develop hypertension. Resolution of the patient’s symptom of snoring may allow both you and the patient to assume that the underlying sleep disordered breathing has also been controlled; snoring often resolves before there is control of the obstructive sleep apnea. This presumption can be very dangerous to the patient and could have serious consequences for your practice.

Many companies now market legal medical diagnostic sleep testing equipment directly to dentists. The sales rep tells you that this will allow you to “screen” patients in your practice for snoring and sleep apnea. These are not screening devices; these are legal medical diagnostic tools. The standard of care requires evaluation of the patient by medical provider not just remote evaluation of the data obtained through home sleep testing by a physician licensed in your state.

So approach this field in a responsible way. Learn about the diseases of sleep disordered breathing. Understand all available treatment options and know when oral appliance therapy may not be appropriate for the individual patient in your practice.

Treating medical diseases requires that you be part of the team. Physician, surgeon, general dentist, orthodontist, nurse practitioner and respiratory technician: all of these have a part to play. As dentistry evolves and continues to move back in synchrony with medicine it is time to forge new alliances with our medical colleagues to provide improved outcomes for all of our patients.

 

Demko

Dr. Gail Demko started her career in dental treatment of OSA at Beth Israel Deaconess Medical Center in 1989. In 1997, she was the first dentist in the US to limit her practice to the treatment of OSA. She became the expert advisor to the FDA in the area of oral appliance therapy in 2004 and has been active in professional groups for some time. At present , she is President of the AADSM, a member of  the Board of Directors of the Massachusetts Sleep Society, on the editorial board of the Journal of Sleep And Breathing and holds the distinction of having the first certified dental sleep medicine office in New England. She continues to practice full-time in Weston, MA.

 

My Greatest Reward

Monday, February 4th, 2013

Dr. Stacy Geisler

July 7th, 2011 began like any other day for me. I remember that there was a beautiful  sunrise that morning. I had a compressed, busy schedule in my oral and maxillofacial surgery practice in Lake Oswego. “We have a trauma patient coming in, Doctor” my front staff informed me when I arrived at my office. We already had fifteen patients scheduled that morning for me to see, three of whom were surgery patients. How would I find the time to see this other patient?

My add on trauma patient turned out to be a wonderful woman named Sunny. From my first meeting with her, I could see why her friends had given her this affectionate nickname. Sunny has a type of effervescence which surrounds her. Joy bubbles out of her. You can’t help feeling good just by being in her presence.  At this first meeting, I was struck by her amazingly positive attitude. It was hard for her to speak clearly because part of her upper right jaw was missing. She kept holding up her hand to hide the right side of her face. Slowly she was able to tell me her story.

Sunny had been at an outdoor function with her soon to be husband on a Saturday afternoon. As she was walking along an unfamiliar path, her foot slipped and she went down. This happened so quickly that she was not able to break her fall, but landed on her right face against a curb. Stunned and bleeding profusely, she sat up. Part of her upper jaw was missing. Looking down, she saw what she thought were bits of bone and tooth on the ground.

Sunny’s partner took her immediately to the closest emergency room for care. They were hoping to have a diagnosis made and treatment. An exam was performed as well as imaging studies.  Since this hospital was not part of Sunny’s health maintenance organization (HMO), she was told by the emergency room to contact the HMO for definitive care. When she called the HMO that evening, she was told that she would have to wait a week for an exam and treatment (she was told this is their policy to allow for swelling to resolve). When Sunny was finally able to see a surgeon at her HMO hospital, it was six days later. The surgeon told her that she had a dental injury and would need to follow up with her dentist. There wasn’t anything he could do for her. She was sent home with a prescription for Amoxicillin.

Sunny called her dentist from the parking lot of the HMO in tears. She knew that something was seriously wrong with her and she was struggling to understand why she couldn’t get the care she needed. Her dentist’s receptionist asked her to come in to his office immediately. When the dentist saw Sunny, he knew that this was more than a dental injury. He could see that part of her upper jaw appeared to be missing, as well as teeth in the anterior maxilla. His office called my office, thus the “add-on” patient for an already busy morning.

Examination of Sunny demonstrated a severe, avulsive injury involving the right anterior maxilla. Computed tomography scanning performed at the emergency room six days previously demonstrated fractures extending through the frontal process of the right maxilla, including the anterior nasal spine and vomer. She had fractured teeth #7 and #8 which were displaced into the right maxillary hard palate and not visible in the oral cavity. Tooth #9 also was extruded and was in hyperocclusion with her mandibular dentition.

Sunny’s dentist had sent electronic records for me to review and I was able to review her CT scan. I was stunned by the severity of her injury. At this point in my career, I have seen many, many things. Not much surprises me any more when it comes to the maxillofacial skeleton. But I was not prepared for how bad this injury was given the mechanism of injury. What Sunny had was more similar to a gun shot wound without the accompanying soft tissue devastation seen with a high velocity injury.

I knew that Sunny needed surgery and that she needed it soon. I also knew that she needed to be asleep for what I was planning for her. Since she had eaten that morning, we scheduled her for surgery the next day. I explained to her the nature of her injuries, that the wound needed to be cleaned, the broken bones stabilized and the damaged teeth removed. I explained that she might need root canals on some of her other teeth, and that she might require more extensive reconstructive surgery to rebuild the missing part of her jaw. I told her that she would also probably require dental implants since her teeth were damaged beyond repair. I prescribed antibiotics and pain medication for her to begin immediately. Sunny agreed to everything that I suggested. One concern was her upcoming wedding. Could I have all the reconstruction done in time for her wedding which was scheduled for December 2012? I told Sunny that I would try my best.

Over the next year Sunny underwent several surgeries to rebuild her maxilla. We began with debridement and fixation of broken bones. As I suspected, the right anterior maxilla had been pulverized by her fall and her wound was quite dirty. I found pebbles and asphalt at that first surgery.  I confirmed that Sunny would require a large bone graft to reconstruct her upper jaw if she ever had any hope of having a normal facial appearance. Hip grafting to the right maxilla was completed in February of 2012 and three dental implants were placed in June 2012.

Sunny handled all aspects of her year long reconstruction with grace and humor. She is a third grade teacher and saw an opportunity to use her injury to teach her class of eight year olds about anatomy and jaw reconstruction. She told me on one follow up visit, “I took out my prosthesis and showed my students how I was missing teeth, just like them. The kids loved it and had all kinds of questions about how my teeth would be put back. They couldn’t believe that part of my hip would become my new jaw!”

It was an amazing privilege to provide surgical care for Sunny following her facial injury. I feel so grateful that things went well: healing progressed as expected and we achieved the outcomes we were hoping for.  I can’t claim sole responsibility for her healing. Sunny’s reconstruction was brought about by a dedicated group of professionals whose sole goal was to restore her to health.

Sunny’s health maintenance organization initially denied medical  benefits for her reconstruction. Several letters were written from those involved in Sunny’s care and eventually she received the benefits needed to cover the cost of her reconstruction. Martha, my front office insurance expert, was instrumental in making this happen. I am grateful to Sunny’s dentist who recognized that she needed speciality care. I also feel lucky to have such a positive working relationship with Dr. Scott Dyer, who handled Sunny’s prosthodontic reconstruction.

Sunny recently stood before her friends and family as a bride and made a commitment to her partner just a few weeks ago. She told me via email “The wedding was spectacular and everything that we had both hoped for.” For a surgeon, there just isn’t any higher reward than that.


Stacy Geisler, DDS, PhD is a board certified oral and maxillofacial surgeon practicing in Lake Oswego, Oregon. She lectures extensively throughout the Pacific Northwest and is known for providing outstanding surgical care of her patients. Dr. Geisler serves as an evidence-based reviewer for the JOurnal of the American Dental Association and has had numerous peer-reviewed publications.

 

Oral Health: A Window To Drug Addiction

Monday, October 8th, 2012

By: Victor J. DeNoble, Ph.D. & Kimi F. DeNoble, MS

Research has shown that oral health problems are very common among people who are addicted to drugs.  Many abused drugs produce chronic tooth decay, cracked teeth, gingivitis and other forms of gum disease.  For example, alcohol is high in sugar which contributes to an increase in tooth decay and frequent chronic consumption can de-mineralize tooth enamel.  Stimulants like ecstasy, amphetamines or cocaine cause severe clenching and grinding of teeth, as well as dry mouth when the individual is under the influence of the drug.  Users of stimulants are also known to have a high intake of sugar.  This combination of side effects can cause serious tooth decay.  Methamphetamine prevents saliva from being produced that results in a condition called “meth mouth” which is characterized by discoloration, rotting and broken teeth, as well as  extreme tooth decay.  The chemical composition of methamphetamine includes a wide range of highly toxic chemicals such as lithium, and muriatic and sulfuric acids all of which are highly corrosive.  Tobacco can cause a wide range of oral problems such as delayed wound healing, sinusitis, soft tissue damage and oral cancer.

Because the relationship between substance abuse and oral pathology is well documented, the dental visit can provide the ideal setting for drug abuse identification and intervention.  In addition, having an understanding drug addiction will assist dental professionals in making decisions when medications with potential for abuse are being considered as part of the overall treatment paradigm for these patients.

Years ago, drug addiction was viewed as a character flaw, an inability to control one’s own behavior.  Today, we know that drug addiction is a disease.  Further, it is a self-inflicted disease; no one addicts us, we addict ourselves.  The motive for drug addiction varies from person to person but the decision to use and eventually abuse the drug is still an individual choice.  Drug addiction is not an event that happens all at once.  It’s a biochemical process that takes time and will eventually result in long-term changes in brain function.  These changes are the underlying mechanism for compulsive drug abuse.  The time it takes to complete this biochemical change varies for each drug.  For some drugs like methamphetamine or crack cocaine, the brain changes can occur in one to three weeks. However, with other drugs such as alcohol or tobacco, the process can take several months.  No matter how long or short the process is the first time, re-addiction for all drugs is fast – – sometimes it can occur within a day.  Therefore, once you are addicted to a drug, you are at risk for re-addiction for the rest of your life.  This makes the choice of pain management medication in dental and medical procedures more difficult.

Everyone is born with specific areas of the brain that recognize and respond to addictive drugs; therefore no one is immune from addiction.  In fact, we are all at risk for addiction.  Once an addictive drug enters our blood, it will be transported to the brain and the process of altering brain function begins.  But why do people use addictive drugs?  Simple.  Addictive drugs make us feel good, at least for a brief period of time.  The major neurotransmitter mediating the addictive process is dopamine.  Dopamine has a wide range of functions in the brain, however, the feeling of happiness is mediated in the mesolimbic system. The mesolimbic system is commonly called the “pleasure center”.  When dopamine levels are normal, we feel comfortable.  If they fall, we can be depressed and, if they rise sharply, we can experience euphoria.  All drugs that are addicting change the way dopamine functions in the mesolimbic dopamine system.  The mechanism for dopamine alteration for each addictive drug is different.  These different mechanisms explain why we can be addicted to several drugs at the same time.  Unlike the normal release of dopamine, when drugs are used to activate this system the resulting dopamine response goes far beyond what the system is supposed to produce and the process of addiction begins.

Addictive drugs make us feel good but the feel good feature of these drugs does not lead to health problems.  Aside from the oral manifestations, these drugs have a wide range of pharmacological side effects that have  other health consequences.  For example, cocaine makes us feel good for about 40-60 minutes, however, the side effects of cocaine put the user at risk for potential life threatening conditions for days.  Atrial fibrillation induced by cocaine has been shown to last for up to 3 days whereas cocaine is metabolized and excreted within 24 hours.  Cocaine renders the addict at risk for heart attacks, strokes, kidney failure and pulmonary embolisms.  Each addictive drug has its own constellation of unique side effects that can be further reviewed at the National Institute of Drug Abuse website.

Research has shown that drug addiction results in dental complications many of which will appear before other less visible complications, e.g., organ failure.  Since many Americans visit their dentists more often than they visit their physicians, dental professionals have an increased likelihood of detecting drug abuse and therefore an increased potential for intervention.

 

Dr. DeNoble has a Doctorate in Experimental Psychology from Adelphi University, NY and two postdoctoral fellowships from NIAAA and NIDA.  He was recruited by Philip Morris to study the behavioral and physiological effects of nicotine on the brain.  He subsequently conducted drug discovery research in CNS diseases for the pharmaceutical industry.  In 1994, after a congressional release from a confidentially agreement with Philip Morris, he testified before Congress and became a key witness in the federal government’s case against the tobacco industry. Currently, he is the Vice President of Hissho, Inc., a scientific and medical communications company.

Forensic Dentistry

Monday, July 23rd, 2012

By Dr. James Wood, DDS

Forensic Dentistry. It isn’t exactly what you see on “CSI” or “NCIS.” There is no way to be out in the field with skeletal remains, dictate the fillings to some federal agency and magically have an identity in seconds. There is no international repository of teeth that would allow us to match them up to a bitemark.

Forensic Dentists assist law enforcement, coroners, and the legal system in a variety of ways – dental identification, bitemark analysis, documentation of injuries, fraud investigation. The lion’s share of the work is in the realm of human identification by dental means.

The most critical information necessary to assist a forensic dentist in a dental identification is complete and accurate antemortem (before death) records. I can’t stress enough how important these records are – especially original dental xrays and charting. Since we are dealing with often minute details original xrays make a huge difference in comparing boney trabeculae, the floor of the sinus, even an overhang of restorative material, or calculus. We don’t serve to critique anyone’s dentistry and I only use the records to make an identification. When a law enforcement agency, coroner or medical examiner requests your records you should copy them for yourself and submit the originals. HIPPA no longer applies when this request is made. If you elect to resist the request, the agency will return with a court-order – probably in the middle of your day with a reception room full of patients……… Consider the family of the deceased that is looking for answers. With good antemortem records and sufficient postmortem remains to examine and compare to, an identification can happen very quickly in most cases. This saves the investigating agency significant time and resources and helps the family begin the process of closure on their loss.

People often ask me how they can get into the field of Forensic Dentistry. My first response is always the same – get as much education in the field as you can. There are a variety of educational opportunities available. A good place to start looking for courses is through the American Society of Forensic Odontology (ASFO.org). This is the entry level organization for forensic dentists (or odontologists) and has an annual meeting in conjunction with the American Academy of Forensic Sciences (AAFS.org). There are some excellent courses out there and the costs are very reasonable. Once you have some background education you become more than someone just looking over the shoulder in an autopsy – you become a potential resource.

No television show can ever really capture the essence of or prepare you for examining a deceased person. It can be overwhelming to all of your senses. Those of us who perform this work on a regular basis have learned to compartmentalize a lot of things to deal with the individual cases we work on. However, it is one of the most professionally rewarding things that I do in the practice of dentistry.

 

Dr. Wood is a graduate of Loma Linda University of Dentistry.  He has maintained a family practice in Cloverdale since 1987. Dr. Wood is a Forensic Dental Consultant to six northern California counties and the California Department of Justice Missing/Unidentified Persons Unit. Dr. Wood was a co-found of the California Dental Identification team. He is also a member of the Federal Disaster Mortuary Operational Response Team. Dr. Wood is an active member of his community. He is a member of the Healdsburg City Council and served as the mayor in 2012.

Trends in Endodontic Therapy: Regenerative Endodontics

Monday, June 25th, 2012

By Aaron Welk, D.M.D.

One of the challenges in endodontics is the treatment and management of an immature tooth with a necrotic pulp.  Traditional treatment approaches include creation of a hard barrier which root canal filling material can be obturated against.   This root end closure procedure is called apexification.  Calcium hydroxide apexification is a procedure that allows for the induction of a hard tissue barrier apically [1].  One of the disadvantages of this approach is it can take a many months for the barrier to form.

The introduction of Mineral Trioxide Aggregate (MTA) in the 1990’s allowed for a similar approach [2] to creating apical barriers in a timelier manner [3].  With MTA apexification, an immediate barrier could be placed.   Both calcium hydroxide and mineral trioxide aggregate have been proven clinically, but with the absence of continued root development, both techniques leave the roots with thin dentin walls and short overall root length, leaving the tooth more susceptible to failure due to root fracture [4].

Regenerative endodontics is a contemporary approach to addressing this problem.  This procedure uses tissue engineering principles in facilitating the continued growth and development of the pulp-dentin complex.  In other words, when you have a case with an immature apex and necrotic pulp, regenerative endodontics allows for continued root development, thicker dentin walls, longer root length, and a closed apex, thus reducing the risk of fracture during tooth function.

Success is dependent on the activity of a newly identified population of stem cells, the so-called stem cells from apical papilla (SCAP) (Fig. 23-38) [5], a hidden treasure with enormous potential for tissue regeneration and bioroot engineering [6].

 

All immature teeth with open apices may be considered candidates for regenerative treatment, even if they have obvious pulp-space infection, a discharging sinus, or have been previously root canal treated [7].

Bioengineering has a tremendous potential in dentistry.  Researchers continue to optimize scaffolds that may encourage revascularization of the pulp space, and to explore the options of seeding cell populations into the properly sterilized pulp spaces of immature teeth [8].  Dentistry’s call for action has never been louder as we seek effective, biologically based treatments for our pediatric patients.  If you have questions about pulp regenerative procedures, I encourage you to contact your local endodontist to discuss this topic.

The pulp regeneration procedure is as follows [9]:

Case Selection

  • Tooth with necrotic pulp and an immature apex
  • Pulp space not needed for post/core, final restoration
  • Compliant patient
Informed Consent
  • Two (or more) appointments
  • Use of antimicrobial(s)
  • Possible adverse effects: staining of crown/root, lack of response to treatment, pain/infection
  • Alternatives: MTA apexification, no treatment, extraction (when deemed nonsalvageable)
  • Permission to enter information into AAE database (optional)
First Appointment
  • Local anesthesia, rubber dam isolation, access
  • Copious, gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility of extrusion of irrigants into the periapical space (e.g., needle with closed end and side-vents, or EndoVac). To minimize potential precipitate in the canal, use sterile water or saline between NaOCl. Lower concentrations of NaOCl are advised, to minimize cytotoxicity to stem cells in the apical tissues
  • Dry canals
  • Place antibiotic paste or calcium hydroxide. If the triple antibiotic paste is used: 1) consider sealing pulp chamber with a dentin bonding agent [to minimize risk of staining] and 2) mix 1:1:1 ciprofloxacin:metronidazole:minocycline
  • Deliver into canal system via Lentulo spiral, MAP system or Centrix syringe
  • If triple antibiotic paste is used, ensure that it remains below CEJ (minimize crown staining)
  • Seal with 3-4mm Cavit, followed by IRM, glass ionomer cement or another temporary material
  • Dismiss patient for 3-4 weeks
Second Appointment
  • Assess response to initial treatment. If there are signs/symptoms of persistent infection, consider additional treatment time with antimicrobial or alternative antimicrobial.
  • Anesthesia with 3% mepivacaine without vasoconstrictor, rubber dam, isolation
  • Copious, gentle irrigation with 20ml EDTA, followed by normal saline, using a similar closed-end needle.
  • Dry with paper points
  • Create bleeding into canal system by over-instrumenting (endo file, endo explorer)
  • Stop bleeding 3mm from CEJ
  • Place CollaPlug/Collacote at the orifice, if necessary
  • Place 3-4mm white MTA and reinforced glass ionomer and place permanent restoration
Follow-up
Clinical and Radiographic exam:
  •  No pain or soft tissue swelling (often observed between first and second appointments
  • Resolution of apical radiolucency (often observed 6-12 months after treatments
  •  Increased width of root walls (this is generally observed before apparent increase in root length and often occurs 12-24 months after treatments
  • Increased root length

Dr. Welk is a 1998 graduate of the OHSU School of Dentistry.  He received his specialty certificate in endodontics in 2002 from OHSU.  Dr. Welk is a Diplomate of the American Board of Endodontics.  He is past-president of the Oregon State Association of Endodontics, past-president of the Clackamas County Dental Society, and currently serves on the board of trustees for the Oregon Dental Association.  He maintains a private practice in West Linn, Oregon.

 

 

 

1.  Attala MN, Noujaim AA: Role of calcium hydroxide in the formation of reparative dentin. J Can Dent Assoc  1969; 35:267.

2.  Tittle KW, Farley J, Linkhardt M, Torabinejad M: Apical closure induction using bone growth factors and mineral trioxide aggregate. J Endod  1996; 22:198.(abstract #41)

3.  Pradham DP, Chawla HS, Gauba K, Goyal A: Comparative evaluation of endodontic management of teeth with unformed apices with mineral trioxide aggregate and calcium hydroxide. J Dent Child  2006; 73:79.

4.  Andreasen JO, Farik B, Munksgaard EC: Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol  2002; 18:134.

5.  Hargreaves KM, Law AS. Regenerative Endodontics. Chapter 16. Pathways of the Pulp 10th ed. Eds, Hargreaves KM, Cohen S. Mosby Elsevier, St Louis, MO, 2011: 602-19.

6.  Huang G T-J, Sonoyama W, Liu Y, Liu H, Wang S, Shi S: The hidden treasure in apical papilla: the potential role in pulp/dentin regeneration and bioroot engineering. J Endod  2008; 34:645.

7.   Iwaya S, Ikawa M, Kubota M: Revascularization of an immature permanent tooth with apical periodontitis ands inustract. Dent Traumatol  2001; 17:185.

8.  Murray PE, Garcia-Godoy F, Hargreaves KM: Regenerative endodontics: a review of current status and a call for action. J Endod  2007; 33:377.

9.  Considerations for Regenerative Procedures.  www.aae.org.  web.  11 Jun. 2012