Clinical Significance.—Coronectomies arevalid surgical alternatives for patients age 40years and over who need treatment of thirdmolars. These older patients are at higherrisk for neurologic deficits than younger pa-tients. If a CBCT indicates that the third molarand the IAN are in direct relationship, a skilledsurgeon can perform the coronectomy safelyand reduce postoperative complications.Longer-term follow-up is needed to verify theseinitial findings.

Patients completed a questionnaire and filled in an esti-mate of the degree and intensity of pain using a visual ana-log scale (VAS). Pain was measured immediately aftersurgery, 6 h after surgery, and twice a day (morning andevening) for the next 6 days. The surgeon reported casesof alveolitis noted during suture removal or follow-up visitsat 3, 6, and 12 months after surgery. Patients rinsed twicea day with 0.2% chlorhexidine for 10 days.

Periapical radiographs were obtained immediately afterthe coronectomy and 3, 6, and 12months later. Panoramic ra-diographs were obtained after 12 months and compared tothe preoperative films. Panoramic radiographs were obtainedif the patient could not undergo periapical films at 3, 6, or 12months. Periodontal probing depth (PPD) distal to the sec-ond molar was measured after 3, 6, and 12 months to assessthe effect of the coronectomy inpromoting pocket reduction.

Results.—There were no neurologic deficits involvingthe IAN or LN, nor did any of the coronectomies fail becauseof root mobilization during the surgical procedure. Time re-quired for surgery was 30-90 min, but there was no correla-tion between time required and postoperative pain. Onecoronectomy patient had a VAS score of 4 or greater threetimes during the first week after surgery. For 53% of thecases, the anti-inflammatory agent remained the same, for30% it was decreased, and for 16% it was increased. One pa-tient had intermittent pain and required a second operationto remove root fragments 10months after the coronectomy.This also was unaccompanied by any neurologic injuries. Al-veolitis was found in connection with only one coronec-tomy and developed 15 days after surgery.

Root migration was more common within the first 3months of surgery and was significantly reduced after 6and 12 months. Bone formation coronal to the root frag-ments inhibited root movement in the coronal direction af-ter 6 and 12 months. In nearly all cases, root migrationdetermined the bone regeneration of the bony defect distalto the second molar in a manner similar to that with ortho-dontically assisted extrusion. Persons who had root

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migration after 3 months were significantly younger thanthose who had no root migration.

Bleeding on probing (BOP) and PPD analysis showedthat 22% of the patients with coronectomies had increasedPPD and BOP after 3months and 13% had increases in thesemeasures after 6 months. PPD and root migration were notsignificantly associated after 3, 6, or 12 months.

Discussion.—Coronectomies are safer to perform thancomplete extractions when the third molar is close to theIAN. Usually root migration is asymptomatic. Patients’ peri-odontal healing is improved because of bone formation in-duced by root migration, which determines boneapposition distal to the second molar, similar to what oc-curs with orthodontic-assisted extraction.

Monaco G, de Santis G, Gatto MRA, et al: Coronectomy: a surgicaloption for impacted third molars in close proximity to the inferioralveolar nerve. J Am Dent Assoc 143:363-369, 2012

Reprints available from G Monaco, Dept of Oral and Dental Science,Univ of Bologna, Via San Vitale 59, 40125 Bologna, Italy; e-mail:studioarno@libero.it

Oral Systemic Health

Diabetes screening

Background.—With increasing numbers of older pa-tients who are retaining more of their natural teeth thereis the potential for higher numbers of patients with root car-ies. Prevention is the best way of managing root caries, sincerestoration can be challenging. Identifying patients at risk isessential to an effective prevention effort, but root caries

risk assessment can be complicated by complex chronicmedical diseases and especially by undiagnosed diabetesmellitus. As many as half of all patients with type 2 diabetesare undiagnosed, yet their disease can have adverse effectson both their oral and their systemic health. Diabetes couldbe screened for in the dental setting using a standard

Fig 3.—Collection of gingival crevicular blood using a test strip.(Courtesy of Garton BJ, Ford PJ: Root caries and diabetes: Riskassessing to improve oral and systemic health outcomes. AustralDent J 57:114-122, 2012.)

Fig 4.—Blood glucosemonitor with used test strip loaded and dig-ital display showing reading in mmol/L. (Courtesy of Garton BJ,Ford PJ: Root caries and diabetes: Risk assessing to improve oraland systemic health outcomes. Austral Dent J 57:114-122, 2012.)

glucometer to analyze gingival crevicular secretions for glu-cose concentration as part of the routine dental examina-tion. By enhancing their risk assessment for both rootcaries and diabetes, the dental team could assist patientsto achieve better oral and systemic health outcomes.

Root Caries.—Root caries is expressed as a soft, pro-gressive lesion located on the tooth root surface lackingits connective tissue attachment. This exposes the toothto the oral cavity. Lesions can be found at the cementoena-mel junction (CEJ), entirely on the root surface, spreadingto undermine adjacent enamel, or recurring at a restorativemargin. Most are found in proximal supragingival siteswithin 2 mm of the CEJ but they can occur subgingivally.Treated early in the process, the dentin can remineralizewithout surgical intervention.

Diabetes.—Diabetes manifests in two types. Type 1 isinsulin-dependent diabetes mellitus and is caused by insu-lin deficiency usually mediated by autoimmune destruc-tion of the insulin-secreting beta cells of the pancreas.Type 2 is acquired and characterized by chronic hypergly-cemia as a result of defective insulin secretion, insulinaction, or both. In prediabetes the patient has elevatedblood glucose levels but does not meet the criteria for di-agnosing diabetes. Both genetic and environmental factorsinfluence the risk for type 2 diabetes. Nonmodifiable riskfactors include age, ethnicity, and family history. The mostimportant modifiable risk factor is obesity. Persons in lowsocioeconomic groups and those living in remotelocations have a higher incidence of disease than the gen-eral population.

Connections.—Diabetic patients are at higher risk fororal complications, including coronal caries, root caries,candidiasis, erosion, xerostomia, and periodontal disease.

Periodontal disease can also affect the diabetic condition.Patients with diabetes and severe periodontal diseasehave a three-fold increased risk of mortality from ischemicheart disease compared to those who have diabetes butless severe periodontal disease. End-stage renal disease inthese patients is also more likely when periodontitis is pres-ent. In addition, obesity is associated with more adipose tis-sue, which is the source of inflammatory mediators. Higherlevels of systemic inflammation can induce insulin resis-tance and lead to diabetes.

Diabetes Screening in Dental Settings.—The finger-tip blood sample is the currently accepted standard sam-ple for assessing blood glucose levels. However, samplesof gingival crevicular blood (GCB) offer a comparable al-ternative. GCB testing can occur as part of the regularexamination process during periodontal assessment. Theextremely small volume of sample needed means nearlyall patients will have some suitable sites for collecting gin-gival blood.

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A trial performed in a public dental clinic used a bloodglucose monitor to screen for diabetes. The monitor waseasy to set up. A small cardboard test strip was loadedinto the barrier-wrapped monitor just before use duringthe periodontal assessment. Anterior sites with a periodon-tal probing depth of at least 3 mm were preferred and pro-vided suitable GCB volume. The site was selected, the areawas gently cleared of plaque and debris, then it was rinsed,dried, and reprobed to ensure an uncontaminated sample.The loaded test strip was brought into contact with theGCB, avoiding contact with the tooth or gingival tissue(Fig 3). The sample was collected and processed within 5s (Fig 4). The monitor was then set aside and the periodon-tal assessment completed. Participants were satisfied withthe screening procedure and weremore interested in learn-ing about diabetes and its importance to oral health.

13

Clinical Significance.—The ability to screenfordiabetes inadentalsettingappears tobeasim-ply and seemingly cost-effective measure thatshould be well-received by patients. Appropriate

4 Dental Abstracts

follow-up with patients who have increasedblood glucose levels could be included with den-tal appointment reminders. This could also serveas a check on diabetes diagnostic testing out-comes. The screening should be accompaniedby health education for the patient so he or shebecomes more aware of the link between oraland systemichealth. A cost-effectiveness analysisshould be conducted along with an investigationinto the efficacy of the GCB glucose screeningmodel and patient and provider satisfactionlevels with the process.

Garton BJ, Ford PJ: Root caries and diabetes: Risk assessing toimprove oral and systemic health outcomes. Austral Dent J57:114-122, 2012

Reprints available from P Ford, School of Dentistry, The Univ ofQueensland, 200 Turbot St, Brisbane, QLD 4000, Australia; e-mail:p.ford@uq.edu.au

OrthodonticsRetention

Background.—After orthodontic treatment, teeth tendto return to their initial position, so a retention phase is anintegral part of orthodontic treatment. Factors that contrib-ute to relapse of position include periodontal causes (bone,periodontal ligament, and gingival fibers remodeling), ac-tive growth after treatment, habits that exert forces for 6-8 h a day or more, and normal maturation and decreasein arch perimeter (adjustments). As a result, arch lengthand intercanine distance decrease and mandibular crowd-ing increases. The timing and extent of relapse cannot bedetermined individually, nor are there pretreatment vari-ables that predict relapse. Despite this known situation,few research data provide a foundation for the clinical basisof retention.

Types of Retainers.—Fixed or bonded retainers can bemade of thick or multistranded wire. Thick wire is bondedto two or three teeth, whereas multistranded wire isbonded to three or more teeth (Fig 1).

Removable retainers include acrylic/wire types, clearthermoplastic types, and other designs. The acrylic/wire(Hawley) retainers are rigid but adjustable and permit the

occlusion to settle somewhat. However, they are not as es-thetic as other options. The clear thermoplastic retainersoffer good esthetics and can be readily fabricated. However,their occlusal coverage does not permit settling. Positionersand silicone-based retainers are also used.

Evidence-Based Use of Retainers.—The principalconcerns associated with retention are efficacy, meaningthe retainer actually maintains orthodontic correction;breakage and repairs with fixed retainers; and long-termeffects in terms of periodontal, gingival, and dental param-eters with respect to adjacent teeth. Fixed retainers arebonded to incisors and can retain tooth alignment.Canine-only bonded retainers maintain orthodontic align-ment for most patients, but incisor irregularity can de-velop in some cases. Removable retainers are only aseffective as patient compliance permits. Most patientscomply with retainer wear less and less over time, withfewer than half of patients wearing retainers as directed2 years after completing orthodontic treatment. However,among removable retainers, clear thermoplastic retainersare associated with better patient satisfaction and compli-ance than are acrylic/wire-type retainers. In addition,