DOI: 10.31038/JDMR.2019235

Abstract

Introduction: Ridge preservation procedures have been utilized to minimize the alveolar ridge dimensional changes following tooth extraction. This case report describes a novel approach to ridge preservation with an application of a carbon dioxide laser (CO₂ laser) to stabilize blood clot formation and stimulate wound healing.

Case presentation: A 76-year-old Caucasian male with history of type 2 diabetes was referred for extraction of #8 and placement of a dental implant to reconstruct the area. Extraction was performed in a minimal traumatic manner and a mineralized freeze-dried bone allograft was placed in the socket. A 10,600 nm wavelength CO₂ laser was used in setting of 1.0 watts focused continuous wave energy to stabilize the blood clot over the extraction site. The laser was used until a char layer was formed. This char layer was a non-bleeding stable blood clot, and the end-point of laser application was set as “no blood flow from the clot are within 10 seconds.” No membranes or sutures were used. Eleven weeks after the extraction and ridge preservation, a 4.1x10mm dental implant was placed with >35N/cm of primary stability and Implant stability quotient (ISQ) value of 83. A provisional crown was delivered at the time of implant placement. Three months following implant placement, the final restoration was delivered. The soft and hard tissue healing were uneventful to achieve esthetic and functional outcomes.

Conclusion: Within limits of this case report, the application of CO₂ laser for “Laser-Assisted Blood Clot Formation” may enhance the soft and hard tissue healing following extraction for ridge preservations.

Keywords

Carbon Dioxide Laser, Ridge Preservation, Implant, Immediate Provisional

Introduction

Ridge preservation procedures have been utilized to minimize the loss of alveolar ridge dimension following extractions [1,2]. One of the most commonly used methods is application of bone substitutes graft materials into the extraction sockets as a scaffold for space maintenance and new bone formation since bundle bone will be resorbed following extractions [3–5]. Several studies have shown the positive effect on extraction site healing with laser irradiation [6,7]. Fukuoka reported that carbon dioxide laser irradiation in rat extraction sites resulted in less concavity and lower vertical alveolar ridge reduction compared to non-irradiated sites [8]. Moreover, histo-immunostaining revealed that less myofibroblastic activity was noted in irradiated areas. In other words, less wound contraction was noted due to the blood clot stability and possible low-level laser therapy (LLLT) effects [8]. A carbon dioxide laser (CO₂ laser: wave length:10,600µm) has been utilized in dentistry primarily for soft tissue and hemostasis procedures [9]. Application of CO₂ laser is considered relatively safer because the energy is absorbed on the surface of water and causes less scatter. The CO₂ laser is used in a non-contact manner which is beneficial to stimulate the blood clot compared to other types of lasers which need direct contact on the tissues [10]. The aim of this case report is to demonstrate the novel application of CO2 laser for alveolar ridge preservation procedures.

Clinical Presentation

A 76-year-old white male presented to Indiana University School of Dentistry Graduate Periodontics Clinic for consultation for an implant of #8 in November 2017. The patient’s chief complaint was “This crown keeps falling out and needs to be fixed”. The patient’s medical history revealed well-controlled Type 2 diabetes (HbA1c:6.2%), hypertension, and history of myocardial infarction (stent and bypass surgery). His medications included clopiogrel 75mg and aspirin 81mg. The patient also reported that he took levothyroxine for hypothyroidism medication and used a CPAP machine for sleep apnea. #8 was deemed to be non-restorable due to recurrent caries. Treatment options were discussed with patient and #8 extraction and subsequent implant placement was chosen (Figure 1, 2).

Figure 1. Pre-operative Clinical Appearance.

Figure 2. Pre-operative Periapical Radiograph.

Case Management

Following the local anesthesia administration, the crown and post were removed. A sulcular incision was made around the root to sever the supracrestal attached tissue. No flap reflection was performed. The remained root was sectioned, elevated and extracted with periotome elevators. After granulation tissue removal, a 2–3 mm fenestration was noted on the facial mid to apical third of the extraction site. Mineralized freeze-dried bone allograft (FDBA)^† was hydrated with saline and placed in the extraction site to the level of the crestal bone. A 10,600 nm wavelength CO₂ laser^‡ was used at a setting of 1.0 watts focused continuous wave energy to stabilize the blood clot over the extraction site. A gold tip was attached to the laser hand-piece. Target distance was set approximate 10mm from the edge of the gold tip. The divergence of beam was 6.2 degree and the spot size at the target was Ø0.48mm. Since we utilized 1W focused continuous wave mode of this device, the power density was 555.6W/cm². A CO₂ laser is absorbed by water, and it does not penetrate into the deep layer of the soft and hard tissue. However the careful attention was taken to keep moving the laser tip to reduce the heat generation and avoid the direct application onto the hard tissue structure including teeth and alveolar bone surfaces. The laser tip was moved continuously with circle motion approximately 3–5 turns/sec over the extraction site. Extraction site is approximately 10mm diameter, so beam movement is 9.4–15.7cm/sec of speed. This movement can reduce the concentration of energy on the one spot which increase the temperature. The laser was used until a char layer was formed. This char layer was a non-bleeding stable blood clot, and the end-point of laser application was set as “no blood flow from the clot are within 10 seconds” (Figure 3–5).

Figure 3. Immediately after the extraction: Buccal bone was present.

Figure 4. Description of laser tip and object.

Figure 5. Laser Assisted Blood Clot Formation and Stabilization were achieved.

Results

The wound healing was uneventful and no complications were noted. The patient returned for 1, 3 and 7 week post-operative visits (Figure 6–8). At 11 weeks following the extraction, the site was re-entered for implant placement. Following crestal and slight vertical incision on mesial on #8, a full thickness flap was elevated. Crestal bone revealed solid and flat alveolar bone upon flap reflection in the former extraction site although slight soft tissue concavity was noted. The buccal-palatal dimension ofalveolar bone was sufficient for the planned dental implant. Implant osteotomy was performed per manufacturer recommendation and a 4.1 x 10 mm implant^§ was placed with an insertion torque of 35 N/cm. Implant Stability Quotient (ISQ) value^‖ showed 83 from both buccal and lingual directions. Due to the high implant stability, an immediate provisional was fabricated chairside and delivered (Figure 9–13). The use of an immediate provisional allowed better soft tissue emergence profile as well as patient comfort and convenience. Three months following implant placement, a definitive restoration was delivered. Final restoration showed good soft tissue esthetics and papillary fill, and the outcome has been stable up to one year (Figure 14,15).

Figure 6. 1 week post-operative clinical view.

Figure 7. 3 weeks post-operative clinical view.

Figure 8. 7 weeks post-operative clinical view.

Figure 9. 11 weeks post-operative clinical view.

Figure 10. 11 weeks post-operative periapical radiograph.

Figure 11. Bone regeneration was noted 11 weeks after the extraction.

Figure 12. 1 week after the implant placement and provisional crown delivery. (Clinical)

Figure 13. 1 week after the implant placement and provisional crown delivery. (Periapical radiograph)

Figure 14. 1 year after the implant placement with the final crown: Acceptable papillae fill and gingival health was obtained

Figure 15. 1 year after the implant placement with the final crown: No marginal bone loss was noted.

Discussion

Extraction sites usually heal by secondary intention, and slight concavity over the crestal area is very common [11]. Amler described the healing process of human extraction wounds [12]. For the undisturbed healing sites, initial blood clot formation fills the entire socket and followed by immature connective tissue formation and epithelization over the wound. Disruption of the blood clot during healing can result in disturbance of the normal healing pattern and is suspected to be the cause of ofalveolar osteitis. The exposed alveolar bone surface causes not only pain also significant wound healing delayed. According to this description, blood clot stability will directly affect the wound stability which can maximize the regenerative capacity. Cortellini and Tonetti compared application of modified minimal invasive surgery with or without graft materials or growth factors [13]. Then the study showed that there were no statistical differences between groups. The key to achieve the maximum potential of regenerative outcome is to create a stable environment for soft and hard tissue healing. In this case report, we tested the application of CO₂ laser to stabilize the blood clot formation over the extraction site. Due to the blood clot stability, relatively faster epithelization over the extraction site was observed during the initial healing process. Meloni et al. utilized a porcine collagen matrix and connective tissue graft to cover the extraction site following placement of a bone graft substitute. Both methods did not show any significant differences for healing outcomes. The concept of those procedures was also to achieve wound stability by placing graft materials. Disadvantages of those soft tissue grafts and those substitutes are required to place sutures to obtain stabilization. In addition to those sutures, harvesting of connective tissue requires a secondary surgical site, and those substitutes are not cost friendly [14]. On the contrary, utilization of CO₂ laser does not require any sutures nor additional soft grafts since this technique is simply stimulating blood coagulation and stabilizing the blood clot. The authors would like to propose that this procedure can be named as a “laser assisted blood clot formation”. However, there is currently no evidence to show how soft tissue healing process with CO₂ laser can induce the bone maturation and preservation of ridge dimension. Due to the nature of case report, the other limitation of this study was that ridge dimension change was not measured prospectively. Although the existing buccal bone thickness was thin at the time of extraction, this case cannot prove which factor (bone substitute grafting or blood clot stability with CO₂ laser) contributed to the outcome of this case report. Further studies are needed to substantiate these results.

Conclusion

Within limits of this case report, the application of CO₂ laser for “Laser-Assisted Blood Clot Formation” may enhance the soft and hard tissue healing following extraction for ridge preservations.

Acknowledgement

The authors would like to acknowledge Dr. Eiji Funakosi, Private practitioner, founder of Funakoshi Research Institute of Clinical Periodontology, Fukuoka, Japan for the assistance to develop this laser protocol.

The authors also would like to acknowledge Mr. Tatsuya Kashima and Mr. Wataru Kikuchi (THE YOSHIDA DENTAL MFG. CO., LTD) for the calculation of the total energy of this laser application.

References

1. Hämmerle CH, Araújo MG, Simion M; Osteology Consensus Group 2011 (2012) Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res 5: 80–82. [crossref]
2. Schropp L, Wenzel A, Kostopoulos L, Karring T (2003) Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 23: 313–323.
3. Araujo MG, Lindhe J (2005) Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 32: 212–218.
4. Frost NA, Banjar AA, Galloway PB, Huynh-Ba G, Mealey BL (2014) The decision-making process for ridge preservation procedures after tooth extraction. Clinical Advances in Periodontics 4: 56–63.
5. De Risi V, Clementini M, Vittorini G, Mannocci A, De Sanctis M (2015) Alveolar ridge preservation techniques: a systematic review and meta-analysis of histological and histomorphometrical data. Clin Oral Implants Res 26: 50–68.
6. Brawn PR, Kwong-Hing A (2007) Histologic comparison of light emitting diode phototherapy-treated hydroxyapatite-grafted extraction sockets: a same-mouth case study. Implant Dent 16: 204–211.
7. Cranska J (2008) Post-extraction laser hemostasis with immediate insertion of a bonded bridge. Dent Today 27: 108–110.
8. Fukuoka H, Daigo Y, Enoki N, Taniguchi K, Sato H (2011) Influence of carbon dioxide laser irradiation on the healing process of extraction sockets. Acta Odontol Scand 69: 33–40. [crossref]
9. Cobb CM (2006) Lasers in periodontics: a review of the literature. J Periodontol 77: 545–564. [crossref]
10. Aoki A, Mizutani K, Schwarz F (2015) Periodontal and peri-implant wound healing following laser therapy. Periodontol 2000 68: 217–269.
11. Lin Z, Rios HF, Volk SL, Sugai JV, Jin Q, et al. (2011) Gene expression dynamics during bone healing and osseointegration. J Periodontol 82: 1007–1017. [crossref]
12. Amler MH (1969) The time sequence of tissue regeneration in human extraction wounds. Oral Surg Oral Med Oral Pathol 27: 309–318. [crossref]
13. Cortellini P, Tonetti MS (2011) Clinical and radiographic outcomes of the modified minimally invasive surgical technique with and without regenerative materials: a randomized-controlled trial in intra-bony defects. J Clin Periodontol 38: 365–373.
14. Meloni SM, Tallarico M, Lolli FM, Deledda A, Pisano M, et al. (2015) Postextraction socket preservation using epithelial connective tissue graft vs porcine collagen matrix. 1-year results of a randomised controlled trial. Eur J Oral Implantol 8: 39–48.

DOI: 10.31038/JDMR.2019234

Introduction

The use of intra-radicular restraint systems for complete dentures, has been indicated as a viable option for decades ago, and have been called “overdentures” [1–6]. The overdentures concept is not new in dentistry and has been used since the 70’s years. Actually, considering its potential benefits, there has been a reduction in the indication over natural supports [2,4,5].

Flaws in the control of dental caries and periodontal disease, possibility of root fractures and the difficulty in understand and reproduce the bilaterally balanced occlusion, takes many professionals to be reluctant to indicates this technique, preferring to remove remaining teeth and install implants [3,4,6]. However, the use of natural tooth roots to support overdentures brings benefits to the patient, assisting the proprioception, eliminating the osseointegration period and reducing the final cost of the prosthesis, because it eliminates the need for the acquisition of prosthetic components, and clinical and laboratory procedures related to installation of implants. Maintaining compliance with oral hygiene and specific care with the natural supports and prosthesis, the time life justifies the indication of this technique. In addition, an appropriate treatment plan for the making of overdentures on natural roots is a mandatory choice for patients who have underwent radiotherapy as a complementary treatment of cancerous lesions. Several authors are unanimous in stating that the radiation is a factor associated with the loss of implants and the decrease in its survival rate [7–16]. The effects of the radiotherapy appear to be more severe in the jaw due the less blood supply in the newly formed bone. So the benefit of the indication of the overdenture on natural roots in these cases, when compared to the overdenture on implant must overcome risk [7].

Patients with changes in the occlusal plane due to absence or inadequate dental position tend naturally to have changes in mandibular positioning, in both vertical (vertical dimension of occlusion) and horizontal plane (distal displacement, midline deviations). Clinical researches have been indicated the use of occlusal devices, occlusal appliance, as a valid resource for the normalization of mandibular position. These devices can be adapted in the superior dental arch on the remaining teeth or alveolar ridge and must be flat and smooth occlusal surface [17–19]. These occlusal devices act as facilitators of the mandibular repositioning, by blocking all or part of the proprioceptive stimuli responsible for the control of masticatory activity, in establishing an ideal position for prosthetic rehabilitation [19,20].

Clinical Case

A male patient, 58 years old, in need of prosthetic rehabilitation, attended the Centre for the Study and Treatment of the Functional Changes of the Stomatognathic System – CETASE, of the School of the Dentistry of Piracicaba – UNICAMP/Brazil, in August 2015, three years after had been submitted to surgical treatment for the removal of a moderately differentiated ulcerating spin cell carcinoma (grade II) in the larynx. The medical history revealed that, in 2004, after the differential diagnosis had been performed, was submitted to supraglottic laryngectomy and cervical bilateral radical deflation followed by postoperative radiotherapy. The treatment was finished in November of the same year. The following year the patient underwent gastrectomy due to a primary tumor of stomach. Three years after they were found metastases in the regions of the base of the tongue and mandible jaw, being subjected to glossopelvemandibulectomy, removing part of the base of the tongue, right inferior part of the mandibular ramus (Figure 1) and the superficial and deep masseter muscles, tendon of the temporal, lateral and medial pterygoid muscles and ligament stylomandibular of the same side. He was not subjected to facial reconstruction and to supplementary feed, used an intestinal bowel probe.

Figure 1. Panoramic radiograph showing the complete absence of the mandible branch of the right side due to the removal of the cancerous lesion.

Dental history began to be recorded in 2016, through the use of the Clinical Chart of CETASE, with the goal of identify signs and symptoms of TMJ disorders, according of the severe mandibular misalignment in horizontal and vertical plane. Facial asymmetry with severe jaw offset to the right side (Figure 2), limitation of mouth opening, occlusion vertical dimension decrease, difficulty in pronunciation of words and to swallow, were detected during the clinical examination. It was also observed that the premolars, inferiors central and lateral incisors on both sides had great destruction. The treatment planning initially aimed to give jaw alignment in relation to the median sagittal plan and the restoration of vertical dimension of occlusion in the light of the absence of the muscles masticatory on the right side. Initially, the patient was underwented to the use of a flat and plan occlusal appliance, manufactured with colorless acrylic resin adapted to the mandibular dental arch, for reconstitute the vertical dimension [17–21].

Figure 2. Mandibular deviation to the right side, due to the removal of lateral and medial pterygoid superficial and deep masseter muscles on the same side.

The patient used the appliance for a period of thirty days, every day, removing it only for the meals. At the end of the period it was observed that the jaw was not completely aligned to the median sagittal plan, because of the removal of muscles on the right side. So a ramp was added on the appliance occlusal surface in the right side (Figure 3) direct the jaw to median sagittal plan. The alignment was got at the 60’s days of use (Figure 4).

Figure 3. Ramp built on the right side of the unit, to the alignment of the mandible in the sagittal plane.

Figure 4. Recovery of facial aesthetics after the alignment of the mandible in relation to the sagittal plane and normalization on the vertical dimension of occlusion.

The use of the appliance allowed not only the jaw alignment to the median sagittal plan, but the occlusal vertical dimension was normalized. Then the patient underwent to a preventive duodenum and stomach endoscopy and the medical report showed that the oral cavity, the oropharynx and the hypopharynx were aligned with the upper structures of the digestive system. Due to the surgical therapy for the oncological treatment, the patient had a supplementary feeding through intestinal probe.

All the mandibular teeth were underwented to an endodontic treatment to receive o’rings systems and copings (Figure 5). The roots of the mandibular canines and premolars of both sides received the o’rings systems. After the cementing of the restraint systems and copings (Figure 6) the over denture was made as usual and the technique determines the capsules with the rubber rings held routinely [1–3]. The patient was instructed to make use of pasty foods in the first 15 days and your new prostheses were submitted to weekly setting. After this period, he began to use solid foods more resilient and more fibrous gradually. The patient expressed sense of satisfaction and comfort with the use of the prosthesis (Figure 7 and 8) and reported an increase in body weight of ten kilograms and plans to the removal of the intestinal probe.

Figure 5. Mandibular teeth received short copings or ball attachment systems for overdenture o’ring type. The illustration shows the restraint systems and the copings being proven in the roots of the teeth.

Figure 6. After casting and machining procedures ball attachment systems and the copings were installed in the mouth.

Figure 7. Prosthesis adapted on restraint systems and in teeth occlusion antagonists.

Figure 8. Facial aesthetics re-established masticatory function, within the limitations of clinical case.

Summary

Male patient undergo laryngectomy and supraglottic glossopelvemandibulectomy cervical bilateral radical emptying due to an ulcerated moderately differentiated spin cell carcinoma and invasive (degree II). Underwent successful before treatment of prosthetic rehabilitation treatment with occlusal appliance smooth and flat and later device with lateral ramp to align the mandible in relation to the median sagittal plan. The prosthetic rehabilitation occurred through mandibular overdenture with o’ring retention system. After a period of adaptation, the patient reported satisfaction and comfort and an increase in body weight of 10 kilograms.

Discussion

Surgical treatment of carcinogenic head and neck injuries often results in often severe intraoral and extraoral defects that lead to changes in chewing, swallowing, phonation and aesthetics, influencing the patient’s quality of life. As a means of restoring function and partially or totally aesthetics, prosthetic rehabilitation becomes the main recommendation for this purpose. Overdenture has been described as a technique indicated for prosthetic rehabilitation, where removal of part of the maxilla or mandible is necessary as a preventive approach to recurrence of invasive carcinomas. The o’ring system is indicated as a form of retention of overdentures whether installed on natural or artificial abutments.

The indication of implant overdenture in irradiated patients who underwent chemotherapy presents a risk of osseointegration loss and, as a consequence, impairment of the prosthesis. In these cases the use of natural teeth as o’ring system receptors are more indicated, having the advantage of maintaining dental proprioception. The concept of a physiological mandibular position, from which the vertical occlusion dimension and the maximum intercuspal position for the construction of prosthetic rehabilitation can be established, is unanimous in the dental environment. Although there are discussions regarding the procedures for obtaining such positions, the tendency of the researchers is to adopt technical procedures to first seek neuromuscular balance and then the vertical dimension of occlusion and maximum intercuspal position. It is noticed that the initial or pre-rehabilitative objective is proprioceptive block, so that the masticatory muscles and associated muscles can equalize their functions, bilaterally.

The use of a rigid, smooth and flat intraoral device that blocks proprioception and as a consequence allows the electromyographic equalization of the masticatory muscles, as a consequence brings the mandible in harmony with the position of the condyles in the mandibular fossae and the muscular electrical activity. Thus, the jaw responding to bilateral functional activity of the muscles in balance, reaches a therapeutic position, ready to receive prosthetic rehabilitation. The case described in this article was planned and executed using initially a rigid, smooth and flat intraoral device, seated on the lower teeth to initially promote muscle equalization. As it was necessary the total removal of the right mandibular ramus and all the muscles inserted in it, later, the intraoral device was transformed, receiving an inclined plane, in its right side to dislocate the mandible, towards the midline of the median sagittal plane and thus centralizing it. After stabilization of the mandible in this position, an o’ring overdenture was performed on the remaining lower teeth, in addition to functional and aesthetic rehabilitation, seeking to improve the patient’s quality of life.

References

1. Burns DR (2004) The mandibular complete overdenture. Dent Clin North Am 48: 603–623. [crossref]
2. Mericske-Stern R (1994) Overdentures with roots or implants for elderly patients: a comparison. J Prosthet Dent 72: 543–550. [crossref]
3. Ledger E (1856) On preparing the mouth for the reception of a full set of artificial teeth. Br J Dent Sci 1: 90.
4. PRINCE IB (1965) CONSERVATION OF THE SUPPORTIVE MECHANISM. J Prosthet Dent 15: 327–338. [crossref]
5. Fenton AH1 (1998) The decade of overdentures: 1970–1980. J Prosthet Dent 79: 31–36. [crossref]
6. Morrow RM, Powell JM, Jameson WS, Jewson CG, Rudd KD (1969) Tooth supported complete dentures: an approach to preventive prosthodontics. J Prosthet Dent 21: 513–522.
7. Chrcanovic BR, Albrektsson T, Wennerberg A (2016) Dental implants in irradiated versus nonirradiated patients: A meta-analysis. Head Neck 38: 448–481. [crossref]
8. Garg A, Guez G (2011) Head and neck cancer, dental implants, and dental oncology. Dent Implantol Update 22: 1–8. [crossref]
9. De la Plata M, Gías LN, Díez PM, Muñoz-Guerra M, González-García R, et al. (2012) Osseointegrated implant rehabilitation of irradiated oral cancer patients. J Oral Maxillofac Surg 70: 1052–1063.
10. Yerit KC, Posch M, Seemann M, Hainich S, Dörtbudak O, et al. (2006) Implant survival in mandibles of irradiated oral cancer patients. Clin Oral Implants Res 17: 337–344. [crossref]
11. Marx RE, Johnson RP (1987) Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol 64: 379–390. [crossref]
12. Jacobsson M, Tjellström A, Thomsen P, Albrektsson T, Turesson I (1988) Integration of titanium implants in irradiated bone. Histologic and clinical study. Ann Otol Rhinol Laryngol 97: 337–340. [crossref]
13. Sammartino G, Marenzi G, Cioffi I, Teté S, Mortellaro C (2011) Implant therapy in irradiated patients. J Craniofac Surg 22: 443–445. [crossref]
14. Schiegnitz E, Al-Nawas B, Kämmerer PW, Grötz KA (2014) Oral rehabilitation with dental implants in irradiated patients: a meta-analysis on implant survival. Clin Oral Investig 18: 687–698.
15. Zheng M, Li L, Tang Y, Liang XH (2014) How to improve the survival rate of implants after radiotherapy for head and neck cancer? J Periodontal Implant Sci 44: 2–7.
16. Ihde S, Kopp S, Gundlach K, Konstantinović VS (2009) Effects of radiation therapy on craniofacial and dental implants: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107: 56–65. [crossref]
17. Casselli H, Landulpho AB, Silva WA, Silva FA (2007) Electrognatographic evaluation of rehabilitated edentulous patients. Braz Oral Res 21: 355–361.
18. Landulpho AB, Silva WA, Silva FA, Vitti M (2002) The effect of the oclusal splints on the treatment of temporomandibular disorders – a computerized electromyographic study of masseter and anterior temporalis muscles. Electromyogr Clin Neurophysiol 42: 187–191.
19. Landulpho AB, Silva WA, Silva FA, Vitti M (2004) Electromyographic evaliation of masseter and anterior temporalis muscles in patients with temporomandibular disorders following interocclusal appliance treatment. J Oral Rehabil 31: 95–98.
20. Landulpho AP, Silva WAB, Silva FA, Casselli H, Silva LLB (2004) Electrosonographic evaluation in patients with temporomandibular disorders, treated by interoclusal appliance. Braz J Oral Sci 11: 624–627.
21. Silva WAB, Silva FA (2000) Epidemiologic study of the temporomandibular disorders. J Dent Res 79: 584–588.

DOI: 10.31038/JDMR.2019233

Abstract

Periodontal disease includes many pathological conditions affecting the periodontium, but gingivitis and periodontitis are the more common types. Gingivitis is a progressive condition, although it is reversible, when left untreated it can lead to periodontitis. Microbial species have a major role in the aetiology of periodontitis.

Method:Information was derived from research papers using PubMed, Science Direct, and Google Scholar using the keywords local drug delivery system, treatment, and periodontal disease. The search included articles up to 2018 with majorly in vivo studies in patients with periodontitis. The usage of local drug delivery systems with controlled or sustained release mechanisms may provide slightly better therapeutic effect in comparison with patients who undergo scaling and root planning only.

Conclusion: The present review of the literature of the currently available local drug delivery systems in the treatment of periodontal diseases.

Keywords

Gingivitis, Periodontal Diseases, Periodontium, Scaling

Introduction

Periodontal disease is a term which comprises several pathological conditions involving the periodontium, which includes the gum, alveolar bone, dental cementum, and periodontal ligament [1]. The more common conditions of periodontal diseases are gingivitis and periodontitis. Periodontal disease is the most prevalent oral condition of the worldwide population, with gingivitis affecting 50% to 90% of adults [2,3]. Gingivitis is the mildest type of periodontal disease. It is a localised inflammation of the gum tissue (gingiva) caused by bacteria in the dental plaque, which is a microbial biofilm that forms on the teeth and the gingiva. Cultural studies have shown that there are more than 700 distinct microbial species that can be found in the dental plaque, although only a small group has been confirmed to contribute to the cause and progression of periodontal disease [3,4]

Gingivitis, when left untreated, can progress to periodontitis [3,5]. Unlike gingivitis, which is confined to the gingiva, periodontitis leads to the loss of connective tissues supporting or surrounding the teeth. This loss of gingiva, alveolar bone, and periodontal ligament creates deep “pockets”. When these deep periodontal pockets have formed and is filled with microbes, the condition becomes highly irreversible, and eventually may lead to loss of teeth [5].

Literature Research

Search strategy

A literature search with several restrictions was done electronically through the following databases: PubMed, Google Scholar, and Science Direct, using search terms that have been summarised in (Table 1).

Table 1. Number of results yielded by searching using keywords through three different databases.

Inclusion and exclusion criteria

The search was restricted to research articles written in English, and the search included studies from 1979 up to 2018, since 1979 was the year that local drug delivery systems were first considered. Apart from articles that do not meet the criteria mentioned, animal studies were also not included.

History of Treatment

As mentioned previously, it has been proven that the bacteria-filled film is one of the main causes of periodontal diseases. The traditional methods of non-surgical treatment of periodontal disease, including mechanical scaling and root planing, did not guarantee improvements of the disease. Treatment of periodontitis focuses mainly on reducing the total microbial count, hence scaling and root planing needs to have an adjunct therapy, in other words, the antimicrobial agents. It was Dr. Max Goodson who pioneered and developed the concept of local drug delivery systems in 1979 [6]. This discovery has led to the increase of studies regarding local drug delivery systems pertaining to periodontal disease in the last decade.

Advantages of local antimicrobial drug delivery directly into periodontal pocket

The advantages of delivering antimicrobial agents directly to the target instead of taking systemic agents [7,8]. These are included and not limited to direct access to the targeted diseases, first-pass metabolism is bypassed, avoids problems regarding the gastrointestinal system, which is a common occurrence with drugs that are orally administered, able to provide more rapid absorption because of the rich blood supply’ reduction in cost of treatment, less chances of antimicrobial resistance and suitable for patients who cannot swallow. However, there are still some limitations, which include inability to administer local irritants, limited dose because of the small area and cost to manufacture delivery devices may get expensive.

Local drug delivery systems

Drugs that need to be delivered locally are done so by inserting them into a vehicle in the form of fibres, gels, strips, among others, which will be discussed in Table 2 below. The ideal characteristics for that are desired for a local anti-microbial agent are able to deliver the drug to the target, in other words, the base of the pocket, has a therapeutic concentration in the pocket, able to maintain the concentration of drug for a period of time where the drug gives therapeutic effect and exhibits little side effects.

Table 2. Summary of some local drug delivery systems [9].

Fibres

Fibres are thread-like devices with a reservoir-based sustained release system. They are circumferentially placed inside the periodontal pockets using an applicator, and to ensure the controlled release of drug, the fibres are secured by applying cyanoacrylate as an adhesive [9].

Actisite^®

Actisite was introduced in 1994 and was the first controlled-release antimicrobial product to be commercialised. It is 23 cm long and 0.55 mm wide, delivering 12.7 mg of tetracycline hydrochloride. The fibre is non-biodegradable and has to be removed after 10 days, which is the end of the therapy. In comparison with 250 mg of tetracycline delivered orally which results in 1 μg/ml in the gingival crevicular fluid, the locally delivered Actisite achieves an initial concentration of 1590 μg/ml in the periodontal pocket. The concentration level remained at a mean of 1300 μg/ml for 7 days [7]

Films

Film is a form of matrix delivery system where the drug is distributed throughout the polymer, and it is released by either drug diffusion, or erosion or dissolution of matrix. This system is more commonly used as it has several advantageous characteristics. The size and shape of the films is flexible it can be easily changed to fit the dimensions of pocket needed to be treated. Larger-sized films can be applied onto the cheek mucosa, or they can also be divided into smaller sizes to be placed into the pocket [9].

Injectable systems

Injectable systems have an added advantage of easy and rapid application. Antimicrobial agents can be delivered using a syringe directly into the periodontal pocket, without the patient experiencing pain. The cost and time taken for the therapy is also considerably lower when compared to delivery systems that need to be applied securely. Furthermore, the injectable system should be able to fill the pocket, hence reaching more pathogens [48].

Gels

Gels are semisolid mucoadhesive systems that have also received attention for the targeted delivery of antimicrobial agents, offering some advantages [8]creation of periodontal pocket and resorption of alveolar bone, resulting in the disruption of the support structure of teeth. According to WHO, 10–15% of the global population suffers from severe periodontitis. The disease results from the growth of a diverse microflora (especially anaerobes. For instance, in terms of preparation and administration, they are easier to prepare. A downside is that gels have faster drug releasing rates. Gels are applied sublingually using a blunt cannula and a syringe [48].

Strips and compacts

Strips are thin and elongated matrix bands where the drug will be distributed throughout the system. Acrylic strips filled with different antimicrobial agents have been developed, and those containing tetracycline or metronidazole were found to have best improved the parameters of periodontitis [49].

Vesicular liposomal systems

Vesicular liposomal systems are investigated intently in order to be used in periodontal diseases. This is because they are designed to mimic the bio-membranes in terms of structure and their behaviour [9].

Microparticle systems

Microspheres are solid structures that are spherical in shape, with sizes ranging from 1 to 1000 μm. The drug is dispersed throughout the matrix. To prepare microspheres, non-biodegradable and biodegradable materials are both being investigated. These materials include natural polymers, modified natural substances, and synthetics. They can be formulated into chips, dental paste, or even directly injected into the targeted area [8,49]creation of periodontal pocket and resorption of alveolar bone, resulting in the disruption of the support structure of teeth. According to WHO, 10–15% of the global population suffers from severe periodontitis. The disease results from the growth of a diverse microflora (especially anaerobes.

Nanoparticle systems

Nanoparticles have sizes ranging from 10 to 1000 nm, which enables them to penetrate through regions that may not be reached by other delivery systems. This is a major advantage above the other systems like microparticles, since the ability to reach these otherwise neglected areas result in a decreased frequency of administration and it also provides a more uniform distribution of the drug [9]. For most of the local drug delivery systems, there is only a limited number of studies that have been published. Even though there are studies available, it is difficult to compare between different trials as the therapy given to the participating patients vary greatly.

Conclusion

Local delivery drug systems are seemingly a good alternative to deliver antimicrobial agents compared to systemic delivery. They produce fewer side effects, which could improve patient compliance. Since there are no studies proving the effective use of locally delivered drugs as a monotherapy, local drug delivery system remains to be a good adjunct therapy.

Acknowledgement

This literature review promoted by the Universiti Brunei Darussalam through the Pharmacy and dentistry team for their bachelor student’s studentship.

References

1. Kaplish V, Walia MK, Kumar SLH (2013) Local drug delivery systems in the treatment of periodontitis: A review. Pharmacophore 4: 39–49.
2. Nazir MA (2017) Prevalence of periodontal disease, its association with systemic diseases and prevention. International journal of health sciences 11: 72–80.
3. Pihlstrom BL, Michalowicz BS, Johnson NW (2005) Periodontal diseases. Lancet 366: 1809–1820.
4. Herrera D, Matesanz P, Bascones-Martínez A, Sanz M (2012) Local and systemic antimicrobial therapy in periodontics. Journal of Evidence-Based Dental Practice 12: 50–60.
5. Kinane DF, Stathopoulou PG, Papapanou PN (2017) Periodontal diseases. Nature Reviews Disease Primers 3: 1–14.
6. Goodson JM, Haffajee A, Socransky SS (1979) Periodontal therapy by local delivery of tetracycline. Journal of Clinical Periodontology 6: 83–92.
7. Nair SC, Anoop KR (2012) Intraperiodontal pocket: An ideal route for local antimicrobial drug delivery. Journal of advanced pharmaceutical technology & research 3: 9–15.
8. Joshi D, Garg T, Goyal AK, Rath G (2016) Advanced drug delivery approaches against periodontitis. Drug Delivery 23: 363–377.
9. Jain N, Jain GK, Javed S, Iqbal Z, Talegaonkar S, Ahmad FJ, Khar RK (2008) Recent approaches for the treatment of periodontitis. Drug discovery today 13: 932–943.
10. Coventry J, Newman HN (1982) Experimental use of a slow release device employing chlorhexidine gluconate in areas of acute periodontal inflammation. Journal of Clinical Periodontology 9: 129–133.
11. Tonetti M, Cugini MA, Goodson JM (1990) Zero-order delivery with periodontal placement of tetracycline-loaded ethylene vinyl acetate fibers. Journal of Periodontal Research 25: 243–249.
12. Golomb G, Friedman M, Soskolne A, Stabholz A, Sela MN (1984) Sustained Release Device Containing Metronidazole for Periodontal Use. Journal of Dental Research 63: 1149–1153.
13. Azoury R, Elkayam R, Friedman M (1988) Nuclear Magnetic Resonance Study of an Ethyl Cellulose Sustained-Release Delivery System II: Release Rate Behavior of Tetracycline. Journal of Pharmaceutical Sciences 77: 428–431.
14. Elkayam R, Friedman M, Stabholz A, Soskolne AW, Sela MN, Golub L (1988) Sustained release device containing minocycline for local treatment of periodontal disease. Journal of Controlled Release 7: 231–236.
15. Minabe M, Uematsu A, Nishijima K, Tomomatsu E, Tamura T, Hori T, Hino T (1989) Application of a Local Drug Delivery System to Periodontal Therapy: Journal of Periodontology 60: 113–117.
16. Steinberg D, Friedman M, Soskolne A, Sela MN (1990) A New Degradable Controlled Release Device for Treatment of Periodontal Disease: In Vitro Release Study. Journal of Periodontology 61: 393–398.
17. Kondreddy K, Ambalavanan N, Ramakrishna T, Kumar RS (2012) Effectiveness of a controlled release chlorhexidine chip (PerioColTM-CG) as an adjunctive to scaling and root planing when compared to scaling and root planing alone in the treatment of chronic periodontitis: A comparative study. Journal of Indian Society of Periodontology 16: 553–557.
18. Ozmeriç N, Ozcan G, Haytaç CM, Alaaddinoğlu EE, Sargon MF, Senel S (2000) Chitosan film enriched with an antioxidant agent, taurine, in fenestration defects. Journal of biomedical materials research 51: 500–503.
19. Perugini P, Genta I, Conti B, Modena T, Pavanetto F (2003) Periodontal delivery of ipriflavone: new chitosan/PLGA film delivery system for a lipophilic drug. International journal of pharmaceutics 252: 1–9.
20. El-Kamel AH, Ashri LY, Alsarra IA (2007) Micromatricial metronidazole benzoate film as a local mucoadhesive delivery system for treatment of periodontal diseases. AAPS PharmSciTech 8: 184–194.
21. Wang LC, Chen XG, Zhong DY, Xu QC (2007) Study on poly(vinyl alcohol)/carboxymethyl-chitosan blend film as local drug delivery system. Journal of Materials Science: Materials in Medicine 18: 1125–1133.
22. Agarwal RK, Robinson DH, Maze GI, Reinhardt RA (1993). Development and characterization of tetracycline-poly(lactide/glycolide) films for the treatment of periodontitis. Journal of Controlled Release, 23: 137–146.
23. Ahuja A, Ali J, Rahman S (2006) Biodegradable periodontal intrapocket device containing metronidazole and amoxycillin: formulation and characterisation. Die Pharmazie 61: 25–29.
24. Higashi K, Matsushita M, Morisaki K, Hayashi S, Mayumi T (1991) Local drug delivery systems for the treatment of periodontal disease. Journal of pharmacobio-dynamics 14: 72–81.
25. Kyun KD, Yun KS, Young JS, Pyoung CC, Heui SS (1990) Development of minocycline containing polycaprolactone film as a local drug delivery. Taehan Ch’ikkwa Uisa Hyophoe chi 28: 279–290.
26. Akıncıbay H, Şenel S, Yetkin Ay Z (2007) Application of chitosan gel in the treatment of chronic periodontitis. Journal of Biomedical Materials Research Part B: Applied Biomaterials 80: 290–296.
27. Jones DS, Woolfson AD, Djokic J, Coulter WA (1996) Development and mechanical characterization of bioadhesive semi-solid, polymeric systems containing tetracycline for the treatment of periodontal diseases. Pharmaceutical research 13: 1734–1738.
28. Bruschi ML, Jones DS, Panzeri H, Gremião MPD, de Freitas O, Lara EHG (2007) Semisolid Systems Containing Propolis for the Treatment of Periodontal Disease: In Vitro Release Kinetics, Syringeability, Rheological, Textural, and Mucoadhesive Properties. Journal of Pharmaceutical Sciences 96: 2074–2089.
29. Poison AM, Stoller NH, Hanes PJ, Bandt CL, Garrett S, Southard G (1996). 2 multi-center trials assessing the clinical efficacy of 5% sanguinarine in a biodegradable drug delivery system. Journal of Clinical Periodontology 23: 782–788.
30. Polson AM, Garrett S, Stoller NH, Bandt CL, Hanes PJ, Killoy WJ, Friesen LR (1997) Multi-Center Comparative Evaluation of Subgingivally Delivered Sanguinarine and Doxycycline in the Treatment of Periodontitis. II. Clinical Results. Journal of Periodontology 68: 119–126.
31. Noyan U, Yilmaz S, Kuru B, Kadir T, Acar O, Büget E (1997) A clinical and microbiological evaluation of systemic and local metronidazole delivery in adult periodontitis patients. Journal of clinical periodontology 24: 158–165.
32. Maze GI, Reinhardt RA, Payne JB, Maze C, Baker RA, Bouwsma OJ, Gerlach RW (1996) Gingival fluid tetracycline release from bioerodible gels. Journal of Clinical Periodontology, 23: 1133–1136.
33. Addy M, Langeroudi M (1984) Comparison of the immediate effects on the sub-gingival microflora of acrylic strips containing 40% chlorhexidine, metronidazole or tetracycline. Journal of Clinical Periodontology 11: 379–386.
34. Addy M, Hassan H, Moran J, Wade W, Newcombe R (1988) Use of Antimicrobial Containing Acrylic Strips in the Treatment of Chronic Periodontal Disease. Journal of Periodontology 59: 557–564.
35. Noguchi T, Izumizawa K, Fukuda M, Kitamura S, Suzuki Y, Ikura H (1984) New method for local drug delivery using resorbable base material in periodontal therapy. The Bulletin of Tokyo Medical and Dental University 31: 145–153.
36. Taner IL, Özcan G, Doganay T, Iscanolu M, Taplamacioglu B, Gültekin SE, Balos K (1994) Comparison of the Antibacterial Effects on Subgingival Microflora of Two Different Resorbable Base Materials Containing Doxycycline. The Journal of Nihon University School of Dentistry 36: 183–190.
37. Higashi K, Morisaki K, Hayashi S, Kitamura M, Fujimoto N, Kimura S, Okada H (1990) Local ofloxacin delivery using a controlled-release insert (PT-01) in the human periodontal pocket. Journal of periodontal research 25: 1–5.
38. Kimura S, Toda H, Shimabukuro Y, Kitamura M, Fujimoto N, Miki Y, Okada H (1991) Topical chemotherapy in human periodontitis using a new controlled-release insert containing ofloxacin. I. Microbiological observation. Journal of Periodontal Research 26: 33–41.
39. Deasy PB, Collins AE, MacCarthy DJ, Russell RJ (1989) Use of strips containing tetracycline hydrochloride or metronidazole for the treatment of advanced periodontal disease. The Journal of pharmacy and pharmacology 41: 694–699.
40. Maze GI, Reinhardt RA, Agarwal RK, Dyer JK, Robinson DH, DuBois LM, Maze CR (1995). Response to intracrevicular controlled delivery of 25% tetracycline from poly(lactide/glycolide) film strips in SPT patients. Journal of clinical periodontology 22: 860–867.
41. Paolantonio M, D’Ercole S, Pilloni A, D’Archivio D, Lisanti L, Graziani F, Perinetti G (2009) Clinical, Microbiologic, and Biochemical Effects of Subgingival Administration of a Xanthan-Based Chlorhexidine Gel in the Treatment of Periodontitis: A Randomized Multicenter Trial. Journal of Periodontology 80: 1479–1492.
42. Friedman M, Golomb G (1982) New sustained release dosage form of chlorhexidine for dental use. I. Development and kinetics of release. Journal of periodontal research 17: 323–328.
43. Jones MN, Kaszuba M (1994) Polyhydroxy-mediated interactions between liposomes and bacterial biofilms. Biochimica et Biophysica Acta (BBA) – Biomembranes 1193: 48–54.
44. Jones MN, Song YH, Kaszuba M, Reboiras MD (1997) The Interaction of Phospholipid Liposomes with Bacteria and Their Use in the Delivery of Bactericides. Journal of Drug Targeting 5: 25–34.
45. Esposito E, Cortesi R, Cervellati F, Menegatti E, Nastruzzi C (1997) Biodegradable microparticles for sustained delivery of tetracycline to the periodontal pocket: formulatory and drug release studies. Journal of Microencapsulation 14: 175–187.
46. Piñón-Segundo E, Ganem-Quintanar A, Alonso-Pérez V, Quintanar-Guerrero D (2005) Preparation and characterization of triclosan nanoparticles for periodontal treatment. International Journal of Pharmaceutics 294: 217–232.
47. Dung TH, Lee SR, Han SD, Kim SJ, Ju YM, Kim MS, Yoo H (2007) Chitosan-TPP nanoparticle as a release system of antisense oligonucleotide in the oral environment. Journal of nanoscience and nanotechnology 7: 3695–3699.
48. Kaplish V, Walia MK, Kumar SLH (2013) Local Drug Delivery Systems in the Treatment of Peridontitis: A Review. Pharmacophore 4: 39–49.
49. Ahmad F, Iqbal Z, Jain N, Jain G, Talegaonkar S, Ahuja A, Khar R (2008) Dental Therapeutic Systems. Recent Patents on Drug Delivery & Formulation 2: 58–67.

DOI: 10.31038/JDMR.2019232

Abstract

Objective: To explore the role of parental education and communication of risks versus benefits of pediatric dental image on parents’ knowledge, comfort and confidence in allowing their children to receive the necessary imaging procedures.

Methods: Parents of children <18 years of age were recruited during routine dental visits at the Boston University Pediatric Oral Health Care Center and Department of Dentistry at the Boston Medical Center, Boston, Massachusetts. Participants completed two brief questionnaires immediately before and after the educational intervention. A brief two-sided printed informational handout and a mobile application called Medical Imaging Risk (MIR) were used in the educational intervention for parental health education and communication of information on radiation risks. Statistical analysis was conducted using STATA version 14.0 to compare pre-intervention and post-intervention responses of participants.

Results: Among 213 parents, the majorities were mothers (83%), African American (55%), with MassHealth insurance (82%) and reported that their child/children have had previous dental radiographs (75%). A significant improvement in confidence of their knowledge on benefits and risks of dental imaging was observed following the educational intervention (p<0.001). Parents’ level of comfort in allowing the use of dental radiographs for their children significantly improved after the educational intervention (p<0.001). Parents preferred the printed handout (53%) only slightly more than the mobile application (47%).

Conclusion: The results from our study suggest that a simple brief educational intervention that includes easy to understand materials can significantly improve parental level of knowledge and confidence towards pediatric dental imaging. Thus dental practitioners should aim to include risk-benefit dialogues as part of the routine dental care visit to improve communication and acceptance of pediatric imaging.

Keywords

Health Communication, Pediatric Dentistry, Children, Radiation Imaging, Radiation Risks, Dental Imaging, Dental Radiography, Parental Knowledge, Educational Intervention.

Introduction

Patient communication of health information is a key component of patient care and management. In particular, communicating risks and benefits of medical and dental procedures enables better understanding and decreases the level of anxiety among patients. Radiation imaging has been known to cause fear and anxiety among patients due to the general perception of radiation as a ‘hazard’ [1]. This fear, caused mainly by incomplete understanding of the benefits versus risks of radiation imaging, has been further fueled by historical radiation related disasters, media reports, social media, previous experience, experiences or shared by family and friends. Recent evidence in the literature also suggests that significant gaps exist between patient expectations and provider communication of benefits versus risks of medical imaging [2]. These gaps also extend to dental imaging procedures which can be overcome through improved risk-benefit dialogues between practitioners and children, and their parents or guardians. To improve the current practices in risk communication strategies the World Health Organization (WHO) organized an International Workshop on Radiation Risk Communication in Pediatric Imaging in September of 2010 and in collaboration with a working group released a publication titled “Communicating Radiation Risks in Paediatric Imaging” [3]. This publication was developed to aid health professionals on communication of radiation risks in pediatric imaging more efficiently and to provide guidance on risk-benefit dialogues with children and their parents.

Dental radiology has evolved over the years and is currently being used widely in children for diagnosis and management. In pediatric dentistry in particular, dental imaging has played an important role in a child’s first visit to the dentist as it is not only a vital part in a thorough examination of the oral cavity but is a simple procedure that is used to also gain the child’s confidence [4]. While radiation emission from dental imaging is lower than from medical imaging procedures, dental practitioners should weigh the benefit and need for the imaging procedure among children over the risks involved to make a clinical judgement keeping in mind the interest of each patient. In recent years there has been a significant increase in the use of dental radiography in the United States (US) with over 500 million intra-oral bitewing and panoramic radiographic procedures [5]. Also, the number of Cone Beam Computed Tomography (CBCT) procedures have also significantly increased over the years. As a result, the overall contribution of radiation exposure from dental imaging procedures is increasing and is about 50% of the annual per capital radiation dose in the US [6]. In light of these increases the American Dental Association (ADA) in collaboration with 80 other health care organizations developed a program called ‘Image Gently’ in 2007 which is an initiative to raise awareness and educate practitioners to provide safe pediatric imaging [7]. This alliance was also developed to educate providers on selecting imaging procedures based on individual needs and to limit the exposure time among children. The ‘Image Gently in Dentistry’ campaign was specifically launched to promote responsible use of dental radiography and to improve radiation safety in pediatric dental imaging [6]. The main goals of this campaign is based on the concept of reducing radiation exposure in children As Low As Diagnostically Acceptable (ALADA) while achieving effective images that aid in diagnosis.

Radiation exposure is the amount of radiation charge produced by ionizing radiation during imaging procedures whereas absorbed dose describes the amount of emitted radiation absorbed at a point [8]. This absorbed dose is converted to equivalent dose by multiplying the radiation delivered for each type of radiation. Effective dose is the total amount of radiation exposure estimated from the total equivalent dosages and [3] can be expressed in Sieverts (Sv) based on the System International nomenclature [3]. The radiation dose emitted in diagnostic imaging is expressed as milliSieverts (mSv) [9]. When comparing the radiation exposure between medical imaging procedures versus dental imaging, the exposure from dental radiographs are much lower. For example, the radiation dose from a set of four intra-oral bite-wing radiographs is 0.005 mSv and from a single panoramic radiograph is 0.01 mSv which is equivalent to <1 day and 1.5 days of exposure to natural radiation respectively [3,8]. In comparison, the radiation exposure from a chest x-ray for a 5 year old child is 0.02 mSv which is equivalent to 3 days of natural radiation exposure. A Computed Tomography (CT) scan to the head of a 5 year old emits 2 mSv radiation and is equivalent to 10 months of natural radiation exposure whereas one CBCT procedure leads to radiation exposure of 0.107 mSv which is less than five months of natural radiation exposure, demonstrating that dental imaging procedures lead to much lower radiation exposure. The risks from exposure resulting from all types of diagnostic imaging and its effects are not completely understood [3]. Effects such as cell death, hair loss, skin redness etc. occur at much higher doses of exposure than the exposure from dental diagnostic imaging. Long-term risk of developing cancer has been suggested based on some epidemiologic evidence for radiation doses of 50–100 mSv which would be the accumulated dose after multiple CT scans. However, since children have a long period of life ahead, the low dose exposures from diagnostic imaging in the early years of life may accrue and eventually may lead to a small increase in lifetime risk of cancer in the future. Hence given the lack of strong evidence and the uncertainty it is important for dental practitioners to take a precautionary approach when using pediatric imaging. Also, by improving patient and parent-provider communication about risks versus benefits, informed decisions can be made that will ultimately benefit the child patients.

There are only a few studies that explored the perspectives of parents and communication of radiation risks most of which are related to medical imaging procedures. Limited evidence exists on communication of dental radiation risks and parents’ knowledge and perception towards dental radiography. A study in Australia explored parental level of knowledge and attitude towards dental radiography for children [10]. That study analyzed 309 surveys completed by parents and the results showed a low level of knowledge but positive attitude towards dental radiographs. Also in that study, parents’ level of education and parents with children who have had radiographs previously were more likely to have a higher level of knowledge. In the same study when participants were asked about whether they received information on radiation risks, <40% reported that they had been informed of the risks by their providers. Similar findings have been reported in studies on medical imaging where participants have low level of knowledge and report that they did not receive the information on the risks of medical imaging [11,12]. A more recent study evaluated patients’ perception on dental radiographs in Malaysia and reported a significant lack of knowledge about the role of dental radiographs. In that study among the participants 57% believed that dental radiographs should be avoided in pregnant women and 32% believed that dental radiographs should be avoided in children [13]. Studies on communicating risks clearly highlight the gaps in provider-patient or parent communication. Evidence also suggests that parents who did receive information prior to imaging procedures report lower levels of anxiety during the procedures [11]. Insufficient data is available on the preferred method of communication in dental imaging risks versus benefits. One study in Spain among 602 participants reported that participants preferred both oral and written forms of communication with no significant preference of one over the other [14]. With the current technological advances there is an increase in usage of other modes of communication such as online resources, phone applications and text messaging however there is a lack of epidemiological data that supports the use of these methods and there is insufficient evidence on the most effective form of communication of health information.

Our study was developed to explore the role of parental education and communication of risks versus benefits of dental imaging on parents’ knowledge, comfort and confidence in allowing their children to receive the necessary dental imaging. Results from our pilot study has been published previously [15,16]. In this report we describe the study that was conducted and the results obtained from a larger sample with additional investigation on the preferred method of communication of risks versus benefits in comparison to our pilot study. Specifically our hypothesis was that a brief educational intervention by the dental provider will increase the level of confidence and comfort among parents and those parents prefer a specific mode of communication of health information.

Methods

Note: A description of the study methods and results from our pilot study was published previously [15,16].

The sample population in this study included parents or guardians of children under 18 years of age. The participants were recruited during routine dental care visits for their children at either the Pediatric Oral Health Care Center in Boston University Goldman School of Dental Medicine or Department of Pediatric Dentistry at the Boston Medical Center, Boston, Massachusetts. A convenience sampling method was used to recruit any one parent or legal guardian per family and only those who were proficient in the English language were included. Following verbal consent, the parents completed two brief questionnaires and an intervention using a handout and a mobile phone application was conducted as well by the study investigator. The parents completed the questionnaires and the intervention while waiting during their children’s dental treatment. The time taken for participants to complete the questionnaires and the educational intervention was between 15–20 minutes. This study was approved by the Boston University Medical Center Institutional Review Board.

Educational Intervention

The materials utilized for the educational component in this study included a short two-sided informational handout titled ‘Are dental radiographs safe for your children?’ (S1a and S1b Figures), and a mobile application called ‘Medical Imaging Risk (MIR)’ (S2 and S3 Figures). The informational handout used in this study was in English language, easy to read and the content was prepared at the 8th grade level as is the standard when preparing patient related text (S1a and S1b Figures). Colorful images, text and tables were used to educate parents on dental radiography and provide information on sources of radiation and their different dose estimations highlighting the radiation dose with routine dental radiographs. The handout while emphasizing the benefits and importance of dental radiography in early diagnosis and treatment also outlined the possible risks from unnecessary imaging procedures.

S1a Figure. Information on side 1 of the printed handout:

S1b Figure. Information on side 2 of the printed handout:

S1 Figure. Printed two-sided informational handout used in the educational intervention.

S2 Figure. Medical Imaging Risk (MIR) mobile application: Types of radiographic tests listed in the application.

S3 Figure. Medical Imaging Risk (MIR) mobile application: Types of dose equivalents for selected radiographic test by age.

Following the discussion using the informational handout, the mobile application (app), MIR was used to continue an interactive discussion on radiation imaging (S2 Figure). The use of the app was demonstrated, and participants were shown that this app can be easily downloaded for free on both the Android and Apple platforms. This user-friendly app provides information on the various dosages and risks by type of radiation imaging (S3 Figure). The app also provides additional resources for further detailed information that the participants can download for free.

Study Questionnaires

Two questionnaires, one immediately before (pre-intervention) and one immediately after (post-intervention) the educational intervention were used to obtain information on parents’ knowledge and perception towards pediatric imaging.

Pre-intervention questionnaire

In the pre-intervention questionnaire, which included 5 questions, parents responded if their child or children ever received dental imaging. Irrespective of their response to this question parents completed the remainder of the questionnaire. Parents responded to questions on the level of confidence in their knowledge on risks and benefits of radiation and were asked to choose from three options: Not confident, somewhat confident and very confident. To evaluate specific knowledge, parents were asked to respond to whether smartphones and electronic devices emitted harmful radiation to which they responded ‘yes’ or ‘no’. Participants also responded to their level of comfort in their child undergoing any type of radiation imaging by choosing from three options: Not comfortable, somewhat comfortable and very comfortable. Demographic information such as participants’ gender, race, ethnicity and insurance type were also obtained in the pre-intervention questionnaire to evaluate differences in parent responses.

Post-intervention questionnaire

The post-intervention questionnaire, which included 8 questions, included the same five questions that was in the pre-intervention questionnaire, to evaluate a change in perception or comfort if any as a result of the intervention. In addition, questions on whether the educational material discussed during the intervention improved their understanding about dental radiographs and if the participants continued to have concerns about them were also included and both of these questions generated a response of ‘yes’ versus ‘no’. One of the goals of the post-intervention questionnaire was also to explore the preferred method of communication when receiving health information during dental care visits and the participants chose between printed materials versus mobile application. This question was not included initially however it was added later during the study as our goal was also to collect data on the parent perspective related to the educational material. As a result not all of the participants responded to this question. The study application was amended with this additional question and IRB approval was obtained to make this change.

Statistical Analysis

Participants’ responses to the questionnaires, pre versus post intervention, were compared and analyzed using STATA version 14.0 statistical analysis software. Differences in knowledge and perception were also evaluated by demographic characteristics. Descriptive and univariate categorical data analysis was conducted to evaluate differences and p-values <0.05 were considered statistically significant.

Results

A total of 213 parents participated in this study, reflecting the population base of the Boston University Goldman School of Dental Medicine. The majority were mothers (82.6%), having Medicaid as their primary dental insurance (81.7%). Also, most of the participants were African Americans, 54.9% followed by 17.8%n White; 7.04% Asian; and 16.4% self-identified as Hispanic/Latino (S1 Table).

Most of the participants in this study (75%) reported that their child/children have had previous dental radiographs (S1 Table). When comparing participants’ level of confidence on their knowledge towards benefits of dental radiographs for their children, 74% of participants reported either not confident or somewhat confident in the pre-intervention questionnaire. This trend changed in the post-intervention period as an improvement in the level of confidence was evident with 65% of the participants reporting that they are very confident. This improvement in the level of confidence was statistically significant with p<0.001 (S1 Table). Similarly, when evaluating the confidence level on the knowledge of risks of dental radiographs for their children, 69% of participants were either not confident or somewhat confident in the pre-intervention questionnaire. However, this trend also changed in the post-intervention period where 58% reported being very confident with statistically significant results (p<0.001).

S1 Table. Characteristics of the study participants (N = 213).

In the pre-intervention, more than half the study population (59%) reported that they were either not comfortable or somewhat comfortable in allowing dental radiographs for their children (S2 Table). However following the educational intervention, in the post-intervention, a significant majority (66%) reported being very comfortable (p<0.001).

In the post-intervention analysis regarding the helpfulness of the educational materials, the great majority (94%) had a positive response (S4 Figure). Eighty two percent reported no concerns with dental radiographs after reviewing the materials during the educational intervention (S2 Table). When evaluating the preferred method of communication of health information, interestingly the responses were almost equally distributed. As mentioned previously, this question was initially not included in the post-intervention questionnaire and was added after our pilot exploration. Therefore, the complete sample population was not included in the comparison of preferred method of communication. Among 147 parents or caregivers 53% reported that they preferred the printed handout versus 47% reported that they preferred the mobile phone application (S5 Figure). No significant differences by gender, race/ethnicity and insurance type was observed as the majority of the participants in this study was women, African-American and had Medicaid insurance (S1 Table). Hence due to the lack of variability by demographic characteristics we did not observe statistically significant differences by these characteristics and were unable to explore potential confounding by these factors in multivariate analyses.

S4 Figure. Helpfulness of the educational materials in understanding of pediatric radiation imaging (post-intervention) N = 213.

S5 Figure. Preference for receiving health information (post-intervention) N= 147.

S2 Table. Evaluation of parental knowledge and attitudes of radiation imaging among pediatric caregivers at the Pediatric Oral Health Center (N = 213)

*Results from Pearson Chi-square analysis.
†Based on results from Fisher’s Exact analysis;
‡Post-intervention question

Discussion

Overall the results from our study indicate that a simple brief educational intervention in the dental office can not only improve parental the level of knowledge but can also increase their level of confidence and comfort thus enabling them to be more accepting and comfortable with radiation imaging procedures for their child/children. Our study also explored the preferred mode of communication among parents and we observed that the majority preferred the printed informational handout over the mobile application.

Communication of health risks and benefits is an important step towards better provider-patient relationship. Particularly in pediatric dentistry the level of anxiety among children and their parents are high due to mainly lack of knowledge among patients and parents, which may be as a result of failing to receive adequate information prior to dental procedures. While dental providers showed an acceptable level of knowledge on radiation risks, evidence from one study reported that the patients’ knowledge was inadequate [17]. Similar findings were reported in another study conducted in Australia where among 309 parents there was a low level of knowledge [18]. In our study, in the pre-intervention questionnaire, parents reported a lower level of confidence in knowledge of risks and benefits of radiation however this significantly improved in the post-intervention following the educational intervention and discussion using the mobile application. This was also observed in the previously mentioned study in Australia where the investigators reported that parents with higher level of education appeared to have not only higher knowledge of radiation risks but were more likely to accept radiation imaging as ‘safe’ and ‘beneficial’. A study in Malaysia among patients reported that insufficient knowledge was associated with higher level of disapproval of the use of dental imaging among children [13]. In our study in the post-intervention when parents were asked if they still had concerns and if they comfortable in allowing their children to undergo imaging procedures, the majority reported that they did not have concerns and that they were very comfortable.

The risk-benefit dialogue is an important component of patient care in the current practice of dentistry and can aid in lowering the level of fear anxiety towards radiation [3,19]. This dialogue should be designed based on individual patient needs. The providers should also keep in mind that each patient and family differ in terms of their social and cultural background, medical and dental history, and access to care, especially given the growing diversity of the demographics in the US [20]. The risk communication strategy should be developed keeping in mind the prominent role of the parents in clinical decision making of dental treatment for their children. Dental practitioners should be aware that parents’ risk perception is often influenced by social factors, personal belief systems, previous health experiences, socio-economic factors and level of education [20]. Therefore, when communicating health information it is vital that dental practitioners take these factors into account and communicate information to the parents and children in a way that is easy for them to comprehend. In our study as we did not collect information on level of education and socio-economic factors. We collected information on insurance type which can be a proxy for economic level however the majority of the participants in our study since the majority reported Medicaid as their insurance we were unable to evaluate differences by economic level of the participants. The demographic characteristics observed in our study are however reflective of the patient population at the Boston University’s Goldman School of Dental Medicine.

Our educational intervention used a brief two-sided printed informational handout and a mobile application. The informational handout included content in simple easy to understand 8^th grade level of English language as is the standard when preparing consent forms in English. The mobile application MIR, which was used in our study intervention was also simple user-friendly application. The preference for material used in health communication was distributed almost equally with slightly higher preference for the printed handout. This clearly points to the need to have various types of parental educational aids available in the dental clinic as individuals tend to have diverse learning styles and preferences. A recent study collected data on patient perspectives on how physicians should communicate information on radiation risks to patients and the results suggest that there was equal preference for both oral and written information [19]. Previous studies that used multi-media educational materials for dental procedures have reported successful improvement in knowledge [21,22]. Another study reported that text-messaging was more effective than printed pamphlets when educating mothers. These methods of communicating health information should also be considered for future long-term studies.

Graphic display and visually appealing text play an important role in enhancing health communication and improving knowledge [1]. Our educational handout with information on radiation risks and benefits was colorful with visual images and tables with clear breakdown of details on radiation dosages. As a result, the parents in our study may have preferred the printed handout a little more than the mobile application for the ease of information description and availability of the handout on hand. However, almost half the population preferred the mobile application MIR which may have been for those who prefer the portability and availability of information in their personal devices.

Limitations of our study include the short follow-up time following the intervention as the post-intervention questionnaire was handed out to the parents immediately after the intervention. Parents’ knowledge of risks and benefits may be higher as a result of this short follow-up time. Future studies should consider a longer follow-up period to evaluate long term retention of knowledge. Also, in our study while we described the availability of the mobile application MIR, there is no information about whether parents who preferred the use of the app downloaded the app and whether they continued to use it. Again, a study with longer follow-up period will be able to determine the frequency of use and the long-term benefits of the mobile application.

According to the policy statement published by the American Academy of Pediatrics (AAP), in the field of medical practice, key elements in improving physician-parent-child communications are  (adapted from Levetown MaCob 2008 AAP policy statement) [24]:

• Informativeness: Quantity and quality of health information provided by physicians.
• Interpersonal sensitivity: Behavior of the physician that reflects his or her attention to or interest in parents’ and child’ feelings or concerns.
• Partnership building: Extent to which the physician opens a dialogue that allows the parents or children to share their perspectives and suggestions.

These concepts can be applied in the field of dentistry as well to improve dentist-parent-child communications which in turn will improve the overall treatment and management thus resulting in improved oral and systemic health of the child. In our study we demonstrated that even a simple brief educational intervention during a child’s dental care visit can significantly improve the level of comfort and confidence among parents and caregivers. Future research can utilize our study model to design larger studies with longer follow-up and more detailed information on patient and parent background. This can lead to better understanding on parental and patient preferences and perspectives that will in turn help practitioners to design more effective health communication strategies.

Acknowledgement

The authors would like to acknowledge and thank the parents who participated in this study.

References

1. Dauer L, Thornton R, Hay J, Balter R, et al. (2011) Fears, feelings, and facts: Interactively communicating benefits and risks of medical radiation with patients. American Journal of Roentgenology 196: 756–61.
2. Thornton R, Dauer L, Shuk E, Bylund C, et al. (2015) Patient perspectives and preferences for communication of medical imaging risks in a cancer care setting. Radiology 275: 545–52.
3. WHO, World Health Organization (2015) Communicating radiation risks in paediatric imaging: Information to support healthcare discussions about benefit and risk. Geneva 2016.
4. Madan K, Baliga S, Thosar N, Rathi N (2015) Recent advances in dental radiography for pediatric patients. Journal of Medicine, Radiology, Pathology & Surgery 1: 21–5.
5. Linton O, Mettler Jr. F (2003) National council on radiation protection and measurements. In National conference on dose reduction in CT, with an emphasis on pediatric patients. American Journal of Roentgenology 181: 321–9.
6. White S, Scarfe W, Schulze R, Lurie A, et al. (2014) The Image Gently in Dentistry Campaign: promotion of responsible use of maxillofacial radiology in dentistry for children. Journal of Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 118: 257–61.
7. ADA, American Dental Association: Image Gently Alliance. [Internet]. 2007 [cited August 26, 2019]. Available from: https://www.imagegently.org/About-Us/The-Alliance.
8. Aanenson J, Till J, Grogan H (2018) Understanding and communicating radiation dose and risk from cone beam computed tomography in dentistry. The Journal of Prosthetic Dentistry 120: 353–60.
9. Brody A, Frush D, Huda W, Brent R (2007) Radiation risk to children from computed tomography. Pediatrics 120: 677–82.
10. Chiri R, Awan S, Archibald S, Abbott P (2013) Parental knowledge and attitudes towards dental radiography for children. Australian Dental Journal 58: 163–9.
11. Lee C, Haims A, Monico E, Brink J, Forman H (2004) Assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 231: 393–8.
12. Ludwig R, Turner L (2002) Effective patient education in medical imaging: public perceptions of radiation exposure. Journal of Allied Health 31: 159–64.
13. Purmal K, Alam M, Nambiar P (2013) Patients’ perception on dental radiographs. International Medical Journal 20: 235–8.
14. Friedberg W, Copeland K, Duke F, O’Brien III K, Darden Jr. E (2000) Radiation exposure during air travel: guidance provided by the Federal Aviation Administration for air carrier crews. Health Physics 79: 591–5.
15. Hwang H. Knowledge, attitude and perception on radiation imaging among children’s caregivers in pediatric dental clinic.: Boston University; 2017.
16. Zavras J, Hwang H, Murray G, Zletni A, Shanmugham J (2018) Educational intervention to increase parental knowledge and acceptance of pediatric imaging. Journal of Pediatrics and Neonatal Care 8: 1–7.
17. Aravind B, Joy E, Kiran M, Shrubin J, et al. Attitude and awareness of general dental practitioners toward radiation hazards and safety. Journal of Pharmacy and Bioallied Sciences. 2016;8(1):553–8.
18. Chiri R, Awan S, Archibald S, Abbott P (2013) Parental knowledge and attitudes towards dental radiography for children. Australian Dental Journal 58: 163–9.
19. Lumbreras B, Vilar J, Gonzalez-Alvarez I, Guilabert M, et al. (2017) Avoiding fears and promoting shared decision-making: How should physicians inform patients about radiation exposure from imaging tests? PLoS One 12: 1–14.
20. Garcia R, Cadoret C, Henshaw M (2008) Multicultural issues in oral health. Dental Clinics of North America 52.
21. Pei D, Liang B, Du W, Wang P, et al. (2017) Multimedia patient education to assist oral impression taking during dental treatment: A pilot study. International Journal of Medical Informatics 102: 150–5.
22. Kazancioglu H-O, Dahhan A-S, Acar A-H (2017) How could multimedia information about dental implant surgery effects patients’ anxiety level? Medicina Oral, Patologia Oral y Cirugia Bucal 22: 102–7.
23. Sharma R, Hebbal M, Ankola A, Murugabupathy V (2011) Mobile phone text messaging (SMS) for providing oral health education to mothers of preschool children in Belgaum city. Journal of Telemedicine and Telecare 17: 432–6.
24. Levetown MaCoB (2008) Communicating with children and families: From everyday interactions to skill in conveying distressing information. American Association of Pediatrics 2008.