Specops Jiacd 200904

Volume 1, No.
2 April 2009
The Journal of Implant & Advanced Clinical Dentistry
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Volume 1, No. 2 • April 2009
Table of Contents
11 No Bone Solution Computer Guided
TM
41 Life Threatening Sublingual Hematoma
Implant Surgery Protocol for Formation Following Placement of
Prosthodontic Rehabilitation of the Two Mandibular Implants: A Case Report
Severely Atrophic Maxilla Michael Tame, David McNeil, Richard Parkin
Thomas J. Balshi, Glenn J. Wolfinger, John J. Thaler II,
James R. Bowers, Stephen F. Balshi
47 The Agony and Ecstasy of Buying
Cone Beam Technology Part II: The Agony
Dale A. Miles
19 Factors Driving Peri-implant Crestal Bone

Loss - Literature Review and Discussion:
Part 1 of 4
Mohammad Ketabi, Robert Pilliar, Douglas Deporter
31 Sinus/Alveolar Crest Tenting Technique: 57 4% Articaine Use in United States and

A Case Report with Histology and Canadian Dental Schools
40-Month Clinical Follow-up Matthew R. Byarlay
Alan A. Winter, Alan S. Pollack, Ronald B. Odrich
63 The Effects of Periodontal Therapy
on Helicobacter pylori Clearance in
Gastritis Patients: A Pilot Study
N. Shumaker, A. Soolari, A. Gentry, H. Liu, A. Dubois
The Journal of Implant & Advanced Clinical Dentistry • 3

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Volume 1, No. 2 • April 2009
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Founder, Co-Editor in Chief Founder, Co-Editor in Chief

Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS
A Minimally Invasive and Systematic Approach to Sinus Grafting
Editorial Advisory Board
Tara Aghaloo, DDS, MD Robert Horowitz, DDS George Priest, DMD
Faizan Alawi, DDS Michael Huber, DDS Giulio Rasperini, DDS
Michael Apa, DDS Richard Hughes, DDS Michele Ravenel, DMD, MS
Alan M. Atlas, DMD Debby Hwang, DMD Terry Rees, DDS
Charles Babbush, DMD, MS Anil Idiculla, DMD Laurence Rifkin, DDS
Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Paul Rosen, DMD, MS
Barry Bartee, DDS, MD James Jacobs, DMD Joel Rosenlicht, DMD
Lorin Berland, DDS Ziad N. Jalbout, DDS Larry Rosenthal, DDS
Peter Bertrand, DDS John Johnson, DDS, MS Steven Roser, DMD, MD
Michael Block, DMD John Kois, DMD, MSD Salvatore Ruggiero, DMD, MD
Chris Bonacci, DDS, MD Joseph Kravitz, DDS, MS Anthony Sclar, DMD
Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Maurizio Silvestri, DDS, MD
Ronald Brown, DDS, MS Burton Langer, DMD Dennis Smiler, DDS, MScD
Bobby Butler, DDS Aldo Leopardi, DDS, MS Muna Soltan, DDS
Donald Callan, DDS Carlo Maiorana, MD, DDS Michael Sonick, DMD
Nicholas Caplanis, DMD, MS Louis Mandel, DDS Ahmad Soolari, DMD
Daniele Cardaropoli, DDS Michael Martin, DDS, PhD Christian Stappert, DDS, PhD
Giuseppe Cardaropoli DDS, PhD Ziv Mazor, DMD Eric Stoopler, DMD
John Cavallaro, DDS Dale Miles, DDS, MS Scott Synnott, DMD
Stepehn Chu, DMD, MSD Robert Miller, DDS Haim Tal, DMD, PhD
David Clark, DDS John Minichetti, DMD Gregory Tarantola, DDS
Charles Cobb, DDS, PhD Jaimee Morgan, DDS Dennis Tarnow, DDS
Spyridon Condos, DDS Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA
Massimo Del Fabbro, PhD Peter K. Moy, DMD Tiziano Testori, MD, DDS
Douglas Deporter, DDS, PhD Mel Mupparapu, DMD Michael Tischler, DDS
Alex Ehrlich, DDS, MS Ross Nash, DDS Tolga Tozum, DDS, PhD
Nicolas Elian, DDS Gregory Naylor, DDS Leonardo Trombelli, DDS, PhD
Paul Fugazzotto, DDS Marcel Noujeim, DDS, MS Ilser Turkyilmaz, DDS, PhD
Scott Ganz, DMD Sammy Noumbissi, DDS, MS Dean Vafiadis, DDS
Arun K. Garg, DMD Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD
David Guichet, DDS Charles Orth, DDS Alan Winter, DDS
Kenneth Hamlett, DDS Jacinthe Paquette, DDS Glenn Wolfinger, DDS
Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Richard K. Yoon, DDS
Michael Herndon, DDS Stan Presley, DDS

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BIO-IMPLANTS DIVISON
Editorial Commentary
Daddy, what is a newspaper?
I
have two young daughters that simply love to edge. While this is true for products and tech-
read. Between the two of them, I would ven- niques, I cannot say the same for our profession’s
ture to say that they have at least three hun- view of dental literature. I cannot even begin to
dred books. They must have received this gene tell you how many times Nick and I receive puzzled
from their mother because I personally do not read looks when we tell our colleagues that JIACD is a
much for pleasure. Considering the fact that I am paperless journal. For some reason, many in our
constantly reading countless numbers of den- industry cling to the antiquated notion that dental
tal articles, the last thing I want to do in my spare literature must be printed to be worthwhile.
time is read. Online dental publishing allows for options
A few days ago, my youngest daughter was that simply cannot be replicated in print issues.
reading a book called If You Lived 100 Years Embedded hyperlinks, flash animation, video,
Ago (McGovern A. Scholastic, New York 1999). audio, and a virtually unlimited number of pho-
This wonderful book describes what life was like tographs are just a few of the benefits of online
at the dawn of the twentieth century in terms that publication. Couple these features with no sub-
a child can understand. Roughhewn cobble- scription fees and instantaneous worldwide
stone streets, horse drawn carriages, iceboxes, access, and you have a combination that benefits
and dime stores are just a few of the many now our entire profession as a whole.
defunct items discussed in this book. One addi- Mark my words, within a few years, all den-
tional item that may soon be added to this list is tal journals will offer online versions, while many
the printed newspaper. will follow the lead of JIACD and eliminate their
Over the past year, dozens of newspapers in print versions entirely. Most will say this change
the United States have either closed their doors is their way of “going green”, but the bottom line
or eliminated their print editions in favor of online is that this change will be based on economics.
publication. In fact, just yesterday, The Seat- Newspapers, the bastion of printed journalism, are
tle Post-Intelligencer published its last print edi- already succumbing to this pressure and dental
tion after 146 years of operation. Can you believe journals are sure to follow.
this? In the classic perception of Americana, the Do not be afraid of change; embrace it! The
newspaper was considered a rock of Gibraltar, benefits of online dental literature will far outweigh
an institution that could not fail. Heck, Clark Kent the ability to hold a collection of printed words in
(a.k.a Superman), the most invincible of all super- your hand. ●
heroes, even worked at a newspaper! All good
things must come to an end, so they say, and
the printed newspaper seems well on its way to
antique status.
Dentistry is an industry that has never seemed
to fear change. New products and techniques are
being constantly introduced, and our thirst for con- Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS
tinuing education keeps most of us on the cutting Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief

Balshi et al
Balshi et al
Case of the Month
No Bone SolutionTM Computer Guided
Implant Surgery Protocol
for Prosthodontic Rehabilitation of
the Severely Atrophic Maxilla
Thomas J. Balshi, DDS, FACP1 • Glenn J. Wolfinger, DDS, FACP1

John J. Thaler II, DDS1 • James R. Bowers, DDS1
Stephen F. Balshi, MBE2
Abstract
Background: Prosthodontic rehabilitation of the mark System® Zygoma implants. The patient
severely atrophic maxilla presents significant chal- received an immediate fixed screw retained provi-
lenges to the restoring dental team. Inadequate sional prosthesis on the day of surgery and was
bone quantity often necessitates time depen- restored with a final prosthesis 5 months later.
dent augmentation procedures that consider-
ably delay delivery of the final dental prostheses. Results: Surgical treatment and implant
This case report demonstrates a newly developed delivery utilizing the No Bone SolutionTM pro-
specialized computer guided dental implant sur- tocol were uneventful. The patient’s maxil-
gery protocol for prosthetic rehabilitation of the lary prosthetic rehabilitation has been without
severely atrophic maxilla: the No Bone Solution.TM complication for 3 years following surgery.
Methods: A 67 year old Indian male with a some- Conclusion: The No Bone SolutionTM com-
what compromised medical history and severely puter guided implant surgery protocol pro-
atrophic maxilla presented for rehabilitation with vides a restorative option for patients with
dental implants. The patient was treated with severely atrophic maxillary bone. This pro-
the No Bone SolutionTM protocol for delivery of tocol does not require bone augmentation
5 standard Brånemark implants and 4 Bråne- and significantly reduces total treatment time.
KEY WORDS: Dental implants, zygoma, maxilla, cone beam computed tomography,
CAD/CAM, osseointegration
1. Pi Dental Center, Fort Washington, PA, USA.

2. CM Ceramics, Mahwah, NJ, USA

Balshi et al
CASE REpORt surgery for placement of five traditional Brånemark

Long-term success of osseointegrated implants implants and freehand placement of four zygomatic
depends on the length of the implants used and implants to support an interim all acrylic screw-
the quality and quantity of bone surrounding retained fixed prosthesis. After 12 weeks of heal-
these implants. As surgical and prosthetic tech- ing and osseointegration, the fixed screw retained
niques have evolved, the success rate for rou- titanium and ceramic prosthesis was fabricated.
tine implant treatment has improved and implant
prosthodontics has become the standard of care. Computer plan
A 67 year-old retired surgeon was referred A virtual plan of the intended surgery was com-
to the Pi Dental Implant Center by his periodon- pleted using the Nobel Biocare Procera soft-
tist and restorative dentist in April 2007 with a ware. Computer data was transmitted to a
prior diagnosis of “no bone in the maxilla.” This rapid prototype machine for production of the
patient’s desire for treatment included “fixed surgical template. Using this template, a mas-
teeth” with improved oral function and esthetics. ter cast was constructed and articulated. The
Some of his medical conditions were potentially screw retained provisional prosthesis was then
detrimental to the long-term prognosis of com- constructed prior to dental implant surgery.
plex dental treatment, but not insurmountable.
The patient was diagnosed with diabetes, emphy- Surgical protocol
sema, high blood pressure and dry mouth syn- Blood was drawn prior to surgery, transferred to
drome. To further complicate matters, he smoked the Harvest cell separator unit and Platelet Rich
two packs of cigarettes a day and admitted to an Plasma was prepared. General anesthesia was
intense parafunctional bruxing and clenching habit. then administered and the patient was fully draped
using the standard sterile protocol. Local anes-
Initial Clinical and Radiographic Assessment thesia was also used for hemostasis. Following
After a thorough oral examination, which the guided portion of the surgery, which assists in
included evaluation of the existing prosthet- the placement of 5 Brånemark implants, the surgi-
ics, articulated diagnostic casts, panorex cal template was removed. A crestal incision and
radiograph, lateral cephalometric radiograph vertical releasing incisions were made bilaterally
and preoperative clinical photographs, the and full thickness flaps were elevated to the level
following treatment plan was developed of the superior aspect of the zygomatic bone. The
using the No Bone Solution™ protocol. transantral osteotomies, using graduated diam-
eter drills, were completed to permit the apex of
treatment plan the implants to penetrate through the lateral sur-
(1) Removal of the non-integrated “mini” implants face of the zygoma. A total of four Brånemark
in the area of teeth 14 and 15. (2) Fabrication of System® Zygoma implants were installed—two in
a new maxillary denture that incorporated radio- each zygoma. Finally, using the Teeth In A Day®
graphic markers to be used in conjunction with an conversion protocol, the previously constructed
i-Cat cone beam scan. (3) NobelGuide™ guided prosthesis was installed on the standard Bråne-
12 • Vol. 1, No. 2 • April 2009

Balshi et al
mark implants and then connected intraorally

to the zygomatic implants. The prosthesis was Correspondence:
then removed, adjusted, polished and reinstalled. Dr. Thomas J. Balshi
467 Pennsylvania Avenue, Suite 201
the Final prosthesis
Fort Washington, PA 19034 USA
Osseointegration, under immediate loading con-
ditions is paramount to the success of this pros- TEL: 215-643-5881
thesis. Research on immediate loading has FAX: 215-643-1149
shown that after eight weeks, osseointegration piteam@pidentalcenter.com
should be mature to allow for a predictable out-
come. Due to this patient’s numerous medical
conditions, the final impression was taken after Disclosure:
a 12-week healing time. He was restored using The authors of this article disclose that they have
agreements and/or financial arrangements with
CM Ceramics technology produced in Mahwah,
the Pi Dental Center and Nobel Biocare®.
New Jersey. The final prosthesis for the maxilla
consisted of a CAD/CAM robotically milled titanium Acknowledgement
The Pi team gratefully thanks two dedicated dental spe-
frame with individual zirconium ceramic crowns
cialists, Dr. Russell Morgan, Restorative Dentist and Dr.
using the Nobel Biocare Procera Technology. Gregory Felthousen, Periodontist (both of Salisbury, MD) for
extraordinary “insights” in their encouragement and genuine
COnCluSIOn concern for the patient illustrated in this issue. Likewise,
we also acknowledge numerous colleagues who have pro-
Patients with extreme maxillary atrophy generally vided similar guidance to clinically “hopeless” patients.
suffer with ill-fitting removable prostheses that
lab Support:
chronically irritate the mucosa and insult what lit-
Stephen F. Balshi, MBE
tle underlying bone remains. For patients with no CM Ceramics, LLC
remaining alveolar bone, the No Bone Solution™
protocol demonstrated in this article is an ideal
treatment that avoids major bone grafting and the
long associated healing and treatment time. The
No Bone Solution™ potentially shortens treat-
ment time to only 3 visits over a 3-month period.
It also provides patients with little or no bone with
a non-removable solid set of teeth in just one day.
No Bone Solution™ is a special treatment
protocol developed at the Pi Dental Center. It
combines unique computer guided implant sur-
gery with precision screw retained fixed prost-
hodontic rehabilitation of the severely atrophic
maxilla. The protocol eliminates the need for inva-
sive bone grafting and extensive procedures ●

Balshi et al
InItIAl pRESEntAtIOn
14 • Vol. 1, No. 2 • April 2009

Balshi et al
pRE-SuRgICAl plAnnIng

Balshi et al
FInAl pROSthESES
16 • Vol. 1, No. 2 • April 2009

Balshi et al
pOSt-SuRgICAl REStORAtIOn

Ketabi et al
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The success of an implant system cannot be determined by one

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Ketabi et al
Factors Driving Peri-implant
Crestal Bone Loss - Literature
Review and Discussion:
Part 1 of 4
Mohammad Ketabi, DDS, MDS1 • Robert Pilliar BASc, PhD2

Douglas Deporter, DDS, PhD3
Abstract
Many factors contribute to the cumulative in English language refereed journals for the
crestal bone loss seen around endosseous decade preceding May 2008 and attempted
dental implants. This can create confusion for to identify the major factors associated with
the practicing clinician and lead to undesirable peri-implant bone loss. Part one of this article
outcomes. In this four part review series, we series examines surgical and anatomical factors
have searched the literature for papers published associated with peri-implant crestal bone loss.
KEY WORDS: Crestal bone loss, dental implants, causative factors
1. Dean, Professor and Chairman, Department of Periodontology, Faculty of Dentistry, Islamic Azad University
(Khorasgan Branch), Arghavanieh, Isfahan, Iran
2. Professor Emeritus, Faculty of Dentistry & Center for Biomaterials, University of Toronto
3. Professor, Discipline of Periodontology and Oral Reconstructive Center, Faculty of Dentistry,
University of Toronto

Ketabi et al
IntRODuctIOn loss. The generally accepted upper limit of crestal

The use of osseointegrated dental implants as a bone loss used to define implant success is less
foundation for prosthetic replacement of miss- than 0.2mm per annum after year one1 with the
ing teeth has become routine clinical practice. majority of implants showing undetectable radio-
Advances in radiographic imaging techniques, sur- graphic changes thereafter.2-7 However, many fac-
gical and prosthetic procedures and implant design tors, both biological and biomechanical, will have
and surface features have evolved to the point a cumulative impact on the final amount of bone
that implant dentistry now offers highly predict- loss seen. It is important for clinicians to under-
able treatment outcomes for cognizant clinicians. stand all of these factors in addition to their rela-
An important parameter in assessing long- tive contributions and interactions. A summary of
term success or failure of a dental implant is the contributing factors to be addressed in this review
extent of its cumulative peri-implant crestal bone paper is provided in Table 1 and their proposed
Table 1: Important Factors Driving Peri-Implant Crestal Bone Loss

Surgical & Patient Biologic Geometry & Biomechanic
Anatomical Factors Width Surface Factors
Factors Factors Features
Flap Design Genetic Profile Level of Geometry Early Load
Microgap
Facial Cortical Oral Hygiene Platform-Switching Length and Overload
Bone Smoking & Width
Thickness Alchohol
Consumption
Bone Quality History & Type Implant-Tooth Neck Design DIsuse
of Periodontitis or Inter-Implant Atrophy
Distance
Single vs Diabetes Surface
2-Stage Implant Roughness
Placement
Early Exposure
of Cover Screw
Quantity of
Keratinized
Tissue
20 • Vol. 1, No. 2 • March 2009

Ketabi et al
Figure 1: Schematic Representation of Possible Interactions Amongst

Factors Contributing to Peri-Implant Bone Loss
interactions are depicted schematically in Figure using submerged or non-submerged technique,

1. These factors include: i) surgical and anatomi- early unintentional exposure of originally sub-
cal considerations such as mucoperiosteal flap merged implant cover screws by mucosal dehis-
design, thickness of facial and lingual/palatal corti- cence and, amount of peri-implant keratinized
cal plate of bone remaining after osteotomy prepa- tissue; ii) patient risk factors such as medical and
ration, bone quality, whether the implant is placed pharmacological status, habits including cigarette

Ketabi et al
smoking, poor oral hygiene and possibly excessive ences were selected on the basis of their titles
alcohol consumption, mucosal abnormalities such and abstracts. As the final selection method, full
as erosive lichen planus, susceptibility to and pre- texts of publications identified as possibly relevant
vious history of periodontitis, type of oral microflora were reviewed for more detailed evaluation. Pub-
present, presence and type of periodontitis (i.e. lications reviewed included experimental animal
chronic vs aggressive); iii) biologic width related studies, prospective and retrospective human clini-
factors such as level of the micro-gap, platform- cal studies, a few case reports and relevant review
switching and implant-tooth or implant-implant papers. Because of the limited numbers of avail-
distance; iv) implant design features including able studies for some factors and their heterogene-
geometry, surface texture, length and diameter; ity, focusing on a specific pre-defined question to
and v) biomechanical factors including early vs be answered by a systematic review was not feasi-
delayed loading, disuse atrophy of crestal bone ble and therefore no meta-analysis was attempted.
or over-loading related to prosthetic design (e.g.
whether the prosthesis is removable or fixed, and if
fixed whether cement- or screw-retained) quality of DIScuSSIOn
prosthetic work (e.g. with or without a well-equili- A number of surgical and anatomical factors
brated occlusion), habits such as bruxism, loosen- may contribute to peri-implant crestal bone loss.
ing of prosthetic retention screws and, repeated The most common factors associated with such
removal and re-insertion of implant restorations. loss include:
In this review, an attempt has been made to iden-
tify relative contributions and interactions of key Flap Design
factors driving crestal bone loss with the pur- Ramfjord and Costich8 reported long ago that,
pose of helping practicing clinicians to plan and whenever a mucoperiosteal flap is reflected about
conduct successful implant treatments resulting a tooth, some crestal bone resorption is inevitable.
in predictable long-term crestal bone equilibrium. Similarly, elevating a flap to place a dental implant
will lead to crestal bone loss and, evidence exists
MAtERIAlS AnD MEthODS to suggest that there is a direct relationship
A literature search of papers published in ref- between size of mucoperiosteal flap and resulting
ereed journals in the English language for the post-surgical bone loss. The least amount of post-
decade preceding May 2008 was performed surgical bone loss is likely to result with flapless
by computer using the National Library of Medi- placement of dental implants. Flapless implant
cine (http://www.ncbi.nlm.hih.gov/PubMed) and placement has been made possible by the innova-
SCOPUS Cochrane Oral Health Group data- tive approach of using CT scan radiographic data
bases. Search strategy included a specific to design and fabricate what are purported by
series of terms and key words. The reference the manufacturers to be highly accurate surgical
lists of identified publications, relevant textbooks templates. However, recent research with “com-
and professional workshops also were scanned. puter-assisted virtual treatment” has indicated that
As the first selection method, relevant refer- complications are higher and thus, this method
22 • Vol. 1, No. 2 • April 2009

Ketabi et al
must still be regarded to be in an exploratory

phase and for highly experienced clinicians.9,10
Jeong et al11 compared bone loss with or
without the use of flaps in dogs. Threaded den-
tal implants were inserted in previously edentu-
lated dog posterior mandible sites. Control sites
had implants placed after elevation of full muco-
periosteal flaps, while test sites had their implants
placed without flap elevation by accessing bone
through 5mm diameter circumferential incisions
and, removal of the resulting gingival plugs. After
8 weeks site healing, crestal bone loss was quan-
tified using micro-computerized tomography and, Figure 2: Example of peri-implant crestal bone loss.
showed statistically significant differences with

crestal bone loss at flapless sites being on aver- ized crestal incisions and soft tissue reflection
age 1 mm less. Becker et al12 also studied this to the area immediately above intended implant
issue in dogs but, reported no statistically signifi- sites and, repositioning and suturing of the mini-
cant differences using more traditional histological flap margins after implant insertion. The majority
evaluation of retrieved specimens after 12 weeks of implants showed bone loss within the range 0
of site healing. Nevertheless, Becker reported the - 0.4 mm, but 9 implants in the flap group showed
same magnitude of difference in buccal vertical > 1.2mm bone loss as compared to no implants
bone loss (1mm less for flapless) as Jeong. Inter- with this level of loss in the mini-flap group. Also,
estingly, Becker et al also found that the flapless of interest is the fact that 5 implants in the flap
approach increased the odds of implant failure by group failed, as opposed to none in the flapless
42%, perhaps because they did not have the ben- group. However, the latter observation should be
efit of pre-operative CT imaging in their experiment. tempered by the fact that all 71 patients managed
Human clinical data comparing crestal with full flaps were completed before the mini-flap
bone loss following flapless versus full flap sur- group was treated. As such, there may have been
gery would not appear to have been available a surgical learning curve biasing the earlier results.
in the published literature at the time of prepa- Gomez-Roman14 reported differences in radio-
ration of the present review. However, Jeong graphic measurements of inter-proximal crestal
et al13 reported no statistically significant differ- bone loss occurring after placement of 21 single-
ences (0.20 mm for mini-flap vs 0.26 mm for tooth implants in 21 patients using either a widely
flap; P > .05) in crestal bone loss with mini-flaps mobilized (that included contiguous papillae) or a
(142 implants / 58 patients) as opposed to con- limited flap design (not involving papillae). Inter-
ventional full thickness flaps (144 implants / 71 proximal crestal bone loss was significantly less
patients) 3 to 4 months after implant placement following the use of the limited flap design. At
surgery. The mini-flap procedure involved local- the time of prosthetic restoration the mean dif-

Ketabi et al
ference in bone loss between the two groups non-damaged sites at the time of implant uncov-
was 0.49mm (P= 0.03) and this difference was ering, regardless of the type of augmentation pro-
even greater one year later (0.83mm; P= 0.006). cedure used at the time of implant placement.
Facial Alveolar Bone thickness Bone quality

The main blood supply for facial alveolar bone Manz21 conducted a prospective human study
is supplied by vessels in the overlying mucope- to quantify marginal bone loss around implants
riosteum15 and is greatly affected by elevating a placed in sites of differing bone density using
mucoperiosteal flap to facilitate placement of a the classification of Lekholm.22 Peri-implant
dental implant. Spray et al16 studied changes in bone loss in the interval from implant insertion to
the height of facial bone from the time of sub- implant uncovering was similar for all bone quali-
merged implant placement using a full-thickness ties (Types I to IV). However, 6 months after pros-
flap until implant uncovering (3-4 months in mandi- thesis delivery, varying levels of post-load bone
ble, 6-8 months in maxilla). Results were classified loss were observed with the least amount for
according to original residual facial bone thick- Type I bone (0.68 mm) and the most (1.44 mm)
ness after osteotomy preparation. Measurements for Type IV bone. This correlation between mar-
were collected for more than 3,000 implants. ginal bone loss and initial bone density was later
After osteotomy preparation, direct measurements verified by other investigators who reported that
of residual facial bone thickness were made using bone loss around implants placed in the maxilla
calipers at a point approximately 0.5mm below the (less dense bone) was greater than that occur-
facial crest. Vertical facial bone height was mea- ring around implants placed in the mandible.23-28
sured in relation to the top of each implant with
a periodontal probe. Results indicated that as Single versus 2-Stage Implant Placement
residual facial bone thickness approached 1.8 to Whether a single or 2-stage implant placement
2mm, loss in vertical bone height decreased sig- protocol is followed will impact crestal bone loss
nificantly. Similar findings were made by Qahash since the 2-stage approach may include a second
et al17 as part of an investigation of facial bone mucoperiosteal flap elevation with attendant bone
healing in dogs. This would suggest that if resid- resorption. To minimize this effect, if at all possible,
ual facial bone thickness is less than 2mm and/or tissue punches or circumscribed incisions with a
if dehiscences or fenestrations of facial bone have scalpel blade are used to expose cover screws of
occurred during osteotomy preparation, consider- integrated implants. One-stage implants also will
ation should be given to augmenting facial bone be exposed to much earlier loading, whether inten-
thickness with a grafting procedure.18,19 It should tional or not. This may have a beneficial or detri-
be noted, however, that in the case of immedi- mental impact on crestal bone levels depending
ate implant placement (maxillary anterior or pre- on the magnitude of the resulting bone strains and
molar sites)20, whenever facial cortical bone was any associated early implant micro-movements.
damaged (e.g. dehiscence), significantly (P= Single stage implants may be one or two piece in
0.005) greater resorption was seen compared to design and this too will impact crestal bone loss.
24 • Vol. 1, No. 2 • April 2009

Ketabi et al
Early Exposure of cover Screw able perforations (Class I), bone loss was signifi-
Following submerged implant placement, per- cantly less than for perforations where the cover
foration of the overlying mucosa and prema- screw was quite visible (Classes II, III, IV). For
ture exposure of an implant cover screw can the 115 early exposed implants assessed, 10
result where mucosal tissues fail to achieve pri- showed greater than 2mm bone loss, 3 implants
mary wound closure, are too thin to avoid dehis- showed 3 to 4mm bone loss, and one implant
cence, or have been somehow traumatized (e.g. showed 5mm of bone loss. In Class II and III
pressure from a transitional prosthesis). Toljianic exposures, there was more bone loss associ-
et al29 reported that patients with prematurely ated with the facial aspect of the implants and
exposed cover screws suffered 3.9 times greater not visible in radiographs. Like Yoo32, Tal sug-
likelihood of bone loss with HA-coated (rough- gested that prematurely and partially exposed
surfaced30) press-fit cylinder implants than non- implants should be fully uncovered as soon
exposed ones. This influence of early exposure as possible after the perforation is observed.
was confirmed in a study with baboons by Sev- In a recent retrospective study, Van Assche
erson et al31 using machine-turned (minimally et al34 reported interesting data on three different
rough30) threaded implants. Spontaneous early scenarios in a group of 60 particle-blasted (moder-
exposure was more common in the mandible and ately rough30) threaded implants. Twenty implants
led to greater bone loss than implants that had not (condition A) were placed using a 2-stage pro-
suffered early exposure. For example, on facial cedure with their healing caps intentionally left
aspects, a highly significant (P= 0.0003) differ- exposed, 20 implants (condition B) were placed
ence of 1mm of bone loss was seen. In another with a 2-stage procedure and submerged for a
animal study, Yoo et al32 assessed the effect of healing time of 3 to 6 months, and 20 implants
early partial exposure of particle-blasted (moder- (condition C) were placed following a 1-stage pro-
ately rough30) implants placed in dog mandible. cedure. Mean bone loss values in the 3 conditions
For half of the implants, the cover screw was left after initial site healing were 1.96mm, 0.01mm and
partially exposed while the remaining implants 0.14mm for conditions A, B and C respectively.
were converted to promote non-submerged heal- The investigators again concluded that early expo-
ing by the immediate addition of healing abut- sure of 2-stage moderately rough implants resulted
ments. Using micro-computed tomography, in significant early bone destruction. This was
significantly greater crestal bone loss was seen at possibly because of inevitable early contamina-
8 weeks for the partially exposed implants. The tion of the microgap by periodontal pathogens.35,36
investigators suggested that when early partial
exposure of submerged implants occurs, healing Quantity of Keratinized tissue
abutments should be added as soon as is feasible. Whether the width and/or thickness of peri-implant
Tal et al33 discovered a correlation between the keratinized tissue have an influence on crestal
degree of cover screw exposure and associated bone loss has not been adequately investigated.
bone loss in humans with TPS-coated (rough30; Apse et al37 reported that the absence of kerati-
Steri-Oss®) threaded implants. For barely detect- nized tissue around Branemark-Type® implants

Ketabi et al
(machine-turned, minimally rough surface finish30) of keratinized mucosa and alveolar bone loss
appeared to have no impact on long-term health around dental implants with a variety of surface
of affected implants, however, a correlation with finishes (machine-turned, acid-washed, particle-
crestal bone loss was not sought. Wennstrom et blasted/acid-washed, TPS-coated). However,
al,38 on the other hand, reported that peri-implant as critiqued by Bouri et al,41 Chung et al did not
tissues around Branemark-Type® implants had adjust for other important variables like smok-
a greater tendency to be inflamed if there was ≤ ing, plaque index and implant surface roughness.
2mm of keratinized tissue present. The investi- Berglundh and Lindhe43 investigated the issue
gators speculated that sites with minimal kerati- of peri-implant mucosal thickness on crestal
nized tissue might be more susceptible to plaque bone loss in an experimental model in dogs. At
accumulation. The results of Warrer et al39 lend test sites at the time of implant (machine-turned)
support to this idea. These investigators used a placement, thickness of peri-implant mucosa
ligature-induced gingivitis model in monkeys and was surgically reduced (to ≤ 2mm) while, at con-
reported that rough implants (TPS-coated hollow trol sites, no mucosal alteration was done. The
cylinder implants) with a keratinized tissue cover- results, assessed at the time of uncovering of
ing were less susceptible to soft tissue recession healed implants suggested that as part of bio-
and bone loss than those without keratinized tis- logic width accommodation at test sites, crestal
sue. Block et al40 found that a lack of peri-implant bone loss occurred to allow for re-establish-
keratinized tissue had a significant impact on fail- ment of lost thickness of peri-implant connective
ure of HA-coated (i.e. rough30) press-fit cylindri- tissue. This factor was also found to be a pos-
cal implants in humans, reporting that HA-coated sible contributor to peri-implant bone loss in the
implants with no keratinized tissue had a 10x study in humans by Bouri et al,41 where mid-facial
greater risk of failure than implants with keratinized mucosa at sites with < 2mm of keratinized tissue
tissue. These results and those of Warrer et al39 width were also significantly thinner. Adequate
suggest that the effect of keratinized tissue could keratinized tissue may be more important around
vary between implant designs and, in particular, implants than natural teeth for several reasons:
between different implant surface characteristics. supracrestal collagen fibers are oriented in parallel
Bouri et al,41 in a cross-sectional study of rather than perpendicular configuration adjacent
200 implants (implant type not specified) in 76 to trans-mucosal surfaces of implants44 provid-
patients, reported significantly greater crestal ing less resistance to local trauma and microbial
bone loss in sites where the width of mid-facial penetration; and, peri-implant mucosa may have a
keratinized mucosa was < 2mm as compared to ≥ reduced capacity to regenerate itself due to com-
2mm. This relationship remained significant even promised number of cells and poor vascularity.45
after taking into account time since implant place-
ment, smoking, thickness of keratinized tissue, Summary of Surgical and
and plaque index using multivariate linear regres- Anatomical Factors
sion analysis. In contrast, Chung et al42 reported Following implant placement surgery, crestal
no association between width (< 2mm vs ≥ 2mm) bone loss is likely to be less with a mini-flap or
26 • Vol. 1, No. 2 • April 2009

Ketabi et al
flapless surgery than with a traditional widely exposed submerged implants should be done as
reflected mucoperiosteal flap, primarily because soon as feasible after the exposure to minimize
of the extent of temporary interruption of the prin- potential bone loss. Finally, while some contro-
ciple blood supply to facial bone. Further, thick- versy remains, it has been argued that a mini-
ness (≥ 2mm is recommended) and integrity mum width (≥ 2mm) and thickness of keratinized
(absence of fenestrations and/or dehiscences) tissue is needed to minimize marginal bone loss
of facial bone remaining after osteotomy prepara- around dental implants, after accounting for other
tion can impact the extent of post-surgical crestal possible driving factors such as smoking and
bone loss. Concerning bone quality, peri-implant plaque index. The importance of keratinized tis-
crestal bone loss has been reported to be least in sue in minimizing crestal bone loss may differ with
Type I and greatest in Type IV bone, which coin- implant type (e.g. implant surface roughness). ●
cides with the general observation of greater
crestal bone loss around maxillary than mandibu-
lar implants. Early partial exposure of implants correspondence:
placed using submerged technique is a risk fac- Douglas Deporter, DDS, PhD
tor for bone loss especially on facial surfaces of douglas.deporter@utoronto.ca
moderately rough or rough implants. Accord-
ingly, connection of a healing abutment at partially
this is part 1 of a 4 part review series.

Parts 2, 3 and 4 will appear in future issues of JIAcD.

Ketabi et al
Disclosure J Clin Periodont 1994; 21: 189-193. 31. Severson S, Vernino A, Caudill R, Holt R,
The authors report no conflicts of interest with 16. Spray J, Black C, Morris H, Ochi, S. The Church C, Davis A. Effect of early exposure on
anything mentioned within this article. influence of bone thickness on facial marginal the integration of dental implants in the baboon:
References bone response: Stage 1 placement through Part 1- Clinical findings at uncovering. Int J Perio
1. Albrektsson T, Zarb G, Worthington P, Eriksson stage 2 uncovering. Ann Periodont 2000; 5: Rest Dent 2000;20:161-71.
A. The long-term efficiently of currently used 119-128. 32. Yoo J, Choi B, Li J, Kim H, Ko C, Xuan F, Jeong
dental implants : A review and proposed criteria of 17. Qahash M, Susin C, Polimeni G, Hall J, Wikesjo S. Influence of premature exposure of implants
success. Int J Oral Maxillofac Impl 1986; 1 : 11-25. U. Bone healing dynamics at buccal peri-implant on early crestal bone loss: An experimental
2. Bower R, Radny N, Wall C, Henry P. Clinical sites. Clin Oral Impl Res 2008; 19: 166-172. study in dogs. Oral Surg Oral Med Oral Pathol
and microscopic findings in edentulous patients Oral Radiol Endod 2008;105:702-706.
18. Jovanovic SA, Spiekermann H, Richter El. Bone
3 years after incorporation of osseointegrated regeneration around titanium dental implants in 33. Tal H, Artzi Z, Moses O., Nemcovsky C,
implant supported bridgework. J Clin dehisced defect sites: a clinical study. Int J Oral Kozlovsky A. Spontaneous early exposure of
Periodont 1989; 16: 580-587. Maxillofac Impl. 1992;7: 233-245. submerged endosseous implants resulting in
3. Lekholm U, Adell R, Lindhe J, Branemark P-I, crestal bone loss: A clinical evaluation between
19. Garg AK. Augmentation and grafting for maxillary
Eriksson B, Rockler B, Lindvall A, Yoneyama T. stage I and stage II surgery. Int J Oral Maxillofac
alveolar ridges. In: Bone. Biology, Harvesting,
Marginal tissue reactions at osseointegrated Impl 2001;16: 514–521.
Grafting for Dental Implants. Rationale and
titanium fixtures. II. A cross-sectional retrospective Clinical Applications. 2004. Quintessence Publ., 34. Van Assche N, Collaert B, Coucke W, Quirynen
study. Int J Oral Maxillofac Surg 1986; 15: 53-61. Carol Stream,IL., chapter 9: 213-240. M. Correlation between early perforation
4. Cox J, Zarb G. The longitudinal clinical efficacy of of cover screws and marginal bone loss:
20. Chen S, Darby I, Adams G, Reynolds E. A
osseointegrated implants: A 3-year report. Int J A retrospective study. J Clin Periodont
prospective clinical study of bone augmentation
Oral Maxillofac Impl 1987; 2: 91-100. 2008;35:76-79.
techniques at immediate implants. Clin Oral Impl
5. Kline R, Hoar J, Beck G, Hazen R, Resnik R, Res 2005; 16: 176-84. 35. Barboza E, Caula A, Carvalho W. Crestal
Crawford E. A prospective multicenter clinical bone loss around submerged and exposed
21. Manz MC. Radiographic assessment of
investigation of a bone quality-based dental unloaded dental implants: A radiographic and
peri-implant vertical bone loss: DICRG
implant system. Implant Dent 2002;11: 224-234. microbiological descriptive study. Impl Dent
Interim Report no. 9. J Oral Maxillofac Surg.
2002; 11: 162-169.
6. Pham A, Fiorellini J, Paquette D, Williams R, 1997;55:62-71.
Weber H. Longitudinal radiographic study of 36. Quirynen M, Vogels R, Peeters W, van
22. Lekholm U, Zarb G. Patient selection and
crestal bone levels adjacent to non-submerged Steenberghe D, Naert I, Haffajee A. Dynamics
preparation. In: Tissue-Integrated Prostheses.
dental implants. J Oral Impl 1994;10: 26–34. of initial subgingival colonization of ‘pristine’
Osseointegration in Clinical Dentistry.
peri-implant pockets. Clin Oral Impl Res 2006;
7. Naert I, Koutsikakis G, Quirynen M, Duyck J, van Branemark P-I, Zarb G, and Albrektsson T, eds.
17: 25-37.
Steenberghe D, Jacobs R. Biologic outcome of Quintessence Publ., Chicago, 1985, pp 199-
implant-supported restorations in the treatment 209. 37. Apse P, Zarb G, Schmitt A, Lewis D. The
of partial edentulism. Part 2 : A longitudinal longitudinal effectiveness of osseointegrated
23. Adell R, Lekholm U, Rockler B, Branemark P-I. A
radiographic evaluation. Clin Oral Impl Res 2002 ; dental implants. The Toronto Study: Peri-implant
15-year study of osseointegrated implants in the
13 : 390-395. mucosal response. Int J Perio Rest Dent 1991;
treatment of the edentulous jaw. Int J Oral Surg
11: 94-111.
8. Ramfjord S, Costich E. Healing after exposure of 1981; 6: 387-416.
periosteum on the alveolar process. J Periodont. 38 Wennstrom J, Bengazi F, Lekholm U. The
24. Jemt T, Lekholm U. Oral implant treatment in
1986; 39: 199-207. influence of the masticatory mucosa on the peri-
posterior partially edentulous jaws: A 5-year
implant soft tissue condition. Clin Oral Impl Res
9. Komiyama A, Klinge B, Hultin M. Treatment follow-up report. Int J Oral Maxillofac Impl 1993;
1994; 5: 1-8.
outcome of immediately loaded implants installed 8: 635-640.
in edentulous jaws following computer-assisted 39. Warrer K, Buser D, Lang N, Karring T. Plaque-
25. Naert I, Duyck J, Hosny M, Jacobs R, Quirynen
virtual treatment planning and flap-less surgery. induced peri-implantitis in the presence or
M, van Steenberghe D. Evaluation of factors
Clin Oral Impl Res 2008; 19: 677-685. absence of keratinized mucosa. An experimental
influencing the marginal bone stability around
study in monkeys. Clin Oral Impl Res 1995; 6:
10. Van de Velde T, Glor F, De Bruyn H. A model implants in the treatment of partial edentulism.
131-138.
study on flap-less implant placement by clinicians Clin Impl Dent Rel Res 2001; 3: 30-38.
with a different experience level in implant 40 Block M, Gardiner D, Kent J, Misiek D, Finger
26. Karoussis I, Salvi G, Heitz-Mayfield L, Bragger
dentistry. Clin Oral Impl Res 2008; 19: 66-72. I, Guerra L. Hydroxyapatite-coated cylindrical
U, Hammerle C, Lang N. Long-term implant
implants in the posterior mandible: 10-year
11. Jeong S-M, Choi B-H, Li J, Kim H-S, Ko C-Y, prognosis in patients with and without a history
observations. Int J Oral Maxillofac Impl 1996; 11:
Jung J-H, Lee H-J, Lee S-H, Engelke W. Flap- of chronic periodontitis: a 10-year prospective
626-633.
less implant surgery: An experimental study. Oral cohort study of the ITI Dental Implant System.
Surg Oral Med Oral Pathol Oral Radiol Endod Clin Oral Impl Res 2003; 14: 329–339. 41. Bouri A, Bissada N, Al-Zahrani MS, Faddoul F,
2007; 104: 24-28. Nouneh I. Width of keratinized gingiva and the
27. Wennström J, Zurdo J, Karlsson S, Ekestubbe
health status of the supporting tissues around
12. Becker W, Wikesjo U, Sennerby L, Qahash M, A, Gröndahl K, Lindhe J. Bone level change at
dental implants. Int J Oral Maxillofac Impl 2008;
Hujoel P, Goldstein M, Turkyilmaz I. Histologic implant-supported fixed partial dentures with
23: 323-326.
evaluation of implants following flap-less and and without cantilever extension after 5 years in
flapped surgery: A study in canines. J Periodont function. J Clin Periodont 2004; 31:1077-1083. 42. Chung D, Oh T, Shotwell J, Misch C, Wang
2006; 77: 1717-1722. H. Significance of keratinized mucosa in
28. Schwartz-Arad D, Kidron N, Dolev E. A long-term
maintenance of dental implants with different
13. Jeong S-M, Choi B-H, Li J, Ahn K-M, Lee S-H, study of implants supporting overdentures as a
surfaces. J Periodont 2006; 77: 1410-1420.
Xuan F. Bone healing around implants following model for implant success. J Periodont 2005;76:
flap and mini-flap surgeries: A radiographic 1431-1435. 43. Berglundh T, Lindhe J. Dimension of the peri-
evaluation between stage I and stage II surgery. implant mucosa. Biological width revisited. J Clin
29. Toljianic J, Banakis M, Willes L, Graham L.
Oral Surg Oral Med Oral Pathol Oral Radiol Periodont 1996; 23: 971-973
Soft tissue exposure of endosseous implants
Endod. 2008; 105: 293-296. between stage I and stage II surgery as a 44. Abrahamsson I, Berglundh T, Wennstrom
14. Gomez-Roman G. Influence of flap design potential indicator of early crestal bone loss. Int J J, Lindhe J. The peri-implant hard and soft
on peri-implant interproximal crestal bone Oral Maxillofac Impl 1999;14:436-41. tissues at different implant systems: A
loss around single-tooth implants. Int J Oral comparative study in the dog. Clin Oral Impl Res
30. Albrektsson T, Wennerberg A. Oral implant
Maxillofac Impl 2001; 16: 61-67. 1996; 7: 212-219.
surfaces: Part I: Review focusing on topographic
15. Berglundh T, Lindhe J, Jonsson K, Ericsson I. and chemical properties of different surfaces 45. Lindhe, J., Berglundh, T. The interface between
The topography of the vascular systems in the and in vivo responses to them. Int J Prosthodont the mucosa and the implant. Periodontology
periodontal and peri-implant tissues in the dog. 2004; 17: 536-543. 2000. 1998;17:47-54.
28 • Vol. 1, No. 2 • April 2009

Ketabi et al
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Winter et al
Winter et al
Sinus/Alveolar Crest Tenting Technique:
A Case Report with Histology and
40-Month Clinical Follow-up
Alan A. Winter, DDS1 • Alan S. Pollack, DDS1 • Ronald B. Odrich, DDS1
Abstract
Background: Pneumatized maxillary sinuses in used to remove a core of bone from the surgical
the posterior maxilla often require augmentation site during implant restoration and was examined
to permit dental implant placement. A number of with low power H&E analysis. Additional radio-
techniques have been developed to accomplish graphic follow up was performed 40 months fol-
such augmentation with most requiring use of lowing implant activation
autografts, allografts, xenografts, or a combination
thereof. This case report reviews the Sinus/Alveo- Results: The surgical procedure was accom-
lar Crest Tenting (S.A.C.T.) technique that uses a plished uneventfully and the patient was func-
crestal approach to raise the sinus membrane in a tionally restored with dental implant restorations.
severely atrophic (2mm) posterior maxilla without Microscopic analysis of the trephine bone core
grafts or tissue barriers. revealed broad trabeculae of viable bone and asso-
ciated loose vascular fibrous connective tissue.
Methods: A 74 year-old Caucasian male was
referred for implant placement in the maxillary left Conclusion: A case report with histology is pre-
posterior sextant in the area of teeth 13, 14, and sented that describes the S.A.C.T. technique
15. The left maxillary sinus was severely pneu- with a 40-month follow-up after activation of the
matized with only 2mm of residual vertical bone implants. This case illustrates the inherent heal-
remaining. A total of 3 dental implants were deliv- ing potential of the residual alveolar bone and sup-
ered, with 2 utilizing the S.A.C.T. technique. One ports the potential for osteogenesis from the sinus
year following implant placement, a trephine was membrane and periosteum.
KEY WORDS: atrophic maxillary ridge, dental implants, sinus graft, S.A.C.T. technique
1. Private practice, Park Avenue Periodontal Associates, P.C., 532 Park Avenue, New York, N.Y. 10021

Winter et al
BACKgROunD infracture the sinus floor and raise the membrane

Pneumatized maxillary sinuses in the posterior without graft material. This technique, the Local-
maxilla often require augmentation to permit den- ized Management of the Sinus Floor (L.M.S.F.),
tal implant placement. After Tatum1 and then utilized osteotomes that extended beyond the
Boyne and James2 first described techniques sinus floor that demonstrated a success rate of
to gain access to the maxillary sinus, a variety of 97.5% in atrophic ridges with > 7mm of bone.
graft materials have been successfully used to Winter et al20 reported on the use of the
increase bone volume for dental implant place- L.M.S.F. technique to treat 34 consecutive
ment. These techniques include the use of autog- patients with atrophic ridges of < 4mm height of
enous bone grafts,3-6 allografts,7-9 and xenografts bone. Fifty-eight implants were placed in ridges
such as bovine bone.10-12 Tatum approached that averaged 2.87mm in height with a 91%
the sinus via a crestal window while Boyne and success rate after twenty-two months. They
James employed a lateral window approach. concluded that implants may be placed in the
Other techniques have subsequently been posterior maxilla when there is < 4mm of bone
described to augment atrophic bone under the under the sinus without the need for bone grafts.
maxillary sinus. Summers13-15 used a trephine to The Sinus/Alveolar Crest Tenting (S.A.C.T.)
core-out the osteotomy site, stopping at or just technique21 evolved as an offshoot of the LMSF
shy of the sinus floor. Osteotomes were used to treat edentulous segments with minimal bone
to pack graft material to displace and raise the under the maxillary sinus floor. This technique
sinus membrane. In this technique, osteotomes combined the crestal window approach first
did not extend beyond the sinus floor. In a multi- described by Tatum1 with the principles underlying
center study, Rosen et al16 demonstrated the high the L.M.S.F. technique described by Bruschi, Scip-
success rate of the Summers technique when ioni, and Calesini.19 In the S.A.C.T. technique, a
the atrophic ridge was > 5mm. Davarpanah et rectangular window is created along the atrophic
al17 demonstrated the benefits of the Summers alveolar crest following partial thickness dissec-
technique when the width of the alveolar ridge tion of soft tissues to preserve periosteal vascular
was > 8mm and the height was > 5mm. Fugaz- supply to the bony ridge. This window is elevated
zotto18 described a variation of this technique and raised through careful dissection of the Sch-
that utilized a trephined bone core to raise the neiderian membrane. Dental implants are inserted
sinus membrane. Fugazzotto used an osteot- so that the bony plate is lifted without placing ten-
ome to advance the freed core so that addi- sion on the Schneiderian membrane which drapes
tional graft material could be pushed into the over it in a tent-like manner. Ultimately, what was
site. As a group, these papers demonstrated once the alveolar crest rests atop the implants; no
a high success rate when elevating the sinus grafts are used to fill the surgically created gaps
membrane with simultaneous implant placement between the implants and the displaced mem-
when > 5mm bone is present under the sinus.16 brane. Collagen sponges are placed to main-
In contrast to the Summers technique, Bruschi, tain the blood clot as secondary intention healing
Scipioni, and Calesini19 used osteotomes to commences. Support for the implants is gained
32 • Vol. 1, No. 2 • April 2009

Winter et al
by making the width of the rectangular box narrow

enough that the residual buccal and palatal walls
of bone firmly grip the implants in a stable posi-
tion. This can be altered to a staged approach if
primary stability of implants cannot be obtained.
Interestingly, Lundgren et al recently described
a maxillary sinus augmentation technique with-
out graft material in ten patients with an aver-
age of 7mm of residual crestal bone.22 Access
to the sinus was created through a conven-
tional lateral window approach. Dental implants Figure 1: Maxillary left presurgical radiograph. Note
were inserted at the time of surgery. While atrophic bone under sinus.
blood filled the surgically created compartment
between the sinus floor and the membrane, no
graft material was used. Lundgren used reso-
nance frequency analysis, radiographs, and clini-
cal examination to conclude (without histology)
that new bone formed around the implants and
that this was a predictable technique. In con-
trast, many investigators have performed histo-
logical examinations of implants placed in the
subantral area in conjunction with graft materials.23-30
This case report illustrates the S.A.C.T. tech-
nique and presents histology of new bone that
formed without using graft material in an area of Figure 2: CT scan demonstrating final implant sites. Icons
the maxillary sinus above an atrophic maxillary site. are proportionate to presurgical bone levels.
Case Report The patient was referred for a dental com-

A 74 year-old Caucasian male was referred for puted tomography (CT) scan (SimPlant®,
implant placement in the maxillary left poste- Columbia Scientific/Materialise, Inc., Mary-
rior sextant in the area of teeth #’s 13, 14, and land) that revealed bilateral atrophic ridges
15 (Figure 1). Tooth #13 had fractured and was with 2mm of residual bone under the left
deemed non-restorable. The patient’s medical sinus in the area of #14 and #15 (Figure 2).
history was notable for adult-onset diabetes, heart A 6.5mm x 10mm Frialit-2 implant (Friadent NA,
disease, mitral valve prolapse, hypothyroidism, Dentsply, York, PA) was inserted in the #13 site
and arthritis. His medications included: Furo- in the conventional manner using graduated burs.
semide, Synthroid, Vasotec, Inderal, Aspirin, After this was completed, the S.A.C.T. technique
Pravachol, Atenolol, Cardura, and Norvasc. was used to insert implants in the #’s 14 and

Winter et al
15 area. The S.A.C.T. technique was employed

to gain access to the Schneiderian membrane
through a rectangular window made at the alveo-
lar crest (Figure 3). The alveolar crest was ele-
vated and the membrane sufficiently released to
displace the alveolar crest into the sinus (Figure
4) until the implants could be inserted without
tearing the membrane. Prior to implant insertion,
Figure 3: Rectangular outline of crestal bony incision.
the patient’s nares were pinched and the patient
asked to blow gently to insure that the sinus mem-
brane was still intact. Next, the implants were
gently tapped to place using a surgical mallet.
It was critical to make the rectangular window
approximately 2mm smaller than the width of the
implants so the implants were stabilized by the
residual buccal and palatal residual bony crests.
With the implants in place, the bony window
(alveolar crest) now rested on the apical ends of
the implants (Figure 5). Once the implants were
secure, a layer of resorbable collagen tape was
Figure 4: Diagrammatic view elevating alveolar crest
placed over the implant heads. Periosteal sutures
with osteotome. Buccal bone is removed for enhanced
were used to apically position the flap without any
visualization.
attempt to gain primary closure. Post-operative
instructions were the same as for sinus graft pro-
cedures. Healing was uneventful. The patient
returned approximately 6 months later to remove
residual tissues about the heads of the implants.
It should be noted that the implant heads were
partially exposed during the entire healing period.
New bone appeared to have formed between
and above the two distal implants on the maxil-
lary left (Figures 6 and 7). With the patient’s
permission, a trephine was used to remove a
Figure 5: Initial implant placement. No grafting material
sample of bone from an area where the sinus
used. floor had been raised for microscopic analy-
sis. A 3mm x 7mm bone core was removed from
between the apices of the two posterior maxillary
left implants (Figures 8 and 9). After the core
34 • Vol. 1, No. 2 • April 2009

Winter et al
Figure 7: Stage-2 uncovering revealing new bone

formation.
Figure 6: Six month postsurgical radiograph taken at
Stage-2 uncovering.
Figure 8: Bone core removed. Figure 9. Bone core measures 7mm.
Figure 10: Placement of healing abutments.

Winter et al
Figure 11A: Low power photomicrograph of trephine core. Figure 11B: High power photomicrograph of trephine
Note viable bone. (Hematolin and eosin stain, original core. Note viable bone. (Hematolin and eosin stain,
magnification 10X). original magnification 40X).
Figure 12 A: Buccal view of final prosthesis 40 months Figure 12B: Palatal view of final prosthesis 40 months
after insertion. after insertion.
was secured, healing abutments were placed window from the alveolar crest was raised and
(Figure 10). All implants were clinically stable. left to rest after implant insertion (Figure 13).
Histological examination revealed broad trabe-
culae of viable bone and associated loose vascular DiSCuSSiOn
fibrous connective tissue. No significant inflamma- Two commonly accepted techniques have
tory component was noted (Figures 11A and 11B). evolved to increase the bone volume of verti-
Custom abutments were fabricated cally atrophic ridges under the maxillary sinus.
and ceramo-metal crowns fabricated (Fig- The first and most widely described technique
ures 12A and 12B). A post-operative radio- uses graft material under the sinus membrane
graph taken 39 months following stage-2 with access gained through a lateral window
surgery demonstrated thickened bone apical technique.2,23,31-33 This approach often requires
to the implants. This is where the rectangular two surgeries for implant placement, but may be
36 • Vol. 1, No. 2 • April 2009

Winter et al
This case report describes the S.A.C.T. tech-

nique plus immediate implant placement with
approximately 2mm of residual ridge height. No
bone grafts or membranes were used for this pro-
cedure. Histological examination of the trephine
core revealed newly formed bone. Additionally,
radiographic examination revealed bone along-
side and above the apical ends of the implants
40 months after the implants were uncovered.
To date, the patient has functioned with the final
prosthesis for 89 months without complication.
Figure 13: Radiograph 40 months after stage-2
uncovering.
COnCluSiOn
A case report with histology is presented
that describes the S.A.C.T. technique with a
accomplished in a single surgery under certain 40-month radiographic follow-up after activa-
circumstances. Kahnberg34 and Tawil35 analyzed tion of the implants. This case illustrates the
the benefits of performing the sinus lift with simul- inherent healing potential of the residual alveolar
taneous implant placement. They concluded that bone and supports the potential for osteogen-
predictable success was achieved when there esis from the sinus membrane and periosteum ●
was > 5mm of residual bone beneath the sinus.
Blomqvist36 suggested that a 2-stage approach
would be more suitable for optimum prosthetic Correspondence:
results. Peleg37 suggested that implants can Dr. Alan A. Winter
be placed simultaneously when sinus grafts Park Avenue Periodontal Associates, P.C.
are performed with as little as 2mm of residual 532 Park Avenue
crestal bone and achieve predictable results. New York, NY 10021
Alternative techniques to augment deficient 212-838-0940
bone in the posterior maxilla use osteotomes Email: a.winter@parkaveperio.com
through the alveolar crest instead of through a lat-
eral window.13-18 While some techniques utilized
graft material and others did not, studies using
osteotomes to raise the sinus floor conclude that
predictable results can be achieved when >5mm
of residual atrophic bone is present. In contrast,
Winter et al 20 demonstrated predictable results
using an osteotome technique in 53 of 58 cases
with an average residual bone height of 2.87mm.

Winter et al
Disclosure 13. Summers RB. A new concept in maxillary 27. Moy PK, Lundgren S, Holmes RE. Maxillary
The authors report no conflicts of interest with implant surgery: the osteotome technique. sinus augmentation: histomorphometric
anything mentioned in this artricle. Compendium 1994; 15:698-708. analysis of graft materials for sinus floor
14. Summers RB. The osteotome technique: Part augmentation. J Oral Maxillofac Surg 1993;
Acknowledgments 51:857-862.
Thank you to Dr. George Hribar for performing the 2 – The ridge expansion osteotomy (REO)
prosthetics and providing Figures 12A and B. procedure. Compendium 1994; 15:422-436. 28. Smiler DG, Holmes RE. Sinus lift procedure
15. Summers RB. The osteotome technique: Part using porous hydroxyapatite: a preliminary
Thank you to Dr. John E. Fantasia, Chief of the report. J Oral Implantol 1987; 13:239-253.
Division of Oral Pathology at Long Island Jewish 3 – Less invasive methods of elevating the
Medical Center, New Hyde Park, NY, who sinus floor. Compendium 1994; 15:698-708. 29. Hürzeler MB, Quinones CR, Kirsch A, et al.
prepared the photomicrographs and performed the 16. Rosen PS, Summers R, Mellado JR, Salkin LM, Maxillary sinus augmentation using different
histological examination. Shanaman RH, Marks MH, Fugazzotto PA. The grafting materials and dental implants in
bone-added osteotome sinus floor elevation monkeys. Part III. Evaluation of autogenous
References: technique: multicenter retrospective report of bone combined with porous hydroxyapatite.
1. Tatum, OH Jr. Maxillary and sinus implant consecutively treated patients. Int J Oral and Clin Oral Implants Res 1997; 8:401-411.
reconstructions. Dent Clin North Am 1986; Maxillofac Implants 1999; 14:853-858. 30. Quinones CR, Hürzeler MB, Schupach P,
30:207-229. 17. Davarpanah M, Martinez H, Tecucianu J-F, Arnold DR, Strub, Caffesse RG. Maxillary
2. Boyne P, James R.: Grafting of the maxillary floor Hage G, Lazzara R. The modified osteotome sinus augmentation using different grafting
with autogenous marrow and bone. J Oral Surg technique. Int J Perio & Res Dent 2001; materials and dental implants in monkeys.
1980; 38:613-616. 21:599607. Part IV. Evaluation of hydroxyapatite-coated
implants. Clin Oral Implants Res 1997; 8:497-
3. Wood RM, Moore DL. Grafting of the maxillary 18. Fugazzotto PA. Immediate implant placement
505.
sinus with intraorally harvested autogenous bone following modified trephine/osteotome
prior to implant placement. Int J Oral Maxillofac approach: success rates of 116 implants to 31. Wood RM, Moore DL. Grafting of the maxillary
Implants 1988; 3:209-214. 4 years in function. Int J Oral and Maxillofac sinus with intraoral harvested autogenous bone
Implants 2002; 17:113-120. prior to implant placement. Int J Oral and Max
4. Daelemans P, Hermanns M, Godet F, Malevez, C.
Impl 1988; 3:209-214.
Autologous bone graft to augment the maxillary 19. Bruschi GB, Scipioni A, Calesini G, Bruschi
sinus in conjunction with immediate endosseous E. Localized management of sinus floor with 32. Kent J, Block M. Simultaneous maxillary
implants: a retrospective study up to 5 years. Int simultaneous implant placement: a clinical sinus floor bone grafting and placement
J Perio & Rest Dent 1997; 17:27-39. report. Int J Oral and Maxillofac Implants 1998; of hydroxyapatite-coated implants. J Oral
13:219-226. Maxillofac Surg 1989; 47:238-242.
5. Blomqvist JE, Alberius P, Isaksson S.
Retrospective analysis of one-stage maxillary 20. Winter AA, Pollack AS, Odrich RB. Placement 33. Jensen OT, Simonsen EK, Sindet-Pedersen
sinus augmentation with endosseous implants. of implants in the severely atrophic posterior S. Reconstruction of the severely resorbed
Int J Oral Maxillofac Implants 1996; 11:512-521. maxilla using Localized Management of the maxilla with bone grafting and osseointegrated
Sinus Floor: a preliminary study. Int J Oral and implants: a preliminary report. J Oral Maxillofac
6. Miyajima H. Experimental study on the healing
Maxillofac Implants 2002; 17:687-695. Surg 1990; 50:15-418.
processes after the immediate reconstruction
of maxillary bone defect – fresh autogenous 21. Winter AA, Pollack AS, Odrich RB. Sinus/ 34. Jensen OT, Greer R. Immediate placement of
iliac bone graft. Ou-dagaku-Shigakushi 1990; Alveolar Crest Tenting (SACT): a new osseointegrating implants into the maxillary
17:168-182. technique for implant placement in atrophic sinus augmented with mineralized cancellous
maxillary ridges without bone grafts or allograft and Gore-Tex: second-stage surgical
7. Small SA, Zinner ID, Panno FV, Shapiro HJ, Stein
membranes. Int J Perio & Rest Dent and histological findings. In: Laney WR,
JI. Augmenting the maxillary sinus for implants.
2003;23:557-565. Tolman DE (eds). Tissue Integration in Oral,
Report of 27 patients. Int J Oral Maxillofac
Orthopedic & Maxillofacial Reconstruction.
Implants 1993; 8:523-528. 22. Lundgren S, Andersson S, Gualini F, Sennerby
Chicago: Quintessence, 1992:321-333.
8. Tidwell JK, Blijdorp PA, Stoelinga PJ, Brouns JB, L. Bone reformation with sinus membrane
elevation: a new surgical technique for maxillary 35. Kahnberg K-E, Ekestubbe A, Gröndahl K,
Hinderks F. Composite grafting of the maxillary
sinus floor augmentation. Clin Imp Dent and Nilsson P, Hirsch J-M. Sinus lifting procedure.
sinus for placement of endosteal implants. A
Related Res 2004; 6:165-173. I. One-stage surgery with bone transplant and
preliminary report of 48 patients. Int J Oral
implants. Clin Oral Impl Res 2001; 12:479-487.
Maxillofac Surgery 1992; 21:204-209. 23. Proussaefs P, Lozada J. Histologic evaluation
of a 9-year-old hydroxyapatite-coated cylindric 36. Tawil G, Mawla M. Sinus floor elevation using a
9. Hirsch J-M, Ericsson I. Maxillary sinus
implant placed in conjunction with a subantral bovine bone mineral (Bio-Oss) with or without
augmentation using mandibular bone grafts and
augmentation procedure: a case report. Int J concomitant use of a bilayered collagen barrier
simultaneous installation of implants. A surgical
Oral and Maxillofac Implants 2001; 16:737- (Bio-Gide): a clinical report of immediate and
technique. Clin Oral Impl Res 1991; 2:91-96.
741. delayed implant placement. Int J Oral and
10. Piatelli M, Favero GA, Scarano A, Orsini G, Maxillofac Implants 2001; 16:713-721.
Piatelli A: Bone reactions to anorganic bovine 24. Wallace S, Froum S, Tarnow D. Histologic
evaluation of sinus elevation procedure: a 37. Blomqvist JE, Alberius P, Isaksson S.
bone (Bio-Oss) used in Sinus Augmentation
clinical report. Int J Perio and Rest Dent 1996; Retrospective analysis of one-stage maxillary
Procedures: A histologic long-term report of
16:47-51. sinus augmentations with endosseous implants.
20 cases in humans. Int. J. Oral & Maxillofacial
Int J Oral Maxillofac Implants 1996; 11:512-
Implants. 1999; 14: 835-840. 25. Rosenlicht JL, Tarnow DP. Human histologic
521.
11. Hallman, M, Nordin T: Sinus floor evidence of functionally loaded hydroxyapatite-
coated implants placed simultaneously with 38. Peleg M, Mazor Z, Chaushu G, Garg AK:
augmentation with bovine hydroxyapatite
sinus augmentation: a case report 2.5 years Sinus Floor Augmentation with Simultaneous
mixed with fibrin glue and later placement
post-placement. J Oral Implantol 1999; 25:7- Implant Placement in the Severely Atrophic
of nonsubmerged implants: a retrospective
10. Maxilla. J Perio 1998; 69: 1397-1403.
study in 50 patients. Int. J. Oral & Maxillofacial
Implants. 2004; 19: 22-227. 26. Wheeler SL, Holmes RE, Calhoun CJ. Six-
12. Ewers R, Goriwoda W, Schopper C, Moser D, year clinical and histologic study of sinus-lift
Spassova E: Histologic findings at augmented grafts. Int J Oral and Maxillofac Implants 1996;
bone areas supplied with two different bone 11:26-34.
substitute materials combined with sinus floor
lifting. Clin Oral Impl Res 2004; 15:96-100.
38 • Vol. 1, No. 2 • April 2009

Winter et al
Tame et al
Preliminary List of Invited Speakers

Dr Paulo Coelho, USA Dr Michael Pikos, USA
Dr Matteo Danza, Italy Dr Paul Rosen, USA
Dr Scott Ganz, USA Dr Philippe Russe, France
Dr Robert Horowitz, USA Dr Maurice Salama, USA
Dr Jack Krauser, USA Dr Marius Steigmann,Germany
Dr Ziv Mazor, Israel Dr Tiziano Testori, Italy
Prof Adriano Piattelli, Italy Dr Tomaso Vercellotti, Italy
Secretariat
Paragon Conventions
18 Avenue Louis-Casai, 1209 Geneva, Switzerland
Tel: +41-(0)-22-5330-948, Fax: +41-(0)-22-5802-953
Email: fti@ftidental.com
Tame et al
Life Threatening Sublingual
Hematoma Formation
Following Placement of
Two Mandibular Implants:
A Case Report
Michael Tame, BDS, MFDS1 • David McNeil, BDS, MFDS1

Richard Parkin, BDS, FRCS, FDS1
Abstract
A 68 year old male patient underwent surgery to an Oral and Maxillofacial surgery unit where
to place two mandibular implants at a dental emergency immediate airway management was
surgery. Ninety minutes later the patient devel- performed. The patient subsequently required
oped a rapidly expanding sublingual haematoma intubation, surgical drainage of the haema-
which was causing a significant life threaten- toma, and admission to the Intensive Care Unit.
ing airway obstruction. The patient was referred
KEY WORDS: Hematoma, dental implant, mandible
1. The Royal Gwent Hospital, Department of Oral and Maxillofacial Surgery, Newport, United Kingdom

Tame et al
CASE REPORT to the Oral and Maxillofacial surgery department

The patient, a 68 year old male presented to at the local Hospital immediately (a journey of
the dental surgery complaining of an inabil- 20 minutes) where the patient was assessed by
ity to wear his lower denture. He had no sig- the Oral and Maxillofacial surgery team. He pre-
nificant medical history other than a penicillin sented with massive bilateral sublingual swell-
allergy. He was treatment planned for two ing which had elevated his tongue against his
mandibular implant fixtures which, following palate and posterior oropharynx. Gross bilat-
osseointegration, would help to restore him eral, submandibular swelling was also apparent.
with an implant retained lower overdenture. The combination of these swellings was caus-
The implant surgery was performed by two ing an airway obstruction (Figures 1 and 2).
experienced oral surgeons, under sterile con- The patient was given high flow oxygen via
ditions within the dental surgery. Anaesthesia face mask and intravenous (IV) access was
was obtained with bilateral mental nerve blocks established immediately. Basic observations
and lingual infiltrations using 12 millilitres (mls) were carried out, which showed normal oxy-
of 2% lignocaine with 1:80,000 adrenaline local gen saturations but an increased respiratory
anaesthetic. A crestal incision was made from rate. The on-call anaesthetist was contacted
the lower left 1st premolar to right 1st premolar and the patient was taken straight to theatre.
area. A buccal flap was raised, mental nerves Consent was taken for a possible tracheostomy
were visualised and protected. A lingual flap and drainage of the haematoma. In view of the
was also raised 15mm subcrestally protect- gross anterior neck swelling the patient under-
ing soft tissue from any potential perforation by went a trial, awake fibro-optic nasal intubation
the implant drill. Standard drilling sequences which was successful. It was noted that he was
were followed and two 3.5mm diameter, 15mm a grade 4 intubation (defined as the most dif-
long Astra (Astra Tech AB, Molndal, Sweden) ficult, in which the epiglottis cannot be seen).1
implants were placed in the lower left and lower An incision in the midline of the floor of
right canine area. They were noted to be in a mouth was made, releasing over 100 mls of
good position and angulation with excellent pri- blood and clot tracking posteriorly beneath
mary stability. The wound was closed with 3-0 the ventral tongue to the anterior wall of the
Vicryl sutures and haemostasis was achieved oropharynx. The area was explored but no
(At no point during the surgery was there any bleeding vessel was found. A corrugated silas-
significant bleeding). The patient was dis- tic drain was inserted and the patient was given
charged home with Paracetamol, Ibuprofen, 16 milligrams (mg) IV Dexamethasone, 1.5
Metronidazole and Chlorhexidine mouthwash. grams Cefuroxime and 500mg of Metronidazole.
After 90 minutes the surgeon received a The patient was transferred, paralysed and
phone call from the patient’s daughter, con- ventilated to the intensive care unit (ITU) for
cerned about swelling occurring in the floor of observation. After 36 hours in ITU and fol-
the patient’s mouth as well as difficulty breath- lowing endoscopic examination to assess
ing. The daughter was told to take the patient tongue oedema and feasibility of extubation, he
42 • Vol. 1, No. 2 • April 2009

Tame et al
Figure 1: Sublingual haematoma formation. Figure 2: Nasotracheal intubation to treat compromised

airway.
returned to theatre. The drain was removed and hospitalisation, 12 were intubated and five
he was subsequently extubated. Following this needed a tracheostomy. No fatalities have been
he was moved to the oral and maxillofacial sur- recorded, but in all cases only appropriate and
gery ward for a further 48 hours, an orthopan- rapid airway management prevented catastrophe.
tomogram and lateral cephalometric radiograph Cases of haematoma following other oral sur-
showed the implants in a good position axially. gical procedures including extractions, osteoto-
The patient was investigated for an underlying mies and floor of mouth biopsies have previously
coagulopathy but screening results were normal been reported.2,3 The most likely cause pos-
and the patient was discharged home on oral tulated in these cases is perforation of the lin-
Metronidazole and Chlorhexidine mouthwash. gual cortex and damage to one of the branches
After four days, continuing resolution of the of the sublingual or facial arteries or vein.4,5
haematoma was noted and subsequent review Cadaver studies have shown accessory foram-
uneventful, with no residual sequelae. The patient ina above or below the genial tubercles in the
planned to continue treatment to provide an entire lingual cortex of the mandible in between
implant retained overdenture at the dental surgery. 72%4and 89%6 of skulls. Through these foram-
ina, the incisive arteries, (branches of the infe-
DISCUSSION rior alveolar artery) form a dense anastomosing
Incidence of such a gross floor of mouth swelling plexus with the sublingual branch of the lingual
following mandibular implant placement is thank- artery and the submental artery (a branch of
fully very rare. Literature review revealed very few the facial artery). Surgeons should be aware
cases of sublingual haematoma formation follow- of their presence as a potential source of hae-
ing implant placement. All previous cases required morrhage when placing implants. Preparation

Tame et al
Figure 3: Basic Life Support General Guidelines

1. BLS algorithm should initially be followed.
2. Practitioner should instruct a team member to summon emergency medical

support.
3. Oxygen should be administered via mask and/or nasal cannula.
4. Attach monitoring equipment and monitor vital signs.
5. Obtain intravenous access.
of the implant site at the wrong angulation may flap designed to protect such a rare occur-
perforate the lingual cortex and possibly rupture rence. However a small lingual perforation can-
these vessels. Trauma to lingual soft tissue and not be ruled out even with direct inspection of
muscles such as stripping the lingual mucosa the lingual cortex and careful instrumentation.
may cause similar damage to these vessels. Early recognition and treatment of acute sub-
The patient claimed that the swelling lingual haematoma is vital. If a practitioner finds
occurred in the space of 5 minutes, approxi- themselves in this scenario the key is to remain
mately 90 minutes following the end of sur- calm and follow basic life support (BLS). (As
gery. This is most likely to be due to rebound demonstrated in the Resus Council UK 2005
vasodilation of an injured blood vessel when guidelines for basic and advanced life support).7
the vasoconstrictor (adrenaline) within the local Airway management is the immediate priority
anaesthetic solution wore off. A haemorrhage in a case such as this. An anaesthetist was imme-
of such a vessel is likely to cause a dissecting diately contacted to assess and treat the patient.
sublingual, submandibular and submental hae- During this same time, the patient was given
matoma3 (as in this case, Figure 2). It is unclear high flow oxygen to maintain oxygen saturation
as to how or why a vessel was traumatised here and pulse oximetry and blood pressure monitor-
as the lingual flap enabled direct visualisation ing measured his respiratory and cardiovascular
of the lingual plate and soft tissue protection status. IV access was established immediately
during the drilling sequence and implant place- in case the patient was to develop a cardio-
ment. One can speculate that a vessel may respiratory embarrassment and his peripheral
have been traumatised on infiltrating lingually circulation shut down. This would make can-
with local anaesthetic or by raising the lingual nulation difficult and thus, delay the administra-
44 • Vol. 1, No. 2 • April 2009

Tame et al
tion of appropriate drugs and fluid replacement. of haematoma via incision or wide gauge needle,
Following anaesthetic assessment, defini- this could however worsen the situation as a
tive airway management (via an awake fibro- draining haematoma will have less of a tendency
optic nasal intubation) by the anaesthetist to tamponade bleeding and we think it would be
was carried out as a life saving measure. It is prudent to ensure secured airway as the priority.
obviously easier to deal with such a patient in
a hospital environment with emergency staff CONCLUSION
and facilities at your disposal, but if this patient A life threatening sublingual haematoma is
had re-attended the dental surgery the situa- something most dental practitioners will never
tion would have been even more dangerous. see. However, clinicians placing mandibular
Any clinician who is placing mandibu- implants should be aware of its rapid develop-
lar implants should be aware of all poten- ment as a potential risk of surgery and be well
tial sequelae and be confident that they versed in the early recognition and immediate
can deal with the situation, should it arise, management of what can be a life threatening
it would be wise to follow the Resus Coun- scenario. A clinician who follows basic emer-
cil (UK) Guidelines7 as depicted in figure 3. gency management correctly will give their
In adjunct to these guidelines it would patient the optimum chance for recovery with-
be good practice to sit the patient up as they out potentially catastrophic consequences. ●
will find it easier to maintain their airway with
their upper body and head leaning forward. A
nasal airway could also be inserted to keep
Correspondence:
the airway patent prior to the anaesthetist
achieving a definitive airway. During this time Michael Tame, BDS, MFDS
it is obviously important to try to keep the Phone: +447919363455, +441633238519
patient calm, providing words of reassurance. Email: miketame@hotmail.com
Some clinicians suggest immediate drainage
Disclosure 3. Kalpidis C D, Setayesh R M. 5. Niamtu J III. Near-fatal airway

The authors report no conflicts of Hemorrhaging associated with obstruction after routine implant
interest with anything mentioned in this endosseous implant placement in placement. Oral Surg Oral Med Oral
article. the anterior mandible: a review of the Pathol Oral Radiol Endod 2001; 92:
literature. J Periodontol 2004; 75: 597-600.
References 631–645.
1. Cormack RS, Lehane J. Difficult 6. Shiller WR, Wisewell OB, Lingual
intubation in obstetrics. Anaesthesia 4. Nagar M, Bhardwaj R, Prakesh R. foramina of the mandible. Anat Rec
1984; 39: 1105-11. Accessory lingual foramen adult 1954; 119: 387-90.
Indian mandibles. J Anatomical Soc
2. Isaacson TJ. Sublingual hematoma India 2001; 50(1): 13-24. 7. Resuscitation Council (UK)
formation during immediate Guidelines 2005. Available at
placement of mandibular http://www.resus.org.uk. Accessed
endosseous implants. J Am Dent February 25, 2009.
Assoc 2004; 135: 168-171.

Miles
Miles
The Agony and
Ecstasy of Buying
Cone Beam Technology
Part II: The Agony
Dale A. Miles, DDS, MS1
Abstract
Background: This is the sec- Results: CBCT scan vol-
ond article in a two part series umes, CBCT scan information,
that presents additional deci- range of interest (ROI), field
sion considerations when pur- of view (FOV), multifunction-
chasing a cone beam computed ality, and potential liabilities
tomography (CBCT) machine are discussed by the author.
for use in dental practice.
Conclusion: When con-
Methods: The author, a Diplo- sidering the acquisition
mate of the American Board of of a CBCT machine, one
Oral and Maxillofacial Radiology, should evaluate a number
draws upon his personal experience from interpret- of factors to make an informed purchase. Fail-
ing over 3,700 CBCT scans to provide general and ure to consider these factors may result in
technical information on a number of CBCT systems. a dissatisfied buyer and potential liabilities.
KEY WORDS: Cone beam computed tomography, digital radiography,

radiographic image enhancemnet
1. Arizona School of Dentistry and Oral Health; Private Practice Fountain Hills, AZ, USA

Miles
IntRODuCtIOn tifunctional, that is, one that can deliver a cone

In part one of this two part article series, “The beam data set or volume, even if only 8cm x 8cm,
Ecstasy,” I presented introductory information and still retain the panoramic and cephalometric
on cone beam computed tomography (CBCT) capability, then a machine like the Planmeca Pro-
machines, the wide array of applications made Max (Roselle, IL), the eWoo Picasso (Va-tech,
possible by the incredible variety of image out- Seoul, Korea) or Morita Veraviewepocs3D (Kyoto,
put choices, and some decision consider- Japan) could be advantageous. Initially, Planmeca
ations for helping you decide which cone beam was the only multifunctional machine and currently
device might best suit your practice. In the sec- remains the only “upgradeable” x-ray machine on
ond installment of this series, I will provide you its existing platform. In addition to its panoramic
with additional “decision points” to consider and cephalometric capabilities, the ProMax CBVT
when selecting the appropriate machine or ser- 3D machine can also perform bitewing and peria-
vice for your practice and some of the reali- pical-like projections as well as selectable tomo-
ties of adopting this technology related to: 1) graphic views of the TMJ and sinus regions. This
The amount of information in each scan volume; is because of its unique technology: SCARA –
2) The types of information in each scan; 3) The Selectively Compliant Articulating Robotic Arm.
potential liability accompanying your purchase. This SCARA technology (figure 2), coupled with
a C-arm mounted on the top of the machine, is
Scan Volume Decisions a patented “one-of-a-kind” device in the dental
Initially, there was a marketing competition x-ray industry. The description of this technology
between companies that sold cone beam is beyond the scope of this article, but its con-
machines, with each making claims about the cept is what allows for all of the following, mak-
value of “large volume” machine advantages ing this machine the most “multi-functional”: 1.
over “small volume” machines and vice versa. True panoramic (not reconstructed from soft-
Some claims, I feel, are valid, and some are not. ware); 2. True cephalometric image; 3. Tomo-
If you are an orthodontist and need to make graphic views (TMJ, sinus and implant if desired);
measurements for various orthodontic analyses, 4: Bite-wing views (large enough to see all peri-
you may require a large volume CBCT machine. apices and at about 6 lp/mm); 5: Orthagonal
Certainly, if the CBCT machine volume is 4cm x panoramic view to see interproximal bone levels.
4cm or less, for example, a small volume machine This concept of “multifunctionality” can be
would not suffice if you do not have a cephalomet- confusing with some claiming you can replace all
ric unit in addition to your cone beam machine. dental imaging with cone beam technology. As in
You would have to select a machine like the Imag- medicine, dentists need to preserve several types
ing Sciences i-CAT (Hatfield, PA) or similar large of imaging modalities and choices to assist their
Field of View (FOV) machine to capture your diagnostic tasks. Medicine certainly does not use
Region of Interest (ROI). Figure 1 shows some or expect one radiographic imaging modality to
image areas captured by a “large” FOV machine. cover all diagnostic tasks. Accordingly, the medi-
However, if you had a machine that was mul- cal profession uses plain radiographic images,
48 • Vol. 1, No. 2 • April 2009

Miles
1a 1b
1c 1d
Figure 1: 1a. Axial slice of 346 slices at the level of the condylar head. 1b. Axial slice of the same patient slightly higher up in
the scan at the level of the sphenoid sinus. 1c. and 1d. Sagittal and coronal slices through the sphenoid region.
CAT scans, PET scans, magnetic resonance To confound your decision-making, many
imaging (MRI), ultrasonography, and nuclear “large volume” manufacturers claim that “you
medicine scanning to assess their patient’s can do ALL of your imaging ONLY with a cone
problems. Dentistry is gradually moving in a beam machine.” In my opinion, this is not true
similar direction, especially with cone beam tech- and should never be considered because of two
nology and cone beam “multifunctional” machines. factors I have previously discussed at length:

Miles
2a
2b
Figure 2: Images
acquired with SCARA
technology. All
images taken on a
panoramic machine
(ProMax, Planmeca
USA, Inc, Roselle,
IL). 2a.“Panoramic
bitewing” radiograph;
2b. Implant
cross-sectionals;
2c. Tomographic images
of the left TMJ condyle.
2c
50 • Vol. 1, No. 2 • April 2009
Miles
3a 3b
Figure 3: 3a. Axial slice of 500 slices at the level of the mid maxillary sinus showing 2 mucous retention cysts.
3b. Coronal slice near a posterior implant site showing the more medial mucosal lesion in the same patient
possibly communicating with the inferior turbinate.
namely, increased dose to children and reduced see these changes in the first case/example (Fig-
productivity required for reconstructing an image ure 1) because of the increased area of coverage.
like the panoramic.1-3 A perfect example of this Remember, you are not looking a single image, but
is monitoring the status of deciduous and perma- rather 300-500+ slices in 3 planes. The examina-
nent successor teeth in young children. When tion of these volumes, large or small, takes time.
performing routine exams such as these, you With respect to the “large vs. small debate”,
must carefully weigh the risks of additional radia- there seems to be a compromise on the horizon.
tion exposure in obtaining CBCT volume sets Large volume manufacturers are moving towards
when a simple panoramic image would suffice. a selectable FOV so that the operator can select
Figure 3 shows some “small” FOV images a smaller region to fit the diagnostic task. Small
and images from multi-functional machines. volume manufacturers, on the other hand, appear
In these examples, the dentist, in most cases, to be getting ready to offer machines with large
would be skilled enough to interpret the antral find- FOVs to attract customers like orthodontists who
ings. If nothing else, he or she would describe the require larger areas for cephalometric analyses.
lesions they found and refer the patient for an oto-
laryngologic evaluation. A simple description of the types of Information in Each Scan
the changes seen would suffice as long as it was So what exactly is found in these scans? Back
accompanied by informing the patient and referring in late 2006, I published an article describing
that patient to a specialist or back to their primary the findings of the first 381 cone beam volumet-
care physician for further evaluation. It is harder to ric cases I examined for various radiology labora-

Miles
Table 1: Common Reportable Findings on CBCT Scans

1. Paranasal sinus disease such as mucous retention cysts, chronic sinusitis and
blocked ostia
2. Enlarged adenoid and tonsillar tissues
3. Tonsilloliths
4. Deviated nasal septae and concha bullosa* (Figure 4)
5. Calcified, elongated stylohyoid ligaments
6. Osteoarthritic changes on TMJ condyles
7. Osteoarthritic changes on cervical vertebrae
8. Missed dental conditions such as palatal root lesions, bone loss and
implant perforations
(usually because 3D imaging was not used)
9. Inferior alveolar nerve proximity to and contact of impacted third molars
tory services.4 Even now, after interpreting almost

Table 2: Significant Findings 4,000 cases to date, I am impressed with the
(number of cases in parentheses) amount of “reportable pathology” in these data
1. Throat masses (4) volumes. Table 1 lists the most common findings
I have seen on the majority of scans I review while
2. Vertebral tumors (2) Table 2 lists some of the more significant findings
that I have reported over the course of my career.
3. Fungus balls
It is important to evaluate the entire data volume.
(aspergillosis), sphenoid sinus (2)
The number of significant and reportable findings
4. Odontogenic cysts and tumors (6-10) I have seen over the years support this concept.
5. Calcified plaques and medial Potential Liability

arterial calcinosis (approximately 30)
One of the biggest misconceptions in the den-
6. Oro-antral fistulae (more than 5) tal profession is who “owns” the liability if a sig-
nificant finding is missed during interpretation
7. Implant perforations (more than 20) of a CBCT scan. Some of this confusion can
8. Cranial tumors (2) be attributed to a so-called “mock trial” held at
the 108th annual session of the American Asso-
52 • Vol. 1, No. 2 • April 2009

Miles
4a 4b
Figure 4: An example of the anomaly “concha bullosa” in the middle turbinates.
*Concha bullosa: Aeration of the middle turbinate, termed “concha bullosa,” is a common anatomical variant of intranasal
anatomy. Of 320 patients evaluated for sinus disease with coronal CT, 34% had concha bullosa on at least one side. The
overall incidence of inflammatory disease in the ostiomeatal complex in these symptomatic patients was not different between
those with and without concha bullosa. However, there were many cases in which an abnormally large middle turbinate
appeared to obstruct the ostiomeatal complex causing secondary infection of the ethmoid, frontal, and maxillary sinuses.
Obstruction of drainage of the concha bullosa itself can lead to mucocele formation. Furthermore, the presence of a concha
bullosa has important implications for the technique of endoscopic surgery used in the management of the sinus disease.
ciation of Orthodontists in 2008. Following the To protect from this exposure, the scans
session of the “Doctor’s Risk Management Pro- should be read by a trained practitioner.” 6
gram”, Ms. Elizabeth Franklin, a claims manager
for the AAOIC (American Association of Ortho- This is prudent advice. In a recent article by
dontists Insurance Company) wrote the following: trial lawyer Mr. Kevin Henry,7 at the 1st International
Congress on 3-D Dental Imaging, California litiga-
“Cone-beam scans are a relatively new form tion attorney Arthur Curly, who specializes in medi-
of imaging available to the orthodontists to cal and dental malpractice, informed dentists that:
enhance patient treatment. Many orthodon-
tists, however, are not trained to read three “Dentists and team members are not
dimensional scans. If the scans are not read licensed to treat medical problems or
accurately and thoroughly, and incidental any other issues outside of the oral cav-
findings are missed, the orthodontist can ity, so they are also not licensed to diag-
assume a greater liability for failure to refer. nose conditions outside the oral cavity

Miles
that are outside the scope of their dental region of interest (orthodontic planning for
practice. Therefore, dentists can recom- example), and that patient release/consent
mend 3-D imaging as an option without forms will absolve you from all responsibility
fears that they could be liable for diag- from any outside specific narrowly tailored
nosing everything seen on the image. usage. This, of course, is a legal rather than
They are only responsible for those areas a medical question and the Board urges
that are within the scope of their prac- you to consult your legal counsel for advice
tice, dentistry: jaws and oral cavity.” before risking exposure to potential liabil-
ity. However, you should always remem-
Unfortunately, some dentists have taken this to ber that the Board views the use of CBCT
mean that they don’t have to look at the data vol- under the rules applicable to radiographs.
ume except as it pertains to their region of inter- Therefore, if you acquire a volume of data,
est or the specific task for which they acquired you should be able to interpret the data
the volume. If you read the assertion by Mr. Curly, for a complete and accurate diagnosis.”
someone has to look at all of the data. The prev-
alence of “occult pathology” is just too great. This, to me as a dentist and a radiolo-
For comparison, let’s consider that you have gist, seems like a prudent approach. Just
had a preliminary chest x-ray taken to examine your because the technique is new and novel, at
heart for enlargement or hypertrophy of the mus- least for dentistry, why would we NOT be
cle. Do you really think your physician or the radi- responsible for interpretation of the data?
ologist would fail to look at the lung field as well in The first is that they are not comfortable with
that chest film? By the same analogy, you would all the anatomy and potential pathology which may
never consider examining only half of a panoramic reside in the volume data. This is a legitimate con-
radiograph because only one lower third molar was cern and many colleagues have sought out special-
thought to be present. Accordingly, why would ists in oral and maxillofacial radiology to help them.
you think that no one has to look at the entire The second is that they do not want to “pay” the
cone beam data volume when only an implant site added cost, or have the patient pay an “extra fee”
is being assessed? If the patient was harmed to have a specialist look at the volume, because
because you didn’t look at the full data volume or it might make the case “too costly” for the patient
have someone look at the data for you, it is my firm and the dentist might lose the anticipated proce-
opinion that you may be facing a future lawsuit. dure fee. This is self-serving and again, in my opin-
In the Spring issue of the North Carolina ion, irresponsible behavior on the part of a dentist.
State Board of Dental Examiners Newslet- I even know of a colleague who has a patient
ter,8 Dr. Clifford Feingold, the editor, stated: sign a “refusal” document to have the cone beam
volume read by a specialist. Regarding “informed
“It is the Board’s understanding that some consent” and “informed refusal” of care or treat-
CBCT manufacturers emphasize that the ment, a succinct explanation is presented in the
machine may be used to evaluate a single May-June 2007 issue of The Reporter, a publication
54 • Vol. 1, No. 2 • April 2009

Miles
of the Texas Medical Liability Trust (TMLT). In this the dentist say that he/she has fully informed the
issue, Ms. Jane Holeman, vice-president of Risk patient? The very thought that they’ve received
Management for the TMLT states the following:9 informed consent from the patient, a dental and
medical necessity, before all the information is eval-
“Implicit in and intrinsic to the concept uated and known is absurd. How can the patient
of consent for treatment is the option of give or sign their “informed refusal” without having
refusal. In Cruzan v Director, Missouri knowledge of all of the information in the x-ray?
Department of Health, the U.S. Supreme
Court ruled that all U.S. citizens have a con- COnCLuSIOnS
stitutional right to refuse unwanted therapy, Despite my rather sobering comments about the
a right residing in the due process clause “Agony” of cone beam imaging, the interest, use,
of the 14th amendment. Authorized surro- and adoption of this modality is welcomed by the
gates can exercise this right of refusal on dental profession. We benefit by better decision-
behalf of the incapacitated patients they making information, our patients benefit by more
represent. This right of refusal pertains precise surgical placement of implants and better
to all therapies, including life-sustaining assessment of orthodontic, TMJ, and sinus prob-
therapies and artificial hydration and nutri- lems in addition to suspected and unsuspected
tion, without which patients will die.” All pathology. We can expect improvement in hard-
patients have the right, after full disclo- ware, software, detectors and knowledge as they
sure, to refuse medical treatment. This relate to this impressive and much needed tech-
can include patients who decline medi- nology. In the end, we can continue to bask in
cation, routinely miss office visits, defer the “Ecstasy” of Cone Beam Imaging, because
diagnostic testing, or refuse hospitaliza- it truly helps us all: both patient and clinician. ●
tion. Physicians are then prohibited from
proceeding with the intervention. “Prob-
lems arise, however, when the patient or Disclosure
The author reports no conflicts of interest with anything mentioned within this
the patient’s family later argues that they article.
References
were not given enough information to make 1. Miles D, Danforth R. A Clinician’s Guide to Understanding Cone Beam
Volumetric Imaging. Academy of Dental Therapeutics and Stomatology Special
an informed decision, or that the patient Issue 2007; 1-13.
2. Miles D. The Future of Dental and Maxillofacial Imaging. Dent Clin N Am
lacked the capacity to make the decision…” 2008; 52(4): 917–928.
3. Miles D. Color Atlas of Cone Beam Volumetric Imaging for Dental
Applications. Quintessence, Ch. 4-14 (pp 47-303), 2008.
The final part of this statement holds the key to 4. Miles D. Clinical Experience with Cone-Beam Volumetric Imaging: Report of
Findings in 381 cases. US Dentistry 2006; 1(1): 39-42.
this dilemma. How can a patient be expected to 5. Zinreich S, Mattox D, Kennedy D, Chisholm H, Diffley D, Rosenbaum A.
Concha bullosa: CT evaluation. J Comput Assist Tomogr 1998; 12(5): 778-
make an informed decision before they have all the 84.
6. Franklin E. “Doctor’s Risk Management Program.” 108th annual session of the
information? If the scan volume is not interpreted American Association of Orthodontists. Denver, Colorado: May 2008.
7. Henry K. 10 tips from a trial lawyer. Dent Economics 2008; 98 (6).
and the dentist lacks ANY information about poten- 8. Feingold C. Cone Beam Imaging. The Dental Forum, NC State Board of Dental
Examiners Spring 2007.
tial diagnoses and problems which might be in the 9. Brockway L. When Patients Decline Treatment: Informed Refusal. The
Reporter, Texas Medical Liability Trust; May-June 2007.
x-ray data, that is the “occult pathology”, how can

Byarlay
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Byarlay
4% Articaine Use
in United States and
Canadian Dental Schools
Matthew R. Byarlay DDS, MS1
Abstract
Background: Since the introduction and rise in dibular blocks, 68% reported only with faculty
popularity of 4% articaine have come reports of approval and 11% restricted it for graduate stu-
nerve injuries and paresthesias following mandibu- dents only. Other responses included restrictions
lar blocks. This study examined how articaine is to surgery department and for supplemental use
being used in educational institutions and if they only. Only 6% (2) of the respondents believed
have had an increase in IAN and LN injury due to their institution has had a nerve injury during man-
this product. dibular block anesthesia related to articaine, while
94% (31) had no such injury to report, and only
Methods: An e-mailed survey questionnaire was one respondent reported inferior alveolar nerve
sent to all U.S. and Canadian dental schools con- injury in 3 cases which could possibly be related
cerning the availability of 4% articaine in their clin- to articaine use
ics, restrictions of its use, and whether or not they
had sustained any possible nerve injuries related Conclusion: Nerve injury due to articaine use was
to its use. extremely low. Even with the lack of conclusive
evidence that 4% articaine should not be used for
Results: A total of 36 of the total 66 schools mandibular block analgesia, most of the reporting
responded to the survey. 83% of the schools institutions have some form of restrictive protocol
have articaine available but 79% have restrictions for its use in their clinics.
placed on its use. 57% do not allow it for man-
KEY WORDS: Articaine, local anesthesia, paresthesia, nerve injury, cytotoxicity
1. Assistant Professor, Department of Surgical Specialties, University of Nebraska Medical Center College of Dentistry,
Lincoln, Nebraska

Byarlay
BACKgROunD the fact that it was introduced only in the middle

Since its introduction into the United States in of the 8-year data collection period.2 Their con-
2000, articaine hydrochloride has gained wide- cluding statement read “there is a need for further
spread popularity. This is likely due to its reported studies focused on the problem of neurotoxicity of
more profound anesthesia, faster onset, and suc- local analgesics with specific focus on articaine
cess in patients who are difficult to anesthetize. It 4%. Until factual information is available, a pref-
has been available in Europe since 1976 and in erence of other formulations to articaine 4% may
Canada since 1984. The approved formulation be justified, especially for mandibular block anes-
for the United States is a 4% solution with an epi- thesia.” In response to this study was a Letter to
nephrine concentration of 1:100,000. With this the Editor by Dr. Malamed which stated, “At this
rise in popularity have come reports of nerve injury time there exists absolutely no scientific evidence
and paresthesias following mandibular blocks. to support the concluding comment regarding
The mandibular block is one of the most the use of other local anesthetics for mandibu-
common injections given by dental practitioners. lar block analgesia in place of articaine 4%.”7
Although it is frequently administered, it is more Due to this continued concern over this par-
technically difficult than infiltration injections due to ticular formulation, we conducted a survey study of
its depth of needle penetration, reliance on varied all U.S. and Canadian dental schools concerning
anatomical landmarks and placement of the anes- their usage of this product in light of the apparent
thetic near the neurovascular bundle.3 Injury to the conflicting information. The purpose of this study
inferior alveolar nerve (IAN) or lingual nerve (LN) dur- was to examine how 4% articaine is being used
ing this injection is reported to be low. Estimates of in educational institutions and if they have had an
the prevalence of temporarily impaired IAN and LN increase in IAN and LN injury due to this product.
function range between 0.15 and 0.54%.3,5 Per-
manent paresthesia, although rare, has been noted. MAtERiAlS AnD MEthODS
The mechanism by which this injury occurs has A list of all Canadian and U.S. dental schools
been the subject of much speculation. Proposed was generated and an e-mail survey question-
mechanisms for paresthesia following injections naire was sent to every Dean of Clinics at these
can include direct trauma to the nerve by the needle institutions in the 2006-2007 academic year. The
itself, hemorrhage into or around the neural sheath questions included in the survey were as follows:
increasing pressure on the nerve leading to par- 1. Do you currently have articaine available
esthesia, and neurotoxicity of the local anesthetic.1,6 for use in your clinics?
A 2006 publication by Hillerup and Jensen 2. Are there any restrictions to the use of
has lent support for the argument that local nerve articaine in your clinics?
injury during a mandibular block anesthesia may be 3. If so, please specify
due to the neurotoxicity of the 4% articaine solu- a. Not allowed for mandibular blocks
tion. This was based on the results of their study in b. Must have faculty approval
which nerve injuries caused by Articaine 4% cov- c. Graduate students only
ered more than half of their sample size in spite of d. Other_______________
58 • Vol. 1, No. 2 • April 2009

Byarlay
4, Has your institution had any nerve injuries calculation by the survey program. The results
possibly related to Articaine use? from this question show 57% (n = 16) do not
5. If lingual nerve involvement, approximately allow articaine for mandibular blocks, 68% (n
how many cases? = 19) must have faculty approval, 11% (n = 3)
6. If inferior alveolar nerve involvement, restrict use to graduate students only, and 28%
approximately how many cases? (n = 8) added additional comments to answer
The questionnaire was re-sent mul- this question. These responses included that it
tiple times over several months to try and is only available through the surgery clinics, is
generate as many responses as possible. for supplemental use only or that it is not avail-
able at all. Eight of the respondents did not
RESultS answer the question. For question #4, only 6%
Responses to the survey were returned from 36 (n = 2) of the respondents believed their insti-
of the 66 total U.S. and Canadian dental schools tution has had a nerve injury during mandibular
(table 1). In response to question (1), 83% (n block anesthesia related to Articaine, while 94%
= 30 schools) of the respondents answered (n = 31) had no such injury to report. A total of
“yes” with the remaining 17% (n = 6) answer- 3 respondents did not answer the question. For
ing “no”. In response to question 2, 79% (n = question #5, regarding involvement of the lingual
29) answered “yes” and 21% (n = 6) answered nerve, 33 of the respondents skipped the ques-
“no.” There was no response by 6 of the schools. tion, and the other 3 did not know of any cases at
For question #3, regarding what types of restric- that time. For question #6, only one respondent
tions are in place, multiple answers could be reported inferior alveolar nerve injury in 3 cases
selected thus interfering with the percentage which could possibly be related to articaine use.
Table 1: Questionnaire Summary

Yes No
Question 1: Articaine available in clinic? 83% 17%
Question 2: Restrictions on use? 79% 21%
Question 3 (a): Allowed for mand blocks? 43% 57%
Question 3 (b): Must have faculty approval? 68% 32%
Question 3 (c): Graduate students only? 11% 89%
Question 4: Nerve injuries related to use? 6% 94%
Question 5: Lingual nerve involvement? N/A 92%
Question 6: Inferior alveolar 3 total cases N/A
nerve involvement? reported

Byarlay
DiSCuSSiOn with the incidence of non-surgical paresthesia

The use of local anesthesia in dentistry is a nec- being 1:765,000.8 Their conclusion agreed with
essary procedure in the profession. According Haas and Lennon as articaine and prilocaine were
to Malamed, it is estimated that dentists in the associated with the nerve injury more frequently
United States administer more than 300 million than any other local anesthetic. In 2005, Legarth
local anesthetic cartridges annually.1 These drugs conducted a retrospective review of reports of
are considered very safe and nerve injury caused paresthesia from 2002-2004 in Denmark. In that
by injection of local anesthetics are considered time span, 32 lingual nerve injuries were reported
very rare. With this being said, there can still be with articaine being the anesthetic administered in
nerve injury following a mandibular block, whether 88% of those cases.9 Most recently, Hillerup and
by direct penetration from the needle, hemorrhage Jensen in 2006 looked at 54 injection injuries in
into the neural sheath or neurotoxicity of the local 52 patients caused by mandibular block analgesia.
anesthetic itself. Our survey wanted to specifi- The lingual nerve was found to be injured more
cally examine if the use of 4% articaine was the often (n = 42) than the inferior alveolar nerve (n
possible culprit in injury to the IAN or LN during a = 12). Again, as in prior studies, was the obser-
mandibular block. The results suggest that nerve vation that 54% of the sensory impairment cases
injury due to articaine use was extremely low with were associated with the use of 4% articaine.2
only 1 respondent reporting possible nerve injury In vitro studies also seem to support the
to this particular anesthetic in 3 cases. What is view that local anesthetics can be neurotoxic
also particularly interesting is that even with the in a dose dependant manner. In 1976, a rat
lack of conclusive evidence that 4% articaine study by Fink and Kish concluded that inhibi-
should not be used for mandibular block analgesia, tion of rapid axonal transport is probably a usual
most reporting institutions do report some form byproduct of nerve block with local anesthetics
of restrictive protocol for its use in their clinics. such as lidocaine and that the effect was dose
Studies lending support to the view that 4% dependent.10 A review by Steen and Michen-
articaine causes a higher incidence of nerve injury felder in 1979 of the neurotoxicity of anesthet-
are numerous. A retrospective study by Haas and ics also sites support for irreversible blocks of
Lennon found the overall incidence of paresthe- nerve trunks being a function of anesthetic con-
sia following local anesthetic administration to be centration, exposure duration and pH.12 Lam-
very low, with only 14 cases being reported out bert in 1994 concluded that high concentrations
of approximately 11,000,000 injections in 1993.4 of local anesthetics like 5% lidocaine have been
They concluded that this can be projected to shown to result in irreversible nerve conduction
an incidence of 1:785,000 injections. Of par- block which was not found with 1.5% lidocaine.11
ticular importance, however, was the fact that Contrary to the above studies is evidence from
compared with other local anesthetics, a higher Malamed published at the time of articaine intro-
incidence of parasthesia was found when artic- duction into the U.S. market. The studies pub-
aine or prilocaine were used. A follow-up study lished in 2000 and 2001 examined the efficacy
by Miller and Haas in 2000 found similar results and safety of 4% Articaine.13, 14 These were both
60 • Vol. 1, No. 2 • April 2009

Byarlay
based on randomized, double-blind, multicenter that the reported incidence of nerve injury from
trials where 1,325 patients received either 4% mandibular block anesthesia with 4% articaine is
articaine with 1:100,000 epinephrine or 2% lido- extremely low with only 1 respondent reporting
caine with 1:100,000 epinephrine for simple and possible nerve injury to this particular anesthetic
complex dental procedures. The results of the in 3 cases. But due to the well publicized informa-
efficacy study found no significant differences tion from retrospective reviews and associations
between the two treatment groups. The results drawn between nerve injuries and 4% articaine,
of the safety study found the overall incidence of it seems that most of the responding institutions
adverse events was 22% for the articaine group keep this anesthetic under tight control. Its use
and 20% for the lidocaine group. Paresthesia seems to be highly restricted, especially for man-
was reported by 8 of the patients in the artic- dibular blocks, and in some cases, may not be
aine group (0.9%) versus 2 of the patients in available at all. The lack of conclusive evidence on
the lidocaine group (0.45%). The conclusion this subject will continue to have an impact on the
from this study was that the adverse event pro- use of 4% articaine and will no doubt continue to
file was similar between the groups. Addition- make its use in dental education controversial. ●
ally, Malamed questions the strong conclusion
from the Hillerup and Jensen paper in his letter Correspondence:
to the editor in 2006 and continues to maintain Matthew Byarlay, DDS, MS
that based on the available evidence, a state- University of Nebraska Medical Center
ment such as “a preference of other formula- College of Dentistry,
tions to articaine 4% may be justified, especially 40th and Holdrege
for mandibular block analgesia” is not merited.7 Lincoln, NE 68583-0740
There seems to be strong opinion on both 402-472-5289 fax
sides of this discussion which adds to the inter- Email: mbyarlay@unmc.edu
esting results from this survey. Our study shows
Disclosure 5. Krafft TC, Hickel R. Clinical investigation into the 10.Fink BR, Kish SJ. Reversible inhibition of
The author reports no conflicts of interest with incidence of direct damage to the lingual nerve rapid axonal transport in vivo by lidocaine
anything mentioned in this article. caused by local anaesthesia. J Craniomaxillofac hydrochloride. Anesthesiology 1976;44(2):139-
Surg 1994;22(5):294-96. 45.
References
1. Malamed SF. Handbook of Local Anesthesia. 5th 6. Haas DA. Articaine and parestheia: 11. Lambert LA, Lambert DH, Strichartz GR.
ed. St. Louis: Mosby, 2004. epidemiological studies. J Am Coll Dent 2006 Irreversible conduction block is isolated nerve
Fall;73(3):5-10. by high concentrations of local anesthetics.
2. Hillerup S, Jensen R. Nerve injury caused by
Anesthesiology 1994;80(5):1082-93.
mandibular block analgesia. Int J Oral Maxillofac 7. Malamed SF. Nerve injury caused by mandibular
Surg 2006;35(5):437-43. block analgesia. Int J Oral Maxillofac Surg 12. Steen PA, Michenfelder JD. Neurotoxicity
2006;35(9):876-77. of anesthetics. Anesthesiology 1979
3. Harn SD, Durham TM. Incidence of lingual
May;50(5):437-53.
nerve trauma and postinjection complications in 8. Miller PA, Haas DA. Incidence of local
conventional mandibular block anesthesia. J Am anesthetic-induced neuropathies in Ontario 13. Malamed SF, Gagnon S, LeBlanc D. Efficacy of
Dent Assoc 1990;121(4):519-23. from 1994-1998. J Dent Res 2000;79(Special articaine: a new amide local anesthetic. J Am
Issue):627. Dent Assoc 2000 May;131(5):635-42.
4. Haas DA, Lennon D. A 21 year retrospective
study of reports of paresthesia following local 9. Legarth J. Lesions to the lingual nerve 14. Malamed S, Gagnon S, LeBlanc D. Articaine
anesthetic administration. J Can Dent Assoc in connection with mandibular analgesia. hydrochloride: a study of the safety of a new
1995 Apr;61(4):319-20, 323-6, 329-30. Tandlaegebladet 2005;109:10. amide local anesthetic. J Am Dent Assoc 2001;
132(2):177-84.

Shumaker et al
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Shumaker et al
The Effects of Periodontal Therapy on Helicobacter
pylori Clearance in Gastritis Patients: A Pilot Study
N. Shumaker, DDS, MS1 • A. Soolari, DMD1 • A. Gentry, MD2

H. Liu, MD3 • A. Dubois, MD, PhD3
Abstract
Background: Prior studies suggest that dental Results: Experimental patients achieved a sta-
plaque in periodontitis patients may be a res- tistically significant reduction in the mean plaque
ervoir for Helicobacter pylori bacteria, nega- index from 1.25 pre-treatment to 0.63 post-treat-
tively impacting gastritis treatment. This pilot ment (p = 0.004; <0.05). The control patient’s
study evaluated whether scaling and root plan- plaque index remained relatively unchanged, with
ing treatment could improve the clearance of 1.42 at baseline and 1.39 at the post-treatment
H. pylori bacteria in patients with both H. pylori exam. The mean experimental group gastric H.
gastritis and periodontitis. pylori levels were reduced from 266,306.43 cop-
ies of H. pylori RNA/100 ng sample pre-treat-
Methods: Four patients with H. pylori gastritis ment to 119.04 copies post-treatment. In the
and chronic periodontitis were evaluated by both control patient, a pre-treatment H. pylori level of
upper GI endoscopy and periodontal clinical and 188,474.37 copies was found, however the post-
radiographic examination before and 8-12 weeks treatment level remained high at 8,643.93 copies.
after gastritis treatment. Gastric biopsies were The control patient demonstrated a 72-fold higher
harvested during both endoscopic examinations. residual H. pylori level after treatment compared
Gastritis treatment consisted of the “triple-ther- to the experimental group.
apy” H. pylori eradication regimen (two antibiotics
and a proton pump inhibitor). Three experimental Conclusion: The findings of this pilot study sug-
patients received scaling and root planing treat- gest that periodontal treatment, targeted at reduc-
ment along with triple-therapy, while one control ing oral H. pylori levels, may result in improved
patient received only oral hygiene instruction. Dur- clearance from the stomach during gastritis
ing the periodontal evaluations the Silness plaque treatment. Further study with a larger number of
index was assessed. Gastric tissue samples were patients is warranted.
tested for H. pylori RNA levels using quantitative
RT-PCR. Data trends were evaluated.
KEY WORDS: Helicobacter pylori, periodontal disease, gastritis, peptic ulcer disease,
dyspepsia, scaling and root planing
1. Department of Periodontics, Naval Postgraduate Dental School, National Naval Medical Center; Bethesda, MD
2. Department of Gastroenterology, National Naval Medical Center; Bethesda, MD
3. Department Medicine, Uniformed Services University School of Health Sciences; Bethesda, MD

Shumaker et al
BACKgROunD sies for H. pylori. Patients with positive evalu-

Helicobacter pylori is a gram-negative, microaero- ation results are commonly treated with an oral
philic, acidophilic organism, first described in medication regimen known as “triple-therapy”
1983 by Marshall and Warren.1 H. pylori infects that includes two antibiotics combined with a
human gastric tissues causing inflammation known proton pump inhibitor or bismuth for 14 days.2
as H. pylori-induced gastritis.2 Gastritis symp- After treatment, a second follow-up EGD proce-
toms include abdominal pain (dyspepsia), gastric dure is recommended to verify clearance of H.
hemorrhage (which includes peptic ulcer disease), pylori, since its persistence is associated with
nausea, reflux and loss of appetite. Infection rates both further gastritis symptoms and the develop-
are reported at 20% for adults in the developed ment of gastric carcinoma and lymphoma, which
world, and 90% in the developing world.2,3 H. has a 5-year mortality rate of 50-75%.14 Triple
pylori is the reported cause of 70-90% of chronic therapy has been shown to achieve an 85-90%
active gastritis cases and is responsible for 5% clearance rate, however recurrence of infec-
of primary care physician visits annually in the tion occurs in up to 25% of treated patients.15,16
United States.2,4 Treatment of H. pylori related Treatment for chronic periodontitis may
gastrointestinal problems accounts for $3 bil- involve both non-surgical and surgical modali-
lion dollars per year of US healthcare spending.5 ties. Non-surgical treatment involves a proce-
Chronic periodontitis is an inflammatory dis- dure known as scaling and root planing (SRP).
ease of the supporting structures of the teeth, SRP is targeted at removal of bacterial plaque
which affects 30% - 50% of the US population.6 and calculus from involved tooth crown and
It is caused by a convergence of dental plaque root surfaces with the use specialized curettes
(a complex biofilm of over 500 types of bacteria) to create a root surface which promotes healing
with an aggressive host immune response that and control of disease.17 If SRP therapy is not
leads to periodontal bone resorption, soft tis- successful various surgical techniques may later
sue attachment loss, tooth mobility and eventual be necessary to restore periodontal health.17
loss.7,8 As periodontitis initiates and progresses, Prior studies have suggested that dental
deep periodontal pocketing with anatomic bony plaque in chronic periodontitis patients may
and soft tissue defects result, providing an eco- be a reservoir for H. pylori bacteria, which
logical niche where plaque can further accumu- may reduce the success of gastritis treatment.
late undisturbed, inaccessible by oral hygiene Chronic periodontitis patients have been found
practices.9,10 In recent studies, a positive asso- to harbor high levels of H. pylori in their den-
ciation has been found for chronic periodontitis tal plaque in as many as 87%-97% of sample
as a risk factor for several systemic diseases sites.18,19 These patients also demonstrate com-
including cardiovascular disease, diabetic gly- paratively higher levels of H. pylori in their den-
cemic control, and obstetric complications.11-13 tal plaque compared to periodontally healthy
Treatment for H. pylori-induced gastritis patients.20,21 Importantly, the treatment of gastric
involves evaluation by an upper GI endoscopy H. pylori with triple-therapy antibiotics has been
(EGD) procedure and testing of gastric biop- found to have very little effect on oral H. pylori
64 • Vol. 1, No. 2 • April 2009

Shumaker et al
levels found in dental plaque.22,23 Furthermore

the presence and persistence of H. pylori in the
oral cavity has been associated with reduced
clearance of gastric H. pylori during gastritis
treatment.24 Despite these findings, no currently
published study has investigated whether an
intervention of periodontal therapy, targeted at
reducing oral H. pylori levels, in conjunction with
gastritis treatment might help to increase the
success of H. pylori clearance from the GI tract.
Therefore, a prospective randomized con-
trolled pilot study was completed at the National
Naval Medical Center; Bethesda, MD, to evalu- Figure 1: Histologic view of H. pylori bacteria in gastric
ate the effects of non–surgical periodontal mucosa.
treatment (scaling and root planing) on the
clearance of H. pylori bacteria from the stom- Camplobacter-like organism test (CLO), four
ach mucosa in patients diagnosed with both H. were submitted for histological examination
pylori-related gastritis and chronic periodontitis. using special Steiner stains for H. pylori, and
the remaining two were placed in RNA Later®
MAtERiAlS AnD MEthODS (Applied Biosystems; Foster City, CA), RNA sta-
The study protocol was reviewed and approved bilizing agent and stored at -20 degrees Celsius
by the Responsible Conduct of Research for later experimental testing using PCR tech-
Department at the National Naval Medical Cen- niques. Of these 50 patients, eight patients were
ter (NNMC). This approval was granted after found to be positive for gastric H. pylori from the
being reviewed by the Scientific Review Panel biopsies collected during the EGD procedure.
and the Institutional Review Board. All patients The eight H. pylori positive patients were
identified as candidates for the study were pro- referred within one week to the Periodontics
vided thorough informed consent both verbally Department at the Naval Postgraduate Dental
and in writing regarding the risks and benefits School, Bethesda, MD (NPDS) for a periodon-
of participation. 50 patients with gastroentero- tal evaluation. During the periodontal examina-
logical symptoms suggestive of dyspepsia or tion, pocket depths (PD) and clinical attachment
peptic ulcer disease (PUD) were consented for levels were recorded (using the cemento-enamel
the study in the Gastroenterology department of junction as a fixed reference) and vertical bitew-
the NNMC and underwent upper GI endoscopy ing radiographs were examined. Dental plaque
(EGD) procedures under conscious sedation to levels were assessed in each patient using the
test for H. pylori bacteria in the stomach. During Plaque Index system described by Silness and
the EGD, eight gastric biopsies were harvested Loe25,26 on 4 surfaces per tooth. The plaque
for H. pylori testing. Two were tested using the index uses a scale of 0-3 with 0 representing no

Shumaker et al
dental plaque and 3 representing heavy plaque reassessment of the plaque index to reevalu-
accumulation. The mean plaque index across all ate the condition of the periodontium post-triple
tooth surfaces was calculated for each patient therapy. The control patient then received scal-
and recorded. Of the eight H. pylori positive ing and root planing after the second periodontal
patients, four were found to also have peri- examination, as this marked the end of the study.
odontal disease (defined as >2 pocket depths At the time of collection, gastric tissue sam-
>4mm with bleeding on probing and evidence of ples were placed immediately in sterile Eppen-
radiographic bone loss). These four patients, of dorf tubes filled with an RNA stabilizing solution
the original fifty enrollees, therefore comprised (RNA Later®, Ambion, Inc.). Specimens were
the study sample. Three of these four patients stored at -20o C until processing. For pro-
received scaling and root planing (SRP) ther- cessing, specimens were transported to the
apy (single session), as well as oral hygiene Digestive Diseases Research Division of the
instruction on tooth brushing and dental floss Uniformed Services University of the Health
techniques at the initial periodontal exam (exper- Sciences, Bethesda, MD, subjected to RNA
imental group). One patient received only oral extraction under sterile endoribonuclease-free
hygiene instruction and did not undergo SRP conditions, and stored at -70o C until testing.
therapy after the initial exam (control patient). When all samples were collected and extracted,
Immediately after this visit all patients absolute quantitative real-time RT-PCR (QRT-
received a prescription “triple-therapy” regimen PCR) was performed in a single-tube reaction
aimed at eradication of H. pylori. This consisted with a TaqMan One-Step RT-PCR Master Mix
of a 14 day oral regimen of two antibiotics, which Reagents kit (Applied Biosystems) designed for
included Clarithromycin (500mg taken bid) with reverse transcription (RT) and polymerase chain
either Amoxicillin (1 gram taken bid) or Metron- reaction (PCR) in a single buffer system and an
idazole (500mg taken bid), and Omeprazole
(20mg taken bid), a proton-pump inhibitor. Eight Table 1: Plaque Index (Silness and Loe
to twelve weeks after completion of the “triple- Method) Pre and Post Treatment
therapy” regimen, all four patients returned to
the Gastroenterology department of NNMC Pre- Post-
where a second EGD procedure was performed Treatment Treatment
to verify clearance of H. pylori from the stomach.
Eight gastric tissue samples were harvested
Mean
of Exp 1.25 (±0.11) 0.63 (±0.17*)
and stored in the same manner as the first
Patients
EGD, including two post-treatment samples in
RNA Later for PCR testing for H. pylori. Within Control 1.42 1.39
one week after the follow-up EGD procedure Patient
patients returned to the Periodontics Department
at NPDS for a follow-up examination including *Statistically significant reduction
reevaluation of periodontal pocket depths and (P=0.004, Paired T-test)
66 • Vol. 1, No. 2 • April 2009

Shumaker et al
ABI PRISM 7500 Sequence Detection System

(Applied Biosystems, Foster City, CA). Bacterial Table 2: Gastric H. pylori Levels
load was reported as copies of H. pylori RNA Pre and Post Treatment
per 100 ng of total RNA sample. Data analy- (in Copies RNA/100ng sample)
sis was completed with descriptive and inferen-
tial statistics using a student’s T-test to evaluate
Pre- Post-
Treatment Treatment
the significance of periodontal therapy on H.
pylori reductions achieved in this patient group. Exp
Patients 266306.43 119.04
RESultS (mean) (±134212.66) (±202.84)
A mean pre-treatment plaque index for the
Control
experimental group patients (n=3) was found 188474.37 8643.93
Patient
to be 1.25 (± 0.10). The pre-treatment plaque
index for the control patient (n=1) was 1.42.
The experimental patients all achieved a sta- estingly, this patient continued to have dyspeptic
tistically significant reduction in their plaque symptoms despite treatment. In comparing the
index after scaling and root planing (p = 0.004; residual post-treatment H. pylori levels between
<0.05 Paired T-test), with a post-treatment the two groups, the control group demon-
mean plaque index of 0.63 (±0.17). The con- strated a 72-fold higher residual H. pylori level
trol patient, who did not receive scaling and compared to the experimental group (Figure 2).
root planing, showed a plaque index similar to
baseline of 1.39 at the followup visit (Table 1). DiSCuSSiOn
Experimental group patients demon- The results of this small pilot study suggest a
strated mean pre-treatment H. pylori levels of trend which may indicate that scaling and root
266,306.43 copies of H. pylori RNA/100 ng of planing treatment could increase the clearance
sample (±134,212.66), with a mean post-treat- of H. pylori from the gastric mucosa during treat-
ment level of 119.04 copies/100 ng of sample ment of H. pylori-related gastritis. The control
(±202.64). This appears to be a large reduc- patient had a high level of residual infection at the
tion, however, it was found only to approach post treatment EGD (8,643.93 copies H. pylori
statistical significance (p=0.07) due to the RNA/100ng sample) in comparison to the exper-
high variability in H. pylori levels between each imental patients (mean=119.04 copies H. pylori
patient and the small number of patients who RNA/100ng sample) by a magnitude of 72 fold.
met the study criteria. The control patient dem- This reduction appeared to correlate to a statis-
onstrated a pre-treatment H. pylori level of tically significant drop in the plaque index in the
188,474.37 copies of H. pylori RNA/100ng of experimental patients which resulted from scal-
sample. At the post-treatment EGD this patient ing and root planing therapy in conjunction with
still harbored a high level of residual H. pylori H. pylori eradication treatment. While the actual
with 8,643.93 copies persistent (Table 2). Inter- reduction in gastric H. pylori was not found to

Shumaker et al
be statistically significant, the magnitude of the the emergence of putative pathogens implicated
comparative reduction in the experimental group in the pathogenesis of periodontitis.27,28 These
suggests a trend which supports our hypoth- include species such as Treponema denticola,
esis. Statistical analysis in this pilot study was Porphorymonas gingivalis, Tanerella forsythia,
challenged by the small sample size obtained Campylobacter rectus, and Fusobacterium
after 13+ months of data collection. Addition- nucleatum.29 Several studies have suggested
ally, the presence of only one control patient that there is an ecological niche for H. pylori in
made statistical comparison between groups dental plaque. Okuda (2003) found that Por-
difficult. Regardless, the trend suggested by the phorymonas gingivalis and Fusobacterium
results of this pilot study is promising and high- nucleatum in dental plaque strongly coaggre-
lights a need for further research on this subject. gate with H. pylori, and may actually entrap H.
Development of dental plaque occurs within pylori cells in the dental biofilm.30,31 While saliva
hours of mechanical removal by oral hygiene or contains immuno-defensive mechanisms, such
professional instrumentation, and proceeds to as secretory IgA, the value of these defenses
develop into an increasingly organized biofilm. may be limited against H. pylori since many
Sequential colonization of dental plaque leads to authors have found H. pylori is present in saliva
Figure 2: Comparison Post-Treatment H. pylori Levels with Plaque Levels
68 • Vol. 1, No. 2 • April 2009

Shumaker et al
samples.22,23,31 Additionally saliva does not mission also have been shown.36 In gastri-
penetrate into subgingival areas including peri- tis patients, vomiting or reflux may facilitate
odontal pockets of periodontitis patients, due infection of the dental plaque from the stom-
to the constant outward flow of gingival crev- ach, however this does not account for how H.
icular fluid which increases with inflammation.32 pylori entered the stomach in the first place.
Our study did not include sampling and Regardless of how it arrives in the oral cavity,
analysis of dental plaque samples for the pres- the presence of H. pylori may serve as an oral
ence of H. pylori. Since prior studies by other reservoir which resists clearance by antibiot-
researchers using PCR techniques have ics during triple-therapy antibiotic treatment.22-24
shown its presence with great frequency, we This persistent H. pylori in dental plaque may
chose only to measure the quantitative dental be constantly translocated to the gut during
plaque reduction with SRP using the plaque eating and swallowing, facilitating reinfection.
index.19-23 Earlier studies using culture tech- The findings of this small pilot study suggest
niques had mixed findings on the presence of that that reducing the level of dental plaque in
H. pylori in dental plaque, and it is only with patients with periodontitis may increase the
the advent of PCR detection techniques that it success of H. pylori eradication with the triple-
has been reliably detected in plaque samples.33 therapy regimen in the treatment of H. pylori-
Compliance with any oral medication regi- induced gastritis. Conversely, the persistence
men can confound study data. In this study, of dental plaque in untreated chronic periodon-
verification of compliance with triple-therapy titis patients may serve as an H. pylori reservoir
was not assessed. Studies on patient compli- which may reduce the success of such treatment.
ance with oral medications appears to decrease
with increasing complexity of the regimen (ie. COnCluSiOn
a single antibiotic would have better compli- This pilot study suggests that there may be
ance than three different medications in tri- enhanced H. pylori clearance in patients
ple-therapy).34,35 However the medical and with both H. pylori gastritis and chronic
dental literature support that patient compli- periodontitis when non-surgical periodon-
ance is highest when patients perceive a distal treatment is rendered as an adjunct to
ease risk exists or have symptoms resulting the triple-therapy regimen. Further investiga-
from a disease which the believe will improve if tion with a larger number of patients is neces-
they follow treatment recommendations.35 All sary to better understand this relationship ●
patients in this study had symptomatic dyspep-
sia or peptic ulcer disease. Therefore, it may
Correspondence:
be expected that they had reasonable com-
Nicholas D. Shumaker DDS, MS
pliance with the recommended medications.
c/o Research Department, Naval Postgraduate
Acquisition of H. pylori appears to occur
Dental School, Building 1, 8901 Wisconsin Ave
person to person via an oral-oral route, but
Bethesda, MD 20889-5600
drinking water, animal, and food borne trans-

Shumaker et al
Acknowledgements 12. Lin D, Moss K, Beck JD, Hefti A, Offenbacher 25. Silness J, Loe H. Periodontal disease in
The authors would like to extend a special thanks S. Persistently High Level Of Periodontal pregnancy; II. Correlation between oral hygiene
to the following individuals who contributed to the Pathogens Associated With Preterm and periodontal condition. Acta Odontol
development and completion of this pilot study: Pregnancy Outcome. J Periodontol Scand. 1964;22:112-135.
John Mumford, DDS, MS; Dong Lee, MD; Rebecca 2007;78:833-841.
26. Loe H. The gingival index, the plaque index,
Christensen, MD and Mary E. Neill, DDS, MS.
13. Rodrigues DC, Taba M, Novaes AB, Sousa and the retention index systems. J Periodontol.
Disclosure SLS, et al. Effect of non-surgical periodontal 1967;36:610-616.
The authors report no conflicts of interest with therapy on glycemic control in patients with
27. Offenbacher S, Costopoulos SV, Odle BM,
anything mentioned in this article. type 2 diabetes mellitus. J Periodontol 2003
Van Dyke TE. Microbial colonization patterns
74(9): 1361-1367.
Disclaimer of loosely adherent subgingival plaque in
“The views expressed in this abstract are those of 14. Hsu PI, Lai KH, Hsu PN, Lo GH, et al. adult periodontitis. J Clin Periodontol.1988
the author and do not necessarily reflect the official Helicobacter pylori infection and the risk of Jan;15(1):53-9.
policy or position of the Department of the Navy, gastric malignancy. Am J Gastroenterol. 2007
28. Loe H. Experimental gingivitis in man. J
Department of Defense, nor the U.S. Government” Apr;102(4):725-30.
Periodontol 1965; 36:177-187.
References 15. Ong SP, Dugan A. Eradication of Helicobacter
29. Socransky SS, Haffajee AD, et al. Microbial
1. Marshall BJ, Warren JR. Unidentified curved pylori in clinical situations. Clin Exp Med. 2004
complexes in subgingival plaque J Clin
bacilli in the stomach of patients with gastritis Sep;4(1):30-8.
Periodontol. 1998; 25:134-144.
and peptic ulceration. The Lancet. 1984 Jun
16. Xia HX, Talley NJ, Keane CT, O’Morain CA.
16;1(8390):1311-1314. 30. Andersen RN, Ganeshkumar N, Kolenbrander
Recurrence of Helicobacter pylori infection
PE. Helicobacter pylori adheres selectively to
2. Talley NJ, Vakil NB, Moayyedi P. American after successful eradication. Dig Dis Sci.
fusobacterium spp. Oral Microbiol Immunol.
Gastroenterological Association technical review 1997;42(9):1821-1834.
1998;13:51-54.
on the evaluation of dyspepsia. Gastroenterol.
17. American Academy of Periodontology
2005;129:1756-1780. 31. Okuda K, Kimizuka A, Nakagawa T, Ishihara
Parameters of Care. Parameter on chronic
K. Ecological and immunopathological
3. Taylor DN, Blaser MJ. The epidemiology of periodontitis with advanced loss of periodontal
implications of oral bacteria in Helicobacter
Helicobacter pylori. Epidemiol Rev. 1999;13:42- support. J Periodontol 2000;71:856-858.
pylori-infected disease. J Periodontol.
59.
18. Dowsett SA, Eckert GJ, Kowolik MJ. 2003;74:123-128.
4. Feldman M, Scharschmidt M, Sleisenger Helicobacter pylori infection in indigenous
32. Hancock EB, Cray RJ, O’Leary TJ. The
H, editors. Sleisenger and Fordtran’s families of Central America: Serostatus and
relationship between gingival crevicular fluid
gastrointestinal and liver disease: oral and fingernail carriage. J Clin Microbiol.
and gingival inflammation: A clinical and
Pathophysiology/diagnosis/management. 6th ed. 1999 Aug:2456-2460.
histologic study. J Periodontol. 1979;50:13-19.
Philadelphia: WB Saunders; 1998: p 604-619
19. Song Q, Lange T, Spahr A, Adler G, Bode
33. Dowsett SA, Kowolik MJ. Oral Helicobacter
5. Sonnenberg A, Everhart JE. Health impact G. Characteristic distribution pattern of
pylori: Can we stomach it?. Crit Rev Oral Biol
of peptic ulcer in the United States. Am J Helicobacter pylori in dental plaque and saliva
Med. 2003;14(3):226-233.
Gastroenterol 1997;92:614-620. detected with nested PCR. J Med Micro.
2000;49:349-353. 34. Greenberg RN. Overview of patient compliance
6. Albandar JM, Brunelle JA, Kingman A.
with medication dosing: A literature review. Clin
Destructive periodontal disease in adults 30 20. Umeda M, Kobayashi H, Takeuchi Y, Hayashi
Ther. 1984;6(5):592-599.
years of age and older in the United States, J, et al. High prevalence of Helicobacter
1988-1994. J Periodontol. 1999 Jan;70(1):13- pylori detected by PCR in the oral cavities 35. Wilson TG. Compliance: A review of the
29. of periodontitis patients. J Periodontol. literature with possible applications to
2003;74:129-134. periodontics. J Periodontol. 1987;58:706-714.
7. Moore WE, Moore LV. The bacteria of periodontal
diseases. Periodontol 2000. 1994;5:66. 21. Souto R, Columbo AP. Detection of 36. Nabwera HM, Logan RPH. Epidemiology of
Helicobacter pylori by polymerase chain Helicobacter pylori transmission, translocation,
8. Genco RJ. Host responses in periodontal
reaction in the subgingival biofilm and saliva and extragastric reservoirs. J Physiol
diseases: current concepts. J Periodontol. 1992
of non-dyspeptic periodontal patients. J Pharmacol. 1999;50(5):711-722.
Apr;63(4 Suppl):338-55.
Periodontol. 2008 Jan;79(1):97-103.
9. Carranza FA, Newman MG, Takei, HH.
22. Gebara EC, Faria CM, Pannuti C, Chehter L, et
Carranza’s Clinical Periodontology. 9th ed.
al. Persistence of Helicobacter pylori in the oral
Philadelphia: WB Saunders. 2002: p. 96-112.
cavity after systemic eradication therapy. J Clin
10. Page RC, Offenbacher S, Schroeder Periodontol. 2006 May;33(5):329-33.
HE, Seymour GJ, et al. Advances in the
23. Czesnikiewicz-Guzik M, Loster B, Bielanski W,
pathogenesis of periodontitis; summary of
Guzik TJ, et al. Implications of oral Helicobacter
developments, clinical implications and future
pylori for the outcome of its gastric eradication
directions. Periodontol 2000. 1997;14:216-
therapy. J Clin Gastroenterol. 2007
248.
Feb;41(2):145-51.
11. Scannapieco FA. Systemic effects of
24. Miyabayashi H, Furihata K, Shimizu T, Ueno I,
periodontal diseases. Dent Clin North Am.
et al. Influence of oral Helicobacter pylori on
2005 Jul;49(3):533-50
the success of eradication therapy against
gastric helicobacter pylori. Helicobacter.
2000;5(1):30-36
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Alan A. Winter, DDS1 • Alan S. Pollack, DDS1 • Ronald B. Odrich, DDS1

The Journal of Implant & Advanced Clinical Dentistry • 31

BACKgROunD infracture the sinus floor and raise the membrane

32 • Vol. 1, No. 2 • April 2009

by making the width of the rectangular box narrow

Case Report The patient was referred for a dental com-

The Journal of Implant & Advanced Clinical Dentistry • 33

15 area. The S.A.C.T. technique was employed