EDITORIAL

Progress in Dentistry
Remarkable paradox. Remarkable challenge.

DENTAL TECHNOLOGY continues to evolve at an unprecedented rate. A cursory perusal of the content of local, state, national and international continuing education programs attests to our perception that there has been a notable surge in relevant scientific advancements in dentistry over the past few years. At the same time, the dental clinicians strong interest in these advances is undeniable. Our ability to replace teeth (implants) as well as our capability, in many instances, to improve the specific biologic environment where these implants will, it is hoped, thrive and remain (site development) could not have been imagined 25 years ago. The link between oral health and systemic disease states has become more clearly defined. Similarly, stem cell research utilizing undifferentiated cells from human tooth pulp tissue holds the promise of dramatically improving future dental and medical care. Additionally, we have identified the etiology of dental caries and its transmissibility mechanisms. And we have developed specific protocols that have shown to be incontrovertibly effective in preventing this disease. The problem of limited access to oral health care has received considerable attention in the past few years. There is growing concern that our modern dental technology and exquisite academic and clinical training programs are not benefiting large segments of the public. There appear to be reversals in oral health status nationally and abroad. Identifying the constellation of complex factors that might be contributing to limiting access will be a fundamental step in removing current obstacles to oral health care for all. Some
4 NYSDJ MARCH 2008

of these areas might include creating incentives for recent dental school graduates to relocate either temporarily or permanently to underserved areas. Incentives should include some form of loan forgiveness or monetary consideration in light of the tremendous personal debt that dental school graduates typically have. Naturally, such an incentive must also include removing any existing barriers to the freedom of professional movement within the U.S. Who will be leading this effort to bring the benefits of modern dentistry to a larger segment of our population? It will be the tripartite dental organization, led by the American Dental Association. It will be the ADA who will visibly and genuinely remain proactive in oral health care access issues as a major stakeholder and who will not remain on the side lines and, perhaps, on the coat tails of other heath professions. The ADA will be challenged to find creative paths to consequentially partner with academic and research institutions, the dental manufacturing industry, government, the public and individual dentists, all in an effort to resolve the pressing problem of oral health care access, while, at the same time, protecting the sanctity of the dentist/patient relationship. These are exciting and challenging times for the dental profession and individual dentists. Only through our powerful collective voice, the American Dental Association, can we hope to achieve our enlightened goals. D.D.S. M.Sd

NYSDA
D i r e c t o r y

Letters
Address Correction Dr. Howell Archard was kind enough to forward me a copy of the article Congenital Diseases and a New York State Regulation that appeared in the June/July NYSDJ, as well as his letter in response to the article, which was printed in the November Journal. In his letter, Dr. Archard says X-Linked Hypophosphatemic Rickets (sometimes still known as Vitamin D Resistant Rickets) should be included in the list of congenital diseases that affect the teeth as well as the bones. Dr. Archard mentioned our organization, but there was an error in the Web site address. Please let people know that the correct Web address for The XLH Network is www.xlhnetwork.org. We also have a listserv open to people affected by the condition, as well as to physicians and researchers interested in the condition. The listserve is FHYPDRR. Somehow, the two addresses became intertwined. We greatly appreciate your help in getting the information out that at least in New York State, medical insurance is responsible for dental treatment that becomes necessary for congenital diseases such as XLH. Joan Reed, President XLH Network 4562 Stoneledge Lane, Manlius, NY 13104

OFFICERS
Stephen B. Gold, President Steven Gounardes, Immediate Past President 8 Medical Drive, Port Jefferson Station, NY 11776 351 87th St., Brooklyn, NY 11209 Michael R. Breault, President Elect 1368 Union St., Schenectady, NY 12308 Robert Doherty, Vice President 280 Mamaroneck Ave., White Plains, NY 10605 Richard Andolina, Secretary-Treasurer 74 Main St., Hornell, NY 14843 William R. Calnon, ADA Trustee 3220 Chili Ave., Rochester, NY 14624 Roy E. Lasky, Executive Director 20 Corporate Woods Boulevard, Albany, NY 12211

BOARD OF GOVERNORS
NY County-Lawrence Bailey 215 W. 125th St., New York, NY 10027 NY County-Matthew J. Neary 501 Madison Ave., Fl. 22, New York, NY 10022 NY County- Robert B. Raiber 630 Fifth Ave., #1869, New York, NY 10111 2-Craig S. Ratner 7030 Hylan Blvd., Staten Island, NY 10307 2-James J. Sconzo 1666 Marine Parkway, Brooklyn, NY 11234 3-Lawrence J. Busino 2 Executive Park Dr., Albany, NY 12203 3-John P. Essepian 180 Old Loudon Rd., Latham,NY 12110 4-Mark A. Bauman 157 Lake Ave., Saratoga Springs, NY 12866 4-James E. Galati Parkwood Plaza, 1758 Rte. 9, Clifton Park, NY 12065 5-William H. Karp 472 S. Salina St., #222, Syracuse, NY13202 5-John J. Liang 2813 Genessee St., Utica, NY 13501 6-Robert G. Baker Jr. 803-805 Cascadilla St., Ithaca, NY 14850 6-Scott Farrell 39 Leroy St., Binghamton, NY 13905 7-Robert J. Buhite II 1295 Portland Ave., Rochester, NY 14621 7-Andrew G. Vorrasi 2005-A Lyell Ave., Rochester, NY 14606 8- Jeffrey A. Baumler 2145 Lancelot Dr., Niagara Falls, NY 14304 8- Kevin J. Hanley 959 Kenmore Ave., Buffalo, NY 14223-3160 9-Edward Feinberg 14 Harwood Ct., Ste. 322, Scarsdale, NY 10583 9-Malcolm S. Graham 170 Maple Ave., White Plains, NY 10601 9- Neil R. Riesner 111 Brook St., 3rd Floor, Scarsdale, NY 10583-5149 N- Peter M. Blauzvern 366 N. Broadway, Jericho, NY 11753-2032 N-David J. Miller 467 Newbridge Rd., E. Meadow, NY 11554 N-Frank J. Palmaccio 2 Bayard Drive, Dix Hills, NY 11746 Q-Chad P. Gehani 35-49 82nd St., Jackson Heights, NY 11372 Q-Robert L. Shpuntoff 28 Beverly Rd., Great Neck, NY 11021 S-Paul R. Leary 80 Maple Ave., #206, Smithtown, NY 11787 S-Steven I. Snyder Suffolk Oral Surgery, 264 Union Ave., Holbrook, NY 11741 B-Stephen B. Harrison 1668 Williamsbridge Rd., Bronx, NY 10461 B-Richard P. Herman 20 Squadron Blvd., New City, NY 10956

You Are Invited

Governmental Affairs Alan L. Mazer P.O. Box 985, 140 Terryville Rd. Pt. Jefferson Station, NY 11776 Insurance Roland C. Emmanuele 4 Hinchcliffe Dr. Newburgh, NY 12550 Membership & Communications Lidia Epel 165 N. Village Ave. #102 Rockville Center, NY 11570 New Dentist David C. Bray 18 Leroy St., Binghamton, NY 13905 Nominations Steven Gounardes 351 87th St., Brooklyn, NY 11209 Peer Review & Quality Assurance Steven Damelio 1794 Penfield Rd. Penfield, NY 14526 Relief Anthony V. Maresca 207 Hallock Rd. Stony Brook, NY 11790 NYSDJ OFFICE Suite 602 20 Corporate Woods Blvd. Albany, NY 12211 (518) 465-0044 (800) 255-2100 Roy E. Lasky Executive Director Carla Hogan General Counsel Beth M. Wanek Associate Executive Director Michael J. Herrmann Assistant Executive Director Finance-Administration Judith L. Shub Assistant Executive Director Health Affairs Sandra DiNoto Director Public Relations Mary Grates Stoll Managing Editor MARCH 2008 5 NYSDJ MARCH 2008 5

COUNCIL CHAIRPERSONS
Annual Meetings Alan L. Mazer P.O. Box 985, 140 Terryville Rd. Pt. Jefferson Station, NY 11776 Awards William R. Calnon 3220 Chili Ave., Rochester, NY 14624 Chemical Dependency Robert J. Herzog 16 Parker Ave., Buffalo, NY 14214 Dental Benefit Programs Ian M. Lerner One Hanson Pl., #2900 Brooklyn, NY 11243-2907 Dental Health Planning/ Hospital Dentistry Robert A. Seminara 281 Benedict Rd., Staten Island, NY 10304 Dental Practice Steven L. Essig 33 Main St., Ravena, NY 12143 Dental Education & Licensure Madeline S. Ginzburg 2600 Netherland Ave., #117 Riverdale, NY 10463 Ethics Kevin A. Henner 163 Half Hollow Rd., #1, Deer Park, NY 11729

NYSDA PRESIDENTS DINNER DANCE HONORING PRESIDENT STEPHEN B. GOLD & THE OFFICERS OF THE ASSOCIATION FOR 2008
SATURDAY, JUNE 7, 2008 Cocktails & Hors dOeuvres 7:30 - 8:30 p.m. DINNER 8:30 P.M. Lombardis on the Sound at the Port Jefferson Country Club at Harbor Hills 44 Fairway Drive Port Jefferson, New York ATTIRE: BLACK TIE $95 PER PERSON RSVP: Beth Wanek, NYSDA

NYSDA Chooses Seaside Resort as Setting

FOR SEMI-ANNUAL MEETING
PRIOR TO 1836, Port Jefferson was known as Drowned Meadow, because of the flooding that took place at every high tide in what is today the villages business district. Town fathers realized that an allusion to death by water was probably not desirable for a community of shipbuilders, and, so, the name of the settlement was changed to Port Jefferson. The new name came easy. It was, after all, a harbor village, and President Thomas Jefferson was reputed to be the major source of funding for a project to prevent the flooding. When NYSDA gathers in Port Jefferson, on the north shore of Long Island, in June for the Semi-Annual Meeting of its Board of Governors, theyll find few remnants from the Drowned Meadow days, but plenty of reminders, nonetheless, that this is a village with close ties to the sea and a storied maritime past. This years meeting will take place June 5-8 at the Port Jefferson Village Center and nearby Danfords on the Sound. The meeting is being hosted by the Suffolk County Dental Society, whose past president,Stephen B.Gold,will be formally installed as NYSDA President at a dinner dance on Saturday, June 7. Standing up with Dr. Gold will be his fellow officers: President Elect Michael R. Breault; Vice President Robert J. Doherty; Secretary-Treasurer Richard F.Andolina; and Immediate Past President Steven Gounardes. The small town of Port Jefferson, for all its colorful history, is a deceptively cosmopolitan community. Located just 56 miles east of New York City, it boasts several unique restaurants and shops and a growing tourism industry, developed around the towns many natural attractions, museums and historic sites, and special events.
10 NYSDJ MARCH 2008

Danfords, which opened in 1986 as an inn, conference center marina, restaurant and catering facility, is itself a tourist attraction. The site is located along the nationally recognized North Shore Heritage Trail and was previously occupied by a painters studio, blacksmith shop, boxing emporium, social club and ice cream parlor. The Board of Governors will hold its opening session from 3 to 6 p.m., Thursday, June 5. It will continue deliberations on Saturday during an all-day session that will begin at 9 a.m. The annual luncheon of the New York State chapter of the Pierre Fauchard Academy is also scheduled for Saturday. Arrangements for the meeting are being coordinated by this years Annual Meeting Chair Alan L. Mazer. Requests for information should be made to NYSDA Associate Executive Director Beth Wanek at (800) 255-2100 or bwanek@nysdental.org.

Getting to Know Port Jefferson

Weekend on Long Island Filled with Local Attractions CHAMPAGNE, CHOCOLATE & JEWELRY (Thursday June 5): Ecolin Jewelers, a family-owned jewelry store located across the street from Danfords, is opening its doors especially for NYSDA so that meeting-goers can browse their collection of fine jewelry. While there, enjoy a glass of champagne and a 10% discount off any purchases made between 4 and 6 p.m. Ecolin represents many renowned designers, among them, Lagos, Carrera y Carrera and Tacori.Your Host: Ruth Gold. There is no fee for this event.

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

LOBSTER BAKE (Thursday June 5): The first social gathering of the meeting takes place at the Three Village Inn. A short ride from the site of the meeting, the Three Village Inn is a charming country get-away, the crown jewel of historic Stony Brook and site of one of Long Islands great restaurants. The night begins with cocktails and hors doeuvres at 7 p.m., followed by an authentic Long Island lobster bake. Price includes transportation from Danfords, open bar and music. Fee: $65 per person. GOLF TOURNAMENT (Friday June 6): Suffolk County Dental Society has invited NYSDA guests to play in its annual tournament at Great Rock Golf Club in Wading River. Great Rock is the newest semi-private club on Long Island. Golfers of all abilities will enjoy this par-71 course, laid out on 136 acres of mature woodlands, overlooking sprawling vistas. This is a shot-gun, scramble tournament. It will begin at 8 a.m. Transportation will be provided for hotel guests and will depart at 6:30 a.m. Entry fee includes greens fees, cart, Continental breakfast, lunch and prizes. Tournament Chairman: Dr. Anthony Maresca. Fee: $195 per person. LONG ISLAND SOUND FISHING (Friday June 6): Spend the morning with Capt. Desmond OSullivan and his crew aboard the Celtic Quest, a pristine and comfortable 60-foot party fishing boat. Set sail at 7 a.m. from the town dock, just a short walk from Danfords. You will return at approximately 1:30 p.m. If youre already an accomplished fisherperson, this is a chance to sharpen your skills. If youre more accustomed to getting your fish from a market, youre still welcome to join the party and learn techniques, tactics and what gear to use to catch the big fish. Who knows? You may get lucky. No prior fishing or boating experience is necessary. Bring a jacket or sweatshirt and a pair of old sneakers. Price includes rods, bait and tackle, gratuity, boxed lunch and beverages. Your Host: Dr. Alan Mazer. Fee: $60 per person. WINERY TOUR (Friday June 6): Take a scenic ride to the North Fork of Long Island to visit two of the Islands premiere wineries.Your first stop will be Paumanok Vineyards, a family-owned, 77-acre estate. Its winery is housed in a renovated turn-of-the-century barn, surrounded by an inviting deck that overlooks the vineyards. Lunch follows at the Jamesport Manor Inn, a beautiful reproduction of a 19thcentury Victorian house, which specializes in new American cuisine, with Mediterranean and Asian accents. Last stop is a wine tasting at Martha Clara Vineyards, owned and operated by the Entenmann family, also known for the baked goods it produces. This is a firstclass winery, noted for the knowledge, skill and experience that go into the wine it produces. The bus will depart Danfords at 9:30 a.m. and will return at approximately 3:15 p.m.Your Hosts: Dr.Kerry Lane and Dr. Thomas Bonomo. Fee: $50 per person. COCKTAIL & DESSERT RECEPTION (Friday June 6): NYSDA will not be hosting a dinner function on Friday evening. This will give you a chance to enjoy any of the excellent restaurants located in

Port Jefferson. To get you started on your evening, Suffolk County Dental Society is sponsoring a cocktail reception from 6 to 7 p.m. at Danfords. And save room for dessert. When you get back from dinner, you are invited to a dessert reception at Danfords. Coffee, sweets and cordials will be served from 9:30 to 11 p.m., courtesy of MLMIC, which is underwriting the cost of this event. There is no fee for this event. STONY BROOK MUSEUM TOUR/SHOPPING (Saturday, June 7): The Long Island Museum of American Art, History and Carriages is a showcase for artifacts depicting everyday life in early America, works of art and nearly 200 historic carriages. Its Long Islands largest privately supported museum and is accredited by the American Association of Museums for excellence in exhibitions and programs. The museums permanent collection numbers over 40,000 items, dating from the late 18th century to the present.Your outing will continue with lunch at Pasta Pasta. If after lunch, youre still not ready to return to the hotel, you will have time to tour the quaint village of Port Jefferson, stopping at its many and diverse shops and boutiques. Visitors guides and maps will be provided. Its just a short walk from the village of Port Jefferson to Danfords. Your Hosts: Lois Mazer, Dr. Robert & Doreen Benton. Suffolk Oral Surgery Associates, LLP (Drs. Steven Snyder, Guenter Jonke, John Guariglia, Sachin Jamdar and Christopher First) are underwriting the cost of this event. Fee: $35 per person. NATURE TRAIL HIKING/PONTOON BOATING (Saturday, June 7): The Ward Melville Heritage Organization, a not-for-profit corporation was founded to preserve and protect historical and sensitive environmental properties in Stony Brook. On this trip, you will spend approximately one hour hiking the trails of the preserve, then board the 35-passenger vessel, the Discovery, for a one and one-half hour tour of the organizations 88-acre wetlands. A naturalist from the Stony Brook University Marine Sciences Center will be on board to describe the wildlife and flora. Bus departs Danfords at 12:45 p.m. and will return at approximately 5:15 p.m. Wear sneakers or hiking shoes. Your Host: Dr. John Primavera. Fee: $23/Adults; $18/Seniors; $10/Children under 6. PRESIDENTS DINNER DANCE (Saturday June 7): Join your friends and colleagues at NYSDAs Annual Dinner Dance as they honor the Associations 2008 President, Stephen B. Gold, his wife, Ruth, and the other officers of NYSDA. This gala event will be held at Lombardis on the Sound at the Port Jefferson Country Club. The evening begins with cocktails and hors doeuvres at 7:30 p.m. Dinner and dancing will follow. Black tie attire. Transportation will be provided for hotel guests. Fee: $95 per person. FAREWELL BREAKFAST (Sunday, June 8): Dr. Barry Rifkin and the office of the dean of Stony Brook University have invited everyone to join them for breakfast at Danfords prior to their departure. A hearty buffet will be available from 7 to 10 a.m.
NYSDJ MARCH 2008 11

NEW YORK STATE DENTAL ASSOCIATION

2008 SEMI-ANNUAL MEETING
Port Jefferson Village Center Dansfords on the Sound Port Jefferson, New York June 5 - 8, 2008

THURSDAY, JUNE 5 10 am - 5 pm 12:30 - 3 pm 3 - 6 PM 4 - 6 PM 7 pm Registration Hotel Lobby (Danfords) NYSDA Support Services Boardroom 4 (Danfords) Board of Governors Port Jefferson Village Center Champagne, Chocolate, Jewelry Reception Ecolin Jewelers Lobster Bake Three Village Inn Bus Transportation Provided

FRIDAY, JUNE 6 7 am Fishing Trip depart from Town Dock return approx 1:30 pm boxed lunch/beverages Annual Golf Tournament w/Suffolk County Dental Society Great Rock Golf Course in Wading River Registration Hotel Lobby (Danfords) Winery Tour & Lunch Cocktail Reception Brookhaven Ballroom (Danfords) Dessert Reception Brookhaven Ballroom (Danfords)

8 am 9 am - 3 pm 9:30 am 6 - 7 pm 9:30 - 11pm SATURDAY, JUNE 7 8 am - 3 pm 9 am - 5 pm 9:30 am

12:45 pm Noon - 1:30 pm 7:30 pm - 12:30 pm

Registration Hotel Lobby (Danfords) Board of Governors Port Jefferson Village Center Museum Tour Stony Brook Museum Lunch Shopping in Port Jefferson Departure for Nature Trail Hiking/Pontoon Boating Returning at 5:15 p.m. Pierre Fauchard Academy Luncheon Brookhaven Ballroom (Danfords) Presidents Dinner Dance Lombardis on the Sound at Port Jefferson Country Club Cocktail Reception 7:30 - 8:30 pm Dinner/Dancing 8:30 pm - Midnight Transportation Provided Black Tie

SUNDAY, JUNE 8 8 - 10 am Farewell Breakfast Danfords Inn Check-in time 4 p.m. Check-out time 11 a.m.

12 NYSDJ MARCH 2008

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

# OF TICKETS THURSDAY JUNE 5

TOTAL COST

CHAMPAGNE RECEPTION No Charge LOBSTER BAKE $65 Per Person

FRIDAY JUNE 6

GOLF (complete separate registration) $195 Per Person FISHING $60 Per Person WINERY TOUR $50 Per Person COCKTAIL RECEPTION No Charge DESSERT RECEPTION No Charge
SATURDAY JUNE 7

STONY BROOK MUSEUM/SHOPPING $35 Per Person NATURE TRAIL HIKE/PONTOON BOATING $23 Adults / $18 Seniors / $10 Child Under 6 PRESIDENTS DINNER DANCE $95 Per Person
SUNDAY JUNE 8

FAREWELL BREAKFAST No Charge

TOTAL $

NYSDJ MARCH 2008 13

Craig Ratner, third from left, receives congratulations on winning Tillis Award for excellence in dental writing. Well-wishers are, from left, NYSDJ Editor Elliott Moskowitz; Deborah Pasquale, NYSDA Council Membership & Communications; Steven Gounardes, 2007 NYSDA President.

Council Selects Craig Ratner to Receive Tillis Award

ROBERT KELSCH GETS HONORABLE MENTION
CRAIG S. RATNER, president of the Second District Dental Society, is winner of the 2007 Bernard P. Tillis Award for excellence in dental writing. Dr. Ratner was selected to receive the award, presented by the NYSDA Council on Membership and Communications, for his editorial A Troubling Trip to the Local Elementary School in the June/July 2007 SDDS Bulletin. Dr. Ratner is co-editor of the Bulletin. He received an inscribed plaque. The Council on Membership and Communications also selected Nassau County Editor Robert D. Kelsch, D.M.D., for an Honorable Mention citation for his untitled editorial about globalization in the November/December 2006 Bulletin of NCDS. Dr. Kelsch is a 1992 graduate of the University of Connecticut School of Dental Medicine. He is an oral pathologist in Rockville Center. The Tillis Award was established in 1996 to honor the memory of the longtime New York State Dental Journal editor. It recognizes members of the Dental Association who, through their writing in The NYSDJ or in any component publication, promotes a positive image of organized dentistry. Dr. Ratner, a 1992 graduate of New Jersey Dental School, is a general practitioner on Staten Island. He represents the Second District on the NYSDA Board of Governors and is an alternate delegate to the ADA. He is past president of the Richmond County Dental Society. His winning editorial is reproduced here.

A TROUBLING TRIP TO THE LOCAL ELEMENTARY SCHOOL

Editorial Craig S. Ratner, D.M.D.

A FUNNY THING happened last week. While at my home in New Jersey, I was called by the school nurse to come to my daughters school. My daughter needed allergy drops placed in her eyes. This is not the funny part. As I arrived in the nurses office, I noticed another little girl playing with a loose tooth. She was unsuccessfully attempting to free it from its gingival jail. She was to the point of tears when I heard the nurse say, Im sorry. I cant help you. Only a dentist can pull a tooth from your mouth. Noting the irony, I replied, Im a dentist. Can I help? Acknowledging my arrival, the nurse did indeed propose to the young girl that I could help. The young girl was a little reluctant, but the discomfort she was having convinced her to let me help. I reached for the nearest tissue and proceeded to do what most parents do for their children all the time. I painlessly plucked the baby tooth from her mouth with nary a yelp or a tear. The nurse provided a piece of gauze for my patient to bite on and sent her back to class. I was a hero, right? On the way home, I was struck by a strange thought. I considered that I had just done something wrong. I had actually treated a minor without her parents consent. Not only that, but I did it in a state in which I wasnt licensed. Now, I knew that I would probably never be arrested for committing these two class B felonies. However, there was
14 NYSDJ MARCH 2008

a small part of me that actually worried that this little girls parents might be some lawsuit-happy Americans who saw this as an opportunity to sue me even though I was doing something I thought was innocent and good. Of course, I kept telling myself that I was overreacting. I was upset nonetheless. I wasnt upset over a potential lawsuit. Rather,I was upset that the thought even crossed my mind.I was upset that I live in a society where this was even a consideration. I was upset that I let myself get caught in the trap of paranoia.Then,I thought of all that NYSDA has done over the past five years to fight off the advances of the New York State Trial Lawyers Association. It is one of the most important yet unnoticed benefits of our membership,one that we often overlook. We have spent untold time and dollars fighting off the NYSTLAs legislative efforts to eliminate the statute of limitations and to create new categories of wrongful death and non-economic damages. It is an ongoing battle. How do we convince legislators who are themselves lawyers to ignore the influences of fellow lawyers? So far we have, but we need to continue the fight.We need to maintain our presence in Albany with numbers and dollars. If our numbers fail to show that we significantly represent our profession, or if our lobbying efforts fail because we lack monetary strength, we are in serious trouble. This is important. I for one dont want to have to worry about helping out another young girl with a loose tooth.

PERSPECTIVES

Dentistry and Dental Technology

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

Burney M. Croll, D.D.S.

IN THE PAST 39 YEARS, since I graduated from the University at Buffalo School of Dental Medicine, there have been many changes in dental education, especially in its relationship to dental technology. There have been changes in dental technology as well, including the number of dental technologists and their education and the prosthetic options available to dentists and patients. At the same time, there has been a steady and gradual corporatism of dental education and dental technology that appears to be irreversible. Voids in the existing dental delivery system have become apparent and require action from both the dental and dental technology communities. During my predoctoral training, students were given broad exposure to the technical aspects of prosthetic dentistry. They were expected to wax, invest and cast gold routinely, and make acrylic veneer bridges under the supervision of dental technicians and dentists, who served on the faculty at UB. Students also set their own denture teeth and processed acrylic resin for the partial and complete dentures provided in the predoctoral clinic. During each step, we interacted with real, live dental technicians. In the late 60s, graduating students predominately entered the military service. The military maintained a staff of dental technicians who were highly skilled and worked side by side with active dental officers to fabricate simple and complex dental restorations. Retiring military dental technicians opened commercial dental laboratories near military bases and were available to
16 NYSDJ MARCH 2008

help with the fabrication of the restorations that were provided to military personnel and their families. Other dental technicians became faculty members in dental schools and dental technology programs throughout the country following their retirement from military service. Today, first-year dentists spend a fifth year of education in general practice residencies instead of going into military service.
Getting to Know the Technology

As late as the early 70s, as an integral part of the educational process, pre- and postgraduate prosthodontic students were required to develop a basic level of dental laboratory skill, competence and attention to detail, as well as an understanding of how to fabricate restorations. The goal was to help students establish principles and learn to recognize standards of excellence for periodontal, occlusal and marginal adaptation, and substructure engineering considerations before treating clinical patients or fabricating prosthetics. Many faculty had either been laboratory technicians before becoming dentists or had developed a high degree of competence in dental technology. In my own postgraduate experience, at Tufts University, one of my mentors, Dr. Lloyd Miller, would bring the porcelain-fused-tometal cases he personally baked to school for us to see. Dental ceramics was in its infancy then. As time went on, postgraduate students were required to visit dental laboratories to meet and

establish communication with the dental technicians who produced the prosthetics the students would be placing in patients. Dr. Miller made sure all of his students visited Bob Welch and Lou Consoulis, two certified dental technicians at Dental Ceramics, Inc., the laboratory that made a significant portion of the fixed restorations the postdoctoral students delivered to patients treated in the postgraduate program. And Bob and Lou freely shared their experience and knowledge with us. They added to our ability to understand the state-of-the-art of dental technology available at the time and to make sure that new materials met established standards of biocompatibility, materials science and durability. In all, they enhanced our ability to do thoughtful case planning and treatment plans. We also learned the fundamental importance of careful tooth preparation, readable dies and appropriate mounting records, all of which enables technicians to perform to their best standards as well.
Human Element is Gone

The situation is not much different in postgraduate educational programs. In the school where I completed my training, I discovered that most if not all of the prosthetics that were delivered to patients were fabricated offshore in Thailand. That effectively reduced or eliminated the two-way communication between students and qualified dental technicians in the area. For many undergraduate and graduate students, interaction with dental technologists has been reduced to a box, a written prescription and a FedEx form. The obvious statement made here by dental school administrators is that the personal nature of a collaboration between dentistry and dental technology is of no value, nor is it good for the bottom line.
Gone Forever?

If you visit predoctoral programs today, you notice many changes. There has been a gradual virtualization and corporatism of the education experience. Students are given DVDs with all of the essential information they need to prepare for the regional dental examinations they will take at the end of their predoctoral training. Visits to the library have been replaced by a PDA or notebook computer. Mentors are gone, and there is less chance for students to develop independent curiosity and personal judgment. There is information overload, but also a simplification of information and the development of a market-based mentality. Many predoctoral programs require that their students keep track of their production figures in dollars instead of meeting the unit requirements and quality requirements of the past. Teachers of predoctoral students lament that there has been a shift in the curriculum, resulting in a reduction in the number of clock hours required for dental students in the area of prosthodontics and a virtualization of dental technology. As a result, students have never performed laboratory procedures, are not able to properly evaluate a prosthesis returned from the dental laboratory, have never met a dental technologist and have no sense of the value the dental technologist has in the delivery of dentistry. They are unaware that technologists are being forced to make decisions about product design that were typically a dentists responsibility. Adding to the market-based mentality of graduating dental students, many are leaving school with debt between $250,000 and $425,000 in education loans. Now, its no longer enough to make a living. One has to turn a profit. No wonder one of the first things these students do upon graduation is create a Web site to extol their excellence in all phases of dentistryimplants, orthodontics, cosmetic dental serviceseven though they have little actual training in these procedures. Preoccupied with meeting their loan payments, recent graduates have shifted emphasis from excellence to productivity and profitability.

The dentist/dental technician interaction within pre- and postdoctoral programs is not likely to be reinstated in the immediate future without a nationally mandated change in the predoctoral curriculum, according to dentists active in dental prosthetic education. Perhaps an educational module explaining dentists responsibilities upon graduation and the standards that have to be met must become part of predoctoral educational curriculum. There are similar problems in dental technology. The gradual Taylorization of the commercial dental technology business, the same philosophy used by Henry Ford to develop his automobile assembly line, has eroded the culture of artistic professionalism that used to characterize dental technology, turning it into an industry based upon productivity relying upon an assembly line model developed to create a profit. The supply of retiring militarytrained dental technologists has declined dramatically. And the number of accredited programs in dental technology has steadily dropped since 1990 from 60 to 20. The Department of Labor, Bureau of Labor Statistics, predicts that 11,000 out of the current 48,000 dental technicians will leave the profession by 2014. In that time, the accredited educational system will replenish that number by only 1,400. Outsourcing the fabrication of dental prosthetics to offshore laboratories will not solve this problem and may diminish our capacity to correct the manpower shortage by limiting our ability to recruit and sustain a workforce of educated dental technicians with a comprehensive knowledge of dental technology. It has also become a fact of life that dentists are less able to talk directly with the dental technologists who are fabricating restorations for dentists patients. Reducing the dental technician to a prescription and a case pan, eliminating the technician from the predoctoral dental educational experience has created a statement that could not be clearer. Public recognition of the essential collaboration that occurs between dentists and dental technicians is not occurring and should be addressed. The number of certified dental technicians (CDTs) has been steadily decreasing due to retirement, and these technicians are not being replaced adequately to meet present and future needs of their industry and those of dentistry. It is necessary
NYSDJ MARCH 2008 17

to acknowledge the professionalism of CDTs who have demonstrated a verifiable level of competence, established through the standardized testing and practical examination conducted by a national certification board. The American Dental Association has firmly established that dentists have the ultimate responsibility for deciding what is acceptable to be placed in the mouths of their patients and for safeguarding their patients health. In practice, however, dentists are relying more than ever on dental technologists to make decisions about the materials that will be placed in patients mouths. Often, these decisions are made without consultation with the dentist.Absent any state or federal mandate, there is no assurance or effective safeguard that the materials chosen for use in restorations fabricated by dental laboratories meet FDA standards, and the ability to track materials is severely limited.
Bolstering the Image of Dentistry

The changes in the de facto responsibilities of dentistry and dental technology deserve consideration by individual dentists, educational programs, state governments and the ADA. Currently, dental laboratories are not licensed or regulated in New York State. There are no minimum standards or training required, no required demonstration of a verified level of competence, no license or regulation required for an individual to operate a dental laboratory in

New York State. There is no minimum or required amount of continuing education for dental technologists who are not certified dental technicians. CDTs who have demonstrated a verifiable level of competence must be recognized for their accomplishments and professional commitment. They should be drawn upon to insure that acceptable standards are met and adhered to. Dentists should document specific materials contained in a manufactured prosthesis, as well as the country of its origin. Currently, more is known about the E. coli in the hamburger and spinach sold in a supermarket than about the materials contained in a dental prosthesis. There is no difference between contaminated medicines or food and a material used in a dental restoration that is potentially damaging to a patients health. Each should meet FDA standards and approval and be specified in the patients record for tracking purposes. In time, the memory of the basis upon which the credibility of dentists has rested, the collaborative efforts with dental technicians, the dedication to the best care possible for the patients health and welfare will fade and so will the prestige and trust that has served dentistry so well. There already has been a decline in professionalism in both dentistry and dental technology, replaced by a more market-based mentality that is coupled with a reduction in the quality-of-life experience in both areas. When dentistry becomes tangled in the bottom line, delivery of mediocre service will accurately define the image of the dentist. Despite what you may have read in advertisements, not everyone needs or can afford porcelain laminates or dental implants. But the need for conventional dentistry remains at an all-time high. Without highly dedicated and skilled dental technologists available nearby to discuss prosthetic design and delivery with dentists, the collaborative efforts of educated, knowledgeable and well-trained dentist/dental technologist teams will disappear, and this will have an impact on the quality of the oral health service provided. We must be the custodians of our profession and act positively on these issues. To begin addressing these changes in dentistry, modifications in the curriculum for predoctoral dental students need to be made to provide a clear description of the dentists responsibilities and the standards to be met when evaluating prosthetics to be placed in patients mouths. Also, recognition must be made of CDTs and their continuing education needs, as well as onthe-job training as a group and as responsible individuals who have demonstrated a verifiable level of competence and are essential collaborators in the dental practice. Licensure and regulation of dental laboratories statewide is a further step in the right direction deserving consideration.
Dr. Croll, a New York City prosthodontist, is executive director of the Dental Laboratory Summit, a group comprising representatives of the dental technology industry, dental and dental technology formal education programs, manufacturers and suppliers to dentistry and dental technology, the ADA, National Association of Dental Technology and publishing industry that is concerned with issues confronting dentistry and dental technology nationally and internationally.

18 NYSDJ MARCH 2008

Stem Cells and the Future of Dental Care

Jeremy J. Mao, D.D.S., Ph.D.

Abstract What are stem cells? As dentists, why should we be concerned with stem cells? How would stem cells change dental practice? Is it possible to grow a tooth or TMJ with stem cells? This article summarizes the latest stem cell research and development for dental, oral and craniofacial applications. Stem cell research and development will, over time, transform dental practice in a magnitude far greater than did amalgam or dental implants. Metallic alloys, composites and even titanium implants are not permanent solutions. In contrast, stem cell technology will generate native tissue analogs that are compatible with the patients own.
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STEM CELLS CAN BE DEFINED as cells that 1. self-replicate and 2. are able to differentiate into at least two different cell types. Both conditions must be present for a cell to be called a stem cell. For example, osteoblasts are not stem cells. Although osteoblasts differentiate into osteocytes, they typically do not differentiate into other cell types except osteocytes. Osteocytes are not stem cells; they are end-lineage cells that typically neither self-replicate nor differentiate.
Different Types of Stem Cells

Embryonic stem cells (ES) refer to the cells of the inner cell mass of the blastocyst during embryonic development. ES are particularly notable for their two fundamental properties: the capacity to differentiate into any cell type in the body and the ability to self replicate for numerous generations (Lyons and Rao, 2007). One potential disadvantage of human ES, besides ethical issues, is precisely their virtually unlimited proliferation and differentiation capacity (Ryu et al., 2004). The clinically observed

teratoma is an example of ES growing into wrong tissues. To date, little attempt has been made towards the use of ES in dental, oral and craniofacial regeneration. Amniotic fluid-derived stem cells (AFS) can be isolated from aspirates of amniocentesis during genetic screening. An increasing number of studies have demonstrated that AFS have the capacity for remarkable proliferation and differentiation into multiple lineages, such as chondrocytes, adipocytes, osteoblasts, myocytes, endothelial cells, neuron-like cells and live cells (Barria et al., 2004; Prusa et al., 2004; De Gemmis et al., 2006; De Coppi et al., 2007; Kolambkar et al., 2007; Perin et al., 2007). The potential therapeutic value of AFS remains to be discovered. Umbilical cord stem cells (UCS) derive from the blood of the umbilical cord. There is growing interest in their capacity for selfreplication and multi-lineage differentiation (Laughlin et al. 2001). UCS have been differentiated into several cell types, such as cells of the liver, skeletal muscle, neural tissue and immune cells (Warnke et al.,

2004; Young et al. 2004). Their high capacity for multi-lineage differentiation is likely attributed to the possibility that UCS are chronologically closer derivatives of embryonic stem cells than adult stem cells. Several studies have shown the potential of UCS in treating cardiac and diabetic diseases in mice (Rebel et al. 1996; Tocci et al. 2003; Lee et al. 2005). UCS are neither embryonic stem cells, nor are they viewed as adult stem cells. Bone marrow-derived mesenchymal stem cells. When bone marrow is aspirated and cultured, a subset of adherent and mononuclear cells are mesenchymal stem cells (MSCs) (Alhadlaq and Mao, 2004; Marion and Mao, 2006). Bone marrowderived MSCs can self-replicate and have been differentiated, under experimental conditions, into osteoblasts, chondrocytes, myoblasts, adipocytes and other cell types, such as neuron-like cells, pancreatic islet beta cells, etc. (Alhadlaq and Mao, 2004; Kim et al., 2006; Marion and Mao, 2006). Bone marrow-derived MSCs are currently being investigated in broad applications, such as cartilage defects in arthritis, bone defects, adipose tissue grafts, cardiac infarcts, liver disease and neurological regeneration. MSCs are often viewed as a yardstick of adult stem cells. Tooth-derived stem cells (TS) are isolated from the dental pulp, periodontal ligamentincluding the apical regionand other tooth structures (Gronthos et al., 2000; Shi et al., 2001; Batouli et al., 2003; Miura et al., 2003; Mao et al., 2006). Craniofacial stem cells, including TS, originate from neural crest cells and mesenchymal cells during development (Zhang et al., 2006; Takashima et al., 2007). Neural crest cells share the same origin as progenitor cells that form the neural tissue. Conceptually, TS have the potential to differentiate into neural cell lineages. Indeed, TS from the deciduous tooth have been induced to express neural markers such as nestin (Miura et al., 2003). Similarly, bone marrow-derived stem cells also have been

induced to express neural cell markers (Kim et al., 2006). The expression of neural markers in TS elicits imagination of their potential use in neural regeneration, such as in the treatment of Parkinsons disease. However, the expression of certain end cell lineage markers by stem cells only represents the first of many steps towards the treatment of a disease. In balance, the potential of TS in both dental and non-dental regeneration should be further explored. TS that have been isolated to date, either from deciduous teeth or permanent teeth, are considered postnatal stem cells or adult stem cells. Adipose-derived stem cells (AS) are typically isolated from lipectomy or liposuction aspirates.AS have been differentiated into adipocytes, chondrocytes, myocytes, neuronal and osteoblast lineages (De Ugarte et al., 2003; Zuk et al., 2002; Peptan et

al., 2006). AS can self-replicate for many passages without losing the ability to further differentiate (De Ugarte et al., 2003; Zuk et al., 2002; Gimble et al., 2007). Many believe that AS have advantages over other adult stem cell populations, for adipose tissue is abundant in certain individuals, readily accessible and replenishable. However, the ability to reconstitute tissues and organs by AS versus other adult stem cells has yet to be comprehensively documented. Induced pluripotent stem cells (iPS) refer to adult or somatic stem cells that have been coaxed to behave like embryonic stem cells. Recent reports have shown that the transduction of a small number of genes or transcription factors, as few as four, transforms adult fibroblasts into cells that proliferate and differentiate into ESlike cells. The four genes are Oct3/4, Sox2, Klf4, and c-Myc in Takahashi et al. (2007),

NYSDJ MARCH 2008 21

but Oct4, Sox2, Nanog, and Lin28 in Yu et al. (2007). The biological and political implications of these studies are quite significant. On the biological front, the induced human somatic cells or iPS cells have the capacity to generate a large quantity of stem cells as an autologous cell source that can be used to regenerate patient-specific tissues. On the political front, iPS cells appear to minimize the need for human embryonic stem (ES) cells. However, even the authors of these recent reports have cautioned that any carcinogenic potential of iPS should be fully investigated before any commercialization can be realized.
Stem Cells and Dental, Oral, Craniofacial Structures

Structures of interest to the dental profession include the enamel; dentin; dental pulp; cementum; periodontal ligament; craniofacial bones; the temporomandibular joint, including bone; fibrocartilage and ligaments; skeletal muscles and tendons; skin and subcutaneous soft tissue; and salivary gland. Without exception, all these dental, oral and craniofacial structures are formed by neural crest-derived and/or mesenchymal cells during native development. Since cells are the centerpiece of growing tissue or organs, the immediate question is how to get hold of the cells that generate dental, oral and craniofacial tissues? Among all possible stem cell sources, adult stem cells have a number of advantages over embryonic stem cells, umbilical cord stem cells and amniotic fluid stem cells for regeneration of many dental, oral and craniofacial structures. Adult stem cells are chronologically closer to the target dental, oral and craniofacial structures than embryonic stem cells, umbilical cord stem cells and amniotic fluid stem cells. Adult stem cells are not subjected to the ethical controversy associated with embryonic stem cells. Adult stem cells can be autologous and isolated from the patient, whereas embryonic stem cells cannot be autologous. It is also impossible for amniotic fluid stem cells or umbilical cord stem cells to be used as autologous cells until these cells are banked. The risk of immune rejection is
22 NYSDJ MARCH 2008

Figure 1. A: Human mesenchymal stem cells (MSCs) isolated from anonymous adult human bone marrow donor following culture expansion (H&E staining). Further enrichment of MSCs can be accomplished by positive selection using cell surface markers, including STRO-1, CD133 (prominin, AC133), p75LNGFR (p75, low-affinity nerve growth factor receptor), CD29, CD44, CD90, CD105, c-kit, SH2 (CD105), SH3, SH4 (CD73), CD71, CD106, CD120a, CD124, and HLA-DR or negative selection (Alhadlaq and Mao, 2004; Marion and Mao, 2006). B: Chondrocytes derived from human mesenchymal stem cells showing positive staining to Alcian blue. Additional molecular and genetic markers can be used to further characterize MSC-derived chondrocytes (Alhadlaq and Mao, 2004; Marion and Mao, 2006). C: Osteoblasts derived from human mesenchymal stem cells showing positive von Kossa staining for calcium deposition (black) and active alkaline phosphatase enzyme (red). Additional molecular and genetic markers can be used to further characterize MSC-derived chondrocytes (Alhadlaq and Mao, 2004; Marion and Mao, 2006). D: Adipocytes derived from human mesenchymal stem cells showing positive Oil Red-O staining of intracellular lipids. Additional molecular and genetic markers can be used to further characterize MSC-derived chondrocytes (Alhadlaq and Mao, 2004; Marion and Mao, 2006).

present for non-autologous cells, whereas autologous stem cells are free from immune rejection. Bone marrow-derived, tooth-derived and adipose-derived stem cells, despite important differences among them, likely belong to subfamilies of mesenchymal stem cells (Marion and Mao, 2006; Gimble et al., 2007). Most dental, oral and craniofacial structures are connective tissue. During native development, dental, oral and craniofacial connective structures are formed by neural crest-derived and mesenchymal cells. Postnatally, clusters of mesenchymal cells continue to reside in various tissues and are the logical sources of adult mesenchymal stem cells (Marion and Mao, 2006).

MSCs can be isolated from the patient who needs treatment, and, therefore, they can be used autologously without immunorejection. MSCs have also been used allogeneically to heal large defects (Alhadlaq and Mao, 2004; Marion and Mao, 2006; Barrilleaux et al., 2006; Prockop, 2007). Figure 1 provides experimental data showing that a single population of mesenchymal stem cells can differentiate into chondrocytes, osteoblasts and adipocytes (Marion and Mao, 2006). Each of the differentiated cell lineages has implications in the treatment of a corresponding disorder. For example, MSC-derived chondrocytes can be used for reconstruction of orofacial cartilage structures, such as nasal cartilage and the temporomandibular joint. MSC-

derived osteoblasts can be used to regenerate oral and craniofacial bones. MSCderived myocytes can be used to treat muscular dystrophy and facial muscle atrophy. Stem cell-derived adipocytes can be used to generate soft tissue grafts for facial soft tissue reconstruction and augmentation.
Stem Cells and Dental Practice

The progress of stem cell-based technologies also depends on the regulatory pathways of the FDA in the United States and equivalent regulatory agencies elsewhere.
tially to sufficient numbers for healing large, clinically relevant defects. Stem cells can differentiate into multiple cell lineages, thus providing the possibility that a common (stem) cell source can heal many tissues in the same patient, as opposed to the principle of harvesting healthy tissue to heal like tissue in association with autologous tissue grafting (Moioli et al., 2007). Stem cells can be seeded in biocompatible scaffolds in the shape of the anatomical structure that is to be replaced (Rahaman and Mao, 2005). Stem cells may elaborate and organize tissues in vivo, especially in the presence of vasculature. Finally, stem cells may regulate local and systemic immune reactions of the host in ways that favor tissue regeneration. When will each stem cell-based technology be available for dental and oral surgery practice? Some of the near-term applications, such as growth factor delivery, are approved or are being reviewed by the FDA, whereas others are being investigated at various stages of product development. However, it is impossible to provide the precise timeline of clinical application for a myriad of dental, oral and craniofacial diseases. Science does not progress linearly, and breakthrough is not always predicted. Furthermore, the progress of stem cellbased technologies also depends on the regulatory pathways of the FDA in the United States and equivalent regulatory agencies elsewhere. What can be predicted is that stem cell-generated tissue analogs will be available for clinical use for certain tissues before others.The first wave of this paradigm shift in dental health care is upon us now. The impact of this paradigm shift will eventually be present in every dental practice.

Patients come to the dentist because of infections, trauma, congenital anomalies or other diseases, such as orofacial cancer and salivary gland disorders. Caries and periodontal disease remain highly prevalent disorders among humans. Whereas native tissue is missing in congenital anomalies, diseases such as caries or tumor resection result in tissue defects. For centuries, dentistry has been devoted to healing defects with durable materials or the patients own (autologous) tissue. But we now realize that metallic alloys or synthetic materials are not permanent solutions (Rahaman and Mao, 2005). Amalgam, composites and even titanium dental implants can fail; and all have limited service time (Rahaman and Mao, 2005). Why are stem cells better than durable implants such as titanium dental implants? A short answer to this question is that stem cells lead to the regeneration of teeth with periodontal ligament that can remodel with the host. Why are stem cells superior to autologous tissue grafts? Autologous tissue grafting is based on the concept that a diseased or damaged tissue must be replaced by like tissue that is healthy. Thus, the key drawback of autologous tissue grafting is donor site trauma and morbidity. For example, we currently harvest healthy bone from the patient. We might take from the iliac crest, rib bone, chin or retro-molar area for bone grafting needs in cleft palate, ridge augmentation, sinus lifting, and maxillary and mandibular reconstruction. In contrast, stem cell-based therapeutic approaches may circumvent the key deficiencies of autologous bone grafting (Rahaman and Mao, 2005). Stem cells from a tiny amount of tissue, such as the dental pulp, can be multiplied or expanded poten-

Physicians and scientists have recommended that umbilical cord stem cells and amniotic fluid stem cells be banked for potential application in the treatment of trauma and pathological disorders. Our understanding of mesenchymal stem cells in the tissue engineering of dental, oral and craniofacial structures has advanced tremendously (Krebsbach et al.,1999; Pittenger et al.,1999; Bianco et al., 2001; Alhadlaq and Mao, 2004; Mao et al., 2006; Marion and Mao, 2006).We have witnessed tissue engineering of the tooth, temporomandibular joint condyle, cranial sutures, soft tissue grafts, craniofacial bone, and other dental, oral and craniofacial structures in animal models (review: Mao et al., 2006). With all that we have learned about stem cells and tissue engineering of dental, oral and craniofacial structures, we are in a position to bring awareness to our patients regarding the proper storage of their extracted teeth in conditions that will preserve craniofacial stem cells, including toothderived stem cells. These include, but are not limited to, extracted wisdom teeth, extracted deciduous teeth, any teeth extracted for orthodontic purposes and any noninfected teeth extracted. Among postnatal tissues that are sources of stem cells that are obtainable without substantial trauma are extracted wisdom teeth, exfoliating or extracted deciduous teeth, teeth extracted for orthodontic treatment, trauma or periodontal disease. Craniofacial stem cells, including tooth-derived stem cells, have the potential, as do bone marrow-derived stem cells and adipose-derived stem cells, to cure a number of diseases that are relevant to dentistry as well as medicine, among them, diabetes, Parkinsons disease and cardiac infarct.
Is it Possible to Grow a Tooth or TMJ with Stem Cells?

As an example of craniofacial regeneration, we have used stem cells in the tissue engineering of a human-shaped temporomandibular joint using MSCs (Alhadlaq and Mao, 2003; Alhadlaq and Mao, 2005; Marion and Mao, 2006; Troken et al., 2007). Given that the mandibular condyle consists of two stratified layers of cartilaginous and bone tissues,
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MSCs were first differentiated into chondrogenic and osteogenic cells (Alhadlaq and Mao, 2003; Alhadlaq et al., 2004). MSCderived chondrogenic and osteogenic cells were encapsulated in a biocompatible hydrogel in two stratified layers molded into the shape and dimensions of an adult human mandibular condyle (Alhadlaq and Mao, 2003; Alhadlaq et al., 2004). Following in vivo implantation in immunodeficient mice for up to 12 weeks, the retrieved mandibular joint condyles retained the shape and dimensions of the native condyle. The chondrogenic and osteogenic portions remained in their respective layers (Alhadlaq and Mao, 2005). The chondrogenic layer was positively stained by chrondrogenic marker, safarnin O, and contained type II collagen. In the interface between cartilaginous and osseous layers, there is a presence of hypertrophic chondrocytes that express type X collagen (Alhadlaq and Mao, 2005). In contrast, only the osteogenic markers, such as osteopontin and osteonectin, stained the osseous layer, but not the cartilage layer. Lastly and most importantly, there was mutual infiltration of the cartilaginous and osseous components into each others territory, which resembles mandibular condyle (Alhadlaq and Mao, 2005). Therefore, the proof of principle has been established to regenerate the human-shaped TMJ condyle. The tooth is a highly complex structure, with a level of complexity equal to that of internal organs, from the perspective of tissue engineering. Dental epithelial and mesenchymal cells isolated from rat or pig teeth have been seeded onto biodegradable scaffolds and implanted in immunodeficient mice. Several studies have shown that a tooth crown has been formed with different layers of enamel, dentin and pulp-like structures (Young et al., 2002; Duailibi et al., 2004; Sumita et al., 2006; Nakao et al., 2007). In vitro-generated tooth germ cells or stem cells have been transplanted into the adult tooth socket, leading to the formation of a tooth crown or root (Nakao et al., 2007; Sonoyama et al., 2007). Current efforts are occurring in several diverse directions, such as the use of sophisticated scaffold materials (Zhang et al., 2005,
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Moioli et al., 2007); the use of enriched dental stem cell populations (Laino et al., 2006; Shi et al., 2005; Sonoyama et al., 2006; Yen and Sharpe, 2006); and the use of specific dental epithelial and mesenchymal cell ratios and seeding (Hu et al., 2006; Honda et al., 2007). Overall, the proof of concept has been established to generate biologically derived tooth structures from stem cells. The remaining challenges are along several fronts, including scale up, accelerated tissue maturation and development of viable commercialization approaches.
Summary

In the dental profession, we treat a myriad of trauma, congenital anomalies and diseases, including tissue defects resulting from dental caries, periodontal bone defects or facial bone defects. These defects not only lead to physical trauma and pain, but they also are detrimental to the psychosocial well-being of patients, given that the oral cavity and the face are intimately involved in self identity, communication and the expression of emotion. Current treatment approaches utilize the patients own tissues, allogeneic grafts, metallic alloys or synthetic implants. Much of what we know as dentists is evolving into a new dentistry in which dental care is delivered increasingly by biologically based approaches. For example, biomolecules will be used for periodontal regeneration; stem cells will be used in the regeneration of dentin and/or dental pulp; biologically viable scaffolds will be used to replace orofacial bone and cartilage; the defective salivary gland will be partially or completed regenerated (Rahaman and Mao, 2006; Mao et al., 2006; Mao et al., 2007). The challenge for the dental professional in the anticipated era of stem cells and tissue engineering is imminent. What would be a dentists response when patients ask whether they can get their own stem cells if they have their wisdom teeth banked? What are the odds that tooth stem cells will grow a new tooth or be used to treat diabetes? Should I use a growth factor called PDGF or BMP2 to treat my periodontal bone defects or have a bone graft? Should

my sons baby teeth be banked for stem cells, and, if so, what are the odds that these baby teeth stem cells will cure a bone fracture he may get during a soccer game? The dental professional needs to be prepared to provide continuing education courses. Dental schools should consider the addition of stem cells and tissue engineering courses to the existing curriculum. Several textbooks are now available in the area of stem cells, tissue engineering and regenerative medicine (e.g. Mao et al., 2007).Without these and similar measures, dental students, postgraduate students and dental practitioners are likely to be ill-prepared for the upcoming era of stem cellbased technologies. Several well-established dental supply companies have established, or are establishing, R&D efforts in the area of stem cells and tissue engineering. Federal funding agencies, such as the National Institutes of Health, have been providing research and training grants on a competitive basis to the external research community in the area of stem cells, tissue engineering and regenerative medicine, including regenerative dental medicine, for over a decade (Wang et al., 2007). Strategies for education, training, research, development, commercialization and practice models need to be formulated and implemented.
Authors acknowledgement: This article is dedicated to my teachers during my dental and specialty training, as well as my scientific training, for their intellectual influence and education. It is further dedicated to my previous and current students, residents, postdoctoral fellows and research scientists who have helped me to understand stem cells, tissue engineering and knowledge in general. The following research grants from the National Institutes of Health are gratefully acknowledged: DE15391, EB002332 and EB006261. Editors Note: Queries about this article can be sent to Dr. Mao at jmao@columbia.edu. Copies of the extensive references that accompanied Dr. Maos manuscript are available upon request to The NYSDJ Managing Editor.

[
Abstract

Use of Metal Conditioner on Reinforcement Wires

TO IMPROVE

DENTURE REPAIR STRENGTHS

Hiroshi Shimizu, D.D.S., Ph. D.; Nobuaki Mori, D.D.S.; Yutaka Takahashi D.D.S., Ph. D.
The purpose of this study was to evaluate the transverse strength of denture base resin repaired with autopolymerizing resin and metal wire using a metal conditioner3-5 and to look at the synergistic effect of a surface preparation6-10 for denture base resin.
Materials and Methods

The purpose of this study was to evaluate the transverse strength of denture base resin repaired with autopolymerizing resin and metal wire using a metal conditioner, along with the synergistic effect of a surface preparation for denture base resin. It was found that the use of Co-Cr-Ni wires air abraded with 50 m alumina, followed by treatment with a metal conditioner and dichloromethane for denture base resin, was the most effective method for repairing fractured denture base resin.

ACRYLIC DENTURE BASE FRACTURE is an infrequent complication of denture care in clinical practice. Satisfactory repairs must be easy to make and performed promptly. They must also provide adequate repair strength. Among the reinforcement methods of denture repair reported to be in use, a common method involves the use of metal wires embedded with repair resin.1,2 The resin is easy to handle, rapidly polymerizes and is cost-effective, although its strength is still not sufficient. To gain optimum repair strength, it is essential for a good bond to exist between the metal wire and the repair resin, as well as between the denture base resin and the repair resin.
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Table 1 lists the materials used in this study. A total of 60 bar specimens (3.0 mm x 10.5 mm x 68.5 mm) of autopolymerizing denture base resin were prepared according to manufacturers instructions in a pressure-curing unit (SSKJ-50, Shofu, Inc., Kyoto, Japan) at 50 degrees C. and 0.39 MPa pressure for 10 minutes. After processing, the specimens were finished with No. 600 silicon-carbide abrasive paper under running water to final dimensions of 2.5 mm x 10.0 mm x 68.0 mm. They were then stored in 37-degree C. distilled water for one day. The 50 specimens were cut in half with a band saw under running water,guided by a standardized positional jig.The remaining 10 control specimens were not cut. The cut surfaces were made parallel to each other and perpendicular to the long axis of the specimens by abrading with No. 600 silicon-carbide abrasive paper under running water. The cut surfaces of the 10 randomly selected specimens were prepared using dichloromethane for 5 s for use as Group 5. The parallel halves of the specimens were placed in openended stone molds with the same dimensions as the original intact specimens. The molds were used so that the ends to be repaired could be fixed 3.0 mm apart, making a bar butt joint gap. This gap

TABLE 1 Materials Used

Material Denture base resin Repair resin Surface preparation agent Metal wire Metal conditioner Product name Pour Resin PO Unifast #3 Dichloromethane Sun-cobalt clasp-wire ( =1.0 mm) Cesead II Opaque Primer Manufacturer Shofu Inc., Kyoto, Japan GC Corp., Tokyo, Japan Nacalai Tesque, Inc., Kyoto, Japan Dentsply-Sankin, Tokyo, Japan Kuraray Medical Inc., Tokyo, Japan Batch number Powder 079255 Powder 140722 V2P6474 C60215 0036A Liquid 099201 Liquid 211022

was then filled with the autopolymerizing acrylic repair resin. The mixing ratio (powder to liquid) was 2:1 (w/w). The free-flowing mix was poured into the joint space to allow for a slight excess, to ensure a complete joint. After processing, the repaired specimens were trimmed a little larger than their original dimensions. A steel bur (D 0023, Dentsply Maillefer, Ballaigues, Switzerland; ISO 027) was used under running water to grind a central groove (2.5 mm wide, 2.0 mm deep, 25 mm long) parallel to the long axis of the specimen into which the metal wires could be placed. A round CoCr-Ni wire ( =1.0 mm) designed for clasps of removable partial dentures (Sun-cobalt clasp-wire, Dentsply-Sankin, Tokyo, Japan) was cut into 20 mm lengths. The specimens were divided into six groups: 1. without wires; 2. with untreated wires; 3. with wires treated with 50 m alumina airabrasion (at a right angle to the surface from 5 mm distance for 10 s at an emission pressure of 0.48 MPa using a grit blaster [Microblaster, Comco Inc., Burbank, CA]); 4. with wires treated with 50 m alumina airabrasion followed by application of a metal conditioner; 5.50 m alumina air-abrasion of the wires, followed by application of metal conditioner on specimens whose cut surfaces and groove were prepared with dichloromethane; and 6. uncut intact group. After inserting the treated wires, the groove was filled with the autopolymerizing acrylic repair resin as described above except for the group 6 specimens. After the polymerization process was completed at 23 degrees C., the specimens were abraded under running water with No. 600 silicon-carbide abrasive paper to final dimensions of 2.5 (0.03) mm x 10.0 (0.03) mm x 68.0 mm. The completed specimens were then immersed in 37-degree C. distilled water for one day. A three-point bending test was used to determine the transverse strength of the test specimens using a screw-driven universal testing machine (TCM-200, Minebea Co. Ltd., Tokyo, Japan) at a crosshead speed of 1.0 mm/minute and with 60 mm between the supports during loading. A compressive load was applied to the center of the repaired site. The data were analyzed statistically using a one-way analysis of variance (ANOVA). The Tukeys post-hoc comparison test was applied when appropriate (95% confidence level).
Results

TABLE 2. Fracture Load of Repaired Autopolymerizing Denture Base Resin Specimens (MPa)
Group 1 2 3 4 5 6 Mean 24.0 46.4 57.2 61.7 69.2 71.3 SD* 3.1 3.3 0.1 3.0 3.3 10.3 Tukeys grouping a b c d e e

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

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

(p>0.05). The means and standard deviations of the transverse strengths for each group with statistical categories are summarized in Table 2. In most of the reinforced specimens, fractures occurred at the denture base resin/ autopolymerizing repair resin interface, and the wire held the two pieces of fractured specimens in position (Figure A). Two of the 10 specimens in group 5 broke into two pieces with fracture at one end of the wire (Figure B).
Discussion

The one-way ANOVA and Tukeys post-hoc comparisons test demonstrated that there were significant differences in the transverse strengths among the groups assessed (p<0.05). Group 5 had the greatest transverse strength among the repair groups (p<0.05). There were no significant differences between groups 5 and 6

Table 2 indicates that the use of air-abraded Co-Cr-Ni wire, followed by treatment using Cesead II Opaque Primer, plus the application of dichloromethane, was the most effective method among the groups tested. These findings point to a synergistic effect of the reinforcement of the metal wire using the metal conditioner and
NYSDJ MARCH 2008 27

surface preparation of the denture base resin. Furthermore, the fact that the transverse strength of group 5 was the same as that of group 6 demonstrated that it is possible to restore the denture base resins original intact strength. A round Co-Cr-Ni wire ( =1.0 mm) designed for the clasps of removable partial dentures (Sun-cobalt clasp-wire, DentsplySankin, Tokyo, Japan; 46% cobalt, 20% chromium, 22% nickel, >3 % molybdenum, >3% tungsten, and <6% others) (wt %) was selected as the reinforcement material. It is well known that the 10methacryloxydecyl dihydrogen phosphate monomer is effective as a functional monomer for bonding base metal alloys.3-5 Cesead II Opaque Primer contains this monomer. The influence of the chromium content on the bond strength and durability of nickel-chromium alloy was evaluated and was shown to decrease the bond strength only slightly between nickel-chromium alloys with higher chromium content and an adhesive resin containing 4-methacryloxyethyl trimellitate anhydride after thermocycling.11 The Co-Cr-Ni wire selected for this study contains 20% chromium; thus, the results of the study presented here agree with the above findings. Dichloromethane is an organic and nonpolymerizable solvent that swells the surface and permits diffusion of the polymerizable material.6 Preparation using dichloromethane creates surface pores on a conventional acrylic resin tooth. It is recommended that it be applied to the denture teeth in the ridge-lap area prior to denture base processing.8 The same morphological change also occurs when dichloromethane is applied to denture base resin.10 Prepolymerizing the PMMA pearls in the denture base resin should allow diffusion of the dichloromethane solvent. On the other hand, dichloromethane has also been the subject of recent toxicological and carcinogenesis studies.12,13 Therefore, a safer surface preparation than dichloromethane is desired. The effect of ethyl acetate as an alternative to dichloromethane for denture base repair was investigated.14 Two of the 10 specimens fractured at one end of the metal wire in group 5 (Figure 1B). Such fractures are occasionally observed in prosthodontic practice, which indicates considerable stress concentrated around the end of the metal wire.Whether fracture occurs at the interface between the denture base resin and the autopolymerizing repair resin near the loading point or at the end of the wire may depend on many factors, including the wires total rigidity; arrangement, including length; and thickness. It may also be related to the resins rigidity and thickness. When the wire in the bar specimens was sufficiently long, fractures at the end of the wire did not occur.1 For most of the maxillary complete denture bases repaired using long reinforcing wires, the pattern reported was that of a fracture line that followed the midline at the interface of the repair resin and the denture base resin. It was initiated from the posterior border and terminated just in front of the wire.3
28 NYSDJ MARCH 2008

Further in vitro studies are needed to analyze this mechanism.

Conclusions

The use of metal wires air-abraded with 50 m alumina, followed by application of Cesead II Opaque Primer embedded in autopolymerizing resin and the application of dichloromethane to the denture base resin at the same time, is the most effective way to repair fractured denture base resin.
The authors gratefully acknowledge the editorial assistance of Mrs. Jeanne Santa Cruz. Queries about this article can be sent to Dr. Shimizu at simizuh1@college.fdcnet.ac.jp.

REFERENCES
1. Polyzois GL,Andreopoulos AG,Lagouvardos PE.Acrylic resin denture repair with adhesive resin and metal wires: effects on strength parameters. J Prosthet Dent 1996;75:381-7. 2. Polyzois GL, Tarantili PA, Frangou MJ, Andreopoulos AG. Fracture force, deflection at fracture, and toughness of repaired denture resin subjected to microwave polymerization or reinforced with wire or glass fiber. J Prosthet Dent 2001;86:613-9. 3. Yoshida K, Kamada K, Atsuta M. Adhesive primers for bonding cobalt-chromium alloy to resin. J Oral Rehabil 1999;26:475-8. 4. Ohkubo C,Watanabe I, Hosoi T, Okabe T. Shear bond strengths of polymethyl methacrylate to cast titanium and cobalt-chromium frameworks using five metal primers. J Prosthet Dent 2000;83:50-7. 5. Shimizu H, Kurtz KS, Tachii Y, Takahashi Y. Use of metal conditioners to improve bond strengths of autopolymerizing denture base resin to cast Ti-6Al-7Nb and Co-Cr. J Dent 2006;34:117-22. 6. Rupp NW, Bowen RL, Paffenbarger GC. Bonding cold-curing denture base acrylic resin to acrylic teeth. J Am Dent Assoc 1971;83:601-6. 7. Shen C, Colaizzi FA, Birns B. Strength of denture repairs as influenced by surface preparation. J Prosthet Dent 1984;52:844-8. 8. Takahashi Y, Chai J, Takahashi T, Habu T. Bond strength of denture teeth to denture base resins. Int J Prosthodont 2000;13:59-65. 9. Chai J, Takahashi Y, Takahashi T, Habu T. Bonding durability of conventional resinous denture teeth and highly crosslinked denture teeth to a pour-type denture base resin. International J Prosthodont 2000;13:112-6. 10. Shimizu H, Kurtz KS, Yoshinaga M, Takahashi Y, Habu T. Effect of surface preparations on the repair strength of denture base resin. Int Chinese J Dent 2002;2:126-33. 11. Salonga JP, Matsumura H, Yasuda K, Yamabe Y. Bond strength of adhesive resin to three nickel-chromium alloys with varying chromium content. J Prosthet Dent 1994;72:582-4. 12. Dell LD, Mundt KA, McDonald M, Tritschler JP 2nd, Mundt DJ. Critical review of the epidemiology literature on the potential cancer risks of methylene chloride. Int Arch Occup Environ Health 1999;72:429-42. 13. Maronpot RR, Devereux TR, Hegi M, Foley JF, Kanno J, Wiseman R, Anderson MW. Hepatic and pulmonary carcinogenicity of methylene chloride in mice: a search for mechanisms. Toxicology 1995;102:73-81. 14. Shimizu H, Ikuyama T, Hayakawa E, Tsue F, Takahashi Y. Effect of surface preparation using ethyl acetate on the repair strength of denture base resin. Acta Odontol Scand 2006;64:159-63.

Treatment of a Mandibular Cleft

Using Distraction
Marguerite Grossman, D.D.S.; Stuart Super, D.M.D.
Abstract Distraction osteogenesis is an alternative treatment method for correction of mandibular hypoplasia. This paper outlines the use of mandibular distraction in a patient with mandibular hypoplasia and a history of a mandibular cleft. Case Report

MEDIAN CLEFTS of the lower lip and mandible are rare craniofacial anomalies.1-3 Couronne, in 1819, was the first person to describe the condition. The mandible develops from the mandibular process known as Meckels cartilage of the first branchial arch. Inferior gnathoschisis, or median mandibular cleft, is a rare malformation, compared with the high frequency of maxillary clefts.4,5 The etiology of mandibular clefting proposed in the literature is the failure of mesodermal penetration into the midline structures of the mandibular portion of the first branchial arch.1,6,7 There is a wide variation in the severity of this anomaly, ranging from a minor cleft of the lower lip with a normal tongue and mandible to a complete cleft with loss of the supporting structures of the neck and sternum.5,7 In patients with extensive clefts, herniation of the lung into tissues of the neck have been reported.4 In a rare case of median cleft lip, limb anomalies and a family history of similar malformations have been described.8 The limb anomalies were brachysyndactyly of the hands and feet.
30 NYSDJ MARCH 2008

Our patient was a 33-year-old male who was born preterm, at 8 months, via natural delivery to healthy parents, of a non-consanguineous marriage, at St. Catherines Hospital in Ontario. His mother was 27 years old at the time of his birth. There was no reported exposure to radiation, consumption of medication or surgical intervention during pregnancy. The patient has two younger, healthy siblings, two and seven years his junior. In 2005, the patient was referred to our office for severe mandibular cleft retrognathia. Upon examination, the patient was noted to have a convex profile with a retrognathic mandible (Figure 1) and severe microstomia. His maximal oral opening was approximately 10 mm in diameter. There was severe crowding with poor arch form to the maxilla and extensive scar tissue and several malpositioned teeth on the mandibular arch. The patient had minimal tongue mobility. His neck was normal; however, the patient was noted to have malformed digits on his right hand with significant scar tissue (Figure 2). The patient had undergone several surgical procedures during infancy at the Hospital for Sick Children in Ontario, including surgical repair of his cleft lower lip and right hand surgery to separate his fused digits. In 1986, the patient underwent a cranial graft harvest to repair his cleft mandible (Figures 3, 4). In this case report, mandibular distraction was performed to gradually lengthen the mandible and expand the muscle and soft

Figure 1. Preoperative frontal and profile views.

Figure 2. Patients hands.

Figure 3. Preoperative panoramic radiograph.

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

Figure 4. Preoperative lateral cephalogram.

In February 2005, surgery was carried out under general anesthesia via nasoendotracheal tube/fiberoptic intubation.A Risdon incision was made to access the mandible. Minimal stripping of the periosteum was performed, thereby preserving the blood supply to the bone. A partial osteotomy was created on the buccal plate until visible bleeding was seen. The corticotomy was continued bicortically at the superior and inferior borders, taking caution to protect the lingual nerve. Upon completion, the distractor, which was prefabricated and adapted to a 3-D model ( Figure 5), was placed along the patients mandible and modified for appropriate fit. The distractor was rigidly fixed to the mandible with several screws to allow for repositioning. The appropriate screw holes were placed, and the distractor was removed to allow completion of the osteotomy with a one-centimeter wide osteotome. The distractor was fixed to the mandible using the previously prepared screw holes. The distractor was activated to ensure movement of the bony segments, and then the device was backed down to the zero position. The vector of dis-

Figure 5. 3-D model with distractor device. NYSDJ MARCH 2008 31

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

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

traction was parallel to the occlusal plane and close to the sagittal plane. The arm of the distractor was placed outside of the wound via a transcutaneous approach. A multiple-layered closure was performed. Antibiotics, analgesics and a mouth rinse were prescribed for daily use postoperatively during the following week.A soft diet was advised during the distraction period. After a latency period of seven days, the device was activated at a rate of 1.00 mm/day, performed in two increments0.5 mm in the a.m. and 0.5 mm in the p.m.for 30 days. The patient visited the office every few days to assess the progress of the distraction. Results were based on clinical observation, postoperative radiographs and postoperative photographs. The patients mandible was elongated successfully, and a satisfactory profile was achieved, with positive soft tissue changes (Figures 6, 7). The patient did not develop sensory disturbances of the inferior alveolar nerve, and he was not subjected to pain at either the distraction site or the TMJs; the distraction period was not uncomfortable. In June 2005, four months after surgery, the transcutaneous activation arms were removed. The distractor remained in place. Several months later, the remaining metal of the distractors seemed to be irritating the overlying skin. In July 2006, the patient was taken back to the operating room to eliminate the irritation from the metal distactors that remained. The consolidation period usually ranges from three and six months, allowing for an optimum regenerate to form. Serial radiographs were taken to evaluate the progression of the healing regenerate. In this case, consolidation was noted on the left side in four months, and at 11 months on the right side. At the time of this submission, there is well-defined bone bilaterally in the distraction sites (Figures 8, 9).
Discussion

Figure 8. Postoperative panoramic radiograph.

Figure 9. Postoperative lateral cephalogram. 32 NYSDJ MARCH 2008

Distraction osteogenesis, also known as callostasis, is a technique of bone generation and osteosynthesis by distraction of an osseous segment. Regeneration of bone occurs between the vascularized bone surfaces that are separated by gradual distraction.9 The technique, which was first described by Codvilla10 in 1905, was written about in the orthopedic literature by Gavril Ilizarov and is sometimes called the Ilizarov method.11 Distraction osteogenesis is an alternative treatment method for the correction of mandibular hypoplasia. Utilizing distraction osteogenesis forgoes the need for bone grafting and associated donor site morbidity.12 It provides an opportunity to provide greater lengthening of the mandible, with potentially greater stability and less relapse compared to conventional surgery.13 Given the significant retrognathic mandible of this patient with a planned elongation of 30 mm, an osteotomy was performed.

As a bone is lengthened by gradual distraction, the surrounding soft tissues also elongate, contributing to improved long-term stability.14,16 In this patient, who presented with significant scarred intraoral mucosa, the gradual distraction of the osseous segments, which in turn gradually stretched the soft tissues, resulted in positive results with well-perfused, non-dehisced soft tissue. Several factors are important to the success of distraction osteogenesis: stability of fixation; displacement of the oseotomy; and the rate and rhythm of distraction.9 While distraction can occur at rates from 0.5 mm to 2 mm per day, 1 mm per day appears optimal9 and was thus used in the treatment of this patient. A modification in the fabrication of the distractors (KLS Martin, Tuttlingen, Germany) used on this patient included 2 mm wide x 5 mm long kleets soldered on both the proximal and distal segments of the distractors. The kleets were adapted to the vertical osteotomy cut. Upon activation of the distractor arms, the kleets and the distractor moved as a unit. The kleets acted as a backup in the event of screw loosening, thereby allowing the distraction to continue. This modification has been used in five additional cases, all with good results.
Conclusion

Using distraction osteogenesis in this patient provided a safe and reliable method for achieving positive results. The slow lengthening of the mandible resulted in osteogenesis and soft-tissue histogenesis,with gradual stretching of the mucosa. In addition, the modifications appeared helpful in providing the distraction to proceed in a predictable fashion.
The authors acknowledge the generous support and collaboration of KLS-Martin LP in the development of this device. Queries about this article can be sent to Dr. Grossman at amgos@yahoo.com.

REFERENCES
1. Fuj ino H, Kyoshoin Y, Katsuki, T. Median cleft of the lower lip, mandible, and tongue with midline cervical cord: a case report. Cleft Palate Craniofac J 1970,7:679. 2. Amaral CM, Cardoso LA, Julio GL, Bueno MA. Median mandibular cleft. J Craniofac Surg 1994,5(5):333. 3. Constantinides CG, Cywes S. Complete median cleft of the mandible and aplasia of the epiglottis. S Afr Med J 1983, 64(8):293. 4. Monroe C. Midline cleft of the lower lip, mandible and tongue with flexion contracture of the neck: case report and review of the literature. Plast Reconstr Surg 1966,38:312. 5. Herman T, Siegel M. Special imaging casebook. J of Periodontology 1995,15(2):63. 6. Oostrom C,Vermeij -Keers C,Gilbert P,Meulen,J.Median cleft of the lower lip and mandible:case reports,a new embryologic hypothesis,and subdivision.Plast Reconstr Surg 1996,97(2):313. 7. Millard DR, Lehman JA Jr, Deane M, Garst WP. Median cleft of the lower lip and mandible: case report. Br J Plast Surg 1971,24:391. 8. Iregbulem LM. Median cleft of the lower lip. Plast Reconstr Surg 1978,61:787. 9. Aronson J. Experimental and clinical experience with distraction osteogenesis. Cleft Palate Craniofac J 1994,31:473. 10. Codvilla A. On the means of lengthening, in lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthop Surg 1905,2:353. 11. Friedman CK, Costantino PD. Use of distraction osteogenesis for maxillary advancement: preliminary results; discussion. J Oral Maxillofac Surg 1994,52:287. 12. Walker D. Management of severe mandibular retrognathia in the adult patient using distraction osteogenesis. J Oral Maxillofac Surg 2002,60:1341. 13. Li K, Powell N, Riley R, et al. Distraction osteogenesis in adult obstructive sleep apnea surgery: a preliminary report. J Oral Maxillofac Surg 2002,60:6.

NYSDJ MARCH 2008 33

The Bennett Angle

Clinical Comparison of Different Recording Methods
Paul J. Boulos, D.D.S. Dr.PH.; Salim M. Adib, M.D., Dr.PH.; Levon J. Naltchayan, D.D.S.
Abstract The use of interocclusal records with semi-adjustable articulators has been proposed as an easier alternative to axiograph. The operator measured the Bennett angle of 30 participants using an axiograph Quick-Axis, an arcon Whip-Mix and non-arcon Dentatus articulators. Wax and polyether interocclusal recording materials were used with both types of articulators. Compared to the reference axiograph, the Whip-Mix plus wax combination was the nearest one and the Dentatus plus polyether was the most significantly different combination.

THE HARMONY OF A DENTAL PROSTHESIS with movements of the jaw is a crucial step toward structural and functional preservation of teeth and oral tissues and reduction of intraoral adjustments. The construction of a dental prosthesis requires use of an articulator able to closely mimic mandibular movements. The articulators condylar settings can be calculated by two methods: extraoral tracing devices and eccentric interocclusal records. Studies that compared extraoral tracing devices in measuring condylar inclinations to eccentric interocclusal records have consistently found that results with the former were more reproducible1 and accurate than with those with the latter. Among the instruments available for extraoral tracing, the simplified jaw tracking devices (Panadent quick analyzer, Whip-Mix quick set recorder, axiograph) are the most practical ones. They record the movements of the jaw in the sagittal plan only in contrast to the more complicated pantograph.
34 NYSDJ MARCH 2008

Various studies have considered the amplitude2-5 and nature of the path of the nonworking condyle in the horizontal plane during lateral excursion, the so-called Bennett angle, especially when an immediate mandibular lateral translation exists.6-11 Investigations have shown that the accuracy of the mechanical axiograph compared favorably with the electronic version in determining the transverse hinge axis.12 Compared to magnetic resonance imaging (MRI), the axiograph showed acceptable results in diagnostic procedures.13 However, extraoral devices are sensitive to the operators skill14 and require additional expenses for equipment. The easier eccentric interocclusal records are widely used and routinely suggested in dental textbooks as an alternative to the axiographs.15 Dos Santos suggested that arcon-type articulators simulated jaw movements more closely than non-arcon types.6 However, Gross et al.16 questioned the reproducibility of three arcon semi-adjustable articulators. And Posselt et al.17 praised the Dentatus articulator for its reliability. Investigations of recording materials in interocclusal records techniques have indicated that elastomeric materials, such as polyether or polyvinyl siloxanes, were superior to wax.18 However, at least one group of authors gave credit to wax over other interocclusal recording materials.19 A clinical trial was conducted to investigate the performance of four methods for measuring Bennett angle (BA),using different combinations of interocclusal materials and semi-adjustable articulators (arcon and non-arcon).This article reports on their respective performances compared to an axiograph that was used as a reference.
Materials and Methods

Thirty dental school graduates and undergraduates of both sexes and between the ages of 18 and 33 agreed to participate in this clinical study. All participants signed an informed consent form. To be eligible, the participants had to have a complete dentition and an

Angle Class I jaw relation and no extractions, artificial crowns or extensive restorations. Participants had to be free of signs and symptoms of temporomandibular disorders or parafunctions, such as bruxism. They could not have any centric slide between the centric relation position and the maximum intercuspation position, to ensure unbiased measurements. All participants were subjected to the same set of combined measurements. Their BAs were measured using the Quick-Axis axiograph (Sintec, East Wakefield, NH). This measurement was considered the standard reference. Their BAs were subsequently measured using interocclusal records on various types of articulators. Procedures An axiograph Quick-Axis (Sintec, East Wakefield, NH) was mounted on the head and the mandible according to manufacturers instructions. The clutch was affixed with quick-setting plaster (Xanthano Hearaus-Kulzer, Inc. Armonk, NY) on the mandibular anterior teeth. The stem of the clutch was centered in relation to the sagittal plane. The incisal edges of the teeth were covered with utility wax (Utility Wax, Round Strips; Henry Schein Co, Melville, NY) to facilitate removal of the clutch later. Participants were asked to hold the clutch in the centered position until the plaster set. The upper part of the axiograph face-bow was secured tightly to the head using the nasal piece, the earpieces and the head band. Special graph papers were fixed on the flags on both sides of the face. The transverse bar was affixed to the stem of the clutch. The lateral arm was attached to the transverse bar, holding a stylus in the direction of the graph papers mounted on the flags. Procedures for measuring BA using the axiograph required that the stylus be replaced with a micrometer, which was zeroed with its tip passively touching the flag at the origin of the axes (Figure 1). The participant was subsequently guided into a contralateral excursion of 3 mm until the tip of the micrometer reached the first arc (Figure 2).At this point, the micrometer was blocked by a lateral screw. The knob of the micrometer was turned clockwise until it stopped, which enabled measurements to be read to 1/10 of a mm (Figure 3) and transformed to an angle according to a chart provided by the manufacturer. Table 1 presents the conversion chart used for this purpose. The same maneuvers were repeated for the right and left sides. Stone casts using an improved dental stone (Silky-Rock; Whip-Mix Corp, Louisville, KY) were obtained for each participant using irreversible hydrocolloid impression material (Jeltrate Dentsply Caulk, Milford, DE) with perforated metallic trays (Coe Stainless Steel Trays; GC America Inc., Alslip, IL). Maxillary casts were mounted respectively on two different semiadjustable articulators with corresponding face-bow transfers: WhipMix #8500 (arcontype) with Whip-Mix Quick Mount (Whip-Mix Corp, Louisville, KY) or Dentatus AHR (non-arcon type) with Dentatus earbow (Dentatus USA, New York, NY), according to manufacturers instructions.Mandibular casts were mounted using centric interocclusal wax records (Beauty Pink Wax; Moyco Union Broach-Thompson, Montgomeryville, PA). Eccentric interocclusal records were made in two sets as required for lateral right and left excursions. An arithmetical mean was computed from the two sets for each condylar setting. Lateral

Figure 1. Zeroed micrometer at origin of axes in centric relation position.

Figure 2. Micrometer at end of eccentric lateral movement. Note displacement visible at center of micrometer.

Figure 3. Reading of displacement, in accordance with white reference line (i.e., here it is 0.5 mm).

TABLE 1 Conversion Table for Calculation of Bennett Angle

Range of Displacement (mm) 0.20 -0.40 0.50 -0.70 0.80 1.00 1.10 1.30 1.40 1.60 1.70 1.90 Bennett Angle (degrees) 5 10 15 20 25 30

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

movements were generated by occluding lightly with opposing canine teeth placed tip to tip. Participants were asked to rehearse the movements in front of a mirror until they were well performed. A 5 mm displacement was considered acceptable when a tip-to-tip relation of anterior teeth was not possible or the eccentric displacement was not sufficient. Two interocclusal recording materials were used for the recordings: wax (Aluwax Bite and Impression Wax, waxed cloth sheets; Aluwax Dental Products Co., Grand Rapids, MI) and polyether (Ramitec by 3M-ESPE AG, Dental Products, St. Paul, MN). The interocclusal records were used within two hours to avoid possible wax distortions. The Whip-Mix and Dentatus articulators
NYSDJ MARCH 2008 35

TABLE 2 Comparison of Bennett Angles Using Various Measurement Techniques (N = 30 patients)

Inclination (in degrees) Axiography Whip-mix + Wax Right Condyle Mean (SD) P-value* Left Condyle Mean (SD) P-value* 10 (4) reference 11.6 (7) 0.22 12.3 (8) 0.13 13.5 (7.2) 0.02 15.8 (7.2) <0.01 12.2 (5.6) reference 13.5 (6.8) 0.27 14.6 (7.5) 0.09 13.8 (7.2) 0.20 15.7 (6.2) <0.01 Whip-mix + Polyether Dentatus + Wax Dentatus+ Polyether

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

were programmed to calculate the condylar inclinations, using the lateral eccentric interocclusal records. Angle measurements were subsequently recorded on the worksheet for every participant. Plan of Analysis The BAs on each side of the jaw for each participant were measured with four different articulator/material combinations and tabulated. The mean values with their corresponding standard deviations (SD) were computed for each combination alone. Every mean value derived from each combination was compared separately to the mean reference value obtained by the axiograph.Differences were tested using the paired t-test and were considered statistically significant with a P-value 0.05.

The aim of the analysis was to identify the combination most similar to the axiograph (that is, upholding the null hypothesis). That combination is the one with the least significant mean difference (that is, the largest possible P-value) from the mean measured by the axiograph. This judgment criteria was applied across all oneto-one comparisons presented in this paper. All computations were conducted with SPSS 11.
Results

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

36 NYSDJ MARCH 2008

was 12.2 degrees (SD = 5.6). The smallest departure from that value by the four alternative methods was obtained with the Whip-Mix articulator with wax (mean: 13.5 degrees; P=0.27). Whip-Mix performed less well with polyether (mean: 14.6 degrees, P= 0.09). The maximum deviation from the axiograph measurement was obtained by the Dentatus articulator with polyether (mean: 15.7 degrees; P<0.01). On the left lateral inclination, the mean angle measured on the axiograph was 10 degrees (SD=4). The departures from that reference value were similar to those found on the right side. Details are presented in Table 2.
Discussion

OA: Magnitude of movement in mm OB: Trajectory of nonworking-side condyle in horizontal plane OC: Immediate mandibular lateral translation : Bennett angle without immediate mandibular lateral translation : Bennett angle with immediate mandibular lateral translation Figure 4. Path of nonworking-side condyle in horizontal plane during lateral excursion movement.

This clinical trial was conducted to evaluate the accuracy of easier alternatives to axiographs in everyday clinical practice. Results presented here suggest that the use of arcon Whip-Mix articulators can reproduce the patients condylar movements in the horizontal plane better than other non-arcon articulators. The use of polyether on non-arcon articulators resulted in significantly different measurements than the axiographs. All other combinations had varying results depending on the side of the jaw that was measured. In this study, the mean BA value of 12.2 degrees, as measured by the axiograph on the right condyle, was similar to that found by Isaacson et al.2 In that paper, a gnathograph was used to measure a mean BA of 12.3 degrees in 36 participants. Curtis et al.3 evaluated 20 patients using the pantograph and found 10.2 degrees as an average BA. The values found in this study and other similar studies are greater than those found by Beard et al.,4 who evaluated 86 patients with an electronic pantograph and calculated a mean BA of 5.15 degrees. The same can be said for findings from Theusner et al.,5 who evaluated 49 patients using a modified SAM axiograph and found a mean BA of 7.8 degrees in the asymptomatic group.Reasons for these discrepancies may be associated with the measurement of the BA after calculation of the immediate mandibular lateral translation, as will be explained later. Mean values of BA found by the interocclusal records on both sides in this study were generally higher than those found with the axiograph, regardless of the recording material or the type of articulator used.This agreed with results reported by Price et al.,11 who compared articulator settings from a computerized pantograph and settings from lateral interocclusal records and concluded that the BA evaluated from the interocclusal record was higher than that evaluated by the pantograph. Dos Santos et al.6 observed in 50% of subjects values of BA on articulators that were greater than the real values. This was also noted by Stern et al.7 When they evaluated the BA using interocclusal wax records with and without taking account of the immediate mandibular lateral translation, the value calculated without the immediate mandibular lateral translation was always higher than the BA evaluated with the immediate mandibular lateral translation. Hobo et al.8 discussed in their study the difference existing in calculating the progressive mandibular lateral translation on the condyle level and outside the face with an extraoral tracing device and concluded that the more laterally the flag was placed outside the face, the smaller the progressive mandibular lateral translation

will be and the greater the immediate mandibular lateral translation will result. The BA values calculated from the interocclusal record will always be higher, especially in the presence of a laterotrusion of the working condyle, as reported to Lundeen et al.9 The lateral movement of the nonworking-side condyle frequently has two components: the immediate mandibular lateral translation and the progressive mandibular lateral translation.10 The immediate mandibular lateral translation is expressed in a tenth of a mm, and the progressive mandibular lateral is translated in degrees. Figure 4, which represents the path of the nonworking-side condyle in the horizontal plane during a lateral excursion move-

NYSDJ MARCH 2008 37

ment, is used to explain the relationship between the BA and the immediate mandibular lateral translation. The curve OB is the path from the centric position to the limit of the movement. The angle formed by the sagittal plane (OA) and the line OB represent the lateral condylar inclination as calculated with a semiadjustable articulator without provision of the immediate mandibular lateral translation. The angle , formed by the sagittal plane (OC) and the line (OB), represents the lateral condylar inclination after the calculation of the immediate mandibular lateral translation (OC). Thus, it becomes obvious that the angle will always be greater than the angle , regardless of the interocclusal recording material or the type of the straight line, semi-adjustable articulator used. The intercondylar distance is adjustable with the Whip-Mix articulator.This characteristic may explain the better performance in measuring the BA compared to the nonadjustable Dentatus articulator. The performance of wax is in contradiction with some findings, suggesting the contrary.18 This discrepancy may be due to the fact that the polyethers might be more accurate in reproducing the incisal and occlusal forms of the teeth than the plaster casts and that they remain nonrigid after setting. Both of these factors can interfere with the placement of the plaster casts into the recording medium during mounting procedures. This was the point of view suggested by Balthazar et al.20 The clinical significance of these results may not be as decisive as the statistical significance since its known that errors in evaluating the BA will affect the ridges and groove positions in the working and nonworking sides and, to a lesser extent, the cusp height. These variations were found to range between 0.18 mm and 0.37 mm on groove and ridge positions for every 5 degrees of error in estimating the BA.21 Clinically, the restorations constructed on the Whip-Mix articulator programmed with lateral interocclusal records will most likely need minor occlusal adjustments in the mouth, especially if the patient has an acceptable incisal guidance.On the other side,restorations,especially fixed prosthesis constructed on a Dentatus articulator programmed with polyether interocclusal records, will present more occlusal prematurities and will subsequently need more intraoral adjustments.
Conclusions

interocclusal recording material was equal to polyether, in contradiction with earlier studies.
This research was funded by research grant number FMD 30 from Saint-Joseph University, office of Vice-President for Research, to the first author. It was performed in memory of our late professor, Dr. Victor O. Lucia, whose remarks to the first author prompted the need to initiate this study. Queries about this article can be sent to Dr. Boulos at polobs@inco.com.lb.

REFERENCES
1. Gross M, Nemcovsky C, TabibianY, et al. The effect of three different recording materials on the reproducibility of condylar guidance registrations in three semi-adjustable articulators. J Oral Rehabil 1998;25(3):204-208. 2. Isaacson D.A clinical study of the Bennett movement. J Prosthet Dent 1958;8(4):641-649. 3. Curtis DA. A comparison of lateral interocclusal records to pantographic tracings. J Prosthet Dent 1989;62(1):23-27. 4. Beard CC, Donaldson K, Clayton JA.A comparison of articulator settings to age and sex. J Prosthet Dent 1986;56(5):551-554. 5. Theusner J, Plash O, Curtis DA, et al. Axiographic tracings of temporomandibular joint movements. J Prosthet Dent 1993;69(2):109-115. 6. Dos Santos J Jr., Ash MM.A comparison of the equivalence of jaw and articulator movements. J Prosthet Dent 1988;59(1):36-41. 7. Stern N, Hatano Y, Kolling JN, et al. A graphic comparison of mandibular border movements by various articulators. Part I: Methodology. J Prosthet Dent 1988;60(2):194-198. 8. Hobo S, Mochizuki S. A kinematic investigation of mandibular movements using an electronic measuring system. Part I: Development of the measuring system. J Prosthet Dent 1983;50(3):368-373. 9. Lundeen TF, Mendoza F. Comparison of two methods for measurements of immediate Bennett shift. J Prosthet Dent 1984;51(2):243- 246. 10. Lundeen HC, Wirth CG. Condylar movement patterns engraved in plastic blocks. J Prosthet Dent 1973;30(6): 866-875. 11. Price RB, Bannerman RA.A comparison of articulator settings obtained by an electronic pantograph and lateral interocclusal recordings. J Prosthet Dent 1988;60(2):159-163. 12. Nagy WW, Smithy TJ, Wirth CG. Accuracy of a predetermined transverse horizontal mandibular axis point. J Prosthet Dent 2002;87(4):387-394. 13. Ozawa S, Tanne K. Diagnostic accuracy of sagittal condylar movement patterns for identifying internal derangement of the temporomandibular joint. J Orofac Pain 1997; 11(3):222-231. 14. ElGheriani AS, Winstanley RB. Graphic tracings of condylar paths and measurements of condylar angles. J Prosthet Dent 1989;61(1):77-87. 15. Shillingburg HT, Hobo S, Whitsett LD, et al. Interocclusal Records: Fundamentals of Fixed Prosthodontics (3rd Ed.). Chicago: Quintessence 1997:44-45. 16. Gross M, Nemcovsky C, Friedlander LD. Comparative study of three semi-adjustable articulators. Int J Prosthodont 1990;3(2):135-141. 17. Posselt UP, Franzen G. Registration of the condyle path inclination by intraoral wax records: variation in three instruments. J Prosthet Dent 1960;10(3):441-454. 18. Fattore L, Malone WF, Sandrik JL, et al. Clinical evaluation of accuracy of interocclusals recording materials. J Prosthet Dent 1984;51(2):152-7. 19. Utz KH, Mller F, Lckerath W, et al. Accuracy of check-bite registration and centric condylar position. J Oral Rehabil 2002;29(5):458-466. 20. Balthazar Y, Fattore LD, Hart TO, Malone WFP. Interocclusal records. In Malone WFP, Koth DL(Ed): Tylmans Theory and Practice of Fixed Prosthodontics (8th Ed). St Louis: Ishiyaku EuroAmerica, Inc. 1989:275. 21. Price RB, Kolling JN, Clayton JA. Effects of changes in articulator settings on generated occlusal tracings. Part I: Condylar inclination and progressive side shift settings. J Prosthet Dent 1991;65(2):237-243.

The values of the Bennett angle recorded from the axiograph were lower than the values recorded from eccentric interocclusal records on both types of articulators. Among all the combinations of various articulators and recording materials, the BA values recorded with the Whip-Mix articulator were the closest to the axiograph on both sides. The advantage of the arcon articulators as a valid alternative to the axiograph has thus been reaffirmed. The poor performance of the non-arcon articulators with polyether has also been a consistent finding on both sides. The results showed that wax used as an
38 NYSDJ MARCH 2008

Epilepsy and Dental Procedures

A Review
Charles K.Vorkas, B.A; Manju K.Gopinathan, M.S., D.D.S.; Anuradha Singh, M.D.; Orrin Devinsky, M.D.; Louis M. Lin, B.D.S., D.M.D., Ph.D.; Paul A. Rosenberg, D.D.S.
Abstract This paper is a review of the dental management of patients with epilepsy. It includes discussion of the effects anti-epileptic drugs have on dental procedures and addresses complications and side effects of these drugs. A clinical case photo is presented to show gingival hyperplasia, along with four tables on which common antiepileptic medications are enumerated.

health. Seizures can cause dental trauma and may occur in a minority of patients, especially those with atonic, tonic and tonicclonic seizures. Dental prosthetics may pose dangers during some seizures. Good communication between the patient, dentist and neurologist can improve dental care.
Clinical History/Patient Management

THE PURPOSE OF THIS ARTICLE is to review the relationship between epilepsy and dental procedures and provide updated information on treating dental patients with epilepsy.Epilepsy and its treatment may present special issues for patients receiving dental care. Neurologists are often asked to provide medical clearance for patients with epilepsy who are about to undergo dental procedures. The safety of dental anesthetics for these patients is an additional concern. Though the vast majority of epilepsy patients can undergo dental procedures without special precautions, dentists should know the patients seizure types and be trained in first aid measures should they become necessary. The physician should provide the dentist with detailed information about patients with poorly controlled seizures. Anti-epileptic drugs, such as Phenobarbital, Phenytoin, Carbamazepine, and Valproic acid, can affect dental

Information about a patients epilepsy should be available to the dentist to improve safety during dental procedures. Dentists often request information from the neurological health-care provider (neurologist, nurse practitioner, nurse) about potential issues of concern. The information the dentist needs differs for patients with well-controlled and poorly controlled seizures. For patients with well-controlled epilepsy, the dentist should know: The patients seizure types, clinical features and frequency. Anti-epileptic drugs the patient is taking. Seizure-related problems during prior dental procedures (Table 1). For patients with poorly controlled seizures, the following supplemental information is helpful: If an aura typically precedes a complex partial or tonic-clonic seizure. Compliance with medication(s). When last blood level was obtained on the current dosage (trough, peak or random). Strategies to prevent seizures.
NYSDJ MARCH 2008 39

TABLE 1 Common AEDs and Their doses for Status Epilepticus in Adults
AEDs Lorazepam Diazepam Fosphenytoin Phenytoin Phenobarbital Depacon Midazolam Propofol Pentobarbital Dose 0.1 mg/Kg (3-6 mg maximum dose) 0.3 mg/Kg (10-20 mg maximum dose) 20mg/Kg at 150mg/min 20mg/Kg at 50mg/min 20mg/Kg at 100mg/min 15mg/Kg followed by 1mg/Kg/h 0.2 mg /Kg bolus followed by 0.05-0.5 mg/Kg/h 1mg/Kg bolus followed by 1-15 mg/Kg/h 5-15 mg slowly followed by 0.5-5 mg/Kg/h

The vast majority of epilepsy patients require few precautions for dental procedures.
Factors that provoke seizures. Emergency protocol for prolonged seizures or clusters (e.g., rectal diazepam). Dentists treating patients with active epilepsy should learn basic first aid for seizures. This information can be found on Web sites (epilepsy.com), in books3,9 or from videotapes available from the Epilepsy Foundation of America (for example,How Medicines Work, Understanding Complex Partial Seizures; 2003). The vast majority of epilepsy patients require few precautions for dental procedures. If patients are compliant with anti-epileptic drugs (AEDs) and are seizure-free, both the patient and the dentist can be reassured. Indeed, following standard protocols for dental therapy may prove the safest and most effective strategy.Changes to routine dental or neurological care can sometimes lead to adverse outcomes. For patients with uncontrolled seizures, benzodiazepines (for example, lorazepam 0.5 mg 1.0 mg) may be given 30 to 45 minutes before the procedure, especially if one of the patients seizures could pose a danger during the procedure. The unpredictable nature of seizures makes it difficult to ensure freedom from seizures during dental procedures. However, most patients can identify factors that are associated with an increased risk of seizures. The most common factors are sleep deprivation, stress, time of menstrual cycle (catamenial epilepsy; premenstrual, menstrual and ovulatory periods), non-compliance, alcohol use and illness.19,29 Thus, patients should rest well and avoid alcohol before procedures. Patients with seizures provoked by stress, especially those who had seizures during prior dental procedures, may benefit from a stress-reduction protocol. Patients with catamenial epilepsy should schedule procedures during low-risk periods.21
AEDs and Dental Procedures

TABLE 2 Side Effects of Anti-Epileptic Drugs

AED Carbamazepine Lamotrigine Phenobarbital Common Side Effects Relating to Dental Procedures ulceration, xerostomia, glossitis and stomatitis xerostomia and oral ulcers hepatic enzyme induction (impaired dental health) Phenytoin gingival hyperplasia Rarely causes thrombocytopenia, neutropenia, aplastic anemia, sedation. hepatic enzyme induction (impaired dental health) Primidone hepatic enzyme induction (impaired dental health) Valproate Can cause thrombocytopenia and decrease platelet aggregation and function. Rarely causes gingival hyperplasia. CBZ, ESM, LTG, OXC, PB, PHT, PRM, TPM and VPA leukopenia

Patients should take their AEDs as usual before undergoing dental or other procedures.10 Depending on the individual case and factors (for example, uncontrolled seizures, variable compliance), it may help to confirm therapeutic AED blood levels before major dental procedures.17 Patients should be especially vigilant about compliance during the days before a dental procedure. There are no clinically significant interactions between AEDs and the local anesthetics that are commonly used. Common side effects of AEDs related to dental procedures are listed in Table 2.
Hemorrhagic Complications

Figure 1. Clinically, initial lesion usually begins as painless enlargement of facial and lingual/palatal-free gingival and interdental papillae, where anterior maxillary and mandibular teeth are involved. 40 NYSDJ MARCH 2008

Valproic acid (VPA) can cause thrombocytopenia and decrease platelet aggregation and function in patients with normal platelet counts.5,24,27,42 The clinical significance of VPA-induced platelet disorders in dental procedures remains uncertain. The lack of reports

TABLE 3 Common Drug Interactions with Anti-epileptic Therapy

about complications during dental procedures suggests that coagulopathy evaluations (for example, bleeding times) are not needed. However, the most recent platelet count should be reviewed before a major dental procedure.For patients with a history of excessive bleeding on VPA, a clotting profile with bleeding time should be considered.14 For patients with thrombocytopenia (<50,000) from VPA or as a rare complication of other AEDs (for example, carbamazepine, phenytoin or felbamate), elective procedures should be postponed until the platelet count improves or another AED is substituted.
Oral/Dental Side Effects of AEDs

Drugs Prescribed by DHCP

Side Effects/Interaction with Anti-epileptic Therapy

Antibiotics
Macrolides Erythromycin and troleandomycin are the most potent inhibitors of CBZ metabolism. Clarithromycin, flurithromycin, josamycin, midecamicin, miocamycin and roxithromycin are moderate inhibitors of CBZ metabolism. Penicillins Benzylpenicillin is more likely to cause seizures than semi-synthetic penicillins. Concurrent use of carbenicillin, piperacillin or ticarcillin may increase bleeding tendencies.

Gingival hyperplasia or enlargement is most often a complication of phenytoin (PHT) (Figure 1), but also results from Phenobarbital (PB)47,51 and, rarely, VPA.2 The free gingival and interdental papillae on the facial and lingual aspects of maxillary and mandibular anterior teeth are involved most frequently and severely.51 PHT is excreted in the saliva and promotes fibrous gingival hyperplasia.21,22 Gingival hyperplasia develops in up to 50% of patients within three months after taking PHT.34,44 It can occur at any age, but is seen more frequently in children.23 Males and females are equally affected.41 There is no clear correlation between PHT serum levels and the severity of gingival hyperplasia.30 Gingival overgrowth usually resolves within six months after PHT is discontinued.7 The mechanism underlying the proliferation of connective tissues is unknown.50 Poor dental hygiene contributes to hyperplasia but cannot fully account for lesions. Bacteria-laden plaque can exacerbate gingival lesions, due to inflammation,28 but the role of plaque in PHT-induced gingival hyperplasia remains controversial. High-plaque levels correlate with the severity of hyperplasia.30,52 Plaque removal cannot prevent gingival hyperplasia in individuals on PHT.30 Genetic factors may contribute to gingival hyperplasia, since some patients with poor oral hygiene on chronic high-dose PHT do not develop gingival hyperplasia.44 Oral hygiene regimens (for example,brushing,flossing and regular cleanings by a dental hygienist) can help prevent or reduce plaque and gingival hyperplasia.1,30 Chlorhexidine and folic acid rinses are recommended by some.45 Oral hygiene should be initiated prior to, or as soon as possible after, the start of PHT therapy.30 In cases in which hyperplasia is severe, gingevectomy may be necessary. When oral hygiene is difficult or gingival hyperplasia severe, alternative AEDs should be considered. CBZ can cause oral complications, including ulceration, xerostomia, glossitis and stomatitis.14 Xerostomia is associated with an increased risk of dental caries and oral candidiasis.46 Lamotrigine (LTG) can also cause xerostomia and oral ulcers. If these conditions persist, a topical fluoride can be used to help prevent caries. Clinically significant leukopenia from AEDs is rare, but when present, it may predispose the patient to dental infections.
AED Interaction with Other Drugs

Antiprotozoal
Metronidazole Can inhibit the metabolism of CBZ. Concurrent use with CBZ, PHT or PB may decrease plasma levels of metronidazole. Rarely causes xerostomia. Rarely convulsant. Narcotic analgesics Dextropropoxyphene can inhibit metabolism of PHT, CBZ and PB.

Non-steroidal anti-inflammatory drugs

(aspirin, ibuprofen) Carbohydrate-based toothpaste & antibiotics

Concurrent use with VPA may exacerbate bleeding problems. Can inhibit the metabolism of PHT. Compromise a ketogenic diet.

TABLE 4 Anesthesia for Epilepsy Patients

Anesthetic Benzodiazepines Side Effects/Observations Anticonvulsant Midazolam rarely convulsant during intravenous use for sedation. Enflurane Flumazenil Lidocaine Convulsant Convulsant Can be used with adrenaline as a local anesthetic agent. Methoxitone Nitrous Oxide Convulsant Anticonvulsant Reduces risk of stress-induced seizure. Nitrous Oxide/ Oxygen Visteril DZP Versed
NYSDJ MARCH 2008 41

Used for conscious sedation in mentally and/or physically handicapped patients. Can be used safely in normal therapeutic doses.

Interactions between some commonly prescribed drugs and AEDs are presented in Table 3. Antibiotics that are most often prescribed

by dentists may interact with AEDs and potentially cause side effects or seizures. For example, some antimicrobials interfere with the absorption or metabolism of AEDs, resulting in either increased or decreased plasma AED levels.40 AEDs can also modify the pharmacokinetics of antimicrobials, leading to loss of efficacy or toxicity.33 However, these effects are rarely clinically significant.
Epilepsy and Anesthesia

Conversely,VPA can increase the plasma concentration of LZP39 and DZP.11 Because benzodiazepines have a wide therapeutic index, the clinical significance of these interactions is usually small.33 The side effects related to use of anesthetics with epilepsy patients are given in Table 4.
Behavioral Management

Local anesthetic agents are usually safe for people with epilepsy. Low doses of lidocaine in dental local anesthetic cartridges are not associated with seizures,37 although accidental administration intravenously could potentially provoke a seizure. AEDs that depress CNS function (for example,benzodiazepines or barbiturates) increase the depressant effects of anesthetic agents. Patients undergoing conscious sedation must be monitored closely, as they often require lower doses of anesthetic agents. However, patients on chronic benzodiazepines show a tolerance to short-term benzodiazepine therapy (for example, midazolam).35 Midazolam (MZL) can cause seizures in patients receiving this agent intravenously for sedation.36 Benzodiazepine receptor antagonists (for example, flumazenil) can provoke seizures and should be avoided.16 Enzyme-inducing AEDs enhance the metabolism of most benzodiazepines, reducing their plasma concentration.48

Inhalational sedation with nitrous oxide or intravenous sedation with a benzodiazepine might reduce the risk of a stress-induced seizure in susceptible patients.14 Behavioral management, combined with conscious sedation using nitrous oxide/oxygen, is often used for severely mentally and physically handicapped patients. A small number of these patients cannot be adequately managed by this technique alone because of their restricted coping resources and inability to carry out continuous nasal breathing, essential for nitrous oxide administration by nasal mask.32 Elective procedures may be delayed if the patient is in a period of increased seizures or behavioral problems. In some patients, however, general anesthesia is required. Patients should take their medication throughout the perioperative period. AEDs should be administered orally with a small amount of water before general anesthesia.
Trauma, Prosthetic Dentistry, Oral/Maxillofacial Therapy

Patients with epilepsy have increased risk of dental trauma.20 The side effects related to the use of anesthetics with patients with epilepsy are given in Table 4. Falls can complicate atonic, tonic and tonic-clonic seizures, causing soft tissue lacerations, facial fractures, temporomandibular joint subluxation and devitalization, fractures, and subluxation or avulsion of teeth.18,42 Patients with LennoxGataut syndrome, who are prone to suffer from multiple seizure types associated with falls, are also prone to suffer dental trauma. Helmets may be used to prevent head trauma, but they often fail to provide protection of the mouth and jaw. In a study of 33 children who were prescribed helmets for intractable seizures causing falls, helmets did not appear to reduce the risk of facial or scalp injury: Twenty-one out of thirty-one (68%) injuries occurred when a helmet was worn, while 16 out of 28 (57%) occurred when a helmet was not worn.8 In a prospective study of multi-handicapped adults with epilepsy, dental injuries accounted for only 5% of seizure-related accidents.31 In a retrospective survey in adult patients, 9.7% reported a dental injury during a seizure; in 86% of these cases, the trauma caused tooth loss or jaw fracture.6 Some patients who lose teeth receive inadequate prosthodontic treatment.20 For example, significantly more epilepsy patients have nickel-chrome rather than the more aesthetic metal-ceramic fixed prostheses.20 Fixed prostheses are preferred over removable partial dentures because of the danger of seizure-related injuries and aspiration. If a removable denture is unavoidable, then a metal base is preferred,
42 NYSDJ MARCH 2008

to minimize the chances of fracture.41 Acrylic facings on anterior crowns can facilitate future repair should a fracture occur.4,38 Replacement of missing teeth may prevent the tongue from being caught in the edentulous spaces during seizures.15 Oral and maxillofacial surgeons treat epilepsy patients regularly for routine as well as reconstructive surgery. Patients with vagus nerve stimulator implants should have them turned off before surgery.53
Conclusion

Patients with well-controlled seizures can be easily treated in routine dental office settings. Such patients are risk category II under the American Society of Anesthesiologists (ASA) Physical Classification System. This is the same risk category as an otherwise healthy patient who is apprehensive, pregnant, has allergies or is over age 60.21 Patients with poorly controlled seizures or poor compliance are ASA risk category III (severe but not incapacitating system disease) or ASA risk category IV (incapacitating disease that is a constant threat to life).26 These higher-risk patients may best be treated in specialized care settings.49
Queries about this article can be sent to Dr. Devinsky at Od4@nyu.edu.

REFERENCES
1. Addy V, McElnay JC, Eyre DG, Campbell N, DArcy PF. Risk factors in Phenytoin-induced hyperplasia. J Periodontol 1983; 54: 373-377. 2. Anderson HH, Rapley JW, Williams DR. Gingival overgrowth with valproic acid: a case report. ASDC J Dent Child 1997;64:294-7. 3. Bazil C. Living Well with Epilepsy and Other Seizure Disorders, 1st Ed. New York: Harper Collins, 2004. 4. Braham, RL, Casamassimo PS, Nowak AJ, Psnick WR, Steiberg AD. The dental implications of epilepsy. Rockville, Md.: U.S. Department of Health Education and Welfare, 1977; DHEW publication no. HSA78-5217. 5. British Dental Association, British Medical Association, Royal Pharmaceutical Society of Great Britain. Dental Practitioners Formulary 1998-2000. London: pp. 210-220. 6. Buck D, Baker GA, Jacoby A, Smith DF, Chadwick DW. Patients experiences of injury as a result of epilepsy. Epilepsia 1997;38:439-444. 7. Dahllf G,Axio E, Moder T. Regression of phenytoin-induced gingival overgrowth after withdrawal of medication. Swed Dent J 1991; (1593): 139-43. 8. Deekollu D, Besag FM,Aylett SE. Seizure-related injuries in a group of young people with epilepsy wearing protective helmets: Incidence, types and circumstances. Seizure 2005;14:347-353. 9. Devinsky O. Epilepsy: Patient and Family Guide, 2nd Ed. Philadelphia: FA Davis, 2002. 10. Devinsky O, Paraiso JO, Rosenberg A, Nordli Jr DR. Procedures in Patients with Epilepsy (Chapter 186). In: Engel J Jr, Pedley T (eds): Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven, 1997. 11. Dhillon S, Richens A.Valproic acid and diazepam interaction in vivo. Br J Clin Pharmacol 1982; 13: 553-60. 12. Epilepsy Foundation of America, Inc. www.epilepsyfoundation.org, 2003. 13. Epilepsy Therapy Development Project. www.epilepsy.com, 2005. 14. Fiske J. Epilepsy and Oral Care. Dental Update 2002; 29:180-187. 15. Friedlander AH, Brill NQ. The dental management of depressed patients. Spec Care Dent 1987; 7:65-6. 16. Greenwood M. General medicine and surgery for dental practitioners Part 4: Neurological disorders. Br Dent J. 2003 Jul 12;195(1):19-25. 17. Grisham PL. Clinical Considerations in Dental Patients with Convulsive Disorders. Dent Clin North Am. 1982 Jan;26(1):123-7. 18. Grundy MC, Shaw L, Hamilton DV.An Illustrated Guide to Dental Care for the Medically Compromised Patient. London: Wolfe Publishing, 1993. 19. Herzog AG, Harden CL, Liporace J, Pennell P, Schomer DL, Sperling M, Fowler K, Nikolov B, Shuman S, Newman M. Frequency of catamenial seizure exacerbation in women with localization-related epilepsy. Ann Neurol 2004 Sept;56(3): 431-4.

20. Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with epilepsy. J Prosthet Dent. 2005 Feb;93(2):177-82. 21. Kennedy BT, Haller JS. Treatment of the epileptic patient in the dental office. NYSDJ 1998 Feb;64(2):26-31. 22. Kimball O. The treatment of epilepsy with sodium diphenyl-hydantoinate. JAMA 1939;112: 1244-1245. 23. Klar LA. Gingival hyperplasia during dilantin therapy; a survey of 312 patients. J Pub Health Dent 1973;33(3):180-5. 24. Lackmann GM. Valproic-acid-induced thrombocytopenia and hepatotoxicity: discontinuation of treatment? Pharmacology 2004 Feb;70(2): 57-8. 25. Little JA, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 6th Ed. Mosby; 2002; 420-423. 26. Malamed S. Medical Emergencies in the Dental Office. 4th Ed. Mosby; 1993; 42. 27. Mallet L, Babin S, Morais JA. Valproic acid-induced hyperammonemia and thrombocytopenia in an elderly woman. Ann Pharmacother 2004 Oct; 38(10): 1643-7. 28. Marrioti A. Dental Plaque-Induced Gingival Diseases.Annals of Periodontology,Volume 4 Number 1, December 1999,7-17. 29. Mattson RH, Fay ML, Sturman JK, et al. The effect of various patterns of alcohol use on seizures in patients with epilepsy. In: Porter RJ, Mattson RH, Cramer JA, et al., eds. Alcohol and Seizures: Basic Mechanisms and Clinical Concepts. Philadelphia: FA Davis, 1990: 233-240. 30. Moder T, Dahlff G. Development of phenytoin-induced gingival overgrowth in noninstitutionalized epileptic children subjected to different plaque control programs. Acta Odontol Scand 1987; 45(2): 81-5. 31. Nakken KO, Lossius R. Seizure-related injuries in multihandicapped patients with therapy-resistant epilepsy. Epilepsia 1993;34:836-840. 32. Oei-Lim VL, Kalkman CJ, Bouvy-Berends EC, Posthumus Meyjes EF, Makkes PC, Vermeulen-Cranch DM, Odoom JA, van Wezel HB, Bovill JG.A comparison of the effects of popofol and nitrous oxide on the electroencephalogram in epileptic patients during conscious sedation for dental procedures. Anesthesia and Analgesia 1992;75:708-714. 33. Patsalos PN, Perucca E. Clinically important drug interactions in epilepsy: general features and interactions between antiepileptic drugs. Lancet Neurol 2003;2:347-56. 34. Prasad VN, Chawla HS, Goyal A, Gauba K, Singhi P. Incidence of phenytoin induced gingival overgrowth in epileptic children: a six month evaluation. J Indian Soc Pedod Prev Dent 2002;20:73-80. 35. Robb ND, Hargrave SA. Tolerance to intravenous midazolam as a result of oral benzodiazepine therapy: a potential problem for the provision of conscious sedation in dentistry. Anesth Pain Control Dent 1993;2:94-97. 36. Robb ND.Epileptic fits under intravenous midazolam sedation.Br Dent J 1996;181:178-179. 37. Rood JP. Local anaesthesia and the medically compromised. Dent Update 1991:18:330-334. 38. Rucker LM. Prosthetic treatment for the patient with uncontrolled grand mal epileptic seizures. Spec Care Dentist 1985;5 (5):206-207. 39. Samara EE, Granneman RG, Witt GF, Cavanaugh JH. Effect of valproate on the pharmacokinetics and pharamcodynamics of lorazepam. J Clin Pharmacology 1997;37:442-50. 40. Sander JW, Perucca E. Epilepsy and comorbidity: infections and antimicrobials usage in relation to epilepsy management. Acta Neurol Scand 2003:108 (Suppl 180):16-22. 41. Sanders, Brian J. Managing patients who have seizure disorders; dental and medical issues. J Amer Dent Assoc Dec 1995;126. 42. Scully C, Cawson RA. Medical Problems in Dentistry. 4th Ed. Oxford:ButterworthHeinemann, 1998. 43. Seymour RA, Smith DG, Turnbull DN. The effects of phenytoin and sodium valproate on the periodontal health of adult epileptic patients. J Clin Periodontol 1985;12:413-419. 44. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug-induced gingival overgrowth. J Clin Periodontol 2000;27: 217-223. 45. Siegel MA, Silverman S, Sollecito TP, eds. Clinicians Guide to Treatment of Common Oral Conditions. 5th Ed. Baltimore: American Academy of Oral Medicine 2001:10-11. 46. Silverman S. Oral cancer: complications of therapy. Oral Surg Oral Med Oral Path Oral Radiol Endoton 1999;88:122-126. 47. Sinha S, Kamath V, Arunodaya GR, Taly AB. Phenobarbitone induced gingival hyperplasia. J Neurol Neurosurg Psychiatry 2002;73:601. 48. Spina E, Perucca E. Clinical significance of pharmacokinetic interactions between antiepileptic and psychotropic drugs. Epilepsia 2002; 43 (suppl 2): 37-44. 49. Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22(3): 26S-39S. 50. Stinett E, Rodu B, Grizzle WE. New development in understanding phenytoin-induced gingival hyperplasia. JADA 1987;114: 814-6. 51. Stroopler ET, Sollecito TP, Greenberg MS. Dent Art Rev Test 2003;July-Aug:361-6. 52. Thomason JM, Seymour RA, Rawlins MD. Incidence and severity of phenytoin induced gingival overgrowth in epileptic patients in general medical practice. Community Dent Oral Epidemio 1992;20:288-91. 53. Turner MD, Glickman RS. Epilepsy in the oral and maxillofacial patient: current therapy. J Oral and Maxillofac Surg 63:996-1005, 2005.

NYSDJ MARCH 2008 43

Gingival Hemangioma with Port Wine Nevi of the Face

A Case Report
Shridhara B. Reddy, M.D.S.; Shiva Prasad, B.M., M.D.S.; Sudhir R. Patil, M.D.S.; Nagaraj B. Kalburgi, M.D.S.; S.S. Vanaki, M.D.S.; R.S. Puranik, M.D.S.
Abstract Hemangioma is a proliferating mass of blood vessels. Its occurrence in gingiva is rare. The diagnosis and treatment of hemangioma is complex, and any attempt to carry out biopsy/surgical excision may lead to fatal consequences due to severe hemorrhage. A rare case of gingival hemangioma with port wine nevi of face is reported. The case is of periodontal interest because the lesion occurred on the gingiva, a reliable diagnostic approach (Ultrasound Spectra Doppler Flow) was used and a conservative treatment using a sclerosing agent was employed.

HEMANGIOMA is a common tumor of the head and neck characterized by the proliferation of blood vessels. It may involve soft tissue and/or bone, and is considered to be a hamartoma rather than a true neoplasm.1 Failure to judge the presence of hemangioma before the initiation of surgical therapy (for example, biopsy or extraction) may lead to severe hemorrhage. Soft-tissue hemangioma is not an unusual tumor in the oral cavity. The most commonly involved site is the tongue, followed by lips, cheek and palate. Hemangioma of gingiva is uncommon.
44 NYSDJ MARCH 2008

Excess levels of angiogenic factors like basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) or decreased levels of angiogenesis inhibitors such as gamma-interferon, tumor necrosis factorbeta and transforming growth factorbeta may play a role in the etiology of hemangiomas.2 The diagnosis of the hemangioma is made on the basis of clinical, radiological/imaging findings, most commonly, angiography and Doppler sonography. The treatment of hemangioma is still a matter of debate. There are published reports of success with several treatment modalities. The choice of treatment depends on the size and location of the lesion, the age of the patient and anticipated complications. Different treatment modalities include irradiation, injection of sclerosing agents, cryotherapy, embolization, interferon-a, laser, electrocoagulation and surgery.3 Sclerosing agents such as sodium morrhuate, sodium psylliate and absolute ethanol have been used successfully but produce adverse effects, including pain, allergic reaction and even anaphylactic shock.4 Sodium tetradecyl sulphate is considered an ideal sclerosing agent and is associated with minimal systemic and local reaction.5 The case presented here is of periodontal interest because the lesion occurred on the gingiva. It was diagnosed using Ultrasound Spectra Doppler Flow and was treated conservatively using a sclerosing agent.

Case Report

A 30-year-old male patient presented to the Department of Periodontics with a solitary, nodular intraoral swelling of the posterior maxillary region of one-year duration. The swelling gradually increased in size and interfered with mastication. History revealed occasional bleeding on mastication, which used to subside on its own. The patients hereditary and familial histories were not significant. Intraoral examination revealed a 2.0 cm x 3.0 cm solitary, sessile swelling of reddish granular appearance that extended from the mesial of tooth #15 to the buccal half of tooth #17. It covered the buccal, occlusal and palatal aspects of the involved teeth and resembled pyogenic granuloma (Figures 1, 2). The lesion was pulsatile, compressible and exhibited signs of emptying on digital pressure with thrills. On auscultation, clear bruits could be heard. No other area of the oral cavity showed the presence of similar swelling. Moderate stains and calculus with generalized bleeding on probing were present. Other dental findings included: 1. Grade II mobility in relation to tooth #14 and Grade III mobility with respect to teeth #15 and #16; 2. teeth #18 and #22 were missing; 3. root stumps in relation to tooth #46. A routine hematological profile was within the normal limit. It was interesting to note that the patient had diffuse port wine nevi on the right side of his face. It had been present since birth and was not connected to the intraoral swelling (Figure 3). Intraoral periapical radiograph showed the periodontal ligament thickening along the roots of pathologically migrated teeth #15 and #16 with the loss of lamina dura. A slight change in the alveolar bone pattern was noted in the interdental bone between teeth #15 and #16, which may have been caused by the pressure effect of the lesion. Overall radiological findings were suggestive of localized periodontitis in relation to teeth #15 and #16. A CT scan revealed no extension of the lesion to underlying structures, like bone and sinus. Nor was the lesion related to the port wine stain present extraorally. Ultrasound sonography showed a diffuse enlarged mass of 2 cm x 2 cm in diameter on the right posterior area of the maxilla. Ultrasound Spectral Doppler Flow (Figure 4) imaged a high density of vessels, suggesting a high vascular nature of the lesion. With the help of the Doppler probe, the course of the feeding vessel was detected. External carotid angiography was attempted but could not be completed because of patient factors. Given the clinical and imaging findings, the diagnosis of gingival hemangioma was rendered to the lesion. The root stumps were extracted and the carious teeth were filled. Meticulous oral prophylaxis was performed.After anesthetizing the area, an intralesional sclerosing agent in aliquots of 0.05 cc to 0.1 cc was injected using a 25-gauge needle at multiple sites. The total dose did not exceed 0.7 cc to 0.9 cc. Injections were repeated 8 times at 15-day intervals. At each visit, Ultrasound Spectral Doppler Flow was done in the Radiology Department of HSK Medical College in Bagalkot, Karnataka, India. The patient was followed for six months without evidence of recurrence (Figure 5).

Figure 1. 2 cm x 3 cm sessile granular soft tissue mass in relation to teeth #15, #16 region (buccal view).

Figure 2. Palatal extension of lesion.

Figure 3. Port wine nevi of right side of face.

Figure 4. Ultrasound Spectral Doppler flow showing increased vascularity.

Figure 5. Six months postoperative. NYSDJ MARCH 2008 45

TABLE 1. Substantiation of Rarity of Present Case

Criteria Arch Sex Location Reported Cases Mandible Female Tongue, lips, cheek, palate Present Case Maxilla Male Gingiva

Discussion

Hemangiomas are benign lesions with increased numbers of blood vessels. They are tumor-like malformations composed of seemingly disorganized masses of endothelium-lined vessels that are filled with blood and connected to the main blood vascular system. They affect numerous tissue types (individually or in combination), including the skin, subcutaneous tissue, viscera, muscle, synovium and bone.2 The case presented here is rare and is of periodontal interest because the lesion occurred on the gingiva (Table 1).Positive response to treatment was evident clinically as shrinkage of the lesion and was confirmed through Doppler ultrasound, which revealed decreased vascularity. It may be analyzed audibly by listening to the intensity and pitch of the sound and may be recorded graphically either as a simple wave form or as a more complete sound spectrum analysis.6

Sclerosing agents have been used for many years to manage hemangiomas of the jaws. This is still an acceptable mode of therapy in selected cases, either alone or in conjunction with surgical excision.Sclerosing agents cause cell death inflammation and fibrosis. The fibrosis leads to sclerosis of the vessels, which subsequently leads to regression of the lesion. A sclerosing agent was chosen in this case after considering the following clinical aspects: The surgical excision of the large hemangioma would be extremely dangerous and fatal due its hemorrhagic complications. The sessile growth of the lesion over a large area of gingival and periodontal structures made complete excision of the lesion impossible. Sodium tetradecyl sulphate proved to be a powerful, almost ideal sclerosing agent. It was associated with minimal local and systemic adverse reactions. This agent has been reported to be an ideal agent in treating similar lesions.
Conclusion

Hemangiomas are tumor-like lesions of blood vessels that can proliferate in soft tissue. Diagnosis of the lesion and monitoring its vascularity with Doppler ultrasound consistently yields a good result and can save both time and money for the clinician and the patient. Sodium tetradecyl sulphate has proved to be a powerful and almost ideal sclerosing agent. Cautious diagnosis, treatment and monitoring of the hemangioma can enable the periodontist and general practitioner to differentiate it from conventional epulides and treat it without a major setback.
Queries about this article can be sent to Dr. Shiva Prasad at drshivaprasad2000@rediffmail.com.

REFERENCES
1. Neville BW, Damn DD,Allen CM, Bouquot. Soft tissue tumors. In: Neville BW, Damn DD, Allen CM, Bouquot (eds). Oral and Maxillofacial Pathology. Philadelphia: WB Saunders 1995:467. 2. Rossiter JL, Hendrix RA, Tom CW, Potsic WP. Intramuscular hemangioma of the head and neck. Otolaryngol Head Neck Surg 1993;108:18-26. 3. Bunel K, Steen S-P. Central hemangioma of the mandible. Oral Surg Oral Med Oral Pathol 1993; 75:565-70. 4. Chin D. Treatment of maxillary hemangioma with a sclerosing agent. Oral Surg 1983; 55(3):247-249. 5. Baurmash H, Mandel L. The nonsurgical treatment of hemangioma with sotradecol. Oral Surg Oral Med Oral Pathol 1963;16(7):777-782. 6. Van Doorne L, De Maeseneer M, Stricker C. Br J Oral Maxillofac Surg 2002;40:497-503.

46 NYSDJ MARCH 2008

Preferred Treatment Methods for Primary Tooth Vital Pulpotomies

A Survey
Richard K. Yoon, D.D.S.; Steven Chussid, D.D.S.; Martin J. Davis, D.D.S.; Karl C. Bruckman
Abstract This investigation evaluated preferred treatment methods for primary tooth vital pulpotomies. One hundred and thirty surveys were sent to a randomly selected sample of board-certified pediatric dentists practicing in the United States. Ninety-two questionnaires were returned, for a 71% response rate. This yielded a sample group of 92 boardcertified pediatric dentists. The most commonly used medicament was formocresol. Seventy-three percent using formocresol said they were not concerned about adverse side effects of formocresol and formaldehyde. Sixty-one percent of respondents used formocresol for primary tooth vital pulpotomies. Twenty-eight percent of respondents used undiluted, and 33% used diluted. The results of this survey suggest that the majority of dentists who used formocresol were not concerned with any adverse effects.

UNTREATED DENTAL CARIES remains a significant problem among American children.1 The Centers for Disease Control reported in August 2005 a caries prevalence among 2 to 5 year olds of 28%, which represents an increase of 15.2% over 8 to 10 years.2 This finding of continuing high prevalence is important to young children and their families since early caries often results in pain, infection and dysfunction. Pharmacotherapeutic approaches, such as vital pulpotomies, facilitate the maintenance of pulpally compromised primary teeth, allowing restoration and healthy function. Efficacy studies on widely used pulp medicaments such as formocresol and ferric sulfate demonstrate overall clinical success rates ranging from 55% to over 90%.3-15 In a survey of primary tooth pulp therapy, as taught in predoctoral pediatric dental programs in the U.S., Primosh concluded that the diluted formulation of formocresol is the preferred technique in a pulpotomy procedure.16 Further, pediatric dental textbooks recommend the diluted formulation.17-19 Hunter, in a 2003 survey of specialists in pediatric dentistry practicing in the United Kingdom, examined clinician attitudes about vital pulpotomies in the primary dentition.20 The most widely used medicament was diluted formocresol. Half of the respondents expressed concern regarding the formaldehyde incorporation in formocresol.Approximately half of the respondents were considering changing their current technique.20
NYSDJ MARCH 2008 47

TABLE 1 Our study sought to survey Preferred Medicament Employed in Vital Pulpotomy Technique board-certified pediatric dentists Frequency Percent Valid Percent Cumulative Percent practicing in the U.S. to: 1. determine their preferred technique Valid Formocresol (1:5 dilution) 30 32.6 32.6 32.6 and medicament for primary Formocresol (full strength) 26 28.3 28.3 60.9 tooth vital pulpotomies; and 2. Ferric Sulfate 29 31.5 31.5 92.4 evaluate any concerns of toxicity Other* 7 7.6 7.6 100.0 regarding their chosen medicaTotal 92 100.0 100.0 ment.A survey of the members of * Electrosurgery, calcium hydroxide, laser, sodium hypochlorite, mineral trioxide aggregate, no medicament the American Board of Pediatric Dentistry (ABPD) was used to establish current trends concerning Results vital pulpotomies in primary teeth. The ABPD is considered a valid One hundred thirty surveys were mailed out. Ninety-two completsample of the members of the American Academy of Pediatric ed questionnaires were returned, for an acceptable return rate of Dentistry (AAPD) at large.21 71%. The distribution of responses was approximately equal from each AAPD Trustee District. Methods Table 1 illustrates respondents preferred medicaments. After Institutional Review Board approval, a survey containing an Formocresol was most widely chosen by 61% of the sample, with explanatory letter, questions inquiring about preferred techniques 33% of all respondents having chosen the diluted formulation. In for primary tooth vital pulpotomies and a prepaid return envelope no particular order, electrosurgery, calcium hydroxide, laser, sodiwas mailed to 130 practicing pediatric dentists certified by the um hypochlorite and mineral trioxide aggregate were specified as ABPD. Respondents were selected randomly by district. Survey being favored by respondents using othertechniques or medicaquestions requested information on the following: 1. preferred vital ments. Two respondents said they used no medicament at all. pulpotomy technique; 2. justification for medicament chosen; and Eighty-two of the 92 respondents (89% of the sample group) 3. concerns regarding possible undesirable side effects of the choindicated that the medicament they used was one to which they had sen medicament. Responses were analyzed by number of years in been introduced as a postdoctoral student. Of these, ninety percent practice and region and were tabulated as frequencies. said they were not concerned about the adverse side effects of their chosen medicament. Other reasons provided for use of chosen medicament were patient safety and literature. Seventy-six of the 92 respondents (83% of the sample group) said they had no concerns about their preferred topical medicament. Of the respondents using formocresol, 73% said they had no concerns (for example, toxicity, mutagenicity and carcinogenicity of formocresol and formaldehyde) about their chosen medicament. An analysis of responses for association between preferred medicament by region and number of years in practice yielded no significant associations. Respondents using formocresol provided 56 free text comments, and several trends seemed to emerge. These included: a reduction in application time (n = 15); a tendency to blot the cotton pellet dry (n = 35); and a belief that formocresol is still the gold standard and safe if used properly (n = 6).

Discussion

The choice of topical medicaments for fixation and disinfection of remaining tissue in vital pulpotomies remains controversial. Current clinical guidelines from the AAPD find a variety of techniques acceptable, among them, formocresol, ferric sulfate or electrosurgery.22 Evidence relating to various modes of use of formocresol has been available since the mid-1970s.6,10,14 Therefore, it is not surprising that respondents continue to use various strength formulations. Although the literature notes considerable controversy regarding the toxicity, mutagenicity and carcinogenicity of formaldehyde and formocresol,23,24 it is interesting that the majority of pediatric
48 NYSDJ MARCH 2008

dentist responding to our survey who use formocresol had no concerns about its potential side effects. From the respondents comments, it is clear that many pediatric dentists are comfortable with their chosen medicament. Further, the majority of pediatric dentists prefer formocresol and are unconcerned about its potential adverse effects.
Conclusion

Within the limits of this sample,it can be concluded that 61% of pediatric dentists in the U.S. continue to use formocresol and that 73% of these pediatric dentists are not concerned about side effects.
The authors thank Yanping Wang for her assistance with data analysis. Queries about this article can be sent to Dr. Yoon at rky1@columbia.edu.

REFERENCES
1. Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life in young children. Pediatric Dentistry 1999;21:325-6. 2. Centers for Disease Control.Surveillance for Dental Caries,Dental Sealants,Tooth Retention, Edentulism, and Enamel Fluorosis - United States, 1988-1994 and 1999-2002. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm.Accessed May 10, 2007. 3. Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. J Dent Child 1965;32:13-28. 4. Beaver HA, Kopel HM, Sabes WR. The effect of zinc oxide eugenol cement on a formocresolized pulp. J Dent Child 1966;33:381-396. 5. Redig DF. Comparison and evaluation of two formocresol pulpotomy techniques utilizing Buckleys formocresol. J Dent Child 1968;35:22-30. 6. Morawa AP, Straffon LH, Han SS, Corpron RE. Clinical evaluation of pulpotomies using dilute formocresol. J Dent Child 1975;42:360-363. 7. Rolling I, Thylstrup A.A 3-year clinical follow-up study of pulpotomized primary molars treated with the formocresol technique. Scand J Dent Res 1975;83:47-53. 8. Willard RM. Radiographic changes following formocresol pulpotomy in primary molars. J Dent Child 1976;43:414-415. 9. Magnusson BO. Therapeutic pulpotomies in primary molars with the formocresol technique. Acta Odontol Scand 1977;36:157-165. 10. Fuks AB, Bimstein E. Clinical evaluation of diluted formocresol pulpotomies in primary teeth of schoolchildren. Pediatric Dentistry 1981;3:321-324. 11. Verco PJW,Allen KR.Formocresol pulpotomies in primary teeth.J Int Dent Child 1984;15:51-55. 12. Landau MJ,Johnson DC.Pulpal response to ferric sulfate in monkeys.J Dent Res 1988;67:215. 13. Fei AL, Udin RD, Johnson R.A clinical study of ferric sulfate as a pulpotomy agent in primary teeth. Pediatric Dentistry 1991;13:327-332. 14. Fuks AB, Holan G, Davis JM, Eidelman E. Ferric sulfate versus dilute formocresol in pulpotomized primary molar: long-term follow up. Pediatric Dentistry 1997;19:327-330. 15. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospective study. Pediatric Dentistry 2000;22:192-199. 16. Primosh RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States. Pediatric Dentistry 1997 19:118-122. 17. Mathewson RJ, Primosch RE. Pulp treatment. In: Fundamentals of Pediatric Dentistry, 3rd Ed. Mathewson RJ, Primosch RE. Chicago: Quintessence 1995. 18. McDonald RE, Avery DR. Treatment of deep caries, vital pulp exposure, and pulpless teeth. In: Dentistry for the Child and Adolescent, 7th Ed. St. Louis: CV Mosby Co. 2000. 19. Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak A. Pulp therapy for the primary dentition. In: Pediatric Dentistry Infancy through Adolescence, 2nd Ed. Philadelphia: WB Saunders Co. 1994. 20. Hunter ML, Hunter B.Vital pulpotomy in the primary dentition: attitudes and practices of specialists in paediatric dentistry practicing in the United Kingdom. Int J Paediatric Dent 2003;13:246-250. 21. Davis MJ. Conscious sedation practices in pediatric dentistry: a survey of members of the American Board of Pediatric Dentistry College of Diplomates. Pediatric Dentistry 1988;10(4);328-9. 22. American Academy of Pediatric Dentistry Reference Manual. Guideline on Pulp Therapy for Primary and Young Permanent Teeth. Pediatric Dentistry 2006;131. 23. Zarzar PA, Rosenblatt A, Takahashi CS, Takeuchi PL, Costa Jr LA. Formocresol mutagenicity following primary tooth pulp therapy: an in vivo study. J Dent 2003;27:479-85. 24. Davis MJ, Myers R, Switkes MD. Glutaraldehyde: an alternative to formocresol for vital pulp therapy. J Dent Child 1982;176-180.

NYSDJ MARCH 2008 49

Peripheral Ossifying Fibroma and Pyogenic Granuloma

A R E T H E Y I N T E R R E L AT E D ? Shiva Prasad, B.M., M.D.S.; Shridhara B. Reddy, M.D.S; Sudhir R. Patil, M.D.S.; Nagaraj B. Kalburgi, M.D.S.; R.S. Puranik, M.D.S.
Abstract Peripheral ossifying fibroma (POF) and pyogenic granuloma (PG) belong to the group of focal reactive overgrowths, having different histomorphologic representations. The pathogenesis of POF remains controversial. It has been observed that POF in some cases may initially develop as a PG that undergoes subsequent fibrous maturation and calcification. A case of focal reactive gingival overgrowth with a recurrence is presented. Clinical, radiological and histological examinations were performed and included a detailed history of the lesions to come up with the proper diagnosis. The primary lesion was diagnosed as POF and the recurrent lesion as PG. The POF might have developed initially as PG and subsequent maturation led to the ossification of the lesion. These two lesions represent the progressive stages of the same spectrum of pathosis.

and ossifying fibroid epulis2,3,4,5 and peripheral fibroma with calcification.6 The pathogenesis of this lesion remains uncertain. According to one theory, POF develops initially as pyogenic granuloma (PG), with subsequent fibrous maturation and ossification.7 But this theory is not applicable to all POFs formed. Cells of periosteum and periodontal ligament7,8 constitute the most likely origin of mineralized product. POF is considered reactive in nature rather than neoplasm.9,10 A number of irritational reasons have been given for the development of POF, namely, microorganisms, masticatory forces, food lodgment, minor trauma, calculus and iatrogenic factors. POF typically is a slow-growing lesion that rarely reaches more than 3 cm in diameter. It occurs exclusively on the gingiva as a pedunculated or sessile mass, with color varying from pink to slightly red. It is found most frequently in teenagers and young adults and has a high recurrence rate of up to 20%.11-14
Case Description and Results

PERIPHERAL OSSIFYING FIBROMA (POF)1 is cited under diverse terminologies, like calcifying fibroblastic granuloma, peripheral odontogenic fibroma, peripheral cementifying fibroma, calcifying
50 NYSDJ MARCH 2008

A 32-year-old female presented to the Department of Periodontology for evaluation of a localized gingival enlargement that had been present in the mandibular premolar area for eight months. It had gradually increased in size, causing interference with mastication and occasional bleeding. A large (6 cm) pedunculated, firm swelling with surface ulcerations was present in relation to the interdental area of teeth #33 and #34 with extension to the lingual side (Figure 1), resulting in the migration of adjacent teeth. Considerable deposition of calculus was also noticed.

The most important clinical feature of the peripheral ossifying fibroma (POF) described here was its size, which was approximately 6 cms in diameter.
Excision of the lesion under local anesthesia revealed bone formation beneath the lesion, evident in the intraoral periapical radiograph taken. The microscopic diagnosis of POF was rendered for the excised mass.The bone formed in relation to the tumor was removed with carbide round burs (Nos. 2, 4), followed by esthetic recontouring. Scaling and root planing of the teeth adjacent to the lesion were performed with curettage of the lesion down to the bone.15
Histopathology

Figure 1. Clinical photograph showing initial lesion.

The initial lesion showed variations from hyperplastic to atrophic epithelium covering dense to edematous fibrous connective tissue with focal areas of inflammatory infiltrate. Deeper regions revealed extensive large focus of ossification surrounded by proliferating fibroblast-like cells, suggestive of POF5,7,10 (Figures 2,3).
Recurrent Lesion

The patient returned to the department after 25 days with a swelling (Figure 4) of about 3 cms in diameter in the previous location.She had been instructed to return seven days after removal of the initial lesion for evaluation and oral prophylaxis. The swelling was sessile, soft, red in color, with increased surface ulcerations when compared with the previous lesion. The swelling extended to the lingual aspect through the interdental area, which had a tendency to bleed on slightest provocation. The lesion was excised in toto and analyzed histologically. Microscopic features of the recurrent lesion consisted of numerous proliferating capillaries and fibroblasts admixed with abundant inflammatory cells comprising polymorphonuclear neutrophils, lymphocytes and plasma cells. The overlying epithelium was mainly hyperplastic and ulcerated in some areas, confirming the diagnosis of PG (Figure 5).
Discussion

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

The most important clinical feature of the peripheral ossifying fibroma (POF) described here was its size, which was approximately 6 cms in diameter. We believe it is one of the largest POFs reported, apart from the lesion (9 cm) reported by Chui-Kwan et al.16 POF has a recurrence rate of about 16% to 20%. Both the POF and the PG were treated with a conservative surgical approach of excisional biopsy and esthetic recontouring of the bone formed in relation to the lesion. Evaluation of the recurrent lesion showed a PG with classical histological features. Reasons for recurrence of the lesion may be as follows: 1. Incomplete removal of the initial lesion. 2. Local deposits like plaque and calculus might have acted as stimulating (irritational) factors for the POF to form. Scaling

Figure 3. 45x, H and E stain showing extensive ossification in deeper region. NYSDJ MARCH 2008 51

and root planing of the teeth adjacent to the lesion were done, but because the patient was not cooperative, scaling and root planing of other teeth were not possible. The patient returned to the dental office only after the recurrent lesion appeared and did not report after excision of the recurrent lesion. The patients lower socioeconomic status and illiteracy may be why she was not cooperative. 3. Surgical trauma while removing the initial lesion might have induced formation of the recurrent lesion (PG). The clinical and histopathological features of the initial and recurrent lesions affirmed the theory that PG and POF may represent progressive stages of the same pathology. Whatever the reason for the occurrence of second lesion, the authors continue to believe that theory and that PG and POF belong to the same spectrum of focal reactive overgrowths. The initial lesion might have started as PG; long duration and maturation then led to development of the POF.6 It is a

Spectrum of Focal Reactive Overgrowths

Tissue irritation Pyogenic granuloma Long duration/chronocity? Fibrous maturation and sclerosis Ossification Peripheral ossifying fibroma

known/ observed fact that longstanding PG may undergo organization/healing, which is evident histologically with features of decreased vascularity, decreased inflammation and focal ossification. In the recurrent lesion, the duration and persistent irrational factors resulted in the development of PG in the subsequent four weeks.
Conclusion

This case report strengthens the concept that focal reactive lesions like PG and POF need not be considered as separate clinical entities but, rather, as the progressive stages of the same pathology. The treatment approach remains the same towards all focal reactive overgrowths8 (peripheral gingival fibroma, peripheral giant cell granuloma, pyogenic granuloma or peripheral ossifying fibroma), that is, complete elimination of the lesion and etiological factors.
Queries about this article can be sent to Dr.Shiva Prasad at drshivaprasad2000@rediffmail.com.

REFERENCES
1. Gardner DG. The peripheral odontogenic fibroma: an attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-48. 2. Buchner A, Calderon S, Ramon Y. Localized hyperplastic lesions of gingiva. A clinicopathological study of 302 lesions. J Periodontol 1977;48:101. 3. Anderson L, Fejerskov O, Philipsen HP. Calcifying fibroblastic granuloma. Oral Surg 1973;31:196. 4. Lee KW. Fibrous epulis and related lesions. Granuloma pyogenicum,pregnancytumor, fibroepithelial polyp and calcifying fibroblastic granuloma. A clinicopathological study. Periodontics 1968;6:277. 5. Shafer WG, Hine MK, Levy BM, editors. Benign and Malignant Tumors of the Oral Cavity. A Textbook of Oral Pathology. 4th Ed. Philadelphia:Saunders. 1993:141-142. 6. Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: report of 376 cases. J Am Dent Assoc 1966;73:1312-1320. 7. Neville, Damm, Allen, Bouquot, editors. Oral and Maxillofacial Pathology. 2nd Ed. Philadelphia: Saunders. 2002:447-453. 8. Hamner JE, Scofield HH, Cornyn J. Benign fibro-osseous lesions of periodontal ligament origin. Cancer 1968; 22: 861. 9. Eversole LR, Rovin S. Reactive lesions of gingiva. J Oral Path 1972;1:30-38. 10. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva: a clinicopathological study of 741 cases. J Periodontol 1980;51: 655-661. 11. Buchner A, Louis SH. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Path Oral Med Oral Surg 1987;63: 452-461. 12. Kenney JN, Kaugars GE,Abbey LM. Comparison between the peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-382. 13. Layfield LL, Shoppr TP, Weir JC. A diagnostic survey of biopsied gingival lesions. J Dent Hyg 1995;69:175-179. 14. Zain RB, Fei YJ. Fibrous lesions of the gingiva: a histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1990;70:466-470. 15. John DW, Joseph KW, Russen DH, David AC, Donald AR. Excision and repair of the peripheral ossifying fibroma: a report of 3 cases. J Periodontol 2001;72:939-944. 16. Chui-Kwan P, Po-cheung K, Shou-yee C. Giant peripheral ossifying fibroma of the maxilla: report of a case. J Oral Maxillofac Surg 1995;53:695-698.

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

Figure 5. 10x, H and E stain showing hyperplastic-to-ulcerated epithelium covering dense proliferative connective tissue consisting of numerous capillaries and inflammatory cells. 52 NYSDJ MARCH 2008

Fourth District Announces Two-Day Dental Conference

THE 12TH ANNUAL SARATOGA DENTAL CONGRESS will take place Thursday and Friday, May 22-23, at the Saratoga City Center in Saratoga Springs. The conference is sponsored by the Fourth District Dental Society. The program on Thursday offers three nationally known speakers. Dr. John Molinari will present Infection Control Update for 2008 and Update on Vaccine Recommendations. Robin Wright, M.A., will enumerate the Top Ten Skills for Success in Dental Communication. Patti DiGangi, R.D.H., B.S., will present Its All Connected: Oral Health and Whole Body Wellness. CPR/AED certification programs will be offered in the morning and afternoon. The program on Friday features Dr. Gerard Kugel, editor of Inside Dentistry. Dr. Kugels presentation is entitled Esthetic Dentistry Update. Also, Bethany Valachi, M.S., P.T., CEAS, of Posturedontics will lead a seminar for the entire staff titled Neck, Back and Beyond: Preventing Pain for Peak Performance. CPR/AED certification will again be offered in the morning. Attendance at the Congress is expected to exceed 1,000 people. There will be over 60 vendors, some of whom will offer conference specials. This years raffle will feature two grand prizes. Winners names will be drawn on Friday. Register early to take advantage of reduced fees. Member dentists are being asked to pay $195 for one day or $295 for both days. Fees for hygienists and staff are $80 for each day. The charge includes a buffet lunch. Chairman for this years Saratoga Dental Congress is Fourth District President Richard Dunham. Dr. Dunham can be reached at (518) 584-2128 or abettersmile@yahoo.com. For registration information, visit the Fourth District Web site, www.4thdds.org, or call the district office at (518) 371-1114. For exhibitor registration, call Robert Sharp at (518) 793-5908.

The Meeting at the Springs

City Center, Saratoga Springs, NY
Thursday, May 22, 2008
Lecture - Infection Control Update for 2008

Dr. John Molinari

Lecture - Top Ten Skills for Success in Dental Communication

Robin Wright, MA
Lecture - Its All Connected: Oral Health and

Whole Body Wellness Patti DiGangi, RDH, BS Sponsored by Fourth District Dental Society Registration 8:00 am Exhibits open at 8:00 am For more information, contact Fourth District Dental Society 981 Route 146 Clifton Park, NY 12065 518-371-1114 e-mail: Fourthdistrictds@nycap.rr.com Registration forms available online: www.4thdds.org
CPR/AED for the Healthcare Professional

Friday, May 23, 2008

Lecture - Esthetic Dentistry Update

Dr. Gerard Kugel

Plus

Lecture - Neck, Back and Beyond:

Table Clinics Exhibitions Luncheons Raffles

Preventing Pain for Peak Productivity Bethany Valachi, MS, PT, CEAS, Prosturedontics
CPR/AED for the Healthcare Professional Raffle

NYSDJ MARCH 2008 53