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Volume83 Number 1
January 2017
23Dentofacial Considerations in Genioplasty
Majid Jamali, D.M.D.
Different scenarios and deformities in the maxillofacial complex that can affect the
chin position and shape of its overlying soft tissue are illustrated. Includes
recommendation that patients be made aware of underlying skeletal issues and
alternative treatments.
30Combined Orthodontic and Restorative Approach to Esthetic Treatment of
Maxillary Peg Lateral Incisor in Adolescent Female Patient
Eugene H. Bass, D.M.D.
The esthetic restoration of a peg lateral incisor can be a transformative event for
adolescent female. Nevertheless, the most conservative and minimally invasive
treatment is appropriate. Author describes a combined orthodontic and restorative
approach to management of this condition, using a direct composite veneer without
tooth reduction. Case report.
Cover: Successful genioplasty begins with
the surgeon’s artistic and scientific
understanding of the relationships between
the mentum and other facial structures.
2Editorial
Embarking on listening tour
4 Attorney on Law
Anesthesia regulations revised
14Letters
15Viewpoint
Having fun with dentistry
17 Association Activities
54 General News
56 Component News
66 Annual Index of Articles
34Mandibular Bisphosphonate Osteonecrosis: A Cautionary Tale
Ashley Coffey, D.D.S.; Louis Mandel, D.D.S.
Both the oncologist and dentist must be aware when bisphosphonates are going to be
administered so dental care can be performed in timely fashion. Prophylactic
measures must be taken if dental surgery is required for patient who has received BP.
Case report.
39Relationship of Psychological Factors to Temporomandibular Disorders in Children
Janaina Habib Jorge, D.D.S., M.Sc., Ph.D.; Daniela A.G. Gonçalves, D.D.S., M.Sc.,
Ph.D.; André Petzet Barreiros, D.D.S.; Thiago Ceregatti, D.D.S.; Graziel Sapienza,
D.D.S., M.Sc., Ph.D.; Karin Hermana Neppelenbroek, D.D.S., M.Sc., Ph.D.; Vanessa
Migliorini Urban, D.D.S., M.Sc., Ph.D.
Evaluation of incidence of TMDs and their relationship to psychological factors in
children ages 6-12 who sought dental treatment at Ponta Grossa State University in
Brazil confirmed a link.
44Postoperative Pain Following Treatment of Teeth with Irreversible Pulpitis
Zahed Mohammadi, D.M.D., M.S.D.; Paul V. Abbott, B.D.Sc., M.D.S., FRACDS
(Endo); Sousan Shalavi, D.M.D.; Mohammad Yazdizadeh, D.M.D., M.S.D.
For patients presenting with preoperative pain, most will continue to experience
pain after root canal treatment. A review of symptoms and classification of
irreversible pulpitis, incidence of postoperative pain following treatment, factors
influencing postoperative pain, prevention and pharmacological management.
75Classifieds
77 Index to Advertisers
80Addendum
Life members
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editorial
Be That Guy (or that Woman)
Twenty years of preparation have brought a new editor to the helm of The NYSDJ.
Y
ou do things for a reason. Usually. Sometimes,
people plan and God laughs. Occasionally, your decisions provide you with the opportunity of a lifetime. I
chose to enroll in law school after 10 years in private
dental practice. The application required an essay on
my reasons for selecting law as a career. I relished the
chance to explain myself, since I knew exactly what I
intended to do with a law degree. I wrote, in so many
words, that I wanted to be “that guy” who bridges the
gap between the diverse interests and forces of the
legal, business, administrative and political worlds
and the noble profession of dentistry and its duty to
act in the best interests of patients. Yikes! Sounds like
a tall order—maybe an unreachable goal—but a worthwhile endeavor.
In order to meet the challenge, for over 20
years, I have taught and written about the issues
facing dentistry. I want to now thank the New York
State Dental Association and you, its members, for
offering me the opportunity of my lifetime: to be
that guy as the editor of our New York State Dental
Journal.
Our Journal must educate, inform and provoke
debate on significant and timely topics. In addition,
I will gauge its success, in part, on how well The
Journal can inspire each of you, individually, to
define what it means to be “that guy” or that
2
JANUARY 2017 • The New York State Dental Journal
woman for your patients, organized dentistry and
our profession. Your definition of what this means
will vary with your particular skill set and with the
myriad challenges you face. Let our editorial staff’s
responses to the varied and changing issues facing
our diverse membership serve as a springboard to
your own involvement. In doing so, The Journal
content should facilitate dialogue among our members essential to its growth and relevance.
Fortunately, I succeed outgoing editor, classmate and good friend Kevin Hanley, who, along
with Managing Editor Mary Stoll, has elevated The
New York State Dental Journal to one of the premier
state journals in the country. Moving forward, I
want our publication to help chart the itinerary for
your journey into service and leadership. Find out
what it means to be “that guy (woman)” and hop
on board.
As dentists, we often lead multidimensional
professional lives with divergent concerns. Some of
us teach, administrate, perform research, or treat
patients in various forms of public or private practice. Each facet of our careers influences our opinions on or response to any given issue. Although my
training as an attorney will always shape my views,
I find I still analyze problems through the prism of
my over 30 years of ownership of a private dental
THE NEW YORK STATE DENTAL JOUR­NAL
EDITOR
Chester J. Gary, D.D.S., J.D.
MANAGING EDITOR
Mary Grates Stoll
ADVERTISING MANAGER
Jeanne DeGuire
ART DIRECTORS
Kathryn Sikule / Ed Stevens
EDITORIAL REVIEW BOARD
Frank C. Barnashuk, D.D.S.
David A. Behrman, D.M.D.
Michael R. Breault, D.D.S.
Alexander Corsair, D.M.D.
Ralph H. Epstein, D.D.S.
NYSDJ Editor Chester Gary, right, with friend, dental school classmate and outgoing editor Kevin Hanley at
House of Delegates Annual Session in June.
Daniel H. Flanders, D.D.S.
Joel M. Friedman, D.D.S.
G. Kirk Gleason, D.D.S.
Kevin J. Hanley, D.D.S.
Brian T. Kennedy, D.D.S.
practice, including my current part-time general practice. In addition, during this same
time, my experiences as clinical assistant professor teaching law and ethics and as a
clinical instructor at the University at Buffalo School of Dental Medicine keep me in
touch with the needs of the new dentist and culturally diverse groups. No doubt, my
role in dental education plays a significant part in how I function as “that guy.”
In the end, an effective editor listens. When any player in the oral health care
delivery system takes a position on a significant or controversial subject, dentistry
should hear it, understand its impact and, when necessary, frame a cogent response.
As your editor, I will listen for these voices of change and present a fair and balanced
commentary. Most importantly, I will listen for your guidance on how The New York
State Dental Journal can help clarify what being “that guy (woman)” means for each
of you.
D.D.S., J.D.
Stanley M. Kerpel, D.D.S.
Elliott M. Moskowitz, D.D.S., M.Sd
Francis J. Murphy, D.D.S.
Eugene A. Pantera Jr., D.D.S.
Robert M. Peskin, D.D.S.
Pragtipal Saini, B.D.S., D.D.S., M.S.D.
Robert E. Schifferle, D.D.S., MMSc., Ph.D.
PRINTER
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NYSDJ (ISSN 0028-7571) is published six times a year,
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and November, by the New York State Dental Association,
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The New York State Dental Journal • JANUARY 2017
3
oral surgery
Dentofacial Considerations in Genioplasty
Majid Jamali, D.M.D.
ABSTRACT
underlying skeletal issues.
sulcus. In this article, emphasis is placed on the importance of
considering the whole face when evaluating the chin. Problems
observed in the chin area could be, and usually are, a component
of abnormalities of the maxilla-mandibular complex. These abnormalities may include such underlying issues as a divergent
skeletal pattern, maxillary excess, short mandibular ramus, or
condylar disease.
With proper diagnosis and treatment of chin abnormalities,
the clinician and patient can be rewarded with superior results
that are esthetically pleasing. Knowledge of osteology and muscle
attachments, understanding and assessment of dental occlusion,
as well as maxilla and mandibular anatomy and function, are all
key to treatment planning, as these structures are all interrelated.
Cephalometric analysis should be used to assist and to confirm
the clinical findings. The clinician must be aware that true micrognathia, or a small chin, is rare.
Facial profile enhancement is becoming increasingly common. In
addition to the nose, the chin plays an important role in the overall esthetic appearance of the face; and chin augmentation has
become an integral component of facial rejuvenation.
Genioplasty, primarily by means of implants, has become a
popular procedure to enhance a receding chin. In younger patients, this procedure is typically performed during rhinoplasty
to give harmonious balance to the face.5 In older patients, it is
usually performed simultaneously with facial and neck rhytidectomy to give definition to the jaw line and improve the pre-jowl
Chin Origin and Significance
In human anatomy, the chin area, which is the lowest part of
the face, is also known as the mental region (Figure 1). The
chin evolved in the Middle and Late Pleistocene periods, anatomically distinguishing modern humans from their archaic
counterparts. 4 The origin of the chin and its biomechanical
significance are somewhat controversial. As the chin allows
for minute movements of the lips associated with speech, it
is theorized that the chin evolved to uphold the jaw from
the stresses associated with chewing and speech.1 Because
Chin augmentation, particularly with implants, has
become popular in recent years. For the most part,
the focus is on the position of the pogonion. The rest
of the mid-face, including the maxilla and mandible,
are usually ignored. In this article, different scenarios and deformities in the maxillofacial complex that
can affect the chin position and shape of its overlying
soft tissue are illustrated. It is the author’s view that
a number of genioplasty augmentation procedures
should be deferred. Discussion of alternative treatments should take place with patients regarding their
The New York State Dental Journal • JANUARY 2017
23
Fig. 2 A
Figure 1. Position of chin, most anterior, inferior part of
mandible.
Fig. 2 B
Figures 2 A,B. Location of muscle attachments. (A) Note attachment location of depressor anguli oris and depressor
labii inferioris on chin. (B) Because of location of these muscles, chin surgery alone would not completely improve large
interlabial gap; therefore, jaw advancement or maxillary impaction would be necessary.
the chin differs in shape, depending upon gender, being more
triangular in females and more square in males, 2 it has also
been hypothesized that sexual selection played a part in its
evolution. 3
In many modern human cultures, a prominent chin is
thought to represent a confident person.
Anatomy
Osteology
The chin has an external and internal surface. On the external
surface, the ridge on the anterior midline is formed in utero by
fusion of the mandible. This ridge divides inferiorly and surrounds the mental protuberance. On each side of the protuberance, slightly raised mental tubercles form. Proximal to the tubercles and inferior to the second premolar, the inferior alveolar
nerve exits the mental foramen on each side.
Myology
Seven muscles attach to the chin. The muscles on the anterior
surface include the mentalis, depressor labii inferioris, depressor
anguli oris (partially) and platysma (Figure 2A). Mobilization of
the lower lip is accomplished by these muscles. The geniohyoid,
genioglossus and anterior belly of the digastric muscles arise from
the posterior surface of chin (Figure 2B). These muscles oppose
the downward pulling of the strap (infra-hyoid) muscles during
speech and swallowing.
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JANUARY 2017 • The New York State Dental Journal
Fig. 3 A
Fig. 3 B
Figures 3 A, B. Taking proper photos. (A)
Importance of evaluating patient with lips in
repose (relaxed) can be appreciated from these
photographs. Mentalis muscle restraining is
frequently seen in patients with skeletal deformities. Lower lip is positioned in anterior and
superior direction, flattening labiomental fold.
(B) With lips in repose, interlabial gap usually
widens and reveals occasionally normal-shaped
labiomental fold.
Figure 5. Shape is
more important than
position of chin. As demonstrated here, shape of
soft-tissue drape is more
important than anteriorposterior (AP) position of
chin. Drawing in middle
demonstrates gentle “S”
curvature of labiomental
fold. Note, pogonion on
these patients are all in
same AP position.
Fig. 6 A
Figure 4. Cephalometric analysis for genioplasty.
Upper facial (G-Sn) and lower facial planes (Sn-Po)
form facial contour angle, which determines facial
convexity that should be between –11 to –14
degrees. Patients with deficient chins will have
obtuse angle. Those with prominent chins will have
acute angle. Facial plane extends from the Nasion
(N) to Pogonion (Po) and should be perpendicular
to Frankfurt plane (FH). Antero-posterior position of
chin in relation to upper face is determined here.
Fig. 6 B
Fig. 6 C
Figures 6 A-C. Maxillomandibular rotation, plus sliding genioplasty. (A) Preoperative photo of patient with
moderate sleep apnea and Class I occlusion accomplished by orthodontic treatment (Invisalign). (B) Postoperative photo. (C) Dental occlusion maintained as Class I, pre- and postoperatively. Although patient could benefit
cosmetically from chin augmentation, to obtain most advancement of the suprahyoid and tongue muscles,
orthognathic surgery is preferred over chin augmentation alone.
Physical Evaluation
After eliciting a medical history and chief complaint, the expectations and degree of motivation of the patient should be evaluated.
To create an appropriate treatment plan, radiographs (such as panoramic X-rays and cephalograms) and photographs are invaluable;
it is highly recommended that they be obtained. Physical palpation
of the mentum area for diagnosing the underlying problem is important but not sufficient. Once all of the data are gathered, it is the
duty of the clinician to not only listen to the chief complaint but
also to educate and guide the patient toward the proper treatment.
Clinical assessment begins with the patient’s head in the
Frankfurt horizontal, teeth in occlusion and lips in a relaxed position (i.e., in repose). The simple task of relaxing the mentalis
musculature might be difficult for some patients. Many times,
they have been subconsciously constricting these muscles for
years in an attempt to appear normal (Figure 3). Therefore, if this
is noticed, a few moments should be devoted to explaining and
demonstrating proper relaxation of the lips and perioral musculature. A lateral cephalogram and photographs are subsequently
obtained, with the lips in the same position.
When the above examination and diagnostic testing is completed, a sequential evaluation begins. Specific information that
must be gathered when evaluating the chin includes the following:
l Mid-face appearance.
l Maxillary incisor show.
l Shape and appearance of the labiomental fold and soft tissue
envelope.
l Dental occlusion.
l Position of the chin relative to the forehead.
l Shape of the chin.
Mid-face Appearance
From the profile view, the mid-face should appear round. Deficiencies in the anterior-posterior position of the maxilla result
in a mid-face that appears flat and yields a mandible that appears pseudo-prognathic, making the labiomental fold obtuse.
Maxillary Incisor Show
The incisor show is a guide to assessing the vertical position of the
maxilla. With a normal upper lip length at rest, 2 mm to 3 mm of
incisors should be visible. Inadequate or excessive exposure of the
incisors may represent vertical insufficiency or overgrowth of the
maxilla. Influenced by the position and angulation of the maxilla,
the mandible rotates around the condyles and dictates the final
position of the pogonion of the chin.
Shape and Appearance of Labiomental Fold and Soft Tissue
The labiomental fold should have a gentle S-shape curve. The vertical position and angulation of the upper and lower incisors, and
the anterior-posterior position of the mandible, the maxilla and
the chin itself, play a role in shaping this fold.
Dental Occlusion
The molar class relationship and the occlusal and incisal an-
The New York State Dental Journal • JANUARY 2017
25
Fig. 7 A
Fig. 8 A
Fig. 7 B
Figures 7 A,B. Patient demonstrating high-angle mandible. (A) Facial feature of patient with highangle occlusion and mandibular plane with open-bite tendency. (B) Dental occlusal angle. This patient
had undergone 5 years of orthodontic treatment and was seeking sliding genioplasty. Due to moderate
retrognathia and deep labiomental fold, genioplasty procedure alone was denied by surgeon.
Fig. 8 B
Fig. 8 C
Figures 8 A-D. Mandibular angle and its effect on chin shape and position. (A)
High-angle occlusion. (B) Normal occlusion. (C) Low-angle occlusion. (D) Cephalometric
drawings of patient.
Fig. 8 D
Fig. 9 A
Fig. 9 B
Figures 9 A,B. Patient with Class II, Division 1, malocclusion. (A) Patient with retrognathic
mandible. (B) Dental occlusion revealing proclined teeth and large overjet. Lips at repose
usually show soft-tissue shape with deep fold overlying chin. Anterior-posterior position can be
changed by chin augmentation, but this would sacrifice existing shape.
gles should be evaluated. These two angles are difficult to accurately assess clinically, emphasizing the importance of obtaining a lateral cephalogram. One must remember that finding a
Class I occlusion does not rule out facial skeletal disharmony.
Occasionally, a skeletal deformity might have been masked by
previous orthodontic treatment. Although orthodontic camouflaging can produce acceptable results in a mild dentofacial
deformity, moderate and severe deformities can be left with
devastating results, with poor soft-tissue profile. Hence, during clinical evaluation of the chin, one must be aware of past
orthodontic treatment. For instance, a skeletal Class II (retrusive jaw) could present itself as a Class I dentally. Much like
orthodontic treatment, a mild skeletal deformity can be corrected by genioplasty. However, moderate or severe deformities
should have a well-formulated plan. In these situations, the
teeth should be realigned to a proper angle and corrective jaw
surgery should be performed. Only rarely could a geniopolasty
alone replicate the esthetic results and functionality produced
by jaw surgery.
Position of Chin Relative to Forehead
Cephalometric analysis is used routinely to gauge the angular
and linear relationships of the jaws and teeth to the cranium
(Figure 4). It is a tool for planning treatment and for confirming clinical findings. When obtaining a cephalogram, the ra-
26
JANUARY 2017 • The New York State Dental Journal
diation should be adjusted to allow the soft-tissue profile of the
face to be evaluated, in addition to the bony structures. Similar to clinical evaluation and photography, the cephalogram
should be obtained with the patient’s teeth in occlusion and
the lips in repose. A posterior-anterior cephalogram is useful in
patients with asymmetry. Once the cephalogram is obtained,
the analysis begins. There are several views regarding the proper position of the chin. A popular view suggests that the ideal
position of the chin is where a vertical line perpendicular to
the Frankfurt plane passes the vermillion of the lower lip and
meets the pogonion (Figure 5). This analysis is ideal in a person with a Class I occlusion and properly angulated incisors.
For instance, in Class II malocclusion, where the mandibular
incisors are proclined, the lip is pushed forward by these teeth.
As a result, the chin would appear posterior and micrognathia
could be easily misdiagnosed as microgenia. Hence, the position of the lower lip alone should not be the deciding factor
when determining the position of the chin.
Shape of Chin
The soft tissue drape overlying the mentum is esthetically
more important than the position of the pogonion. The teeth
and shape of the bone should give a gentle curvature to the
soft tissue, making the labiomental fold appear as a gentle
S-shaped curve.
Dentofacial Deformities and the Chin
Surgical and Orthodontic Considerations
A youthful, natural-looking face is supported by a well-balanced
skeleton. The facial skeleton plays a major role in supporting the
overlying soft tissue; therefore, when the skeleton is deficient, deep
creases may form. As a result, aging can become more pronounced
and occur at an earlier age, thereby requiring cosmetic procedures
(such as fillers) to substitute for the skeletal deficiency.
Orthodontic treatment has been successful in creating optimal dental occlusion in patients who present with malocclusion.
As discussed earlier, in mild skeletal deformities, good occlusion
can camouflage the underlying facial deformities. Overlooking
such signs as mid-face deficiency, a nasal dorsal hump, lack of
nasal tip support, a large interlabial gap or a receding chin will result in suboptimal function and esthetics post-treatment. Young
patients and their parents are usually satisfied with a masking
procedure; however, many of these patients will be disappointed
with their facial appearance when they reach adulthood.
In addition to poor esthetics, obstructive sleep apnea is an
important condition that could result from retrognathia that has
been untreated since an early age (Figures 6 A,B). The combination of sliding genioplasty and orthognathic surgery is a more
effective treatment in sleep apnea patients than either surgery
alone. Because most patients start their treatment by seeing an
orthodontist, the responsibility rests with the orthodontist to
educate patients about the necessity of surgery and the benefits of
having it performed at a young age.
There are several types of dentofacial deformities that require
treatment by means of orthodontics and orthognathic surgery instead of genioplasty alone. Some of the most common scenarios
are discussed below. Many retrognathic patients tilt their chin
upward to normalize the esthetics and open the posterior airway. Placement of the head in the Frankfurt horizontal position
with the lips in repose will assist in diagnosing and treating a
high-angle mandible. In these situations, rotation of the maxillomandibular complex will generally produce the best esthetics
(Figure 7).
Occlusal Angle Abnormalities
The occlusal angle can cause major disharmony in the esthetics
of the lower third of the face (Figure 8). A low occlusal angle
may cause collapse of the lower third of the face and a protruding chin. A C-shape or concave face is usually observed in these
patients; most will desire a smaller chin. By contrast, individuals
with a large angle usually have a receding mandible or pseudo-microgenia. Examples can be seen in patients who present with condyle disorders or hemifacial microsomia. Guided by the amount
of maxillary incisor tooth showing, maxillary and mandibular osteotomies are usually the best solutions to correct either a small
or large occlusal angle.
Malocclusion
Class II
Division I: In this division, an increase in over-jet is seen, and
the upper molars are anterior to the mesiobuccal groove of the
lower molars (Figure 9). The anterior teeth are proclined, and the
labiomental fold is acutely folded because of the upper incisors.
Division II: In this division, the molar relationship is the
same as above, but the maxillary anterior teeth are retroclined.
Usually a deep bite exists (Figure 10). With collapsed occlusion
and a deep overbite, the posterior region of the mandible appears
broad and the chin appears pointed and narrow. The chief complaint is usually the presence of a broad-shaped face and short,
V-shaped chin. Advancing the mandible surgically increases the
occlusal height and height of the lower third of the face, eliminating the need for genioplasty. Most patients with this condition
would not be fully satisfied with genioplasty alone. Presurgical
orthodontic treatment planning includes leveling the occlusion,
with possible removal of teeth to decompensate for the proclined
anterior mandibular teeth. Because the surgeon uses the new
dental over-jet to advance the mandible and to place the pogonion in the correct position, esthetics are not sacrificed.
Class III
In this class, the upper molar is posterior to the lower molar’s
buccal groove. The over-jet is negative, and the lower incisors are
in front of the upper incisors. The labiomental fold becomes flat,
with a protruding mandible. Decompensation of the teeth and
mandibular setback are ideal. In general, shaving of the protruding chin should be avoided.
Vertical Maxillary Excess
Vertical maxillary excess (VME) causes the mandible to rotate
around the condyles in a clockwise fashion (Figure 11). The pogonion, therefore, is placed in a posterior and inferior position,
increasing the lower facial height and interlabial gap. Clinically,
excessive exposure of maxillary incisors and a large interlabial gap
will be seen. Genioplasty to close the interlabial gap is not completely successful. Proclining or intruding the incisors orthodontically may mask VME, but this orthodontic treatment is usually
not stable. And it will not produce the best esthetic outcome in
the mid-face region. Recently, the use of Botox has become popular for treating this condition. By paralyzing the perioral musculature, the lips become elongated and the gummy smile is hidden.
However, this treatment inhibits all perioral musculature animation, so use of Botox in this region requires careful consideration.
The only treatment that can produce a multitude of beneficial effects is osteotomy. Superior positioning of the maxilla surgically can produce long-lasting, natural-appearing results. When
surgery is chosen, orthodontic decompensation of the incisors to
reveal the maxillary excess cannot be overemphasized. Only then
The New York State Dental Journal • JANUARY 2017
27
Fig. 10 A
Fig. 11 A
Fig. 10 B
Fig. 11 B
Fig. 10 C
Fig. 11 C
can the bony VME be truly appreciated and proper correction
performed by superior positioning of the maxilla surgically. This
procedure would restore the height of the lower face to a normal
range, close the interlabial gap and remove excess gingival show.
The condyles will be rotated and place the pogonion in a superior,
anterior position, possibly eliminating the need for a genioplasty.
Anterior Open Bite
Similar to VME, anterior open bite will also result in a large interlabial gap. Most patients with an anterior open bite present with
a Class II or Class III malocclusion. The shape of the chin and
its position may be normal. Again, if the patient’s lips are not in
repose during the examination, the labial fold would disappear,
and the clinician might consider augmentation. Augmenting an
otherwise normal chin would deepen the labiomental fold and
produce highly unaesthetic results.
Mentoplasty
Sliding genioplasty and implants have been used frequently to
augment a weak chin or enhance the effects of rhinoplasty. We
suggest performing any chin or jaw surgery prior to rhinoplasty,
because advancing these structures can make the nose appear
smaller in an anterior-posterior direction. Recently, cosmetic fillers have become popular; however, they are temporary and the
degree of augmentation is limited. Autografts have been tried in
28
JANUARY 2017 • The New York State Dental Journal
Figures 10 A-C. Patient with Class II deep bite. Patient initially wanted longer, lower
face with protruding chin. (A) Photo showing deep fold, unattractive, “bulgy “chin as result
of implant. Note already deep labiomental fold that implant worsened. Large chin implant
had been placed below pogonion to accomplish this. Implant placed in presence of deep
overbite, low occlusal plane and retrognathia will create unsightly, acute labiomental fold.
If orthognathic surgery is deferred, sliding genioplasty with down-grafting can be performed
to give more esthetically appealing soft-tissue chin. Bulginess of misplaced implant revealed
submental scar. Patient’s main complaint was constant mild pain in area that often occurs
with migration of chin implant. Erythema, which cannot be appreciated in preoperative
photograph, disappeared few days after surgery. (B) Radiograph showing displaced implant
below pogonion. (C) Gentler shape of chin postoperatively.
Figures 11 A-C. Patient presented with chief complaint of long chin. (A)
Patient with maxillary excess. Large interlabial gap, midface deficiency can be
appreciated. (B) Radiograph confirming clinical findings. In radiograph, note
proclined maxillary teeth. Vertical maxillary excess was diagnosed, accompanied by large interlabial gap at repose. Orthognathic surgery was deferred
by patient, as he only desired shorter chin. Wedge of bone was removed
during osteotomy and segment was repositioned in anterior-superior direction.
(C) Interlabial gap did not improve significantly after surgery; however, chin
was shortened by 3 mm. Chin segment was anteriorly placed to recreate
labiomental fold.
the past, but they have become unpopular because of their relatively high morbidity.
With the advent of improved biomaterials, the use of implants has increased.6,7 Implants can be used to successfully augment soft or hard tissue. They have a high safety margin, and the
insertion can be completed in minutes under local anesthesia.
The types of alloplastic materials include mesh polymers, expanded polytetrafluoroethylene, polymethacrylate, polyethylene and
silicone. Among these, solid silicone has gained in popularity because of its low toxicity and ease of placement and removal.8 After several months, a fibrous tissue capsule is formed around the
implant. When placed incorrectly, implants can cause infection,
and seromas and might migrate to the overlying dermal layer.
Extended anatomic mandibular implants, which are available in
four sizes, tend to migrate less than central implants. Bony resorption of up to 5 mm9,10 is commonly observed on radiographs,
especially with larger implants.
The first transoral sliding genioplasty was described by Trauner and Obwegeser.11 Sliding genioplasty is a simple and effective
procedure. One of its most useful advantages is the ease with
which it can be moved. When the osteotomy is completed, the
segment can be moved or reshaped in any direction the clinician
wants. Conversely, an implant cannot increase the vertical height
and should not be placed in the inferior section of the mandible.
Implants placed in this area may cause discomfort, since the over-
Fig. 12 A
Fig. 12 B
Fig. 12 C
Fig. 12 D
Fig. 12 E
Fig. 12 F
Figures 12 A-F. Chin implant migration below pogonion resulted in elongation of chin and face, resulting in V-shaped appearance. (A) Note V-shaped face preoperatively. (B) Unnatural look to
chin with irregular folds and wrinkles. (C) Increase in vertical height, as well as improper shape of labiomental fold is seen. (D, E, F) By removal of mal-positioned implant and performing sliding
genioplasty with advancement, shape and position of chin is recreated. Patient’s other complaint was presence of wrinkling over chin when she smiled or was at rest. This is surgical wound closure
issue, which can be corrected by re-approximating mentalis muscle into its initial position.
lying platysma is a thin muscle. No matter which technique is
used, the augmented chin should exhibit a smooth transition to
the body of the mandible without producing a bulbous appearance.
Revision Genioplasty
As the number of genioplasties has increased, so has the number
of revision surgeries. Dissatisfaction with the initial procedure,
which may not have satisfied a more severe dentofacial deformity,
will often lead patients to seek a revision genioplasty. With moderate dentofacial deformities, edema in the early postoperative period plays a major role in masking the deficiencies. However, over
time, many of these patients will seek removal of their implant
and request other treatment options. With malpositioned and/or
migrated implants, the symptoms and signs include erythema,
pain and soft-tissue changes (Figure 12). Submental displacement of the implant can occasionally lead to the implant breaking through the soft tissue because the thin muscle layer in the
area provides little soft-tissue coverage and support.
If the chin implant is removed for whatever reason, insertion
of another implant or a sliding genioplasty should be performed.
This will prevent collapse of the fibrous capsule and maintain the
soft-tissue projection. The goal is to recreate the gentle curvature
of the soft-tissue drape.
including the posterior airway space. Sliding genioplasty is
recommended over other methods because of its versatility
and esthetically natural results. Again, although many genioplasties are currently performed, true microgenia remains a
rare condition. p
Queries about this article can be sent to Dr. Jamali at [email protected].
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Conclusion
Genioplasty is a relatively simple and short procedure. Although
it is a minor procedure, the diagnostic process prior to contemplating surgery can be challenging, especially when the surgeon
seeks high-quality results. Successful genioplasty begins with the
surgeon’s artistic and scientific understanding of the relationships between the mentum and other facial structures.
During examination, the clinician must consider all the
deformities that are related to the chin position and shape,
Ichim I, Kieser J, Swain M. Tongue contractions during speech may have led to the development of the bony geometry of the chin following the evolution of human language: a
mechanobiological hypothesis for the development of the human chin. Medical Hypotheses
2007;69 (1): 20–24. doi:10.1016/j.mehy.2006.11.048.
O’Loughlin MM, Dean V. Human Anatomy. Boston: McGraw-Hill Higher Education. 2006,
pp. 400–401. ISBN 0072495855.
Thayer ZM, Dobson SD. Sexual dimorphism in chin shape: implications for adaptive hypotheses. Amer J Physical Anthropology 2010;143 (3):417–425. doi: 10.1002/ajpa.21330.
Daegling DJ. Functional morphology of the human chin. Evolutionary Anthropology: Issues, News, and Reviews 1993;1(5):170–177. doi:10.1002/evan.1360010506.
Davis PKB. Chin augmentation with rhinoplasty: a tutorial dissertation. Br J Plast Surg
1983;36:204-209.
Beekhuis GJ. Augmentation mentoplasty with polyamide mesh. Arch Orolaryngol
1984;100:364-367.
Silver WE. Chin and molar augmentation. Head and Neck Surg. Otolaryngol. Philadelphia:
Lippincott Co. 1993, 2284-2298.
Scaccia FJ, Allphin AL, Stepnick DW. Complications of augmentation mentoplast: a review
of 11095 cases. Int J. Aest Restorative Surg 1993;1:3-8.
Robinson M, Shuken R. Bone resorption under plastic chin implants. J Oral Surg
1969;27:116-118.
Robinson M, et al. Bone resorption under plastic chin implants. Follow-up of a preliminary
report. J Oral Surg 1969;27(2):116-118.
Trauner R, Obwegeser H. Surgical correction of mandibular prognathism and retrognathism
with consideration of genioplasty. Oral Surg 1957;10:677.
Majid Jamali, D.M.D., is an oral and maxillofacial surgeon practicing in
New York City.
The New York State Dental Journal • JANUARY 2017
29
restorative dentistry
Combined Orthodontic and Restorative
Approach to Esthetic Treatment of Maxillary
Peg Lateral Incisor in Adolescent Female Patient
Case Report
Eugene H. Bass, D.M.D.
ABSTRACT
The presence of a peg lateral incisor is an example
of an autosomal dominant genetic condition that
is often associated with several other dental abnormalities, including tooth agenesis. It can occur either
unilaterally or bilaterally. Individuals with peg lateral incisors often present with an associated midline
diastema, as well as other anterior diastemas. The esthetic restoration of a peg lateral incisor can become
a transformative event for an adolescent female patient. This article describes a combined orthodontic
and restorative approach to the management of this
condition, using a direct composite veneer without
tooth reduction. This most conservative and minimally invasive treatment is especially appropriate in
the adolescent patient. Final esthetic results are optimized by this combined interdisciplinary approach.
By planning for the resultant space mesial and distal to the peg lateral incisor, composite resin can be
veneered directly over the tooth to provide excellent
esthetics. Other treatment options can be considered
in adulthood, if necessary.
30
JANUARY 2017 • The New York State Dental Journal
The presence of a peg lateral incisor is an example of an autosomal
dominant genetic condition that is often associated with several
other dental abnormalities, including tooth agenesis.1 Individuals
with peg lateral incisors often present with an associated midline
diastema caused by the distal movement of the central incisor.2
Because of their diminished size, other anterior diastemas may also
be associated with a peg lateral incisor. In one study, the incidence
of peg lateral incisors was found to be 0.8% in 739 children.3 This
can occur either unilaterally or bilaterally, with one study showing
increased occurrence on the left side of the maxilla.4
The esthetic management of the peg lateral incisor can vary
depending upon a variety of factors, among them, the age of the
patient.5 Treatment options include the following:
1. Extraction of the peg-shaped tooth and orthodontic movement of the canine into the space of the lateral incisor; the
canines can then be recontoured to resemble lateral incisors.
2. Extraction and replacement with a single tooth implant restoration or a fixed partial denture (FPD).
3. Direct or indirect restoration of the peg lateral incisors to
develop normal tooth morphology.
All of these treatment approaches have been employed to
produce acceptable results.
The most conservative and minimally invasive option is placement of a direct composite veneer bonded over the peg lateral
Figure 1. Occlusal view of diagnostic maxillary cast after
orthodontic treatment.
Figure 2. Mounted diagnostic casts after completion of orthodontic
treatment.
Fig. 5
Figure 4. Clear stent of diagnostic wax-up mounted on
preoperative maxillary diagnostic cast.
Figure 3. Facial view of diagnostic wax-up.
Fig. 6
Figures 5, 6. Preoperative view of peg lateral incisor during shade selection using Vita A1 and Vita A2 shade tabs.
incisor. This technique is especially appropriate in the adolescent
patient; and results are optimized by combined orthodontic and restorative treatment. By planning for the resultant space mesial and
distal to the peg lateral incisor, composite resin can be veneered
directly over the tooth to provide excellent esthetics. At the same
time, future growth and development can continue to occur. Other
treatment options can be considered in adulthood, if necessary.
This case report describes the orthodontic management and
subsequent esthetic treatment of an adolescent female patient
utilizing a direct composite veneer technique.
Treatment recommendations included full edgewise appliances,
as well as a head gear device. Spaces will be preserved mesial and
distal to the peg lateral incisor #10 for subsequent restorative
treatment. Objectives were to level and align the arches and to
attain an ideal overbite and overjet relationship with a Class I
occlusion throughout. A mid-labial maxillary frenectomy was
recommended and was accomplished using a CO2 laser system
(Novapulse by Luxar Care LLC, Woodinville, WA) prior to the start of
orthodontic treatment. This allowed for a more predictable maxillary mid-labial diastema closure to occur.
Case Report
Orthodontic Management
A 12-year-old patient presented for orthodontic evaluation and
subsequent management of a peg lateral incisor (Tooth #10). Full
orthodontic records were taken. The following is a summary of
findings:
l The patient has a Class I malocclusion with some Class II
tendencies.
l The maxillary arch displayed spacing, and a central incisor
diastema exists.
l The mandibular arch exhibited minor crowding.
l The patient is congenitally missing her mandibular third molars.
l A high maxillary mid-labial frenum attachment exists.
Restorative Management
Upon collaboration with the orthodontist, it was decided to leave
a 1 mm space mesial and a 2 mm space distal to the peg lateral
incisor for the subsequent direct composite veneer to be placed.
Approximately 1 mm of space distal to tooth #10 will be preserved for the Class I canine relationship and midline coincidence
to be kept intact.
Restorative Technique
After removal of the orthodontic brackets, study models were taken (Figures 1,2). A diagnostic wax-up was made to simulate the
ideal tooth morphology (Figure 3). A clear stent was fabricated
from the diagnostic wax-up (Glidewell Laboratory, Newport Beach, CA)
The New York State Dental Journal • JANUARY 2017
31
Figure 7. Super Bond SEP was used to provide separating Figure 8. Empress Direct Composite, Excite F bonding agent and
medium to adjacent teeth to prevent adhesion of bonding Soflex XT polishing discs.
materials.
Figure 10. Vertical facial view of completed direct
composite veneer.
Figure 9. Horizontal facial view of completed direct
composite veneer.
Figure 11. Occlusal view of completed direct composite veneer showing articulating paper markings.
as a guide for the esthetic composite buildup (Figure 4). A preoperative assessment of the shade determined the use of Vita A1
composite (Figures 5,6). Adjacent teeth #9 and #11 were coated
with Super Bond Sep (Super Bond Sep, Sun Medical Co, Ltd, Moriyama,
Shiga, Japan ) to prevent adhesion of bonding materials (Figure 7).
Tooth #8 was acid-etched for 15 seconds using Etch-Rite 38%
Phosphoric Acid Gel (Etch Rite Dental Etching Gel, 38% phosphoric Acid,
Pulpdent Corp.,Watertown, MA).
After thorough water rinsing of etchant and air drying of
tooth, Excite F bonding agent (Excite F Bonding Agent, Ivoclar Vivadent
AG Schaan/Lichtenstein) was applied to the tooth and scrubbed for
10 seconds before light-curing for 10 seconds (Flashlite 1401 Curing
Light, Discus Dental, Den Mat, Santa Maria, CA) (Figure 8). Incremental layering buildup of Empress Direct (Empress Direct Composite,
Ivoclar Vivadent AG, Schaan/Lichtenstein), a nano-filled hybrid resin
composite, shade Vita Al, was used to restore the ideal tooth morphology (Figures 9,10). Each layer was light-cured for 30 seconds
and built up in 2 mm increments. Final polishing and finishing
were accomplished with Astropol Finishers and Polishers (Astropol
Polishers and Finishers, Ivoclar Bivadent AG, Schaan/Lichtenstein) and Soflex XT discs (Soflex Discs, 3M ESPE, St. Paul, MN). Shaping and final
contouring were done using fine grit football- and flame-shaped
diamond burs (Neo Diamond # 1923F, 1510 8F, Microcopy, Kennesaw
GA). Occlusion was checked in centric, excursive and protrusive
movements (Figure 11).
32
JANUARY 2017 • The New York State Dental Journal
Results
The treatment for this patient involved the long-term coordination of surgical, orthodontic and restorative modalities. A laser
frenectomy allowed closure of the central incisor diastema to be
done in the most predictable fashion. Comprehensive orthodontics over a two-year span created a stable Class I occlusion, leveled
and aligned the arches, and created the ideal positioning of the
peg lateral incisor #10 for the subsequent placement of a direct
composite veneer.
The presence of a peg lateral incisor can create significant
psycho-social effects on a patient’s behavior. These may manifest
as social introversion or a reluctance to smile. The restoration of
this patient’s tooth morphology resulted in a profound improvement in her self-esteem and self-confidence.
REFERENCES
1.
2.
3.
4.
5.
Arte S, Nieminen P, Apajahati S, Haaviko K, Thesslef I, Pirinen, S. Characteristics of incisorpremolar hypodontia in families. J Dent Res 2001;80(S):1445-50.
Geiger A, Hirschfeld L. Minor Tooth Movement in General Practice. 3rd ed. St Louis: Mosby; 1974. p1-129, 349-434.
Backman B, Wahlin YB. Variations in number and morphology of permanent teeth in
7-year-old Swedish children. Int J Paediatr Dent 2001;11-7.
Peck L, Peck S, Attiya Y. Maxillary canine-first premolar transposition, associated dental
anomalies and genetic basis. Angle Orthod 1993;63:99-109.
Miller WB, McLendon WJ, Hines FB. Two treatment approaches for missing or peg-shaped
maxillary lateral incisors: a case study on identical twins. Am J Orthod Dentofacial Orthop
1987;92:249-56.
Eugene H. Bass, D.M.D., has been a full-time clinical instructor at New York
University College of Dentistry since 2012. He maintains a private general dental
practice in New City, New York. Queries about this article can be sent to Dr. Bass
at [email protected].
Conclusions
Direct composite resin veneers can be an economical, conservative and esthetically pleasing restoration for the treatment of a
peg lateral incisor in the adolescent patient. Careful treatment
planning and coordination of specialty care can improve the final
outcome for these patients. p
The New York State Dental Journal • JANUARY 2017
33
cancer patient treatment
Mandibular Bisphosphonate Osteonecrosis:
A Cautionary Tale
Case Report
Ashley Coffey, D.D.S.; Louis Mandel, D.D.S.
ABSTRACT
The authors examined a 55-year-old female who had received eight intravenous infusions of a potent bisphosphonate (BP) for metastatic bone disease. A mandibular
extraction was subsequently performed. At presentation, infection with suppuration and sequestrum formation were observed in the area of extraction. Both the
oncologist and dental practitioner must be made aware
that when BPs are going to be administered, dental care
should be performed in a timely fashion. Prophylactic
measures must be taken by the dentist if dental surgery
is required for a patient who has received BP.
Medication-related osteonecrosis of the jaw (MRONJ) is defined1
by the American Association of Oral and Maxillofacial Surgeons
as meeting the following criteria:
1. Current or previous treatment with antiresorptive or antiangiogenic agents.
2. Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that
has persisted for more than eight weeks.
3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws.
Osteonecrosis of the jaw (ONJ) is initiated by antiresorptive
agents such as the bisphosphonates (BP), denosumab and anti-
34
JANUARY 2017 • The New York State Dental Journal
angiogenic drugs. BPs are common medications used for treating
bone loss due to metastatic breast or prostate cancer, hypercalcemia
from malignant bone disease, multiple myeloma and even Paget’s
disease and osteoporosis.1-3 A third generation BP, zoledronate, administered intravenously and in widespread use, has proven to be
very effective in maintaining bone integrity.4 It has an increased
potency over that of the second generation pamidronate.5
However, BP use comes with the caveat that it sets the stage
for ONJ. The ONJ develops because BPs impede osteoclastic activity, induce apoptosis and have an inhibitory effect on local angiogenesis.1,6,7,8 Intravenous BP-related ONJ has been reported to
occur in 18% to 27% of cancer patients who are treated with the
drug.2,3,9,10 The risk is increased if the patient is a diabetic or is
receiving steroids.11
Recognition of the presence of ONJ may be difficult because
the initial signs are subtle and varied. Diagnosis is facilitated
when patients who have received BP present in the dental office
with signs and symptoms that may include dental pain, exposed
bone, fistulae, paresthesia, tooth mobility, swelling, suppuration, and sclerotic areas involving mandibular and/or maxillary
bones.3,5,9,12,13
ONJ after BP use involves the mandible 70% of the time,
with 94% of these cases developing after the use of intravenous
BPs rather than the oral versions.7 The jawbones are most often involved for reasons that are not totally clear. It is possible
From Columbia University College of Dental Medicine, New York, NY
that the greater vascularization and bone remodeling that occurs
around periapical disease and the periodontal ligament allow for
greater local BP accumulations.14,15 It has also been suggested that
the jawbones’ increased metabolism, when compared to other
skeletal structures, makes them more susceptible.15
Spontaneous symptomatic ONJ onset is rare.3,7,13 Symptoms
are usually triggered by an extraction or other surgical procedure
associated with intraoral exposure of bone,6,13,16,17 such as periodontal therapy or periapical surgery.6 Patients who have received
intravenous BP and undergo an extraction are at significant risk for
the onset of ONJ, with 52% to 61% of ONJ cases occurring after
an extraction.1 Secondary invasion by oral bacteria can then lead
to suppuration and further bone necrosis in a vulnerable jawbone.
After extraction, the second most common cause of ONJ is
mucosal breakdown with bone exposure resulting from wearing
a prosthesis.18
Ideally, all necessary dental care should be completed four to
six weeks prior to intravenous BP infusions. Clinical studies indicate a decreased incidence of ONJ onset when preventive dentistry is initiated before BP therapy.9,19,20 Coronectomy and endodontic procedures have been recommended to avoid any unnecessary
extractions in susceptible bone.1,9,13,21 If extraction is necessary
following the use of a potent intravenous BP, protocols have been
established that include a variety of techniques to inhibit the development of ONJ.1,2,7,10,11,22,23 Oral hygiene therapy with an antiseptic mouthwash should be instituted prior to extraction. Antibiotics (amoxicillin/clavulanate) should be prescribed pre- and
postoperatively. The extraction must be carried out with minimal trauma and followed by careful debridement and smoothing of sharp bone edges. A primary wound closure should be accomplished with the aid of suturing. Autologous plasma, rich in
growth factors, can be introduced into the wound.13 Hyperbaric
oxygen as an adjunct may have some value.1 The importance of
a drug holiday is questionable, because once the agent involves
bone, the half-life of the BP extends over many years.3
The authors document a case of suppurative ONJ that resulted from an unavoidable failure to dentally clear a patient with
metastatic skeletal bone disease before the initiation of intravenous BP therapy. The problem was compounded by a missed opportunity before a dental extraction to institute some form of
preoperative protocol aimed at discouraging the onset of a suppurative ONJ. This case serves to call the dental practitioner’s
attention to the destructive events associated with the unimpeded
progression of ONJ following an extraction.
Case Report
A 55-year-old female was referred in March 2015 to the Columbia
University College of Dental Medicine (CDM) because of severe
pain and suppuration that followed the extraction of a non-vital
lower left second molar in August 2014.
A medical history indicated that the patient had been a diabetic for
29 years. At the time of her referral she was being medicated with
insulin, liraglutide and metformin. She has been taking lisinopril
and hydrochlorothiazide for hypertension. In April 2013, the patient was diagnosed with a follicular lymphoma following the excision of an enlarged cervical lymph node. Imaging studies revealed
the presence of several metastatic skeletal lesions, none of which
involved the jaws, and multiple scattered lymphadenopathies. Chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone) was initiated in August 2013. Beginning in May 2013, intravenous zoledronate (4 mg) was administered at periodic intervals.
By the time the patient was seen in her dentist’s office (July 2014),
she had received eight intravenous zoledronate (4 mg) infusions.
The patient’s visit to the dental office was precipitated by a
two-month history of severe pain that focused around an end-
Figure 1. Clinical photo. Left facial soft tissues.
Figure 2. Intraoral view. Suppurative flow from gingival fistulous
tract (white arrow). Granulation tissue exuding from socket of previously extracted lower left second molar (black arrow).
The New York State Dental Journal • JANUARY 2017
35
Figure 3. CT scan (axial view). Note thickened mandible left
molar area. Left masseter muscle is inflamed (myositis) and
thickened (arrows).
Figure 4. PET scan (axial view) demonstrates increased
metabolic activity of left mandible and adjoining soft tissue.
Figure 5. Panoramic radiograph. Large sequestrum forming in
mandible (arrows).
36
JANUARY 2017 • The New York State Dental Journal
odontically treated lower left second molar with periapical pathosis. All attempts to alleviate the “horrific” pain failed and an
extraction was performed (August 2014) without the use of any
preemptive prophylactic protocol. Subsequent to the extraction,
the severe pain persisted and a fistula in the left molar area, along
with a facial buccal area swelling, developed one month later.
Antibiotics, analgesics and chlorhexidine mouthwash were prescribed, and the patient was referred to CDM because of persistent pain, suppuration and swelling.
At the time of our clinical examination, a left facial swelling
with moderate pain was noted involving the buccal soft tissues
(Figure 1). Cervical lymphadenopathy and trismus were absent.
Intraorally, a non-fluctuant swelling and shallowing of the mucobuccal fold in the mandibular left premolar/molar area were
evident. A fistulous tract with a free suppurative flow was noted
involving the buccal gingival tissue adjacent to the site of the extracted second molar (Figure 2). Probing of the fistula revealed
bone at the tract’s base. Granulation tissue also was observed
extruding from the incompletely healed socket of the extracted
tooth (Figure 2). The remaining areas of the oral cavity were asymptomatic, with the dentition requiring no immediate care. The
oral hygiene was good.
A CT scan taken in January 2015 revealed left mandibular
soft tissue and bone involvement in the molar area with an associated periosteal reaction (Figure 3) and areas of sclerotic bone.
At the same time, a PET study demonstrated increased metabolic
activity involving the left mandible and adjoining soft tissues
(Figure 4). Regarding the lymphoma, no new or growing lymph
node activity were noted on these imaging studies. A panoramic
radiograph (March 2015) clearly demonstrated the existence of
a large bone sequestrum developing in the left mandibular molar
area and an infected lower left first molar (Figure 5).
A diagnosis of ONJ was made based on the intravenous use
of a potent BP, the presence of a fistula and the absence of metastatic jaw disease, as evidenced by imaging studies. We then referred the patient for surgical care regarding the developing infected sequestrum and the adjacent infected first molar.
Discussion
Patients with lymphomatous bone metastases are at significant
risk for low bone mineral density.24,25 Lymphomatous bone involvement leads to increased bone destruction by stimulating
osteoclastgenesis, which increases resorption and inhibits osteoblast differentiation.26 Hypercalcemia can be anticipated.26
The mechanism by which the lymphoma affects bone physiology is unclear.24,27 Furthermore, the decrease in bone density is
intensified when a steroid (prednisone) is incorporated into the
chemotherapeutic cocktail. Corticosteroids increase bone resorption, while decreasing bone formation.24 The use of intravenous
zoledronate has become the most effective measure to counter-
act the bone loss and hypercalcemia associated with malignant
lymphomas.24,28 Zoledronate is reported to be between 850- and
4,000-times more potent than the second generation pamidronate.24,29 Unfortunately, zoledronate’s potency and its repeated
use come with the complicating side effect related to its profound
ability to impede normal bone physiology.
Imaging studies play a key role in the diagnosis of ONJ. Because of the failure of adequate osteoclastic activity, the CT scan’s
revelation of osteosclerosis has proven to be an effective adjunct
in identifying the extent of BP bone involvement, even in the
absence of exposed bone.30,31 Localized or diffuse osteosclerosis,
or thickening of the lamina dura, may indicate future areas of necrosis.32 The presence of osteosclerosis in clinically symptomatic
jawbone areas is a known and consistent feature of BP-caused
ONJ.30-32 Our patient’s CT scan, taken in January 2015, did reveal osteosclerotic areas surrounding necrotic bone. It can be assumed that the sclerotic bone pre-existed and predisposed the jaw
to the eventual clinical onset of ONJ subjective symptomatology.
In turn, the ONJ set the stage for infection following the dental
extraction. Viewing of the involved bone with positron emission
tomography (PET) has proven to be of value because it depicts
functional activity of tissues.32 Sequestrum formation and periosteal activity were authenticated in our patient by PET.
We hypothesize that the failure of root canal therapy, as evidenced by the reported periapical pathology, and the sclerotic
bone assumed to be present at the time of the extraction were
factors in the acute pain symptomatology that prompted the patient’s visit to her dentist. The ensuing extraction served to magnify the problem when alveolar bone was exposed to the oral environment. Oral bacterial bone invasion was facilitated because
bone viability had been compromised by zoledronate.
The obvious breakdown in our patient’s care originated from the
failure to appropriately start preventive dental care. Before beginning
intravenous BP therapy, dental treatment for infected and potentially
infected teeth must be instituted and supplemented with aggressive
oral hygiene measures. However, at times, the exigencies of patient
neoplastic care take precedence over the time required for dental care.
Once our patient’s diagnosis of lymphoma was made, osseous
concerns became paramount and required immediate attention.
Consequently, no referral for dental clearance was made by the
oncologist prior to the use of zoledronate, and it was overlooked
during zoledronate administration. In such situations, necessary
extractions can be performed during or after BP therapy, provided
the established preoperative protocol is inaugurated.
Our patient’s problem was compounded by the failure to initiate some form of prophylactic care prior to extraction. Admit-
The New York State Dental Journal • JANUARY 2017
37
tedly, even if our patient had received such care, the outcome may
not have been positive. The risk of infection is reduced but not
eliminated.8 Nevertheless, such care is required to decrease the
incidence of infection superimposed on a BP-caused diminished
bone viability. The need for preventive measures is accentuated by
the difficulty in treating infected ONJ and mandates an interdisciplinary approach to patient care. p
Queries about this article can be sent to Dr. Mandel at [email protected].
9. 10. 11. 12. 13. REFERENCES
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Surgeons position paper on medication-related osteonecrosis of the jaw−2014 update. J
Oral Maxillofac Surg 2014;72:1938.
Hinchy NV, Jayaprakash V, Rositto RA, et al. Osteonecrosis of the jaw−prevention and treatment strategies of oral health professionals. Oral Oncol 2013;49:878.
DeJuliis F, Taglieri L, Amoroso L, et al. Prevention of osteonecrosis of the jaw in patients
with bone metastases treated with bisphosphonates. Anticancer Res 2014;34:2477.
Vandome AM, Donadio M, Mozzati M, et al. Impact of dental care in the prevention of
bisphosphonate-associated osteonecrosis of the jaw: a single-center clinical experience. Ann
Oncol 2012;23:193.
Bonacina R, Mariani U, Villa F, et al. Preventive strategies and clinical implications for bisphosphonate-related osteonecrosis of the jaw: a review of 282 patients. J Can Dent Assoc 2011;77:6147.
Moretti F, Pelliccioni GA, Montebugnoli L, et al. A prospective clinical trial for assessing
the efficacy of a minimally invasive protocol in patients with bisphosphonate-associated
osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112: 777.
Schubert M, Klatte I, Linek W, et al. The Saxon Bisphosphonate Register-Therapy and prevention of bisphosphonate-related osteonecrosis of the jaw. Oral Oncol 2012;48: 349.
Bramati A, Girelli S, Farina G, et al. Prospective, non-institutional study of the impact of a
14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. systemic prevention program on incidence and outcome of osteonecrosis of the jaw in patients treated with bisphosphonates for bone metastases. J Bone Miner Metab 2015;33:119.
Fedele S, Kumar N, Davies R, et al. Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review. Oral Dis 2009;15:527.
Heufelder MJ, Hendricks J, Remmerbach T, et al. Principles of oral surgery for prevention
of bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral
Radiol 2014;17: e429.
Bittner T, Lorbeer N, Reuther T, et al. Hemimandibulectomy after bisphosphonate treatment for complex regional pain syndrome: a case report and review on the prevention and
treatment of bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral
Pathol Oral Radiol 2012;113:41.
Silverman SL, Landesberg R. Osteonecrosis of the jaw and the role of bisphosphonates: a
critical review. Am J Med 2009;122:533.
Scoletta M, Arata V, Arduino PG, et al. Tooth extractions in intravenous bisphosphonatetreated patients: A refined protocol. J Oral Maxillofac Surg 2013;71:994.
Bhuyan R, Bhuyan S, Panigrahi RG, et al. Bisphosphonate-induced osteoradionecrosis. J
Oral Maxillofac Pathol 2013;17:460.
Cheong S, Sun S, Kang B, et al. Bisphosphonate uptake in areas of tooth extraction or periapical disease. J Oral Maxillofac Surg 2014;72:2461.
Migliorati CA, Siegel MA, Elting LS. Bisphosphonate-associated osteonecrosis: a long term
complication of bisphosphonate treatment. Lancet Oncol 2006;7:508.
Assael LP. A time for perspective on bisphosphonates. J Oral Maxillofac Surg 2006;64: 877.
Patel V, McLoed NMH, Rogers SN, et al. Bisphosphonate osteonecrosis of the jaw−a literature review of UK policies, versus international policies on bisphosphonates, risk factors
and prevention. Br J Oral Maxillofac Surg 2011;49:251.
Dimopoulos MA, Kastritis E, Bamia C, et al. Reduction of osteonecrosis of the jaw (ONJ)
after implementation of preventive measures in patients with multiple myeloma treated
with zoledronic acid. Ann Oncol 2009;20:117.
Ripamonti CI, Maniezzo M, Campa T, et al. Decreased occurrence of osteonecrosis of the
jaw after implementation of dental preventive measures in solid tumour patients with bone
metastases treated with bisphosphonates. The experience of the National Cancer Institute
of Milan. Ann Oncol 2009;20:137.
Kyrgidis A, Arora A, Lyroudia K, et al. Root canal therapy for the prevention of osteonecrosis
of the jaws: an evidence-based clinical update. Aust Endod J 2010;36:130.
Lodi G, Sardella A, Salis A, et al. Tooth extraction in patients taking intravenous bisphosphonates: a preventive protocol and case series. J Oral Maxillofac Surg 2010;68:107.
Mozzati, M, Arata V, Gallesio G. Tooth extraction in osteoporotic patients taking oral
bisphosphonates. Osteoporosis Int 2013;24:1707.
Westin JR, Thompson MA, Catalso VD, et al. Zoledronic acid for prevention of bone loss
in patients receiving primary therapy for lymphomas: a prospective, randomized controlled
phase III trial. Clin Lymphoma Myeloma Leukemia 2013;13:99.
Paccou J, Merlusca L, Henry-Desailly I, et al. Alterations in bone mineral density and bone
turnover markers in newly diagnosed adults with lymphoma and receiving chemotherapy: a
1-year prospective pilot study. Ann Oncol 2014;25:481.
Abe M. Blood disease and bone. Clin Calcium 2013;23:256.
Cabanillas ME, Lu H, Fang S, et al. Elderly patients with non-Hodgkin lymphoma who receive
chemotherapy are at a higher risk for osteoporosis and fractures. Leuk Lymphoma 2007;48:1514.
Hadji P, Kauka A, Ziller M, et al. Effects of zoledronic acid on bone mineral density in
premenopausal women receiving neoadjuvant or adjuvant therapies for HR + breast cancer:
the Pro-Bone II study. Osteoporosis Int 2014;25:1369.
Green JR, Muller K, Jaeggi KA. Preclinical pharmacology of CGP 42’466, a new, potent
heterocyclic bisphosphonate compound. J Bone Miner Res 1994;9:745.
Bedogni A, Stefano F, Bedogni F, et al. Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease. Br J Oral Maxillofac Surg 2014;52:603.
Bisdas S, Chambron Pinho N, Smolarz A, et al. Bisphosphonate-induced osteonecrosis of
the jaws: CT and MRI spectrum of findings in 32 patients. Clin Radiol 2008;63:71.
Khan AA, Morrison A, Hanley DA, et al. Diagnosis and management of osteonecrosis of the
jaw: a systematic review and international consensus. J Bone Miner Res 2015;30:3.
Ashley Coffey, D.D.S., is a former research assistant in the Salivary Gland
Center at Columbia University College of Dental Medicine, New York, NY. She
is an oral and maxillofacial surgery resident at Montefiore Hospital, Bronx, NY.
Dr. Mandel
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JANUARY 2017 • The New York State Dental Journal
Louis Mandel, D.D.S., is associate dean and clinical professor, oral and maxillofacial surgery, Columbia University College of Dental Medicine, New York, NY.
tmd in children
Relationship of Psychological Factors to
Temporomandibular Disorders in Children
Janaina Habib Jorge, D.D.S., M.Sc., Ph.D.; Daniela A. G. Gonçalves, D.D.S., M.Sc., Ph.D.;
André Petzet Barreiros, D.D.S.; Thiago Ceregatti, D.D.S.; Graziela Sapienza, D.D.S., M.Sc., Ph.D.;
Karin Hermana Neppelenbroek, D.D.S., M.Sc., Ph.D.; Vanessa Migliorini Urban, D.D.S., M.Sc., Ph.D.
ABSTRACT
This study evaluated the incidence of TMDs and their
ing problems and TMD were classified as having mild
relationship to psychological factors in children ages
(n=18), moderate (n=5) and severe TMD (n=1). In
6 to 12 years who sought dental treatment at the
addition, 36 children had behavior problems (with
Ponta Grossa State University. Following ethics com-
TMD, n=26; without TMD, n=10), of whom 19 chil-
mittee approval and informed consent, 75 children
dren had mild, 6 children had moderate and 1 child
were included in the study. Exclusion criteria were
had severe TMD.
craniofacial malformations, history of orthodontic
treatment and maxillary fractures. TMD severity was
classified, using the Fonseca anamnesis index questionnaire, as “no TMD” (control) and “mild,” “moderate” and “severe.” Parents completed the Child Behavior Checklist, which measures behavior problems
and competencies. Data were analyzed using the Chisquare test (a=0.01).
Regardless of gender, 40 children had internalizing problems (with TMD, n=32; without TMD, n=8).
Children presenting internalizing problems and TMD
were classified as having mild (n=23), moderate (n=8)
and severe TMD (n=1). Thirty-one children interviewed had externalizing problems (with TMD, n=24;
without TMD, n=7). Children presenting externaliz-
Psychological problems were related to TMD in
Brazilian children ages 6 to 12.
Temporomandibular disorder (TMD) is a generic term referring
to a large number of clinical conditions involving the structures
related to the stomatognathic system. It has been used to define
dysfunctions of the temporomandibular joint (TMJ) and the masticatory muscles.1 TMDs are responsible for most chronic orofacial
pain. And the large population affected normally does not receive
information about what the disorder is and how to treat it.
The etiology of TMDs continues to be a point of controversy;
possible causes include structural, psychological, immunological
factors, trauma, degenerative joint disease, parafunctional habits,
masticatory hyperactivity and muscular spasms. Today, a majority
of authors propose a multifactorial etiology for TMD, considering
that the factors involved, as well as their influence, differ depending upon each case.2
Studies have been conducted in several countries in order to
verify the prevalence of these diseases in the general population.
The New York State Dental Journal • JANUARY 2017
39
The prevalence of TMD is higher in the female gender and in the
age group between 21 and 40 years.3 And it has been described as
a condition that affects primarily adults.
The high percentage of children with signs and symptoms
associated with temporomandibular disorders suggests the possibility that the TMJ dysfunction originates at the beginning of craniofacial growth.4 Thus, it is worth highlighting the importance
of early diagnosis of TMDs in children, since the occurrence of
TMD and deleterious oral habits, especially in childhood, interfere with the function of the stomatognathic system and may
result in changes in breathing, chewing, swallowing and speech.
According to Sonnesen et al.,4 children may develop oral habits at
an early age, affecting the balance between growth and function.
Although TMDs are multifactorial, the importance of the
psychological factor should be considered, because the typical
signs and symptoms often occur in patients at moments of intense concentration, anxiety and nervousness. Klasser et al.5 suggest that occlusal and psychological issues are among the main
triggers of bruxism, the latter strongly associated with the development of TMDs. However, controversy surrounds the concepts
that bruxism in children is related to local factors, mandibular
instability resulting from the transition phase between deciduous
to permanent dentition,6 and that there is an association between
emotional factors and the habits involved.7 The psychological factor is noteworthy because of the large number of pediatric patients affected by fears, tension and anxiety.
The Department of Dentistry at the Ponta Grossa State University receives a large number of children who are assisted in
the pediatric clinic; however, no study of the incidence of TMD
in children has been carried out to date. Because of the possible
relationship between TMD and psychological factors and the lack
of information on this subject, the aim of this study was to determine the incidence of TMD and its relationship to psychological
factors, using the psychological indicators of the Child Behavior
Checklist, in children attending the pediatric clinic of the Department of Dentistry at the Ponta Grossa State University.
Material and Methods
Seventy-five children (ages 6 to 12) treated in different pediatric clinics at the Department of Dentistry of the Ponta Grossa
State University were selected for this study. Children exhibiting neurological problems, craniofacial malformations, systemic
musculoskeletal diseases (which could involve the TMJs), history
of mandibular fractures or orthognathic surgery (who were undergoing orthodontic treatment) or whose age did not meet the
research were excluded from the study. Children whose parents
gave permission, who were able to read and who answered the
data collection instrument properly, were included. Children and
their respective guardians were interviewed. The study was approved by the Human Research Ethics Committee of the Depart-
40
JANUARY 2017 • The New York State Dental Journal
ment of Dentistry of the Ponta Grossa State University (Protocol:
03596/09). Each child’s parents signed the informed-consent
form, after they understood the nature and objectives of the research, giving their child permission to participate in the study.
The subjects were subsequently asked to complete a general
health questionnaire, which, because the factors mentioned above
could affect research results, was used to refine the selection further. The questionnaire also helped us to consider the health condition of the patient at the moment he or she was interviewed.
Children were interviewed using the Fonseca anamnesis index questionnaire8 to detect the presence and severity of TMD
symptoms. The questions were directed to the children; however,
if a child did not understand the question, the guardian interceded to facilitate understanding and thereby avoid the influence
of the examiner. The instrument allowed the examiners to classify
the patients according to the degree of severity of TMD symptoms as mild, moderate, severe and without TMD, according to
the score for each answer.
For the psychological evaluation, the guardians answered the
questionnaire “Child Behavior Checklist for Ages 6–18 (CBCL),”
consisting of 118 questions pertaining to behavior problems. In
this survey, the parent or guardian who has daily contact with the
child completed the questionnaire. The CBCL describes the social
competence profile and internalizing and externalizing problems
of children in two formats. The first one investigates parental perceptions, with versions for children from 18 months to 5 years
(CBCL/2–3) and for children and adolescents from 6 to 18 years
(CBCL/6–18). The second investigates the perceptions of the
teacher(s) (Teacher Rating Form-TRF).9 The CBCL has good internal consistency, which allows an overall evaluation. The application of the questionnaire is easy, which favors its insertion into
the clinical routine.10 The survey contains 138 items that provide
an overall behavioral assessment of children. Of these, 20 are intended to evaluate the social competence profile of children and
118 are related to evaluation of behavior problems. This instrument aims only to detect whether or not behavioral, emotional
or relationship problems exist and does not provide a specific diagnosis of mental disorder.11 Therefore, the survey lists a number
of behaviors, desirable and disruptive, and presents a gradation of
frequency as follows: 0 = Not true; 1 = Sometimes true; and 2 =
Often true.
According to Drotar et al.,12 the analysis of the CBCL
provides a profile of the children on 11 individual scales: 3
for social competence (Activities, Sociability and Scholarity),
which together lead to the Total Social Competence Scale;
and 8 for behavior problems (Withdrawal, Anxiety/Depression, Somatic Complaints, Social Contact Issues, Attention,
Thought, Behavior of Breaking Rules and Aggressive Behavior), which together lead to the Total Behavior Problems
Scale. Analysis of the CBCL allows classification of the in-
children were diagnosed as having mild TMD; 6 as having moderate
TMD; and 1 as having severe TMD (p = 0.0000).
Table 1 shows the percentages of children within each psychological profile according to the diagnosis of TMD. It was obtained by performing the crossover of psychological analysis data
from the CBCL questionnaire with data from the anamnestic index questionnaire for TMD. Values were converted to percentages
to improve visualization of the results obtained.
The scales of internalizing problems (A), externalizing problems (B) and total behavior problems (C) were compared. Figure
1 illustrates whether and to what degree these problems influence
TMD in children.
We observed only four cases of children with TMD who were
on the scales of externalizing problems and/or behavioral problems
that did not meet the criteria for internalizing problems; however,
of 38 children with TMD and internalizing problems, 12 had no
externalizing problems, and 10 did not fit total behavior problems.
Because the scale of internalizing problems corresponds to the
first three scales of behavior problems (Anxiety/Depression, Withdrawal and Somatic Complaints), we compared the three scales to
the rest of the behavior problems (Social, Thought, Attention Problems, Rule-breaking and Aggressive Behavior). Only five cases of children with TMD were negative for the first three scales and positive
for any of the remaining. The other results for children with TMD
were negative in all scales or positive for at least one of the first three.
dividual clinically, non-clinically or by gender in each of the
sums of scales. The raw score from the survey is converted to
a T score that has cutoff points for clinical ranges, limitrophe,
and non-clinical. The set of obtained T scores, and the classification of these into clinical, limitrophe, or non-clinical,
results in the profile of the child/adolescent.
The general health, Fonseca anamnesis index for TMD and
CBCL questionnaires were applied by two calibrated examiners.
After the clinical diagnosis, patients who had some kind of TMD
were sent to the Clinic of Temporomandibular Disorders of the
Department of Dentistry at the Ponta Grossa State University for
possible treatment.
The data from the CBCL were analyzed using Assessment Data
Manager software, which produced the psychological profile of the
child/adolescent. The chi-squared test (X2) was applied to show
differences between the groups, with a significance level of p < 0.01.
Results
The results showed that, regardless of gender, 40 of the 75 children
had some kind of internalizing problem. Of these, 8 were diagnosed
as “without TMD” and 32 “with TMD” (p = 0.0001). Among the
children with TMD, 23 had mild TMD, 8 had moderate TMD and
one child had severe TMD (p = 0.0000). Thirty-one interviewed
children had externalizing problems, 7 of whom were diagnosed
as “without TMD” and 24 “with TMD” (p = 0.0023). Among the
children with TMD, 18 demonstrated mild TMD, 5 had moderate
TMD and one had severe TMD (p = 0.0001). The results also showed
that 36 children demonstrated behavior problems. Of these, 10 had
no TMD (p = 0.0077). The others demonstrated TMD: 19 of these
Discussion
This study demonstrated no significant association of TMDs with
psychological factors between genders, which is consistent with
TABLE 1.
Distribution of Children (%) according to TMD and Psychological
Diagnoses
Psychological Problems
TMD Diagnosis (%)
Absence
Presence
Mild
TMD
Moderate
TMD
Severe
TMD
Anxiety/Depression
10.7
31.9
31.4
44.4
0.0
Withdrawal
17.9
31.9
31.4
44.4
0.0
Somatic complaints
10.7
25.5
20.0
44.4
33.3
Social problems
14.3
23.4
20.0
44.4
0.0
Thought problems
3.6
19.1
14.3
44.4
0.0
Attention problems
10.7
21.3
20.0
33.3
0.0
Behavior of breaking rules
17.9
23.4
22.9
33.3
0.0
Aggressive behavior
7.1
42.6
42.9
55.6
0.0
Internalizing problems
28.6
68.1
65.7
88.9
33.3
Externalizing problems
25.0
51.1
51.4
55.6
33.3
Total behavior problems
35.7
55.3
54.3
66.7
33.3
Figure 1. Distribution of children with TMD who fit into one or more of
following profiles of psychological problems: A = Internalizing problems;
B = Externalizing problems; C = Total behavior problems.
The New York State Dental Journal • JANUARY 2017
41
other studies.13 In addition, the results revealed a high prevalence
of TMD in children included in this study (62%). Relevant studies in young patients include one by Thilander et al.,14 who analyzed a sample of 4,724 children and adolescents (ages 5 to 17)
and found that 25% of subjects demonstrated one or more clinical symptoms of TMD. Santos et al.15 carried out a study to evaluate the frequency of signs and symptoms of parafunctional habits
and occlusal characteristics in 80 children. They found a greater
frequency of teeth-grinding, headaches and TMJ sounds, and that
onychophagy and bruxism were the more prevalent parafunctional habits. Therefore, the authors from the present study advise
evaluation of signs and symptoms of TMJ dysfunction in children
routinely during the initial clinical examination.
Currently, psychological factors have been shown increasingly
to contribute to the development of TMD and orofacial pain and
are of fundamental importance to the correct diagnosis and determination of causal factors so that appropriate treatment can
be established. However, we cannot say whether such factors are
considered predisposing or just coincidental. A correlation between
psychological variables and temporomandibular disorders has been
found in children.16 This study showed a strong association between children with TMD and the scale of internalizing problems
(Anxiety/Depression, Withdrawal and Somatic Complaints),
which may or may not be associated with externalizing problems
(Behavior of Breaking Rules and Aggressiveness) and/or total behavioral problems (Internalizing Problems, Externalizing Problems,
Social Problems, Thought Problems and Attention Problems). It is
thus suggested that problems related to TMD may be manifestations of issues such as anxiety, depression, withdrawal and somatic
complaints, in agreement with studies performed by Rudy et al.,17
Alamoudi,18 Dworkin et al.,19 Yap et al.20 and Pereira et al.21
Dworkin et al.19 and Yap et al.20 stated that non-biological
factors such as depression and somatization have been demonstrated to be potentially strong influences on the development
and symptoms of TMDs. Likewise, Alamoudi18 demonstrated high
correlation between TMD and emotional states and reported the
necessity for dental surgeons to pay attention to emotional factors in children diagnosed with some type of TMD. According to
Rudy et al.,17 both depression and somatization may contribute to
the development and maintenance of TMD and/or interfere with
the acceptance and maintenance of the treatment. Besides, painful
sensations, muscle fatigue, noises and cracking from joints, and
limited mouth opening, among other manifestations of TMD, can
also be a source of frustration and stress. Thus, we might expect a
positive feedback between TMD and emotional state.
The symptoms of anxiety are caused by excessive activity of the
central nervous system that occurs from the interpretation of a situation as dangerous. Anxious people tend to be apprehensive, believing that something terrible is about to happen, often activating false
alarms, and holding onto the belief even after a series of evaluations
42
JANUARY 2017 • The New York State Dental Journal
because of failed information processing. They tend to overestimate
the danger and underestimate personal resources to deal with it.
Anxiety, depression and withdrawal in children may also be associated with traumatic experiences. Traumatic experiences in childhood
can manifest as chronic pain, which may lead to the development of
some kind of TMD.22 Melzack23 postulated the existence of a pain
neuromatrix in which the experience of pain is produced by multiple
influences and constitutes a wide distribution of the neural network,
with entry of stimulus in the stress regulatory system, including the
thalamocortical circuit and the limbic and opioid systems. The body
is strongly modulated by stress and influence of the brain’s cognitive
functions on the traditional sensorial functions; thus, psychological
factors can be involved in pain perception.
Psychological factors (stress, anxiety) can cause children to develop oral habits, including bruxism, which can cause damage to the
TMJ, masticatory muscles, periodontium, and occlusion.24 In this
context, Cheifetz et al.7 observed that 38% of interviewed parents
described the presence of bruxism in their children. According to
these authors, some etiologic factors were associated with psychological disorders. However, Restrepo et al.25 concluded, by means of a
systematic review, that there is no proper and effective treatment for
bruxism in children and that further study was necessary.
For a child diagnosed with TMD who shows signs of psychological problems, the best approach would be to recommend
psychological counseling, since the resolution of psychological
problems in children could promote improvement in the symptomatology of TMD by identifying its source and preventing recurrence. In this regard, there is consensus among some researchers about the importance of evaluating and treating both physical
and psychological factors in patients with TMD.21 Moreover, according to Rudy et al.,17 a conservative intervention consisting
of occlusal splint, biofeedback and stress management can significantly reduce parafunctional oral habits, pain and incapacity
associated with TMD. However, the correct diagnosis, as well as
determination of the possible etiologic factors, must precede any
intervention so that the treatment can succeed. p
Queries about this article can be sent to Dr. Jorge at [email protected].
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Cheifetz AT, Osganian SK, Allred EN, Needleman HL. Prevalence of bruxism and associated
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Nomura K, Vitti M, Oliveira AS, et al. Use of the Fonseca’s questionnaire to assess the prevalence and severity of temporomandibular disorders in Brazilian dental undergraduates. Braz
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Achenbach T. Manual for the Child Behavior Checklist/ 4-18 and 1991 Profile. 1991.
Hudziak JJ, Copeland W, Stanger C, Wadsworth M. Screening for DSM-IV externalizing
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Drotar D, Stein REK, Perrin EC. Methodological issues in using the Child Behavior Checklist and its related instruments in clinical child psychology research. J Clinical Child Psychology 1995;24:184-192.
Vanderas AP. Mandibular movements and their relationship to age and body height in children with or without clinical signs of craniomandibular dysfunction: Part IV. A comparative
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Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence of temporomandibular dysfunction
and its association with malocclusion in children and adolescents: an epidemiologic study
related to specified stages of dental development. Angle Orthod 2002; 72:146-154.
Santos ECA, Bertoz FA, Pignatta LMB, Arantes FM. Avaliação clínica de sinais e sintomas da
disfunção temporomandibular em crianças. Rev Dent Press Ortodon Facial 2006; 11:29-34.
Pilley JR, Mohlin B, Shaw WC, Kingdon A. A survey of craniomandibular disorders in 500
19-year-olds. Eur J Orthod 1997;19:57-70.
Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment responses of TMD patients
as a function of psychological characteristics. Pain 1995;61:103-112.
Alamoudi N. Correlation between oral parafunction and temporomandibular disorders and
emotional status among Saudi children. J Clin Pediatr Dent 2001;26:71-80.
Dworkin SF, Turner JA, Mancl L, et al. A randomized clinical trial of a tailored comprehensive
care treatment program for temporomandibular disorders. J Orofac Pain 2002; 16:259-276.
Yap AU, Tan KB, Chua EK, Tan HH. Depression and somatization in patients with temporomandibular disorders. J Prosthet Dent 2002;88:479-484.
Pereira LJ, Pereira-Cenci T, Pereira SM, et al. Psychological factors and the incidence of
temporomandibular disorders in early adolescence. Braz Oral Res 2009;23:155-160.
Eitner S, Stingl K, Schlegel AK, Wichmann M, Nickenig A. Biopsychosocial correlations
in patients with chronic oro-facial pain. Part II. Experiences of pain and dramatic events
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Melzack R. From the gate to the neuromatrix. Pain 1999;Suppl 6:S121-126.
Pizzol KEDC, Carvalho JCQ, Konishi F, Marcomini EMS, Giusti JSM. Bruxismo na infância:
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Restrepo C, Gomez S, Manrique R. Treatment of bruxism in children: a systematic review.
Quintessence Int 2009;40:849-855.
Janaina Habib Jorge, D.D.S., M.Sc., Ph.D., is assistant professor, Department of Dental Materials and Prosthodontics, Araraquara Dental School, University Estadual Paulista, Araraquara, SP, Brazil.
Daniela A. G. Gonçalves, D.D.S., M.Sc., Ph.D., is assistant professor, Department of Dental Materials and Prosthodontics, Araraquara Dental School, University Estadual Paulista, Araraquara, SP, Brazil.
André Petzet Barreiros, D.D.S., is a graduate, Department of Dentistry, Ponta Grossa State
University, Ponta Grossa, PR, Brazil.
Thiago Ceregatti, D.D.S., is a graduate student, Department of Dentistry, Ponta Grossa State
University, Ponta Grossa, PR, Brazil.
Graziela Sapienza, D.D.S., M.Sc., Ph.D., is adjunct professor, Department of Psychology,
Pontifical Catholic University of Parana, Curitiba, PR, Brazil.
Karin Hermana Neppelenbroek, D.D.S., M.Sc., Ph.D., is adjunct professor, Department of
Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil.
Vanessa Migliorini Urban, D.D.S., M.Sc., Ph.D., is assistant professor, Department of Dentistry, Ponta Grossa State University, Ponta Grossa, PR, Brazil.
The New York State Dental Journal • JANUARY 2017
43
pain management
Postoperative Pain following Treatment of
Teeth with Irreversible Pulpitis
A Review
Zahed Mohammadi, D.M.D., M.S.D.; Paul V. Abbott, B.D.Sc., M.D.S., FRACDS (Endo);
Sousan Shalavi, D.M.D.; Mohammad Yazdizadeh, D.M.D., M.S.D.
ABSTRACT
Patients typically associate dental care with pain. Pain
has both physiological and psychological components.
Endodontic post-treatment pain continues to be a
significant problem facing the dental profession. For
patients presenting with preoperative pain, most will
continue to experience pain after root canal treatment, with pain levels ranging from mild to severe.
The purpose of this paper was to review the symptoms
and classification of irreversible pulpitis, including
acute and chronic pulpitis, incidence of postoperative
pain following treating teeth with irreversible pulpi-
immediate and complete. Postoperative pain is usually mild in
nature and rarely lasts longer than 72 hours. It is often well
managed with non-steroidal anti-inflammatory agents (NSAID)
or acetaminophen.5
Definition of Pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Although pain is often referred
to as a sensation, it is probably better described as a multidimensional or multifactorial experience encompassing sensory, affective (emotional), motivational and cognitive dimensions.6
erative pain.
Pulpitis
The term pulpitis, by definition, means inflammation of the pulp.
But this term is commonly used by clinicians to refer to toothache. However, pain associated with teeth may be caused by various factors and is not necessarily due to inflammation of the pulp
(pulpitis).7
Pain following root canal treatment continues to be a significant problem facing the dental profession. For patients presenting with preoperative pain, it has been reported that up to 80%
will continue to experience pain after root canal treatment, with
pain levels ranging from mild to severe.1-3 It has been shown
that endodontic treatment, either in the form of pulpotomy
or pulpectomy, is efficacious in reducing pain,4 but it is rarely
Symptoms and Classification of Irreversible Pulpitis
The symptoms will vary because the disease process is a continuum that progresses through several stages.8 Irreversible pulpitis
can also be acute or chronic; and the symptoms will vary accordingly. Any tooth may be affected by irreversible pulpitis; and it is
not restricted to particular age groups. It usually occurs as a result
of dental caries, a crack in the tooth, breakdown of a restoration,
tis, factors influencing postoperative pain, persistent
pain after root canal treatment, preventing postoperative pain and pharmacological management of postop-
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JANUARY 2017 • The New York State Dental Journal
a fracture of the tooth or a restoration, or as a result of trauma to
the tooth. The involved tooth is usually not tender to percussion
unless acute apical periodontitis has also developed. Palpation
tests do not produce an untoward reaction.
The characteristics of irreversible pulpitis are a pulp that responds with pain much more quickly than other teeth to cold
pulp testing. The pain is usually quite sharp but then becomes a
dull throb or ache that lingers for a considerable time. Occasionally, cold may alleviate the pain,9 which is typically indicative of a
pulp with necrobiosis (a later stage of the disease process) where
some of the pulp has become necrotic and infected.9
Some authors have outlined variations of irreversible pulpitis, including acute, subacute, chronic, partial or total, infected
or sterile.10 However, it is not possible to clearly differentiate
between most of these except by histopathological methods—although it is possible to distinguish between chronic and acute
irreversible pulpitis, based upon the amount of pain and the time
that the pain has been present.11
Irreversible Pulpitis
In irreversible pulpitis cases, the pulp is severely inflamed so that
healing is unlikely with conservative pulp therapy. Therefore, if
conservative pulp therapy is attempted, pulp necrosis and infection are the predicted outcomes and will lead to apical periodontitis. While it can be assumed that all pulps that become necrotic
and infected will have irreversible pulpitis at some stage prior to
necrosing, not all patients will report having had symptoms of irreversible pulpitis. Some patients might have had the symptoms,
but they may not recall having had them, while others may not
have had symptoms severe enough or long-lasting enough for
them to seek dental treatment.11
Barbakow et al.12 and Bender13 reported that 20% to 60%
of pulps had progressed to being necrotic without pain being reported by the patients. Michaleson and Holland14 demonstrated
that gender and tooth type had no effect on symptoms associated
with pulpitis; although age was a factor, as the older the patient
was (over 53 vs. under 33 years of age), the less likely there was
any pain associated with pulpitis.14
Although it is not known how pulp death can occur without symptoms, there are two possible explanations. The more
probable hypothesis is that there is effective modification by local, as well as centrally mediated systems. There are several local regulatory factors and systems, including endogenous opioid,
adrenergic sympathetic and nitric oxide systems that exist in the
pulp.15–17 One example is somatostatin, which may inhibit pulp
pain activation under certain conditions.17–19 Another less probable hypothesis is that, at least in some cases, the progression
of inflammation to pulp death is so rapid there is no pain or,
conversely, that the inflammation is so slow that the classical inflammatory mediators that participate in the pain process never
reach a critical level.14 Although CNS plasticity can both enhance
and reduce pulpal pain, its exact mechanism of action is yet to be
clarified.20,21
If the pulp is symptomatic, it is most often very sensitive
to thermal changes, and the pain sensation has the tendency to
linger as a dull ache after the stimulus has been removed. This
fact can be used with caution to predict if the pulp is likely to be
irreversibly inflamed or not. In a normal pulp, only very intense
stimuli will activate the more centrally located C fibers.22,23 When
a long and intense-enough stimulus is placed on a healthy pulp,
there is sharp pain at first, mediated by the A-delta fibers, followed by a poorly localized, dull pain sensation mediated by C
fibers.23
In teeth with severe inflammation, there are several inflammatory mediators that can cause increased sensitivity in the pulp
nociceptors. Initially, these effects will be primarily on the more
peripheral A-delta fibers. But when the inflammation reaches
deeper structures, the C fibers will be affected. This will cause
their firing threshold to be lower and the receptive field larger.24
Therefore, it is important when the patient is being questioned
about lingering pain after the stimulus has been removed to not
only ask about the time it took for the pain to go away, but also
the nature of the lingering sensation. The more C-fiber-mediated
pain complaint (dull, throbbing and poorly localized), the more
severe the inflammation might be and, thus, the more likely it is
that the pulpitis is irreversible in nature.
Although there is no relationship between the histological
condition of the pulp and the clinical symptoms, the more severe
the pain and the longer it has been symptomatic, the more likely
it is irreversibly inflamed.13 The most obvious sign of irreversible
pulpitis is the history of spontaneous pain, which may wake the
patient from sleep.6
Acute Irreversible Pulpitis
Acute irreversible pulpitis is usually determined by a recent
or even a sudden onset of pain that may wake the patient at
night. The pain is spontaneous, with moderate to severe intensity, and it lingers in response to temperature changes. The
pain may be intensified by posture changes, such as when lying
down or bending over. Common analgesics are rarely effective
in controlling the pain. Radiographs are not useful in diagnosis
in most cases; however, they can be helpful in identifying the
possible cause of the disease (e.g., deep caries, an extensive or
fractured restoration, pins, etc.). The tooth may be tender to
biting pressure and/or percussion and, if present, this usually
indicates spread of the inflammatory process to the periapical
tissues (that is, primary acute apical periodontitis). In some
cases, the biting or percussion pain may indicate a crack in the
tooth; this is particularly noticeable when the crack is undermining a cusp.11
The New York State Dental Journal • JANUARY 2017
45
Chronic Irreversible Pulpitis
Chronic irreversible pulpitis has signs and symptoms similar
to those of acute irreversible pulpitis, but they will be much
less severe than those in acute cases. In addition, the pain has
been present for some time—typically several weeks but possibly
months. Patients may complain of moderate pain, which is more
intermittent rather than continuous, and it may be controlled by
common analgesics. In the early stages of the disease process, the
diagnosis can be difficult because the tooth may not show any
demonstrable periapical change on the radiographs or a definitive
sign of tenderness to percussion. However, information from the
patient and pulp sensibility tests should be useful. As the disease
progresses to involve the periapical tissues, periapical changes are
more likely to be evident radiographically and/or clinically.11,25
Postoperative Pain following Root Canal Treatment
Although current endodontic treatment can be virtually pain free
during the procedure itself, patients still may experience pain after the appointment.
Incidence of Postoperative Pain
Most studies that have investigated the prevalence of postoperative pain following root canal treatment refer to the so-called
“flare-up.” There have been many different definitions for a flareup but most include severe pain and/or swelling after endodontic
treatment that requires an unscheduled appointment and active
treatment. However, patients may also experience pain or discomfort that does not meet this definition and, therefore, it is quite
limited in its applicability. A more comprehensive term to use is
“postoperative pain following root canal treatment.” The reported
frequencies of postoperative pain range from 1.5% to 53%.26 The
large range is due, in large part, to differences in the definitions
used. In a prospective clinical study, Georgopoulou et al.1 showed
that 57% of the patients reported no pain after debridement of
the root canal system, 21% had slight pain, 15% had moderate
pain, and 7% had severe pain.
Genet et al.3 found that the incidence of severe and moderate postoperative pain was 7% and 23%, respectively. By far, the
greatest number of cases of postoperative pain (65%) was related
to patients who reported at the first appointment with preoperative pain. In contrast, only 23% of those who developed postoperative pain were free of pain prior to treatment. Most postoperative
pain occurred on the first day after treatment.
Clem,27 Calhoun and Landers,28 Marshal and Liesinger,29
Fox et al.,30 and Udoye and Jafarzadeh31 found that postoperative pain was more common following treatment of teeth with
inflamed pulps. In contrast, Albashaireh and Alnegrish,32 Mor et
al.33 and Mattscheck et al.34 reported greater incidence of postoperative pain following treatment of teeth with infected root canal
systems. The discrepancy may be due to different criteria used to
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JANUARY 2017 • The New York State Dental Journal
evaluate postoperative pain or to different endodontic materials
and techniques.
Gotler et al.35 showed that the incidence of postoperative
pain was high, ranging from 34.6% to 63.8%, depending upon
the pulp condition. Furthermore, they found that root canal
treatment of teeth with pulpitis was associated with a higher
incidence and intensity of postoperative pain (six hours after
treatment) compared to teeth with infected root canal systems
or retreatment cases (which were probably also infected). This is
in accordance with Levin et al.,36 who showed that 53% of patients receiving root canal treatment reported postoperative pain.
In contrast, in a systematic review, Tsesis et al.37 showed that the
incidence of postoperative pain was only 8.4%.
Kusner et al.38 reported that 72% of their patients experienced moderate-to-severe postoperative pain. According to a
systematic review, the frequency of “all-cause” tooth pain at six
months or longer after root canal treatment of permanent teeth
was approximately 5%.39
Wang and Xu40 revealed that the incidence and intensity of
postoperative pain after the root canal filling was placed following
one- or two-visit root canal treatment on teeth with pulpitis and
a single canal were not significantly different.
Factors Predicting Postoperative Pain
Torabinejad et al.2 revealed that the presence of preoperative pain,
tooth type, sex, age, history of allergy and retreatment were significantly predictive for the incidence of postoperative pain. They
further showed that intra-canal medicaments, systemic disease
and establishment of the patency of the apical foramen had no
relationship to the incidence of postoperative pain. Specifically,
the highest incidences of postoperative pain were associated with
mandibular teeth, retreatment procedures, females over the age
of 40 and patients with a history of allergies. Furthermore, the
number of treatment sessions may influence postoperative endodontic pain.41
Persistent Pain after Root Canal Treatment
Pain at six months after root canal therapy (i.e., persistent pain)
is known to occur and has many possible explanations, including an untreated or incompletely filled root canal, unsatisfactory coronal restoration, tooth fracture, pain associated with an
adjacent tooth, referred pain from a non-odontogenic structure
or differentiation pain. Thus, such pain might best be characterized as all-cause pain. Whatever the underlying etiology, it is
important for dentists to keep in mind that the subjective feeling
of pain is the contributing negative factor for their patients. Although persistent pain is an important outcome in dentistry, its
frequency, severity and extent of interference with daily life has
not been well characterized in dental care populations. Adequate
treatments for some of these pains are emerging, and early identi-
fication and treatment may improve prognosis.42 But the first step
is to determine how widespread the problem is.
Preventing Postoperative Pain
Although pulpotomy and pulpectomy reduce endodontic pain,
postoperative pain has been reported in 25% to 40% of patients.43-45 The pain is thought to be associated, in part, with a
periapical inflammatory response produced by the endodontic
instrumentation. A significant relationship also exists between
preoperative and postoperative pain. Patients with severe preoperative pain tend to have more severe postoperative pain than patients with mild or no preoperative pain.43-45
Prostaglandins (PGs) are important mediators of inflammation, the synthesis of which is initiated by release of arachidonic
acid from damaged cell membranes. PGs probably are the most
important hyperalgesic and inflammatory mediators. By sensitizing nerve endings to bradykinins and histamines, PGs increase
vascular permeability, raise chemotactic activity, induce fever and
increase sensitivity of pain receptors to other active inflammatory
mediators.46 If the periapical inflammatory reaction is a major
contributor to postoperative pain, then it is possible that a nonsteroidal anti-inflammatory drug (NSAID) will be useful in its
management. NSAIDs inhibit inflammation and induce analgesia
by inhibiting the activity of cyclooxygenase (COX) enzymes.
Two forms of COX enzymes have been identified: COX-1 and
COX-2. The COX-1 enzymes are present in tissue at all times and
are responsible for synthesizing prostanoids that have cytoprotective functions. The COX-1 enzymes regulate normal cell activities
in the stomach, kidneys and platelets. COX-2 enzymes normally
are not present in the tissues (other than in the kidneys), but they
come into play when tissue injury and inflammation occur.47,48
Therefore, the COX-2–mediated inflammatory response is generally delayed because of activation and release of COX-2 enzymes
by macrophages, monocytes, synovial cells, leukocytes and fibroblasts, which require one to three hours to occur.49 Ibuprofen,
ketoprofen, aspirin and naproxen are nonselective NSAIDs that
inhibit both cytoprotective COX-1 enzymes and inflammatory
COX-2 enzymes. Consequently, the prolonged use of these agents
is associated with possible damage of the gastrointestinal tract
causing gastric erosions, ulcers and bleeding.49 Drugs that specifically inhibit COX-2 enzymes and leave the cytoprotective COX-1
enzymes intact may provide analgesia, anti-inflammatory and antipyretic activities while avoiding adverse effects on the gastrointestinal tract and other tissues, as well as on platelets.49
The New York State Dental Journal • JANUARY 2017
47
Managing Postoperative Pain
Endodontic treatment, either in the form of pulpotomy or pulpectomy, is very efficacious in reducing pain. However, it is rarely
immediate and complete. Therefore, postoperative analgesic intervention is often required in a variable percentage of patients.
There are three pharmacologic approaches to the management of postoperative pain following root canal treatment: 1.
drugs that block inflammatory mediators that sensitize or activate nociceptors (e.g., NSAIDs and glucocorticoids); 2. drugs that
block the propagation of impulses along the peripheral nerves;
and 3. drugs that block central mechanisms of pain perception
and hyperalgesia.50,51
Non-steroidal Anti-inflammatory Drugs
NSAIDs have been the traditional treatment for moderate pain.
Numerous NSAIDs are available for managing pain and inflammation. Nevertheless, moderate-to-severe pain of dental origin is
best managed through the use of ibuprofen or other NSAIDs; and
its maximum analgesic effect is at least equal to that of standard
doses of acetaminophen-opioid combinations.50,51 It is important
to understand that NSAIDs generally require a higher dose to
achieve maximum anti-inflammatory action than that to achieve
analgesic action. For example, 200 mg to 600 mg ibuprofen four
times a day (i.e., 800 mg to 2,400 mg in one day) or 800 mg
three times a day (i.e., 3,200 mg) may be needed for analgesic
effect, but 2,400 mg to 3,400 mg a day may be needed for an antiinflammatory effect.50,51
In a meta-analysis of randomized clinical trials, Mehlisch
found that ibuprofen given in doses of 50 mg to 400 mg was superior to a placebo at all dose levels.52 In addition, he showed that
monotherapy with ibuprofen managed dental pain better than
acetaminophen. Another study revealed that preoperative administration of ibuprofen one hour before local anesthesia injection
was an effective method for achieving a deep anesthesia during
treatment of teeth with pulpitis.53
According to Torabinejad et al,54 the effectiveness of ibuprofen (400 mg) on postoperative pain was similar to ketoprofen
(50 mg) and was superior to placebo treatment. A study demonstrated that ketorolac was a potent NSAID that significantly
reduced pain after apicoectomy.55 Ketorolac (60 mg) provided
significantly more pain relief than a placebo at 12 hours and 24
hours after intracanal medication administration, although there
was no difference at 6 hours and 48 hours.55 Penniston and Hargreaves56 indicated that intraoral injection of ketorolac was a useful adjunct in the management of endodontic pain. It has been
proposed that intramural injection of ketorolac may be useful for
the management of endodontic pain, especially in cases where
local anesthetic administration is ineffective because of inflammation or an injection located at a mandibular site.57
Another study compared oral administration of ketorolac
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JANUARY 2017 • The New York State Dental Journal
and acetaminophen codeine in the management of acute apical periodontitis. Findings showed that patients in the ketorolac
group had significantly less pain than those who received acetaminophen codeine.58
COX-2 NSAIDs
Although NSAIDs are remarkably effective in managing pain and
inflammation, their use is limited by several adverse effects, including gastrointestinal bleeding and ulceration, impaired renal
function and inhibition of platelet aggregation. Discovery of a
second cyclooxygenase-2 led to the hypothesis that NSAIDs’ side
effects could be decreased, as the inhibition of COX-2 is more
directly implicated in ameliorating inflammation, while the inhibition of COX-1 is related to adverse effects in the gastrointestinal tract. This stimulated the development of selective COX-2
inhibitors that are better tolerated than nonselective NSAIDs but
comparable in analgesic efficacy.51 However, recently identified
adverse cardiovascular reactions associated with these drugs mandate a reappraisal of their use in dental practice.49
Khan et al59 demonstrated that administration of Celecoxib, 200 mg prior to extraction of impacted third molars, had no
effect on thromboxane B2 (a product of COX-1) and inhibited
PGE2 only at time points, which are consistent with the induction of COX-2. However, another study, using an oral surgery
model, showed that Celecoxib was superior to a placebo, comparable to 650 mg of aspirin, but generally less effective than a
standard dose of naproxen.
Brown et al.61 compared 50 mg of rofecoxib (withdrawn from
the market in 2004 because of safety concerns) to ibuprofen 400
mg and a placebo in a single dose study in the oral surgery model
of acute pain using traditional analgesic end points as well as the
two-stop watch method for estimating analgesic onset. Results
indicated that the total pain relief and sum of the pain intensity
difference scores over eight hours following a single 50 mg dose of
rofecoxib was superior to a placebo, but not distinguishable from
ibuprofen (400 mg). The median time to the onset of pain relief was indistinguishable for rofecoxib (0.7 hour) and ibuprofen
(0.8 hour). But significantly fewer subjects in the rofecoxib group
required additional analgesic within 24 hours of the study drug
than in the placebo or ibuprofen groups. Chen et al.62 reported
that the analgesic efficacy and tolerability of single-dose COX-2
inhibitors were more effective than opioid-containing analgesics
and similar to non-selective NSAIDs in postoperative pain management.
Valdecoxib, a second-generation coxib, is a potent and highly
selective COX-2 inhibitor.10 According to Daniels et al.,63 valdecoxib could be an efficacious oral safe alternative to other analgesics used to treat pain after oral surgery.
Gopikrishna and Parameswaran64 showed that the efficacy of
prophylactic rofecoxib was similar to ibuprofen at four and eight
hours after pulpectomy. However, at the 12- and 24-hour periods,
rofecoxib demonstrated significantly better pain relief than both
ibuprofen and a placebo. In a randomized, double-blind, placebocontrolled, parallel-group trial, Nekoofar et al.65 compared the
pain-reducing effect of oral preparations of meloxicam, piroxicam, and placebo in endodontic emergency patients. According
to their findings, there was no significant difference between the
tested groups.
Acetaminophen
Acetaminophen (N-acetyl-p-aminophenol), alone or in combination with an NSAID or a narcotic, is also used for pain relief.
Menhinick et al.66 showed that, following pulpectomy, the combination of acetaminophen (1000 mg) and ibuprofen (600 mg)
provided greater pain relief than ibuprofen (600 mg) alone.
Corticosteroids
Glucocorticoids have been used in endodontics for their potent
anti-inflammatory effects.50 They have been employed as an intracanal medication either alone or in combination with antibiotics or antihistamines, and systemically as a means to decrease
pain and inflammation in endodontic patients.50 It has been in-
dicated that using hydrocortisone as an intracanal medication resulted in reduction and elimination of inflammatory reactions in
periapical tissues.67 Ledermix paste (containing a corticosteroid,
triamcinolone and a tetracycline antibiotic, demeclocycline, in
a water soluble cream) placed as an intracanal medicament has
been reported to be very effective at reducing the pain associated
with apical periodontitis.68 It has been demonstrated that Ledermix eliminated postoperative pain within minutes to a few hours
after placement.69
A double-blind study assessed the effect of intracanal prednisolone acetate 2.5% compared with saline on postoperative
pain and revealed that prednisolone acetate 2.5% was effective
and significantly better in reducing the incidence of pain in teeth
with irreversible pulpitis when compared to saline. In a randomized double-blind study on teeth with irreversible pulpitis,
Negm70 showed that the intracanal application of a corticosteroid-antibiotic medication significantly reduced the mean pain
when compared to placebo.
Another randomized, prospective, double-blind, placebocontrolled study assessed the effect of intramuscular injection of
dexamethasone on postoperative endodontic pain. The findings
indicated that at 4 and 24 hours after endodontic instrumenta-
The New York State Dental Journal • JANUARY 2017
49
tion and/or obturation, IM injection (1 ml) of dexamethasone
significantly reduced pain incidence and severity.71 Krasner and
Jackson72 evaluated the effect of oral dexamethasone (0.75 mg/
tablet) on post-treatment endodontic pain. Results showed that
patients receiving oral dexamethasone had significantly less pain
at 8 and 24 hours compared to a placebo. This result was confirmed by Glassman et al.73 Lin et al.74 demonstrated that both
etodolac and dexamethasone had significant effects on reducing
postoperative pain in patients who had surgical endodontic procedures compared with a placebo. Marshall and Liesinger6 showed
that taking 0.07-0.09 mg/kg of dexamethasone IM reduced pain
more significantly at eight hours compared to a placebo.
Gallatin et al75 showed that an intraosseous injection of depomedrol (methylprednisolone) reduced pain in untreated irreversible pulpitis over the seven-day observation period. Bramy et
al.76 evaluated the intraosseous administration of corticosteroid
for pain reduction of symptomatic-infected teeth and found that
the steroid group had significantly less postoperative pain compared to the placebo group.
In a double-blind, parallel-designed clinical trial, Jalalzadeh
et al. revealed that pre-treatment with a single oral dose of prednisolone reduced postoperative pain for up to 24 hours in both
teeth with pulpitis and those with infected root canal systems.
Long-acting Local Anesthetics
Bupivacaine—According to the pre-emptive analgesia hypothesis, by reducing the peripheral barrage of nociceptors, the amount
of pain is reduced.78 Local anesthetics represent an important
component in pain control. Bupivacaine is available as a 0.5%
solution with 1:200,000 epinephrine. The patient’s requirement
for postoperative opioid analgesics can be considerably lessened
when bupivacaine is administered for pain control. For postoperative pain control following a short procedure, the bupivacaine
may be administered at the start of the procedure; for postoperative pain control following a lengthy procedure, it might be reasonable to administer bupivacaine at the conclusion of the procedure, immediately before the patient’s discharge from the office.79
For many patients receiving bupivacaine, the onset of anesthesia will be similar to that observed with other amide anesthetics (two to four minutes); however, in some patients the
onset of anesthesia will be delayed for 6 to 10 minutes, a finding
understandable in view of its pKa of 8.1. The duration of action
of bupivacaine in block techniques is approximately eight hours.
If this occurs, it may be advisable, at subsequent appointments, to
initiate procedural pain control with a more rapid-acting amide
(e.g., mepivacaine, lidocaine or prilocaine), which provides clinically acceptable pain control within a few minutes and permits
the procedure to commence more promptly.79 Gordon et al.80
showed that patients given an inferior alveolar nerve block injection with bupivacaine prior to an oral surgical procedure reported
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JANUARY 2017 • The New York State Dental Journal
less pain at 24 and 48 hours after the procedure, compared to
placebo-injected patients.
Opioids—Opioids block central mechanisms of pain perception and hyperalgesia. They are often used in dentistry in combination with acetaminophen, aspirin or ibuprofen. This analgesic blocks pain perception in the cerebral cortex by binding to
specific receptor molecules (opiate receptors) within neuronal
membranes of synapses. These bindings result in a decreased synaptic chemical transmission throughout the central nervous system, thereby inhibiting the flow of pain sensation into the higher
centers. Mu and kappa receptors are the two subtypes of opiate
receptors that narcotics bind to and cause analgesia. The narcotics are not anti-inflammatory in nature and do not inhibit cyclooxygenase or block the production of inflammatory factors such
as prostaglandins.81
Codeine, hydroquinone, oxycodone and meperidine are the
most commonly used narcotic analgesics. Codeine is an opioid
analgesic that occurs naturally as a component of the poppy
plant, along with morphine, and can be recovered as such from
the opium extract of the plant.81 Codeine is often considered the
prototype opioid for orally available combination drugs. Most
studies have found that a 60 mg dose of codeine produces significantly more analgesia than a placebo, although it often produces
less analgesia than either 650 mg of aspirin or 600 mg of acetaminophen.70
Tramadol is a synthetic, centrally acting analgesic that is
thought to relieve pain through synergistic monoaminergic and
µ-opioid mechanisms of action.82 It is widely used for the treatment of acute and chronic pain, but has low abuse potential,83
and unlike pure opioids, clinically relevant effects on respiratory
or cardiovascular parameters are rare at recommended doses for
postoperative pain.83 A meta-analysis of data from 3,453 patients
in 18 placebo-controlled trials established the safety and dosedependent efficacy of tramadol in the treatment of moderate-tosevere dental or postsurgical pain.84 In patients with dental pain,
100 mg of tramadol provided at least equivalent analgesia compared with an opioid combination (e.g., codeine/aspirin 60/650
mg or propoxyphene/acetaminophen [APAP] 100/650 mg). A
single dose of 100 mg of tramadol was clearly more effective than
50 mg or 75 mg of tramadol in this patient population, but increasing the dose to 150 mg provided no additional analgesia.
Dose-related adverse events with tramadol treatment included
vomiting, nausea, dizziness and somnolence.85
Combination Analgesia Therapy for Postoperative Pain
Analgesic monotherapy has shown equivocal success in treating dental pain. The goal of combining analgesics with different mechanisms of action is to use lower doses of the component drugs, thereby improving analgesia without increasing
adverse effects.52
NSAIDs Combinations
There are two general methods of combining an NSAID with an
opioid in treating cases of moderate-to-severe pain. The first method achieves the analgesic advantages of both an NSAID and an opioid by prescribing an alternating regimen consisting of an NSAID
followed by an acetaminophen and opioid combination.86 For example, the emergency pain patient could take 400 mg of ibuprofen
(or an NSAID of choice) at the office. Then, the patient could take
an acetaminophen and opioid combination two hours later. The
patient would then receive each treatment every four hours, taking each drug on an alternating two-hour schedule. In most cases,
these treatments do not need to be continued beyond 24 hours.87
The second method for combining an NSAID with an opioid in treating rare cases of moderate-to-severe pain achieves the
analgesic advantages of both an NSAID and an opioid by administering a single combination drug consisting of an NSAID and
opioid combination.88 For example, oxycodone/ibuprofen 5/400
mg (Combunox) is an oral fixed-dose combination tablet with
analgesic, anti-inflammatory and antipyretic properties. It is approved in the U.S. for the short-term (up to seven days) management of acute, moderate-to-severe pain and is the first and only
fixed-dose combination containing ibuprofen and oxycodone.87
Ziccardi et al.88 found that the combination of 400 mg ibuprofen and 15 mg hydrocodone was superior to the combination of
600 mg acetaminophen and 60 mg codeine in providing analgesia after third-molar extraction, as demonstrated by superior total analgesic effect, duration of analgesia and global evaluation.
Traumatol has been shown to be effective in managing dental
pain when combined with a peripherally acting NSAID. Doroschak et al.89 demonstrated that combining 100 mg traumatol
with 100 mg flurbiprofen significantly reduced pain compared
to a placebo at 6 hours and 24 hours following pulpectomy. They
also reported that compared to a placebo, neither traumatol nor
flurbiprofen significantly relieved pain in 6 and 24 hours when
they were used alone.
Pre-emptive Analgesia
The concept of preventing the development of central sensitization was first explored as a clinical strategy through a retrospective review of medical records. McQuay90 reported the amount of
time to the first request for postoperative analgesics in patients
immediately following a variety of surgical procedures performed
under general anesthesia. The preoperative administration of a
local anesthetic and an opioid delayed the postoperative request
The New York State Dental Journal • JANUARY 2017
51
for medication by approximately six and three hours, respectively.
The combination of a local anesthetic and an opioid resulted in
an even greater delay, suggestive of an additive effect.
Tverskoy et al.91 provided evidence that administration of a
local anesthetic before the surgical incision resulted in substantially less pain for up to 72 hours postsurgically, particularly when
pain intensity was elicited after a standardized movement. Gordon et al.77 demonstrated that preoperative administration of bupivacaine (a long-acting local anesthetic) in patients undergoing
removal of impacted third molars under general anesthesia resulted in less pain and analgesic consumption at 48 hours than a
parallel group of subjects administered saline placebo injections.
Although less pain was experienced in the bupivacaine group long
after the local anesthetic had dissipated, it was not clear whether this was a result of less nociceptive input during surgery, less
postoperative pain or the additive effects of both.
Preventive Analgesia
Most studies in which an NSAID is administered orally after the
onset of pain demonstrated an onset of activity within 30 minutes
and peak analgesic activity in two to three hours after drug administration. The administration of an NSAID before pain onset
(preventive) will suppress the release of inflammatory mediators,
particularly prostaglandins, which contribute to the sensitization
of peripheral nociceptors.92 According to Dionne,93 the combination of NSAID preoperative before pain onset and a long-acting
local anesthetic markedly prevents pain during the initial six to
seven hours after oral surgery.
Preventive Analgesia or Pre-emptive Analgesia
It appears that optimal clinical benefits can be achieved by administering drugs such as local anesthetics and NSAIDs before the
onset of postoperative pain. Administering these drugs before a
surgical or an endodontic procedure may be of benefit for longer
procedures or for minimizing peripheral sensitization, which is a
result of the cascade of inflammatory mediators that are released
by tissue injury and fuel the subsequent inflammatory process.93 p
Queries about this article can be sent to Dr. Mohammadi at [email protected].
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Zahed Mohammadi, D.M.D., M.S.D., is affiliated with the Iranian Center
for Endodontic Research (ICER), Shahid Beheshti University of Medical Sciences,
Tehran, Iran, and the Iranian National Elite Foundation, Tehran.
Dr. Mohammadi
Paul V. Abbott, B.D.Sc., M.D.S., FRACDS (Endo), is on the faculty at
the School of Dentistry, The University of Western Australia.
Sousan Shalavi, D.M.D., is in private dental practice in Hamedan, Iran.
Mohammad Yazdizadeh, D.M.D., M.S.D., is in the Department of Endodontics, Ahvaz University of Medical Sciences, Ahvaz, Iran.
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