During extraction, bone can be lost due to it being removed alongside the tooth or because of gradual bone loss over time due to the site being edentulous, as dictated by Wolff’s law.^1,2 Regardless of the cause, the preservation of surrounding bone dimension and volume becomes very important for aesthetic or functional reasons, such as when trying to utilize an edentulous site for implant placement and prosthetic restoration. Traditionally, the means of preserving vertical and horizontal bone dimensions involves the use of bone grafts. These grafts could be from self (autogenous), from others (allogenic), synthetic (alloplastic), or from various animal sources (ie, porcine or bovine xenografts).^1,3,4 Human bone autografts are obtained from, but not limited to, the iliac crest, mandibular ramus, or ribs.^4,5 However, these procedures are often invasive, and, at times, there is not sufficient material available for grafting.³ Furthermore, although the safety and biocompatibility of these grafts have been established, many patients do not accept allografts and xenografts due to religious, social, and personal reasons.^3,6 As such, researchers and clinicians have been searching for alternative sources of bone graft material for ridge augmentation and preservation, thus leading to the utilization of natural tooth structure, such as dentin.

Being that dentin and bone both are derived from neural crest cells and express the same or similar growth factors within the same family, such as TGF-Beta and BMP,^7,8 it is not surprising that the ability of dentin grafts as both osteoinductive and osteoconductive agent in bone augmentation has been investigated. Therefore, even though the exact concentrations have not yet been determined, autogenous dentin grafts, similar to autogenous bone grafts, contain growth factors that may aid in a more rapid healing process and an earlier and greater acquisition of bone.^3,7,8 Furthermore, the majority of teeth are discarded after extraction. As such, creating dentin particulate grafts from extracted teeth that would otherwise be discarded as medical waste can provide us with a previously unavailable source and supply of grafts that could be used for ridge preservation and augmentation.^9,10

A histomorphic animal study investigating the regenerative capacity of dentin grafts saw that, compared to control groups with no graft placement, the treatment group had a significantly greater amount of bone formation as well as more mature bone being formed when evaluated at 30- and 90-day intervals. In both groups, they also saw that, compared to the 30- and 90-day samples, the amount of immature bone decreased and was replaced by mature bone with less connective tissue and a more robust vascular infiltration.¹¹ In other words, as new bone increases in quantity and quality, the dentin graft resorbs and thus decreases in quantity over time.^7,11-13 Another animal study showed greater amounts of osteopontin staining, a marker for osteogenesis and bone deposition, adjacent to the demineralized dentin graft sites as well as the borders of the newly forming vasculature.⁷ They also showed that, when compared to the control groups, the sites containing demineralized dentin grafts had earlier placement of immature and mature trabeculae, greater quantities of trabeculae at any given time point, and lower amounts of inflammation.⁷ As such, this study showed that demineralized bone graft could result in a greater quantity of bone and accelerate bone deposition and remodeling processes.

Numerous studies have shown dentin grafts to be effective in maintaining as well as enhancing ridge width and height following impacted third molar extractions,^12,14-16 anterior tooth extractions,¹⁷ and sinus lifts,^18,19 as well as in implant placement.^{9,10,13,16-22}

The timing associated with implant placement after dentin grafting depends on the type and quantity of bone. Still, on average, they are placed at least 2 and 3 months after graft placement for the mandible and maxilla, respectively. Due to dentin’s ability to be remodeled, as well as the osteopromotive growth factors it has embedded within its matrix, dentin grafts are viewed to be both osteoinductive and osteoconductive.^3,7 Furthermore, it has been shown in animal studies that dentin grafts result in faster healing and bone deposition at any given time frame as compared to control sites.⁷ Thus, they are effective in augmenting alveolar bone defects to allow for sufficient bone quantity and quality, which is required for maxillary implant placement after 3 to 6 months of healing post extraction.^18,20,21 It should be noted that although a study has shown that dentin grafts provide a favorable environment for immediate implant placement in the mandible,¹⁰ the clinical application for early implant placement of the posterior maxilla has not been investigated previously. Therefore, in this case study, we wanted to report on the use of dentin particulate grafting for the application of early implant placement and simultaneous vertical sinus elevation in the posterior maxilla at 8 weeks post extraction and grafting.

CASE REPORT

The purpose of this proof-of-concept study was to determine the viability of early implant placement (at 8 weeks) into maxillary sites grafted with autogenous dentin particles. The practice of both early implant placement and autogenous dentin grafting for socket preservation have been well-documented in the literature. However, no studies to date have demonstrated that the combination of these strategies might be a feasible option, particularly in the posterior maxilla. This case report was designed to determine the osteopromotive potential of autogenous dentin and whether successful integration of dental implants placed at 8 weeks post socket preservation might be possible.

Methods 

A periodontal and radiographic exam was performed to rule out any pretreatment inflammation, significant periodontal disease, or mobility. Upon examination, 2 implants and one natural tooth in the maxillary right quadrant (implant sites Nos. 3 and 4 and tooth No. 5) were deemed non-salvageable and planned for removal (Figure 1a) and simultaneous autogenous dentin grafting of the processed first premolar (tooth No. 5). Two percent lidocaine with 1:100,000 epinephrine was administered via local infiltration. Tooth No. 5 was elevated and delivered using a straight elevator and forceps. The failing implant prosthesis (Nos. 3 and 4) was sectioned, and implants were reverse-torqued and removed with forceps easily without complications. After tooth extraction and implant removal, tooth No. 5 was processed following the KometaBio SDG protocol,¹⁸ including an additional wash with a 10% EDTA solution, and prepared for use as a graft material for sites Nos. 3 to 5 (Figure 1b). Processing the tooth involved removing any enamel and restorative materials during the cleansing process. 

Figure 1. Extraction and grafting. (a) Preoperative evaluation of failing implants (Nos. 3 and 4) and a natural tooth (No. 5) prior to implant/tooth removal and site debridement. (b) Immediate postoperative clinical photo of ridge preservation using autogenous dentin graft. Sockets were stabilized with collaplug wound dressing and 4-0 vicryl sutures.

Figure 2. Biopsy and Implant Placement. (a) Second-stage surgery with flap elevation. Prior to implant placement, a core hard-tissue biopsy of site No. 5 was taken via a trephine bur. (b) Immediate post-op radiograph after implant placement with internal sinus elevation utilizing Versah protocol without complications. Primary closure was achieved with 4-0 vicryl sutures.

Re-entry surgery was performed at 8 weeks post grafting. During osteotomy preparation for site Nos. 3 and 5, a trephine core was taken from implant site No. 5 and submitted for histological analysis. Additionally, an internal sinus elevation was performed following Versah protocols without the use of additional graft material as the amount of native bone at the implant site was adequate for long-term implant stability. Implants were placed successfully with favorable insertion torques greater than 35 Ncm (Figure 2) and then successfully uncovered at 18 weeks without complications. Figures 3a and 3b denote the pre- and post-implant CBCT scans that were taken to assess healing. Overall, good primary stability of both implants was achieved and noted during the uncovery appointment.

Results 

At the conclusion of the study, the clinical evaluation revealed that there was no mobility or significant inflammation present at the implant sites, and radiographically, there was no apparent evidence of significant bone loss or active disease. Based on the CBCT analysis, direct bone-to-implant contact can be noted around both implants, while an apparent increase in bone fill was noted within the maxillary sinus around the apical area of implant No. 3 due to the internal sinus elevation and subsequent fill from the osteoid-dentin complex (Figures 3c and 3d). 

Figure 3. The 8-week post-op radiograph and CBCT images of radiographically dense surgical sites (a) No. 3 and (b) No. 5. (c and d) The 4.5-month post-implant-placement radiograph and CBCT during the uncovery appointment with good osseointegration noted.

Histologically, we noted viable new bone formation in continuity with the dentin complex, with regions of immature woven bone giving rise to mature lamellar bone (Figure 4). The implant-related inflammatory reaction was generally minimal and not interpreted to be adverse.

Figure 4. H&E-stained histological samples. (a) Histological image of the osteoid-dentin complex, with the core (centered) and surrounded in a background of connective tissue (CT) and the formation of adjacent woven bone (WB) (10x magnification). (b) Mature bone (MB) forming from woven bone (WB) (10x magnification). (c) Osteocytes adjacent to newly formed woven bone (WB) arising from the osteoid-dentin complex (D) (20x magnification). (d) Histological image of osteoblasts (OB) adjacent to woven bone (WB) and entrapped in mature bone (MB) formation, giving rise to the presence of osteocytes (10x magnification).

Figure 5. Clinical try-in radiographs depicting the various stages of FPD fabrication. (a) Vertical bite-wing and (b) periapical radiographs of the custom-milled abutments. (c) Buccal view of the custom-milled abutments.

Figure 6. (a and b) Periapical and vertical bite-wing radiographs of the 3-unit FPD framework with porcelain during the delivery appointment. (c) Direct buccal and (d) facial views of FPD with porcelain added during the delivery appointment.

The 3-unit FPD was produced over 3 appointments: The first appointment involved the clinical try-in of 2 custom-milled titanium abutments on sites Nos. 3 and 5, with the buccal and palatal margins being 1 mm subgingival and flush with the gingival margin, respectively (Figure 5). The second appointment involved the clinical try-in of the metal framework prior to porcelain application. It was decided that porcelain shade A3 would be applied to the cervical and middle thirds, while a B3 porcelain shade would be applied to the incisal thirds of the prosthetic teeth. The third appointment was the clinical try-in and delivery of the prosthesis with porcelain added (Figure 6).

DISCUSSION 

The lack of clinical mobility and CBCT imaging showed that there was sufficient primary and secondary stability to allow for clinically acceptable osseointegration of the implant and a successful internal sinus elevation following early implant placement into sites grafted with autogenous dentin. The histology taken 8 weeks postoperatively showed newly formed bone alongside osteocytes flanking and integrating with the dentin complex, which supports the idea that the dentin graft was ankylosed with newly formed bone. Over time, this osteoid-dentin complex will change in composition, such that the dentin will resorb and be continually replaced by bone.^7,11-13 It should be noted, however, that there are differences in the literature regarding the amount of dentin that is resorbed over time. Mazor et al¹³ stated that although there was significant deposition of new bone after 7 months, 25% of the 7-month post-op biopsy consisted of the dentin graft, while another study indicated that there was no dentin present after a 6-month healing period in almost all subjects.¹ As such, dentin grafts may or may not completely resorb, even over an extended period of time, depending on the patient population and physiology. Regardless, the dentin graft becomes ankylosed to newly formed bone, as shown by our histological samples, and should gradually be replaced by bone to a greater extent if studies investigate the graft composition changes on a more prolonged duration than 8 months. Overall, our data serves as a proof of concept that autogenous dentin grafts can be successfully used in a clinical setting for ridge augmentation, internal sinus lifts, and subsequent early implant placement in the posterior maxilla 8 weeks post-op, a parameter that has not been investigated previously.

CONCLUSION 

Based on the limitations of this study, the proposed treatment of ridge preservation with autogenous dentin and early implant placement at 8 weeks may be a viable therapeutic option even in traditionally slower healing sites like the posterior maxilla. The current investigation may open new avenues into the use of autogenous dentin and its osteogenic potential, especially within the maxillary sinus. Further research into the cellular and inflammatory mechanisms behind dentin remodeling and subsequent bone formation is needed to fully understand the quality and timing of healing when using these promising autogenous graft substitutes.

ACKNOWLEDGMENTS

We would like to thank Jeffrey Eskendri, DMD, for preparing and analyzing the histological samples that were used in this paper. Dr. Eskendri is an oral and maxillofacial pathologist and is currently an assistant professor in the department of pathology at the Yale School of Medicine.

REFERENCES

1. Bartee BK. Extraction site reconstruction for alveolar ridge preservation. Part 1: rationale and materials selection. J Oral Implantol.   2001;27(4):187–93. doi:10.1563/1548-
1336(2001)027<0187:ESRFAR>2.3.CO;2 

2. Pelo S, Boniello R, Moro A, et al. Augmentation of the atrophic edentulous mandible by a bilateral two-step osteotomy with autogenous bone graft to place osseointegrated dental implants. Int J Oral Maxillofac Surg. 2010;39(3):227–34. doi:10.1016/j.ijom.2009.11.004 

3. Khanijou M, Seriwatanachai D, Boonsiriseth K, et al. Bone graft material derived from extracted tooth: A review literature. J Oral Maxillofac Surg Med Pathol. 2019;31(1):1-7. doi:10.1016/j.ajoms.2018.07.004

4. Raghoebar GM, Louwerse C, Kalk WW, et al. Morbidity of chin bone harvesting. Clin Oral Implants Res. 2001t;12(5):503–7. doi:10.1034/j.1600-0501.2001.120511.x 

5. Roche YA, Schwartz HC. The mandibular body bone (MBB) graft: an alternative source of membranous bone. J Craniomaxillofac Surg. 1993;21(5):199-201. doi:10.1016/s1010-5182(05)80481-0 

6. Güngörmüs Z, Güngörmüs M. Effect of religious belief on selecting of graft materials used in oral and maxillofacial surgery. J Oral Maxillofac Surg. 2017;75(11):2347–53. doi:10.1016/j.joms.2017.07.160 

7. Fernandes AM, Mauad de Abreu FA, Fernandes MLDMF, et al. Demineralized human dentin matrix as an osteoinductor in the dental socket: an experimental study in wistar rats. Int J Oral Maxillofac Implants. 2020;35(5):910–6. doi:10.11607/jomi.8279 

8. Schmidt-Schultz TH, Schultz M. Intact growth factors are conserved in the extracellular matrix of ancient human bone and teeth: a storehouse for the study of human evolution in health and disease. Biol Chem. 2005;386(8):767–76. doi:10.1515/BC.2005.090 

9. Binderman I, Duda M. Extracted teeth are not a biological waste anymore: they are processed and grafted back to preserve best the alveolar ridge. PSI Imp Dent. 2018;2(18):48-52.

10. Demiraqi G, Nocka E, Sulaj E, et al. Tooth graft socket augmentation and immediate implant placement case report. Alb Dent J. 2019;18(1):14-20.

11. Calvo-Guirado JL, Maté-Sánchez de Val JE, Ramos-Oltra ML, et al. The use of tooth particles as a biomaterial in post-extraction sockets. Experimental study in dogs. Dent J (Basel). 2018;6(2):12. doi:10.3390/dj6020012. Retraction in: Dent J (Basel). 2020;8(3)

12. Andrade C, Camino J, Nally M, et al. Combining autologous particulate dentin, L-PRF, and fibrinogen to create a matrix for predictable ridge preservation: a pilot clinical study. Clin Oral Investig. 2020;24(3):1151–60. doi:10.1007/s00784-019-02922-z 

13. Mazor Z, Horowitz RA, Prasad H, et al. Healing dynamics following alveolar ridge preservation with autologous tooth structure. Int J Periodontics Restorative Dent. 2019;39(5):697-702. doi:10.11607/prd.4138

14. Kuperschlag A, Keršytė G, Kurtzman GM, et al. Autogenous dentin grafting of osseous defects distal to mandibular second molars after extraction of impacted third molars. Compend Contin Educ Dent. 2020;41(2):76-82; quiz 83. 

15. Sánchez-Labrador L, Martín-Ares M, Ortega-Aranegui R, et al. Autogenous dentin graft in bone defects after lower third molar extraction: a split-mouth clinical trial. Materials (Basel). 2020;13(14):3090. doi:10.3390/ma13143090 

16. Schwarz F, Hazar D, Becker K, et al. Efficacy of autogenous tooth roots for lateral alveolar ridge augmentation and staged implant placement. A prospective controlled clinical study. J Clin Periodontol. 2018;45(8):996-1004. doi:10.1111/jcpe.12977 

17. Valdec S, Pasic P, Soltermann A, et al. Alveolar ridge preservation with autologous particulated dentin-a case series. Int J Implant Dent. 2017;3(1):12. doi:10.1186/s40729-017-0071-9

18. Binderman I, Hallel G, Nardy C, et al. A novel procedure to process extracted teeth for immediate grafting of autogenous dentin. JBR J Interdiscip Med Dent Sci. 2014;2:154. doi:10.4172/2376-032X.1000154

19. Jun SH, Ahn JS, Lee JI, et al. A prospective study on the effectiveness of newly developed autogenous tooth bone graft material for sinus bone graft procedure. J Adv Prosthodont. 2014;6(6):528–38. doi:10.4047/jap.2014.6.6.528

20. Binderman I, Hallel G, Leretter M. Alveolar ridge preservation: Particulate dentin of extracted teeth are optimal for immediate grafting of extracted site. Dentalife. 2017;4:7-12

21. Cardaropoli D, Nevins M, Schupbach P. New bone formation using an extracted tooth as a biomaterial: a case report with histologic evidence. Int J Periodontics Restorative Dent. 2019;39(2):157-163. doi:10.11607/prd.4045 

22. Joshi CP, D’Lima CB, Samat UC, et al. Comparative alveolar ridge preservation using allogenous tooth graft versus free-dried bone allograft: a randomized, controlled, prospective, clinical pilot study. Contemp Clin Dent. 2017;8(2):211–7. doi:10.4103/ccd.ccd_147_17 

ABOUT THE AUTHORS

Dr. Fakhrzadeh is a board-certified periodontist practicing in New Jersey. He received his DMD degree from the Boston University School of Dental Medicine in 2014. In 2017, Dr. Fakhrzadeh completed a NIH T32 postdoctoral research fellowship in regenerative medicine at the New Jersey Center for Biomaterials. Upon completion of his research fellowship, he completed his clinical residency in periodontics and implant surgery and a master’s degree in biomedical science at the Rutgers School of Dental Medicine (RSDM) and New Jersey Medical School, respectively. His clinical and research interests are focused primarily on translational research in the fields of oral implantology and regenerative dentistry. Aside from his clinical practice, Dr. Fakhrzadeh serves as a clinical/research consultant and has held adjunct faculty positions at Rutgers University. He can be reached at amirfa9@gmail.com.

Dr. Cappetta is the director of the postgraduate periodontics program at RSDM. He received his dental degree from the University of Medicine and Dentistry, now RSDM. He studied at the Boston School of Graduate Dentistry and received his certificate of advanced graduate study in periodontology. He practiced periodontics and implantology in Summit, NJ for more than 40 years. He was president of the state board of dentistry 3 times and received a special recognition award from the New Jersey Dental Association. He is a Fellow of the International College of Dentists, an Associate Fellow in the Academy of Implantology, and a Fellow and Diplomate of the International Congress of Oral Implantology and is board-certified in periodontology and in the American Board of Oral Implantology. He has received the Outstanding Teaching and Mentoring award from the American Academy of Periodontology. He can be reached at cappeteg@sdm.rutgers.edu.

Dr. Oryan is a recent graduate of RSDM and is currently in his first year as a postdoctoral student in the department of periodontics at RSDM. He can be reached at ao419@sdm.rutgers.edu.

Dr. Drew is a professor, a director of implantology, and the vice chairman in the department of periodontics at RSDM. He received his doctorate and degree in periodontics from RSDM. He has been awarded the RSDM Excellence in Teaching Award and the Stuart D. Cook Master Educators Guild Award, and he received the prestigious American Academy of Periodontology Educator Award. Dr. Drew was inducted into the American College of Dentists, and he was awarded the RSDM Alumni Association Decade (1980s) Award. He has authored more than 30 publications and has lectured throughout the country. He was in full-time clinical practice for more than 25 years. He can be reached at drewhj@sdm.rutgers.edu.

Disclosure: The authors report no disclosures.

It has been reported that the surgical extraction of a tooth is the most common surgical procedure in the United States.¹ A 2015 study by Gilbert et al² found that 64% of general dentists routinely remove teeth. A common occurrence during tooth removal is a fractured and retained root (Figure 1). At least 11 studies from 1927 to 2007 examined patients with retained roots. Their studies yielded percentages of retained roots from 15% to 37%. An incidental finding was that maxillary molars and premolars fracture the most. Maxillary left molars have the highest proportion of root fractures and oral-antral complications.³

Figure 1. Broken root tip.

This article will address 2 common clinical complications and their recommended solutions. The author would like to note that a plethora of complications could be simply avoided with  rigorous patient vetting. Although this article is about clinical complications, recommendations would start by limiting your surgical removal to patients with a medical history that would fall under ASA I and II classification. Maxillofacial surgery offices are better equipped to manage the range of serious medical complications that arise from treating brittle patients. Further, every surgical case performed would be better managed with some level of oral sedation. Anxious patients are more inclined to experience hypertensive episodes. The moment your patient becomes unpredictable in your chair, your clinical skills will be compromised.

BROKEN ROOT TIPS 

Keep in mind this important axiom: The primary cause of root tip breakage is too much force in the coronal portion of the tooth, as opposed to the apical region. The best way to prevent root tip breakage is to execute protocols to drive forces apically. This begins with decoronating the crown. The very act of separating the crown from the root trunk creates better vision and access of the roots. Next, it is advised to section the roots. On maxillary molars, this would be the MB from the DB and then the palatal root. On mandibular molars, it would be the MB root from the DB root and then the MB from the ML. Finally, create mesial and distal troughs (not buccal or palatal) and then elevate the roots with any number of the myriad of root tip elevators available. The author defines a trough as a small slot between the root and alveolus that parallels the root.⁴ The use of dental elevators to remove roots is historically an old concept. When used properly, it allows biomechanical creep to occur, ultimately resulting in bone expansion.⁵ 

Modernization of the elevator and root tip picks (another form of an elevator) has dramatically improved the ability of today’s clinicians to both avoid root breakage and elevate remaining root tips, if broken. Salvin Dental Specialties and Hu-Friedy both have wide arrays of elevators to execute these principles (Figure 2). It is recommended that a Brasseler 859.36.010 bur (Brasseler USA) on a high-speed drill be employed to create the trough (Figure 3). Even then, all surgeons experience root tip breakage.

Figure 2. Sectioning for prevention.

Figure 3. The Brasseler 859.36.010 bur (Brasseler USA).

Recommended Solution

Vision and Access: Creating a small flap one tooth mesial and distal to the tooth to be removed will instantly improve the ability of the clinician to see and access the area. Retrieving a broken root tip requires magnification and surgical enhanced lighting to eliminate shadows in the working field. 

Once the surgical site can be clearly inspected, a trough (1.0 mm) mesial and/or distal around the broken root tip is created. The trough in the bone parallels the root to at least half of its length. This space allows the use of root tip elevators to then torque the root until it is easily retrieved (Figure 4). The root tip elevator is essential for the broken root tip. It is important once the root is engaged that a constant—not back and forth—torque with the elevator is applied for 10 seconds (Figures 5 and 6).

Figure 4. Creating the trough.

Figure 5. Examples of the wide range of available root tip elevators.

Figure 6. Elevator inserted in trough. Torque 10 seconds for elevation.

Leaving the root tip: Historically, there was a consensus that “all root tips should be removed. Not doing so would lead to pain, infection, and cyst development.”³

In the past 11 years, there has been abundant literature weighing in on the outcome of leaving retained roots. It is a concept reviewed as early as 1960 by Helsham,⁶ who examined 2,000 patients referred for the removal of retained roots. He found that most retained roots “develop tissues that heal over them and there was a progression of root canal closure and fibrosis of the pulp.”⁶

He further concluded that 83% were associated with neither symptoms nor pathology. It is worth noting that sometimes vital roots are intentionally retained for improved prosthetic outcomes. Roots are reduced 2.0 mm subosseously to preserve bone. These roots undergo typical wound closure and healing.³ 

Conversely, there is clear evidence that if the broken root tip is left in, communication with the oral cavity as opposed to sequestered in the bone, the incidence of complications increases. These complications include local inflammation, cyst formation, and pain.⁷ 

Risk Assessment 

One governing aspect in the clinician’s decision tree is the consideration of further danger to surrounding anatomy that would adversely impact the outcome by removing the root fragment. Perforation of the maxillary sinus, injury to the inferior alveolar bundle, and injury to the mental foramen are 3 common examples. This is precisely the theory behind the coronectomy approach of third molars: to avoid the IAN bundle.^8,9

Conclusion and Guidelines

1. Literature review does not identify the size of the remaining fragment as a factor in the final decision to leave a root fragment.

2. Non-vital fragments with periapical pathology communicating with the oral cavity should be removed.

3. Healing of the fractured root is favorably influenced by vitality of the root and its non-mobility from the extraction process.³

MAXILLARY SINUS PERFORATION 

Some studies have suggested that 50% of maxillary molars maintain roots that line the wall separating the oral-antral cavities.¹⁰ During the removal of these teeth, an oral-antral communication (OAC) can occur. A 2019 article by Parvini et al¹¹ revealed the following: Maxillary second molar extractions result in 5% of OACs; third molars, 30%; first molars, 27.2%; and first premolars cause 5.3%. Additionally, a 2001 study by Hirata et al¹² reviewed 2,038 teeth removed from 1,337 patients. This study observed a rate higher in males with 5.2% over females at 3%. Sinus perforations increased gradually with age and occurred most often in the third decade of life.. Sinus perforation was highest with the removal of the first maxillary molar.¹² It is anecdotal from my experience with numerous live clinics that many clinicians are surprised when they do encounter a torn sinus following the extraction and are often unsure of the proper clinical approach.

What If You Are Uncertain or Unaware of a Breach?

Visual inspection is one way to identify an OAC. As stated, this requires high magnification and headlamps. However, most experienced clinicians have encountered in real-time, or postsurgical times, situations where it wasn’t clear if the sinus was breached. The escape of fluids and air from the mouth into the nose, unilateral congestion, or a yellow discharge are common patient reports if a sinus has been violated. The first clinical response should be to not poke or explore the suspected tear. A literature review also reveals the “nose blowing test” as a common exercise to confirm an opening. The patient is asked to blow through his or her nose as he or she pinches his or her nostrils together. The presence of blood or mucoid secretions in the mouth as they travel through the opening is evidence of a tear.¹³

Solutions to OAC

Treatment of the OAC is dependent on the size of the perforation (Figure 7).

Figure 7. Sinus perforations in the 2.0- to 5.0-mm range.

1. At 2.0 mm or less: If there is no known sinus infection, these defects can resolve on their own following blood clot formation and secondary healing.¹⁴ However, larger tears will lead to acute maxillary sinusitis within 48 hours in 50% of the patient population. Some clinicians treat the smaller tears by placing a collaplug in the socket and prescribing an antibiotic regimen of Augmentin 850 mg (20 tablets) twice daily until all used, along with Sudafed ER decongestant.¹⁴ If allergic, the following alternate Rx is recommended: Levofloxacin 400 mg BID per OS until 72 hours to symptoms remission. This prescription will be part of all 3 approaches covered in the article. 

2. From 2.0 mm to 5.0 mm: Cover the floor of the socket over the tear with a long-lasting (cross-linked) collagen membrane. Cross-linked collagen typically absorbs in 36 weeks. Mem-Lok (BioHorizons) is an easy-to-handle membrane that has provided consistent outcomes. The second layer would again be collagen in the form of a plug. The collagen should then be stitched with an “X” type of suture with a non-resorbable PTFE-type suture. This suture is far less likely to attract any type of bacterial wick. 

3. Greater than 5.0 mm: Follow the protocol described above, but add a third layer of dense PTFE membrane tucked in the buccal and palatal flaps 4 to 5 mm past the buccal and palatal crests of bone. This membrane can safely be exposed to the oral cavity. Leave in place for 4 to 6 weeks. This will provide the same outcome as primary closure from the patient’s own tissue. The advantage of this approach will be that it does not require primary closure and will not alter the depth of the natural vestibule. Although there are many dense PTFEs commercially available, Osteogenics has a wide array of both PTFE membranes and sutures (Figure 8).

Figure 8. Oral-antral communication closed with dense PTFE.

CONCLUSION

Root tip fractures and OACs are not uncommon complications. As with all complications, prevention is the best solution. Part of a clinician’s protocol prior to removal should be a strategy and risk assessment of the tooth to be removed: Does the tooth have a history of a root canal? Is the tooth in dense bone? Perhaps, this is a patient with parafunction and buccal buttresses of bone? Are the roots longer than average? Do the roots line the maxillary sinus? In the rigorous routine of daily practice, it wouldn’t be unusual for the clinician to proceed with an extraction without this beneficial review. Exercising a strategy session allows for preparation—including the proper, and potentially needed, armamentarium—or even a referral. If the clinician removes enough teeth, they will encounter one or both of these complications. It is the responsibility of the clinician to manage the complication within the standard of care.

REFERENCES

1. Colgate. When surgical extraction of teeth is necessary. 

2. Gilbert GH, Gordan VV, Korelitz JJ, et al; National Dental PBRN Collaborative Group. Provision of specific dental procedures by general dentists in the National Dental Practice-Based Research Network: questionnaire findings. Tex Dent J. 2016;133(12):726–46. 

3. Nayyar J, Clarke M, O’Sullivan M, et al. Fractured root tips during dental extractions and retained root fragments. A clinical dilemma? Br Dent J. 2015;218(5):285–90. doi:10.1038/sj.bdj.2015.147 

4. Rasner SL. A modern approach to exodontia, part 1: Helping to ensure successful implant outcomes. Dent Today. 2018;37(1)108-113. 

5. Misch CE, Suzuki JB. Tooth extraction, socket grafting, and barrier membrane bone regeneration. Contemporary Implant Dentistry, 3rd ed. St. Louis, MO: Mosby; 2007:870-874.

6. Helsham RW. Some observations of the subject if roots of teeth retained in the jaws as a result of incomplete. Aust Dent J. 1960;5:70–7. doi: 10.1111/j.1834-7819.1960.tb03154.x

7. Glickman I, Pruzansky S, Ostrach M. The healing of extraction wounds in the presence of retained root remnants and bone fragments: an experimental study. Am J Orthodontics Oral Surg. 1947;33:263–83. doi:10.1016/0096-6347(47)90063-x

8. Patel V, Moore S, Sproat C. Coronectomy — oral surgery’s answer to modern day conservative dentistry. Br Dent J. 2010;209(3):111–4. doi:10.1038/sj.bdj.2010.673

9. Renton T, Hankins M, Sproate C, et al. A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Br J Oral Maxillofac Surg. 2005;43(1):7-12. doi:10.1016/j.bjoms.2004.09.002 

10. Howe, GL. Some complications of tooth extraction. Ann R Coll Surg Engl. 1962;30(5):309–23. 

11. Parvini P, Obreja K, Begic A, et al. Decision-making in closure of oroantral communication and fistula. Int J Implant Dent. 2019;5(1):13. doi:10.1186/s40729-019-0165-7 

12. Hirata Y, Kino K, Nagaoka S, et al. [A clinical investigation of oro-maxillary sinus-perforation due to tooth extraction]. Kokubyo Gakkai Zasshi. 2001;68(3):249-53. Japanese. doi:10.5357/koubyou.68.249

13. Haanaes HR, Pedersen KN. Treatment of oroantral communication. Int J Oral Surg. 1974;3(3):124-32. doi:10.1016/s0300-9785(74)80043-8 

14. Khandelwal P, Hajira N. Management of oro-antral communication and fistula: various surgical options. World J Plast Surg. 2017;6(1):3-8. 

ABOUT THE AUTHOR

Dr. Rasner earned his DMD degree from the University of Pennsylvania. He has completed the Misch International Implant Institute curriculum and the Pikos Institute continuum. Dr. Rasner has been teaching for 20 years. His courses, “Atraumatic Extractions for the GP” and “The Bulletproof Guide to Implant Success,” have been popular at ADA and AGD component society meetings, as well as at the national ADA meeting. His newest course, “Hands-on Atraumatic Extractions for the GP,” features 2 days of live-patient experience in his office. He has authored 3 books and more than 50 industry and journal publications. He can be reached at drrasner@aol.com.

Disclosure: Dr. Rasner reports no disclosures.

Tavares et al⁹ reported a study of 34,127 archived histopathologic specimens. They noted that 458 were pigmented lesions, of which 230 were melanocytic. Approximately 60% were macular. Regarding the 458 pigmented lesions, amalgam tattoos were noted as the diagnosis of 46.3% of the specimens, melanotic macules represented 22.9%, and nevi represented 20.5%. Other diagnoses included racial pigmentation, exogenous pigmentation, and melanoma. Hassona et al⁵ reported a study of 386 patients with oral pigmentations. They noted that racial pigmentation represented 39.9% of the cases, smokers’ melanosis represented 32.9%, amalgam tattoos represented 18.9%, melanotic macules represented 5.7%, post-inflammatory pigmentation represented 1.6%, medication-related or systemic disease-related pigmentations represented 0.52%, heavy metal deposits represented 0.26%, and oral nevi represented 0.26%. Kauzman et al² listed other differential diagnoses, including Addison’s disease, Kaposi’s sarcoma, hemangioma, varices, PJS, LHS, thrombi, hematoma, blue nevi, and melanoacanthoma.

The diagnosis of an amalgam tattoo is based upon several factors, which include a history of prior dental restorative and surgical therapies, the length of time the lesion has been present, the clinical appearance of the lesion, the determinative differential diagnosis of other oral pigmented lesions, and radiographic and histopathologic findings.^1-5

We present a case of an oral mucosal amalgam tattoo and also review the differential diagnoses of other oral mucosal macular pigmented lesions.

Figure 1. Appearance of the darkened gingiva inferior to the implant replacing the right mandibular first molar.

Figure 2. Periapical radiograph taken prior to placing the implant.	Figure 3. Periapical radiograph taken after placement of the implant.
Figure 4. Histopathology of a biopsy specimen at 100x.	Figure 5. Histopathology of the biopsy specimen at 200x.

AMALGAM TATTOO CASE REPORT
A 47-year-old female patient presented to her periodontist for a periodontal evaluation in late January 2019 with the following chief complaint: “I bit down on an olive pit and felt some discomfort for about a day, and when I looked in my mouth, I noted a bruise.” The blackish gingival lesion buccal to the right mandibular first molar that was approximately 2 cm in diameter palpated as normal gingival tissue and appeared to be consistent with the appearance of an amalgam tattoo (Figure 1). However, the lesion was not present prior to implant surgery 3 years ago or at the postoperative appointments. The patient reported that the lesion was asymptomatic.

The working diagnosis was of an amalgam tattoo, and the initial differential diagnosis was that of an amalgam tattoo, a melanotic macule, hemangioma, and malignant melanoma. The patient’s radiographs from 5 years ago and 3 years ago, after the implant was placed, demonstrated opacities consistent with amalgam restoration fragments (Figures 2 and 3). Numerous opacities at the edentulous site of the right mandibular first molar were consistent with foreign dental material, the most common being amalgam. The occlusal surfaces of both the right mandibular second bicuspid and second molar had a flattened appearance. Also, the mesial lamina dura of the right mandibular second molar appeared to be thickened. The clinical appearance at the time was not consistent with amalgam tattoos.

The patient was seen toward the end of February 2019 for followup, and the lesion was perceived to be slightly larger and darker. A periodontal probe was utilized to apply pressure to the lesion, and the lesion failed to blanch. Therefore, the diagnosis of hemangioma was ruled out. A scalpel biopsy procedure was performed with one cartridge of 2% lidocaine with 1:100,000 epinephrine. The specimen was sent out for a histopathologic evaluation. The histopathology evaluation (Figures 4 and 5) reported a diagnosis of an amalgam tattoo. The connective tissue was noted for containing the incorporation of both faint (100x) amalgam particles and more prominent (200x) amalgam particles within collagen fibrils. The patient was informed of the benign diagnosis and educated regarding the condition.

DIFFERENTIAL DIAGNOSES OF ORAL MUCOSAL MACULAR PIGMENTATION MELANOACANTHOMA
Melanoacanthoma is an uncommon, benign, hyper-pigmented lesion. The clinical presentation is well-circumscribed, typically macular, dark-brown-to-black lesions. It preferentially occurs in young African American females and is relatively uncommon in white subjects. There is an association with continuing trauma. Approximately 20% of patients with melanoacanthoma present with multiple lesions. The histopathologic appearance is noted for the proliferation of dendritic melanocytes scattered through an acanthotic and hyperkeratotic epithelium. A biopsy is necessary for a definitive diagnosis.^2,10

Melanotic Macule
A melanotic macule is a benign macular oral pigmented lesion and a relatively commonly occurring oral lesion. The condition is due to increased melanin production, and melanotic macule lesions can occur singly or in multiples, although most often singly. This lesion typically presents as a solitary macular with a well-defined, smooth border and homogeneously pigmented lesions and varying in size from 1 to 2 cm (although they can be smaller than 1 cm) and varying in color from tan to dark brown. The condition is more common in females than males, and the age range is from 1 to 98 years old. The lesions of such systemic conditions as PJS are multiple melanotic macules. The most common oral locations are the gingiva, palate, lower lip, and buccal mucosa. The histopathologic appearance demonstrates increased melanin pigmentation within the melanocytes and keratinocytes within the basal layer of the stratified squamous epithelium and sometimes within the upper portion of the lamina propria. A biopsy should be considered to rule out a diagnosis of melanoma, especially with regard to palatal lesions.^2,8,11

Figure 6. Multiple melanocytic macules of the lip in a Peutz-Jeghers syndrome (PJS) patient.	Figure 7. Multiple melanocytic macules of the buccal mucosa in a PJS patient.
Figure 8. Hemangioma of the buccal mucosa.	Figure 9. Blanching of the hemangioma due to pressure with a periodontal probe.

Pigmented Oral Nevi
Oral pigmented nevi are rare macular benign lesions. Melanocytic nevi are a variable group of benign melanocytic neoplasms. They are characteristically brown or blue. Pigmented nevi are separated into several histologic categories: junctional, intradermal/intramucosal, and compound nevi. Congenital nevi present at birth, and banal nevi, also known as acquired melanocytic nevi, present in childhood and may continue to enlarge in adults over time. The most common lesion site is the hard palate, and these lesions are typically round to ovoid and sometimes macular. As the palate is known as a site of oral malignant melanoma lesions, it is necessary to biopsy pigmented lesions of the hard palate. The most common site for the intramucosal nevus is the buccal mucosa. Histologically, nevi are formed by an accumulation of nevus cells in the basal epithelium, lamina propria, or both. The transformation of oral pigmented nevi to melanoma is questionable.^1-3,12,13

Post-Inflammatory Pigmentation
Chronic oral inflammatory mucosal disorders such as oral lichen planus can cause mucosal pigmentation. The condition is associated with darker complexions. The condition may present with multiple brown-to-black pigmented lesions of oral mucosal areas. The histopathologic picture notes increased melanin production by melanocytes and melanin-incorporated macrophages in the superficial lamina propria.^2,3,14

Systemic Disease/Condition and Physiologic-Related Oral Mucosal Hyperpigmentation
The main characteristic of this group of conditions is bilateralism.

Physiologic (Racial) Oral Mucosal Pigmentation
Physiological pigmentation is associated with dark-skinned populations. The most common oral mucosal location is the attached gingiva. The condition is usually bilateral, with irregular, poorly defined borders.¹⁵

Smokers’ Melanosis
The condition of smoker’s melanosis presents as a black-brown oral mucosal pigmentation of the labial gingiva that is found in heavy smokers. The condition is more common in women compared to men.¹⁵

Medication-Induced Mucocutaneous Pigmentation
Drug-induced mucocutaneous pigmentation is associated with the long-term utilization of a number of systemic medications, including tetracyclines, antimalarials, antifungals, anti-mycobacterial drugs, anti-retroviral drugs, chemotherapeutics, psychotropic drugs, and oral contraceptives.¹⁵

Peutz-Jeghers Syndrome
PJS is an autosomal dominant genetic condition. The oral findings are pigmented macules (melanotic macules) of the lips and buccal mucosa. Melanotic macules also occur on the skin. These findings are significant as PJS is associated with benign hamartomas (polyps) of the intestines. These polyps increase the PJS patient’s risk for gastrointestinal (GI) cancers as demonstrated in a 50-year-old female with PJS (Figures 6 and 7).^2,15,16 The patient presented at a university dental clinic in 1992, and she reported having a diagnosis of PJS, which her physicians previously established. When a dental patient presents with multiple melanotic macules of the lips and/or buccal mucosa, it is important for dentists to pursue the possibility of a PJS diagnosis in order to alert the patient of the risk of GI cancer.^2,15,16

Laugier-Hunziker Syndrome
In Laugier-Hunziker Syndrome (LHS), mucocutaneous pigmentary melanotic macules occur on the labial, oral, and acral areas. Longitudinal melanonychia occurs in half of the patients diagnosed. Dermoscopic findings include regular reticular, linear, curvilinear arc streaks or parallel ridge patterns in mucocutaneous pigmentary lesions occurring most commonly on the lower lip, tongue, gingiva, or palatal mucosa, and they are brown, blue-black, or black in color. The average age of reported cases is 47.4 years old, and women are affected more than men. The occurrence of these lesions on the gingiva are similar to amalgam tattoos. LHS has a similar oral presentation to PJS but is a benign condition. Therefore, it is important to distinguish LHS from PJS. Besides oral lesions, cutaneous and/or genital melanosis may be present.^2,5,15

Addison’s Disease
Addison’s disease is an autoimmune endocrine condition characterized by adrenocortical insufficiency. Hyperpigmentation may present on the skin, lips, oral cavity, conjunctiva, and/or genitalia. The treatment includes corticosteroid systemic drug therapy. If untreated, this condition is fatal.¹⁵

Heavy Metal Oral Discoloration
Increased levels of heavy metals such as lead, bismuth, mercury, silver, arsenic, and gold in the blood represent a known cause of oral mucosal discoloration. In adults, the most common cause for these increased levels is occupational exposure to heavy metal vapors. It is important to assess changes in the color of the oral mucosa and as a marker of disease with a thorough evaluation.3,9 Infrared spectroscopy can be used to evaluate the metallic deposits from melanocytic lesions. Intraoral biopsies and subsequent histopathologic examinations still represent the diagnostic gold standard. FTIR spectroscopy is another very useful diagnostic tool to differentiate amalgam tattoos from melanocytic lesions.^4,15

OTHER PIGMENTED ORAL CONDITIONS
Varices
Varices (also known as varicosities) are distended veins. Oral varices may be observed in some patients at the ventral base of the tongue, and they appear dark blue. The cause of the distention is believed to be related to smoking, age, and hypertension.^2,17,18

Hemangioma
Hemangioma, a relatively common benign proliferation of endothelial cells that line vascular channels, is another lesion to consider differentially. The lesion is flat or slightly raised, varying in color from red to bluish-purple, depending on the vessels involved.² It can occur anywhere on the body and commonly appears on the face and lips. Two primary forms of hemangioma are infantile and congenital. Congenital hemangiomas appear at birth, and the infantile ones appear 1 or 2 months after birth and grow in size for a short time. They may either remain stable in appearance or regress. The treatment of macular hemangiomas is usually unnecessary, unless the lesion presents a cosmetic complaint. Sclerotherapy with ethanolamine oleate was utilized in years past. Presently, however, the laser is the surgical instrument of choice. Diagnosis can usually be accomplished by demonstrating the vascularity of the lesion through utilizing pressure to show blanching of the lesion when the pressure is applied. Diascopy, or placing a glass pathology slide over the lesion and applying pressure, has been the accepted standard.^19,20

To illustrate the diagnosis of an oral mucosal hemangioma, a case is presented here. In early October 2020, a 70-year-old male patient, referred by his dentist, presented with a chief complaint of a sub-dermal lump in his left inner cheek (Figure 8). The lump was asymptomatic. Approximately 5 weeks prior, the patient discovered the lump as he could feel it with his tongue. The condition was described as a 1.5-cm, bluish-colored, round, slightly papular lesion of the left buccal mucosa. The lesion blanched when compressed by a periodontal probe, which determined a diagnosis of hemangioma (Figure 9).

Melanoma
Oral cancer only accounts for approximately 3.5% of cancers. Oral melanoma, or malignant melanoma of the oral cavity, is a very rare lesion, occurring in less than 1% of all oral malignancies. Malignant melanoma of the oral mucosa may be considered one of the most lethal of all human neoplasms. The most common oral location is the hard palate. This site represents approximately 40% of oral melanoma lesions. The main secondary site is the gingiva. Oral melanomas present as asymptomatic, slow-growing, brown-to-black lesions with irregular borders or as fast-growing lesions that may be associated with pain, ulceration, tooth mobility, bone destruction, and bleeding. The histopathologic picture is noted for the proliferation of malignant melanocytes adjacent to the basement membrane and within the lamina propria. Early diagnosis is essential with respect to treatment outcomes. The treatment is aggressive surgery with wide, clear margins. Nevertheless, oral melanoma has a poor prognosis.^2,3,9,13,21

DISCUSSION
The amalgam tattoo oral mucosal lesion is a benign, asymptomatic condition. This condition can be safely diagnosed with dental radiographs to confirm the presence of radiopaque amalgam particles within the area of pigmentation. The pigmentation is typically blue to gray to black. The size is typically between 0.1 cm and 2 cm, and the lesions are not well-circumscribed.^7,22

However, in some cases in which the patient or the clinician believes that the size of the lesion is increasing, it may be necessary to biopsy the lesion in order to provide a definitive diagnosis. The amalgam tattoo case presented was somewhat confusing. The patient or dentist did not notice the discoloration until years after the mandibular first molar had been removed and replaced with an implant. There was a perception by the dentist and the patient that the pigmented lesion had continued to enlarge.

The history and the radiographic appearance were consistent to determine a diagnosis of an amalgam tattoo. As the dental radiographs revealed radiopaque fragments within the area of the discoloration, an amalgam tattoo was the logical diagnosis. However, the possibility that the pigmented lesion was slow-growing necessitated a biopsy procedure to definitively determine the diagnosis and specifically to rule out oral malignant melanoma. Amalgam tattoos do not tend to grow in size.^3,4,7,22

Another rationale for considering a biopsy procedure is the number of differential diagnoses related to oral mucosal pigmented lesions. In 2004, Buchner et al12 reported on an evaluation of 773 solitary pigmented melanocytic lesion cases from cases submitted from the files of the oral and maxillofacial pathology laboratory of the University of the Pacific School of Dentistry from 1984 through 2002. They reported the frequency of the various diagnoses of these lesions. They came to the following conclusions:

• Solitary pigmented melanocytic lesions are uncommon in the oral cavity and accounted for only 0.9% of the total biopsies accessed, while amalgam tattoos comprised 1.8%.

• Oral and labial melanotic macules were the most common solitary pigmented melanocytic lesions (86.1%), followed by oral melanocytic nevi (11.8%), oral melanoacanthoma (0.9%), and oral melanoma and atypical melanocytic proliferations (0.6% each).

Amalgam has been recognized as the primary posterior tooth restorative material for a great many years. Although there has been a decrease in the utilization of amalgam in the recent past, amalgam is still recognized as having advantages over other dental restorative materials. It is less sensitive to moisture during placement, it is very durable, it requires less expertise to place, and it is less expensive compared to other restorative dental materials. The use of amalgam has been attacked by the misconception that it is more toxic when compared to other dental materials. The issue of the amalgam tattoo is a relatively minor concern but a concern, nevertheless. Upon removing teeth with amalgam restorations, amalgam fragments may be incorporated within the stroma and may cause stable discoloration in the gingiva and other adjacent oral mucosal tissues. There are a large number of oral mucosal differential diagnoses, and the vast majority of them are benign lesions. The amalgam tattoo is localized, and there is no associated malignant transformation. The amalgam tattoo lesion is a relatively common condition, and the diagnosis is usually relatively straightforward. However, the diagnostic procedure of biopsy comes into play when the presentation or history is atypical. Fortunately, with respect to the case presented, the biopsy confirmed a diagnosis of an amalgam tattoo.^3-5,22

CONCLUSION
In summary, amalgam tattoo lesions are relatively common benign oral lesions. With respect to the diagnostic process, there are a number of oral lesions with a similar appearance. It is important to define the diagnosis due to the seriousness of oral malignant melanoma, which may present similarly to many of these oral macular pigmented lesions.

References

1. Natarajan E. Black and brown oro-facial mucocutaneous neoplasms. Head Neck Pathol. 2019;13:56-70.
2. Kauzman A, Pavone M, Blanas N, et al. Pigmented lesions of the oral cavity: review, differential diagnosis, and case presentations. J Can Dent Assoc. 2004;70:682-683.
3. Eisen D. Disorders of pigmentation in the oral cavity. Clin Dermatol. 2000;18:579-587.
4. Laimer J, Henn R, Helten T, et al. Amalgam tattoo versus melanocytic neoplasm—differential diagnosis of dark pigmented oral mucosa lesions using infrared spectroscopy. PloS One. 2018;13:e0207026.
5. Hassona Y, Sawair F, Al-Karadsheh O, et al. Prevalence and clinical features of pigmented lesions. Int J Dermatol. 2016;55:1005-1013.
6. Lambertini M, Patrizi A, Fanti PA, et al. Oral melanoma and other pigmentations: when to biopsy? J Eur Acad Dermatol Venereol. 2018;32:209-214.
7. Lundin K, Schmidt G, Bonde C. Amalgam tattoo mimicking mucosal melanoma: a diagnostic dilemma revisited. Case Rep Dent. 2013;2013:787294.
8. Gondak RO, da Silva-Jorge R, Jorge J, et al. Oral pigmented lesions: clinicopathologic features and review of the literature. Med Oral Patol Oral Cir Bucal. 2012;17:e919-e924.
9. Tavares TS, Meirelles DP, de Aguiar MCF, et al. Pigmented lesions of the oral mucosa: a cross-sectional study of 458 histopathological specimens. Oral Dis. 2018;24:1484-1491.
10. Gonçalves IMF, Gomes DQC, Pereira JV, et al. Clinical and histopathological study of oral multifocal melanoacanthoma: a case report. J Clin Exp Dent. 2019;11:e391-e394.
11. Rosebush MS, Briody AN, Cordell KG. Black and brown: non-neoplastic pigmentation of the oral mucosa. Head Neck Pathol. 2019;13:47-55.
12. Buchner A, Merrell PW, Carpenter WM. Relative frequency of solitary melanocytic lesions of the oral mucosa. J Oral Pathol Med. 2004;33:550-557.
13. Hicks MJ, Flaitz CM. Oral mucosal melanoma: epidemiology and pathobiology. Oral Oncol. 2000;36:152-169.
14. Mergoni G, Ergun S, Vescovi P, et al. Oral postinflammatory pigmentation: an analysis of 7 cases. Med Oral Patol Oral Cir Bucal. 2011;16:e11-e14.
15. Duan N, Zhang YH, Wang WM, et al. Mystery behind labial and oral melanotic macules: clinical, dermoscopic and pathological aspects of Laugier-Hunziker syndrome. World J Clin Cases. 2018;6:322-334.
16. Mărginean CO, Meliţ LE, Patraulea F, et al. Early onset Peutz-Jeghers syndrome, the importance of appropriate diagnosis and follow-up: a case report. Medicine (Baltimore). 2019;98:e16381.
17. Jassar P, Jaramillo M, Nunez D. Base of tongue varices associated with portal hypertension. Postgrad Med J. 2000;76:576-577.
18. Hedström L, Albrektsson M, Bergh H. Is there a connection between sublingual varices and hypertension? BMC Oral Health. 2015;15:78.
19. da Silva WB, Ribeiro ALR, de Menezes SAF, et al. Oral capillary hemangioma: a clinical protocol of diagnosis and treatment in adults. Oral Maxillofac Surg. 2014;18:431-437.
20. Pal M, Saokar A, Gopalkrishna P, et al. Diode laser-assisted management of intraoral soft tissue overgrowth: a case series. Gen Dent. 2020;68:28-31.
21. Gorsky M, Epstein JB. Melanoma arising from the mucosal surfaces of the head and neck. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86:715-719.
22. Galletta VC, Artico G, Dal Vechio AMC, et al. Extensive amalgam tattoo on the alveolar-gingival mucosa. An Bras Dermatol. 2011;86:1019-1021.

Dr. Cherry-Peppers is an associate professor at the Howard University College of Dentistry. She can be reached via email at gail.cherrypeppers@howard.edu.

Dr. Karapetian is in private practice in Vienna, Va.

Dr. Kumar is an assistant professor at the New York University School of Dentistry.

Dr. Morton is an associate professor at the Howard University College of Dentistry.

Dr. Edwards is a clinicial instructor at the Howard University College of Dentistry.

Dr. Brown is professor emeritus, Howard University College of Dentistry, and a clinical associate professor at Georgetown University Medical Center.

Disclosure: The authors report no disclosures.

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Periotomes were introduced approximately 25 years ago to improve luxation as an adjunct to use of the elevators.⁴ These instruments had thinner, more delicate tips intended to be utilized differently then elevators and were designed to be placed into the periodontal ligament (PDL) space with pressure applied in a vertical direction along the root’s long axis.^5-7 The tips were provided in 3 orientations to allow access to different areas of the mouth. The periotome was pushed into the PDL, then withdrawn and moved to an adjacent position around the root and pushed apically. This process was repeated while working circumferentially around the root. An elevator could be used next, or, if mobility was noted, a forcep could be used to complete the extraction process. One caution with periotomes: due to the thinner tips on these instruments, if one uses them like an elevator to apply leveraging forces to the root, breakage of the instruments’ tips will occur.

Figure 1. Luxator LX (Directa Dental) power periotome with tip in handpiece.

More Efficiency with a Power Periotome
To improve the process, a unique power periotome—the Luxator LX (Directa Dental)—was developed. It fits a standard “E” connector used for dental handpieces to provide activation of the tip (Figure 1) and, unlike hand periotomes with their fixed tips, the Luxator LX tips freely rotate circumferentially. This self-directing tip allows the practitioner to place it into the PDL and, when activated, walk the tip around the tooth without the need to remove it for repositioning (Figure 2). When activated, the tip moves vertically in a reciprocating motion. These tips are not intended for use as elevators. If they are used as elevators, such forces applied will damage not only the Luxator LX periotome tips, but may also damage the alveolar bone at the buccal or lingual crest.

The Luxator LX periotome tips have a concave inner and convex outer surface in cross section, available in 2.0-mm and 3.0-mm wide versions and in short and long lengths (Figure 3). The tips are very thin and sharp, and, when inserted into the PDL space, they will separate the ligaments between the root and alveolus while compressing the alveolar bone of the socket to create space and mobilize the tooth. The titanium-nitride coating makes the tips more durable. The hardening process also gives excellent long-term durability to the sharpness of the tip. The tips are provided in an autoclavable carrier to prevent losing them between uses on patients (Figure 4). To remove the tip from the handpiece, a metal plunger is provided. Insert the plunger into the back of the handpiece head to pop the tip out (Figure 5).

Figure 2. The tip is placed into the periodontal ligament (PDL) space of the tooth to be extracted, activated via the foot rheostat, then slowly walked around the tooth while applying light apical pressure.

The recommended speed when operating the Luxator LX is 4,000 rpm, and the author recommends starting at a low speed and increasing if the tip is not advancing into the PDL with light apical pressure. Speeds faster than 4,000 rpm will not make extractions easier or faster, but may cause uncomfortable vibrations for the patient. Higher speeds may also damage the Luxator LX contra-angle handpiece.

CLINICAL CASE EXAMPLES
Extraction of Intact Teeth
When an intact tooth is to be extracted, the appropriate Luxator LX periotome tip is selected and inserted into the handpiece. The tip is placed into the PDL space at the mesial-interproximal-buccal aspect and light apical pressure is exerted (Figure 6). The tip is maintained in a position that aligns it with the long axis of the tooth’s root. With the tip in the PDL space, the rheostat is then activated, and the tip is walked to the distal-interproximal-buccal aspect while maintaining light apical pressure (Figure 7). The handpiece is deactivated, and the tip is then moved to the lingual and reinserted into the PDL space. Next, the handpiece is reactivated and the tip is moved to toward the interproximal area where the process initially started (Figure 8). Mobility in the buccal-lingual direction is checked and, if sufficient, an extraction forceps is then utilized to complete the extraction process. If the tooth is not sufficiently mobile, the tip is reinserted into the PDL space and the process is simply repeated.

Figure 3. Luxator LX periotome tips, shown here at 2 angles to emphasize how the concave shape of the tips match the contours of the root(s).

Figure 4. The auotclavable Luxator LX tip holder.	Figure 5. The Luxator plunger being used to remove the periotome tip from the handpiece.

Extraction of Roots and Nonintact Teeth
The Luxator LX periotome can be utilized on nonintact teeth and residual roots with a flapless or flap procedure. The technique is identical to the one used on intact teeth. However, without the coronal tooth structure present, the tip can be moved circumferentially, without having to remove and reposition the tip around the proximal contact with the adjacent tooth. The tip is introduced on the buccal (Figure 9) and, once activated, it is moved circumferentially around to the lingual (Figure 10) to complete the process. An elevator (such as the Luxator Forte Elevator [Directa Dental], Luxating Elevator [Hu-Friedy], or Zators [Zoll-Dental]) or a similar instrument can be applied into the widened PDL space to further luxate the remaining root before moving to a forceps or rongeur to complete the extraction process.

Figure 6. In this clinical case, the tip was introduced into the mesial buccal of the intact central incisor that was to be extracted, then activated.	Figure 7. While activated, the periotome tip is walked slowly to the distal buccal while applying light apical pressure.
Figure 8. The periotome tip was reoriented to the palatal and inserted into the PDL space at the distal palatal, then activated and walked to the mesial palatal.	Figure 9. In this clinical case, the Luxator LX periotome tip was inserted into the PDL space at the buccal of the root to be extracted and activated.

Figure 10. The Luxator LX periotome tip was walked around the root to be extracted while activated, applying light apical pressure to luxate the tooth.

CLOSING COMMENTS
Tooth extractions can be a stressful appointment for both the patient and the practitioner. When the practitioner rushes the process, the tooth being extracted may fracture, thus complicating the procedure and requiring more time and effort to retrieve any remaining root in the alveolus. The key to tooth extraction is taking time to mobilize the root so that it can be removed as atraumatically as possible. The Luxator LX power periotome is an improvement over hand periotomes, as it requires less hand force by the practitioner to luxate the root and is more efficient in motion. Additionally, it provides a gentler experience for the patient, helping to alleviate fears that may have caused them to be hesitant with future dental treatments.

References

1. Malden N. Surgical forceps techniques. Dent Update. 2001;28:41-44.
2. Krekmanov L. Extraction with an elevator [in Swedish]. Tandlakartidningen. 1974;66:1365-1370.
3. Fries R, Platz H. Use of the elevator in tooth extractions [in German]. Osterr Z Stomatol. 1974;71:334-339.
4. Thomson PJ. Minimising trauma in dental extractions: the use of the periotome. Br Dent J. 1992;172:179.
5. Sharma SD, Vidya B, Alexander M, et al. Periotome as an aid to atraumatic extraction: a comparative double blind randomized controlled trial. J Maxillofac Oral Surg. 2015;14:611-615.
6. Kaijin H, Yongfeng L. Application of micro-power system in the surgery of tooth extraction [in Chinese]. Hua Xi Kou Qiang Yi Xue Za Zhi. 2015;33:1-5.
7. Levitt D. Atraumatic extraction and root retrieval using the periotome: a precursor to immediate placement of dental implants. Dent Today. 2001;20:53-57.

Dr. Kurtzman is in private general practice in Silver Spring, Md, and is a former assistant clinical professor at the University of Maryland and a former assistant program director for the American Academy of Implant Dentistry implant maxi-course at Howard University College of Dentistry (Washington, DC). He has earned Fellowships in the AGD, American Academy of Implant Prosthodontics, American College of Dentists, International Congress of Oral Implantologists (ICOI), Pierre Fauchard, and the Academy of Dentistry International; Masterships in the AGD and ICOI; and Diplomate status in the ICOI and American Dental Implant Association. He has lectured internationally on the topics of restorative dentistry, endodontics, implant surgery, removable and fixed prosthetics, and periodontics and has more than 525 published articles globally. He has been honored to be included in the Leaders in Continuing Education directory in Dentistry Today annually since 2006 and was featured on its June 2012 cover. He can be reached via email at dr_kurtzman@maryland-implants.com.

Disclosure: Dr. Kurtzman reports no disclosures.

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Laser Troughing to Improve Scanning and Impressions

INTRODUCTION
Every so often, we have a patient who presents with clinical challenges that need to be handled outside of the usual protocol. So it was with Lucinda, who presented with caries in 2 specific teeth that would normally have been treated by doing extractions. However, the health history showed Fosamax use and, upon further questioning, it was found that she had a history of heavy use of this prescription drug within the last 5 years. Consulting with Dr. Mark Ericson, our oral surgeon, the decision was made not to remove teeth Nos. 3 and 18 because of potential healing problems in the bony socket sites due to the use of Fosamax.

This article will present the case introduced above, demonstrating the alternative treatment that was done, and the current research for deciding upon the course of action outlined below.

Fosamax Issues
Patients who have resorptive bone diseases such as osteoporosis (often women) can benefit from the use of oral bisphosphonates (BPs). For the last 11 years, a number of studies have been published that have documented the condition of osteonecrosis of the jaw (ONJ) that is associated with the use of oral BPs; thus called bisphosphonate-related osteonecrosis of the jaw, or BRONJ. From the studies, one can learn how these jaw necroses are tied to the use of BPs (such as Fosamax, risedronate, or alendronate).¹

A clinical study important to the dental profession² documented the healing issue faced when extracting teeth or bone work, namely slow or nonhealing of sockets. When patients have taken BPs for the treatment of osteoporosis, the ability for bone to heal after surgery can be limited. Should nonhealing take place, the patient’s life is affected, which can be a significant issue for the clinician too. The study observed 7 patients who had taken BPs and had extractions, with 6 of the patients having had sequestration during nearly a year of observation, and only 3 had experienced healing. It should be noted that the current standard treatment for BRONJ does not always provide good results.³

BPs have been widely, efficiently, and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers, and multiple myeloma bone diseases. Accumulating recent reports describe that dental surgery treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with BRONJ.⁴

Figure 1. Severe decay in tooth No. 3 that would usually require extraction.	Figure 2. Severe decay in tooth No. 18 that would usually require extraction.
Figure 3. Preserved root sealed with glass ionomers (GC Fuji II [GC America]).	Figure 4. Acytel resin unilateral partial over preserved root (tooth No. 3). Note: photo was taken after 4 months of wearing the prosthesis.
Figure 5. Tooth No. 18 root preserved with root canal and glass ionomer.	Figure 6. Retention preparation in No. 18 before composite resin was placed.

Because BPs can be given to many cancer patients who also have a need for invasive dental care involving bone, it should be noted that ONJ cannot be effectively treated with debridement and antibiotics or even hyperbaric oxygen exposure. To prevent negative outcomes, the clinician must recognize that there are no effective treatments for ONJ. If treatment (such as extraction) is absolutely needed with a patient taking a BP, the treating medical doctor should be contacted about his or her BP delivery.⁵

A study concerning implant placement for those who were actively taking BPs showed no discernable healing issues. There was no significant difference between groups in the success rates of dental implants at stage-2 surgery (test 93.5%, control 95.5%).⁶ In another study, new bone formation in extraction sockets, bone area around the implant site, and bone-implant contact were not delayed in the bisphosphonate group.⁷

One report⁸ confirmed 2 other patients who experienced osteonecrosis from BP causes were successfully treated with teriparatide, when used as adjunct therapy in ONJ; this is because it has an anabolic effect and presumed role in accelerating bone healing. ONJ is a serious but infrequent condition that has been recently associated with nitrogen-containing bisphosphonate therapy. Teriparatide may be a useful adjunctive therapy when ONJ develops.

Hsiao et al⁹ found that the results of this preliminary short-term study suggest that patients taking long-term oral BPs can expect a satisfactory outcome with evidence of periradicular healing after conventional root canal treatment. Thus, root canal treatment may be considered a safe and realistic alternative to extraction in patients on bisphosphonate therapy.

The issue facing all dental clinicians is to extract or not to extract a tooth when the patient has been or is taking BPs. Even if the potential for osteonecrosis is small for any given patient, no dentist wants to be responsible for the patient getting this condition, and therefore, hesitancy on the decision to proceed with an extraction would be reasonable.

CASE REPORT
Lucinda presented as a new patient with extensive decay in 2 teeth that would have ordinarily been treated with extractions (Figures 1 and 2).

However, since her medical history included the use of Fosamax during a period of 5 years, it became apparent that extraction could lead to osteonecrosis in one or both sites, even though she reported having stopped taking the drug just prior to this dental visit. The question of an alternative approach seemed vital to getting an outcome that would provide a clinically good result while keeping her healthy.

Figure 7. Glass ionomer in No. 18 prepared for ZAAG (ZEST Anchors) female attachment.	Figure 8. ZAAG One-Step Drill (ZEST Anchors) for ZAAG female attachment preparation.
Figure 9. ZAAG attachment cemented into tooth No. 18.	Figure 10. ZAAG male attachment placed into female ready for pickup.
Figure 11. Triad VLC Bonding Agent (DENTSPLY Trubyte) placed on lower partial denture for male ZAAG attachment.	Figure 12. Triad DuaLine dual-cure (self- and light-cured) reline composite material (DENTSPLY Trubyte).

Figure 13. Lower partial denture with the male ZAAG attachment snapped into female in tooth No. 18.

The first course of action was to sever the maxillary bridge at crown No. 5 and to remove the existing crown on No. 3. After determining that the root canals of tooth No. 3 were calcified, the root was sealed with a glass ionomer (GC Fuji II [GC America]) (Figure 3). Since this tooth was without symptoms or swelling, it was determined that the roots could be left at this point. If any symptomology would appear at a later time, that could be dealt with by prescribing antibiotics. (Note: that need has not arisen, as of the writing this article.)

In order to restore the missing teeth, a unilateral partial denture of acytel resin was produced (Figure 4). At this point, this tactic has been successful for the patient.

Endodontic therapy was done on the lower left second molar (tooth No. 18) by Dr. June Chang to keep it from extraction (Figure 5). Since the patient would now need a removable partial denture, a unilateral type was offered with tooth No. 18 receiving a ZAAG attachment (ZEST Anchors) for distal-end anchorage. Because No. 18 had a temporary restoration after the root canal, because the occlusal height above to No. 15 was limited due to super eruption, and because crown lengthening was ruled out due to the BP issue; the tooth was restored with composite down into the pulp chamber. The preparation can be seen in Figure 6. This restoration allowed for preparation for the ZAAG female attachment placement (Figure 7) using the ZAAG drill (Figure 8) and the actual attachment.

The ZAAG female attachment was cemented into the preparation (Figure 9) using SEcure Cement (Parkell). The male attachment was tried in to evaluate the fit (Figure 10). The unilateral partial denture was primed with Triad VLC Bonding Agent (DENTSPLY Trubyte) (Figure 11), so that the male ZAAG could be “picked up” with Triad DuaLine (DENTSPLY Trubyte) dual-cure reline material (Figure 12). The result was giving the patient a firmly fitting unilateral partial denture, using a tooth that normally would have been extracted. Figure 13 shows the unilateral partial denture with the ZAAG attachment bonded in using Triad DuaLine.

CLOSING COMMENTS
During a dental career, we are sometimes presented with opportunities to be creative, offering the chance for a better outcome for a patient than his or her condition might normally warrant. Having written extensively about and practiced minimally invasive dentistry, this case where the patient presented with a history of BP use for treating osteoporosis required that kind of approach. This compromised situation and the research supporting caution led to the alternate treatment shown. Each subject tooth continues to function well under the partial dentures.

References

1. Mozzati M, Arata V, Gallesio G. Tooth extraction in osteoporotic patients taking oral bisphosphonates. Osteoporos Int. 2013;24:1707-1712.
2. Ng AJ, Yue B, Joseph S, et al. Delayed/non-union of upper limb fractures with bisphosphonates: systematic review and recommendations. ANZ J Surg. 2014;84:218-224.
3. Nomura T, Shibahara T, Uchiyama T, et al. Bisphosphonate-related osteonecrosis of jaw (BRONJ) in Japanese population: a case series of 13 patients at our clinic. Bull Tokyo Dent Coll. 2013;54:117-125.
4. Yoneda T, Hagino H, Sugimoto T, et al. Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons. J Bone Miner Metab. 2010;28:365-383.
5. Urade M. Bisphosphonates and osteonecrosis of the jaws [in Japanese]. Clin Calcium. 2007;17:241-248.
6. Memon S, Weltman RL, Katancik JA. Oral bisphosphonates: early endosseous dental implant success and crestal bone changes. A retrospective study. Int J Oral Maxillofac Implants. 2012;27:1216-1222.
7. Kim JH, Park YB, Li Z, et al. Effect of alendronate on healing of extraction sockets and healing around implants. Oral Dis. 2011;17:705-711.
8. Narongroeknawin P, Danila MI, Humphreys LG Jr, et al. Bisphosphonate-associated osteonecrosis of the jaw, with healing after teriparatide: a review of the literature and a case report. Spec Care Dentist. 2010;30:77-82.
9. Hsiao A, Glickman G, He J. A retrospective clinical and radiographic study on healing of periradicular lesions in patients taking oral bisphosphonates. J Endod. 2009;35:1525-1528.

Dr. Whitehouse is a founding member and past president (2003 to 2005) of the World Congress of Minimally Invasive Dentistry (MID). He has authored many articles on MID and other clinical issues. He continues to practice 2 days per week after having sold his dental practice in Castro Valley, Calif. He can be reached at (510) 881-1924 or via email at cvdental@aol.com.

Disclosure: Dr. Whitehouse reports no disclosures.

In April 2007, the ADA and its Council on Scientific Affairs published a position paper that provides newly revised guidelines for the prevention of infective endocarditis (IE).1 These guidelines, endorsed by the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Heart Association (AHA), among others, reflected current research assessing dental procedure related bacteremia, endocarditis prevention, and the most common pathogens associated with the condition. The new guidelines reduce the classes of patients for whom antibiotic prophylaxis is recommended because the risk of morbidity resulting from antibiotic use outweighs its probable benefits. However, the guidelines also suggest that dental manipulation of any type may result in the introduction of potentially pathogenic bacteria into the bloodstream. This raises an important question whether less risky approaches to controlling oral bacteria prior to dental procedures and general oral care might be a useful preventative strategy for individuals previously defined as at-risk for IE and where antibiotics are not now recommended. Given this, the following discussion is directed toward a possible new approach for reducing the oral bacteria associated with blood born infection using xylitol incorporated into a time release disk that adheres to the gingiva and/or teeth.

Factors in the Pathogenesis of Infective Endocarditis

The pathogenesis of IE is complex and involves a number of different factors. There must be vessel turbulence leading to platelet deposition and damage to the endothelium of the cardiac valve or surgically constructed pulmonary shunt or conduit, combined with a bacteremia arising from oral trauma with microorganisms that are capable of adhering to the site (typically streptococci, staphylococci, and enterococci), and bacterial proliferation at the site of adherence.2

Multiple studies suggest that procedures such as tooth extraction, periodontal surgery, tooth cleaning and scaling, rubber dam placement, and root canal therapy can cause a bacteremia.‎3-5 Even though there is evidence that bacteremia follows dental treatment and dental hygiene procedures, because of potential allergy, resistance, and cost-effectiveness, among other factors, the counsel restricted the classes of patients for whom short-term antibiotic prophylaxis before dental procedures are recommended. Prevention via systemic antibiotic application is generally discouraged because, in addition to the above, there is a lack of viable supportive research and further, there are contradictory results. Additionally, limited studies assessing topical antiseptic rinses or germicides as a strategy for reducing bacteremia arising from dental procedures suggest that they are not likely to be effective.8,9

To control the risk of IE in patients for whom antibiotic prophylaxis is no longer recommended, the ADA recommends that individuals simply maintain good oral hygiene and avail themselves of professional dental care. The underlying assumption is that good oral hygiene will reduce overall bacterial counts leading in turn to a reduction in the number of bacteria introduced during dental or hygiene procedures. Good oral hygiene includes daily tooth brushing, flossing, and minimizing sugars that feed resident bacteria. While this proposal makes eminent sense, from a public health standpoint it is not all that clear that the majority of people will follow good preventative practices and present for routine dental care. In fact, based on the US Surgeon General’s Report in 2000,10,11 there remains a substantial discrepancy between American children, young adults, and older adults in terms of access to preventative and other dental care services based on ethnicity, income, education, and special needs status. It is estimated that the fastest growing populations in the US (eg, Black, Hispanic) have the highest disease rates and lowest access to dental care12 even in the face of current National Health Insurance Programs.13 In addition, there appears to be considerable disparity between states with respect to implementation of the State Child Health Insurance Program and comparisons of children in states with and without the plan suggesting that there is over a 24% difference in terms of likelihood of preventative care based on this variable alone.14 The issue concerning adults may even be worse. Thus, many people in the US will not receive the preventative training and skills development necessary to satisfy the ADA’s basic requirements for prevention of IE associated with routine home care.

Other Methods to Reduce Oral Bacterial Burden

Among many of the other continuing and unanswered questions in relation to the introduction of bacteria into the bloodstream and potential IE is whether there are low risk methods besides “good oral hygiene” for reducing the overall burden of oral bacteria prior to dental procedures, specifically the bacteria that are known to cause bacteremia and IE, and whether such a reduction in these disease causing bacteria might result in a drop in the incidence of IE and its associated morbidity or mortality, particularly in the aged and disabled. To date, there have been no prospective, controlled, randomized studies to assess these issues. In a review of IE and dental procedures, it is concluded that, given the current evidence regarding pathogenesis and prevention of endocarditis, novel strategies need to be developed as alternatives to current approaches using antibiotic prophylaxis.15

Assuming, as has been suggested by the AHA’s report, that it might be helpful to reduce the oral bacterial burden prior to dental procedures in individuals where antibiotic prophylaxis is not recommended, the literature regarding xylitol, a sugar substitute that occurs widely in nature which can be delivered topically in the mouth, offers a potential means for achieving this end. Specifically, in a number of dental studies addressing control of caries, it has been found that delivery of xylitol in a controlled manner with chewing gum significantly reduces salivary Streptococcus (Streptococcus mutans) counts.16-18 This is of particular significance not only in the arena of public dental health and caries but also because recent research completed by a group of investigators from Japan, with their findings published by the Journal of Clinical Microbiology, has revealed that S mutans (presumed to be derived from the oral cavity) is the most numerous specie in heart valve and atheromatous plaque specimens.19

Use of xylitol chewing gum four or five times per day has been shown to reduce not only S mutans but also Streptococcus salivarius and Streptococcus sanguis,20 and regular consumption by mothers has been shown to reduce mother-child transmission.21 Further, a xylitol induced reduction in bacterial counts has been shown to continue for a prolonged period of time (age 3 to age 6 years) in children studied.22 Xylitol has also demonstrated efficacy in reducing counts of Streptococcus sobrinus, Lactobacillus rhamnosus, Actinomyces viscosus, Porphyromonas gingivalis, and Fusobacterium nucleatum that have been experimentally incorporated into model biofilms,23 in reducing counts of Porphyromonas aeruginosa in maxillary sinus specimens,24 in altering the viability of strep pheumococci responsible for acute otitis media,25 and in altering cytokine expression induced by P gingivalis (one of many bacteria suspected in periodontal disease).26 These as well as other studies provide a potential medical use for xylitol in reducing bacterial counts potentially involved in cardiac disease and suggest an adjunctive application in the management of IE and other infective diseases (eg, sinus infection, middle ear infection, gingivitis, and periodontitis).

Presently, xylitol is primarily delivered via chewing gum.15,27-29 but it has also been incorporated into lozenges and syrup. In a study assessing the effect of xylitol on hunger, xylitol has been put into yogurt,30 and it is also found in other food products.31 However, one of the problems with its incorporation into foods is whether an adequate concentration can be maintained over a long enough time in the mouth to effectively reduce oral bacteria. Delivery of xylitol via gum appears to be effective in this regard. However, xylitol released from gum is dissipated in about 15 minutes,34 new 32 which requires that it be used 5 times or more per day to be effective and be used in larger quantities than desired.

Xylitol has also recently been incorporated into a time-release adhering disc called XyliMelts (OraHealth Corporation) that can be adhered to the teeth or adjoining gingiva to time-release 500 mg of xylitol. Xylitol delivered in this manner is very likely to be present in the mouth for longer periods of time (30 to 120 minutes—based on reports from subjects in a pilot study) and may be more tolerated by patients unwilling or unable to chew gum (eg, the edentulous, those with temporomandibular joint disorder or disabilities). XyliMelts can also be used while sleeping, when saliva flow is lowest, potentially increasing the effectiveness of the overall antibacterial action. A similar oral adhering disc called Oramoist (Quantum) designed to adhere to the roof of the mouth and release flavor to stimulate saliva also contains xylitol but the amount of xylitol in each disc is not published by the manufacturer and is likely insignificant.

Studies suggest that a dose of xylitol in the range of 6.5 g per day to 10.3 g per day delivered with chewing gum over 4 or 5 uses per day is sufficient to reduce streptococci levels.27 Studies of quantities of xylitol that must be delivered with the time release discs to achieve the same effect have not been completed. One would expect the required dosage for an equal effect to be significantly lower and the effect of an equal dosage to be significantly greater. A preliminary study (which cannot be cited because of proprietary issues) has apparently shown that only one gram per day delivered over time by XyliMelts can significantly reduce S mutans counts.

While providing the required dosage in gum can be “cumbersome” as one of the above authors has suggested,27 delivery in a dissolving disc adhered to a molar or gingiva in the buccal vestibule is easily accomplished and could make the process considerably more palatable. To achieve an effect equal to 1.3 g of xylitol chewing gum used 5 times per day (6.5 g per day), the manufacturer (OraHealth) of XyliMelts suggests that a time release disc containing one-half g of xylitol should be used at bedtime and “after each meal, at least 4 discs per day,” for a minimum of 2 g per day. Until studies are completed to determine whether this usage is sufficient to obtain optimal reduction of pathogenic bacteria, to be conservative, based on prior chewing gum studies, one could increase the usage to 4 g per day (8 discs). As previously noted, this approach to the delivery of xylitol prior to dental procedures would likely be particularly worthwhile in those with physical or mental disabilities and in frail older people where maintenance of good oral health is often problematic and where bacterial endocarditis can be a significant problem.32,33 new 33,34

New American Heart Association Recommendations

The AHA now recommends antibiotic prophylaxis before dental procedures only in patients with high risk of IE where that risk outweighs the risks of problems from the antibiotics. (The cardiac conditions that present this level of risk include: prosthetic cardiac valves; congenital heart disease including unrepaired cyanotic coronary heart disease (CHD), including palliative shunts and conduits; completely repaired congenital heart defect with prosthetic material or devices, whether placed by surgery or by catheter intervention during the first 6 months after the procedure, repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device; and cardiac transplantation recipients who develop cardiac valvulopathy). Also included are individuals with a previous IE history. However, another problem associated with IE is the presence of comorbid disease. Hence, individuals with diabetes mellitus, immunosuppressive conditions, and kidney disease necessitating dialysis may have an increased risk of morbidity and mortality from IE. And as previously mentioned, disability and age may also confound the risk of developing the condition in susceptible individuals. However, antibiotics are no longer recommended for this cohort of patients.

New Questions for New Technology

Important questions raised by the new technology for time release of xylitol in the mouth are: (1) whether the XyliMelts discs should be used for several days or weeks before undergoing dental procedures; (2) whether this prophylaxis should be recommended for all dental procedures or only those where substantial bleeding is expected; (3) whether this prophylaxis should be recommended for all patients or only those with a moderate risk of IE; and (4) how patients with moderate risk are to be distinguished from patients with low risk. As an initial step in answering these questions, both in vivo and in vitro studies need to be pursued to assess the effect of xylitol delivered by time-release adhering disc on the oral carriage of the previously defined pathogens causing IE. Then additional prospective randomized controlled trials should be considered to assess the efficacy of this delivery system in preventing IE in select patient cohorts. Finally, it would also be useful to assess the effectiveness of xylitol delivered via adhering disc on other conditions identified as also being caused, in part, by the identified bacteria and where other xylitol-based applications have been found to prevent disease (eg, sinusitis, otitis media).29

Conclusion

Given what is now known regarding oral bacteria and their introduction into the bloodstream, until the above questions are answered, it would seem prudent for individuals with previously identified risk factors for IE who are not now prescribed antibiotics to use over-the-counter products including xylitol (eg, XyliMelts, xylitol gum) for as many days as practically achievable (one to 20 days) prior to dental procedures. These products might also be recommended by health care providers other than dentists for individuals who, for varying reasons, are not able to avail themselves of routine dental preventative care and where there is perceived risk.

ACKNOWLEDGEMENT

The author wishes to thank OralHealth Corporation for its support for this article. 

References

1. Wilson W, Taubert KA, et al: Prevention of Infective Endocarditis, Guidelines from the American Heart Association. A Guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasake Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 138(6):739-745, 747-760 2007.
2. Bashore TM, Cabell C, Fowler V Jr. Update on infective endocarditis. Curr Probl Cardiol. 31(4):274-352, 2006.
3. Martin MV, Longman LP, et al: Infective endocarditis and dentistry: the legal basis for an association. Br Dent J. Feb 2; E15 [Epub ahead of print], 2007.
4. Savarrio L, Mackenzie D, et al: Detection of bacteraemias during non-surgicalroot canal treatment. J Dent 33: 293-303, 2005
5. Heimdahl A, Hall G, et al: Detection and quantitation by lysis-filtration of bacteremia after different oral surgical procedures. J Clin Microbiol 28: 2205-2209, 1990
6. Sconyers JR, Crawford JJ, Moriarty JD: Relationship of bacteremia to toothbrushing in patients with periodontitis. J Am Dent Assoc 87: 616-622, 1973
7. Lucas V, Roberts GJ. Odotogenic bacteremia following tooth cleaning procedures in children. Pediatr Dent. 22(2):96-100, 2000.
8. Hall G, Heimdahl A, Nord CE. Effects of prophylactic administration of cefaclor on transient bacteremia after dental extraction. Eur J Clin Microbiol Infect Dis. 15:646-649, 1995.
9. Witzenberger T, O’Leary TJ, Gillette WB. Effect of a local germicide on the occurrence of bacteremia during subgingival scaling. J Periodontol. 53(3):172-179, 1982.
10. http://www.nidcr.nih.gov/AboutNIDCR/SurgeonGeneral/default.htm , accessed 11/27/07
11. Bentley LP. Disparities in children’s oral health and access to care. J Calif Dent Assoc. 35(9):618-623, 2007
12. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr. 2(2 Suppl):141-147, 2002.
13. Wang H, Norton EC, Rozier RG. Effects of the State Children’s Health Insurance Program on access to dental care and use of dental services. Health Serv Res. 42(4):1544-1563, 2007.
14. Lewis CW, Johnston BD, et al: Preventive dental care for children in the United States: a national perspective. Pediatrics 119(3):544-553, 2007
15. Ito HO. Infective endocarditis and dental procedures: evidence, pathogenesis, and prevention. The J of Med Investigation 53:189-198, 2006
16. Burt B. The use of sorbitol-and xylitol-sweetened chewing gum in caries control. JADA 137:190-196, 2006.
17. Makinen KK, Chen CY, Makinen PL, et al. Properties of whole saliva and dental plaque in relation to 40-month consumption of chewing gums containing xylitol, sorbitol or sucrose. Caries Res 30(3):180-188, 1996.
18. Ly Kiet A, Milgrom P, et al: Linear response of mutans streptococci to increasing frequency of xylitol chewing gum use: a randomized controlled trial. BMC Oral Health 6:1-6, 2006. http://www.biomedcentral.com/1472-6831/6/6 ; accessed 2007.
19. Nakano K, Inaba H, et al: Detection of cariogenic streptococcus mutans in extirpated heart valve and atheromatous plaque specimens. J of Clinical Micro 44(9):3313-3317, 2006.
20. Sahni PS, Gillespie MJ, et al: In vitro testing of xylitol as anticariogenic agent. Gen Dent. 0(4):340-343, 2002.
21. Soderling E, Isokangas P, et al: Influence of maternal xylitol consumption of acquisition of mutans streptococci by infants. J Dent Res 79(3):882-887, 2000.
22. Soderling E, Isokangas P, et al: Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6-year follow up. Caries Res. 35(3):173-177, 2001.
23. Badet M-C. Effect of xylitol on a model of oral biofilm. IADR abstract, 2007. http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_88048.htm
24. Brown CL, Graham SM, et al: Xylitol enhances bacterial killing in the rabbit maxillary sinus. Laryngoscope. 114(11):2021-2024, 2004.
25. Tapiainen T, Sormunen R, et al: Ultrastructure of streptococcus pheumoniae after exposure to xylitol. J Antimicrob Chemother. 54(1):225-228, 2004.
26. Han SJ, Jeong SY, et al: Xylitol inhibits inflammatory cytokine expression induced by lipopolysaccharide from porphyromonas gingivalis. Clin Diagn Lab Immunol. 12(11):1285-1291, 2005.
27. Milgrom P, Ly KA, et al: Mutans streptococci dose response to xylitol chewing gum. J Dent Res 85(2):177-181, 2006.
28. Thorild I, Lindau B, Twetman S. Caries in 4-year-old children after maternal chewing of gums containing combinations of xylitol, sorbitol, chlorhexidine, and fluoride. Eur Arch Paediatr Dent. 7(4):241-245, 2006.
29. Uhari M, Kontiokari T, et al: Xylitol chewing gum in prevention of acute otitis media: double blind randomized trial. BMJ 313:12180-1183, 1996.

30. King N, Craig S, et al: Evaluation of the independent and combined effects of xylitol and polydextrose consumed as a snack on hunger and energy intake over 10d. British J of Nutrition 93:911-915, 2005.
31. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners, and dental caries. Pediatr Dent. 28(2):154-163, 2006.
32. Milgrom P, Riedy C., et al: Bioavailability of xylitol-containing products in saliva. J. Dent Res 86(Spec Iss A):Late Breaking News, 2007 (www.dentalresearch.org
33. Takeda S, Nakanishi T, Nakazawa M. A 28-year trend of infective endocarditis associated with congenital heart diseases: a single institute experience. Pediatr Int 47(4):392-396, 2005.
34. Carmona TI, Posse JL, et al: Bacterial endocarditis of oral etiology in an elderly population. Arch Gerontol Geriatr. 36(1):49-55, 2003.
35.  Ruba N Khader, Morton Rosenberg, The 2007 American Heart Association Guidelines for the Prescription of Antibiotic Prophylaxis. Journal of the Massachusetts Dental Society http://www.massdental.org/?id=2778, accessed 12/14/07

Jeff Burgess received his DDS from the University of Washington school of Dentistry, Seattle, and his MSD in Oral Medicine from the University of Washington. He completed a 2-year post-doctoral fellowship in the Department of Anesthesiology and the University of Washington Medical Center and served 15 years as a Consultant/Attending at the Medical Center Pain Center. He also practiced general dentistry for 10 years and was a Research and Clinical Research Assistant Professor in the Department of Oral Medicine for 15 years. In addition, he had a private practice in Oral Medicine for 18 years. He has work experience with dental PACS and DICOM. He has been the co-investigator on numerous studies and authored and co-authored multiple chapters in medical and dental texts and articles in peer-reviewed journals.

As a dentist reading the title to this article, you may be thinking to yourself one or more of the following thoughts:

• I do not have an issue with the way I currently extract teeth;
• I typically refer out all and/or difficult extractions;
• I wish I was more comfortable with extractions in general;
• I wish my extractions were more predictable; or
• I wish I could increase my overall bottom line by not referring out extractions and losing patients.

No matter what you, the dentist may be thinking, exodontias of any tooth (except impacted third molars), in any condition, can be simple, predictable and extremely efficient if you are willing to think about exodontias in a manner unlike anything you have been taught through your formal education. I do not care if you graduated from dental school this year or forty years ago, the methods of performing and teaching exodontias have been relatively unchanged in more than 200 years until very recently.

Figure 1. Broken crown, little to grasp onto with conventional forceps. Tooth No. 5.	Figure 2. Large cavity, difficult to grasp with conventional forceps.
Figure 3. No crown to grasp onto with conventional forceps.	Figure 4. Endodontically treated with no crown.

What if I told you in general, that any tooth, in any condition (Figures 1 to 4), by any general dentist, can be performed in less than 4 minutes using only wrist movement?

Would you believe me, or at least be willing to consider a new unconventional technique of extracting teeth.

What is All the Hype With Atraumatic and/or Predictable Extractions?

Let’s face it, the economy has not been great over the last couple years and this has taken a toll on many practices. In my hometown of Detroit, many autoworkers have lost their healthcare due to unemployment, which means paying out of pocket for all dental care and putting off any dental work that is absolutely not 100% necessary. The free dental clinics that I volunteer at are overwhelmed with patients needing dental care at alarming numbers. This is a scary situation and dentists are looking more and more to expand their service offerings to avoid losing the paying patients that are coming into their office. Not only are we, as dentists, looking to increase our service offerings, we are looking to do them more efficiently. This is evident in dental magazine advertisements and at trade shows where you will see a mixed bag of courses entitled strategies to increase your bottom line, learn how to be more efficient and profitable, to name a few of the many. This is very telling of the economic environment we are operating in—we must adapt or potentially fail since in this business, time is money.

Figure 5. Before: Physics Forceps lower universal. (Courtesy of Ara Nazarian, DDS)	Figure 6. After: preparation for implant placement (Courtesy of Ara Nazarian, DDS)

In addition to the economic factor noted above, another area that has greatly increased the interest in atraumatic extractions over the last decade relates to implants. Atraumatic tooth extractions are desired more and more to preserve bone for immediate implant placement. Also, in connection with the economic factor noted above, implants can be a very profitable procedure, especially when performed in conjunction with full mouth extractions (Figures 5 and 6).

As a result, more dentists are now placing implants or have a desire to learn how to place implants.

With this said, it’s time for general dentists to become specialists in exodontias.

There is a Better Way

Traditional forceps may not be effective, but if you equate traditional extraction techniques to other common life events such as removing a nail embedded securely in a piece of wood or opening a nonscrew off cap from a bottle, you would never approach these events in the same manner. For example, when removing a nail, would you use pliers or would you use a hammer (Figures 7 and 8)?

Similarly, while enjoying yourself at a social gathering would you use pliers to grasp a bottle cap and pull it off, or would you look for a bottle opener (Figures 9 and 10)?

This is far from a novel concept, but it you think about it, traditional forceps are like the pliers in the examples above and clearly do not make sense in these situations. So why have dentists been approaching exodontias in this manner for hundreds of years? Good question, right? The answer is simple—this is how I was educated and the instruments available did not provide for alternatives.

Figure 11. Beak placement on tooth (animation).	Figure 12. Beak placement on tooth. (Courtesy of Ara Nazarian, DDS)
Figure 13. Beak placement on root (animation).	Figure 14. Beak placement on root. (Courtesy of Ara Nazarian, DDS)

Conventional exodontias requires 2 equal forces applied on the tooth (squeezing) combined with a third force, which is the movement of your arm, to release the tooth from its socket. This is something we, as dentists, are all aware of and were taught in school, so I will not elaborate on the background of conventional exodontias in this article. What I would like to focus on is what if instead, one force is applied (without squeezing) and the need for pulling with your arm was replaced with only slight wrist movement, which is what happens when the mechanical advantage of a first class lever is utilized.

It’s All in the Wrist—Let’s Get Predictable

The Physics Forceps (Golden Dental Solutions, formerly known as GoldenMisch) have a revolutionary beak and bumper design that allows for efficient atraumatic extractions using only wrist movement based on a Class I lever. The Physics Forceps technique eliminates the need to firmly grasp, twist, rock, push and pull with your arm. When this technique is first attempted, a conscious effort must be made to retrain your hands to not squeeze the instruments and to not pull with your arm. This can be the largest barrier to break through and be successful with this technique, but once this barrier is broken the advantages of the Physics Forceps are unlimited. In my profession, I talk to many dentists each week either on the phone, through email or at lectures, where I find that many dentists get the technique on the first or second try and have great success immediately.

The Physics Forceps act simply like a class I lever, where only one force is applied with the beak on the lingual aspect of the tooth (Figures 11 and 12) or root (Figures 13 and 14). Once the beak is placed, the bumper is placed on the alveolar ridge at the approximate location of the mucogingival junction to balance the beak. The beak grasps the tooth, while the bumper is the fulcrum to provide leverage and stability for the beak and wrist movement.

Figure 21. Rotational force using wrist only. (Courtesy of Ara Nazarian, DDS)	Figure 22. Tooth and root—tooth had vertical fracture and was removed with physics forceps. (Courtesy of Ara Nazarian, DDS)

Once the instrument is properly placed, your hands (or fingers) should be loosely placed toward the end of the handles to obtain maximum leverage. This may be simply 2 fingers or any similar position where the instrument feels comfortable in your hand as long as you are not squeezing the handles (Figures 15 through 20).

Once the instrument is properly placed, pressure is slowly applied using only wrist movement, using only wrist movement, using only wrist movement—yes, I am aware I said this 3 times since it is very important that there is no squeezing of the handles. I cannot emphasize this point enough. If you squeeze or move your arm you will fail (Figure 21).

Apply a steady and gentle pressure toward the buccal with only your wrist. During this holding period, you may be sitting there asking yourself should I be doing something else or am I doing this correctly and before you know it in a matter of seconds (approximately 30 seconds to a minute) the internal force or “creep” will build up allowing the bone to slowly expand and the periodontal ligament to release at which point the tooth will disengage from its socket (knows as the “pop”). The buccal only rotation of the tooth is only successful by rotating your wrist, very similar to the bottle opener example above, but in reverse.

Once the tooth has disengaged from the socket, stop. The instrument has completed its task and another instrument of choice (eg, rongeurs) or your fingers can be utilized to remove the tooth (Figure 22).

The mechanical advantage created by the Physics Forceps makes them a very efficient set of instruments, where if used properly will surprise you at just how simple and predictable extractions can be performed.

Some of the many advantages of utilizing this technique and the Physics Forceps include:

• Predictable and efficient extractions typically in less than 4 minutes;
• Preserving the buccal bone and cortical plate;
• Preventing having to lay flaps and removing bone to access roots;
• Virtually eliminating root tip fractures;
• Increasing services available to your patients so you do not need to refer them out;
• Increasing patient referrals based on atraumatic tooth extraction;
• Increasing your bottom line by eliminating referrals;
• Assisting with efficient full mouth reconstructive extractions; and
• Supporting immediate implant placement as now being taught in many dental implant courses.

What About the Buccal Bone?

If this technique is performed properly it will not cause buccal bone damage.

It is generally understood in our profession that the physical change of expanding the dental alveolar bone (socket) along with the severing of the periodontal ligament is the basis of tooth extraction. Although this does happen, it is more important to understand what is occurring biochemically with the tooth and its socket. When the periodontal ligament is traumatized with forceps or elevators, hyaluronidase (hyluronate glycanohydrolase) is released. This is an enzyme that catalyzes the hydrolysis of the interstitial barrier, hyaluronan (hyaluronic acid), which is the cement substance (extracellular matrix) of all human tissue. The tooth is released from its attachment to the alveolus and can be removed, once chemical breakdown of the periodontal ligament by hyaluronidase occurs.

The technique described in this article applies a steady rotational trauma to the periodontal ligament quantitatively creating a release of hyaluronidase in a shorter period of time than traditional forceps or elevator extractions because the trauma from these conventional techniques is intermittent (ie, not a steady constant force). As a result, the Physics Forceps technique is more efficient, faster, and less traumatic to the alveolar bone than conventional methods.1,2

Having alveolar bone come out with the tooth can be caused by several things. First of all, proper placement of the beak as subgingival as possible, and apical placement of the bumper to ensure an arc of rotation allowing the tooth to move occlusally when it is first disengaged from the socket, is critical. If it is not completely a wrist rotation this can also lead to alveolar fracture. And of course squeezing the handles can also cause this problem.

Become an Everyday “Houdini”

We refer nowadays to people who escape from impossible situations as “Houdinis.” I encourage you to learn more about the technique discussed in this article by visiting the Web site physicsforceps.com. It is time to add a little magic to your practice by performing extractions you once viewed as impossible on a routine basis in less than 4 minutes. You may be surprised at just how easy difficult extractions can be performed.

References

1. Abrahamsen, TC. Biochemistry of Tooth Extractions. physicsforceps.com/features.html. Accessed April 21, 2011.
2. Frasher JR, Laurent TC, Laurent UB. Hyaluronan: its nature, distribution, functions and turnover.  J Intern Med. July 1997;242: 27-33.

Dr. Golden graduated from the University of Detroit Mercy School of Dentistry in 1971, and he currently serves as a board of directors for the University. He is a general dentist with a private practice in Detroit, Mich. His strong business background prompted him to be the first general dentist in Michigan to advertise, open multiple offices, offer a 5-year guarantee, and to provide general anesthesia. His most notable breakthrough was the discovery of applying the power and predictability of controlled leverage to the extraction procedure. This resulted in the development of the Physics Forceps extraction instruments. He can be reached at (877) 987-2284 or at info@goldendentalsolutions.com.

Disclosure: Dr. Golden is President of Golden Dental Solutions.

Figure 1. Preoperative retracted view.	Figure 2. Occlusal view of maxillary arch.
Figure 3. Occlusal view of mandibular arch.	Figure 4. Illustration of the positioning of the Physics Forceps (Golden Dental Solutions) (upper first molar).
Figure 5. Positioning of Physics Forceps for a broken down tooth (lower molar).	Figure 6. Extraction of 32 teeth in 15 minutes.

Periodontal Problems
When every step has been taken, utilizing modern periodontal therapy and surgery, to treat or delay periodontal disease without improvement, then the only treatment may be partial or full-mouth edentulation. Otherwise, the disease affects supporting structures of teeth, causing their destruction along with the health of the patient by raising the risk to heart disease. It is important to note that when these teeth are already excessively loose from infection, then they must be extracted to prevent further progression of the disease into bone, which could lead to problems of denture construction or strategic implant placement.

Extensive Caries
When the extent of decay is far beyond proper restoration with a good prognosis, then it may be best to remove these teeth with the delivery of a complete set of dentures to initially control the pain and infection followed by implant reconstruction. After many decades of improvements in oral health, tooth decay is still on the rise. Much of the blame can be placed on today’s diet consisting of fast food, soda pop, sport drinks, juices, and energy drinks. Another factor that comes to mind is aging baby boomers who are living longer. A majority of these patients may be taking medications that are causing severe drying in the mouth (xerostomia) that results in a high caries rate, or simply they are unable to brush and floss properly because of hand dexterity issues.
When a patient has been diagnosed by the dentist that he or she needs full-mouth extractions and no other alternatives are available, then most of the anxiety in the patient’s mind is on how the full-mouth extractions will be carried out by the dentist or oral surgeon, how much pain and suffering he or she will have to undergo, and how will the definitive restoration, whether denture or implant prosthesis, look and function.

CASE REPORT
Diagnosis and Treatment Planning
A young man in his late 30s presented to the practice dissatisfied with the appearance of his smile. He commented that he was experiencing constant sensitivity to hot and cold as well as tenderness to biting. He also mentioned that he could feel some broken portions of tooth structure causing food to be trapped, resulting in swelling in his gum tissue.
Initial diagnostic evaluation consisted of a series of digital images with study models, a panoramic x-ray, and a full set of radiographs. Upon clinical examination, it was very evident that the patient had gross decay in his whole dentition as well as localized advanced periodontal disease in the posterior regions (Figure 1). Overall health of these teeth was severely compromised with poor prognosis (Figures 2 and 3). Upon examination of the radiographs, it was clearly obvious that he needed to have all his teeth extracted. Although he denied any drug use, the patient did admit to smoking 2 packs of cigarettes per day and drinking a 2 liter bottle of Mountain Dew soda every day. All risks, benefits, and alternatives were reviewed with the patient regarding his diagnosis and treatment plan.
To develop a treatment plan and to determine if the vertical dimension could be increased, a diagnostic wax-up was fabricated. Based on information gathered from the initial consult, it was determined that all his teeth (Nos. 1 to 16 and Nos. 17 to 32) should be removed, the maxillary and mandibular alveolar ridges leveled and then grafted with immediate placement of removable maxillary and mandibular dentures. It was also determined that aesthetics and function could be further enhanced later on (4 to 6 months) with the placement of dental implants once the grafted areas had healed. The final treatment plan would consist of fixed PFM bridges for each arch after proper healing as long as it fit the patient’s budget.
Advantages of full-mouth extractions in a single visit include: the number of appointments is reduced, local anesthesia has to be given in only one visit, and the patient doesn’t have to go through the procedure multiple numbers of times. A disadvantage of full-mouth extractions in a single visit is that the patient has to face the aesthetic and functional problems associated with a period of complete edentulism. However, considering the pain and infection this patient was suffering, it was most advantages to do full-mouth extractions in one seating.

Figure 7. Maxillary soft reline.	Figure 8. Mandibular soft reline.
Figure 9. Postoperative retracted view.	Figure 10. Healed maxillary arch.
Figure 11. Healed mandibular arch.	Figure 12. Retracted view of maxillary and mandibular dentures.

Extractions
If all the teeth have to be extracted in a single visit, then anesthesia is given in all regions of mouth, and the teeth are extracted in a particular order. Since the patient is sedated utilizing an intravenous infusion pump, it is necessary to keep the patient’s mouth open using a mouth prop. For this reason, I routinely extract teeth in quadrants starting from the upper left to the upper right and then down to the lower right and lower left. This way we can keep the patient’s mouth open while working in a consistent sequence, saving time.
One set of instruments that I have personally found that make my extractions more effective and efficient are the Physics Forceps (Golden Dental Solutions). The Physics Forceps act simply like a Class I lever, where only one force is applied with the beak on the lingual aspect of the tooth. Once the beak is placed, the bumper is placed on the alveolar ridge at the approximate location of the mucogingival junction to balance the beak. The beak grasps the tooth, while the bumper is the fulcrum to provide leverage and stability for the beak and wrist movement.
Once the instrument is properly placed, pressure is slowly applied using only wrist movement applying a steady and gentle pressure toward the buccal. Approximately within 30 to 60 seconds the internal force or “creep” will build up, allowing the bone to slowly expand and the periodontal ligament to release at which point the tooth will disengage from its socket (known as the “pop”) (Figure 4). Once the tooth has disengaged from the socket, the instrument has completed its task and another instrument of choice (eg, rongeurs) or your fingers can be utilized to remove the tooth. If the tooth is severely broken down (Figure 5), the tooth may be relieved with a bur on the lingual aspect, so that the beak of the Physics Forceps may engage a solid portion of the tooth.
Once the teeth in each quadrant were removed (Figure 6), any sharp areas of the alveolar crest were leveled and bone grafting material placed in the sockets to further enhance preservation of the ridge. The soft tissue was trimmed and sutured from quadrant to quadrant. Once all 4 quadrants were completed, the sutures were inspected to ensure there were no excessive sutures remaining to prevent them from being pulled during the soft reline procedure.

Relining Procedure
Routinely, I prefer to use a vinyl polysiloxane (VPS) soft reline material that that will not degrade in a short amount of time and that works well when relining immediately after extractions (such as Soft Reline [GC America]). Usually, I will start with the upper immediate denture and verify that there are no undercuts before applying the adhesive on the internal aspect of the denture. Once verified, I will place the adhesive, allow it to dry for a few minutes, and then fill the soft reline material in the internal aspect and borders of the immediate denture (Figure 7). The same process will be followed for the lower denture (Figure 8).

Postoperative Instructions
At this point the patient had already been in recovery, awake and alert when doing the reline procedure. He was instructed not to remove his denture for the first 24 hours and to return the following day for another check to make sure the fit, aesthetics, and phonetics were appropriate. Follow-up appointments were scheduled for one-, 3-, and 4-month recall visits. If a new reline was necessary at those appointments, the same protocol for a soft reline was followed.

Fabrication and Delivery of the Definitive Prostheses
Four months postoperatively the areas had healed very well (Figure 9). From the occlusal view, it was very evident that the patient had sufficient width for implant in the future in both maxillary and mandibular ridges (Figures 10 and 11). At this point, a Panorex x-ray was taken to visualize bone integration in the areas that had been grafted. Utilizing the immediate dentures as custom trays, impressions were taken using a medium body VPS impression material (Take One Advance [Kerr]). The laboratory was instructed on what the patient desired for tooth shade, shape, and contour. Within a week, the final dentures were completed and delivered (Figure 12). The patient was so pleased with the final outcome that he is currently saving up to have implants placed in both upper and lower arches with corresponding fixed bridges.

CONCLUSION
Within your practice, a time may come where you, the dental provider, will encounter a patient who might need full-mouth extraction due to severe decay or infection. Having the ability to perform full-mouth extractions in a fast, predictable, and atraumatic way for the patient and the dental team will help eliminate stress for everyone. Using a process that takes advantage of efficient Class I lever principles, as well as biochemical properties while conserving bone and soft tissue will ensure more efficiency and effectiveness. The techniques discussed in this article should allow the general dental practitioner the opportunity to offer more services under one roof.

Dr. Nazarian maintains a private practice in Troy, Mich, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists. His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on aesthetic materials and dental implants throughout the Untied States, Europe, New Zealand, and Australia. Dr. Nazarian is also the creator of the DemoDent patient education model system. He can be reached at (248) 457-0500 or at aranazariandds.com.

Disclosure: Dr. Nazarian reports no disclosures.

EXTRAORAL AND INTRAORAL EXAMINATIONS
The following is a concise overview of the components of the extraoral and intraoral examination. It stresses a systematic and consistent approach to these examinations. (The order of the examination steps as described herein, is the systematic sequencing that the author uses. The order of the examination steps may vary depending individual clinician-determined protocols.)

Systematic Extraoral Examination
A review and assessment of the systemic health and pharmacological status of the patient is always done prior to any dental examination. The extraoral examination continues with observation of the head and neck, as well as observation of the sound of the patient’s voice and eye movements commencing from when the patient is first seated in the treatment room (Figure 1). Hoarseness in the voice may warrant further investigation if it has been persistent, since this may be an indication/suspicion of a growth within the larynx/oropharynx. Abnormal breathing may be a sign of anxiety or fatigue. Pupil size may signify a reaction to drugs or state of emergency as well as an indication of a disease state or inflammatory presence. The appearance of the face is further evaluated noting any asymmetry, swelling or discoloration. Inspection of the skin includes the color, texture, the presence of eruptions or swellings, or any abnormal growth. Observe all areas of exposed skin, paying particular attention to areas behind the ears and the back of the head and neck. Most people will have freckles, birthmarks, or moles; irregularities or a change in the shape, edge, color, and/or size can be a warning sign of skin cancer thus warranting further investigation.
Have your patients remove their eyeglasses to make certain there are no hidden growths or developments that would have otherwise gone unnoticed. The areas along the hairline and under the eyeglasses will require tactile palpation in order to discern or identify any swellings/growths.

Figure 1. Initial observation of head and neck, speech, and eye movements.	Figure 2. Examination of the temporomandibular joint.
Figure 3. Bilateral palpation of parotid salivary glands.	Figure 4. Bilateral palpation of submental nodes.
Figure 5. Bilateral palpation of submandibular nodes.	Figure 6. Bilateral palpation of cervical lymph nodes.
Figure 7. Bilateral palpation of supraclavicular nodes.	Figure 8. Bilateral palpation of occipital nodes.
Figure 9. Bilateral palpation of postauricular nodes.	Figure 10. Bilateral palpation of preauricular nodes.

Next is the examination of the temporomandibular joint, utilizing a bilateral examination technique (Figure 2). This is accomplished by placing your finger pads over the joint just anterior to the ear; instructing the patient to open and close as well as move the jaw to the left and right; checking for any limitations or deviations upon opening, subluxation, any tenderness, sensitivity or any noises such as a grating, clicking, or popping.
The next area to be examined is the parotid salivary glands (Figure 3). The extraoral palpation of the parotid salivary glands is best examined using a bilateral technique, employing light pressure and placing fingers at the angles of the mandible over the parotid glands. Compare the bilateral findings for symmetry. Normal parotid glands are not palpable and exhibit no tenderness. Abnormal salivary glands may be painful, swollen, and indurated.
The lymph nodes are examined next with the clinician behind the patient and the patient’s chin slightly elevated. Areas of particular concern in a systematic examination can be found in the Table.
It is important to inform the patient as to the relevance of the examination of the lymphatics of the head and neck before commencing this portion of the extraoral examination. In addition, one should indicate what areas of the head and neck will be examined. Due to the diverse multiculturalism that exists within our patient population, we must be culturally aware and sensitive to the different possible comfort levels of our patients.
Evaluation of the lymph nodes is done by a gentle rolling motion of the fingers, using the bilateral palpation technique. Note any enlargement, tenderness, lack of mobility, hardness, or asymmetry. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes. Enlargement or lymphadenopathy may be attributed to either an infectious or inflammatory process or a malignant neoplasm. Clinical characteristics can help discern the difference.
In the broadest clinical terms, the enlarged node, if related to infection, is most often soft, freely movable, and painful. Also, the patient may have presented with an infection (or presence of inflammation) and may occasionally possess some knowledge of the etiology. Malignant neoplasm related nodes are normally fixed, particularly in the later stages, and they are generally not painful. One could compare the consistency of an infection related node to a blueberry or pea, whereas a malignant neoplasm related node is normally firmer in consistency, like a stone.
Next, submental and submandibular nodes should be examined carefully. With the patient’s head back slightly, first examine the submental nodes (Figure 4). Instruct the patient to bite together lightly and place the tongue into palatal vault. This results in a tensing of the mylohyoid muscle, allowing for easier palpation of submental glands. Moving posterior toward the angle of the mandible and palpating directly below the line of the mandible are the submandibular glands (Figure 5).
Another area to examine are the cervical nodes; both superficial and deep nodes. This set forms a complex chain of numerous nodes. Instruct the patient to turn the head in order to reposition the sternocleidomastoid muscle for ease of palpation and better access of both the superficial/deep cervical nodes (Figure 6).
The supraclavicular nodes are palpated next, found superior to the clavicle in the hollow area or supraclavicular fossa directly above the collarbone (Figure 7). They drain a part of the thoracic cavity and abdomen. Virchow’s node is a left supraclavicular node, which receives the lymph drainage from most of the body (especially above the abdomen) via the thoracic duct; this node may serve as an early site of metastasis for various malignancies.
The next nodes to be palpated are the occipital nodes (Figure 8). These are associated with the occipital artery at the posterior base of the skull. Using a bilateral technique, palpation is done directly below the base of the occipital bone. Reclining the patient’s head to the front, exposing the occipital area may facilitate better access for palpation of the occipital nodes.
The posterior auricular, or postauricular, nodes are next in the systematic order of lymph node palpation and are usually 2 in number (Figure 9). The anterior auricular or preauricular nodes are from one to 3 in number and lie immediately in front of the tragus (Figure 10). Both pre- and postauricular nodes’ efferent vessels drain into the superior deep cervical nodes.
The thyroid gland, normally not detected by palpation, is examined next.
An abnormal gland could be indurated, enlarged on one or both sides, or contain palpable nodes. When using bilateral palpation, palpation is done on both sides of the gland, noting any nodules or masses (Figure 11). Instruct your patient to swallow, which in turn will elevate the thyroid gland; allowing for an abnormality to become more apparent. Asymmetrical movement of the thyroid cartilage during swallowing might indicate that the gland is fixed to underlying tissues. If the patient is obese, it may be easier to palpate this area positioned behind the patient, having him or her turn the head toward the examining side. Suspicious thyroid gland findings should be referred to your patient’s physician for further evaluation.

Systematic Intraoral Examination
It is best to follow a systematic and consistent approach when performing the intraoral examination. The following is a suggested 7-step systematic approach:
Step 1: Inspect the lips with the patient’s mouth both closed and open. The lips should have a normal/well-defined vermilion border and be even in coloration. Use the method of bidigital palpation to note any swelling, indurations or observed texture or color change (Figure 12). Documentation when dryness and/or unclear demarcation of lip vermillion and skin exist should be noted as “lip at risk” to flag the area for subsequent examinations. Also examine for loss of vertical dimension manifested often on labial commissures with the outcome being angular cheilitis. Further investigation to determine the causative factor behind the loss of vertical dimension would be warranted. Reinforce the need for sunblock protection, especially related to those patients who are active outdoors and have prolonged exposure to sunlight. Sunblock protection for the lips has had a positive effect on reducing the number of cancers related to the lip.
Step 2: Inspect the labial mucosa using a visual and tactile method (Figure 13). This is accomplished with the patient’s mouth partially open, allowing examination of the labial mucosa and sulcus of the maxillary and mandibular vestibule and frenum.
Step 3: Inspect the buccal mucosa using visual inspection and tactile palpation (Figure 14). This is best accomplished by using a bidigital palpation technique with the thumb placed against the buccal mucosa simultaneously with external palpation, noting any change in pigmentation, texture or diminished mobility or other abnormalities of the mucosa. Inspect the parotid gland from the intraoral aspect at this time as well as palpating both the maxillary tuberosities and retromolar pads.
Step 4: Examine the gingival tissues. Observe attached and free gingiva on both arches, assessing for normal color and contour using digital palpation. Use a 2-x-2 gauze to dry the tissues to provide an enhanced assessment (Figure 15).
Step 5: Inspect all surfaces of the tongue. The tongue is a very high-risk area for oral cancer as well as for candida infections. Candida infections can be an indication of an underlying systemic disease. The tongue should be examined thoroughly using both visual and tactile methods. Visual inspection alone is inadequate in its ability to identify early changes to the mucosal surface of the tongue. It is best to follow a systematic approach when inspecting the tongue, commencing with examination of the dorsum, then lateral borders and concluding with the ventral surface.
The dorsum is the first area of the tongue to be examined. Ask the patient to protrude the tongue, moving from side to side, noting any abnormality of mobility or restriction of movement. With the patient’s tongue at rest, and mouth partially open, inspect and palpate the dorsum of the tongue to detect any swelling or fixed mass (Figure 16).
Following inspection of the dorsum, examine the lateral borders. A common site for oral cancer is on this lateral aspect of the tongue. With retraction of the cheek, inspect the left and right lateral margins of the tongue. Handling the tip of the tongue with a piece of gauze will assist full protrusion and will aid examination of the more posterior aspects of the tongue’s lateral borders, including the lingual tonsils (Figure 17). With the tongue fully protruded (held and manipulated forward and side by side by the clinician for optimal visual access), inspect the posterior aspect and base of tongue using digital palpation along the lateral borders to identify any changes in tissue texture or consistency, noting any swelling/induration. If detected, compare with the opposing lateral border. Be suspicious of an abnormality that is unilateral.
The last area of the tongue to be examined is the ventral surface. Instruct the patient to touch the roof of the mouth with the tip of the tongue (Figure 18). This will allow full inspection of the ventral surface of the tongue. Digitally palpate the ventral surface of the tongue to aid in any detection of growths, swelling or area of tenderness, as well as any color or texture changes. Observe for any asymmetry, comparing one side to the other.
Step 6: Examine the floor of the mouth carefully, keeping in mind that this is another highly vulnerable area that requires close and thorough inspection. Areas are easily hidden from visual inspection. With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings, or other surface abnormalities. Using bimanual palpation, compress the floor of mouth against the opposite hand (Figure 19). This is the only effective way to identify any area of firmness or mass as well as locating any feeling of tenderness.
Step 7: Inspection of the oropharynx and palatal tissues. Check the entire area of the oropharynx, examining the tonsil region including the uvula, tonsillar pillars, and palatine tonsils for presence, color, size, or any noted abnormalities. When examining the oropharynx, it is best to depress the tongue down toward the floor of the mouth using either a tongue blade or the back of the mouth mirror while instructing the patient to take a deep breath and hold or say “ah” (Figure 20). This method enables the clinician to gain better visual access of the oropharynx area. The soft palate should be visually examined next, accompanied by digital palpation of the hard palate, noting any asymmetries, swelling or mucosal changes.

ADJUNCTIVE SCREENING METHODS
The purpose of this article is to provide a pathway of decision making rather than an endorsement of a specific order of examination or the use of specific screening devices. There are a number of adjunctive screening technologies that are available and continue to emerge in the dental marketplace. It is vitally important to recognize that adjunctive screening technologies can provide valuable additional information (beyond the visual and tactile examination process) for further evaluation/assessment. A definitive diagnosis is obtained through a surgical biopsy to either rule out a malignancy or establish another diagnosis. This can sometimes be done in conjunction with other special testing methods.
When lesions are found that are highly suspect, the need for a referral becomes evident. Adjunctive screening devices can serve as a critical component in our decision making, particularly those that aid identification of an abnormal finding before it becomes visible under traditional white light examination.

Figure 11. Bilateral palpation of the thyroid gland.	Figure 12. Bidigital palpation of lips.
Figure 13. Palpation of the labial mucosa.	Figure 14. Examination of buccal mucosa.
Figure 15. Examination of the gingival tissues.	Figure 16. Palpation of dorsum of tongue.
Figure 17. Examination of lateral borders of tongue.	Figure 18. Palpation of the ventral surface of the tongue.
Figure 19. Bimanual palpation of floor of mouth.	Figure 20. Examination of oropharynx and palatal tissues.

Many epithelial lesions typically start below the surface of the tissue, at the basement membrane, and can remain occult until they reach the surface, making earlier discovery more challenging. There are a number of light-based detection systems used to enhance visualization techniques. One must be careful to not be pulled into the marketing rhetoric rather than evidence-based research and scientific data. The weakest science involves tissue reflectance.
A technique referred to as direct fluorescence visualization is supported by a strong body of scientific evidence related to its inherent ability to detect cancers and high-risk lesions including occult or nonapparent lesions or areas.⁴ This technique has a long history of use in other body sites such as the cervix, lungs, and colon.
Direct fluorescence visualization works on the premise of the ability of human tissue to fluoresce due to naturally occurring fluorophores in oral mucosa under excitation with a specific wavelength and intensity. By utilizing special optical filters, the clinician is able to immediately view different fluorescence patterns in the oral tissue to help differentiate between normal and abnormal cellular activity. When normal tissue is exposed to the blue excitation light, it will emit an apple-green glow. As dysplasia begins to develop, there is a breakdown in the stroma and specifically in the connective tissue or collagen cross-links coupled with a reduction in the naturally occurring fluorophores greatly diminishing the ability of the tissue to fluoresce. This allows for real-time feedback of an irregular dark area, presenting a stark contrast to the surrounding tissue that appears as an apple-green glow.
The advantages of the examination are its relative ease in implementation and patient comfort. The examination is noninvasive and does not involve any additional rinses or dyes. It also provides photo documentation for means of evaluation, referral and management.

Vital staining of a mucosal lesion using pharmaceutical grade 1% tolonium chloride or toluidine blue (referred to as TBlue) is an adjunctive aid as a tissue marker that has been utilized for more than 40 years. TBlue is applied to the tissue and then decolorized. The decolorization is done with reapplication of the acetic acid. The dye has an affinity for nuclear material with a high DNA or RNA content which supports its selective concentration in dysplastic or malignant cells within the oral epithelium.
The “brush test” (previously known as the oral brush biopsy) is part of the diagnostic process rather than the discovery process, as it further examines an already visible clinical finding. Further limitations of a brush test refer to the fact that only individual cells are examined, thus eliminating the opportunity to evaluate in their proper tissue relationships. A positive result must be followed with a full-thickness biopsy (can be either incisional or excisional) in order to further determine the extent and nature of the disease process.
Our task is simply to discover, not diagnose, an abnormal clinical finding. There are several data points to consider which are enhanced by the use of adjunctive screening devices such as:

• Has the tissue become friable, exophytic, indurated, etc?
• Does the tissue manifest a loss of autofluorescence?
• Is the tissue picking up tolonium chloride?
• Has the lesion existed for more than 14 days?
• Is there an absence of an identified etiology?

WHAT DOES THE FUTURE HOLD?
A closer look at molecular biology, specifically genomics and proteomics through examination of the saliva may be the breakthrough to deriving rich genetic information. In a major step towards earlier diagnosis of oral cancer, Wong⁵ (University of California’s Los Angeles School of Dentistry) has identified 5 biomarkers for the disease utilizing salivary diagnostics.⁵ The possibility of a simple saliva test for oral cancer has moved one step closer to reality. Determining genetic predisposition and examination of direct behavior of cellular activity will add a new dimension to screening. This will enable more people to be moved toward accelerated monitoring by means of sifting through huge populations, resulting in a revolutionary change in disease management.

CONCLUSION
Consider the quote by Charles Darwin, who was the first of evolutionary biologists and certainly no stranger to change, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” We have, as a professional community, every opportunity to write our own success stories related to opportunistic screening and to be a catalyst for change. As a wise family friend once wrote in my autograph book in my teenage years, “Your life is like a path of snow; walk carefully for every step will show.” The power is within your own hands to impact this insidious disease and change the face of oral cancer. It is your practice, your legacy, and your responsibility.

Acknowledgement
All photographs and accompanying video appear with permission from the Canadian Dental Hygienists’ Association. Additional practice resources to support the endeavors of the professional community to elevate oral cancer awareness are available through the Web site cdha.ca and the online course, “Oral Cancer Awareness—4 Life Saving Minutes: The Extraoral and Intraoral Examination.” The author also wishes to acknowledge Brian Hill, the founder of the Oral Cancer Foundation (oralcancerfoundation.org) for his insight and direction in development of this article.

References

1. Horowitz AM, Drury TF, Goodman HS, et al. Oral pharyngeal cancer prevention and early detection. Dentists’ opinions and practices. J Am Dent Assoc. 2000;131:453-462.
2. Hein C, Kunselman B, Frese P. Preliminary findings of consumer-patient’s perceptions of dental hygienists’ scope of practice/qualifications and the level of care being rendered. American Dental Hygienists’ Association Annual Session, Orlando Fla, June 21 to 28, 2006.
3. Bregman JA. Early oral cancer detection: Why you? Why now? oralcancernews.org/wp/early-oral-cancer-detection-why-you-why-now. Accessed on: February 19, 2010.
4. Poh CF, Zhang L, Anderson DW, et al. Fluorescence visualization detection of field alterations in tumor margins of oral cancer patients. Clin Cancer Res. 2006;12:6716-6722.
5. Wong DT. Salivary diagnostics powered by nanotechnologies, proteomics and genomics. J Am Dent Assoc. 2006;137:313-321.

Ms. Jones is an international speaker for the profession of dental hygiene and the owner of RDH CONNECTION, a consulting and training company dedicated to excellence in quality dental hygiene education. Having a career that has spanned over 3 decades, Ms. Jones’ experience has encompassed clinical practice, education, international lecturing, and is published internationally. She has been appointed to serve on the advisory board for Dentistry Today and is one of Dentistry Today’s 2011 Leaders in Dental Consulting. She can be reached via e-mail at jjones@rdhconnection.com or at the Web site rdhconnection.com.

Disclosure: Ms. Jones reports no disclosures.

The term MIND stands for the 4 major divisions of the classification system: Metabolic (systemic diseases)(eg, hypophosphatasia, hyperparathyroidism, etc), Inflammatory (eg, periodontal inflammation, osteomyelitis, etc), Neoplasia (eg, osteoblastoma, ossifying fibroma, etc) and Developmental (eg, stafne defect, cherubism, etc). All the categories have been further divided into subcategories (Table 1). An idiopathic category has also been added to include the lesions with unknown etiologies.

METABOLIC

The metabolic category can be subcategorized into nutritional and hormonal and further divided into those diseases that are of genetic or acquired origin. The acquired defects associated with osseous metabolism can be seen in the general skeleton as well as the jaws and these would include vitamin C, D and Ca/P metabolism, associated with deficiencies in intake. Other pathologic conditions affecting metabolism may be of genetic type (eg vitamin D resistant rickets, hypophosphatasia and osteogenesis imperfecta).

INFLAMMATORY

Inflammation is the complex biological response of tissues to harmful stimuli such as trauma and irritants. It is a protective attempt by the body to remove the injurious stimuli, as well as initiate the healing proces. The classic signs of inflammation are redness, pain, swelling, heat and loss of function.

Inflammatory lesions are divided into four subcategories: Lesions caused by extrinsic factors (physical agents), reactive lesions, infections and the lesions of immunologic origin. External factors like radiation and chemical agents can lead to inflammatory lesions such as osteoradionecrosis and osteochemonecrosis (localized death of the osseous tissue). The reactive subcategory includes lesions occurring in response to chronic irritation. The intraosseous reactive lesions like central giant cell granuloma and the aneurysmal bone cyst are occasionally seen in the jaws. The third subcategory includes the intraosseous lesions caused by the infections in the oral cavity. Bacterial infections in the oral cavity are mostly seen in the alveolar bone, leading to periodontitis and pulpal necrosis, which can lead to periapical inflammatory lesions. Rarefying osteitis or a periapical radiolucency is the collective term used for any periapical lesion of inflammatory origin, which includes a cyst, granuloma or an abscess.5The last subcategory in the inflammatory division is the immunologic type. This includes lesions such as rheumatoid arthritis, which may be presented as a chronic disorder of the temporomandibular joint disorder.

NEOPLASIA

The term neoplasia refers to a uncontrolled growth of tissue, that results from an abnormal proliferation of cells. The neoplastic lesions are broadly divided into two major categories on the basis of their ability to metastasize—benign and malignant.

Benign neoplasms are dysmorphic proliferations of tissues that are characterized by the lack of metastasis. These have been further subcategorized as odontogenic and nonodontogenic on the basis of the tissue of origin. The odontogenic neoplasms include the lesions derived from parts of the odontogenic apparatus (eg, ameloblastoma, ameloblastic fibroma, adenomatoid odontogenic tumor, and odontoma). The nonodontogenic neoplasms include the lesions of the osseous tissue that are unrelated to the tooth development but originate from osseous tissue (eg, osteoblastoma, desmoplastic fibroma of the bone, and ossifying fibroma).

Malignant neoplasms can be subcategorized on the basis of tissue of origin into sarcomas and carcinomas. Sarcomas include the malignancies of mesenchymal origin (eg, Ewing’s sarcoma, osteosarcoma, chondrosarcoma and multiple myeloma). Carcinomas include the malignancies of epithelial origin.The odontogenic carcinomas result from the malignant alteration of the residuals of the odontogenic apparatus [eg, reduced enamel epithelium and dental lamina rests (Serres)].
 
DEVELOPMENTAL

The developmental category includes pathologic changes in bone that develop both as a genetic or acquired defect. However, in many of these lesions the exact etiologic factors have not been yet determined. The genetic determinants of some of these developmental conditions have been identified and this list is growing steadily. Many of the acquired conditions have been linked to both osteogenesis and facial development (eg, nasopalatine cyst) and also to odontogenesis (eg, follicular cysts, dentigerous cysts). Other developmental conditions include lesions such as the Stafne defect or an arteriovenous malformation.

IDIOPATHIC

Unfortunately there are large numbers of jaw lesions for which the etiology is unknown at this time (eg, fibrous dysplasia, idiopathic bone cavity or traumatic bone cyst, focal osteosclerosis, etc). They cannot be clearly categorized in any one category presently. An idiopathic category has thus been added to include all such lesions with unknown etiology.

HISTORY TAKING

An important part of the diagnostic process is the history taking of a lesion, including both the dental and medical history. A few examples of the major questions that need to be asked in order to reach a definitive diagnosis have been listed below (Table 2). The answers to these questions will be able to provide the clinician with a better understanding of the lesion and help in deciding on the etiopathogenesis.

The first question to be posed to the patient is “How long has this problem been present?” A short history of the disease will hint at inflammatory or malignant causes, whereas, a history of the lesion being present since birth or of long duration would increase the possibility of a developmental disorder.

The next question is “Does it hurt? Choose one word to describe the pain.” Since pain is one of the first symptoms to be noted by the patient, it can be expressed by the patient more elaborately. The presence of pain, its intensity and duration helps differentiate between the possible diagnoses. The presence of pain will attest for inflammation, as pain is one of its five classic symptoms. The description of pain in terms of its intensity and duration helps narrow the list of the causative factors and can be helpful, especially with odontogenic infection (pulpal). Other more ominous symptoms (e.g. paresthesis) may indicate a neoplastic condition.

“Have you noticed any swelling? If yes, how long did it persist and has it increased in size over time?” A swelling in the jaws could be an indication of a neoplastic growth in the bones (eg, ameloblastoma, ossifying fibroma, etc) or may be a deformity of the bone due to trauma or a developmental disorder (eg, cherubism, dentigerous cyst, etc). An inflammatory lesion caused by bacterial infection may also present as a swelling, usually of a short duration.

An important question to ask would be “Do you remember injuring the area of the lesion?” Fracture is a common result of trauma to jaw bones. This can also lead to a nonvital tooth and subsequent periapical pathosis of pulpal origin. These periapical lesions usually heal completely, if the source of irritation is removed (eg, endodontics).

“Do other people in your family have anything similar?” A condition that tends to occur more often in family members increases the probability of it being genetically inherited. This type of lesion may be placed in the genetic division of the developmental category (eg, Cherubism).

The clinician must ask the patient “How is your general health? Other than the oral problem, do you feel medically well?” If the patient presents with good general health, that would lessen the possibility of a metabolic or systemic disease. The presence of other systemic signs or symptoms such as fever, pain in different parts of the body, bone fractures, etc. may indicate undetected systemic diseases.

“Are you taking any medications currently? Were you taking medication recently?” The answer to this question verifies the previous question. If the patient has been taking medication for a long time, the definition of good health would be different for the patient. The stability of the condition for that person would be equivalent to good general health. But the lesion could be a secondary reaction to the primary disease induced by the medication (bisphosphonate associated osteonecrosis).

CONCLUSION

The MIND acronym is hopefully a useful tool that clinicians may utilize in helping to form a differential diagnosis, along with a careful history and physical examination. Various imaging modalities are extremely useful as well as the histopathologic evaluation of the jaw lesions, to allow a correct and definitive diagnosis. Of course, this will allow for a plan that ensures correct treatment.

References

1. Carpenter WM, Jacobsen PL, Eversole LR. Two approaches to the diagnosis of lesions of the oral mucosa. CDA Journal. 1992;27:619-624.
2. Jacobsen PL, Carpenter WM.  MIND: A method of diagnosing oral pathology. Dentistry Today. 2000;19: 58-61.
3. Bhaskar SN. Roentgenographic interpretation for the dentist. St Louis, Mo: Mosby Inc; 1970.
4. White SC, Pharoah MJ. Oral radiology-principles and interpretation 6th ed. St. Louis, Mo: Mosby/Elsevier; 2009.
5. Sapp JP, Eversole LR, Wysocki GP. Contemporary Oral and Maxillofacial Pathology 2nd edition. St. Louis, Mo: Mosby-Year Book Inc; 2004.   

Dr. Carpenter earned a DDS from the University of Pittsburgh and a MS in oral biology from George Washington University. He retired as a colonel after a 21-year career with the US Army Dental Corps where he was Chief of the Divisions of Pathology and Professional Development at the US Army Institute of Dental Research at the Walter Reed Army Medical Center. Dr. Carpenter currently is Professor and Chairman, department of Pathology/Medicine, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, Calif. He is a member of many professional societies, including the American Academy of Oral Medicine (past president) and the American Academy of Oral Pathology, both of which he holds Fellowship and Diplomatic Status. He can be reached at wcarpent@pacific.edu.

Dr. Sidhu is a Diplomate American Board of Oral and Maxillofacial Radiology and is the director of Radiology and a clinical assistant professor in the department of Dental Practice at University of the Pacific, San Francisco, Calif. She conducts private practice in maxillofacial radiology at Pacific Dental Diagnostics. Dr. Sidhu received her DDS degree from the University of the Pacific Arthur A. Dugoni School of Dentistry. She also holds a Masters in Science degree in Oral and Maxillofacial Radiology from the University of Iowa College Of Dentistry. She has published articles and lectured to various dental organizations. She can be reached at g_sidhu@pacific.edu.

Dr. Kaur received her BDS from Dashmesh Institute of Research and Dental Sciences, India. She is currently a research assistant and an adjunct faculty with the Department of Dental Practice at the Radiology clinic at University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, Calif. She is also a member of the Indian Dental Association. She can be reached at skmann@gmail.com.