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DENTAL ABSTRACTS

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VOLUME 71, NUMBER 3, MAY/JUNE 2026

DENTAL ABSTRACTS Volume 71, Number 3, May/June 2026

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DENTAL ABSTRACTS The new, online home just for dentistry professionals DentalAdvance.org is the gateway offering high-quality research, news, jobs and more for the global community of dental professionals.

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Abstract Writer Elaine Steinborn © May 2026, Elsevier Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher.

Publication Information Dental Abstracts (ISSN 0011-8486) is published bimonthly by Elsevier Inc.,1600 John F. Kennedy Boulevard, Suite1818 Market Street, Philadelphia, PA 19103, United States. Months of publication are January, March, May, July, September, and November. Customer Service Office: 11830 Westline Industrial Drive, St. Louis, MO 63146. Periodicals postage paid at New York, NY, and additional mailing offices. Annual subscription rates for 2018 (domestic): $144.00 for individuals and $71.00 for students; and (international) $194.00 for individuals and $105.00 for students. USA POSTMASTER: Send address changes to Dental Abstracts, Elsevier Health Sciences Division, Subscription Customer Service, 3251 Riverport Lane, Maryland Heights, MO 63043. Copyright 2026 by Elsevier Inc. All rights reserved. Dental Abstracts is a trademark of Elsevier Inc. Dental Abstracts is a literature survey service providing abstracts of articles published in the professional literature. Every effort is made to ensure the accuracy of the information presented in these pages. Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editors or the publisher. The Editors and the publisher disclaim any responsibility or liability for such material. Mention of specific products within this publication does not constitute endorsement. All inquiries regarding journal subscriptions, including claims and payments, should be addressed to: Elsevier Health Sciences Division, Subscription Customer Service, 3251 Riverport Lane, Maryland Heights, MO 63043. Tel: 1-800-6542452 (U.S. and Canada); 314-447-8871 (outside U.S. and Canada). Fax: 314447-8029. E-mail: support@elsevier.com (for print support); support@elsevier.com (for online support). Notice: Journals published by Elsevier comply with applicable product safety requirements. For any product safety concerns or queries, please contact our authorized representative, Elsevier B.V., at productsafety@elsevier.com or Radarweg 29, 1043 NX Amsterdam, Netherlands.

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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments contained herein. Health care practitioners must exercise their professional judgement and make all treatment-related decisions based solely on the specific conditions of each patient. Because of rapid advances in the medical sciences, independent verification of diagnoses and drug dosages should always be made. The content is provided “as-is” and Elsevier makes no representations or warranties, whether express or implied, as to the accuracy, completeness, or adequacy of any content. To the fullest extent permitted by law, Elsevier assumes no responsibility for any damages, adverse events, or liability arising from use of information contained herein including for any injury and/or damage to persons or property, whether as a matter of product liability, negligence or otherwise. Inclusion of any advertising material in this publication does not constitute a guarantee or endorsement of the quality or value of such product or service or of any of the representations or claims made by the advertiser. Printed by Sheridan at 450 Fame Avenue, Hanover, PA 17331

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DENTAL ABSTRACTS A SELECTION OF WORLD DENTAL LITERATURE Editorial Board Editor-in-Chief Douglas B. Berkey, DMD, MPH, MS Professor Emeritus, School of Dental Medicine, University of Colorado, Aurora, Colorado

Associate Editor Daniel M. Castagna, DDS Associate Professor, Department of Preventive and Restorative Dentistry, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California P. Mark Bartold, DDSc, PhD, FRACDS(Perio) Professor Emeritus School of Dentistry, University of Adelaide Adelaide, Australia Rob Berg, DDS, MPH, MS, MA Professor and Chair, Department of Applied Dentistry, University of Colorado School of Dental Medicine, Aurora, Colorado Tyler H. Berkey, DMD General Dentist Aurora, Colorado Fiona M. Collins, BDS, MBA, MA Consultant and Editor, General Dentist Longmont, Colorado

Anthony J. DiAngelis, DMD, MPH Chief of Dentistry, Hennepin County Medical Center, Professor, University of Minnesota, School of Dentistry, Minneapolis, Minnesota Raul I. Garcia, DMD, MMedSc Professor and Chairman, Department of Health Policy and Health Services Research, Boston University School of Dental Medicine, Boston, Massachusetts Michael Schafhauser, DDS General Dentist, St. Paul, Minnesota Joe Verco, DClinDent Paediatric Dentist North Adelaide, Australia

DENTAL ABSTRACTS MAY/JUNE 2026 VOL. 71 No. 3

Commentary Fluoridation Support for community water ﬂuoridation

156

Safety Ethical approach to safety

158

The Front Office

US Dentistry Decline Perspective on dentistry’s future in the US

182

Hands-On Bloodborne Pathogens Diagnosis, treatment, and prophylaxis for newer bloodborne pathogens

184

Business Factors Modifying the business side of dentistry

160

Bruxism Redeﬁning bruxism

187

Branding Following your vision

161

Crown Preps Changes in preps to address problems

189

Consulting Hiring a consultant to improve the business side

162

Drugs Clarifying the use of drugs in dental care

190 193

Retirement Advanced ﬁnancial plans

163

Self-care Take care of yourself as well as your patients

166

Implants Failure of dental implants Surgical, restorative, and aesthetic phases of implant failure Maintaining dental implants Nanotechnology Using nanotechnology in dental situations

201

Orthodontics Anomalies in developing dentition

203

Pain Management Postprocedural pain in dental settings

207 212

Social Media 167 Crafting social media content to represent your practice Stafﬁng Using frameworks to tackle stafﬁng problems

168

The Big Picture Artiﬁcial Intelligence Applications of artiﬁcial intelligence in dentistry

170

Tongue-ties Ankyloglossia management

214

Dental Shame Addressing dental shame and shame competence

174

Toothpaste Homemade oral health products Tooth Avulsion Acronym-based tooth avulsion intervention

215

Domestic Abuse Supporting dental professionals dealing with domestic abuse

175

Special Care Challenges Special Care Dentistry

177

Suicides Dentist suicides in the United States

180

154 Dental Abstracts

Inquiry Antibiotic Prophylaxis 217 Single-shot versus longer regimens for antibiotic prophylaxis Fluoridated Milk Fluoride in milk for adolescents

218

DENTAL ABSTRACTS

MAY/JUNE 2026 VOL. 71 No. 3

Implants Rating aesthetics, function, and cleaning of single dental implants Removal of nonstandard and complex dental implants

220

Maternal Care Dental care for women from preconception through lactation

224

Oral Cancer 229 Investigating oral cancer numbers and outcomes for women Orthodontics Clear aligner therapy evaluation

Extracts 239 Brain health protection through exercise, relationships, and passion Hideki Tojo’s Dentures Carried a Secret Message

Dental World From the Executive Director From the International President From the International President-elect From the International Vice President Section News

e1 e3 e4 e4 e5

230

Periodontal/Systemic Linkages 231 Periodontitis and chronic obstructive pulmonary disease Nonsurgical periodontal therapy and cardiovascular disease Sleep Apnea Mandibular advancement devices to manage severe obstructive sleep apnea

233

Smokeless Tobacco Swedish snus risks for oral health

235

Third Molar Extractions Difﬁculty of extractions related to age, sex, and jaw

237

Notes To facilitate the use of Dental Abstracts as a reference tool, all illustrations and tables included in this publication are now identiﬁed as they appear in the original article. This change is meant to help the reader recognize that any illustration or table appearing in Dental Abstracts may be only one of many in the original article. For this reason, ﬁgure and table numbers will often appear to be out of sequence within Dental Abstracts.

Standard Abbreviations The following terms are abbreviated: acquired immunodeﬁciency syndrome (AIDS), human immunodeﬁciency virus (HIV), and temporomandibular joint (TMJ).

Volume 71 Issue 3 155

COMMENTARY FLUORIDATION Support for community water fluoridation BACKGROUND

PUBLIC HEALTH AND ECONOMIC BENEFITS

Water fluoridation is credited with making substantial reduc tions in caries prevalence in various populations. Some observa tional studies, often conducted in countries other than the United States and using questionable methods, see fluoride exposure as leading to neurocognitive outcomes, including impaired IQ. As a result, community water fluoridation has become a contentious issue, with some states or communities banning or discontinuing the practice. The preponderance of scientific evidence supports the safety and effectiveness of community water fluoridation at the US recommended levels (0.7 ppm). An examination of the evidence of a fluoridationneurodevelopmental link, the public health and economic bene fits of fluoridation, the ethical and policy perspectives, and the role of the dental team in educating patients regarding the safety and benefits of fluoride in addressing caries was offered.

Health Benefits Studies spanning decades show that water fluoridation reduces caries in children by about 35% and in adults by 26%, even with the widespread use of fluoride toothpaste. Often disadvan taged populations benefited most because they are at higher risk for developing dental disease and have limited access to oral health care. In real-world rollbacks of water fluoridation, evi dence shows a significant increase in childhood caries within a few years. Calgary, Alberta, Canada removed fluoride from its water supply in 2011, but the significant increase in childhood caries over the next few years led to its reimplementation in 2025.

FLUORIDATION-NEURODEVELOPMENTAL LINK A 2012 meta-analysis triggered controversy over the use of fluo ridation and the risk for neurodevelopmental harm, showing a slight reduction in IQ scores in children living in high-fluoride ru ral areas of China. In this and subsequent studies, researchers included studies from areas having fluoride concentrations in water that often surpassed 4.0 ppm. In addition, there are envi ronmental toxins found in China, India, and Iran that can add to the exposure risk. Researchers have found that high fluoride levels in these regions are often teamed with high levels of arsenic, iodine, aluminum, and other ions that can affect neuro development, but most research did not adequately account for these co-exposures. A robust cohort study in 2025 indicated no significant difference in IQ between people exposed to fluori dated and non-fluoridated water during childhood (Table). Among the studies identified as offering unclear analyses of sta tistics and methods and not linking neurodevelopmental harm only with higher exposure levels, researchers also found a lack of rigorous exposure assessment, a high risk of bias, and evalua tions using environmental contexts not representative of fluori dated communities in the US.

156 Dental Abstracts

Economic Benefits A European study in 2009 found the lifelong costs of oral health care were 75% lower with fluoride interventions (including fluo ridated salt, toothpaste, and gels) than without, with costs of about $218 to $338 with fluoride and about $10,254 without it. It was shown that the use of population-wide fluoride inter ventions offers the best cost-to-benefit ratios. A cost-effectiveness analysis in 2025 using data from the Na tional Health and Nutrition Examination Survey projected out comes if fluoridation was removed from US public water systems. Over 5 years, the model predicted 25.4 million addi tional teeth would develop caries, 2.9 million quality-adjusted life-years would be lost, and $9.8 billion would be spent on dental treatment. Over 10 years, costs would double, with the burden falling disproportionately on publicly insured and unin sured children.

ETHICAL AND POLICY PERSPECTIVES Policy reversals based on inaccurate research regarding water fluoridation can come at a high cost in terms of health and eco nomics. Ending community water fluoridation is health negli gence but also is fiscally and morally irresponsible because of

Table. Fluoride Levels in Drinking Water in IQ Studies Abroad vs Community Water Fluoridation Levels in the United States STUDY

LOCATION

FLUORIDE LEVEL,* PPM, MEAN (RANGE) OR MEAN

POPULATION CONTEXT

NOTES

Mostly in poor rural areas with endemic fluorosis in China 20-30 y earlier

Found slightly lower IQ in endemic areas with 3.7 ppm fluoride than in areas with 0.7 ppm fluoride

Controlled community water fluoridation

No IQ difference between fluoridated and nonfluoridated groups

Controlled municipal water supply

Environmental Protection Agency maximum contaminant level: 4.0 ppm; safety level: 2.0 ppm; optimal level: 0.7 ppm

International studies with fluoride levels comparable with community water fluoridation

Found no significant association of fluoride with lower IQ at 0.9ppm level

Choi and Colleagues, 2012

Meta-analysis of 27 cross sectional studies (25 in China, 2 in Iran)

Broadbent and Colleagues, 2015

New Zealand cohort

Boehmer and Colleagues, 2023 New Zealand cohort

United States

Kumar and Colleagues, 2023

Meta-analysis of 8 studies in China, India, Mexico, New Zealand, Canada, and Spain

Do and Colleagues, 2025

Australian cohort

0.8-1.1 0.3-0.7 [Reference: 0.0]

Population-based birth cohort

No adverse cognitive effects found with early fluoride exposure at < 1.2-ppm level

Taylor and Colleagues, 2025

Meta-analysis of 34 studies (21 in China, 5 in India, 4 in Iran, 2 in Canada, 1 each in Pakistan and New Zealand)

5.9 (4.6-8.3) [Reference: 1.0 (0.5-2.0)] 2.38 (0.6-4.1) [Reference: 0.6 (0.1-1.1)] 1.6 (0.6-2.0) [Reference: 0.6 (0.1-1.1)] 1.0 (0.6-1.4) [Reference: 0.3 (0.1-0.6)]

Similar to Choi and colleagues, with updated literature and stratification of water fluoride levels into < 4 ppm, < 2 ppm, and < 1.5 ppm Water fluoride levels were > 4.6 ppm (mean, 5.9 ppm) in at least 6 studies and 24 of the 34 studies were rated as highly biased

Found slightly lower IQ in areas with fluoride at 4-ppm level than in areas at 0.6-ppm level No association of fluoride with lower IQ at < 1.5-ppm level.

3.7 (0.9-11.0) [Reference: 0.7 (0.3-1.8)]

0.7-1.0 [Reference: 0.0-0.3]

0.7

0.9 (0.6-1.2) [Reference: 0.3 (0.1-0.6)]

Volume 71 • Issue 3 • 157

* Mean (range) or range of fluoride levels calculated from the reports included in the meta-analyses or reported in individual studies. (Courtesy of Ren et al., 2026 (Courtesy of Ren Y, Ross LF, Xiao J, et al: Defending community water fluoridation. J Am Dent Assoc 157:204-207, 2026.)

its significant negative impact on young children from under served families. In addition to fluoridation or even without it, robust preventive services can be instituted, including universal oral health care access, school-based programs, and routine use of fluoridated toothpaste or salt. The US low-income house holds tend to have limited access to dental services and benefit most from fluoridation. Removing it without implementing alter native services will increase the disparities in oral health. Policy choices need to be informed by well-developed and re searched evidence rather than isolated findings. Regulatory agencies continue to endorse water fluoridation as safe and effective and should not be swayed by findings in rural China or other areas with endemic fluorosis. Additional research is needed that uses better methodological rigor and ensures that the findings are robust, reproducible, and meaningfully applied to the real-world conditions.

DENTAL TEAM’S ROLE Dental teams should be prepared to address misinformation and reinforce the safety and benefits of community water fluorida tion for their patients and families. They can help patients under stand the scientific evidence and the public health implications, especially if they have been confused about the various positions taken in the marketplace. Continuing community water fluorida tion is more than good public health policy, carrying a profes sional obligation for dental care professionals to advocate for evidence-based care. The dental personnel may provide info graphics, fact sheets, and data comparisons, as well as written, oral, and video information aids. They should also engage in shared decision making with patients.

Clinical Significance A quick summary of the information that is based on the best available evidence regarding water fluorida tion includes the following: • Water fluoridation at 0.7 ppm is safe and no credible ev idence ties it to cognitive harm. • Fluoride is highly effective in preventing caries in both chil dren and adults. • Removing water fluoridation will lead to billions of dollars in avoidable treatment costs, along with worsened oral and overall health levels in vulnerable children. • Economic models in many countries affirm fluoride as one of the most cost-effective public health investments available. • Added research should focus on areas of equivocal evidence. • Clinicians can translate public health evidence to those in their communities. Dental care professionals should be well educated so they can address patients who have been misinformed and so they can support effective strategies to prevent caries. Science, ethics, and economics all support the use of com munity water fluoridation.

Ren Y, Ross LF, Xiao J, et al: Defending community water fluori dation. J Am Dent Assoc 157:204-207, 2026 Reprints available from Y Ren, Eastman Inst for Oral Health, School of Medicine and Dentistry, Univ of Rochester, 625 Elmwood Ave, Rochester, NY 14620; e-mail: yanfang_ren@urmc.rochester.edu

SAFETY Ethical approach to safety BACKGROUND

CURRENT STATUS OF SAFETY IN DENTISTRY

The father of safety in health care, Dr. Lucian Leape, passed away in June 2025 after contributing greatly to saving lives and avoiding suffering for patients over many years. Safety in health care and its ethics may have begun with Hippocrates’ urging to “first do no harm,” but, unlike the case in medical practice, dentistry has been slow to move toward quality measures. The current status of the safety focus in dentistry, a proposed system for integrating a safety ethic, and the results of not acting to adopt a quantification of safety measures and to set forth strict repercussions for infractions were discussed.

The American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) is essentially silent regarding safety. The incorporation of safety is generally only seen in conjunction with nonmaleficence. In contrast, the American Medical Association and American Nurses Association both directly address safety in their ethical codes. Dentistry likely can attribute this to their standard structure of practice, with siloed independent dental practices that each have their own organization. However, the absence of a focus on safety means there is little to spur on movement

158 Dental Abstracts

toward addressing patient harm or instituting national guidelines for safety. This absence means dentistry tends to be outside mainstream health care, with state dental boards (SDBs) providing simple gatekeeper functions and addressing problems reactively and based on voluntary reporting instead of the active monitoring of safety elements. When medicine addressed the problems of unintended harm from errors, the charge was led by institutions and not the practice community. A similar path appears to be the likely case for dentistry. Safety initiatives have already been instituted by the American Academy of Pediatric Dentistry and the American Association of Oral and Maxillofacial Surgeons. Outside of dentistry, there are other groups that have addressed the safety aspects of dental practice. However, the penetration into dental practices remains scarce.

PROPOSED SYSTEM TO INTEGRATE A SAFETY ETHIC A list of harm events in oral health care has been proposed as a framework for SDBs. These may provide a pathway to creating harm event identification and mitigation measures. The elements are as follows: Repair the lack of safety in the ADA Code by adding safety measure information and expectations for dentists. These should support positive change, direct education, and encourage practices that will address safety. • Recognize that SDBs must be able to institute ongoing safety monitoring. The entry-level validation of professional qualifications and handling of complaints that form the major tasks of SDBs are insufficient to achieve safety and a quality care ethic, which requires systematic monitoring, reporting, and action. • Develop a hierarchy of harm events and a mechanism to collect, quantify, and report annually the frequency with which these events occur and actions taken in mitigation. This document should be formulated collaboratively under the auspices of the American Association of State Dental Boards and supported through licensing fees. • Establish a national coalition for safety to engage organized dentistry, federal agencies and services already involved in health safety, and SDBs to maintain a current dashboard that can be accessed. Bridging the coalition to practice and •

critical communities could include the participation of the American Dental Association’s Dental Quality Alliance.

REPERCUSSIONS SHOULD DENTISTRY FAIL TO ACT The result of dentistry not adopting quantifications of safety infractions is a diminished stature compared to the rest of health care. The safety focus adopted by the medical health care community has seen success in reducing nosocomial infections and unintended deaths from medical error. SDBs have the structure, authority, and legitimacy to guide dentistry into the safety culture circle in health care. Overall, health is diminished by the lack of a safety ethic and a national safety reporting framework in dentistry. Without this focus, oral health care deprives itself of a learning culture that links existing health care providers and educates new ones. Between patients and physicians, having no ethical safety imperative can lead to compromised care outcomes, poorer patient health, and a fractured physician-patient relationship.

Clinical Significance The efforts of various groups in attempting to move dentistry forward as a safety- conscious and proactive profession are to be commended. Much remains to be done, but patients shouldn’t have to settle for dental care providers who haven’t participated in instituting national quality measurement tools to safeguard patient health and voiced support for the ethical safety principles of the dental profession.

Czerepak C, Casamassimo PS: The ethics of safety. J Am Dent Assoc 157:208-209, 2026 Reprints available from PS Casamassimo, Dept of Dentistry, Nationwide Children’s Hosp, 700 Children’s Dr, Columbus, OH 43205; e-mail: Casamassimo.1@osu.edu

Volume 71 • Issue 3 • 159

THE FRONT OFFICE BUSINESS FACTORS Modifying the business side of dentistry BACKGROUND

LOW INSURANCE REIMBURSEMENT

Both internal and external factors can influence the success of dentistry as a business. It’s important to be aware of the most significant forces that are influencing dental businesses and plan for ways to achieve and maintain a successful practice. Factors that are among the most significant to be aware of and address are economic uncertainty, the decline of solo practice, low insurance reimbursement, the staffing crisis, the growth of dental support organizations (DSOs), and the growth of digital technology and artificial intelligence (AI).

Dental reimbursements have remained static or been reduced, problematic situations that affect the 89% of dental practices who participate in insurance plans. If no increase in reimbursement rates occurs, the profit per procedure decreases because of inflation. Often it’s worthless to negotiate with insurance companies and the exiting plans tend to be associated with a significant decline in production. Insurance companies have one of the most powerful lobbies in the US, so the reimbursements will likely continue to lag behind basic inflation, with adverse effects on profits for dental companies. The best way to deal with flat or low insurance reimbursements is to create a highly efficient practice with excellent systems that can manage higher patient volume.

ECONOMIC UNCERTAINTY Today’s economic uncertainty isn’t like what was experienced in 2008-2009, but rests on new federal trade tariffs and their effect on dentistry and on the overall economy. Even if the tariffs don’t cause significant disruption, at some point in the business cycle the economy will slow. Dentists need to be aware of the first indicators of this slowing, which are greater numbers of no-shows and last-minute cancellations and a decline in case acceptance. Seeing these occur should prompt quick reactions to protect the practice from a decline in economic viability. These include protecting the patient base and referrals by adopting effective practice management strategies. Among these are keeping patients scheduled, providing an outstanding new patient experience, encouraging patients to refer family and friends, and maintaining highly efficient systems. Although uncertainty means something is hard to predict, having excellent systems in place, well-trained dental teams, and a maximum patient flow combine to make it less likely to suffer through a downturn and more likely to continue to have a strong performance if the economy remains strong.

DECLINE OF SOLO PRACTICE Over the past 30 years, the percentage of solo dental practices has been declining, so that it now stands at about 38%. If this trend continues, dentists will need to learn how to manage a partnership with others and engage in group dynamics. The change will require excellent communication, honesty, the ability to compromise, and respect for the goals and desires of others.

160 Dental Abstracts

STAFFING CRISIS Few places in the US have an abundance of dental staff members. Before the 2019 pandemic, staff shortages were present, but the numbers of open positions has skyrocketed since. This includes hygienists, assistants, and front desk team members, and many of these have left the profession, preferring to work remotely. As a result, practices have higher overhead, with some estimating an increase in staffing costs of about 12% over the past 5 years. Practices need to begin training staff to produce revenue that will offset the increase in overhead. Often the employees hired are less skilled than those hired in the past, which can create chaos in the office and stunt the growth of production and profitability. Leadership must be open, honest, and transparent in setting goals for team members and identifying how they will be measured. Missing a goal should not mean an unpleasant conversation but rather a discussion outlining how the goal can be achieved. Additional training should be provided to team members who consistently fail. If the dentist can take care of the team, the team will take care of the dentist.

GROWTH OF DSOs Although there’s room for DSOs and corporate groups to coexist with private practices for many years ahead, private practices need to view DSOs as competition and understand the differences in the marketing approaches of the 2 types of

offices. Some DSOs are well run; others aren’t. Marketing campaigns vary along, as do plans for growth. Often smaller DSOs can be sold to larger DSOs. For private practices to compete effectively, they need to operate with a high level of efficiency, provide excellent staff training, and offer 5-star customer service. Having high customer service levels will attract patients and differentiate the practice from the DSOs. The customer service strategies must be followed for every patient, every day, and with almost no exceptions. With these approaches in place, the numbers of new patients and referrals tend to grow, reviews are glowing, and case acceptance is at a high level. Generally people judge the quality of clinical dentistry more by how they are treated than by the quality of the clinical care that’s performed.

DIGITAL TECHNOLOGY AND AI Implementing technology can increase the practice’s efficiency and quality of care without adding staff. However, it’s wise not to adopt first-generation technology but rather to wait and allow it to become established and prove its value. When considering technologies to add to the practice, the owner should ask if the technology will improve the quality of care significantly; reduce the time required for procedures; make practicing more efficient, easier, effortless, and enjoyable; or provide a satisfactory return on the investment. It’s not important that the technology be able to deliver on all 4 areas, but the owner should ensure that the purchase will be worthwhile. What can AI do? It can provide assistance in diagnosis, treatment planning, surgery, and more; it can remove some pressure

from the practice, especially in the front desk activities; and it may allow for fewer workers to be hired, which lowers overhead and enhances performance. Often practices feel pressured to invest in technologies, but the cost must be considered. Practices should put a technology implementation plan in place, formulated along with reputable sales representatives, so technologies are adopted according to the practice’s priorities of needs and desires.

Clinical Significance Most dental practices will benefit by considering the factors that have been listed. Owners must also consider the degree to which their practice will be affected. A good understanding of what the factors will add and how the practice will benefit is essential. Dental practices today must be well run, use excellent operational systems that are regularly updated, have well-trained teams who are motivated and inspired to deliver optimal care, practice effective communication, and base their decisions on the practice’s needs and potential opportunities.

Levin RP: Six factors that are reshaping the business of dentistry. Inside Dent 21:10-13, 2025 Reprints not available

BRANDING Following your vision BACKGROUND

CREATING A BRAND

When you have a vision of what you’d like to do as an occupation, it may lead you to places you hadn’t expected. A dental practitioner found herself becoming a certified nutritionist to ensure that her patients received minimally invasive techniques that supported the body’s natural healing processes and helped them feel better. Her brand is now focused on integrating natural health with functional medicine to provide a multi-specialty approach to detoxifying the mouth for whole-body health. Creating a brand, moving from mission to mentor and educator, ensuring a consistent patient experience, and maintaining inspiration were all part of her journey to achieve her vision.

The vision of the dental office should reflect a brand that aligns with the values of the dental practice owner. In the case of the practitioner who developed an integrated approach, having a multispecialty approach to detoxifying the mouth for whole body health involved practices such as nutrition plans and advanced technology, along with other aspects of personalized care. The brand should be that feeling patients have when they come into the office. Offices may employ natural essential oils rather than artificial fragrances, serve water that supports detoxification, and use color combinations that reflect harmony. To achieve the right brand will require knowledge of what you believe in and choosing approaches, colors, and practices that reflect those beliefs.

Volume 71 • Issue 3 • 161

BECOMING A MENTOR AND EDUCATOR

MAINTAINING INSPIRATION

With growth, the dentist can find himself or herself stretched thin to ensure that each facility is aligned with the overall mission. At this point, the dentist must become a leader, mentor, and educator. Investments must be made in consultants, operational systems, and allowing others to take on tasks the dentist would have adopted before the growth. Delegating effectively requires the creation of structure and accountability—and the earlier these are implemented, the better it is.

Inspiration is an important part of having an effective approach to care. In keeping patients focused on living longer, healthier lives, it’s important to remain inspired. Undertaking practices such as meditation can help one stay grounded, calm, and connected to one’s purpose. Balance can be maintained by seeing it as a mindset.

BUILDING CONSISTENT PATIENT EXPERIENCES

Dentists can create a practice that they love and not focus so much on paying the bills. It’s essential to begin with a vision, what you are passionate about. If your patients can benefit from it, let that passion shape your creation from the beginning on. Clear roles, systems, and expectations can help to maintain stability.

The turnovers that many practices have experienced since the pandemic have made maintaining a consistent patient experience in multiple offices challenging. The goal is to create an atmosphere that is the same regardless of the location, and having a definitive team culture is essential in achieving this aim. Each month, performance and systems are reviewed. Wellnessbased team events are undertaken to strengthen teams. Managers keep the energy high and the purpose clearly in view. Rather than power and control, leadership is about enrolling others into the vision. An inspired team will take ownership and help grow the mission.

Clinical Significance

Moldovan S: Building a brand you believe in. Inside Dent 21:22, 24, 2025 Reprints not available

CONSULTING Hiring a consultant to improve the business side BACKGROUND Dentistry is not just a profession but also a business. Sometimes a dental practice is in need of information and guidance to improve the business side of the venture so that production, profit, and income are increased and part of a highly efficient environment that functions with little stress or hiccups. If most days aren’t spent being able to focus and practice dentistry without worrying about reaching goals and business tactics, it may be time to enlist the help of a consultant. The dentist/owner should investigate the consulting industry, consider the best time to hire a consultant, and be prepared with questions for the consultant to help a practice function better.

THE CONSULTING INDUSTRY The consulting industry has firms that offer strategies and analysis for any industry, business, or challenging situation. Consultants may be able to help dental practices with certain characteristics, such as having dentists who have little business training in charge; consisting of complex, small business elements with many systems and components as well as the same staffing problems other businesses face; those experiencing problems in dental operations because of no-shows,

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last-minute cancellations, and other roadblocks; and dentist/ owners/staff members who can’t seem to access dental business education sufficiently to put together a comprehensive and easily understood plan. Coupled with these problematic situations are the challenges facing dentistry today, such as flat or lower insurance reimbursements, significant staffing problems, and the rapid changes in clinical techniques and technology. Dentists and staff members can only expend so much time, energy, and creativity in managing all of these challenges while still performing clinical care.

TIMING FOR HIRING A CONSULTANT Although comprehensive consulting programs can help practices grow significantly in a short time span, under certain circumstances the help of a practice management consultant can be especially effective. Before selecting a consultant partner, the dentist and practice must truly commit to follow the advice and guidance offered. If the practice doesn’t follow through with the methods the consulting firm has suggested, the program tends to fail. Dentists/owners should also be aware that the consulting firm selected should fit with the needs of practice and with the culture of the management and care teams.

Among the specific circumstances that indicate that working with a consultant would be helpful are situations dealing with practice improvement, solving a problem, following through on a particular desire of the dentist/owner, making the practice of dentistry more enjoyable, and when making fundamental changes in the practice. Improving the Practice Many elements can contribute to an improved practice. It might be getting more organized, more efficient, and increasing production, profit, and income. Decreased stress is certainly valued. Some consulting firms focus on a single aspect of the practice, whereas others may institute proven systems that can lead to a more universal improvement. Technology consulting firms may help with installing specific equipment or software and how to use it most effectively. The dental practice should decide which firm will help to achieve its goals. Problem Solving Daily problems can interfere with production, profit, and income, or chronic recurring problems may arise through poor leadership. Some of the vital elements of leadership are having a vision, a mission, and goals, with a plan to align the team around them so everyone is moving in the same direction. Meeting a Specific Goal/Desire Comprehensive office manager training may help office managers function at a chief operating officer level. With this role covered, dentists can focus on clinical dentistry. Bringing Back the Joy in Practice Dentistry can be challenging and stressful and last a lifetime. To keep the practice of dentistry enjoyable and engaging, a consulting firm may be able to allow for the pursuit of more fun and fulfillment. Often this joyful aspect increases production and provides a return on investment, even if this isn’t the major goal. Making Fundamental Changes Changes in a dental practice can occur when the dentist’s child becomes a dentist and joins the practice, when an associate is added, when multiple practices are merged, or when a practice

is bought or sold. The practice owner should be careful to choose a consulting firm with areas of practice that fit the situation and not settle for an organization that doesn’t have appropriate skills. This may mean choosing a consultant specifically for the change in practice rather than assume the normal firm will stretch beyond their expertise and produce suboptimal results.

CHECKING THINGS OUT The dentist/owner and perhaps even staff members should ask questions to find out important information about possible consulting firms. Among the basics that should be sought are the length of time the firm has been in business, the number of dental practices they’ve worked with, specific processes they ascribe to, when the practice will be analyzed (beginning, monthly, and end?), the background of the consultants, and where they gained their expertise. It’s also important to determine if they have resources that can be accessed to provide advice and guidance for specific, unique situations. Asking what the expected results of the collaboration will be and ensuring the firm will be able to accomplish the goals established are vital inquiries.

Clinical Significance Consulting firms can help dental practices achieve business results that are supportive of the role of the clinical dentist and staff members. Good firms will explain their process, the results, and how long their services will be helpful. It’s best to set an end to the consulting firm’s participation to avoid becoming dependent instead of learning to become an expert in the tasks of the business side of a dental practice.

Levin RP: When is the right time to engage a consulting firm? Dent Econ 116:10-12, 2026 Reprints not available

RETIREMENT Advanced financial plans BACKGROUND Financial planning considerations can be a concern for dentists, whether they are just starting out as an associate or opening their own practice. Two of these considerations are related to saving for retirement and tax planning. It can be challenging to

find opportunities to optimize retirement savings and manage tax implications. Many feel that once they reach the maximum level of annual savings in a 401(k), they have exhausted their options. Although it’s positive to have the practice and the production grow, earnings also rise, creating more challenges

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Figure 1. How a backdoor Roth works. (Courtesy of Melchiorre K: Filling the gap: Advanced retirement plan strategies for dentists. Dent Econ 116:46-48, 2026.)

for tax minimization. The values that can be managed through some advanced strategies offering the dual benefit of current (or future) tax savings and tax-advantaged growth potential were explained, focusing on a backdoor Roth IRA, a mega backdoor Roth, and a cash balance pension plan.

BACKDOOR ROTH IRA Because dentists have a high level of taxable income, it’s likely that they won’t be able to make regular contributions to a Roth IRA. An alternate strategy is the use of a backdoor method (Figure 1). In this approach, the dentist makes a nondeductible contribution to a traditional IRA, leaves the funds in cash or a money market fund in the IRA for a reasonable duration, and then converts the balance to a Roth IRA. If there are no earnings during the period the contribution is in the IRA, the conversion is nontaxable. This approach doesn’t save on taxes today, but helps save on future taxes. In traditional IRAs and pretax 401(k) accounts, funds grow tax deferred but will be taxed when withdrawn in

retirement. Assets in a Roth IRA grow tax free and distributions in retirement are tax free as long as the account has been open and funded for at least 5 years and the holder is over age 591/2 years. In addition, required distributions for persons in their 70s don’t apply to Roth IRAs. Dentists should coordinate with their financial advisor or tax preparer about backdoor Roth accounts because of the pro-rata rule. Having any pretax IRA accounts already in existence may make some portion of the converted amount of the backdoor Roth taxable.

MEGA BACKDOOR ROTH The mega backdoor Roth allows high-earning dentists to save amounts beyond the annual Roth IRA maximum in Roth accounts. To make it work, dentists must incorporate their 401 (k) and must ensure it allows for after-tax contributions, providing a way to convert those funds to a Roth. After-tax contributions don’t offer the same tax-free growth as a Roth, but the contributions can exceed the standard deferral limits and can be converted. Technically, it’s possible to defer the maximum but then make added after-tax contributions exceeding that. With

Figure 2. Benefits of using a cash balance plan. (Courtesy of Melchiorre K: Filling the gap: Advanced retirement plan strategies for dentists. Dent Econ 116:46-48, 2026.)

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Figure 3. Pros, cons, and ideal candidates for a cash balance plan. (Courtesy of Melchiorre K: Filling the gap: Advanced retirement plan strategies for dentists. Dent Econ 116:46-48, 2026.)

respect to in-service distributions, this approach offers the ability to withdraw or roll over the 401(k) account assets while still employed. Dental practice owners may also be able to customize the 401(k) plan to permit these features even if they aren’t already in the plan. This is possible for owners who are launching a new 401 (k) plan or who want to update the documents and design of their existing plan. The practice’s 401(k) plan provider (specifically the third-party administrator) should be consulted as well. The mega backdoor Roth strategy involves a degree of complexity, and the 401(k) plan must allow for both after-tax contributions and a way to move funds from after-tax instruments to a Roth. It’s wise for the dentist to consult with a financial advisor and/or tax professional if this seems like an approach he or she would want to try.

CASH BALANCE PENSION PLAN Although it’s not as well-known as the other plans, the cash balance pension plan offers a powerful option. This specialized retirement plan can supercharge the dentist’s retirement savings but also potentially provide a significant tax benefit for each year of contribution. This is a hybrid of defined benefit (DB) and defined contribution (DC) plans, carrying the usual DB

requirements but functioning more like a DC plan with higher contribution limits. Dentists can potentially triple or quadruple their annual retirement savings and receive a tax deduction for the business (Figure 2). Not all types of businesses will qualify for these plans, with professional service businesses with high, recurring cash flow being best suited for them (Figure 3). Businesses with 15 or fewer employees are generally the optimal candidates.

Clinical Significance Advanced strategies such as those outlined may help dentists plan for short-term and long-term financial situations. Consultations with a financial planner and tax professional are needed to ensure the plan aligns with the dentist’s specific situation and is suited to his or her goals.

Melchiorre K: Filling the gap: Advanced retirement plan strategies for dentists. Dent Econ 116:46-48, 2026 Reprints not available

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SELF-CARE Take care of yourself as well as your patients BACKGROUND The American Dental Association (ADA) Council on Communications Trend Report noted that over 80% of dentists were experiencing major career stress in 2024. Health care workers who are fatigued and stressed out can have trouble concentrating, making accurate diagnoses, and being attentive, which can result in errors. Burnout also causes medical errors and infections. In contrast, health care workers whose physical, mental, and emotional status is well cared for are less likely to become fatigued, stressed, or suffer burnout. Self-care is an essential for health care workers, including dental staff members, as well as for their patients. The physical and mental toll of burnout, the impact of dentist self-care, and developing a sustainable self-care routine were described.

PHYSICAL AND MENTAL TOLL OF BURNOUT Dental work can contribute to the development of physical pain in the shoulders, neck, back, hips, joints, and feet. In addition, dental care can cause stress or frustration, worry and anxiety, a loss of ambition, depression, and mental exhaustion. Nearly a third of those surveyed have noted, however, that providing dental care can positively impact the caregiver’s health. This was explained as the result of seeing patients being a desire in caregivers to take better care of their own health and motivating them to include healthy habits in their own life.

IMPACT OF DENTIST SELF-CARE Having a career in dentistry allows the dentist to exert a positive impact on patients’ physical and emotional well-being. Patients observe their caregivers to detect signs of wellness or poor health, making judgments based on what they see that can affect how they view their care and feel about the doctor-patient interaction. If the dentist isn’t taking care of himself or herself, patients can sense his or her burnout, perhaps even let it influence their own health. Providers who are more satisfied with their work are likely to deliver better patient care and be more motivated to make the effort for their patients.

Habitually putting others’ needs ahead of your own can lead to resentment and burnout. You must make a commitment that you are confident you can keep. Maintain the attitude that you are worth it. Set a schedule, but don’t stress over it. If time doesn’t allow a trip to the gym before or after work, substitute stretching for 5 minutes before leaving for work in the morning, taking a walk at lunch time, or breathing mindfully at any time during the day. Promising yourself and following through will boost trustworthiness and self-confidence. The program doesn’t have to include professional massages, pedicures, or pampering and needn’t be expensive or timeconsuming. Self-care begins with self-awareness, so it’s good to ask what you need right now. If you’ve just completed a complex dental procedure, you may need a drink of water, a stretch, sitting with your eyes closed, or eating a healthy snack. At meal times, plan ahead and pack a nutritious meal and eat it mindfully. When you get home, hydrate with a glass of water, go outside, play with your children or pets, or call a friend to wind down after work. Building a Sustainable Routine Planning a self-care routine should address the physical, mental/ emotional, social, and spiritual facets of your life. In the physical realm, focus on regular exercise and movement, nutrition and hydration, and physical self-care strategies such as quality sleep and rest. Good sleep hygiene should include no alcohol or vigorous exercise within 3 to 4 hours before bed, refrain from eating at least 2 to 3 hours before sleep, and avoid blue light/screen time for an hour before bedtime. The same bedtime and wake time should be observed on weekends as well as weekdays to help your brain and body recognize when it’s time to rest.

DEVELOPING A SUSTAINABLE SELF-CARE ROUTINE

In the mental/emotional realm, sleeping for 7 to 8 hours a night without interruptions will allow the parasympathetic nervous system to process the stress you’ve accumulated over the day. Restorative sleep minimizes the impact of anxiety or depression and improves the ability to focus. Engaging in hobbies and leisure activities helps to channel the intensity of dentistry into mindfulness, which releases stress and is soothing.

Getting Started The beginning of a self-care program is your recognition that you deserve time, care, and attention and should listen to self-talk.

Social self-care consists of building connections and relationships inside and outside of the dental practice. Dates to meet with

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friends, loved ones, family, or others show that you value them. This connection to others provides mutual support and validation. Engaging in community activities, such as donating time or skills and talents, can provide added meaning to your life. The spiritual realm involves setting aside time to feed your soul, whether that be in a place of worship, in nature, or in any other space that buoys you up. Regular reflection through journaling and practicing gratitude also feed your spirit.

Clinical Significance Practicing self-love and self-care is an essential part of being a healthy human being. Creative ways to work self-care activities into your day can be easier and more accessible than you might think. Taking a few minutes to breathe, hydrate, stretch, and practice mindfulness requires very few resources and can translate to ways to bring your best self to your dental care activities.

Garceau R: Self-care isn’t selfish—it’s clinical. Dent Econ 116:18-20, 2026 Reprints not available

SOCIAL MEDIA Crafting social media content to represent your practice BACKGROUND Artificial intelligence (AI) is changing how people look for and assess dental practices. Instagram posts and Facebook content provide sources for AI references when someone searches for a dentist to care for their oral health needs. Instead of speaking with front desk workers, people ask AI for information and don’t contact the dental office until they have an answer from the digital source. If dentists ignore this shift in the search pattern for dental care, it’s possible that AI will never know that some practices exist. Discovering AI’s patterns, understanding its blind spots, and taking practice steps to add your content to AI’s sources will help to put your dental practice on the list of offices future dental patients may be seeking. Several steps can be taken to craft useful AI fodder that represents your practice. Testing the practice’s current AI visibility, planning a long-term commitment, and building an AI-optimized strategy are additional measures to take.

AI PATTERNS, BLIND SPOTS, AND CONTENT AI Patterns Those searching for a dentist are most likely to ask about dental care for their particular dental problem in their search. Normal searches produce a long list of dentists. In contrast, AI tools synthesize information to provide singular comprehensive responses. The searcher receives the responses, but your practice may or may not be listed. The AI algorithm references available online information that is found in social media activity, patient testimonials, educational content, and community engagement to create an assessment of trustworthy practices.

Blind Spots AI is unable to actually see the photos, videos, or promotional graphics. Instead, it relies on written descriptions. Unless a detailed written description accompanies videos or beforeand-after photographs, AI can’t include them in any responses. Even a 2-sentence description can be used by AI to serve as a reference or recommendation. Content for Your Practice It’s not necessary to completely redo your social media approach. Instead, you should become more strategic about making your expertise visible to humans and algorithms. This can be accomplished by creating original insights, documenting community connections, and answering questions patients actually ask. Sharing observations from actual practice experiences gives AI something unique and valuable to reference when building comprehensive answers to dental care questions. Documenting insights is much more useful and more likely to be selected than advice such as “don’t forget to brush your teeth and floss.” Participating in local health fairs, school dental education programs, or charity events is proof of a commitment to community health. This establishes credibility when AI assesses your practice’s trustworthiness. Any pictures should have detailed captions that explain the practice’s involvement and the impact of the intervention.

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During appointments the dentist should pay attention to the questions patients ask. They may ask about what makes their teeth hurt when they eat ice cream or how long their implant will last, or whether whitening their teeth is safe. These concerns from real patients are perfect for social media content and provide AI with helpful content to use when similar concerns arise in chatbot conversations.

Build an AI-optimized Strategy It’s important to be consistent. Placing 1 well-crafted and informative post each week that focuses on your expertise or a community event is better than daily generic posts. The content should be substantial enough to lead AI into referencing it when building answers about dental care in your area.

STEPS TO CRAFT AN AI IMPRESSION

Clinical Significance

Test Your Current AI Visibility Before jumping into content creation, it’s wise to evaluate your current position in the AI world. A quick exercise involves opening ChatGPT and searching for information about your practice. You might ask about the practice directly, ask about yourself as a dentist, or look into the services provided. You can discover gaps in the AI listing or find yourself absent from the directory listings. You should then create content so potential patients can obtain meaningful information about your approach to patient care, specialty offerings, or community involvement. Any absence of detailed responses should be addressed.

Dentists need to remember a few things when using AI. First, AI values depth and authenticity over frequency and superficial engagement. Including a detailed explanation of your approach is more valuable than dozens of reminders about tooth brushing. Second, the social media content should reflect the care and attention to detail that characterize your patient treatment. Third, each post is an opportunity to educate, reassure, or connect with your community. In addition, dentists need to remember that AI doesn’t care if you get 10,000 likes or 3 likes. Viral content is irrelevant to AI’s view of your trustworthiness. You should be authentic and give genuinely helpful information that actual patients will value. Relax, be yourself, and serve your community.

Long-term Commitments As AI tools become more sophisticated and adopted more widely, they will be used more in health care decision making. Dental practices that adapt to this change now may have significant advantages over practices that put this off. Success in this new world includes documenting existing strengths in ways patients and AI can understand and value.

Lefler A: Why dental practices need to rethink social media in the age of AI. Dent Econ 116:28-30, 2026 Reprints not available

STAFFING Using frameworks to tackle staffing problems BACKGROUND Employee turnover has a negative effect on profitability, incurring costs for recruitment, training, and going through the hiring process. Offices can undergo challenges in terms of the culture of the workplace, faulty decision-making, insecurity, and difficulty breaking unhealthy habits. Often leaders don’t understand the underlying causes of organizational failure and target individuals while ignoring large system failures. Leaders need to view their organizations through the lens of various frameworks to better manage problems. Within the various frameworks, the dentist can analyze the strengths, weaknesses, opportunities, and threats (SWOT) involved in the situation. The goal is to leverage strengths and opportunities and overcome weaknesses and threats. Four frameworks can be used to analyze situations and guide changes for successful outcomes for the practice, the employees, and the patients. These frameworks are the

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structural framework, the human resource framework, the political framework, and the symbolic framework.

STRUCTURAL FRAMEWORK The structural framework is based on concepts from sociology, economics, and management science. Organizations using this framework create rules, policies, procedures, and systems, then allocate responsibilities to employees by a division of labor plan. Progress is measured using specific indicators. When performance isn’t up to expectations, the structure in the organization often requires realignment. The use of the structural framework is focused on tasks, facts, and logic. The redesign of processes is selected as the way to resolve problems because the perceived source is structural flaws rather than problems related to individuals.

HUMAN RESOURCE FRAMEWORK

APPLYING THE SWOT ANALYSIS FINDINGS

Within the human resource framework, the organization is viewed as an extended family where people should feel good about themselves and their work. Psychology is the root for this framework, which focuses on needs, feelings, skills, prejudices, and limitations. The organization is tailored to the people in the organization and aims to meet their needs for security and trust to keep them from taking unfriendly actions. The leaders are to provide employees with adequate compensation, support, skills, and resources.

Dental leaders doing a SWOT analysis using these frameworks will then assess the findings to better manage their practices, especially staffing issues. Focusing on tasks, facts, and logic may be needed to redesign processes. People should be valued, which is proven by investing in them as the heart of the practice. Authority and power should be used cautiously, avoiding destructive conflict. Harmony and collaboration permit the organization to expend effort to achieve a productive outcome rather than fighting one another. Traditions, shared values, and a culture of meaning and cohesion should be used by leaders to inspire employees to be loyal and committed to the mission of the dental practice.

People are the heart and focus of the organization, and if their needs are met, they tend to be committed and loyal. Leaders in a human resource framework organization focus on communication, empathy, and the best interests of their people.

POLITICAL FRAMEWORK The political framework depends on the work of political scientists and the competition for power and resources in the workplace. Negotiation, bargaining, coercion, and compromise are widely practiced, with conflicts occurring as a result of differences between individuals and groups. Leaders must manage conflicts productively, use power wisely and cautiously, and engage in reasonable compromises. Harmony and collaboration in the organization are based on progress and success.

SYMBOLIC FRAMEWORK Culture, symbols, and spirit are considered keys to organizational success in a symbolic framework. Social and cultural anthropology provide the basis for this framework, treating organizations as temples that house cultures, with rituals, ceremonies, stories, heroes, history, and myths rather than rules, policies, and managerial authority. Symbols, myths, and magic help the organization to become successful, with leaders inspiring their followers to be loyal and committed. Dramatic and visible symbols are used to communicate organizational missions. Traditions and values serve as the basis for culturebuilding to achieve cohesiveness, meaning, and a shared vision.

Clinical Significance Organizations are formed to accomplish a common set of goals. Dental practices are organizations with a shared mission for delivering patient care and maintaining a high level of excellence for all components of the process. To avoid employee turnover and build a cohesive and focused dental team will require an understanding of the relevant aspects of all 4 frameworks. It’s up to the dental team leader and/or delegated team member to perform a SWOT analysis and take what is learned and apply it in their practice. The result should be a place where performance is outstanding and employees are much more likely to want to remain at that practice.

Kerimova R: 4 frameworks to reduce staff turnover and boost practice performance. Dent Econ 116:33-34, 2026 Reprints not available

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THE BIG PICTURE ARTIFICIAL INTELLIGENCE Applications of artificial intelligence in dentistry BACKGROUND The gradual integration of artificial intelligence (AI) into many aspects of life is offering potential benefits and improving human-based systems and data management. AI is a machinebased system that offers the ability to make predictions and recommendations based on objectives dictated by human input. Various subfields of AI have proved useful in the various dental practice fields. A definition of useful terms in AI; AI applications in science, technology, and medicine; potential transformations brought by AI in the fields of dental practice; and the ethics and standardization of AI were explored.

USEFUL TERMS Terms used in AI can refer to techniques, models, data management, algorithms, and functions. A subfield of AI is machine learning (ML), which involves algorithms and statistics to predict unknown data and can self-learn and improve based on its own experience rather than explicit programming. Neural networks (NNs) are machine learning models applied to complicated data structures, with artificial neurons (ANs) forming the basis of an NN. The functions of ANs are similar to those of human neurons. When there are several layers of NNs, the term is Deep learning (DL), which is used to manage sophisticated data. Convolutional neural networks (CNNs) are DL algorithms that are widely used in dental applications such as diagnosis and detection. AI functions are training and testing, with the training data defining the frameworks for the model set. Models use the data from preceding inputs, then these settings are implemented in test sets.

APPLICATIONS IN SCIENCE, TECHCNOLOGY, AND MEDICINE During the COVID-19 pandemic, AI proved useful in predicting the anticipated course of the disease based on imaging and laboratory data input. Patient variables, such as vital signs, can be monitored using AI-integrated wearable health devices that can identify possible medical emergencies.

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AI can also help to optimize infrastructure design, the operation of traffic systems, and structural performance forecasts. AI can postulate, create study designs, gather and analyze data, and predict 3-dimensional protein structures. In medicine, the term diagnostic cockpit has been used to identify the integration of imaging and clinical data for early, accurate diagnoses. Care can be personalized through AI-analyzed data on genetics, lifestyle, history, tumor detection, and predictions of treatment outcomes. Computational drug design can accelerate drug discoveries, and robotics have improved surgeries. The automation of medical documentation, billing, and scheduling can facilitate office procedures and patient care. Evidence-based treatment guidance, risk prediction, telemedicine, remote care, and mental health support are all areas where AI has been applied.

APPLICATIONS IN DENTISTRY In various dental fields, AI is transforming data integration, combining medical and dental histories, imaging, clinical records, and social media to present a more unified view of the patient. Clinical dental practices have benefited from the use of AI in cavity detection through image analysis, using virtual reality to educate patients, conduct training programs, and streamline electronic record management (Figure 2). The many applications for AI in dentistry include uses in dental imaging, periodontics, prosthodontics, implants, oral and maxillofacial surgery, endodontics, oral pathology, orofacial pain, orthodontics, aesthetic dentistry, forensic dentistry, and community dentistry. Dental Imaging With AI support, dental images are used to provide faster and more efficient identification of abnormalities, leading to more acute diagnoses and treatment planning. AI can differentiate normal soft and hard tissue anatomy and pathology more efficiently than humans can. In 2D dental imaging, AI offers the potential of accurately detecting radiographic caries, periapical lesions, and peri-implant pathology. Precise tooth numbering is also possible, helping especially in localizing and delineating lesions in children with mixed dentition. In 3D imaging, AI enhances diagnosis, treatment planning, and precision in the findings (Table 1).

Figure 2. Artificial intelligence models and their potential applications in dentistry. (Courtesy of Sadanandam S, Ruby GF, Singer SR, et al: Artificial intelligence. Dent Clin N Am 70:99-115, 2026.)

Periodontics In periodontics, AI has computed the prevalence of periodontitis in the world's population. It also helps detect and assess periodontal bone loss, identify compromised teeth on radiographs, use intraoral images to diagnose gingivitis, and predict disease progression based on biomarker data. Periodontal staging can be done using radiographic bone loss on panoramic radiographs. Clinical and immunologic data such as leukocyte counts, cytokine levels, and antibody levels can be evaluated to differentiate between aggressive and chronic periodontitis. Prosthodontics Prosthodontic practices use AI to improve treatment strategies and diagnosis. Computer-aided design/computer-aided manufacturing (CAD/CAM) software, intraoral scans, and AI have allowed for rapid preparation, fabrication, and delivery of full-coverage restorations. AI helps identify the margins on prepared teeth, locate subgingival abutment finish lines, prevent misalignment, and prioritize occlusal integrity. Crown configuration anticipated to be in occlusion with the opposing teeth can benefit from the use of AI. Aesthetic prostheses can be customized through the use of AI to consider facial, features, ethnicity, and specific patient-satisfaction factors. The diagnostic accuracy for these applications is about 97%.

Implants, Oral and Maxillofacial Surgery (OMFS), and Endodontics AI's accuracy in predicting implant outcomes based on radiographic and diagnostic data ranges from about 70% to 95%. AI also helps analyze implant position, angle, and depth. The initial anchorage of implants based on implant insertion protocols using AI technology is about 94%. AI may be useful in augmenting the clinical procedures in OMFS and can improve precision. It may quickly, precisely, and reliably measure molar angulations to help in extractions. Surgical simulations and planning can be improved with enhanced visualization. Preoperative evaluations done through AI can guide computed tomography (CT) scans and 3D models. In endodontics, AI offers the potential to help in many areas, ranging from caries detection to predicting retreatment and assessing pulpal stem cell viability (Figure 6). Oral Pathology, Orofacial Pain, and Orthodontics AI has dramatically reduced how long it takes to obtain a histopathologic diagnosis of oral lesions compared to human analysis. A DL model can predict malignant transitions successfully, and AI has offered predictions for human papillomavirus (HPV) infections,

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Table 1. Applications of Artificial Intelligence in Dental Imaging Imaging Modality CBCT

MRI

PET & SPECT

AI Applications

AI Methodology Used

Automated Diagnosis: AI detects dental and maxillofacial conditions such as cavities, fractures, and bone lesions. CNNs for image classification and segmentation. Airway Analysis: AI improves airway assessment for sleep-related disorders DL models for automated diagnosis. Segmentation & Landmark Detection: AI aids in precise segmentation of anatomical structures for orthodontics and implant planning.

CNNs for image classification and segmentation.

DL models for automated diagnosis.

U-Net and Mask R-CNN for airway segmentation and bone structure identification.

CBCT Image Generation: AI converts MRI scans into CBCT-equivalent images, offering a radiation-free alternative. DLR enhances cervical spine MRI quality on a 1.5 T unit for evaluating degenerative changes without extending imaging time Soft Tissue Analysis: AI enhances visualization of soft tissues, improving orthodontic and TMJ disorder assessments.

GANs for CBCT synthesis from MRI.

Image Quality Enhancement: AI-based algorithms reduce noise and artifacts, improving clarity. Bone Density Analysis: AI assesses bone quality for dental implant planning and jawbone pathology detection. Fracture Detection: AI enhances the detection of maxillofacial fractures in trauma cases.

Hybrid CNN models for artifact reduction and image denoising. Random forest classifiers for bone density prediction.

Functional Imaging Analysis: AI aids in early detection of metabolic bone diseases and oral cancers. Lesion Detection: AI improves sensitivity in identifying abnormal metabolic activity in dental pathologies. Radiotracer Optimization: AI optimizes radiotracer dose and improves image reconstruction quality.

Deep learning-based autoencoders for PET/SPECT image reconstruction. Bayesian neural networks for lesion detection and uncertainty estimation. 3D CNN models for volumetric analysis of functional images.

—

RNNs for time-sequenced MRI processing.

Transformer-based AI models for feature extraction.

Abbreviations: DLR, Deep learning reconstruction; GAN, generative adversarial networks; RNNs, recurrent neural networks; SPECT, single photon emission computed tomography; TMJ, temporomandibular joint. (Courtesy of Sadanandam S, Ruby GF, Singer SR, et al: Artificial intelligence. Dent Clin N Am 70:99-115, 2026.)

tumor histopathology, and in vivo optical biopsy principles. Various dysplastic features of oral mucosal and hard tissue lesions can be detected and a differential diagnosis of cysts and oral white lesions can be obtained that could avoid having a biopsy. AI achieves greater precision in test analysis, reduces errors in diagnosis, and enhances the efficacy of oral pathology laboratory results. AI can help to analyze facial pain and TMDs as well as neuropathic, neurovascular, and cardiac referred pain, providing lifesaving diagnoses. Nonspecialists can better assess headaches and their subtypes as well as pain patterns through the use of an AI-supported questionnaire. Diagnoses of epilepsy, movement disorders, and neurocognitive conditions are more readily achieved with AI. Trigeminal neuralgia is better evaluated through AI, using the specific features of cortical and subcortical regions, the cerebellopontine angle, and differential myofascial pain. A post-surgical prognostic framework developed by AI may be helpful in predicting orofacial pain courses of treatment.

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AI has a number of roles in orthodontics, such as facilitating the cephalometric assessment, with human supervision. AI can also predict which patients will need extractions, indicate extraction outcomes, make growth and cervical maturation value predictions, and distinguish permanent from primary teeth. Combined with cone-beam CT (CBCT) evaluation, AI can provide a 360-degree visualization of dental and maxillofacial structures, furthering orthodontic efficiency. It can also flag high-risk areas and help to select sites for implant placement to reinforce anchorage. Additional research and improvements are needed before AI can offer reliable computer-aided care plans. Aesthetic and Forensic Dentistry Dentists can use AI-driven software to replicate the results of aesthetic dentistry procedures. Virtual treatment plans can be developed, and AI may help measure the aesthetic outcomes of orthognathic surgery, analyze facial attractiveness, and make age predictions. DL can predict postoperative soft tissue profiles in mandibular advancement surgery. Dental shade matching has

Figure 6. Potential applications of artificial intelligence in endodontics. Abbreviations: DD, Differential diagnosis; EPT, electrical pulp test; P, periapical lesions; RC, root canal; VRF, vertical root fracture. (Illustration by Dr. Gifty Francis Ruby, BDS. Courtesy of Sadanandam S, Ruby GF, Singer SR, et al: Artificial intelligence. Dent Clin N Am 70:99-115, 2026.)

become more accurate with AI's help, and the outcomes of professional whitening treatments have been predicted. Digital smile designs can benefit from AI labels and data taken from facial and intraoral images, making treatment planning easier. Customized 3D smile designs may be generated, possibly replacing mock-ups and conventional wax-ups. Forensic dentistry has been revolutionized by AI, which provides better identification, age estimation, and facial reconstruction based on image processing and pattern recognition. Bite mark analysis, disaster victim identification, and fraud detection based on dental record analysis benefit from AI. Comparisons of antemortem and postmortem data can be done through radiographs and enhanced facial recognition. New algorithms can extract cranial patterns. Gender can be determined radiographically, and sexually dimorphic parameters of the skull and pelvis can enhance forensic identification. Community Dentistry AI models may be able to predict and enhance risk assessments, the recognition of disorders, diagnostic predilections, and customized treatment plans for cancer in various organs. Radiographic and biomarker data could be used with AI to identify high-risk oral disease populations so that timely interventions can be instituted. Microbiome management has been advanced by using AI to synthesize polymers and peptides. In addition, vaccines have been developed with AI's involvement.

ETHICS AND STANDARDIZATION OF AI Various organizations worldwide have begun to develop initiatives to standardize AI in health care. Ethics, regulation, technology, and

clinical use have been addressed in these efforts. The American Dental Association released guidelines outlining image analysis standards, highlighting the importance of continuous monitoring, instituting human oversight, and strengthening cybersecurity measures. For autonomous AI tools, strict protocols must be followed to confirm clinical effectiveness and provide proper supervision. Transparency, reliability, and data security are vital aspects in these efforts.

Clinical Significance Before jumping into the use of AI-assisted software and tools, clinicians should obtain sufficient knowledge about what the use of these elements entails. Significant investments must be made and regular maintenance is required, which may be difficult to access for some clinicians. AI has limitations, so findings should be interpreted with caution. Clinicians should ensure there is transparency with patients regarding the sharing of data across AI systems.

Sadanandam S, Ruby GF, Singer SR, et al: Artificial intelligence. Dent Clin N Am 70:99-115, 2026 Reprints available from S Sadanandam, Rutgers School of Dental Medicine, Rm D885 A, 110 Bergen St, Newark, NJ 07101, USA; e-mail: sandhyasadanandham@gmail.com.

Volume 71 • Issue 3 • 173

DENTAL SHAME Addressing dental shame and shame competence BACKGROUND Although dental anxiety is commonly seen as a consideration that practitioners should address, dental shame hasn’t been widely investigated. It’s not the same as dental anxiety but instead is an emotional experience that arises from the patient’s desire to avoid exposing the teeth and any relevant lifestyle factors, such as smoking and dietary choices. Shame arises when an individual is worried about negative judgments from others or when a person transgresses a social norm or rule. It’s highly shaped by the personal and cultural contexts in which is exists. It also can result from specific triggers in a patient’s life, based on personality traits, personal moral standards, religious beliefs, upbringing, and history of trauma, among other factors. A complex assortment of negative self-conscious emotions occurs and changes in unpredictable patterns. Because dental shame has significant implications for oral health and systemic inequities, the concept of dental shame can be used as a lens to understand the social, cultural, personal, economic, and systemic aspects of oral health. A deeper understanding of dental shame can lessen the consequences of oral health problems and lead to shame competence that addresses the problem head on. Interventions can then be developed and patient outcomes improved.

DEFINITIONS Dental shame is both a consequence and a determinant of oral health issues. Oral health issues can cause shame that becomes a barrier to daily dental care and engagement with dentistry. This can involve visible dental problems such as broken, carious, dark, and missing teeth as well as oral malodors and difficulties with tooth function. Dental shame can become a selfreinforcing spiral, with the shame leading to poor oral health behaviors, creating more intense oral health issues, and causing more shame. Dental shame also can result from broader social vulnerabilities, which may lead to complex interactions with oral health. Social and economic factors can influence how one maintains oral health. Social vulnerabilities can include trauma, abuse, food poverty, low literacy ability, and harmful coping strategies. Dental shame is also a relational phenomenon, meaning that an individual can experience it on behalf of others, such as children. Other people can be drawn into sensitive shame situations so that people become uncertain about how to address the individual with challenging oral health. The effect can alter relationships,

174 Dental Abstracts

social life, work life, and encounters with dental practitioners and other health care professionals.

USING THE SHAME LENS TO CHANGE FOCUS Shame can also lead to growth and enlightenment, create social harmony, and motivate positive changes in behavior. It has been used in public health campaigns to motivate growth in positive behaviors. Health care practitioners may shame patients both intentionally and unintentionally, with no guarantee that positive changes will result. The shame lens provides an important focus in the campaign to improve outcomes and make services more sensitive and humane. The shame lens directs one’s attention to how shame might be manifesting in individuals and what coping or defensive behaviors might result. It also helps to reveal where shame or shaming may be embedded in the policies, practices, or conditions in an organization. This allows systems and practitioners to avoid reinforcing or inducing dental shame, and instead prompt changes to more inclusive and empathic ways. The nonjudgmental environments created allow patients to trust and feel empowered to prioritize their health. Five key aspects that underscore the influence of dental shame as a critical factor in oral health were selected: Dentistry and clinical encounters, health care and social services, everyday life and oral health behaviors, broader systemic contexts, and in relation to trauma. Dentistry and Clinical Encounters The clinical settings examined through the shame lens reveal a pervasive presence of shame, both from the patient’s and the dental practitioner’s perspective. Patient shame stems from a number of sources, including dental neglect, fear of judgment, and insufficient socioeconomic factors. Dentists can address these challenges by navigating the balance between providing effective care and mitigating shame-induced barriers to communication and treatment participation. Shame should be recognized and addressed in ways that foster trust, initiate conversations, improve patient-provider relationships, and support patients’ everyday dental health care. Health Care and Social Services Dental shame is also seen in interactions with health care workers and social workers, such as psychiatrists, elder care

personnel, social situations, and employment agencies. Although dental care isn’t generally an important part of their day, patients can suffer dental shame and feel at risk for embarrassment and other negative responses. The acknowledgement of dental shame is critical to creating a supportive environment and ensuring access to care without judging or stigmatizing the individuals. Everyday Life and Oral Health The everyday life practices and behaviors of individuals can also be influenced by shame. Dental habits such as dental neglect can offer insight into the underlying psychosocial determinants behind oral health behaviors. The complex entanglements between dental shame, societal norms, and individual agencies should be investigated to develop better dental health behaviors.

SHAME COMPETENCE Creating a shame-sensitive practice can help to overcome the negative effects of dental shame. The shame lens can be used to identify the potential for shame in organizational policies, education, and practice, then create increased sensitivity to the potential for shame developing. Shame competence is a set of skills and knowledge that permits the identification of shame in oneself or others, makes an individual aware of how shame develops and spreads, identifies shaming in policies and practices, and reduces the potentially damaging and anti-social effects of shame. Shame competence should be developed by fostering emotional intelligence in the workplace, professional environments, and community-based practices. Any taboos or stigmatized states and experiences must be addressed directly and discussed openly.

Broader Systemic Contexts Health care fee structures are among the most important systemic inequities that can contribute significantly to dental shame. The effects are especially notable among marginalized populations. Other aspects that build dental shame are poor access to dental care, differences in daily dental care habits, homelessness, substance abuse, and violence. Research is needed to examine how oral health issues relate to these sources of oppression and vulnerability and lead to shame. The goal is to develop policies, interventions, and campaigns that promote equitable access to dental care and mitigate any harmful effects on the outcomes of dental health care.

The dynamics of dental shame require added research to better understand the resulting implications in practical terms. The shame lens offers a significant potential to advance knowledge and social justice in dental care and to develop preventive measures as well as effective treatments. Dental shame competence should also be included into dentistry education and training.

Trauma Trauma and shame are closely linked, with those who experience trauma likely to be more susceptible to experience shame or to anticipate shame in interpersonal situations. Coming into contact with professional services may also prompt the individual with shame to exhibit avoidance and other shame defensive behaviors.

Folker L, Dolezal L, Jespersen AP, et al: Dental shame: A call for understanding and addressing the role of shame in oral health. Community Dent Oral Epidemiol 54:1-6, 2026

Clinical Significance

Reprints available from L Folker; e-mail: folker@hum.ku.dk

DOMESTIC ABUSE Supporting dental professionals dealing with domestic abuse BACKGROUND Although domestic abuse (DA) is a global public health issue and a violation of individuals’ rights, it’s often not recognized among dental health care providers. The controlling and power-wielding effects of DA tend to create dependency in the victim, with patterns of threatening and coercive actions along with degrading behaviors and physical and sexual

violence (Box 1). As a result, those being abused can develop long-lasting physical and mental health consequences, including direct injury or even death from the abuse. Women are the ones subjected to DA in about 72% of DA-related crimes. A systematic review of the literature was done to explore dentists’ and dental care providers’ (DCPs’) lived experience of DA.

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Box 1. Domestic Abuse Examples of Controlling and Coercive Behaviours •

Making someone dependent on or subordinate to the abuser Isolating someone from their friends, relatives, or other sources of support • Controlling, regulating, or monitoring someone’s day to day activities • Depriving someone of, or restricting their freedom of, action, e. g., controlling their phone/communication access or access to money • Frightening, humiliating, degrading or punishing someone, e.g., abusive name calling, playing mind games that causes someone to doubt their sanity. •

(Courtesy of MacNab LK, Cannon P, McFeely C, et al: Domestic abuse experienced by healthcare practitioners: What about dentists and dental care professionals? A systematised review. Br Dent J 239:768-773, 2025.)

METHODS The literature had no papers about dentists’ or DCPs’ lived experiences of DA. It was decided to review papers relating to DA in other health care providers, expecting that the experiences and outcomes would be applicable to dental professionals as well.

RESULTS Impact of DA in the Workplace The description of victims’ and survivors’ experience in the workplace after DA includes reduced concentration, feeling ill, and missing work. Those who continue to work tend to experience lack of confidence or worry about making a mistake, which would compound the stress they are under. Employers often see these actions as worthy of discipline without seeking the cause. Survivors may be equipped to identify and respond to DA among patients, but can experience considerable distress when doing this for themselves. Barriers to Disclosure Survivors tend to find disclosure and seeking help as difficult and are reluctant to engage in the process or even recognize the abuse as occurring. Some are fearful of their perpetrator’s retaliation or the potential impact on and fear of having children removed from their care. They can feel isolated, ashamed, or discouraged by close relatives. Some blame themselves, fearing exiting the relationship abruptly, and lack practical and financial resources for the future. Victims tend to be at highest risk when reporting or leaving the abuser.

176 Dental Abstracts

Barriers specific to health care providers include being silenced by a fear of not being believed, feeling pressured to tell the police, feeling like a nuisance, and worrying that the disclosure would raise questions about their suitability as a health care provider. Survivors often seek to avoid being recognized and want to remain anonymous. They also fear the perpetrator will make false allegations to the regulator or social services about them. Often the survivor believes he or she is isolated and misses opportunities to disclose the abuse and obtain emotional and practical support. Health care providers are expected to respond when they suspect DA, even in colleagues, but they may not feel confident enough to act or may not recognize the abuse for what it is. Actions Taken in the Workplace Work can offer a place where there is stress, but it can also feel safe, comforting, and supportive of those who have been abused. Those at work may have a sense of identity, agency, social support, and escape from the perpetrator. Having a job offers financial independence. Staff disclosure and help-seeking for one’s own experience can be an unintended consequence of DA staff training, which indicates the need for support mechanisms that cover staff members. The fundamental support needs sought by victims and survivors include understanding, flexibility, and confidentiality (Box 3). Employer’s Responsibility and Workplace Policies Employers have a statutory responsibility to take care of the health and safety of their staff. They should ensure that the workplace offers helpful responses to DA. Many agencies in

Box 3. Examples of Employer Responses Desired by Healthcare Employees •

Open, supportive and flexible to the needs of employees Improve understanding among colleagues of the staff experience of domestic violence and abuse • Acknowledgement that they may not be able to work to the best of their ability without feeling that they might lose their jobs • Sensitive support from qualified professionals • Domestic violence and abuse training for staff in supportive roles is recommended (especially those in supporting roles such as occupational health or human resources) and referral pathways to domestic violence and abuse agencies • Guarantee of confidentiality • Support options: flexible leave and working more formalised in policy. •

government have attempted to improve workplace responses to DA, offering guidelines for actions employers should take, support measures that should be in place, the need for legislative and policy changes, employee assistance programs, paid leave for DA support, and trade union support. The boards of health should offer a point of contact with trained staff to respond to these needs. Professional registration bodies should receive DA training and implement policies to ensure DA disclosures won’t harm professional registration automatically. Among the recommended policies for a safer and more supportive work place are flexible working policies, locations, and leave. DA-specific safety factors include risk assessment and safety planning, clear directions for managers and colleagues, emotional support, and advocacy. However, many of these elements are not yet in place, with workplaces often short of trained DA staff and lacking written procedures and information on interventions.

CONCLUSIONS So far dentists and DCPs have been overlooked in the establishment of proper policies and procedures regarding DA in the workplace. What has been learned is based on the experiences of other health care professionals.

Clinical Significance Research is needed to establish how dental staff can access safety, be heard and supported, recover, and continue practicing safely after experiencing DA. The support of colleagues is a big part of this support network as well. Cases where the abuser and survivor are employed by the same organization must also be addressed. Survivors need to know how to access the support they need and how to heal from the emotional and practical disruptions that are caused by DA.

MacNab LK, Cannon P, McFeely C, et al: Domestic abuse experienced by healthcare practitioners: What about dentists and dental care professionals? A systematised review. Br Dent J 239:768-773, 2025 Reprints available from C McFeely; e-mail: Clare.McFeely@glasgow. ac.uk

SPECIAL CARE CHALLENGES Special Care Dentistry BACKGROUND

and patients having cognitive and/or degenerative conditions. Patients are now living longer, so older patients are also more common and present their own treatment challenges. Poor oral health can severely affect patients with special needs, including their general health and wellbeing, exacerbating medical co-morbidities such as cardiovascular disease and diabetes.

Special care dentistry (SCD) was formally declared one of the 13 dental specialties in 2008, but services to care for patients with special needs were available long before that. Among the needs addressed were those involving physical, sensory, intellectual, mental, medical, emotional, and social impairments. Modified or alternative approaches were often needed to deliver even routine dental care. Specialists proficient in caring for patients with additional needs and providing appropriate treatment approaches for them benefit from a structured training pathway to prepare them. Patients with special needs now are addressed with more comprehensive service delivery models, where dental care is integrated into broader health care frameworks at hospitals and community care settings. The patients’ needs; the clinicians’ qualifications, training, challenges, and opportunities; and plans for the future were reviewed.

Patients qualifying for care in SCD present diverse situations that require different environments and strategies. Their care tends to be highly complex and complicated by the need to adapt clinical techniques and communication strategies, to use alternate treatment modalities, and to modify the environment to suit the patient’s special conditions. Care may be delivered in a wide range of settings, including dental practices, community dental services, hospitals, and domiciliary care. Often shared care arrangements between settings are made (Table 2).

PATIENTS’ NEEDS

CLINICIAN INVOLVEMENT

The numbers of patients requiring SCD have increased over the years, with the latest estimates including those with disabilities, those living with cancer, patients with mental health problems,

Qualifications SCD tends to appeal to clinicians who are highly empathetic and want to improve the lives of vulnerable people with complex

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Table 2. Complexity Levels of Care in Special Care Dentistry Level of care 1

Explanation Needs that require a skill set and competence as covered by dental undergraduate training and dental foundation training, or its equivalent

Setting* GDS

Examples • Oral health assessment • Prevention advice and treatments • Provision of basic care • Emergency treatment and management of pain,

infection and dento-alveolar trauma • Delivery of treatment following the provision of a

treatment plan for a SCD provider • Continuing care

3a 3b

Procedural and/or patient complexity requiring a clinician with enhanced skills and experience who may or may not be on a specialist register. This care may require additional equipment or environment standards but can usually be provided in primary care. Level 2 complexity maybe delivered as part of the continuing care of a patient or may require onward referral

CDS

Needs that require management by a dentist recognised as a specialist in SCD Needs that require management by a dentist recognised as a consultant in SCD

CDS/HDS

• Significant communication difficulties due to

multi-sensory or cognitive impairment • Patients who present with a disability,

psychological or mental health state that limit cooperation where advanced anxiety and behaviour modification is needed, or sedation or general anaesthesia is indicated, or where treatment is provided by a dental team with appropriate training in clinical holding • Medical complexity, such as patients with moderately controlled medical conditions or those with progressive or degenerating conditions • Patients may have barrier to accessing dental care, e.g., requiring patient transport or specialist equipment to access the dentist or who need domiciliary care • Those with higher oral risk, such as relying on a third party to deliver oral hygiene • Legal and ethical considerations, such as requiring a best interest’s decision with a second clinical opinion or those with fluctuating capacity

CDS/HDS

• Those patients at the most severe end of the

spectrum in all categories. Many of these patients will be identified and signposted via a Level 2 provider triage

Abbreviations: CDS, Community Dental Service; GDS, General Dental Service; HDS, Hospital Dental Service; SCD, special care dentistry. (Courtesy of Bradley N, Kauser K: Special care dentistry: Overcoming future challenges. Br Dent J 239:829-835, 2025.)

medical conditions or those hampered by barriers to standard dental care. Providing treatments tailored to these patients is both rewarding and personally fulfilling. SCD candidates face significant intellectual challenges and benefit from skills in problem-solving and adapting to unusual situations. Working in collaboration with other health care professionals and employing nonstandard treatment modalities are common, so the treating professional should be able to use ingenuity and adaptability in creating a successful approach to care.

Training The training for work in SCD will vary, depending on the professional background of the individual. Undergraduate dentists and dental care professionals (DCPs) can lack exposure to SCD and require significant training. The career pathways in SCD for dentists are generally through postgraduate training, whereas those for other DCPs are tailored to their previous skills and their roles in supporting SCD teams.

Being an advocate for accessibility in health care is also part of delivering care through SCD. Disparities faced by patients with disabilities in accessing dental services are addressed by professionals who chose SCD as their practice but may be called to take on educational, community outreach, and policy-making roles. The ability to integrate medicine and dentistry and in-depth knowledge of diverse medical histories and their impact on oral health are valuable assets for SCD practitioners.

Dentists After completing a Bachelor of Dental Surgery and gaining experience in hospital-based or community dentistry, general dentists can engage in specialty training in SCD. This will include specialty training programs and rotations in hospital, community services, and other health care environments handling SCD patients. The program usually takes 3 to 4 years and focuses on clinical management and knowledge and multidisciplinary team collaboration.

178 Dental Abstracts

Table 3. Employment Grades and Salaries of Employed Special Care Dentistry Dentists and Dental Care Professionals Contract Salaried dental terms and conditions

Hospital terms and conditions

Agenda for change

Grade

Salary (full-time, most recent figures taken 2024)

Band A

£50,512–£75,767

Band B

£78,573–£91,903

Band C

£94,007–£108,038

Dental core training

£43,923–£55,329

Dental specialty training

£55,329–£63,152

Specialty dentist/doctor

£59,175–£95,400

Consultant Clinical support worker (Band 2)

£105,504–£139,882 £24,071–£25,674

Dental nurse (Band 3–5)

£26,530–£36,483

Oral health practitioner/dental hygienist or therapist (Band 5–7)

£29,970–£52,809

Dental technician (Band 5–7)

£29,970–£52,809

(Courtesy of Bradley N, Kauser K: Special care dentistry: Overcoming future challenges. Br Dent J 239:829-835, 2025.)

Alternatively, dentists may pursue postgraduate diplomas or master’s degrees in SCD with or without entering the specialty training. Their advanced knowledge and skills in the management of patients with special needs can provide a pathway toward further specialty training. General dentists looking to gain more exposure to SCD may engage in mentorship opportunities or continuing professional development (CPD) courses. DCPs DCPs can seek specific qualifications and CPD courses to enhance their ability to care for patients with special needs. Among the topics are certification in SCD nursing, communication strategies for patients with learning disabilities, sedation, and providing care in nonclinical settings. DCPs may also take advantage of workforce transformation initiatives and add more roles on the dental team. Among the areas of service are preventive care, oral health education, and supportive care for patients within SCD settings. Mentorship programs on SCD teams allow DCPs to gain experience in clinical settings where special needs patients are being treated. This can lead to more specialized roles in SCD. Challenges SCD challenges can affect practitioners’ emotional and psychological health, especially when patients are highly anxious or uncooperative. The emotional strain of managing special needs patients and the higher stakes associated with this specialized care can cause practitioners stress and lead to burnout over time if self-care isn’t a part of their practice. Physical needs can be tiring because they require practitioners to work in nonstandard positions, use specialized equipment, and take additional time and effort to accomplish treatment. The effects of this can be fatigue and musculoskeletal issues that affect the

clinician’s long-term health. The practitioner’s physical health must be prioritized. The SCD workforce is usually employed under salaried dentist terms and conditions, under hospital terms and conditions, or under an agenda for change (Table 3). It’s been challenging to recruit dentists and DCPs to work in the CDS because of competitive salaries in the private sector. The workload of SCD services is increasing, especially with difficulty accessing dental services. As a result, clinicians are suffering from low morale, stress with the long waiting lines for service, and frustration because of barriers to accessing services. Some patient groups may benefit from the development of more collaborative working between sectors such as domiciliary dental services contracted from general dental practitioners, conscious sedation services managing suitable patients in primary care, or the commissioning of bariatric dental services. The administrative workload in SCD can also be substantial and involve thorough risk assessments; coordination with medial clinicians, families, and care providers; seeking advice from medical teams; and follow-up appointments. Such administrative tasks are essential to ensure patient safety. Stress can also result from unpredictable and complex cases, with a need to adapt to unexpected challenges. The high demands of this practice can be overwhelming, so practitioners should be resilient and adaptable. Opportunities Because SCD requires the use of a wide range of skills and expertise to meet the needs of patients, career opportunities in SCD

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are plentiful. Some of the key career paths are clinical practice, academic and teaching roles, research, public health and policy advocacy, interdisciplinary and multidisciplinary roles, and continuing education and professional development.

FUTURE DEVELOPMENTS The treatment needs of the special needs population continue to change, and SCD will need to adapt. Among the areas where the care of special needs patients must adapt are treatment advances, especially in sedation techniques and new dental technologies. This can include intraoral scanning and computer-aided design/computer-aided manufacturing (CAD/ CAM) technologies. The availability of services is an area of concern, with existing services already stretched thin. Domiciliary care may offer some relief, but more innovative solutions are needed for this special needs population. In addition, the workforce in SCD must be expanded and training provided. Consultant roles in SCD are also needed, along with advocacy to communicate the value of SCD.

Clinical Significance SCD is more in demand as the needs of the population of patients it cares for increase. These patients are vulnerable and present complex situations not just in oral health care but also in adaptations to manage physical and mental health challenges. Many fulfilling career opportunities are available in this dental specialty that can provide life-enhancing treatments for patients in need of special care.

Bradley N, Kauser K: Special care dentistry: Overcoming future challenges. Br Dent J 239:829-835, 2025 Reprints available from N Bradley; e-mail: natalie.bradley @nhs.net

SUICIDES Dentist suicides in the United States BACKGROUND There are growing numbers of health care professionals who are taking their own lives or experiencing suicidal ideation not just in the United States, but in many other countries. Studies show that dentists have higher suicide rates than are found in the general population. However, many of these studies were done more than 20 years ago and included only white male dentists. Since that time, more women have joined the dental workforce and there is greater diversity. A study was undertaken to determine the suicide mortality among male and female US dentists, to assess the methods of suicide, and to evaluate trends over time.

SUICIDE MORTALITY DATA Demographics Four hundred seventy-five of the 21,928 decedents between 1979 and 2018 were identified as dentists who died of selfinflicted harm, with 98.4% being male and 1.6% female practitioners. About 96% were white and about 4% were of other races. Median age at death for these persons was 61 years, with a range from 26 to 101 years for male dentists, and 44 years, with a range from 28 to 87 years for female dentists (Table 1). About 62% were ≤ 64 years at death and about 18% were listed has having served in thea US military during their career. About 88% of the dentists were dental practice owners.

180 Dental Abstracts

Table 1. Characteristics of 475 Dentists Who Died By Suicide from 1979 through 2018* CHARACTERISTIC

TOTAL, NO. (%)

Age at Death, Y 25-34

16 (3.4)

35-44

44 (9.3)

45-54

91 (19.2)

55-64

141 (29.7)

65-74

83 (17.5)

≥ 75

100 (21.1)

Race White

457 (96.2)

All other races

18 (3.8)

Practice Modality Associate

16 (3.4)

Independent contractor

10 (2.1)

Nonowner

23 (4.8)

Owner

373 (78.5)

Unknown Uniformed Services, Yes

53 (11.2) 83 (17.5)

* See Figure 1 for information on data set selection. (Courtesy of Tomasi SE, Lipman R, Bloom F, et al: Suicide deaths among dentists in the United States. J Am Dent Assoc 156:10241033, 2025.)

Table 3. PMRs* for 475 Dentists Who Died By Suicide from 1979 Through 2018 By Sex MALE DENTISTS VARIABLE All

FEMALE DENTISTS

Observed, No.

Expected, No.

PMR (95% CI)

P Value

Observed, No.

459

227.9

2.01 (1.83 to 2.21)

< .001

Expected, No. 7.4

PMR (95% CI)

P Value

2.15 (1.23 to 3.49)

.009

Practice Modality Associate

Independent contractor

< 10

7.8 < 10

1.79 (0.98 to 3.01)

.06

< 10

2.39 (0.29 to 8.64)

.41

1.63 (0.70 to 3.22)

.25

< 10

12.71 (1.54 to 45.92)

.02

Nonowner

6.5

3.25 (2.01 to 4.97)

< .001

< 10

5.98 (0.72 to 21.58)

.09

Owner

367

170.5

2.15 (1.94 to 2.38)

< .001

< 10

1.76 (0.64 to 3.82)

.26

Unknown

38.2

1.28 (0.95 to 1.70)

.10

< 10

1.48 (0.40 to 3.80)

.57

Uniformed Services

31.8

2.55 (2.02 to 3.17)

< .001

< 10

5.40 (0.65 to 19.50)

.11

* The proportionate mortality ratios (PMRs) indirectly standardized for age, race and 5-year calendar period were generated by using Life Table Analysis System software (National Institute for Occupational Safety and Health) with 95% confidence intervals (CIs) and 2-sided P values based on an assumed Poisson distribution; values > 1.00 indicate that the proportion of deaths from a specific cause among dentists was larger than the proportion of deaths from that specific cause among the general US population during the study period, with values of P < .05 considered significant. Cell sizes of fewer than 10 decedents were suppressed to comply with National Death Index data presentation requirements. (Courtesy of Tomasi SE, Lipman R, Bloom F, et al: Suicide deaths among dentists in the United States. J Am Dent Assoc 156:1024-1033, 2025.)

Figure 3. Method of suicide for male and female dentist decedents identified from the underlying cause of death. (Courtesy of Tomasi SE, Lipman R, Bloom F, et al: Suicide deaths among dentists in the United States. J Am Dent Assoc 156:1024-1033, 2025.)

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Comparison with General US Population The proportionate mortality ratios (PMRs) were higher for dentists committing suicide than among the general US population. Regardless of their race and whether they served in the US military, dentist decedents had a significantly higher suicide PMR than the general US population. The PMR was 2.01 for male dentists and 2.15 among female dentists (Table 3).

METHODS OF SUICIDE The most common method of suicide was firearms (about 60%), followed by hanging, suffocation, or drowning (about 17%). Male decedents used firearms about 61% of the time and hanging, suffocation, or drowning about 17% of the time. Female dentist decedents used firearms about 31% of the time, and hanging, suffocation, or drowning about 31% of the time (Figure 3). Drug poisoning was used in about 10% of both groups.

TRENDS OVER TIME The number of suicides among dentists was higher than those in the general population, with a steady increase since 1995. Both male and female dentists committed intentional self-harm more often than people in the general population.

Clinical Significance Understanding the propensity for dentists in the US to commit suicide may help inform efforts to institute evidence-based safety and health strategies for dental practitioners. Dental support organizations, mental health care providers, professional dental associations, dental schools, and employees should all be involved in the prevention of suicide by dentists. Resources are available from the Centers for Disease Control and Prevention as well as other sources to educate not just dental health care workers but also care providers around them about interventions to help them cope with stress and suicidal ideation and to make positive changes in their lives.

Tomasi SE, Lipman R, Bloom F, et al: Suicide deaths among dentists in the United States. J Am Dent Assoc 156:1024-1033, 2025 Reprints not available from SE Tomasi, Respiratory Health Div, National Inst for Occupational Safety and Health, Ctrs for Disease Control and Prevention, 1000 Frederick Ln, MS 2800, Morgantown, WV 26508, USA; e-mail: suzannetomasiDVM 2005@gmail.com

US DENTISTRY DECLINE Perspective on dentistry’s future in the US BACKGROUND A worldwide problem is growing in the dental world. Nations whose oral health care systems are well-established are facing challenges ranging from the commercialization of health care to professional burnout. Some key structural concerns are seen in US dentistry that will require reforms to set the ship right before it flounders. Some thoughtful reform may fix the hole in the ship and avoid dental professionals’ acceptance of low expectations and the public’s loss of trust in dentists.

KEY STRUCTURAL CONCERNS Debt and Incentives Government funding for higher education in the United States has declined substantially since the early 1980s. As a result, public universities are compensating by raising tuition and having students pay more of the bill. In 2019-20, student tuition and fees accounted for about 42% of US dental school revenues, with state and local government support only covering about 10%, causing a significant increase in the reliance on tuition.

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This change in funding also means the average educational debt for indebted dental school graduates was about $300,000 in 2024, with the average dental school graduate owing about $296,000 in student loan debt. Private dental schools or outof-state public institutions are associated with student debt of more than $500,000. With the increased financial pressure, practice patterns are affected, and treatment fees become inflated. However, better clinical outcomes aren’t the result. US dental expenditures per capita are among the highest in the world, but the care quality of US dentistry is similar to that of other high-income countries. The Product-driven Model The rise of dental support organizations accelerated the transformation of clinical dental practice into a productivity-driven model. Efficiency and volume are prioritized over individualized treatment planning. Dentists are constrained with respect to clinical autonomy because financial metrics determine patient care decisions. The standardized approach of dental support organizations tends to marginalize professional discretion.

Too Many Between 2020 and 2024, the number of US dental schools grew from 67 to 75. Access to care may be positively influenced by this increase, but there is concern over whether there will be too many graduates, a lowering of compensation, and possibly a fall in clinical training standards. Lack of Motivation In many dental systems, especially those with a strong public health infrastructure, general dentists are trained and expected to manage a wide range of procedures. In the US, dentists are encouraged to specialize early on or choose a risk-averse general practice. All of the dental programs must comply with the quality and performance standards set by the Commission on Dental Accreditation (CODA), but many graduates report having limited clinical experience at graduation, especially in endodontics and surgery. About half would prefer more clinical experience in endodontic therapy and 75% would like more exposure to surgical implant placement. CODA requires graduates to be competent in comprehensive patient care and doesn’t set specific procedural quotas. Advanced programs exist, but run into problems because they’re optional and the dentist’s student loan burden would increase further. General practice education should prepare dentists so they can perform comprehensive, competent care at graduation. Clinical Opacity A fundamental vulnerability in dentistry is the fact that patients can’t see or verify most of what is done. The profession is built on trust, but subjective assessments shouldn’t be transformed into objective diagnoses that aren’t challenged or checked by the patient. Dentists play the roles of diagnostician, provider, and financial beneficiary simultaneously, unlike in medicine where the requirement of accountability separates these roles. Increased transparency through objective diagnostic documentation could help to support the trust relationship and avoid vulnerability. Loss of Trust and Skill When the dentist graduates and is under intense pressure to repay educational loans, he or she often undertakes highvolume, routine-based practices. Once the debt is cleared, the dentist may feel less motivated to pursue clinical excellence or advanced training. The basic general practice procedures create a comfort zone that disincentivizes growth. In response, the practice may stagnate, with the dentist content to perform at levels that reflect complacency and not excellence. The result of this attitude on the dentist’s part is that patients pay more for treatment and receive less comprehensive care. This gradual erosion in clinical excellence and the lack of desire for improving dental competence can lead the public to question the integrity of the dental profession. If the practice of dentistry adopts opaque pricing, unverifiable treatment, and inconsistent standards, it can be impossible to reestablish trust.

NEEDED CHANGES The dental profession must take measures to ensure public trust and professional integrity continue. The needed changes aren’t just professional upgrades; they are ethical imperatives. Aligning the profession with the core values of the dental model— transparency, quality, and equity—will only be achieved through institutional and structural changes. Recommendations include the following: Reinvest in public dental education Strengthen continuing education requirements to a focus on established clinical proficiency and relevance to evolving standards of care • Establish objective diagnostic protocols • Implement peer-reviewed clinical audits, modeled after quality assurance mechanisms that promote consistency and mitigate diagnostic bias • Integrate dentistry more fully into the broader health care system, with interdisciplinary collaboration and patientcentered, holistic care • •

CONCLUSIONS The challenges to dentistry are being seen worldwide. Although the US remains a global leader in dental innovation, research, and technology, it must also prioritize service supporting the public good. Dentists should choose to put the needs of their patients before their own personal or commercial interests.

Clinical Significance With thoughtful structural reform, the oral health care system can overcome the concerns that have been enumerated. Rather than accept the gradual reduction in expectations and dental quality, dental professionals must be willing to engage with difficult issues and to commit to the profession in ways that exceed the interests of a single practice. Interdisciplinary as well as international collaboration should be encouraged to improve education, policies, and clinical and ethical standards.

Iwanaga J: The silent decline of US dentistry. J Am Dent Assoc 156:967-969, 2025 Reprints available from J Iwanaga, Dept of Neurosurgery, Clinical Neuroscience Research Ctr, School of Medicine, Tulane Univ, 131 S Robertson St, Ste 1300, New Orleans, LA 70112, USA; e-mail: iwanagajoeca@gmail.com

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HANDS ON BLOODBORNE PATHOGENS Diagnosis, treatment, and prophylaxis for newer bloodborne pathogens BACKGROUND

PREVENTION

Health care workers, including dentists and auxiliary staff, face a higher risk for exposure to bloodborne pathogens (BBPs), which are infectious microorganisms that cause disease and are spread through the blood. The primary way these pathogens are transmitted are via percutaneous and/or transmucosal injuries in the workplace, and the most common BBPs raising the highest concern are hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV). The Occupational Safety and Health Administration has created universal precautions that reduce BBP exposures for decades. New BBPs have emerged, and the modes of transmission possible in a clinical dental practice need to be reviewed and advances in preventive practices put in place.

Advances Sharps injuries are less common because of the use of instruments with engineered sharps injury protection or safetyengineered devices. Devices with passive activation mechanisms have been especially valuable. Retractable needles, blunted suture needles, and self-sheathing syringes reduce needle-stick injuries for adequately trained individuals. Other ancillary measures include magnets, modified suturing and recapping techniques, and modified personal protection equipment (PPE) textiles. The drawbacks to these devices include considerable training for proper use and cost.

PATHOGENS AND TRANSMISSION RISKS Pathogens Historically, epidemics and pandemics have resulted in widespread infections with disease-causing organisms. Examples include the bubonic plague, the Spanish flu, the HIV/acquired immunodeficiency syndrome (AIDS) pandemic, and the COVID-19 pandemic (Figure 1). Currently, over 30 species can be transmitted through blood from the source to a recipient. Dentists are at significantly higher risk for acquiring bloodborne infections. Clinicians must implement practice protocols to ensure safety when managing individuals infected by BBPs. Transmission Although pathogens may be transmitted through other forms of contact, health care workers are usually exposed through infectious materials or body fluids, which include semen, vaginal secretions, saliva, and serous fluids. In health care environments, transmission is most commonly due to percutaneous injury, inadvertent puncture, bites, cuts, abrasions, or mucocutaneous contact with fluids from an infected patient (Figure 4). In surgical settings, the use of sharp instruments contributes to most injuries.

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Screening, Diagnostics, and Post-exposure Prophylaxis for Major BBPs HIV The US Preventive Services Task Force recommends HIV screening for individuals age 15 to 65 years. The US Food and Drug Administration (FDA) approved oral fluid and bloodbased rapid HIV self-tests, which provide results in 30 minutes. Positive results should be re-confirmed using laboratory tests. If oral lesions associated with HIV are found, the patient should promptly be referred to a physician, infectious disease specialist, or HIV testing facility. The latest Centers for Disease Control and Prevention (CDC) recommendation is for HIV testing with an FDA-approved supplemental HIV-1/2 antibody differentiation immunoassay. The HIV-1 nucleic acid test (NAT) is recommended for persons with indeterminate results or negative HIV-1/2 antibody results. Post-exposure prophylaxis (PEP) is required after exposure to the virus because the transmission of HIV can occur within 24 to 36 hours of exposure. Health care workers should be assessed within 72 hours, with the status of HIV determined using rapid combined antigen/antibody or antibody tests. PEP should be initiated promptly and discontinued if the exposed person is HIV positive or the source is proven to be HIV negative. Antiretroviral medications are given in PEP.

Figure 1. A timeline of the pandemics and epidemics. (Courtesy of Mathai BC, Alnuaimy ZA, Hadad R, et al: Bloodborne pathogens in dentistry. Dent Clin N Am 70:255-273, 2026.)

HBV CDC guidelines recommend triple panel HBV screening tests for adults at least once to detect HBV surface antigen (HBsAg), antibody to HBsAg (anti-HBsAg), and total antibody to HBV core antigen. The World Health Organization recommends re-confirming with a qualitative in-vitro or rapid diagnostic test. Health care workers should receive postexposure management and treatment promptly, including hepatitis B immune globulin and hepatitis B vaccines, which should be administered as soon as possible after exposure. After 6 months, these individuals should be tested to ensure they remain protected. HCV CDC guidelines recommend universal HCV screening for adults over age 18 years. Diagnosis requires an antibody test; if the antibody test results are positive, supplemental NAT is used.

Post-exposure treatment for HCV is not recommended. The transmission rate from needle-stick injuries is low at 0.2% and 0% for mucocutaneous exposures. HCV PEP effectiveness and duration remain unproven. Education and Training Virtual reality is used in training sessions and has proved effective in lowering the incidence of sharps injuries. As a result, most trainees are less anxious about needle-stick injuries and preventive measure requirements. The Health Belief model shows that for individuals to adopt preventive behaviors, they must recognize their susceptibility, understand the physical and psychologic consequences (severity), and determine action must be taken if the benefits outweigh the obstacles. Use of this model helps to raise awareness about needle-stick injuries, strengthen the perception of health risks, and underscore the importance of prevention (Figure 9).

Figure 4. Various modes of transmission in dental setting. Abbreviation: OPIM, Other potentially infectious material. (Courtesy of Mathai BC, Alnuaimy ZA, Hadad R, et al: Bloodborne pathogens in dentistry. Dent Clin N Am 70:255-273, 2026.)

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Figure 9. Infection prevention guidelines for healthcare worker. (Courtesy of Mathai BC, Alnuaimy ZA, Hadad R, et al: Bloodborne pathogens in dentistry. Dent Clin N Am 70:255-273, 2026.)

Clinical Significance Infection control measures must be stringent in clinical dental practices for health care providers to avoid exposure to BBPs. New pathogens must be controlled using the same proactive and adaptive approaches to infection control outlined in the original universal precautions, coupled with new approaches that may prove more efficacious. Educational training programs should be developed that involve hands-on training regarding the proper usage, handling, and disposal of safety devices to keep health care workers safe. In addition, infection control protocols and postexposure management guidelines should be followed.

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Mathai BC, Alnuaimy ZA, Hadad R, et al: Bloodborne pathogens in dentistry. Dent Clin N Am 70:255-273, 2026 Reprints available from BC Mathai, Dept of Oral and Maxillofacial Surgery, The Christiana Ctr Oral Surgery and Dental Implants, Newark, DE, USA; e-mail: blessy2009@gmail.com

BRUXISM Redefining bruxism BACKGROUND Over the last few decades, the concept of bruxism has changed significantly. Formerly it was considered an oromandibular condition that included sleep bruxism (SB) and awake bruxism (AB) and involved the jaw muscles in grinding or clenching the teeth or thrusting or bracing the mandible. As health care providers became aware that this was an insufficient construct for bruxism, further investigation defined it as an umbrella term for a multifaceted condition requiring standardized assessments. Its etiology is recognized as multifactorial, with a complex interplay of peripheral, psychological, genetic, environmental, and systemic factors. In addition, the Standardized Tool for the Assessment of Bruxism (STAB) was created and advocates for multiple domains. These include self-reported tools, extraoral and intraoral examinations, and instrumental assessments, with electromyographic or ecological momentary assessment (EMA) for AB and polysomnographic (PSG) recordings for SB. Potential risk factors, comorbid conditions, and clinical consequences are also considered within the STAB framework. The outcome is that bruxism is now seen as a muscle behavior that can be indicative of or associated with various underlying conditions. It can be harmless, harmful, or even protective of health outcomes. The current links between bruxism and the various dental specialties was detailed.

IMPLICATIONS FOR DENTAL SPECIALTIES Various dental specialties can be involved in the diagnosis and management of bruxism. Dentists often must deal with its significant effect on occlusal wear, restoration failure, and TMDs, sometimes using appliances or bio-behavioral management. Some SB symptoms can indicate underlying comorbid conditions, such as obstructive sleep apnea (OSA), prompting management by sleep specialists. The relationships between bruxism and the dental specialties were explored. Prosthodontics and Restorative Dentistry Bruxism’s negative clinical effects on dental and supporting structures and restorations are widely recognized and include fractures, attrition, and restoration failure. The result is frustration for the dentist, increased stress, loss of time, and added financial outlay. Before restoring the teeth, the dentist should screen patients for bruxism, snoring, and OSA and plan for restorations using appropriate materials and types. Shear-resistant porcelain and full porcelain restorations may be preferable to porcelain-fused-to-metal restorations. Such possible complications should be included in the informed patient consent discussion. A full-coverage occlusal guard may be fabricated after the restoration is completed and measures planned to mitigate the effects of bruxism.

Periodontics The literature appears to indicate there are no significant associations found between periodontitis and bruxism. Bruxism has, in fact, been associated with better periodontal health. Implants No conclusive evidence exists for the effects of bruxism on dental implants. SB may cause implant fractures, but the links seem to be inconsistent across the available studies. TMDs TMDs involve conditions encompassing muscle and intra-articular disorders, with bruxism often suggested to cause painful TMDrelated pain. Objective measures tend to reveal no significant difference in the frequency or intensity of bruxism between patients with and without TMDs. A recent investigation found that TMD patients have a higher frequency of AB than healthy individuals, usually characterized by jaw bracing. In addition to self-reported bruxism found to be linked to TMDs in early studies, repetitive, low-level, long-lasting, nonfunctional muscle activity is associated with muscle fatigue and pain. Oral appliances may help with managing masticatory musculoskeletal pain in bruxers. Those who brux and have pain in the TMJ or associated structures should be evaluated for systemic factors that contribute to or perpetuate the pain and lead to refractory episodes. Orthodontics Although older orthodontic literature notes a causal relationship between malocclusion and bruxism, a number of the contributing elements appear to be unreliable, such as most bruxism was self-reported and the studies tended to be limited in their ability to draw definite causal temporal conclusions. In addition, many other studies and systemic reviews failed to see the relationship. Some evidence supports a higher likelihood of having crowding in patients with bruxism, and when there is selfreported bruxism in patients having orthodontic treatment, these individuals have a 3-fold higher risk of having TMDs. Occlusal appliances in general transiently reduce bruxism activity but it’s likely to resume within about 3 months. Reports of using clear aligners indicate that there is no effect on sleep and awake bruxism activity, with minor exceptions. Pediatric Dentistry Children can have either primary (without an underlying medical condition) or secondary (associated with a medical condition) bruxism. The prevalence of bruxism in children varies based on the definition used, the diagnostic criteria, and the population.

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Figure 2. Available assessment tools and possible management options of bruxism in pediatric patients. (Courtesy of Thomas DC, Manfredini D, Colonna A, et al: Bruxism. Dent Clin N Am 70:63-74, 2026.)

Comorbid conditions with bruxism in children include sleep disorders, neurodevelopmental disorders, and other syndromes. Some sleep disorders and parasomnias may be associated with parentreported SB. Pediatric dentists have found that nasal obstruction, mouth breathing during daytime or nighttime, limited tongue mobility, and tonsillar hypertrophy are significantly associated with probable SB in more than 90% of affected children. However, no consensus exists on the best and most effective management strategies for pediatric patients. If an underlying condition is suspected, the child should have an interdisciplinary intervention involving pediatricians, sleep specialists, pediatric dentists, and orthodontists to manage the situation. For sleep-related/disordered breathing diagnoses, the frequency of SB may be reduced through tonsillectomy and adenotonsillectomy. The use of a rapid palatal expander may be clinically indicated and can significantly reduce snoring and self-reported SB episodes. Other management options are available for pediatric patients (Figure 2).

CONCLUSIONS Bruxism isn’t considered a disorder but rather a muscle behavior that may be affected by various underlying conditions. It can be a significant concern because of its adverse effects on occlusion, restorations, and TMDs. An interdisciplinary approach is often advisable.

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Clinical Significance The definition of bruxism has been altered based on additional research and the advances in diagnostic and management options. It may even be protective in patients with obstructive apneic episodes. For bruxism patients, dental personnel may be helpful, but other specialists can also contribute to their treatment. The approach should be based on finding evidence of bruxism and performing appropriate diagnostic tests, then crafting interventions to fit the patient’s unique manifestation.

Thomas DC, Manfredini D, Colonna A, et al: Bruxism. Dent Clin N Am 70:63-74, 2026 Reprints available from L Sangalli, College of Dental Medicine – Illinois, Midwestern Univ, 555 31st St, Downers Grove, IL 60515, USA; e-mail: lsanga@midwestern.edu

CROWN PREPS Changes in preps to address problems BACKGROUND Dentists have noted that the new generation of ceramic crowns suffers problems with coming off, caries development on the margins, and sometimes breaking. Several types of preps have been developed to address the type of material used for the crown, the tooth or implant, the patient’s occlusion, esthetic needs, lab spacing of the die, and the cement used. The types of crowns used most often are full cast, ceramic over zirconia, esthetic zirconia, e.max, composite, and porcelain-fused-tometal (PFM) crowns. Challenges related to the routine scanning of impressions, whether by the dentist or by the lab, can introduce weaknesses in the crown and require the dentist to make the prep slightly deeper on the axial walls and occlusal surface. Taking these considerations into account, the optimal preparations for the crown type and the materials selected for crown restorations were explained. The focus is on full-strength zirconia, esthetic zirconia, and lithium disilicate (e.max) crown preps.

Figure 3. Molar preps must be cut slightly deeper for all materials as shown, required because of scanning by dentist or lab and spacing by lab. (Courtesy of Christensen GJ: What is the best type of crown prep? Dent Econ 116:39-40, 2026.)

ESTHETIC ZIRCONIA AND LITHIUM DISILICATE FULL-STRENGTH ZIRCONIA (3Y ZIRCONIA) Full-strength zirconia has a significant lack of breakage while functioning for over 1 decade in the mouth. No 3Y posterior tooth crowns have broken over this period, and 3Y zirconia as thin as 0.3 mm has not broken. Changes have been made in tooth preparations as a result of scanning and spacing that have evolved over a decade of use. Spacing of virtual dies by labs has required dentists to prepare teeth for 3Y zirconia slightly deeper (60 μm) on axial walls and moderately deeper (up to 500 μm) on the occlusal area (Figure 2).

Figure 2. Prep as it was before scanning by dentist or lab showing red line, which is computer spacing. Blue is the internal of the now loosely fitting crown. (Courtesy of Christensen GJ: What is the best type of crown prep? Dent Econ 116:39-40, 2026.)

Over the decade of use, some breakage has occurred in both e.max and esthetic zirconia. When the situation requires esthetics, the dentist should use these more esthetic options, but should also advise patients to be careful when chewing hard foods. The use of 3Y zirconia is appropriate for molars. The tooth prep characteristics needed for these materials have also evolved with the use of scanners and die spacing. The recommendations are 2 mm or more in occlusal reduction, at least 1.5 mm reduction on the axial walls, moderate-depth margin chamfer of about 1.0 mm, and a 20-degree or less lack of parallel from the long tooth axis. The esthetic and e.max products are weaker than the full-strength zirconia and can break, so tooth preps should be deeper than for the full-strength zirconia (Figures 3 and 4).

Figure 4. Example: Premolar preps must be cut deeper for all materials made necessary by scanning by dentist or lab and lab spacing. (Courtesy of Christensen GJ: What is the best type of crown prep? Dent Econ 116:39-40, 2026.)

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Clinical Significance With improved tooth preps, much of the problematic issues with zirconia and lithium disilicate crowns may be addressed. Scanning impressions has altered the crown preps so that the choice of material, the occlusion, esthetic needs, and normal tooth anatomy acquisition are all important components for creating the best crown prep.

Christensen GJ: What is the best type of crown prep? Dent Econ 116:39-40, 2026 Reprints not available

DRUGS Clarifying the use of drugs in dental care BACKGROUND Using accurate drug dosages is essential for ensuring patient safety during dental care. The determination of optimal drug dosages involves considering patient factors such as age, weight, and gender; patient and clinician preferences; and the medical status of the patient. Knowing the proper drug dosages and interactions relevant to each situation is required to deliver safe, effective care and avoid adverse outcomes. Several of the common dental drugs and their appropriate dosages were explained, along with modifications and alternative agents for use in special situations.

COMMON DENTAL DRUGS Anesthesia Anesthesia is a standard procedure for dental practice, often using local anesthesia (LA) to mitigate patient anxiety and provide sedation. Clinicians must balance the effectiveness of anesthesia against the risk of toxicity. These topics should be a critical aspect of training in dental schools, and efforts are needed to standardize the use of anesthesia for dental procedures. Intravenous sedation (IVS) is used to achieve conscious sedation, offering a quick onset, precise titration, and uneventful recovery, among other advantages. Local Anesthesia Dentists use various guidelines when determining appropriate LA doses (Figure 1). However, a pitfall in calculating maximum dosages is the fact that the total volume of each dental cartridge is usually 1.7 mL, but the dental literature refers to it as 1.8 mL. The maximum recommended dosage of various anesthetic agents based on the volume of the cartridge of choice is important information in determining a safe dose (Table 1).

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Epinephrine is a vasoconstrictor added in LA formulations in standard concentrations (usually 1:50,000 to 1:100,000), depending on the specific agent used. Clinicians must consider the patient’s medical condition, especially cardiovascular status, advanced pregnancy, and uremia. LA agents can be combined to enhance efficacy, duration, and onset of anesthesia, but care must be taken to ensure differences in pH don’t cause problems in the event of an overdose. The total administered dose should be limited to 100% of the combined maximum allowable dosages for each agent, although careful clinical judgment and close patient monitoring are needed with LA combinations. Nerve blocks usually can be achieved without articaine and bupivacaine. Clinicians must consider why they feel these should

Figure 1. The guidelines followed for the administration of the LA solution. (Courtesy of Prabhakar S, Sreehari S, Naik V, et al: Drug dosages and interactions. Dent Clin N Am 70:225-242, 2026.)

Table 1. Summary of the Maximum Recommended Dosage of Various Anesthetic Agents in Regards to the Volume of Carpule of Choice Local Anesthetic Agent Articaine Bupivacaine

Concentration 4% 0.5%

1.7 mL Carpule

1.8 mL Carpule

2.2 mL Carpule

68 mg 7.3 carpules

72 mg 6.9 carpules

88 mg 5.6 carpules

8.5 mg 23.5carpules

9 mg 22.2 carpules

11 mg 18.1 carpules

Lidocaine

34 mg 14.7 carpules

36 mg 13.8 carpules

44 mg 11.36 carpules

Mepivacaine

34 mg 11.7 carpules 51 mg 7.8 carpules

36 mg 11.1 carpules 54 mg 7.4 carpules

44 mg 9.09 carpules 66 mg 6.06 carpules

68 mg 7.3 carpules

72 mg 6.9 carpules

88 mg 5.6 carpules

3% Prilocaine

(Courtesy of Prabhakar S, Sreehari S, Naik V, et al: Drug dosages and interactions. Dent Clin N Am 70:225-242, 2026.)

be used, although in most cases articaine and bupivacaine aren’t required. Intravenous Sedation IVS most often uses sedatives such as benzodiazepines, propofol, or adjunctive opioids. The titrated dose is maintained when the patient verbally confirms feeling relaxed and shows physical signs of relaxation. Propofol has limited analgesic properties but offers antiemetic effects and accelerated recovery, so it’s widely employed for general anesthesia procedures. Although up to 6 mg/kg/h has been recommended, doses <3 mg/kg/h can effectively sedate the patient and reduce movement. The dose is administered via slow injection, with a loading dose of 0.5 to 1 mg/kg IV, and an added 0.5 mg/kg IV every 3 to 5 minutes as needed. Inadvertent oversedation can occur, so only qualified personnel should administer propofol. Pregnant women and children under age 3 years should not receive propofol. Adverse effects include hypotension and respiratory suppression, among others. Midazolam has no specific guidelines for its maximum dose in dental practice, but most dentists use a maximum of 7.5 mg. Flumazenil should be available when using midazolam for sedation. The regulations and practice procedures for midazolam vary widely in US dental schools. Opioids are widely known as a gateway to misuse, especially by adolescents, with the initial exposure possibly increasing susceptibility. Genetic predisposition has also been shown to influence opioid misuse and dependency. Clinicians should follow the guidance of the Centers for Disease Control and Prevention and other appropriate guidelines. Nitrous oxide (N2O) provides conscious sedation or relative analgesia in dentistry. Clinicians should be aware that the concentration of gas exchanged at the alveolar level can be as much as 40%

less than the concentration administered. The American Academy of Pediatric Dentistry (AAPD) has recommended dosages for pediatric patients, with exposure limited through the appropriate use of ventilation, equipment maintenance, and compliance with other regulations. The Food and Drug Administration (FDA) has issued warnings against the inhalation of N2O for recreational purposes. Patients should not eat before having conscious sedation to avoid emesis. Scavenging systems can significantly reduce exposure risks for the dental staff. The systems should have regular inspections and maintenance, and they should be monitored every 12 to 14 weeks after installation. Some controversy involves the use of N2O for patients with demyelinating conditions such as multiple sclerosis (Figure 2). Anxiolytics Triazolam is considered safe and effective at a dosage of 0.125 to 0.25 mg. If sublingual administration is added, clinicians achieve a higher drug plasma concentration than that achieved with oral administration. Flumazenil can be used to reverse triazolam’s effects, although complete reversal may not be achieved. The side effects include altered thinking and behavior, aggression, loss of inhibition, variation in blood pressure, amnesia, and congenital malformations if used in the first trimester of pregnancy. Patients with obstructive sleep apnea should not be given triazolam. This drug has a potential risk of tolerance and abuse. Midazolam can be used for sedation for patients with a moderate cardiac safety profile. Adults’ recommended dose is 0.25 to 0.5 mg/kg orally given less than 30 minutes before the dental procedure, with a maximum dose of 20 mg. It is contraindicated in pregnancy. If it’s given intravenously after delivery, mothers shouldn’t nurse their baby until the drug has been eliminated from the mother’s system, and the baby should be monitored for drug side effects. For patients with medical compromise and anxiety, sedatives can be given orally before any dental procedure.

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Figure 2. Contraindications for the use of N2O sedation. (Courtesy of Prabhakar S, Sreehari S, Naik V, et al: Drug dosages and interactions. Dent Clin N Am 70:225-242, 2026.)

Analgesia Clinicians may administer pain control measures before a procedure to reduce postprocedural pain, an approach called preemptive analgesia. This can reduce the need for excessive analgesics during the recovery period. Agents used include corticosteroids and nonsteroidal anti-inflammatory analgesics (NSAIDs). These agents reduce pain, swelling, and mouth opening limitations after procedures such as third molar extractions and implant placement. Postprocedural pain can also include peripheral nerve blocks using longer-acting LA solutions. The preoperative use of propionic acid derivatives can offer better analgesic effects than acetaminophen alone or opioid combinations. Antibiotics No conclusive evidence supports the effectiveness of antibiotic prophylaxis (AP) for dental procedures to prevent infective endocarditis or prosthetic joint infection. The risk-benefit ratio is an important consideration. Antibiotics may also be given after invasive dental procedures to protect against systemic involvement. For immunodeficient patients having invasive procedures that can cause bleeding, antibiotic use is considered essential. The treatment of odontogenic infections does not specify which antibiotics are recommended. Most clinicians prescribe amoxicillin or clindamycin. Antibiotics are considered a nonsurgical therapeutic modality for patients with pulpitis, dry socket, and periapical infections, for example. However, this can produce antimicrobial resistance or cause allergic responses. Antibiotics are not indicated for healthy adults with pulpal necrosis or apical periodontitis if swelling or systemic involvement is absent. If either systemic involvement or acute apical abscess is present,

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antibiotics may be indicated as an adjunct measure for conservative dental treatment. For the antibiotic coverage of pediatric patients, the AAPD recommends amoxicillin. For those allergic to penicillin, macrolides, and cephalosporins, doxycycline is the drug of choice, but for penicillin allergy, azithromycin is the drug of choice, but is associated with cardiotoxicity. Often clinicians prescribe antibiotics for children when they are not indicated. In addition, inconsistencies have been seen in the calibration of antibiotics. Infections of pulpal and periodontal origin but without systemic spread should be managed locally or surgically without antibiotic coverage. The buildup of antibiotic resistance is the result of using too many antibiotics when they are not indicated.

SPECIAL CONSIDERATIONS Antibiotics for Dental Implants The prophylactic antibiotics given before dental implant surgery aren’t supported by conclusive evidence and their benefits are debatable. A single preoperative dose of 1 to 3 g of amoxicillin 1 hour before surgery could decrease implant failure, but the benefits are limited and more research is needed. Drug Interactions Clinicians should be aware of the drug interactions in dentistry and carefully manage the use of pharmacologic agents. Among the most common are the following; •

Warfarin may potentially interact with various medications, especially antibiotics.

•

Herbal dietary supplements can be used along with or instead of traditional pharmacologic agents. Clinicians and patients should be aware of their interactions and effects.

Analgesia in Pregnancy Clinicians also need to consider the systemic changes in pregnancy when prescribing drugs and avoid those that are contraindicated. The risk is for serious repercussions for the fetus. Among the analgesics considered for pregnant patients are the following: Acetaminophen is considered safe for pregnant patients. Young healthy adults can receive 500 mg every 4 hours, with a maximum of 3 g daily. No clear evidence links acetaminophen and the development of attention deficit/ hyperactivity disorder (ADHD), autism, and reduced intelligence. • Opioids and NSAIDs during pregnancy have been used to manage severe pain. Usually oxycodone is the opioid of choice. A low dose of opioids and NSAIDs must be given for a short time to adhere to safety guidelines. The FDA cautions against using NSAIDs during the last trimester of pregnancy and opioids during the first trimester. • LAs are considered conservative measures for pain control. Lidocaine is the safest and most widely used agent during pregnancy. The optimal dose is 2% lidocaine with 1:100,000 epinephrine, with epinephrine used only if its benefits outweigh its risks, which include damage and lack of oxygenation of the fetus. Cardiovascular issues in the fetus have been linked to mepivacaine, articaine, and bupivacaine. • N O should be avoided during pregnancy to prevent the risk 2 of fetal deformities. •

•

Benzodiazepines can cause structural and functional deformities in the fetus and can lead to addiction when given in the last 3 months of conception. Anxiolytic drugs such as zaleplon and zolpidem can be used as alternatives.

Clinicians should consult the patient’s obstetrician before prescribing medications for pain management.

CONCLUSIONS Clinicians should be aware of the guidelines for the use of LAs, antibiotics, and analgesics to avoid risks for adverse reactions or outcomes. It’s important to be cautious when administering drugs that are assumed to be safe during pregnancy, with careful research of the literature and consultation with obstetricians required for safety.

Clinical Significance There is a lack of standardization in the drug dosages that are appropriate for dental care situations. Antibiotic use needs to adhere to the most current evidence and be undertaken with an understanding of the potential for harm such as antibiotic resistance or allergic reactions. Most drugs are not safe for patients who are pregnant or breastfeeding.

Prabhakar S, Sreehari S, Naik V, et al: Drug dosages and interactions. Dent Clin N Am 70:225-242, 2026 Reprints available from S Prabhakar, Rutgers School of Dental Medicine, Newark, NJ, USA; e-mail: prabhakarshranya@gmail.com

IMPLANTS Failure of dental implants BACKGROUND

DEFINITIONS

Although the emphasis in implantology is usually on the technical precision of placement and adherence to established protocols, identifying and managing risk factors associated with implant failure must also be considered an important component in achieving implant success. Often the comprehensive evaluation and mitigation of risk factors are given insufficient time. Dental implant clinicians should develop an in-depth understanding of the factors that contribute to implant failure to ensure a good prognosis and long-term success. Implant failure was defined, its basis was classified, and contributing factors were explained.

No definitive and universally accepted definition exists for implant failure, but implant success is defined as having an implant remain in place with healthy surrounding hard and soft tissues, proper osseointegration, and functional stability without any signs of pathology. There appears to be a spectrum from success to survival to failure. Contributing to the status of an implant are factors such as the achievement of the patient’s desired outcome without complications, any suboptimal success, and the patient’s biologic state. Generally, failure specifically refers to loss of the implant fixture rather than subjective or aesthetic considerations. The 10-year survival rate of dental implants is about 95%. The prevalence of

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early and late implant failure ranges from 0.5% to 5% and 0.5% to 8%, respectively. Factors contributing to failure prevalence are implant design, surgical protocol, and sample characteristics, as well as length of the follow-up period.

Table 3. Patient Factors in Implant Failure Patient Factor Systemic factors

1. Age 2. Smoking 3. E-cigarette and cannabis 4. Diabetes mellitus 5. Osteoporosis 6. Anti-resorptive medications 7. Glucocorticoid 8. Anti-depressant 9. Proton pump inhibitors 10. Radiation therapy (head and neck) 11. Prophylactic antibiotic 12. Immunosuppressants 13. Nonsteroidal 14. Anti-inflammatory drugs 15. Vitamin D 16. Thyroid hormones 17. Cardiovascular diseases 18. Anti-hypertensive medications 19. Movement disorders 20. Genetic disorders 21. Penicillin allergy 22. Inflammatory bowel diseases 23. Fibrous dysplasia 24. Cement-osseous dysplasia 25. Osteogenesis imperfecta 26. Epidermolysis bullosa 27. Oral lichen planus 28. Sjogren syndrome 29. Systemic sclerosis 30. Rheumatoid arthritis � vre Syndrome 31. Papillon-Lefe 32. Psychiatric disorders

Local factors

1. Bone quality (maxillary vs mandibular) 2. Location of implant (maxillary vs mandibular; anterior vs posterior) 3. Raw (immediate) vs healed (delayed) socket 4. Health of oral tissues

Parafunction

Bruxism

Other factors

1. Allergic reaction 2. Periodontal disease 3. History of orthodontic treatment 4. Oral hygiene 5. Post-implant neuropathy and pain

CLASSIFICATIONS Implant failure can be classified as early or late. Early failure is the failure or lack of osseointegration before functional loading of the dental implant and occurs in the first weeks to months after placement. Generally, the initial healing phase fails and represents a biologically driven phenomenon rather than a mechanical or functional problem. In contrast, late failures involve the loss of an osseointegrated implant and occur during or after the restorative phase following occlusal loading. These late failures can be caused by biologic or mechanical complications and are often associated with significant peri-implant bone loss. Compared to early failure, late failure presents more significant challenges in terms of retreatment, costs, and patient dissatisfaction. Failures can also be based on phases of implant treatment. These range from preoperative planning to long-term prosthetic function. Each phase has unique challenges and involves differing risk factors that contribute to failure. In addition, patient factors can cause implant failures. These factors can include systemic, anatomic, and parafunctional factors, as well as others (Table 3).

CONTRIBUTING FACTORS Age Although earlier implant literature reported older age was significantly associated with increased failure rate, more recent studies report no correlation between age and early implant failure except among older adults (80s and beyond). Younger patients have a higher incidence of early implant failure that decreases by about 13% to 15% for every decade of age. Other factors work with age to contribute to failure. Smoking Smoking affects the oral tissues, with both soft and hard tissue integrity compromised. It also contributes to impaired wound healing, dry socket, implant failure, and marginal bone loss near natural teeth and dental implants. Implant failure is increased in smokers. This includes the use of e-cigarettes and cannabis in addition to tobacco. E-cigarettes compromise healing and implant outcomes, and cannabis is linked to impaired gingival healing, inhibition of cell proliferation, and wound repair compromise. Heavy cannabis use causes decreased bone mineral density, lower body mass index, higher fracture rates, and reduced serum levels of vitamin D. The result is a negative impact on soft tissue healing as well as overall bone health. Systemic Factors Local, parafunctional, and patient-related factors can influence implant success and survival (Figure 1 and Table 5). Although

194 Dental Abstracts

Entities

(Courtesy of Rupapara R, Ravi A, Iyer S, et al: Implant failures: Part 1. Dent Clin N Am 70:173-189, 2026.)

there are others, common factors include bruxism, bone quality, implant location, titanium allergy, and oral hygiene. Implant Location Evidence suggests implants placed in the maxilla, especially the anterior region, have higher failure rates than those placed in the mandible. Anterior maxillary region failure may be caused by a combination of anatomic and biomechanical risk factors, such as lack of optimal bone density, unfavorable occlusal loading as a result of implant angulation, and thin cortical bone. Meticulous, site-specific planning is required to avoid problems. In high-

Figure 1. A, Bisphosphonate-induced implant failure. B, Selective serotonin reuptake inhibitor (SSRI)− induced implant failure. C, Radiation-induced implant failure. (Courtesy of Rupapara R, Ravi A, Iyer S, et al: Implant failures: Part 1. Dent Clin N Am 70:173-189, 2026.)

risk regions, bone integration is preferable. Implants that rely on bone compression for stability may be contraindicated in dense bone regions. Post-implant Neuropathy Peripheral nerve injury can cause pain to persist beyond healing. Generally, post-implant neuropathy is the result of iatrogenic injury often caused by direct or indirect trauma. Neuropathic pain can also occur after implant loading. The pain can be burning, shooting, pricking, tingling, or electric shock−like and may occur in continuous or paroxysmal patterns. If nerve injury is suspected during or immediately after

implant surgery, early interventions offer better clinical outcomes and a lower risk of chronic neuropathic pain. Posttraumatic trigeminal neuropathic pain has a poor prognosis, with just a third of patients reporting relief of pain and up to half having no improvement or worsening over time. Management suggestions include a precise imaging-based treatment plan, surgical techniques such as implant drill stops, a safety margin of at least 2 mm from the inferior alveolar nerve, early implant removal or pharmacological intervention for post-implant neuropathic pain, and referral to orofacial pain specialists for evaluation and pharmacologic management.

Table 5. Local, Parafunctional, and Other Patient-related Factors Affecting Implant Failure: Possible Mechanism and Management Local/Other Factors

Potential/Shown Effect on Dental implant

Clinical Pearls in Management

Bruxism

Higher implant failure and prosthetic complication.

Screening of awake and sleep bruxism.

Bone quality

Both very sparse and very dense bone patterns are associated with an increased risk of implant failure.

Modifications of surgical technique.

Raw (immediate) vs healed (delayed) socket

• Conflicting evidence.

• Immediate implant placement should be

• Higher failure rates in fresh extraction socket. • No significant difference in failure rate.

Oral hygiene

• Long-term success is closely associated with the

maintenance of effective oral hygiene.

reserved for cases with sufficient apical bone to ensure initial implant stability. • Design prosthetic components to facilitate easy

maintenance. • Comprehensive oral hygiene instructions and

emphasize their importance. Allergic reactions

• Titanium allergies, though rare, are clinically

relevant and should be considered during treatment planning, as they can contribute to implant failure. Periodontitis

• Lower survival rates compared to those in

History of orthodontic treatment

periodontally healthy patients. • No significant difference in implant failure rates with or without prior orthodontic treatment.

• Zirconia implants present a viable alternative, as

no-documented allergies to zirconium oxide currently exist. • Comprehensive periodontal treatment should

precede implant placement to minimize risks.

(Courtesy of Rupapara R, Ravi A, Iyer S, et al: Implant failures: Part 1. Dent Clin N Am 70:173-189, 2026.)

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Clinical Significance Thorough evaluations as well as appropriate patient selection are critical factors in reducing the risk of dental implant failure. Few absolute contraindications exist to dental implant placement, with most conditions manageable through meticulous treatment planning. Patients should be educated about any risk factors involved in their care and how they will be managed in the informed consent discussion. Systemic conditions should prompt collaboration with the patient’s medical physician to ensure optimal control of the situation and successful dental implant outcomes.

Rupapara R, Ravi A, Iyer S, et al: Implant failures: Part 1. Dent Clin N Am 70:173-189, 2026 Reprints available from DC Thomas, Dept of Diagnostic Sciences, Ctr for Temporomandibular Disorders and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA; e-mail: davisct1@gmail.com

Surgical, restorative, and aesthetic phases of implant failure BACKGROUND Dental implant failures can involve biologic, mechanical, or aesthetic functions that aren’t met. Clinicians need to understand the causes of these failures and their management options so they can create optimal conditions for successful function and patient satisfaction. Various measures can be taken to address problems in implant placement, even removing the implant to address failure of osseointegration. The surgical, restorative, and aesthetic phases of implant failure were addressed.

SURGICAL PHASE Errors in diagnosis and treatment planning or in the surgical procedure can lead to surgical failures. Among the most common failures are those occurring during a flapless implant placement, when the patient has preoperative acute or chronic infections at the implant site, where there is a lack of initial stability, and when a fracture occurs. Flapless Implant Placement Implants placed using the flapless technique are inserted after the gingival tissue is perforated using a tissue punch or rotary instrument without elevating or reflecting the flap. This technique can provide a successful implant if done after proper patient selection and precise execution. It’s recommended only for experienced surgeons because it requires a blind surgical approach, carries a higher risk of cortical bone perforation, can create improper implant depth, may lead to bone overheating, and can reduce keratinized gingiva after placement.

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Acute and Chronic Infections A delay in implant placement by 3 to 4 months is appropriate if there is an acute infection at the implant site. Chronic dentoalveolar infections increase the risk of bacterial contamination as well, possibly leading to delayed implant periapical lesions or retrograde peri-implantitis, both of which can cause implant failure. Clinicians can place implants successfully if a previously infected area is thoroughly debrided and disinfected. If primary stability is achieved and all infected tissues are removed, immediate implant placement may be considered. Otherwise, the socket should be grafted and implant placement delayed to permit proper healing and fewer complications. Antibiotic prophylaxis, thorough cleaning, and debridement are needed preoperatively and postoperatively. Lack of Initial Stability Contributing factors to low torque during implant placement include overpreparation of the implant site, repeated in-andout drilling, and placement in low-density bone, along with others. A conservative approach during osteotomy preparation helps to ensure sufficient implant stability. If the implant is loose, it should be removed and replaced with a longer and wider one, the site may be abandoned for a more favorable one, or the clinician can graft the site and allow a 4-month healing period before attempting implant placement in the same area. Fracture Fracture of an implant can occur during placement or after delivering the implant-supported prosthesis. Factors that contribute include reduced implant diameter, placement in the molar and

Table 2. Implant Failures in the Restorative Phase Type of Failure Screw loosening

Causes

Management

• Inadequate torque.

• Use of calibrated torque wrench for precise

• Excessive overload and pitting corrosion in

titanium. • Improper screw/ abutment design. • Bruxism or parafunctional movements. • Fatigue of screws due to wear and tear.

torque application. • Implant designs with internal implant abutment

connections. • Avoid excessive occlusal load and repeated

tightening of screws. • Use wider implant diameters and longer

abutment collars. • Use high-quality materials, like gold or

diamond-coated screws. Fracture of the frame work

• High occlusal loads from teeth grinding. • Poorly designed framework.

• Use fatigue-resistant materials, such as titanium

alloys or zirconia.

• Material fatigue from repeated loading.

• Ensure precise fitting of the implant framework.

• Corrosion due to environmental factors.

• Design framework with uniform load distribution. • Minimise angulation and occlusal stress by using

an appropriate occlusal design. Fracture of abutment/ screw

Chipping or fracture of veneering material

• Over-tightening.

• Use correct torque settings.

• Multiple manipulations of screws leading to

• Select high-quality materials for screws and

material fatigue. • Incorrect torque application.

• Ensure proper alignment during placement.

• High occlusal forces.

• Use porcelain fused to metal for better durability,

abutments.

• Material incompatibility.

as zirconia reported higher veneer chipping.

• Lack of proper bonding.

• Ensure proper bonding between veneer and core

• Air bubble entrapment.

material. • Avoid high occlusal forces and stress points. • Monolithic zirconia.

Decementation

• Improper manipulation of luting agent. • Voids in the luting agent.

• Follow manufacturer’s guidelines for resin luting

agent application.

• Incompatible luting agent.

• Ensure complete curing of the luting agent.

• Inadequate surface preparation.

• Properly prepare the abutment and restoration

• Improper fit of the prosthesis.

surfaces. • Check for occlusal contacts and use occlusal

guards if necessary. (Courtesy of Iyer S, Annamma LM, Rasheed MH, et al: Dental implant failures: Part 2. Dent Clin N Am 70:191-208, 2026.)

premolar regions, and the design and material used. Other causes include cantilevered prostheses, biomechanical overload from bruxism or excessive occlusal forces, severe peri-implant bone loss, and male gender because of men’s stronger bite forces.

RESTORATIVE PHASE During the restorative phase, failure of the implant can result when the intended function is affected irrevocably. This includes abutment screw loosening, framework fracture, abutment/screw fracture, chipping or fracture of veneer material, and decementation. The factor of most concern is screw loosening. Screw Loosening The screw connects the implant to the abutment and the abutment to the prosthetic crown or fixed partial denture. Various factors can contribute to screw loosening (Table 2), including anterior restoration with external

connection implants and metal abutment material. Measures to reduce screw loosening include angulation-correcting implants, torque precision, screws coated with gold or diamond, and choosing a wider implant diameter with an increased abutment collar length. Framework Fracture The framework connects the implants and holds the prosthetic components in place. If it fractures, this functional and aesthetic failure requires a complete prosthesis replacement. External hexagon implants don’t prevent microleakage in static and dynamic loading compared to internal conical implants. Oral environmental factors and repeated exposure to hot and cold foods can cause corrosion or material degradation and weaken the framework, especially if it’s metal. To avoid framework fracture, the clinician should use high-quality, strong, fatigue-resistant materials such as titanium alloys, zirconia, or high-noble-content metal alloys. A minimum angulation in the implant placement is more successful. In addition, artificial intelligence finite element

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Figure 5. High aesthetic risk factors. (Courtesy of Iyer S, Annamma LM, Rasheed MH, et al: Dental implant failures: Part 2. Dent Clin N Am 70:191-208, 2026.)

analysis is now available to evaluate issues with the framework design.

favor PFM, with monolithic zirconia a good option compared to veneered zirconia.

Abutment/Screw Fracture The abutment connects the dental implant to the prosthetic restoration, transferring forces from the prosthetic crowns to the implant during function. Fractures of the implant abutment are rare, with most within the internal conical implant-to-abutment connection. Fractures can result from over-tightening and multiple manipulations of the screw, which can create material fatigue. The fractured screw should be removed for prosthodontic restoration. The rate of failures in implant-supported fixed partial restorations is greater than for single-implant prostheses. If the screw fracture occurs at the apical portion of the implant body and cannot be retrieved after assessing the implant’s osseointegration, a custom-made post and core may be required.

Decementation When bonding between the restoration and the implant abutment, decementation occurs and the prosthesis detaches from the implant. Bonding fails between the luting agents that secure the prosthesis and can lead to functional and aesthetic failure. Cement-retained implants with single crowns and prostheses have more failures than screw-retained prostheses. Fixed prostheses have a lower decementation rate than single crowns. Prevention of decementation requires careful adherence to the manufacturer’s guidelines for luting agent application, with the luting agents completely cured before the patient bites down, and with proper isolation before the luting is done.

AESTHETIC PHASE Chipping or Fracture of Veneer Materials Fracture of veneer materials is also termed chipping. Porcelain fused to metal (PFM) has more data regarding longevity of service than zirconia, but zirconia veneers may suffer highresidual tensile stress, large chip size, and low resistance to interfacial energy between the veneer and the core. Longevity data

198 Dental Abstracts

Aesthetic implant failure refers to an inability to meet the visual expectations of the dentist or the patient or both. Often the prosthesis appears unnatural or fails to blend with the adjacent teeth. Patient-reported outcomes (PROs) capture the patient’s own evaluation of their health without clinician interpretation and are assessed through self-administered questionnaires.

Higher satisfaction levels are common with well-informed patients who have realistic expectations. Measuring Aesthetic Failures Aesthetics are subjective but ways to capture objective measurements have been developed. Combining the professional’s and patient’s evaluations will reduce the subjectivity of aesthetic evaluations. The Pink Esthetic Score/White Esthetic Score Index is often used to assess aesthetics in single implant-supported crowns. Several other indices are used historically, including Jemt’s Papilla Index, Subjective Esthetic Score, Implant Crown Aesthetic Index, Implant Esthetic Score, implant restoration esthetic index, peri-implant and crown index, complex esthetic index, and the Copenhagen index score. PROs are determined using numerical scales, visual analog scales, the Oral Health Impact Profile, and the Psychological Impact of Dental Aesthetics Questionnaire, along with newer indices. Risk Factors The aesthetic zone will vary depending on the width of the individual’s smile and can extend up to the second premolar. Implant placement in this zone is complex because patients have high expectations (Figure 5). Aesthetic failures are divided into pink and white. Some unusual aesthetic complications have been noted

with maxillary anterior segment implants. These are being investigated.

Clinical Significance The skill of the clinician is an important contributing factor but other factors also play a role in the success or failure of implants. Surgical, restorative, and aesthetic causes of failure exist, so the clinician must be adept at surgical planning, precise prosthetic execution, and continuing patient education and follow-up. Proper case selection, technique, communication with the patient, and understanding of his or her expectations, especially in the aesthetic zone, are significant components in achieving a successful implant placement.

Iyer S, Annamma LM, Rasheed MH, et al: Dental implant failures: Part 2. Dent Clin N Am 70:191-208, 2026 Reprints available from N Ahmed; e-mail: dr.ahmednoa@gmail.com

Maintaining dental implants BACKGROUND Because dental implants are now placed in patients of the general population rather than being limited to early edentulous individuals, dental clinicians must educate implant patients on how to maintain their implant superstructures and abutments. The pellicle that develops on titanium differs from that developing on enamel and cementum, so it requires a different approach to cleaning and maintenance measures. A healthy implant has no clinical signs of inflammation, bleeding, suppuration, increased probing depths, and bone loss on radiographs. Clinical challenges can arise during probing around implants, and radiographs may offer problems with making clinical diagnoses. Patients need to be educated about the maintenance care they should provide for their dental implants, which includes hygiene measures. In addition, clinicians must assess dental health by using special care approaches for implants.

HYGIENE MEASURES Among the hygiene measures patients will perform are removing plaque, flossing and using interdental brushes, and using irrigation devices. Because the materials in the implants and the oral

structures surrounding implants are not the same as for natural teeth, it’s important to be aware of the pitfalls and the best ways to maintain a clean dentition. Plaque Removal The surface chemistry and design features of an implant abutment or collar are significant factors in biofilm formation because of surface free energy. The pellicle on titanium surfaces tends to consist of cystatins and low-molecular-weight mucin, whereas that found on enamel surfaces is high-molecularweight, proline-rich glycoproteins (Figures 3 and 4). Because the plaque grows faster on titanium than that on enamel, effective plaque removal is needed for dental implants. An electric toothbrush tends to be more effective at plaque removal than a manual toothbrush. It’s also important to maintain a correct, consistent approach to plaque removal. Studies find that there is a clear individual patient pattern in the amount of plaque formed on implant abutments. In addition, dual acid-etched surfaces have significantly less marginal bone loss than machined surfaces.

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Figure 3. Plaque and calculus adherence to an old IMZ (intramobile cylinder) implant surface, resulting in its exfoliation. (Reproduced with permission from Barclay C: Oral Implantology: Assessment to Maintenance, BDJ Clinician’s Guides. Springer Nature Switzerland AG: Cham, Switzerland, 2024. Courtesy of Barclay C: Implant maintenance and aftercare. Br Dent J 240:93-96, 2026.)

Flossing and Interdental Brushes Several hypothetical concerns have been raised concerning flossing around dental implants. These include a less well-innervated soft tissue around the dental implant than around a tooth, so the pain sensation caused by incorrect flossing may not deter a patient from proceeding. Flossing can also be problematic and can thread, leaving floss remnants in the soft tissues around dental implants. Patients must be instructed to never push the floss down into the gingival pocket. If they can’t floss around a restoration without disturbing the peri-implant seal, they should not floss at this site at all. Interdental brushes have been found effective in removing plaque as far as 2 to 2.5 mm below the gingival margin. Various interdental brushes are useful for cleaning the interproximal surfaces of teeth and implants. It’s wise to select an interdental brush with the correct size and shape for the patient who will be using it.

Figure 4. Plaque and calculus adherence to an old IMZ (intramobile cylinder) implant surface, resulting in its exfoliation. (Reproduced with permission from Barclay C: Oral Implantology: Assessment to Maintenance, BDJ Clinician’s Guides. Springer Nature Switzerland AG: Cham, Switzerland, 2024. Courtesy of Barclay C: Implant maintenance and aftercare. Br Dent J 240:93-96, 2026.)

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Figure 5. Probing around a dental implant. (Reproduced with permission from Barclay C: Oral Implantology: Assessment to Maintenance, BDJ Clinician’s Guides. Springer Nature Switzerland AG: Cham, Switzerland, 2024. Courtesy of Barclay C: Implant maintenance and aftercare. Br Dent J 240:93-96, 2026.)

Irrigation Devices Oral irrigators for implant maintenance have been linked to significantly greater bleeding reductions than carrying out flossing around implants. The adjuvant use of an oral irrigator and 0.06% chlorhexidine along with mechanical biofilm removal and oral hygiene instruction can reduce the presence and severity of peri-implant mucositis after 12 weeks of treatment. Biofilm removal can be significantly improved with an oral irrigator and either chlorhexidine or Listerine aids.

ASSESSING DENTAL HEALTH Keratinized Mucosa Around the Collar The amount of soft tissue recession can be significantly increased at implant sites with narrow keratinized mucosa, but the amount of keratinized mucosa has not affected the deepening of periimplant pockets. Lack of sufficient keratinized mucosa around an implant may impede proper oral hygiene and compromise aesthetics. With sufficient keratinized tissue, there is less plaque accumulation, gingival inflammation, recession, and bone loss. Bleeding on probing, plaque index, and probing depth are not altered by the amount of keratinized tissue present. It’s generally accepted that patients will be better able to clean effectively around a dental implant if a collar of keratinized mucosa is present. Probing Around Implants Because dental implants have no cementum layer covering their surface, no soft tissue attachment such as that seen with a natural tooth exists. Collagen fiber bundles are present but originate from the bone surface and run vertically and parallel to the implant surface. If a platform switch has occurred, the shape of the junction between the implant and the abutment/crown may not accept conventional dental probing. Bleeding on probing around dental implants can be the result of disrupting the fragile soft tissue architecture of the collar rather than indicating

marginal bone loss and inflammation. Gingival health can be monitored by observing the tissue to see if the peri-implant mucosa is inflamed or there is exudate from the soft tissues (Figure 5). Bone Loss Criteria If a dental implant has a peri-implant bone loss exceeding 1.0 mm in the first year and more than 0.2 mm per year thereafter, it should be considered to be failing. The clinician should appreciate the difference between physiological bone loss around a dental implant and pathological bone loss. Determining whether the pathological bone loss is acute or chronic will dictate the measures needed to maintain the implant and manage the pathological condition.

Clinical Significance Keeping a dental implant free of plaque and other adverse conditions requires an awareness of the fragility of the implant system and the need to tailor care to each individual patient. Dental clinicians should coach patients in the best measures to take to keep their implants clear of plaque and healthy, with regular follow-up checkups to ensure that the goal is being met.

CONCLUSIONS Patients require guidance on how to maintain their dental implants. Clinicians should evaluate the situation and ensure that the patient is aware of what is needed and when he or she should contact the clinician for additional measures.

Barclay C: Implant maintenance and aftercare. Br Dent J 240:9396, 2026 Reprints available from C Barclay; e-mail: craig.barclay@mft.nhs.uk

NANOTECHNOLOGY Using nanotechnology in dental situations BACKGROUND Nanoscience and nanotechnology are the study and application of functional materials at the nanoscale, which means structures measuring about a billionth fraction of a meter (10−9). In medicine, nanotechnology and nanoparticles (NPs) are used in imaging and targeted drug delivery to cancer and diseased cells. In dentistry, NPs and nanomaterials are used to improve oral health and treatment outcomes. Nanoscale modifications optimize physicochemical properties such as increased surface area, better reactivity, size-dependent optimal properties, and improved mechanical and thermal characteristics compared to their larger cousins. In dentistry, the improved antimicrobial, bioactive, and regenerative potential of NPs may be useful in a wide range of dental areas (Figure 1). A look at the range of nanotechnology in dental settings shows the potential of NPs.

DENTAL APPLICATIONS OF NANOTECHOLOGY Applications for NPs have been identified in preventive dentistry, restorative dentistry, endodontics, prosthodontics, periodontics, orthodontics, and oral medicine and oral pathology. In some cases the NPs are incorporated into products that are already in use, whereas research is underway for other uses that aren’t yet available to the public.

Preventive Dentistry NPs have been incorporated into dental products in the hope of preventing dental caries. This includes mouthwashes and dentifrices. Mouthwashes need to have rapid action, be safe, and achieve targeted actions without disrupting beneficial oral bacteria. Silver NPs and iron oxide NPs are used to reduce harmful bacteria and dental plaque in alcohol-free mouthwashes. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) nanocomplexes help prevent tooth demineralization and promote remineralization. Mouthwash with nanosilver and xylitol has been shown to be more effective in reducing lesions than mouthwashes with 0.05% chlorhexidine or fluoride. Dentifrices containing nano-sized calcium carbonate (NC) particles raise the mineral content in early enamel lesions, so that they adhere to tooth surfaces and continue to release calcium and promote apatite minerals in carious lesions. Bioactive glass NPs repair enamel by reducing mineral leaching and facilitating remineralization. Dentifrobots aren’t yet in clinical use, but they are magnetically controlled robots in mouthwashes or toothpaste that can evaluate the gingiva, remove dental plaque and pathogenic microbes, support beneficial bacterial, and produce a healthy oral environment.

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Figure 1. Implications of nanotechnology and nanoparticles in dentistry. (Courtesy by Dr Anu Priya Guruswamy Pandian, BDS, MDS. Courtesy of Pandian APG, Walhekar A, Jujuru SR, et al: Nanotechnology and nanoparticles. Dent Clin N Am 70:155-172, 2026.)

Restorative Dentistry In restorative dentistry, NPs are primarily used to enhance the mechanical and physical properties of dental materials. This includes dental adhesives and composites and glass ionomer cements (GICs). In composite resins, silica, zirconia, and hydroxyapatite (HAP) are the most used NPs and can enhance optical properties, wear resistance, and polishability, while minimizing polymerization shrinkage. They also offer biomineralization and anticaries activity, reinforcement of the resin-dentin bond, durability, and antibacterial properties. The use of NPs in GICs minimizes porosities and microcracks in set cement, improving strength. HAP NPs and fluorapatite NPs can enhance the tensile, compressive, and flexural strength of GICs. Currently, nano-GICs tend to be limited for clinical use. Endodontics The uses of nanomaterials in endodontics are focused on enhancing antimicrobial activity, improving mechanical properties of dentin, and regenerating pulpal and periapical tissues. No widely accepted NP-enhanced intracanal medicaments, commercial irrigants, or obturating materials are currently available for clinical use. The applications that have been studied include NPs in root canal disinfection, drug delivery, regenerative endodontic procedures, and nano-based endodontic sealers. Among those used in root canal disinfection are silver, chitosan, and metal and metal oxide NPs. For antimicrobial photodynamic therapy, NPs carry photosensitizer molecules and can combine, encapsulate, or load photosensitizers to enhance antimicrobial efficacy. Biodegradable NPs achieve targeted drug delivery with chitosan NPs and polyester-

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based NPs to enhance biocompatibility and low cytotoxicity. The chitosan NPs can trigger the reparative and antibacterial properties of calcium hydroxide. Nanofibrous scaffolds offer enhanced mechanical properties for the controlled and sustained release of embedded bioactive molecules. This may involve nanospheres and nanocapsules used as drug carriers. Nanofibers are under research for a possible use in enhancing the proliferation of dental pulp stem cells and odontogenic differentiation. Chitosan NPs can condition dentin to promote adhesion, cell viability, and differentiation. Bioceramic NPs such as zirconia, glass-ceramics, and bioglass enhance the adhesion to dentin and facilitate the release of calcium and phosphate ions. Epoxy resin−based sealers are improved by the addition of quaternary ammonium polyethyleneimine (QPEI) NPs. Prosthodontics Nanotechnology has been used to improve the antimicrobial and mechanical properties of materials used in prosthodontics, enhancing the strength and reactivity by forming new, strong bonds that are more effective than larger micro-particles or macro-particles. In particular, polymethyl methacrylate (PMMA) denture base and implants have received NPs. Copper, titanium, zirconium, and silicon NPs have been used to increase the durability and performance of the denture base resins and make them more reliable. NP-based PMMA materials are mostly in experimental phases. Implant surfaces can be coated with HAP NPs to enhance soft tissue attachment and bone growth, which stabilizes the placement. In addition, implants with certain nanoscale features, such as nanogrooves and nanopillars, significantly improve osseointegration. Because they also enhance bone regeneration

and encourage blood vessel growth around the implant site, NP contribute to the long-term success of implants. Managing peri-implantitis using nanotechnology has also been suggested. Conditioning the implant surface with citric acid and applying HAP NPs can stabilize the blood clot, promote fibroblast proliferation, enhance tissue regeneration and improve implant integration. Few NP-coated implant systems are currently available, with most still being tested for clinical viability. Periodontics Most NP applications in periodontics are under experimental investigation, with proposed uses including drug delivery systems. They offer antimicrobial properties to combat gramnegative bacteria linked to periodontal infections, tissue regeneration and prevention of alveolar bone resorption, and diagnostic applications. These NPs can achieve early, rapid, and accurate detection of periodontitis. Orthodontics NPs used in orthodontics are primarily used to inhibit bacterial colonization on orthodontic appliances. This minimizes the risk of dental caries and white spot lesions during treatment. Silver HP−coated appliances have better anti-adherence activity against Streptococcus mutans and offer an alternative to metal-based orthodontic materials. Nanofillers can enhance mechanical properties and provide antibacterial effects. Coating stainless steel or nickel-titanium arch wires with NPs minimizes friction between wires and brackets and enhances tooth movement. Clinical applications of these nanotechnologies are not yet practiced. Oral Medicine and Oral Pathology Oral cancer detection and treatment can be improved using NPs, especially in more precise detection and targeted therapy areas. Semiconductor nanocrystals (quantum dots) are highly sensitive probes that help in detecting cancer biomarkers even at low concentrations. They can also recognize hidden tumors. Treatment involves combining therapeutic agents with drug carriers, permitting targeted delivery, better stability, and the controlled release of the therapeutic agents. This approach can minimize adverse effects. Gold NPs are used extensively

to inhibit cancer cells by inducing targeted cellular apoptosis and helping to delineate tumor margins for more accurate surgical resection. They can also serve as drug delivery agents. Other NPs promote programmed cell death or help in controlling pain. Oral medicine and pathology uses are primarily experimental at this time. A nano-formulated version of resveratrol offers better solubility, an extended half-life, improved stability, and better pharmacokinetic and pharmacodynamics properties than the natural polyphenolic compound resveratrol.

TOXICITY OF NANOPARTICLES Extensive biocompatibility studies must be done for NPs because metal and metal oxide NPs demonstrate cytotoxicity. Some nanomaterial liposomes, solid lipid NPs, and dendrimers used as dental nanomaterials have demonstrated nanoemulsions that require modification to improve the nanomaterials’ biocompatibility. The smaller size, greater surface area, and reactivity require ongoing assessment protocols to be in place to test for toxicity, characterization, and quality control.

Clinical Significance Nanotechnologies and NPs have demonstrated enhanced diagnostic, therapeutic, and preventive care in mostly experimental dental situations. Dental materials can be improved with respect to mechanical properties, antimicrobial activity, and targeted drug delivery by adding nanotechnology. Currently many of these clinical uses are still under study, with further research needed to assess long-term biocompatibility and the safety of NPs.

Pandian APG, Walhekar A, Jujuru SR, et al: Nanotechnology and nanoparticles. Dent Clin N Am 70:155-172, 2026 Reprints available from APG Pandian, 6130 Nevada Ave, Apt E107, Woodland Hills, Los Angeles, CA 91367, USA; e-mail: dr.anupriyagowtham@gmail.com

ORTHODONTICS Anomalies in developing dentition BACKGROUND Anomalies in the developing dentition should be identified as early as possible to allow for the child to have a stable, aesthetic, and functional occlusion. Delayed referrals can require more complex treatment with adverse sequelae. General dental

practitioners (GDPs) are responsible for assessing the child’s teeth and noting any problems in the developing dentition, then referring or performing treatment, depending on their level of experience and competence. The common anomalies that should be identified during the primary dentition (ages 3 to

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5 years), early mixed dentition (ages 7 to 9 years), and late mixed dentition (ages 10 to 12 years) were identified, and treatments that could be undertaken at each stage were outlined. Being aware of these key anomalies and addressing them early on will prove to yield more successful management and avoid adverse outcomes.

PRIMARY DENTITION Nonnutritive Sucking Habits Nonnutritive sucking habits, including the use of pacifiers and thumb sucking, that persist for more than 6 hours a day can adversely affect the child’s developing dentition. This habit often carries a psychological element, with the child using it to selfsoothe. Generally, children grow out of the habit by age 3 years, but some can persist because of life experiences involving stress and sadness. In these persistent cases, children may develop an anterior open bite, a unilateral posterior crossbite, maxillary incisor proclination, or retroclination of the mandibular incisors with an increased overjet. Management A combination of interventions is often needed, along with behavior modification methods and psychological support. The techniques should be employed for at least 6 months. Physical barriers may be used to help with habit cessation, as can orthodontic habit breakers. No treatment modality has been found to be superior to the others. If the habit remains when the child reaches permanent dentition, he or she can develop irreversible changes that can only be managed with complex orthodontics or orthognathic surgery that achieves various levels of stability. Early interventions may allow for self-correction and avoid complex treatment.

EARLY MIXED DENTITION Unerupted Central Maxillary Incisors Most maxillary incisors erupt at age 7 to 7.5 years. They are the third most impacted tooth and affect boys more than girls. Unerupted maxillary incisors are unattractive and can negatively affect facial and dental aesthetics, self-esteem, and social interactions. Usually failure of eruption is associated with a supernumerary, ectopically positioned, or traumatically altered tooth in the primary dentition. Diagnosis During the routine examination of a child age 6 to 9 years, the GDP should note when a contralateral incisor has erupted more than 6 months previously, when the opposing tooth has been erupted for more than 1 year, and when the normal sequence of eruption has deviated from usual. Children may also have a primary incisor that is retained, lack of space due to rotations, or a lateral incisor that has drifted into the central

204 Dental Abstracts

incisor space. The adjacent teeth should be evaluated for angulation and inclination, along with any labial and palatal swellings. If a delayed or unusual eruption pattern is noted, radiographs should be obtained. Usually a parallax with 2 radiographs at different angulations can add to finding the position of the incisor and any obstructions. A horizon parallax using periapical radiographs or a vertical parallax using periapical and upper standard occlusal or a panoramic radiograph and upper standard occlusal can be obtained. Cone beam tomography (CBCT) can be used in cases where it’s justified. Referral to a local orthodontic practitioner is done promptly. Earlier referral is associated with better outcomes because of the eruptive potential of the tooth with an immature apex and to avoid space loss with tipping of adjacent teeth. A negative psychosocial impact can occur if treatment is delayed until the child enters secondary school and is bullied, which is common among those age 12 to 14 years. Management A robust and comprehensive treatment plan should be made before using the general anesthetic is administered (Table 2). An orthodontic/pediatric dentistry assessment should be done to determine if the incisor may be removed because of significant ankylosis or dilacerations. Space for the eventual placement of a fixed or removable replacement prosthesis should be planned. Autotransplantation is another option, with a developing tooth, such as a premolar, used to replace the unerupted central incisor. Management includes surgical removal of the physical obstruction alone or removal of the obstruction and creation of space for eruption orthodontically with surgical exposure of the unerupted incisor. When the obstruction is to be removed under general anesthetic, concurrent exposure and bonding of an orthodontic attachment should be done to avoid the need for repeat general anesthesia. After receiving treatment, the child should be monitored closely because nearly half of these children will have an impacted canine on the ipsilateral side. Less than 5% have the impaction on the contralateral side. Infraocclusion of Primary Molars In 8% to 14% of children in the early mixed dentition stage primary teeth can become ankylosed and infraoccluded, failing to maintain their vertical position in relation to the occlusal plane. Failure to detect the problem can cause complete infraocclusion below the mucosa and requires surgical extraction, which leaves vertical bony defects and can be difficult to restore. Infraoccluded teeth are normally ankylosed, which is confirmed by the presence of a metallic sound on percussion. The child may

Table 2. Factors Considered During Treatment Planning for Impacted Incisors

Table 3. Clinical Assessment of Maxillary Canine Development and Eruption

Patient factors

Dental factors

Clinical assessment

Medical history

Position of the impacted incisor particularly vertical height. A higher vertical position has been associated with a lower chance of spontaneous eruption after removal of a supernumerary Nature of the physical obstruction (such as the morphology and location of the supernumerary)

Cooperation and compliance with varying treatment modalities Patient and parental preference

Unfavourable root formation (such as dilaceration). Chaushu et al. (2015) reported a high risk of failure with dilacerated incisors

Age of the patient (correlating to root development stage)

Stage of root development

(Courtesy of Elsherif N, Murthy VE, Moseley H: What to spot and what not to miss: Key anomalies during the developing dentition. Br Dent J 239:836-842, 2025.)

have potential space loss, tipping of adjacent teeth, and overeruption of opposing teeth, plus centerline shifts and lateral open bites. Infraocclusion can be classified as mild, moderate, or severe. In mild infraocclusion the occlusal surface is less than 2 mm below adjacent teeth, in moderate cases it’s at the level of the interproximal contact, and in severe cases the occlusal height is below the interproximal contact. Management Infraoccluded primary teeth can’t be managed with orthodontic treatment. The severity of the infraocclusion, the age of the patient, and the presence or absence of the successional premolar, along with other factors in the malocclusion, will dictate the treatment options. Maintenance of the retained primary molar may preserve buccolingual bone volume for future implant cases. GDPs should conduct thorough investigations of patient-specific factors when determining whether to extract or maintain the successor tooth and should make the decision in conjunction with a pediatric orthodontist. Teeth should be maintained if there is hypodontia of the premolar, root length and remaining coronal tooth structure are good, and the infraocclusion is not considered severe, risking submergence below the mucosa, occlusal disturbance, or food impaction that causes caries and periodontal disease. The occlusal height can be restored to prevent tipping, overeruption, and crowding of adjacent teeth, especially if the premolar is hypodontic. The GDP can use composite or preformed metal crowns to accomplish this. Extraction is indicated if there is a risk

Visual inspection

Features • Delayed eruption of the canine • Retention of the deciduous canine with lack of

mobility • Asymmetry of dental development • Inclination and angulation of the lateral incisor,

which may indicate impingement of an impacted canine on its root • Children with dental anomalies have a 2.5-fold increased risk of developing an impacted canine compared to those without dental anomalies. The anomalies include microdont lateral incisors, hypodontia of any tooth or impaction of other teeth Palpation

• Commenced from the age of ten with 70% of

canines palpable, increasing to 95% by 11 years of age. A palatal bulge may be palpable if the tooth is palatally impacted (Courtesy of Elsherif N, Murthy VE, Moseley H: What to spot and what not to miss: Key anomalies during the developing dentition. Br Dent J 239:836-842, 2025.)

for future submergence, the premolar has signs of a disturbed eruptive path with distal tipping under the primary molar, or the premolar has more than half to two-thirds of the root formed and the primary molar does not move.

LATE MIXED DENTITION Ectopic Maxillary Canines Girls are 2.3 to 3 times more likely to have maxillary canines that are ectopic compared to their male counterparts. Three-fourths of the maxillary impacted canines are palatal because buccal canines often erupt buccally but are displaced because of crowding. Failure to diagnose an ectopic maxillary canine early results in long-term orthodontic treatment and the potential resorption of adjacent teeth. Canine eruption should be evaluated by the GDP in the late mixed dentition period. Those with normal eruption paths should be palpable in the buccal sulcus by age 10 to 11 years and erupt at a mean of 10.8 years in girls and 11.6 years in boys. The individual variation ranges from 3 to 4 years (Table 3). Diagnosis Radiographic assessment is needed if the canine isn’t palpable and its position can’t be ascertained. The parallax method may be used, or the clinician could proceed directly to the use of a CBCT as clinically indicated. Sometimes the GDP takes a panoramic radiograph and sends the patient to the specialist for evaluation regarding the need for additional imaging. Early palpation of canines should be done to avoid delays in diagnosis. In children

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Figure 1. Summary of the key anomalies that can occur during the different stages of the developing dentition. (Courtesy of Elsherif N, Murthy VE, Moseley H: What to spot and what not to miss: Key anomalies during the developing dentition. Br Dent J 239:836-842, 2025.)

under age 12 years, referral for an orthodontic assessment should be made if there is no buccal bulge and no mobility of the primary canine, if there is symmetric eruption at age 11 years, and if there is a palatal bulge. Management Once the child has been seen by the orthodontist, the treatment options generally include interceptive extraction of the primary canine, exposure and alignment of the canine with fixed appliances, extraction of the impacted canine, or autotransplantation Figure 1.

Clinical Significance When performing regular checkups on children, GDPs should evaluate the eruption of their dentition and the possible complications that have developed. Identifying anomalous conditions early and instituting appropriate management will save the patient from having to experience irreversible sequelae. Elsherif N, Murthy VE, Moseley H: What to spot and what not to miss: Key anomalies during the developing dentition. Br Dent J 239:836-842, 2025 Reprints available from N Elsherif, Dept of Orthodontics, Watford General Hosp and Dept of Orthodontics, Eastman Dental Inst, UCL, London, UK; e-mail: NusaybahElsherif@gmail.com

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PAIN MANAGEMENT Postprocedural pain in dental settings BACKGROUND After dental treatments, postprocedural pain (PPP) is common and can result from the combined effects of the treatment, the tissues involved, and the complexity of the procedure. Managing PPP requires careful consideration of patient factors such as the chief complaint; gender; age; physical, medical, and psychosocial status; and reactions to medications. Proper pain assessment must be done in conjunction with educational strategies for patients to achieve optimal pain management. PPP was defined and characterized according to neurophysiologic aspects, patients’ psychosocial contributions, and procedures related to pain. The management of PPP was then detailed.

PPP DEFINED AND CHARACTERIZED PPP is associated with therapeutic, operative, and diagnostic procedures, with acute PPP occurring immediately after a procedure and lasting from 7 days to 3 months. Chronic PPP is that which lasts for more than 3 months. The process known as peripheral sensitization increases the excitability and spontaneous nerve firing related to nociceptors. The information travels from first-order neurons to second-order neurons in the subnucleus caudalis of the spinal trigeminal nucleus, traverses the trigeminothalamic tract to the ventral posteromedial nucleus of the thalamus, and is eventually projected into the somatosensory cortex, where pain perception occurs. Other centers also contribute to pain perception, which manifests in a first pain and then a second pain. In somatic symptoms disorder (SDS), various emotional or psychologic factors can manifest as physical symptoms such as pain but not be traceable to a specific medical cause. Patients experience an increased sensitivity to bodily sensations, anxiety, and excessive focus on pain, increasing their discomfort. Occlusal dysesthesia (OD) is an SDS that occurs after dental interventions and involves a persistent sensation of having an uneven bite without actual occlusal discrepancies. Even minor dental interventions can worsen symptoms. Information and counseling are needed to defocus patients’ preoccupation with their occlusion; cognitive behavioral therapy (CBT) can also prove helpful, along with occlusal splint therapy and medications. The nocebo effect is expressed as worsened symptoms, undesirable treatment outcomes, and adverse effects after appropriate dental treatment. Having negative thoughts and expectations about the potential side effects of a dental procedure can exacerbate the problem. The effect can be minimized with effective communication and patient

education. Generally, the cause of pain should be established as odontogenic or nonodontogenic; collaboration with a trained psychologist or psychiatrist can provide helpful interventions.

PROCEDURES RELATED TO PAIN PPP is usually associated with more invasive dental procedures, but can be seen after seemingly minor interventions. Dentists should be alert to the possible clinical presentations of PPP and to the procedures that may have triggered them. Tooth Extraction PPP is commonly seen after third molar extraction. Having anxiety or phobia can significantly impact the patient’s quality of life. Most PPP complaints occur 4 to 6 hours after the extraction, with the peak intensity in the first 24 hours after surgery. Patients may misinterpret the cause as related to the clinician’s skill or the result of preoperative, perioperative, intraoperative, or postoperative protocols. Patient gender and biological, psychosocial, and anatomic characteristics may also contribute. Older adults are more likely to experience pain after third molar extraction. Alveolar osteitis is a common postoperative complication causing pain in and around the extraction site, but is caused by the disintegration of the blood clot in the socket and produces pain within 3 days of the procedure. Postendodontic Pain Pain after pulp capping procedures is most commonly felt the first day after the procedure and dissipates over time. Partial pulpectomy is believed to be associated with better pain relief. Moderate to severe pain occurs 2 to 3 days after root canal treatment (RCT) but peaks within the first 36 hours after pulpotomy. Because there isn’t much difference between the pain caused by these 2 approaches, clinicians shouldn’t choose the procedure based on PPP differences. Pulpectomy in Young Children Anxiety can significantly amplify the PPP experienced by young children having pulpectomy. Immunologic reaction, microbial invasion, and tissue injury can contribute to pain. It’s common to hear complaints of inflammation of the periradicular tissues immediately after pulpectomy, with the pain peaking in 48 hours and gradually subsiding over a week. Mechanical instrumentation, antimicrobial irrigation, and proper obturation should be optimal for the best outcomes. Less PPP has been associated with modified techniques using rotary rather than hand instruments.

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Root Canal Treatment A strong correlation exists between preoperative pain and PPP intensity, with the most pain associated with pulpectomy. Significant pain and swelling occur a few days after RCT in up to 16% of cases, with contributing factors including accuracy of the working length measurement, demographic factors, and general health status of the patient. PPP can also be altered by microbial and chemical factors, pain before the procedure, type of tooth being treated, and number of appointments required. If the pain persists for 6 months or longer after successful RCT, it may be nonodontogenic pain. The clinician should consider that the original pain prompting the RCT may have been nonodontogenic also. Delineating the temporal relationship of the toothache to other causes should be pursued diligently. A known but undesirable adverse effect of RCT is pain related to deafferentation from pulpectomy that persists and is eventually diagnosed as post-traumatic trigeminal neuropathic pain. Postoperative Sensitivity Postoperative sensitivity (POS) after restorative procedures using direct adhesive restorative materials isn’t uncommon, with patients complaining of tooth pain while chewing or reacting to stimuli such as cold, hot, or sugary substances. POS is more frequently found in deeper cavity preparations after composite restorations, with the involvement of added tooth surfaces also related to POS. Dental Implant Surgery Preoperative and postoperative expectations as well as anxiety can predispose patients having implants placed to experience increased PPP. Factors that affect the pain experience include nerve injury and neuropathic pain. Periodontal Treatment Nonsurgical Approaches After scaling and root planing (SRP), mild to moderate PPP of inflammatory origin can be anticipated. Usually this pain resolves within 3 days, especially when anti-inflammatory agents are given. When the PPP after SRP persists, the clinician should consider the possibility of it being either neuropathic pain and deafferentation pain. Surgical Approaches Various surgical approaches can be used for periodontal diseases. The complications seen with these measures include swelling, bleeding, delayed wound healing, infections, and flap dehiscence, all of which may be accompanied by pain. A minimally invasive flap design can enhance postoperative healing and minimize PPP. More PPP is seen with guided tissue regeneration, but the adjunctive use of enamel matrix derivative at the recipient site is accompanied by less intense PPP. Greater PPP intensity is associated with free soft tissue grafting, subepithelial connective tissue grafting procedures, and postsurgical

208 Dental Abstracts

periodontal dressings, especially in the first 48 hours after surgery. The exact mechanisms for the various surgical approaches remain to be properly identified. Orthodontic Treatments Pain can accompany orthodontic treatment that involves separator placement, arch wire insertion, appliance activation and debonding. Various orthodontic forces, ischemia, inflammation, and edema in the affected tissues may combine to produce the pain. Typically, pain begins within 4 hours of appliance placement,

Table 2. Preprocedural and Intraprocedural Approach to Prevent/Manage Postprocedure Pain Preprocedural and Intraprocedural Approach Preemptive analgesia

Description • Administering 400–600 mg of

ibuprofen 30 min before the procedure ensures that the maximum plasma concentration is reached by the time the procedure begins • NSAIDs reduce release of inflammatory mediators • Preprocedural administration of pregabalin for surgical interventions • Profound local anesthesia Multimodal analgesia

• Combination of ibuprofen and

acetaminophen (APAP) prior to the procedure Corticosteroids

• Potent anti-inflammatory

property, reduces edema, and pain • Known to reduce intensity of pain following procedures such as RCT and third molar extractions • Route of administration: IV or oral Management of anxiety

• Maintenance of trust and rapport

with the patient • Counseling • Educate patients on realistic pain

expectations and management strategies following a procedure • Judicious use of nitrous oxide, preoperative anxiolytics, IV, or general sedations Reducing tissue trauma

• Atraumatic dental procedures

Long-acting local anesthetic

• Profound long-acting local

minimize inflammation/PPP anesthesia may minimize PPP (eg, bupivacaine) • Liposomal bupivacaine, an extended-release bupivacaine is being explored for this purpose Abbreviations: NSAIDs, Nonsteroidal anti-inflammatory drugs; RCT, root canal treatment. (Courtesy of Thomas DC, Ravi A, Shapurwala M, et al: Post-procedural pain in dentistry, as related to dental specialties. Dent Clin N Am 70:117-136, 2026.)

Table 3. Pain Levels, Associated Dental Procedures, Recommended Medication Protocols, and Contraindications Pain Severity Mild

Procedure • Simple extraction

Drug Class • NSAIDs

• Single implant surgery

gingivectomy • Crown lengthening • Soft tissue biopsy • Osseous surgery • Simple RCT and retreatments • Crown preparation • Pain associated with prosthesis • Operative procedures • Prophylaxis

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• GI effects

• Opioid receptor (mu-

• Hypersensitivity

• Respiratory

receptor) agonist • Also activates delta and kappa opioid receptors

• Bronchial asthma

• As above

• APAP

• Antipyretic and analgesic

properties centrally • Weak inhibitor of COX

or oxycodone)

As above

Adverse Effects

Same as mentioned above When adequate PPP relief is • Severe hepatic impairment not achieved after first-line • Acute hepatic disease therapy • Chronic alcohol misuse Option 1: When only • Allergy NSAID (400–600 mg ibuprofen) Drug interactions with: was prescribed initially then • Antiepileptic drugs consider the following: • Antitubercular drugs (these 325–500 mg APAP every 4–6 h drugs are inducers of + 5 mg hydrocodone every 4–6 h cytochrome P450 enzyme for breakthrough pain that converts APAP to a (prescribe for 2 d) hepatotoxic metabolite) Option 2: When a combination of NSAID and APAP was prescribed initially then replace with: 400 mg of ibuprofen +325 mg of APAP + combination of 325 mg of APAP with an opioid such as 5–7.5 mg of hydrocodone or 5 mg of oxycodone every 4–6 h (prescribe for 3 d)

• NSAIDs

• Opioid (hydrocodone

Recommended Dosage

• GI effects

• Dry socket

without alveoloplasty • Preprosthetic surgery • Complex implant procedures such as multiple implants, implant placement with bone grafting • Multiple quadrant SRP, gingivectomy, or crown lengthening • Complicated RCT and retreatments, surgical endodontic therapies • Bone biopsy

Relative/Absolute Contraindications

To be used after consultation First-line therapy to manage with physician in patients PPP with: Option 1: 400–600 mg ibuprofen • Heavy alcohol use every 4–6 h • GI disease OR • Liver disease Option 2: Combination of 400– • Renal disease 600 mg ibuprofen +325– 500 • Pregnant/lactating females mg APAP every 4–6 h Drug interactions with: • Anticoagulants • Corticosteroids • Lithium • SSRI • ACE

• Surgical extractions • Multiple extractions with/

Severe

• Reversible inhibition of COX

1 and 2 which in turn inhibits formation of prostaglandin and thromboxane

• Single quadrant SRP,

Moderate

Mechanism of Action

As above

• Allergic

reactions: itch, rash

• Allergic

reactions: itch, rash • Hepatotoxicity

depression

• GI obstruction

• Sedation

• Respiratory depression

• Drowsiness

• Use with alcohol

• Nausea

Drug interactions with: • Zolpidem • Ketoconazole • Erythromycin

• Severe

As above

constipation • Bradycardia • Hypotension

such as fracture repair, TMJ surgery • Orthognathic surgery

• Major maxillofacial surgeries

Abbreviations: ACE, Angiotensin-converting enzyme inhibitors; APAP, acetaminophen; COX, cyclooxygenase; GI, gastrointestinal; h, hours; NSAIDs, nonsteroidal anti-inflammatory drugs; PPP, postprocedure pain; RCT, root canal treatment; SRP, scaling and root planing; SSRI, selective serotonin reuptake inhibitors; TMJ, temporomandibular joint. (Courtesy of Thomas DC, Ravi A, Shapurwala M, et al: Post-procedural pain in dentistry, as related to dental specialties. Dent Clin N Am 70:117-136, 2026.)

400–600 mg ibuprofen + 325– 500 mg APAP every 4–6 h +5 mg hydrocodone/ oxycodone every 4–6 h for breakthrough pain (prescribe for 3 d)

Adverse Effects Recommended Dosage Relative/Absolute Contraindications Mechanism of Action Drug Class Procedure Pain Severity

Table 3. Continued

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becomes more intense over the next 24 hours, and slowly subsides over a few days. The first 72 hours are when peak pain levels occur. Fixed and functional appliances usually cause more discomfort than removable appliances. Biting and chewing remain painful for an extended time, with many patients modifying their diets to focus on soft foods. Pain and discomfort during chewing persists beyond the acute phase of treatment. TMDs Transient TMD pain is a common complaint after dental treatment when the mouth is held open for an extended period of time. Signs and symptoms are dull or intermittent sharp pain and stiffness of the TMJs and masticatory muscles, limited mouth opening, and new onset clicking of the TMJ; occasional intermittent catching and locking episodes can also occur. The risk for PPP related to TMDs is higher when there are predisposing factors such as pre-existing TMDs or orofacial symptoms, psychological conditions, pain disorders, and sleep disorders. Understandably, patients may assume their new manifestations are directly related to inappropriate dental care and they may become upset. Preventive measures include taking breaks to rest the jaw, supporting the jaw with bite blocks, and keeping the procedure as short as possible. The painful signs and symptoms can be addressed with education and reassurance that these problems are self-limited. The clinician should offer self-care strategies such as applying cold or warm compresses, doing gentle jaw exercises, and advising the patient to adhere to a soft diet to rest the jaw, along with avoiding nail biting, gum chewing, chin resting, and awake teeth clenching and jaw bracing to reduce overuse pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and sometimes muscle relaxants may be helpful. Referral to an orofacial pain specialist is recommended for persistent pain.

MANAGEMENT Pain management should be planned across the various stages the patient may experience. This includes the preprocedure, intraprocedure, and postprocedure phases. In addition, nonpharmacological management and pediatric postprocedural pain measures should be part of the planned approach to pain management. Preprocedural and Intraprocedural Approaches To evaluate the patient’s susceptibility to pain related to the dental procedure, the clinician should carefully examine his or her medical and dental histories. Anxiety is a key component in the development of PPP. Managing anxiety through education and counseling may help to minimize PPP. Approaches can include preemptive analgesia and multimodal analgesia (Table 2). Postprocedural Approaches A core principle of optimal PPP management is the use of antiinflammatory drugs to manage inflammation-related pain before local anesthesia wears off. If opioids are considered to address

Figure 3. Nonpharmacological management of PPP. (Courtesy of Thomas DC, Ravi A, Shapurwala M, et al: Post-procedural pain in dentistry, as related to dental specialties. Dent Clin N Am 70:117-136, 2026.)

moderate to severe PPP, the risk-benefit ratio should be carefully considered. Multimodal analgesia should be used, with anti-inflammatory drugs given on a regular schedule rather than “as needed” to ensure the patient benefits from sustained anti-inflammatory effects and optimal PPP management (Table 3). Nonpharmacological Treatment When managing PPP, it’s advisable to prioritize nonpharmacological management. Although pharmacological and nonpharmacological approaches reduce PPP, the pharmacological strategies carry a greater risk for adverse effects, including drug dependence (Figure 3). Pediatric Pain Treatment By effectively managing pain in pediatric patients who have had dental procedures the clinician can ensure the child’s comfort, reduce his or her anxiety, and promote a positive attitude toward dentistry that can carry through to adulthood. Age-appropriate doses and local anesthesia use are essential for intraoperative and postoperative pain management, with nonopioid analgesics serving as the first-line treatment for PPP in children under age 12 years. It’s recommended that children receive NSAIDs alone or in combination with acetaminophen. Adolescents age 12 to 17 years are included in this approach. Opioids should be limited because of their side effects and potential for abuse. Clinicians should specify any additional local anesthetics before patient

discharge, with nonpharmacological modalities also offering benefits. Distraction techniques, guided imagery, relaxation exercises, positive reinforcement, and presence of the parents can reduce anxiety and pain perceptions.

Clinical Significance Patients who undergo dental procedures may develop temporary pain. The dental clinician should ensure that proper measures are taken to minimize procedural pain and prevent disease. Preemptive and multimodal analgesia are significant approaches to providing optimal pain management. If the patient develops persistent pain after a successful RCT, the pain may be nonodontogenic in origin. Referral to a pain management specialist should be considered if the measures provided aren’t achieving optimal pain control.

Thomas DC, Ravi A, Shapurwala M, et al: Post-procedural pain in dentistry, as related to dental specialties. Dent Clin N Am 70:117136, 2026Reprints available from DC Thomas, Dept of Diagnostic Sciences, Ctr for Temporomandibular Disorders and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA; email: davisct1@gmail.com

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TONGUE-TIES Ankyloglossia management BACKGROUND Tongue-tie, or ankyloglossia, is a congenital condition involving a shortened lingual frenulum of varying severity. It can alter tongue mobility and function and may require treatment to resolve problems, most notably breastfeeding challenges. No comprehensive guidelines exist to help practitioners determine the severity of the problem and how a patient should be managed. A review of the Embase database identified studies analyzing the anatomy, epidemiology, and classification of ankyloglossia; management strategies; and suggestions for navigating functional effects on breastfeeding , speech, oral hygiene, eating, moving, sleeping, social tongue movement, and the stomatognathic system.

although further investigations are needed to reveal the associations. Not all those with ankyloglossia have functional issues that require management. Several criteria are used to classify ankyloglossia, but there is considerable ambiguity surrounding the clinical diagnosis. Among the classifications used are the Coryllos classification and Kotlow’s classification. Tools used for diagnosis include the Hazelbaker Assessment Tool for Lingual Frenulum Function and its more concise version, the Bristol Tongue Assessment Tool. Other assessment tools focus specifically on its impact on breastfeeding.

MANAGEMENT STRATEGIES ANATOMY, EPIDEMIOLOGY, AND CLASSIFICATION The tongue has a range of physiological functions, including chewing, taste, swallowing, speech, and oral hygiene. It consists of 2 main paired muscle groups, with the intrinsic muscles controlling the shape and fine motor control of the tongue, allowing for curling and flattening. The extrinsic muscles control gross motor movement and allow for protrusion, retraction, and lateral motion. The tongue’s ventral surface is connected to the mouth floor by the lingual frenulum, which is a midline mucosal fold that facilitates extensive mobility. Patients with ankyloglossia can have a congenitally shortened or thickened frenulum, limiting tongue movement (Figure 2). Ankyloglossia has a prevalence of 4% to 11% of newborns but its etiology is unknown. It’s suspected that genetics contributes, and males are affected more than females, with a ratio of 2.6 to 1. Several syndromes include ankyloglossia. Factors that may contribute include maternal smoking, diabetes, and medications,

The options for management of ankyloglossia are to leave it and monitor the situation; perform nonsurgical management, which includes speech and language therapy, physiotherapy (massage), and lactation counseling; and undertaking surgical management, which involves frenulotomy (division of the frenal attachment), frenuloplasty (rearrangement of the attachment), or frenectomy (removal of the frenulum). Because many cases will resolve spontaneously in the first few months of life, with the frenulum stretching with use, ankyloglossia is seen in newborns more than in children and adults. Conservative (nonsurgical) management includes complementary procedures, lactation interventions, and physical, occupational, myofunctional, and speech therapy (Table 5). Children with moderate to severe ankyloglossia may have difficulty with breastfeeding and require division of the ankyloglossia. This can be done without anesthesia in most infants, but risks associated with the surgery are excessive bleeding, infection, no improvement in form or function, scarring, reattachment of the frenulum, damage to the salivary glands or tongue muscle, or incomplete division, requiring additional surgery. Because of these risks, surgical treatment should not be chosen lightly. Such procedures should be done in a hospital to ensure that the risks can be managed.

FUNCTIONAL EFFECTS

Figure 2. A, Normal lingual fraenum, allowing unrestricted tongue movement. B, Severe ankyloglossia, limiting tongue movement. (Courtesy of Shivji S, Chandrasekara B, Ria B: Tongue-ties: A review. Br Dent J 240:27-32, 2026.)

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Most persons with ankyloglossia live with the condition without limitations. However, breastfeeding is widely recognized as compromised in infants who have ankyloglossia. The short, tethered lingual frenulum can restrict tongue movement and affect the stomatognathic system. Signs and symptoms can indicate whether the child and mother are having feeding challenges (Table 6). Release of the ankyloglossia through frenotomy ibute to breastfeeding problems so the release may not resolve all the issues.

Table 5. Non-surgical Management of Ankyloglossia Intervention Complementary/alternative procedures

Lactation intervention

Physical/myofunctional therapy

Speech/oromotor therapy

Description Diverse group of therapies not conventionally practised by healthcare professionals (e.g., craniosacral therapy). There is no reliable evidence to suggest these are effective in resolving symptoms associated with ankyloglossia Counselling and recommendations from a lactation consultant for more effective breastfeeding. Focus on latching techniques and infant-maternal positioning Approaches to reduce tension in, and stretch muscles, improving range of motion. Includes myofascial release and other manual techniques. Myofunctional therapy may be used in conjunction with surgical therapy to improve outcomes and has been found to improve sleep apnoea associated with ankyloglossia Exercises and techniques to improve strength, coordination, and mobility of oral muscles. Evaluation and treatment of swallowing and speech disorders using specific exercises and procedures

(Courtesy of Shivji S, Chandrasekara B, Ria B: Tongue-ties: A review. Br Dent J 240:27-32, 2026.)

Any speech problems are commonly seen during childhood and deal with clarity and a prominent lisp accompanied by difficulties with the pronunciation and articulation of certain sounds and sibilants. Studies remain inconclusive regarding the value of surgery to manage breastfeeding challenges, with many of those referred for ankyloglossia release found to have ageappropriate speech errors. It’s also possible to have both ankyloglossia and speech errors. Oral hygiene can be difficult to maintain in children with ankyloglossia because of the restrictions on mobility that keep the tongue from clearing debris and moving saliva effectively. Food packing, plaque accumulation, dental caries, and periodontal disease can result, especially affecting the lingual aspect of the mandibular dentition. Patients may also complain of discomfort and mucosal trauma to the frenulum caused by the lower incisor teeth. Mechanical complications affecting tongue movement have been suggested to be caused by ankyloglossia. Eating difficulty can persist after childhood, with problems performing lateral and protrusive movements, which are needed for bolus formation

Table 6. Summary of Signs and Symptoms of How Ankyloglossia Can Affect Breastfeeding Infant breastfeeding experience

Maternal breastfeeding experience

• Poor latching

• Inadequate secretion

• Irritability during feeding

• Incomplete emptying

• Slow or prolonged feeding

• Pain while feeding

• Poor weight gain

• Mastitis

• Fatigue during feeding

• Nipple soreness, bleeding,

• Clicking noises while feeding

cracking, ulceration

• Colic

• Early abandonment of feeding

• Reflux, wind, hiccup

• Rapid transition to bottle-feeding • Anxiety, frustration and distress

(Courtesy of Shivji S, Chandrasekara B, Ria B: Tongue-ties: A review. Br Dent J 240:27-32, 2026.)

and swallowing of solid foods. Licking ice cream, playing wind instruments, and kissing can be challenging and the difficulty can have a negative effect on the individual’s self-esteem and quality of life. Untreated ankyloglossia at birth has been associated with obstructive sleep apnea, with the shortened frenulum leading to mouth breathing and altered development of the oral cavity. Some children with ankyloglossia have changes in their craniofacial growth, leading to the development of malocclusions such as open bite. However, no studies indicate that patients with ankyglossia fail to thrive, so the long-term effects remain uncertain.

Clinical Significance The primary reason treatment of ankyloglossia is done is to address breastfeeding-related complications. Conservative measures have proved sufficient in many cases. When surgical treatment is indicated, ankyloglossia release achieves limited efficacy. A standardized approach to treatment is needed to improve accessibility and quality of care for patients and their families. Health care providers need to have better criteria for determining the severity of the problem and knowing when they should refer patients for treatment.

Shivji S, Chandrasekara B, Ria B: Tongue-ties: A review. Br Dent J 240:27-32, 2026Reprints available from S Shivji, Dept of Oral and Maxillofacial Surgery, Lister Hosp, East and North Hertfordshire NHS Trust, UK; e-mail: sarika.shivji@nhs.net

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TOOTHPASTE Homemade oral health products BACKGROUND Dentists recommend brushing the teeth at least twice a day with fluoride toothpaste to eliminate dental plaque and prevent dental caries. With growing interest in alternative oral care practices, homemade or do-it-yourself toothpaste (DIYT) has become popular as a way to eliminate potentially harmful products and adopt a more natural and eco-friendly lifestyle. To determine if DIYT products are as effective as commercial products and free from biological and toxicological risks, an inventory of DIYT recipes available online over the past 10 years and a literature review to identify evidence-based information regarding the DIYT recipes over a similar time period were conducted.

METHODS The electronic inventory of DIYT recipes was done in the Baidu, Ecosi, Google, and Yahoo browsers over a 10-year period. One hundred sixteen recipes were screened for ingredients, noting nature, measurement unit, and preservation methods. The Cochrane Library, Embase, Google Scholar, PubMed/Medline, and Web of Science databases were searched for DIYTs, with 6 articles identified that met the criteria for inclusion.

RESULTS

inconsistencies in replicating the usages. Preservation methods were included in 79 products, but only 2 mentioned sterile containers. Refrigeration was seldom mentioned even though most DIYTs were stored in warm, humid environments such as bathrooms. Literature Review The 6 articles covered different areas and different recipes. None of the recipes contained fluoride, and some had abrasive or poisonous agents such as lead. The effectiveness of various recipes for whitening on extracted teeth was based on formulations of baking soda, activated charcoal, lemon juice, and strawberries. These were compared to professional products after 4 weeks, with lemon juice having the greatest whitening, Opalescence 20% system the next greatest, then Colgate Optic Whitening, and strawberries. The remineralization of extracted premolars with early artificial carious lesions was compared between fluoride gel, sodium fluoride toothpaste, and a DIYT containing nanohydroxyapatites and olive oil. All groups showed potential remineralization without significant differences between them. A test of dental plaque elimination between a DIYT with coconut and a commercial toothpaste for 1 week also revealed no difference in their effectiveness.

DIYT Inventory The recipes contained 2 to 11 ingredients that fell into 8 major categories. The abrasive agents often included sodium bicarbonate and clays. The excessive use of abrasives can erode hard and soft dental tissues. Surfactants were used in 10 recipes, with Marseille soap being used most often. Oils and fats included coconut oil or wax and were included to achieve a toothpaste-like texture. Gelling agents were used in 9 recipes, usually guar gum or xanthan gum.

The conclusion of the articles overall was that dental health care professionals should be aware of the risks of DIYT products and warn patients. They should recommend fluoridated alternatives, specifically, commercial toothpastes with controlled compositions and evidence-based effects.

The antimicrobial agents and preservatives included honey, which has antibacterial properties but also contains a good deal of sugar, which is cariogenic. Two recipes included a clear preservative, making the microbial stability questionable. The acidic components included lemon juice, which has a pH around 2.4 and can be demineralizing. Among the essential oils, plant extracts, and related substances, fewer than 20% of the products contained essential oils and most were for taste rather than therapeutic reasons. Peppermint essential oil and stevia were used to enhance flavor.

The trend toward using online DIYT recipes for oral hygiene lacks proper oversight and professional evidence-based guidance for their use. Better public education is needed regarding dental health, with dentists prepared to discuss patient misconceptions regarding the use of home recipes. The benefits and risks of both homemade and evidence-based commercial products need to be clearly stated.

In terms of universal excipients, 26 of the recipes used water, which differs significantly from commercial toothpaste formulations, which are mostly water. The units recommended ranged from tablespoons to milliliters, leading to significant

Queneau V, Bourgeot A, Couteau C, et al: Homemade toothpastes: What recipes for what effects? Br Dent J 240:84-88, 2026Reprints available from V Queneau; e-mail: victoire.queneau@uca.fr

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Clinical Significance

TOOTH AVULSION Acronym-based tooth avulsion intervention BACKGROUND Tooth avulsion is the complete displacement of a tooth from its socket. Immediate management is critical because the viability of the periodontal ligament (PDL) cells and the success of replantation are time sensitive, with the best outcome occurring when the tooth is replanted within 15 minutes. An acronym-based concept has been developed to ensure that parents, teachers, and care providers can accomplish appropriate first aid for tooth avulsion and avoid the pitfalls of delaying replantation. The acronym Tooth F.I.R.S.T Aid guides laypersons through the steps essential to managing permanent tooth avulsion injuries.

TOOTH F.I.R.S.T AID METHOD

T—Transport the Tooth in a Suitable Medium If Not Replanted Action: If the tooth can’t be replanted in the socket, put it in suitable storage medium in the following order of preference based on availability: milk, person’s saliva (have person spit into a container), saline. Water is a poor medium but better than leaving the tooth to air-dry. Rationale: Appropriate storage of the tooth preserves PDL cell viability until professional care is available.

DISCUSSION Managing permanent tooth avulsion requires immediate action to achieve the best outcomes. Using the Tooth F.I.R.S.T Aid

The Tooth F.I.R.S.T Aid method includes both an action and the rationale for that action (Figure 1). With each step, the action begins with the appropriate letter and is spelled out, followed by the action directions and rationale. The steps to be followed when facing a tooth avulsion injury are as follows: F—Find the Tooth Action: Locate the tooth immediately. Rationale: Time is critical, with better results when the tooth is found quickly. I—Inspect and Rinse Action: Hold the crown without touching the root and inspect it for debris. If it’s dirty, rinse it gently with milk, saline, or the person’s saliva. Rationale: Removing visible dirt reduces the risk of infection and preserves PDL cell viability. R—Reposition in the Socket Action: Place the tooth into its position in the socket facing the correct way. Have the person bite gently on gauze, a handkerchief, or a napkin. Rationale: Immediate replantation preserves PDL cell viability and improves outcomes. S—Seek Urgent Care Action: Visit a dentist immediately even if the tooth was replanted. Rationale: Professional assessment and treatment will manage the injury properly and avoid complications.

Figure 1. “Tooth F.I.R.S.T Aid” acronym-based awareness tool for emergency management of tooth avulsion. (Courtesy of Mathew MG, Cherian JM, Varghese KG, et al: Tooth F.I.R.S.T Aid: An acronym-based awareness tool aligned with updated guidelines for emergency management of tooth avulsion. Dent Traumatology 41:516-519, 2025.)

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acronym to identify the steps to take in caring for the individual and the tooth offers even laypersons the confidence to respond to this emergency situation. The tool also prioritizes the use of evidence-based, commonly available storage media such as milk or saliva when immediate replantation isn’t feasible. Incorporating the tool into public education can positively influence patient outcomes.

Clinical Significance Having a clear, simple tool such as the Tooth F.I.R.S.T Aid acronym can help guide laypersons as well as dental professionals through the process of handling a tooth avulsion emergency. With a time-sensitive situation such as tooth avulsion, it’s vital for rescuers to be able to take decisive action, and this tool is well-presented and easy to follow.

Mathew MG, Cherian JM, Varghese KG, et al: Tooth F.I.R.S.T Aid: An acronym-based awareness tool aligned with updated guidelines for emergency management of tooth avulsion. Dent Traumatology 41:516-519, 2025Reprints available from MG Mathew; e-mail: mebingmathew@gmail.com

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INQUIRY ANTIBIOTIC PROPHYLAXIS Single-shot versus longer regimens for antibiotic prophylaxis BACKGROUND Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gramnegative (MRGN) bacteria along with general antimicrobial resistance have increased the pressure to tailor prophylactic and therapeutic options in health care situations to the least likely to create problems with antibiotic resistance down the line. However, emerging antibiotic resistance remains a challenge. In oral and maxillofacial surgery, especially intraoral procedures, the area is colonized by bacteria, with the mandibular region especially conducive to colonization. Thus wound contamination and infections are more likely to follow surgical procedures. Appropriate wound care and strict aseptic precautions during procedures are accompanied by antibiotic prophylaxis as an added safeguard. The focus is especially on potential pathogens in the mouth and throat causing infections of the bone. Aminopenicillins with β-lactase inhibitors are often used for prophylaxis and treatment. For patients allergic to penicillins, lincosamide antibiotics such as clindamycin are often given. Studies comparing selective and comprehensive peri- and postoperative antibiotic prophylaxis in patients having oral and maxillofacial surgeries have been undertaken to determine if reduced antibiotic administration could result in fewer postoperative complications, shorter hospital stays, which are associated with a reduced risk for nosocomial infections, and reduced antibiotic consumption.

METHODS A total of 856 patients were enrolled in the study. For the first year and 5 months of the study, all patients received a prolonged antibiotic scheme of 48 hours or longer. Over the next 2 months, a single shot was given intraoperatively for the 6 surgeries included, which were fracture repair, plate removal, orthognathic surgery, tumor surgery, neck dissections, and bone augmentation. The data reported were type of operation, gender, age, body mass index (BMI), allergies,

general illnesses, medication, type of antibiotic prophylaxis, type of agent used, form of administration, clinical signs of infection, wound dehiscence, surgery duration, surgical approach, laboratory results of parameters indicating infection, inpatient length of stay, postoperative complications, and any revision surgery.

RESULTS Four hundred eighty-two patients had antibiotic prophylaxis of 48 hours or longer, and 316 had only a single dose of antibiotic prophylaxis. Patients’ average age was about 42 years, and about 30% were women and 70% men. Mean BMI was 24.3. Analysis of the data was sufficient only for fractures, plate removals, orthognathic surgeries, and overall surgeries. The parameters reported included postoperative complications, length of stay, and consumption of antibiotics. Postoperative Complications Comparing prophylaxis >48 hours versus single-shot prophylaxis, the infection rates were 6.36% versus 8.16% for fractures, 12.96% versus 7.27% for plate removal, and 7.89% versus 20.00% for orthognathic surgery. The overall infection rates were 7.93% for extended prophylaxis and 9.40% for singleshot prophylaxis. Although there were no significant differences in the laboratory parameters indicative of infection for orthognathic surgeries, there was a significant difference in C-reactive protein (CRP) values for plate removal, with prophylaxis >48 hours having a value of 1.74 mg/dl versus single-shot prophylaxis with a value of 2.69 mg/dl. Length of Stay The overall inpatient length of stay differed significantly for patients with single-shot prophylaxis (4.32 days) and those with prophylaxis >48 hours (5.83 days). Patients having fracture

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osteosynthesis and plate removal also had significant differences in their length of stay depending on the length of prophylaxis. Single-shot prophylaxis was associated with 4.94 days for fracture osteosynthesis and 1.81 days for plate removal, versus prophylaxis >48 hours associated with 6.39 days and 2.48 days, respectively. Antibiotic Consumption The review showed that the antibiotic consumption in defined daily doses (DDD) per 100 patient days declined over the 2 years of the study. It was 63.8 DDD/100 patient days in 2018 and fell to 47.0 DDD/100 patient days by 2020.

CONCLUSIONS The postoperative infection rates for patients treated with a single-shot antibiotic prophylaxis regimen were similar to those of patients receiving antibiotics for >48 hours. Length of stay for patients having fracture treatment and removal of osteosynthesis plates was shorter without increasing the frequency of postoperative complications. Antibiotic consumption was also reduced with the single-shot approach.

Clinical Significance Selected bone-related maxillofacial procedures such as orthognathic surgery, trauma, and augmentation may be adequately covered prophylactically using a single-shot antibiotic regimen. In addition, patients’ length of stay and total consumption of antibiotics may be reduced. Maxillofacial departments should assess patients, adapting the single-shot regimen for those who are having special surgical techniques and considering hospital-specific aftercare regimens. Additional studies are needed to identify ways to mitigate the emergence of multidrug resistant pathogens in patients having dental procedures.

Schorn L, Singh DD, Mrochen F, et al: Is single-shot antibiotic prophylaxis really enough for standard OMF-surgeries? Clin Oral Invest 30:68, 2026 Reprints available from DD Singh, Dept of Oral-Maxillofacial and Facial Plastic Surgery, Univ Hosp D€usseldorf, Moorenstr. 5, 40225 D€usseldorf, Germany; e-mail: DamanDeep.Singh@med. uni-duesseldorf.de

FLUORIDATED MILK Fluoride in milk for adolescents BACKGROUND

METHODS

Over 35% of the global population has cavities in their permanent teeth. In addition, 77% of European adolescents have caries, with a significantly higher prevalence among youth age 16 to 19 years. Topical fluoride has a significant role in caries prevention, offering resistance to low pH acid production by dental biofilms, promoting enamel remineralization, providing antimicrobial protection, and inhibiting sugar transport and glycolysis. The antimicrobial effect of fluoride on dental biofilms contributes to the prevention of caries. The fluoridation of milk may benefit specific demographic groups and may prove useful in countries that don’t offer fluoridated water. Milk tends to be a significant part of many adolescents’ diets, and fluoridated milk may constitute an alternative useful in preventing caries among adolescents. Low doses of fluoride administered daily in milk coupled with daily oral hygiene regimens with fluoride toothpaste were studied for their effects on caries development in adolescents in Sweden.

The 2-year randomized controlled trial (RCT) recruited 292 adolescents (mean age 12.6 years, range 11.7 to 14.1 years) during their scheduled annual checkups at 3 public dental clinics in rural areas in southern Sweden. The intervention group (87 participants) received tubes with daily doses of sodium fluoride solution in 0.5 mL sterile water to be added to 200 mL of milk. The control group (72 participants) received tubes with 0.5 mL sterile water to be added daily to 200 mL of milk. The subjects were instructed to drink the mixture slowly from a glass during the evening meal. They were also to continue their usual oral hygiene routines, which consisted of tooth brushing twice a day with toothpaste containing fluorides. The subjects underwent assessments for caries status at baseline and after 2 years, along with radiographic examination of the proximal surfaces of premolars and molars and 1 bitewing on each side of the mouth. The baseline and 2-year images were compared for the presence or change in caries enamel lesions. The primary outcomes were caries lesion arrest, caries

218 Dental Abstracts

lesion progression, and caries decayed-missing-filled surfaces (DMFS) for enamel and dentin lesions.

RESULTS Forty-four percent of the intervention group and 47% of the control group were lost to follow-up, with the major reason being an anti-fluoride debate that influenced the subjects’ willingness to participate, although life events and the COVID-19 epidemic contributed as well. No teeth were lost in any subjects over the 2-year period, so the M factor was eliminated. Caries DFS Status In the intervention group, 70% of the subjects at clinic A, 64% of those at clinic B, and 94% of the clinic C subjects had unchanged DFS values. The control groups had unchanged DFS values in 30%, 36%, and 6% of clinics A, B, and C, respectively. The mean number of surfaces with enamel or dentin caries was significantly less in the intervention group than in the control group. The incidence of new enamel lesions was less in the intervention group than in the control group, leading to the conclusion that fluoride primarily affected enamel caries development. Mean DFS increment or incidence for dentin lesions didn’t differ between the groups. Caries Lesion Arrest Mean number of caries lesions arrested in the enamel was significantly higher in the intervention group than in the control group, with no differences in the arrests of dentin lesions. The proximal lesions in premolars and molars at baseline were compared to the lesion arrests data after 2 years. The proportion of lesion arrest was higher in the intervention group (73%) than in the control group (48%). The proportion of caries lesion arrest in the outer half of the enamel was higher in the intervention group than in the control group. This suggests that fluoride mainly affects lesions in the outer half of the enamel. Caries Lesion Progression The intervention group had a lower mean number of caries lesions that progressed to or within enamel together with or within dentin than the control group did. The incidence of caries lesion progression to or within enamel was statistically lower in the intervention group than in the control group. The total mean number of proximal surfaces with caries progression didn’t differ between the 2 groups. The incidence of caries lesion progression to or within enamel for proximal surfaces was statistically lower in the intervention group than

the control group. After 2 years, the total number of lesions that progressed was the same magnitude between the intervention and control groups. Fewer lesions went from sound to the inner half of enamel over 2 years in the intervention group than in the control group (2% versus 31%, respectively). However, there tended to be a higher proportion of lesions that progressed from sound to the outer half of enamel in the intervention group than in the control group (58% versus 39%, respectively). No adverse events occurred and, because of the subjects’ age, there was no concern for dental fluorosis development.

CONCLUSIONS The low doses of fluoride added to milk along with the maintenance of oral hygiene routines with fluoridated toothpaste reduced caries lesion progress and increased caries lesion arrest. The incidence of individuals in the intervention group who had lesion progression to or within enamel at proximal surfaces was significantly lower than that in the control group.

Clinical Significance Based on these findings, the fluoride was adsorbed and took up residence on the surface of partially demineralized hydroxyapatite crystals, which diminished the enamel demineralization during low pH periods produced by dental biofilm bacteria. The effects of fluoride were mainly focused on lesions in the outer enamel. Because of the prevalence and distribution of enamel caries in younger adolescents, preventive efforts should focus on those with enamel caries. Using interventions to control enamel caries lesions should be individualized to each patient or patient group. Fluoridated milk may provide an alternative to community water fluoridation.

Rohlin M, Neilands J, Davies JR, et al: Fluoridated milk is effective in prevention of enamel caries in adolescents: A randomized trial. Acta Odontol Scand 84:673-684, 2025 Reprints available from G Swens€ater, Malm€ o Univ, 205 06 Malm€ o, Sweden; e-mail: gunnel.svensater@mau.se

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IMPLANTS Rating aesthetics, function, and cleaning of single dental implants BACKGROUND

METHODS

Dental implants are often used to replace missing teeth, with single implants now the most common type of implant therapy performed. Patients’ expectations for the esthetic outcome of dental implants are high, especially if the tooth is placed in the aesthetic zone. The challenge is to create a harmonious mucosal margin without any abrupt changes in tissue height and with a convex contour of the alveolar crest. A black triangular space should be avoided. Patient opinions regarding the aesthetics of the outcome of implant placement should be included, with information gathered from both objective and subjective means. A study was undertaken to describe the patient-reported cleaning, function, and aesthetic outcomes of single dental implants 10 to 15 years after placement. Secondarily, the goal was to evaluate objective esthetics in single dental implants at this same time period.

The patients completed 2 questionnaires using visual analog scales (VAS) and also had intraoral photographs taken of their frontal view and a close-up of the crown. The contralateral reference tooth was included to make comparisons. A dentist reviewed the photographs using the Pink Esthetic Score (PES) and the White Esthetic Score (WES) index. The PES/WES assesses the mesial papilla fill, distal papilla fill, curvature of the facial mucosa, level of the facial mucosa, root convexity, and color and texture of the soft tissue, along with crown form, volume/outline, color, surface texture, and translucency (Figure 1). The clinical measurements included probing pocket depth (PPD), peri-implant mucositis, and peri-implantitis. Analog periapical and bitewing radiographs were taken as well.

Figure 1. A patient with a single dental implant in the region of tooth 11, 13 years after placement. Pink esthestic score (PES) = 5, white esthetic score (WES) = 8, according to Belser et al. 2009. The patient’s perception of the esthetics on a visual analogue scale (VAS) = 40. (Courtesy of Bengtsson VW, Lindahl C, Scholander S: Patient-reported outcomes of esthetics, function and oral hygiene with single dental implants 10-15 years after placement: A cross-sectional study. Acta Odontol Scand 84:47-53, 2025.)

220 Dental Abstracts

RESULTS After 10 to 15 years, 58 patients were evaluated, with 45 having a single dental implant. Of these 45 patients, 19 (about 42%) were women, and the mean age of the patients was 40 years (range 30 to 80 years). Nine patients (20%) were current smokers. Fortyone had standardized titanium abutments and 4 had a single abutment direct cast abutment. The single crowns were ceramic in 38 patients and metallic ceramic in 7. The implants were placed because of trauma, aplasia, or decayed teeth. Questionnaire Results Function and Cleaning Ability Chewing function was given the highest mean satisfaction rating. This was followed by speech function and cleaning ability. Aesthetics Patients expressed the greatest satisfaction with color and shape of the single crown. The mucosal margin surrounding the implant was less satisfying. Overall satisfaction with the aesthetics was a mean of 8.6, with a median of 9.0. PES and WES Index Overall, the PES index had a mean score of 6.2 and a median of 6.0. Thirteen patients had a PES score of <6. For the WES index, the mean was 8.4 and median 9.0. One patient had a WES score of <6. Peri-implant Status Peri-implant mucositis was diagnosed in 40 patients and 2 had a diagnosis of peri-implantitis. Mean PPD was 3.8 mm, with 22.2% being ≥6 mm. The combined PES/WES was a mean of 14.6, with a median of 15.0. Three patients had a score <12. Peri-implant Diseases and Aesthetics Patients with peri-implant mucositis had an overall aesthetic satisfaction score of 8.7 and a median of 9.0. Patients with peri-implantitis had an overall aesthetic satisfaction score of 7.5 and a median value of 7.5.

Peri-implant Diseases and PES/WES Index For patients with peri-implant mucositis, the PES score was 6.1, the WES score was 8.5, and the combined PES/WES score was 14.7. For patients with peri-implantitis, the PES score was 7.0, the WES score was 7.5, and the combined PES/WES score was 14.5.

CONCLUSIONS The patients reported high levels of satisfaction with the cleaning, chewing ability, and overall aesthetics of their single dental implants. Less favorable opinions were shared regarding surrounding peri-implant mucosa, whether the results were subjective or objective.

Clinical Significance After at least 10 years of having single implants, patients reported satisfaction with chewing and speaking functions as well as overall aesthetics. Objectively, the aesthetics of the single dental implants and surrounding peri-implant mucosa were clinically acceptable. However, the PES was less favorable than the WES, suggesting that the aesthetics of the mucosa could be improved. It’s important to gather information from subjective as well as objective assessments of single dental implants to form a comprehensive aesthetic evaluation from the patient’s and the clinician’s perspectives.

Bengtsson VW, Lindahl C, Scholander S: Patient-reported outcomes of esthetics, function and oral hygiene with single dental implants 10-15 years after placement: A cross-sectional study. Acta Odontol Scand 84:47-53, 2025 Reprints available from VW Bengtsson, Dept of Oral Health, Faculty of Oral Health Science, Kristianstad Univ, Kristianstad SE-291 88, Sweden; e-mail: viveca.wallin_bengtsson@hkr.se

Removal of nonstandard and complex dental implants BACKGROUND Despite the high success rates achieved by dental implants, some situations—whether biological, mechanical, prosthetic, or other complications—can develop that require dental implants to be removed. The process of removing dental implants is influenced by the complexity of the implant type and structure, the implant site, the reason for its failure, and the level of bone loss around the implant and degree of osseointegration. Clinicians must understand the potential complications of dental implant

removal so that they can adopt preventive strategies, follow proper treatment protocols, and achieve good patient outcomes. Treatment planning must be comprehensive, surgical techniques used meticulously, and ongoing monitoring maintained. A series of patients had nonconventional design dental implant removal as a result of complications over the course of 11 years. The factors and techniques to consider for implant removal and the results achieved with the various approaches were documented.

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METHODS The 264 patients (mean age about 67 years, range 32 to 87 years) had 503 implants removed, with 40 of these implants being considered nonconventional. Analysis of the cases focused on the mechanical and biological determinants of the implant removal process and the rehabilitation required after the removal.

FACTORS AND TECHNIQUES INVOLVED Factors Affecting Implant Removal Complexity The complexity of implant removal depends on implant type, the 3-dimensional structure involved, implant site, and reason for failure. The level of bone loss around the implant compared to the level and degree of osseointegration can determine how challenging the difficulty may be. Understanding the complications that can accompany dental implant removal allows clinicians to plan preventive strategies, institute proper treatment protocols, and improve outcomes. Techniques for Implant Removal Anticlockwise Torque Rotation In conventional implant removal, the implant is accessed with or without a soft tissue flap, inserting a special key into the implant using anticlockwise torque to detach and remove it. For cases where anticlockwise torque rotation cannot be used, the removal of bone is required. Sectional Implant Removal For fractured implants, especially for subperiosteal, blade, or severely integrated implants, a sectional removal approach may be used. The implant is divided into segments for ease of removal and to avoid bone damage. This approach is also useful for very long root-form implants. When reimplantation isn’t planned, the implant can be buried under the bone and soft tissue. Guided Implant Removal Guided implant removal uses computer-aided design/computeraided manufacturing (CAD/CAM) technology to create a surgical guide. This provides a precise, minimally invasive map for implant removal. Post-implant Removal Management Site-preservation techniques such as socket preservation or guided bone regeneration can maintain bone and soft tissue volume and facilitate future implant placement. If there has been soft tissue damage or recession, grafting procedures can restore aesthetics and function. They should be done before bone grafting and reimplantation. Treatment Stages and Procedures A thorough evaluation of the patient’s medical and dental history should be done, noting implant lifespan, signs of infection or complications related to the implant, and any associated

222 Dental Abstracts

symptoms. Implant stability and soft tissue health should be evaluated and radiographs of the surrounding bone and adjacent structures taken. Cone beam computed tomography (CBCT) scans can evaluate the anatomical relationships between the implant and its surroundings. The appropriate anesthesia is administered as indicated. Local anesthesia or intravenous sedation or general anesthesia should be administered to anxious or apprehensive patients when extensive implant removals are planned. The clinical procedures include caution to preserve vital structures such as adjacent teeth, nerves, and blood vessels. After the implant is removed, clinicians should thoroughly debride the socket, remove infected or compromised tissue, evaluate the need for bone grafting or soft tissue manipulation/grafting to promote optimal healing, and lay the groundwork for later implant placement. Postoperatively, clinicians should provide appropriate instructions to the patient that cover pain management, oral hygiene, and dietary restrictions. Follow-up appointments should be set up to monitor the patient’s healing, assess complications, and plan for subsequent implant placement as appropriate.

RESULTS The implants most difficult to remove in the patient group studied were the subperiosteal, blade, and fractured root-form implants, all of which required more time than conventional root-form implants with peri-implantitis. The bone and soft tissue damage in these cases made it difficult to perform bone grafting to the implant removal site (Figure 1). The various implant removal approaches and their complexity, complications, and outcomes were detailed. Blade Implant Removal Usually a crestal approach is used to uncover the implant, followed by sectional detachment of the implant from the bone using surgical burs and piezosurgery, then completing the process with soft tissue closure. Zygomatic Implant Removal Careful planning, meticulous surgical technique, and preservation of adjacent vital structures are needed for complex zygomatic implant removal. If possible, the implant is accessed using a crestal approach through the alveolar crest, with a flap created to expose the implant. If no direct access is available through the crest or the implant head is damaged, a lateral approach using a lateral window osteotomy can access the implant through the maxilla. When there are signs of infection and failure caused by high stress from the absence of anterior support to the prosthesis and the anteroposterior rotation causes unfavorable loading on mesial implants, an anterior implant support may reduce the need for removal of the implant.

Figure 1. Massive bone resorption around subperiosteal implants: CBCT before removal (A) and panoramic after removal (B) (Case 1). (Courtesy of Manor Y, Joachim MV, Oz I, et al: To remove or not remove non-conventional dental implants? Eleven-year retrospective study on implant outcomes. Clin Implant Dent Rel Res 28:e70112, 2026.)

Conventional Implant Removal A cortical screw implant uses the cortical bone for anchorage, stability, and support of dental restorations. The removal of these implants because of implant fracture and soft tissue infection means there are suboptimal conditions for immediate bone grafting and normal anatomy is lost. Removing implants near the mental nerve can damage that nerve and cause hypoesthesia or anesthesia complications. After implant removal, the clinician

should evaluate the soft tissue and bone loss to determine if it’s possible to achieve optimal conditions for reimplantation (which is rare). The removal of single-piece implants can be challenging (Figure 7). Pterygoid Implant Removal Pterygoid or zygomaticomaxillary implants are specialized and used for severe maxillary bone resorption or failed conventional

Figure 7. Bone resorption around one-piece root-form implants; four new implants were placed for overdenture: CBCT before removal (A) and panoramic after removal (B) (Case 8). (Courtesy of Manor Y, Joachim MV, Oz I, et al: To remove or not remove non-conventional dental implants? Eleven-year retrospective study on implant outcomes. Clin Implant Dent Rel Res 28:e70112, 2026.)

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implant placement. These offer an alternative for implantsupported restorations in the posterior maxilla but pterygoid implants can require removal because of complications, failure, infection, etc. Either a transmucosal or intraoral approach may be used to access the implant, offering direct visualization and removal. The pterygoid implant is carefully loosened while avoiding excessive torque or stress on the bone and adjacent structures and minimizing trauma to the tissues. Excessive bleeding, dislocation of the implant, or pterygoid plexus nerve damage can complicate the procedure. If no other options are available, partial removal or simple follow-up can be done. A team of prosthodontists and maxillofacial surgeons should be gathered to determine whether pterygoid implant removal should be done. Endosseous Screw-type/Root-form Implant Removal Endosseous or conventional dental implants are often selected to replace missing teeth and provide stable support for dental restorations. Although highly successful, they may need to be removed because of failure, infection, periimplantitis, prosthetic complications, or patient discomfort. Careful planning, precise surgical techniques, preservation of vital structures, and consideration of patient factors are needed. The technique chosen will vary, but a crestal approach is best for implants with loose osseointegration or advanced peri-implantitis. A reversed torque approach is usually sufficient for removal of a failing implant. If this doesn’t work, a lateral approach and flap elevation allows for the use of trephines, elevators, and ultrasonic instruments to remove the implant while causing minimal trauma to the bone and soft tissues. Immediate or delayed bone grafting can be considered, depending on the amount of soft tissue loss.

Subperiosteal Implant Removal Subperiosteal implants may require removal because of rehabilitation complications, implant failure, infection, or patient discomfort. A subperiosteal dissection is needed to expose the implant framework, then the implant is carefully detached and sectioned for ease of removal. The surgical site must be thoroughly debrided, removing any infected or compromised tissue. The condition of the residual bone and consideration of bone grafting are done to ensure optimal site volume for implant placement. When the site is near nerves, damage is a risk. Bone defects typically can’t be regenerated during implant removal because of soft tissue injury or loss. Most cases require soft tissue regeneration and bone grafting if reimplantation is to be done.

Clinical Significance Clinicians need to understand the reasons for implant removal so they can select appropriate techniques and implement comprehensive treatment planning. Implant design selection and long-term follow-up need to be priorities to avoid or at least minimize the need for complex removal procedures.

Manor Y, Joachim MV, Oz I, et al: To remove or not remove nonconventional dental implants? Eleven-year retrospective study on implant outcomes. Clin Implant Dent Rel Res 28:e70112, 2026 Reprints available from G Ben-Izhack; e-mail: gil.ben.izhack@gmail. com

MATERNAL CARE Dental care for women from preconception through lactation BACKGROUND Over the period from conception to age 24 months, a child may be exposed to unfavorable factors vertically from the mother that can cause irreversible damage. This period should include continuous maternal care, beginning with optimizing the mother’s health 3 to 6 months before conception, undertaking proactive interventions throughout pregnancy, and continuing support during delivery through lactation for 2 years. Mothers will undergo hormonal fluctuations during the first trimester of pregnancy that can have profound effects on oral health, making them susceptible to pregnancyassociated gingivitis as well as tooth erosion from morning sickness, emesis, and gastric acid reflux in the second trimester. Dental

224 Dental Abstracts

plaque−induced inflammation can lead to progression of the gingivitis to pregnancy epulis. During the third trimester, gingival inflammation can develop into periodontitis, which compromises alveolar bone and other tooth-supporting structures. Shifts related to immunologic and metabolic adaptations coupled with modifications in diet and lifestyle can increase the mother’s vulnerability to periodontal disease and caries. Adverse fetal developmental outcomes can be instigated by these maternal changes. Dental practitioners should be able to manage oral diseases in women from preconception to lactation, covering both preventive measures for oral conditions and management, including imaging protocols, medication use, and dental surgical approaches.

ORAL DISEASES The primary oral diseases dental practitioners should be equipped to manage in pre-pregnant and pregnant women are periodontal infection, dental caries, pulp infection, and third molar pericoronitis. The primary findings of these diseases should be familiar to dental professionals, who can then institute proper interventions. Periodontal Infection The most prevalent periodontal disease in women who are pregnant is pregnancy-related gingivitis, which complicates 60% to 70% of pregnancies, with a peak in the third month of gestation. Dental plaque biofilm triggers gingivitis, and endogenous steroid hormones can exacerbate the condition. The pregnancy-related levels of estrogen and progesterone drive the development of gingivitis. The clinical manifestations are gingival bleeding, swelling, and tenderness, accompanied by discomfort or pain that makes it difficult to maintain good nutritional intake or perform oral hygiene. Rigorous oral hygiene maintenance is needed, with more severe cases requiring professional interventions. If pre-existing gingivitis has not been controlled before pregnancy, it can progress to pregnancy pyogenic granuloma or pregnancy epulis, which is a benign, vascular, hyperplastic lesion. The lesion tends to arise in connective tissues of the periodontal ligament and gingiva, usually at the interdental papilla. It develops in the first or second trimester in more than 5% of pregnancies. The solitary deep red or purple gingival mass about 2 cm in diameter can complicate chewing and oral hygiene. In asymptomatic cases, observation may be sufficient until the problem resolves after delivery of the child. Recurrent bleeding, impaired chewing ability, and postpartum persistence may require surgical excision, but the problem may recur after this approach. If the patient’s condition progresses to pregnancy-associated periodontitis, this destructive inflammatory disorder can affect the periodontal supporting tissues, with alveolar bone resorption and loss of periodontal attachment. Seen in over 40% of pregnant women, it can also lead to adverse pregnancy outcomes such as pre-eclampsia, preterm birth, and low birth weight, as well as long-term sequelae in offspring, including a higher risk for cardiovascular disease, allergies, and asthma. The risk for perinatal mortality may be increased by 88% and preterm birth risk by 31%. Factors that increase the risk of pregnancy-associated periodontitis are socioeconomic status, dietary habits, and oral hygiene practices. Even without overt periodontitis, women may experience transient tooth mobility as a result of their hormonal status. Generally, this mobility resolves gradually after delivery as hormone levels return to normal. Dental Caries and Pulp Infection The acidic byproducts released in the fermentation of dietary carbohydrates by oral microorganisms can produce dental

caries, with localized destruction of the tooth hard tissues. Prevalence of caries is increased during pregnancy, with contributing factors including gestational vomiting, which lowers salivary pH and causes demineralization of the enamel. Hormonal and metabolic shifts, behavioral modification such as increased meal frequency, and cravings for sugary foods also increase susceptibility to caries. The discomfort and reduced mobility of pregnancy can undermine oral hygiene practices, as can psychological factors such as dental anxiety and fear of treatment. Untreated lesions can progress to pulpitis, which can become severe and develop into oral abscesses or orofacial cellulitis. Significant risks are associated with gestational pulpitis, including intense pain and adverse pregnancy outcomes such as preterm birth or miscarriage. As a result, women planning to become pregnant should undergo a comprehensive oral examination at least 6 months before conception, allowing for restoration for pre-existing carious lesions and reinforcement of oral hygiene protocols Third Molar Pericoronitis Third molar pericoronitis is a dental emergency that requires closer attention in pregnant populations. These women’s symptoms tend to be more severe, their disease progresses more quickly, and more complex clinical management is required. If the third molar is partially or fully covered by a flap of soft tissue, a deep blind pocket may form and create a microenvironment where food debris and pathogenic bacteria can accumulate. Factors that can complicate the situation are the elevated estrogen and progesterone levels, which potentiate the inflammatory response of gingival tissues to bacterial toxins in dental plaque. Acute infection in otherwise asymptomatic pericoronal pockets is more common in these cases. The peak incidence tends to be in those age 18 to 30 years, overlapping the childbearing years. Dentists should be aware of the risk and be alert for the development of gestational third molar pericoronitis with persistent dull or throbbing pain in the retromolar region, erythema, edema, and tender pericoronal tissues. Palpation may yield purulent exudate. In severe cases, the adjacent tissues or fascial spaces can develop cellulitis or abscess formation. Preventive strategies include a pre-conception oral examination and the removal of symptomatic or high-risk wisdom teeth to avoid flare-ups during pregnancy.

MANAGEMENT PRINCIPLES Safety, Necessity, Comfort, and Multidisciplinary Collaboration The American Dental Association (ADA) released evidencebased clinical practice guidelines based on the core principles of safety, necessity, comfort, and multidisciplinary collaboration. Optimal treatment timing is the basis for safety, with the second trimester the ideal time to perform elective dental procedures. For acute oral conditions arising during the first and third trimesters, management should prioritize symptom palliation rather than definitive care, ensuring that essentials are addressed. Comfort for the patient should include ongoing monitoring of vital signs, effective pain management, keeping sessions to

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20 minutes or less, and proper positioning. During third trimester care, the patient should be positioned in a semireclined, left lateral tilt posture to avoid supine hypotensive syndrome. After treatment, the dentist should provide oral health information, observe patients for less than 30 minutes, and recheck vital signs before discharge. Pregnant patients with comorbid conditions should undergo a multidisciplinary evaluation before treatment. Care should be delivered in collaboration with obstetricians or specialists to follow evidence-based, individualized plans, choose pharmacological agents, minimize any nonessential elements, and ensure patients and their families complete the informed consent process before treatment. Dental Imaging Pregnancy has been generally considered a primary contraindication for radiological diagnostic procedures. Common dental radiographs expose the patient to ionizing radiation, with fetal harm based on the exposure dose. Based on the dose, the American Dental Association (ADA) and the Food and Drug Administration (FDA) confirm the safety of oral imaging for pregnant women and those planning to become pregnant. The banana equivalent dose (BED) has been adopted for the equivalent quantification of dental imaging procedures (Table 1). A single banana emits about 0.1 μSv of radiation, and the radiation dose of a single dental x-ray ranges from 1 to 8 μSv, or the equivalent of 10 to 80 bananas. A cone beam computed tomogram (CBCT) exposes the patient to a dose equivalent to 60 dental x-rays. The safety standard specifies an annual allowable dose limit of 1000 μv, which is equivalent to the radiation from 192 dental x-rays or 3 CBCT scans. For dental images in women in the preconception and pregnancy phases, a lead apron and/or lead neck collar may be used, along with adherence to the As

Low As Reasonably Achievable (ALARA) principle. Anytime imaging is essential for emergency clinical management, comprehensive lead shielding should cover the abdomen and thyroid gland. Lactating women, especially if they are breastfeeding, are under no contraindications to undergoing dental imaging. The embryo or fetus should not receive a cumulative radiation exposure throughout pregnancy that exceeds 1 mSv. Generally, the fetus receives a radiation about 0.002% of that absorbed by the mother. Radioresistance develops in the zygote within 1 to 2 weeks after fertilization. Dental imaging can be performed safely during this window. The 3 to 12 weeks of the first trimester is when fetal organogenesis takes place, so non-urgent imaging examinations should be deferred until the second trimester. Medications The use of pharmacological agents should balance maternal therapeutic needs with the safety of the fetus or infant. Ovum quality and fertilization processes can be compromised, some medications disrupt the endocrine system, some alter hormone levels, and ovarian folliculogenesis and ovulation can be disrupted. The transplacental passage can expose the fetus to drug actions. In lactating women, drugs enter the breast milk via the bloodmilk barrier, with passage promoted by low molecular weight, high lipid solubility, and weak protein binding; the opposite characteristics hinder passage. The FDA issued the Pregnancy and Lactation Labeling Rule (PLLR) and mandated labeling to included detailed information regarding pregnancy exposure, risks, clinical considerations, and findings of human and animal reproductive studies. Dentists should carefully review labels before prescribing to women along the preconception to lactation continuum (Table 2).

Table 1. Equivalent Comparison of Dental Radiation Dose Between “Invisible” and “Visible” International Safety Standards Standard Type

Allowable Dose (μ Sv)

Equivalent to the Number of Periapical Films

Equivalent to the Times of CBCT Scans

Annual Safety Limit

1000

192

Annual Maximum Limit

5000

961

100,000

19,230

333

Carcinogenic Risk Threshold

Dental Radiation Examination Radiation Safety Comparison Table Examination Item

Radiation Dose (μ Sv)

Equivalent to the Number of Bananas

Single Periapical Film

5.2

Full-mouth Periapical Films

72.32

723

Panoramic Film

10∼23

Small-field CBCT

≤300

3000

1∼3

10∼30

Cephalometric Lateral Film

100∼230

Comparison with Daily Activities 1-hour flight 3-day natural radiation 2∼5-hour flight 3 long-distance flights 10 bananas

One banana = 0.1 μSv. The data are calculated based on the values provided by the website of ICRP (https://www.icrp.org/publication.asp?id=ICRP% 20Publication%20103). (Courtesy of Yin Q-Y, Liang J, Wang F: Continuous maternal care of oral diseases from preconception to lactation. J Dent 167:106555, 2026.)

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Table 2. FDA Guidelines for Oral Medication from Preconception to Lactation Preconception Recommendation

Pregnancy Recommendation

Lactation Recommendation

Normal preconception

Discontinue for 72 h before conception

First choice, low placental permeability Avoid oral administration in early pregnancy

Tetracycline

Discontinue for at least 1 month before conception

Contraindicated (causes tooth discoloration)

Breastfeed 1 hour after medication (RID <0.1 %) Suspend breastfeeding for 72 h after administration Contraindicated during lactation

Acetaminophen

Safe

Breastfeed 2 h after medication

Ibuprofen

C/D (third- trimester)

Short-term pain relief (<3 days), normal preconception Normal preconception

Use with caution in early pregnancy, contraindicated in late pregnancy

Breastfeed 4 h after medication

Lidocaine

Normal preconception

Breastfeed 4 h after medication

Articaine

Control dose, normal preconception

Maximum dose: 7mg/kg (clinical suggestion: <3 cartridges) Short-term use when necessary

Drug Category

Common Drugs

FDA Classification

Antibiotics

Amoxicillin Cephalosporins Metronidazole

Analgesics

Local Anesthetics

Breastfeed 4 h after medication

Note: The aforementioned medication recommendations for preconception, pregnancy, and lactation are elaborated based on the pharmacokinetic properties of drugs, with the core centered on the calculation of drug half-life (t1/2). These recommendations do not constitute an absolute safety threshold, as individual variations in maternal metabolic capacity, drug sensitivity, and the severity of underlying diseases may all modulate the actual safety profile. Clinicians ought to further adjust the medication regimen through a comprehensive assessment of the patient’s specific clinical conditions, so as to balance therapeutic efficacy and the safety of both the mother and fetus/infant. (Courtesy of Yin Q-Y, Liang J, Wang F: Continuous maternal care of oral diseases from preconception to lactation. J Dent 167:106555, 2026.)

Clinical Practices and Procedures Dental materials selected for maternal use must balance the mother’s therapeutic needs with fetal safety. Clinical procedures should be planned according to the safety of these materials and the fetus’ gestational age (Table 3). Basic periodontal treatments are safe and effective. However, periodontal surgery is complex and lasts a considerable time, so non-acute cases should be delayed until after delivery. Amoxicillin can be given for severe chronic or aggressive periodontitis, with cephalosporins also considered safe. The oral use of metronidazole in the first trimester should be avoided. The topical use of chlorhexidine mouthwash in the third trimester is safe, with topical use considered acceptable during pregnancy and lactation. Iodine preparations should generally be avoided. Clinicians should comprehensively asses the use of povidone-iodine in perinatal oral care, maintaining short-term, low-dose topical application. Safer alternatives should be preferred. For caries removal in women, chemomechanical minimally invasive excavation is standard practice. Carisolv can selectively soften carious dentin, allowing for manual removal to preserve healthy tooth structure, keeping pain levels minimal, and not risking cross-infection. Resin-based restoratives are the first-line choice, followed by glass ionomer cements (GICs). Pregnant women with acute pulpitis may suffer pain during pulp extirpation that isn’t managed using anesthesia.

Multirooted posterior tooth treatment can require complex techniques and x-rays. Simplified interventions should be selected for emergency pulp disease management. Because severe tooth pain can trigger miscarriage or preterm birth, intrapulpal pressure should be released, temporary obturation performed, and root canal filling completed in the second trimester or after delivery. Pulp-devitalizing agents are not recommended. Common intracanal medicaments can be used, having proved both efficacious and safe for maternal pulpitis. Calcium hydroxide intracanal medication is explicitly recommended. Managing Oral Health Oral health education, daily care guidance, and dietary adjustments are the essential elements in oral health management for women from preconception to lactation. These women require regular education on pregnancy-specific oral care and mental health. Before conception they should have a professional oral examination to reduce the risk of oral issues. Existing dental caries are treated and the eruption of third molars or their extraction can be managed. Women should be educated in the Bass method of plaque removal, soft deposit clearance, and the elimination of food residue. Fluoride-containing toothpaste and mouthwash should be used as needed. Dental floss and interdental brushes help clean interdental spaces and hard to reach areas. Health lifestyle habits should be encouraged as replacements for habits that can risk fetal malformation and cognitive impairment.

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Table 3. Maternal Periodontal and Dental Infection Management & Medication Safety Infection Source Periodontal Infection

Dental Infection

Disease

Procedure Type

Drug Name

Safety

Pregnancy Gingivitis Pregnancy Epulis Pregnancy Periodontitis

Ultrasonic scaling Hand scaling Abscess incision and drainage Periodontal surgery

Amoxicillin Cephalosporins Tetracyclines Metronidazole Iodoform Glycerin Chlorhexidine Povidone Iodine

√

Caries

Caries removal Restoration

Carisolv Amalgam Glass Ionomer Cement/Resin

√ □ √

Pulp Infection

Devitalization

Metallic Arsenic Paraformaldehyde Camphor Phenol Formalin Phenol Vitapex Paste

Medicament sealing

× □ × √ □

× √

Key: √: Completely safe; maybe be used with confidence. Refers to drugs proven safe in both animal experiments and human clinical trials. No fetal risk has been demonstrated in controlled studies involving first-trimester pregnant women, nor has evidence of risk been identified in the second or third trimester. □: Relatively safe; use as appropriate based on the patient’s general condition and disease severity. No fetal risk was shown in animal reproductive studies, though no controlled trials have been conducted in pregnant women; alternatively, animal reproductive studies have indicated adverse effects, which, however, cannot be confirmed in controlled studies involving first-trimester pregnant women. x: Unsafe; use not recommended from preconception to lactation. Adverse fetal effects (eg, teratogenicity, embryonic lethality, or other harms) have been confirmed in animal experiments, yet no human research data is available to verify such effects. Drugs in this category may only be used if the benefits to the pregnant woman are assessed to outweigh the potential harms to the fetus. (Courtesy of Yin Q-Y, Liang J, Wang F: Continuous maternal care of oral diseases from preconception to lactation. J Dent 167:106555, 2026.)

Gentle tools and methods should be used for daily care during pregnancy. Brushing may be required 2 to 3 times a day for 3 minutes at a time. Regular oral examinations should be scheduled in the second trimester. Consultations should be scheduled to allow dentists to detect and prevent oral disease. Selfmedication or delayed treatment should be replaced by professional care for any acute oral disease. Dietary planning is vital to safeguard maternal and fetal health and reduce the risk for oral disease. Key dietary practices are to control high-sugar food intake, to limit carbohydrate consumption to moderate levels, and to add supplements to achieve an adequate intake of protein, vitamins, and trace elements. Folic acid supplementation is advised for the prevention of fetal cleft lip and palate. Pregnancy-related xerostomia or sialorrhea can be managed with sugar-free chewing gum.

associated with pregnancy and lactation are important to the safety of mother and infant.

CONCLUSIONS

Yin Q-Y, Liang J, Wang F: Continuous maternal care of oral diseases from preconception to lactation. J Dent 167:106555, 2026

The effective control of behaviors and exposures that can lead to adverse pregnancy outcomes may protect the fetus/child and mother from having problems. Dental care is an essential part of the preconception to lactation continuum women go through. The common periodontal and dental diseases, radiological imaging measures, procedures, and preventive measures

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Clinical Significance Health care providers should be available and well educated regarding the needs of women who want to become pregnant or have become pregnant and will be caring for their infant through lactation. Gestational age-specific interventions and preventive measures that can avoid problems are more likely to achieve a safe, comfortable, and successful pregnancy and first 2 years of life for the child.

Reprints available from F Wang, Ctr for Cariology, Endodontics and Periodontics, Optical Valley Branch, School & Hosp of Stomatology, Wuhan Univ, Wuhan, China; e-mail: wangfang-nm@whu. edu.cn

ORAL CANCER Investigating oral cancer numbers and outcomes for women BACKGROUND Oral cancer is the third most common cancer in countries with a low or medium Human Development Index, and over 90% of oral cancers are oral squamous cell carcinoma (OSCC). In women, the disease is primarily seen among non-smokers who are young and the site affected is most often the tongue. The number of OSCC cases in women at a single center was shown to have increased since 1991, with the ratio of women to men of 0.19:1, but over the past 10 years the ratio increased to 0.34:1. OSCC is often diagnosed at an advanced stage, so that effective treatment is challenging. Surgery is the main therapeutic choice, but the choice depends on the cancer stage. Single-modality treatment with surgery or radiotherapy is recommended for patients with early-stage tumors, whereas those with locally or regionally advanced disease are usually treated with combination-modality approaches. Both radiotherapy and intensive therapy are less commonly chosen for women compared to men. The demographics, risk factors, and clinicopathological and prognostic data for women treated for OSCC were evaluated, along with predictors for outcomes and survival.

METHODS One hundred thirty-three women with OSCC were seen between 1991 and 2023 at a single center. Demographic, clinicopathological, and risk factor data were collected from their clinical records. In addition, recurrence and second primary tumor development were noted.

RESULTS Demographics Data as to patients’ age, ethnicity, and marital status as well as smoking and alcohol use were collected. Most women were over age 65 years and white. Forty-two patients were married and 38 were widowed. Clinicopathological and Risk Factor Data The tongue was the area most often involved with OSCC. About 54% of the patients had early stage disease, and surgery was done in about 68% of these patients. Tumor-related pain was reported by about 53%. Most patients (about 52%) were nonsmokers, with the majority of those who smoked (about 31%) being considered heavy smokers. Thirty percent of the patients had a history of alcoholism and about 43% were heavy drinkers.

About 72% of the patients had at least 1 comorbidity, with the most common comorbid conditions being hypertension (about 44%) and depression (about 23%). Less common comorbidities were gastritis (about 16%), diabetes (about 13%), hypothyroidism (12%), and osteoporosis (9%). Recurrence and Second Primary Tumors Data from 103 patients were analyzed for recurrence and second primary tumors (SPTs). Recurrence was seen in about 225 of patients and about 15% had a SPT. Recurrence was higher in women who reported a tumor evolution time of 4 to 7 months compared to those whose evolution time was more than 7 months. None of the patients with regional metastasis when diagnosed had tumor recurrence. About 26% of those with N-negative status had tumor recurrence. Obesity was associated with recurrence, but the tendency didn’t reach statistical significance. Similarly, the SPT development was lower for patients having nonsurgical treatment, but the difference wasn’t statistically significant. Multivariate analysis failed to show significance for these variables. Overall and Disease-specific Survival Data from 105 to 87 patients were evaluated for the 2- and 5-year, respectively, overall survival (OS) and disease-specific survival (DSS). The OS rate for 2 years follow-up was 39% and that for 5 years was about 36%. The DSS rate for 2 years was about 63% and that for 5 years was about 62%. Clinical stage and type of treatment were associated with higher OS and DSS rates at both time points. Tumors diagnosed at an early stage and treated surgically had better survival outcomes. Advanced stage increased the risk of death by 3.116 times. Nonsurgical treatment increased the risk of death for 2 year OS by 3.012 times. The risk of death in 5-year OS was 4.088 times higher for patients with tumors diagnosed at an advanced stage. The risk of death in patients with DSS was 2.843 higher at 2 years for those with a diagnosis at an initial stage and 4.282 times higher at 5 years for those receiving a diagnosis at an advanced stage.

CONCLUSIONS The proportion of women diagnosed with oral cancer has nearly doubled over the past 10 or so years. Most are elderly and nonsmokers and have comorbidities, including hypertension and depression. Diagnosis or OSCC at an advanced stage is associated with poor survival outcomes.

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Clinical Significance Research is needed in understanding the epidemiology of OSCC in women. This should include factors that contribute to an increase in the incidence of disease and the implications these factors have for survival. The investigation needs to include research on early detection, even in women lacking any known risk factors. The goal is to improve outcomes for women with OSCC.

de Melo Cardoso D, Nogueira RMP, Duarte GD, et al: Oral cancer in women: Clinical profile, risk factors, treatment outcomes and survival predictors in 32 years of experience. Clin Oral Invest 30:7, 2026 Reprints available from DG Bernab�e; e-mail: daniel.bernabe@unesp.br

ORTHODONTICS Clear aligner therapy evaluation BACKGROUND

RESULTS

Orthodontic treatment has been changed vastly by the development of clear aligner therapy (CAT). Technological advances and a preference for aesthetic treatments have led to a need for dental professionals to comprehensively understand the biomechanical principles and effectiveness of clear aligners for various orthodontic scenarios. A wealth of complexities exist that present challenges in CAT, especially related to the management of tooth movements during the closure of extraction spaces. Deviations from the planned outcomes have been discovered and verified through cone beam computed tomography (CBCT). To better understand the treatment of moderate to severe crowding through CAT and enable insight into the 3-dimensional tooth movements and the automated digital model superimposition technique in extraction and non-extraction protocols, an analysis was done of patterns in tooth movement and biomechanical control, especially in anchorage loss, incisor retraction, and posterior tipping.

Significant differences were noted between the extraction and non-extraction groups. In the patients having extractions, the incisors in both arches had significant retroclination with no torque control. Control of anchorage was limited, which allowed about equal amounts of molar mesialization and incisor lingualization. The mean mesialization of the posterior teeth in the upper arch was −3.94 mm and the mean lingualization of the anterior teeth in the upper arch was 3.19 mm. The mean mesialization of posterior teeth in the lower arch was −2.83 mm and the mean lingualization of anterior teeth in the lower arch was 2.81 mm. The extraction group had a greater mesial rotation of the posterior teeth. Vertical changes were similar between the 2 groups.

METHODS Forty-six patients were selected for study. Twenty-three were in each of 2 groups, of which one group received CAT with premolar extractions (mean age 20 years) and the other group received non-extraction treatment (mean age 17.3 years). Pre- and posttreatment digital dental models superimposed using the Slicer Automated Dental Tools module quantified the 3-dimensional tooth linear and angular displacements.

230 Dental Abstracts

CONCLUSIONS The study illustrated the variation in achieving precise tooth movements in moderate and severe crowding cases managed using clear aligners with premolar extraction or non-extraction methods.

Clinical Significance Clear aligner therapy for crowding that uses premolar extractions presents significant challenges in controlling buccal inclination, anterior torque, and mesiodistal tip management with significant retroclination of the incisors and mesial tipping of the molars. Clinicians need to carefully manage the biomechanical limitations that occur with tooth movement control. In addition, further investigation is needed to answer questions that arose during this study. For example, how can clear aligner protocols be optimized to make tooth movements in extraction cases more predictable? What biomechanical strategies would improve anchorage control and minimize undesirable tipping? Occlusal results, treatment efficiency, and patient satisfaction could be added to achieve a more comprehensive evaluation and better overall clinical outcomes.

Eason M, Tai SK, Loh CT, et al: Three-dimensional assessment of tooth movements in clear aligner treatment of moderate and severe crowding. Clin Oral Invest 30:6, 2026 Reprints available from R Teixeira; e-mail: rodrigoteixeira@usp.br

PERIODONTAL/SYSTEMIC LINKAGES Periodontitis and chronic obstructive pulmonary disease BACKGROUND Chronic obstructive pulmonary disease (COPD) is a progressive condition marked by persistent airflow limitations, with chronic cough, sputum production, and dyspnea. The global prevalence of COPD is about 13%, with a higher prevalence in men than in women (approximately 15% versus 9%). Periodontitis is a chronic inflammatory disease that affects the dental supporting structures. It has been significantly associated with several systemic diseases, including COPD. Both COPD and periodontitis have a significant impact on the quality of life of individuals, and they share risk factors such as smoking, microbial infections, environmental pollution, diabetes, poor socioeconomic status, and inadequate dental care behaviors. Periodontal pathogens can contribute to systemic inflammation and exert detrimental effects beyond the oral cavity. Patients with periodontal disease may have mouths colonized by respiratory pathogens that exacerbate COPD. In addition, COPD patients can have an elevated expression of mucin proteins induced by certain periodontal pathogens. These microorganisms can contribute to mucous hypersecretion and airway obstruction, which compromise lung function. The transfer of pathogens from the oral cavity to the lungs can create an inflammatory response in the respiratory epithelium and impair lung function. An assessment was done of the prevalence and severity of periodontal disease in persons

with COPD, with the goal of uncovering insights into the potential links between the 2 disorders.

METHODS A search was done in the PubMed, Scopus, Embase, and Web of Science databases. The primary outcome was the number of participants with periodontitis in those with and without COPD. Severity of periodontitis, smoking status, number of patients with periodontitis and clinical attachment loss (CAL) greater than 3 mm, number of patients with greater than 5 mm in probing depth (PD), mean bleeding on probing (BOP) scores, mean CAL scores, and mean PD scores were also recorded.

RESULTS Prevalence of Periodontitis in COPD Patients Thirteen studies reported the prevalence of periodontitis in 18,581 patients and had a pooled prevalence of 35%, with a 25% prevalence of moderate periodontitis and a 26% prevalence of severe periodontitis in these COPD patients. Smoking status was also noted, revealing that studies with more than 50% smokers had a pooled periodontitis prevalence of 44%, with 34% of the patients having severe periodontitis and 30% with moderate periodontitis. Studies with less than 50% smokers in the COPD group

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had a significantly lower pooled prevalence (19%), with 21% having moderate and 18% having severe periodontitis. Periodontitis and COPD Six studies investigated the prevalence of periodontitis in COPD patients compared to persons without COPD. Significantly greater odds of periodontitis were found in patients with COPD compared to controls. Periodontal Measures Four studies reported mean BOP in patients with COPD. There was a significantly higher mean BOP score among COPD patients than among non-COPD patients. Mean CAL was noted in 21 studies. COPD patients had significantly higher mean CAL measurements than in non-COPD patients. The mean PD in COPD patients was reported in 19 studies, The mean PD in COPD patients was reported in 19 studies. Patients with COPD had a significantly higher mean PD level compared to controls. CAL and PD greater than 3 mm were reported in 14 studies. Greater odds of CAL and PD exceeding 3 mm were noted in patients with COPD than in non-COPD patients. COPD patients also had significantly higher odds of having PD exceeding 5 mm compared to non-COPD patients.

CONCLUSIONS Periodontitis appears to be associated with COPD based on a higher prevalence of periodontal disease in individuals with COPD. The pooled prevalence of periodontitis in the COPD group was 35%. Moderate periodontitis affected 25% of the COPD group, and severe periodontitis affected 26% of these individuals.

Clinical Significance COPD may be related to a worse clinical periodontal status. A clinically relevant link may exist between pulmonary and oral health, but future research is needed to provide longitudinal studies with standardized periodontal case definitions and adjustments for shared risk factors. With this plan, causality and the impact of periodontal therapy on COPD progression and exacerbation may be clearer, and interventions may be suggested by the outcomes.

Sivaramakrishnan G, Sridharan K: Linking lungs and gums: A meta-analysis of periodontitis prevalence and severity of chronic obstructive pulmonary disease. BDJ Open 12:16, 2026 Reprints available from G Sivaramakrishnan, Bahrain Defence Force Royal Medical Services, Riffa, Bahrain; e-mail: Gowri. sivaramakrishnan@gmail.com

Nonsurgical periodontal therapy and cardiovascular disease BACKGROUND Cardiovascular disease (CVD) involves complex interactions across multiple organ systems and is the leading cause of mortality worldwide. Among the conditions contributing to it are periodontal disease, which is a potentially modifiable risk factor for adverse outcomes. Periodontitis is a chronic inflammatory disease resulting from pathogenic bacteria in the dental biofilm and can promote endothelial dysfunction, accelerate atherogenesis, and influence the development and progression of CVD. Studies suggest periodontitis may influence the lipid profile, specifically, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), and total cholesterol (TC). Vascular biomarkers such as systolic blood pressure (SBP) and diastolic blood pressure (DBP) may also be impacted. The treatment of periodontitis potentially may exert systemic benefits. Currently, nonsurgical periodontal therapy (NSPT) is the gold standard for

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managing periodontitis. A meta-analysis of systematic reviews was done to assess the effect of NSPT on markers of systemic inflammation, lipids, and vascular health.

METHODS The search was done in the Dentistry and Oral Sciences Sources (DOSS), Scopus, Embase, PubMed, Google Scholar, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) evaluating the effect of NSPT on cardiovascular biomarkers in adults with periodontitis. The inflammatory markers included tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1β (IL-1β), and fibrinogen; the lipid markers included HDL, LDL, TC, and TG; and the vascular health indicators were SBP, DBP, pulse wave velocity (PWV), flow-mediated dilatation (FMD), and carotid intima−media thickness (CIMT).

RESULTS Seventeen systematic reviews were selected. IL-1β, fibrinogen, PWV, and CIMT were omitted because only 1 review addressed each of these. NSPT was shown to reduce CRP. No beneficial effect was seen on TNF-α. HDL showed a significant improvement, with LDL demonstrating consistent reductions. The beneficial effect was considered significant. However, no clear effects were noted for TC or TG. NSPT had no clear or consistent effect on vascular outcomes. DBP was reduced in pooled estimates but without statistical significance. FMD had similar findings. SBP was shown to have high heterogeneity in its effects.

CONCLUSIONS NSPT is associated with reduced systemic inflammatory markers and improved HDL, especially in patients with established periodontitis. The strength of the evidence related to other biomarkers is low.

Clinical Significance Oral health education, comprehensive periodontal assessment in cardiovascular patients, and a multidisciplinary approach to managing cardiovascular risks should be coupled with NSPT to effect positive alterations in the risk for CVD in patients with periodontitis. An interdisciplinary approach should be undertaken that recognizes the importance of periodontitis as a risk factor for cardiovascular disease.

Shi R, Jamieson L, Nath S: Does non-surgical periodontal therapy improve biomarkers associated with cardiovascular disease? An umbrella review. Clin Oral Invest 30:10, 2026 Reprints available from S Nath; e-mail: Sonia.nath@adelaide.edu.au

SLEEP APNEA Mandibular advancement devices to manage severe obstructive sleep apnea BACKGROUND

METHODS

Mandibular advancement devices (MADs) are approved oral appliances for the management of obstructive sleep apnea (OSA), especially for those with mild to moderate disease and those unable to tolerate continuous positive airway pressure (CPAP) devices. MADs reposition the mandible forward during sleep, advancing the tongue and soft tissues of the upper airway. This reduces airway collapse, stabilizes the pharyngeal walls, and improves neuromuscular tone. Patients using MADs have better adherence because of the comfort of the device, ease of use, portability, and greater partner acceptance. With appropriately selected patients, MADs can provide improved daytime sleepiness, blood pressure (BP), and quality of life similar to what is accomplished with CPAP treatment. In clinical practice, MADs are generally not recommended for patients with severe OSA because they aren’t as effective as CPAP for reducing the apnea-hyponea index (AHI), which measures OSA severity. With the clinical relevance of AHI being questioned and the poor BP control and high incidence of adverse cardiovascular events seen in untreated severe OSA, MADs may offer a viable alternative, especially if CPAP isn’t tolerated. A study of 144 individuals with moderate-to-severe OSA assigned to treatment with CPAP or MAD was undertaken to determine the effectiveness of the 2 approaches. The measures were used to determine the 24-hour ambulatory BP, sleep-related quality of life, myocardial remodeling, ambulatory heart rhythm, and biomarkers.

Seventy-three patients were randomized to the MAD group and 71 to the CPAP group. About 62% of the participants were obese, and about 56% of the participants had coronary artery disease. Approximately two-thirds of the subjects were nonsleepy. The MAD group had an AHI of 44.0 events per hour and the CPAP group had an AHI of 50.7 events per hour. Sixty-one patients in each group completed the study.

RESULTS The results were analyzed in relation to device adherence, efficacy on AHI, 24-hour ambulatory BP, sleep-related quality of life, cardiac magnetic resonance imaging (MRI), ambulatory electrocardiograph (ECG) monitoring, cardiovascular biomarkers, and side effects related to the treatment. Device Adherence For the MAD group, mandibular protrusion at the beginning of acclimatization was about 70%. It was progressively titrated based on the patient’s comfort and symptom control, reaching nearly 96% at the end of acclimatization/beginning of treatment. After 12 months of follow-up, mean protrusion was 88%. Median duration of MAD usage over the 12-month period was 5.4 hours per night. About 71% of the participants used MADs for 4 or more hours a night, and about 26% used the devices

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Figure. Blood pressure (BP) changes from baseline to 12-month follow-up for the mandibular advancement devices (pink) and continuous positive airway pressure (CPAP) (green) groups. The analysis was based on 122 patients with both baseline and 12-mo BP in the mandibular advancement device (MAD) (n = 61) and CPAP (n = 61) groups. All BP components of the ambulatory BP (except asleep diastolic BP) increased from baseline to 12 months in the CPAP arm. On the contrary, all components of the ambulatory BP decreased from baseline to 12 months in the MAD arm. The between-group difference in asleep mean blood pressure (− 3.70 mm Hg, 95% CI: − 7.40 to 0.00, P = 0.050) and asleep systolic blood pressure (− 4.78 mm Hg, 95% CI: − 9.51 to − 0.04, P = 0.048) favored the mandibular advancement devices. Abbreviation: CI, Confidence interval. (Courtesy of Colpani JT, Ou Y-H, Kosasih AM, et al: Mandibular advancement device versus CPAP in severe obstructive sleep apnea. J Dent Res 105:112-119, 2026.)

for 6 or more hours a night. In comparison, the 95th percentile pressure in the CPAP group was about 10 cm H2O at baseline and about 11 cm H2O after 12 months. Median duration of CPAP usage over the 12-month treatment period was about 5 hours a night, with 75% using CPAP for at least 4 hours per night and about 28% using it for at least 6 hours per night. Efficacy on AHI For the MAD group, residual AHI was measured in a home-based sleep study using a wrist sleep monitoring device. In the CPAP group, residual AHI was measured by the built-in sensor in their machine. The MAD group experienced a drop in AHI from 44 events at baseline to about 21 events per hour after 6 months. The CPAP group began at about 51 events and dropped to 2.1 events per hour. After 6 months, about 5% of the MAD group and about 92% of the CPAP group achieved a residual AHI of less than 5 events per hour. About 74% of the MAD group and 100% of the CPAP group achieved a 50% or greater reduction in AHI. Residual AHI data were available only for the CPAP group after 12 months, with about 92% having an AHI of <5 and all had sustained at least a 50% reduction in AHI. 24-hour Ambulatory BP From baseline to 12 months, MAD was associated with a reduction in 24-hour diastolic BP, asleep mean BP, asleep systolic BP, and asleep diastolic BP, whereas CPAP had an

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increase in BP (Figure). The between-group difference in asleep mean BP and asleep systolic BP favored the patients treated with MADs. Quality of Life The Epworth Sleepiness Scale (ESS) over the period from baseline to 12 months of treatment improved in both the MAD and the CPAP groups. The between-group difference in changes in ESS favored the CPAP group. The Functional Outcomes of Sleep Questionnaire (FOSQ) scores improved in both groups, with no statistically significant differences between groups. The Sleep Apnea Quality of Life Index (SAQLI) scores also improved in both groups, but the between-group differences in changes favored the MAD group, but was statistically insignificant. Cardiac MRI About 40% of the MAD group and about 54% of the CPAP group underwent cardiac MRI. The ejection fraction, end-diastolic volume, end-systolic volume, and stroke volume of the left and right ventricles remained in the normal range at baseline and after 12 months in both groups. Ambulatory ECG Monitoring Between baseline and the 12-month follow-up, no differences in median heart rate were shown between the MAD and CPAP groups. At baseline, valid ambulatory ECG monitoring results

were obtained in approximately 90% of the 2 groups. The duration of monitoring was 3.5 days for the MAD group and for the CPAP group. After 12 months, about 90% of the MAD group and about 85% of the CPAP group had valid monitoring results, with median durations of 3 days for the MAD patients and 2 days for the CPAP group. Side Effects Common side effects reported at 12 months in the MAD group were dry mouth, jaw pain, tooth discomfort, sleep disturbances, and hypersalivation. Those reported in the CPAP group at 12 months were dry mouth, air leakage, nasal congestion or runny nose, headache or body ache, facial rash, sleep disturbances, mask discomfort, eye irritation, and partner complaints.

CONCLUSIONS BP control was better with MADs than with CPAP in these patients with severe OSA. However, the improvements in sleeprelated quality of life were comparable between the 2 treatments.

Clinical Significance MAD could be an acceptable and effective treatment for patients who have severe OSA and hypertension. Dentists and sleep specialists may be able to develop a multidisciplinary approach that will provide more personalized care for patients at high risk for cardiovascular disease. Customized titration may improve both adherence and cardiovascular outcomes with MAD therapy.

Colpani JT, Ou Y-H, Kosasih AM, et al: Mandibular advancement device versus CPAP in severe obstructive sleep apnea. J Dent Res 105:112-119, 2026Reprints available from C-H Lee, Dept of Cardiology, National Univ Heart Ctr Singapore, 1 E Kent Ridge Rd, NUHS Tower Block Level 9, Singapore, 119228, Singapore; email: mdclchr@nus.edu.sg

SMOKELESS TOBACCO Swedish snus risks for oral health BACKGROUND Swedish smokeless tobacco or snus use has been documented since the 17th century, although it’s undergone significant changes over time. In the 1970s the introduction of portionpacked snus enhanced the product’s accessibility and popularity. New product categories have also been introduced, and the various brands differ, as do the doses, exposure times, personal dental care habits, and socioeconomic status of users. Swedish snus has been banned from the market of countries in the European Union because of the associated health risks. Snus may increase blood pressure and impair the vasodilatory function of blood vessels, but no direct association has been found between snus use and myocardial infarction or stroke data. A systematic review was performed to determine the impact of Swedish snus on such oral health concerns as gingivitis, gingival recession, periodontitis, caries, tooth wear, and oral cleft malformations.

METHODS The original scientific articles addressing relationships between Swedish snus and gingivitis, gingival recession, periodontitis, caries, tooth wear, and oral cleft malformations were identified through a search of the PubMed, Scopus, and EMBASE databases. Twenty-six articles were included in the review. In nearly three fourths of the studies it was impossible to relate the outcome measure to a specific type of snus, but authors tended to assume

there was a mixture of loose and portion-packed sinus when the type wasn’t specified.

RESULTS Patient data were retrieved from interviews, questionnaires, clinical examinations, radiographic assessments, saliva samples, pH measurements, impressions of the upper and lower jaw, and medical records. The results were reported according to the possible adverse medical conditions, specifically, caries, periodontitis, oral cleft malformations, tooth wear, and TMD. Caries The caries-related studies produced contradictory results regarding the risk of caries caused by snus use, with the majority showing no correlation. Analysis of salivary pH showed it was significantly higher during snus use and increased even more after snus removal. Salivary secretion rates were higher in snus users than in non-tobacco users. For the plaque pH, nicotinecontaining snus increased it compared to the nicotine-free products, which lowered it. A positive correlation was noted for decayed, missing, filled teeth (DMFT) and number of years of snus use. Most studies found no correlation between snus and caries when evaluating decayed, filled surfaces (DFS) and decayed teeth (DT).

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Consuming sports drinks is common among regular exercisers, and snus users tend to be more physically active than the general public and consume more sports drinks. The cariogenic effects of sports-related drinks may be offset if these athletic individuals have better dietary habits in other areas, such as fewer snacks between meals and less consumption of cookies and buns. Exercise may have a protective effect against caries as well, but it can be compromised by the frequent consumption of sports drinks and reduced salivary flow during prolonged physical activity. Periodontitis Swedish snus use tends to be associated with gingivitis and gingival recession but studies did not indicate a higher risk for developing periodontitis. Although plaque index (PLI) did not differ significantly between snus users and non-users, gingival index (GI) results indicated a significant positive correlation after adjusting for plaque levels. In addition, 60% of current snus users reported gum bleeding, compared to 37% of non-users. No significant relationship was noted between snus use and marginal bleeding scores. Gingival recession was reported in just 2.9% of those using portion-bagged snus but 23.5% of those using loose snus. Form of the product was the factor associated with the greatest relative risk for developing caries. In addition, 17% of snus users had gingival recession, with none of the non-users having this problem. Recessions were most prominent in the anterior region, where snus is placed. One study reported a 34% increase in the odds of developing gingival recession for each added year of snus use. Probing pocket depth (PPD) was evaluated as an indicator of periodontal disease in relation to snus use. Overall, no significant association was found between snus use and increased PPD. Oral Cleft Malformations, Tooth Wear, and TMD A population-based study including over 1 million infants in Sweden identified 11,000+ whose mothers had used snus. Use during early pregnancy increased the risk of oral cleft malformation. However, infants of mothers who suspended use before the antenatal period did not have this increased risk. Maternal age less than 35 years, a Nordic country of birth, chronic hypertension or preeclampsia in

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the mother, multiple births, and male infants were associated with increased rates of oral cleft malformation. Pre-pregnancy diabetes reduced the rate of this malformations. Using Swedish snus has also been associated with increased tooth wear. A reduced number of teeth, male sex, occurrence of bruxism, increased age, and reduced salivary buffer capacity also influenced the degree of incisal and occlusal wear. Using snus has been related to self-reported TMD symptoms among Finnish men. This increased the risk of TMD symptoms, particularly facial pain, but jaw clicking wasn’t affected.

CONCLUSIONS Further research is needed to explore possible oral health risks associated with newer tobacco-free nicotine products. These products are increasing in popularity, especially among women and teenagers. The use among adolescents in particular has risen from 4% to 21% over the past decade. In addition, snus should not be recommended as an alternative to smoking tobacco products.

Clinical Significance Further research is needed to determine the potential health risks of products such as snus. Enforcing public health measures should offer a way to regular snus use, particularly among young users. Some significant oral health consequences are related to the use of such products, and users and potential users need to be aware of the risks that they are taking.

Bankvall M, Jontell M: Swedish smokeless tobacco and its impact on oral health: A systematic review. Acta Odontol Scand 85:84-95, 2026Reprints available from M Jontell, Dept of Oral Medicine and Pathology, Inst of Odontology, Sahlgrenska Academy, Univ of Gothenburg, PO Box 450, 405 30 G€ oteborg, Sweden; e-mail: jontell@odontologi.gu.se

THIRD MOLAR EXTRACTIONS Difficulty of extractions related to age, sex, and jaw BACKGROUND Older patients having third molar surgery are associated with an increased rate of postoperative complications, including alveolitis, persistent pain, and paresthesia. The complication rate for these procedures depends on patient-specific, radiological, and operative factors, including the difficulty of the surgery required. No comparison of extraction method among younger and older patients has been evaluated comprehensively. The association of the patient’s age with the level of difficulty of the third molar extraction was assessed.

METHODS The 12,649 third molar extractions performed and recorded in 2016 in Helsinki’s primary care register were included. The primary outcome was extraction difficulty, which was classified as simple (done with an elevator and forceps) or surgical extraction (including flap raising with osteotomy and sectioning as

indicated). The secondary outcome was an extraction additionally classified as demanding or not.

RESULTS Patients’ mean age was 32.2 years, and they ranged in age from 12 to 97 years. Forty-five percent of the extractions were done for men and 55% for women. Oral surgeons performed 16% of the extractions and general dentists performed the remaining 84%. The most common procedure was simple extractions in all age groups. The rate of surgical extractions was reduced by half between the youngest and oldest patients, with differences between subgroups found to be significant. Simple Extractions Demanding extractions in the oldest age group were twice as common as those in the youngest group. The differences in the difficulty level between the age groups were statistically significant. Surgical Extractions Demanding extractions were more common among older patients than among younger ones. At age 50 to 59 years, demanding surgical extractions were 8 times more common than in the youngest age group. The differences in the difficulty levels of the subgroups were statistically significant. All Third Molar Extractions The proportion of demanding extractions was greater for men than women. Significant differences between men and women were noted in 3 age groups (Figure 4). Extractions with forceps were more likely to be demanding in older patients. Maxillary extractions in men were 1.4 times more likely to be demanding than those in women. Mandibular extractions were considered simple and were easier in older patients than in younger patients. The analysis of surgical extractions found that higher age made the procedure more demanding in the maxilla and mandible.

Figure 4. Rates of demanding extractions of all third molars in each age group according to sex. Significant differences between men and women in age groups are shown with asterisks, *P < 0.05 and **P < 0.001. €ll J, Venta € I: The effect of age on third molar (Courtesy of Noro A, Sna extraction difficulty: A retrospective cross-sectional cohort study. Acta Odontol Scand 85:33-39, 2026.)

CONCLUSIONS The primary findings were that surgical extraction was more demanding in older patients than in younger patients. In addition, simple extractions in the maxilla were also more demanding. However, simple extractions in the mandible were easier in older patients than in younger ones.

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Clinical Significance This study indicated that age, sex, and jaw were significant predicting factors of the difficulty of a third molar extraction. Other factors are also involved, including anatomical variables, procedure-related factors, and clinician-related factors. Mouth opening ability, cheek flexibility, and even body mass index (BMI) can influence tooth removal. The primary conditions to be considered include age, operator experience, procedure type, and number of teeth extracted.

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Noro A, Sn€all J, Vent€a I: The effect of age on third molar extraction difficulty: A retrospective cross-sectional cohort study. Acta Odontol Scand 85:33-39, 2026Reprints available from A Noro, Dept of Oral and Maxillofacial Diseases, Faculty of Medicine, Univ of Helsinki, PO Box 41, Helsinki, FI-00014, Finland; email: abiel.noro@helsinki.fi

EXTRACT BRAIN HEALTH PROTECTION THROUGH EXERCISE, RELATIONSHIPS, AND PASSION Based on studies seeking a possible link between physical activity, relationships, and passion and brain health, researchers believe they have found evidence that these factors can protect against cognitive decline The changes that develop in the brain affect gray matter and white matter. Gray matter included such biological structures as neuronal cell bodies, synapses, and capillaries. In contrast, white matter consists of myelinated axons through which signals pass between neurons. The volume of gray matter begins to decline at age 10 years, but individuals who are medically and cognitively healthier tend to experience less brain atrophy than individuals who are less healthy. Over the aging process, regular exercise, strong relationships, and passion are key factors to maintaining brain health. Psychological traits such as grit and a growth mindset may be linked to the development of gray ma terial in different areas of the brain. In the study, published in Brain Science, a thorough review of the literature was performed to reveal links between brain phys iology development, physical activity, social relationships, and passion. The evidence indicates that a passion for an area of skill leads to more physical activity, more social relationships, and better well-being. Hermundur Sigmundsson, professor of psychol ogy at the Norwegian University of Science and Technology and lead author of the study, said, “We have found that passion—or strong interest—may be a [key motivational factor for achievement and well-being] as it sets the direction of the arrow.” He recommends, “Therefore, we say: Find your passion and develop it! Grit, or perseverance, is the size and strength of the arrow. Find your interest area and focus on the process. [Be ready to] take challenges! Challenges are key for development!” The study advises that an active lifestyle is helpful for maintaining cognitive and neurological heath across age groups—especially in higher order processes such as switching between tasks, working memory, and cognitive inhibition. Rearhe also indicated the physical activity increases functionality in brain areas linked to attention and control of attention, daily life activities, and cognitive reserve, which contains thinking abilities that can act as a buffer against age-related cognitive decline. Maintaining social ties can also enhance cognitive reserve and work through cognitive strategies, producing greater neural growth and synaptic density, which protect against pathological processes. Imaging reveals larger social networks produce a larger orbitofrontal cortex and amygdala volume. In contrast, less socially active people have more white matter lesions. More robust evidence is needed based on randomized controlled trials to demonstrate causality. The researchers defined passion as “a strong feeling toward a personally important value/preference that motivates intensions and behaviors to express that value/preference.” It may be important for maintaining neural plasticity and has been shown to lead to more deliberate practice among football players and increases well-being and performance in workers. Passion was seen as giving direction to the area of interest, which may reflect a connection to the dopamine system, where attention, learning, goaldirected behaviors, and rewards are controlled. The researchers wrote that “Passion may be providing the focus essential for long-term goal achievement. Art Kramer, professor emeritus at the University of Illinois Urbana-Champaign and not connected to the research, said, “The animal literature suggests a number of brain changes associated with physical activity, including new neurons in brain regions that support memory, more connections among neurons (called synapses), and increases in vascular structure, increases in neurotransmitters and nerve growth factors (among other changes) have also been associated with increases in physical activity in animal models.” [Lennon A: Passion, Exercise, And Meaningful Relationships Are A Boon To Brain Health. Medical News Today, Sept 28, 2022]

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HIDEKI TOJO’S DENTURES CARRIED A SECRET MESSAGE On September 11, 1945, American soldiers surrounded former Japanese Prime Minister Hideki Tojo’s house to arrest him, but Tojo chose to shoot himself in the chest. The bullet missed his heart, and American medics transfused him with American blood and saved him. Once he recovered, Tojo was transferred to Sugamo Prison to wait for his trial. Because he was Japan’s prime minister from October 1941 through July 1944, American wartime propaganda coupled him with Adolf Hitler and Benito Mus solini as the face of the enemy. Tojo was seen as the man behind the surprise attack on Pearl Harbor that had pulled the United States into World War II. His teeth were in terrible shape, with all the upper ones extracted or rotted away and just 7 left on the bottom. He needed dentures to speak at his war crimes trial, and the dental team at the nearby 361st Station Hospital in Tokyo. In 1945, E.J. “Jack” Mallory graduated from the College of Physicians and Surgeons in San Francisco and got married, then vol unteered for an overseas assignment in August 1946. The Navy had a surplus of dentists and lent about 800 to the Army. Mallory ended up at the 361st Station Hospital, making dentures and bridges for staff and inmates at the nearby Sugamo Prison. His room mate, George Foster, was an oral surgeon who was called on to examine Tojo, the most infamous patient he’d ever treat. He brought in Mallory to handle the prosthetics, who recommended a complete set of upper and lower dentures. Tojo chose an upper plate only because he expected to be executed and didn’t want to waste the doctors’ time. Mallory expected a monster, but said, “I knew I was going to meet an evil man. It was a shock to see him. He was very humble and just a meek, little guy.” Standard military procedure required that the patient’s name, rank, and serial number be engraved on dental appliances. When Mallory’s colleagues learned he was building false teeth for Tojo, they suggested placing a hidden message instead of the required data. Mallory knew that writing words in plain English could end his career, but he was also an amateur ham radio operator and knew Morse code. He decided to drill a message using the Morse dots and dashes: Remember Pearl Harbor. Mallory said it was clear when it was dried, but 99% of the time you couldn’t tell what it was. Foster knew what Mallory had done, but the 2 decided to keep it under wraps. Tojo accepted his new upper plate and spent the next 3 months chewing, speaking, and preparing for his trial with an American message hidden in his mouth. He never knew the truth. Mallory tried to keep quiet about the prank, but eventually bragged about it to some new dental recruits. One of the new recruits wrote a letter to his parents in Texas and the story was eventually on a local radio station. Wire services picked it up and it was spread worldwide. When the Armed Forces radio station in Tokyo ran it, Mallory knew he was in trouble and told his command ing officer what he had done. He agreed it was a great prank but ordered Mallory to get rid of the evidence. On February 14, 1947, Mallory and Foster slipped away from a Valentine’s Day party at the hospital and drove a Jeep to the prison. Foster knew one of the guards who let them in and brought Tojo to have his dentures removed for an emergency dental treatment. Mallory used a crude grinding stone to erase the Morse code message and then returned the dentures. Tojo never knew why they needed the dentures in the middle of the night. The erasure came just in time. The next morning Stars and Stripes published the story and a furious colonel in charge of the prison summoned the men to his office. “Is there any truth in this report that ‘Remember Pearl Harbor’ is inscribed in the dentures?” the colonel asked. Both answered, “No, sir!” and reporters and military investigators checked, but the inscription was gone. Although neither man was formally reprimanded, Mallory was stripped of a commendation he had recently received. Tojo mentioned there was something different about his dentures. He told a dentist who took over after Mallory left Japan that the dentures fit more loosely after that night visit, but he never connected it to the news reports. The International Military Tribunal found Tojo guilty of waging aggressive war and ordering atrocities and he was sentenced to death by hanging on December 23, 1948. He didn’t need his teeth for long. Mallory returned to the United States in June 1947 and began practicing in Paradise, California, then moved to Chico and prac ticed there until the mid-1980s. Foster died in December 1989. The Navy Dental Corps Historical Museum in Bethesda,

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Maryland, came to collect mementos of the prank in 1991 for the museum. The story was essentially buried until 1995 when Mallory’s son Paul encouraged him to write a memoir. It was picked up by the news magazines and spread again. Mallory had traveled to Japan for a reunion with Japanese dentists in 1969. Over dinner, he told them what he had done. They all enjoyed a laugh about it. In 1995, Mallory told the AP, “It wasn’t anything done in anger. It’s just that not many people had the chance to get those words into his mouth.” Mallory died in 2013 and his obituary mentioned his long dental career and included a brief reference to a dental prank performed on the mastermind behind the Pearl Harbor attack. His message engraved on Tojo’s teeth remains one of the greatest pranks in military history. [Frazier A: This Navy Dentist Engraved ‘Remember Pearl Harbor’ on Hideki Tojo’s Dentures, Military.com, Feb 13, 2026]

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