DOI: 10.3897/folmed.68.e173421

Authors: Pravallika Kakada, Monal Yuwanati

Abstract: Introduction: Monosodium glutamate (MSG) is extensively used in processed foods to enhance umami flavor, and its lingering presence in the oral cavity may influence salivary composition and microbial activity. Materials and methods: This pilot cross-sectional observational study was conducted at the Dental Institute, between March 2025 and April 2025. Twenty healthy participants aged 18–35 years were recruited using convenience random sampling. Unstimulated whole saliva samples were collected under standardized conditions, and salivary monosodium glutamate levels were quantified using a derivatization-based high-performance liquid chromatography (HPLC) method. Dental caries experience was assessed clinically using the Decayed, Missing, and Filled Teeth (DMFT) index and caries index (CI). Associations were explored using non-parametric correlation analysis and exploratory logistic regression. Results: Participants with higher DMFT scores showed higher salivary MSG concentrations. Salivary MSG levels showed a significant positive association with dental caries (ρ=0.62, p<0.01). Logistic regression analysis indicated that higher MSG levels were associated with increased odds of belonging to the higher caries experience group (OR=1.05, p=0.03). Conclusion: Salivary MSG concentration demonstrated an association with dental caries development. Future larger and longitudinal studies are warranted to ascertain the role of salivary MSG as a non-invasive indicator of caries risk.

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DOI: 10.3897/folmed.68.e177275

Authors: Nedana E. Georgieva

Abstract: Prevention of occlusal caries has been a longstanding challenge in dentistry, evolving appropriately from invasive mechanical techniques toward increasingly adhesive and bioactive strategies. Early attempts, such as the application of silver nitrate and preventive restorations, were limited by questionable efficacy and unnecessary removal of sound tooth structure. The advent of adhesive dentistry and the acid-etching technique enabled the development of resin-based sealants, providing a minimally invasive and effective method for fissure protection. Over time, sealant materials have evolved through four generations, introducing improved polymerization mechanisms, fillers, and fluoride release to enhance wear resistance, retention, and antibacterial properties. However, conventional glass ionomer cements (GICs) demonstrate lower mechanical strength and retention compared to resin-based sealants. Subsequently, resin-modified GICs were developed to address these shortcomings while maintaining fluoride release. More recently, hybrid materials such as compomers and giomers have combined the advantages of composites and GICs, offering improved adhesion, esthetics, and release of bioactive ions—although their fluoride release remains lower than that of conventional GICs. Overall, the evolution of pit and fissure sealants reflects a transition from invasive preventive approaches to minimally invasive, bioactive, and fluoride-releasing materials.

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DOI: 10.3897/folmed.68.e162497

Authors: Manu Rathee, Mathiyazhagan Stalin, Sarthak Singh Tomar, Divakar Santhanam, Senthilvelpalani Balavignesh, Nang Nalika Moungkhom

Abstract: The integration of digital technologies in removable prosthodontics has significantly enhanced the precision, efficiency, and predictability of cast partial denture (CPD) fabrication. Conventional methods, often involving multiple manual steps, are prone to inaccuracies and technical errors that may compromise the prosthesis fit, patient comfort, and long-term clinical success. The advent of computer-aided design and computer-aided manufacturing (CAD/CAM), along with direct metal laser sintering (DMLS), has enabled the fabrication of high-precision frameworks and extracoronal precision attachments with improved biomechanical and esthetic outcomes. This case report presents the digital rehabilitation of a partially edentulous maxillary arch classified as Kennedy Class II Modification 2, utilizing a CAD/CAM-designed and DMLS-fabricated cast partial denture. The digital workflow encompassed intraoral scanning, virtual framework design, and additive manufacturing of the prosthesis with integrated precision attachments. Clinical outcomes demonstrated enhanced accuracy of fit, improved retention, and increased patient satisfaction, with a reduction in chairside adjustments. This report highlights the transformative impact of digital technologies on enhancing clinical standards and fostering personalized, patient-centered care in removable prosthodontics.

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DOI: 10.3897/folmed.68.e177266

Authors: Aleksandar V. Naydenov, Todor T. Uzunov, Georgi Kostadinov

Abstract: Aim: To investigate the relationship between the angles describing the emergence profile of an implant crown and the metric data used to validate the digital design modeled via a 3D GAN. Materials and methods: Twenty crowns were generated for the study using 3D GAN. Their validation metrics, including IoU (intersection over union), F1 score, precision, and recall, were recorded. The initial voxelized files were processed with MeshMixer software, followed by the registration of longitudinal cuts using ExoCad software. CorelDRAW was used for outlining. Three angles were then measured for each examined surface—the mucosal emergence angle (MEA), the deep emergence angle (DA), and the total contour angle (CA)—resulting in a total of 240 measured angles. Results: The mean values of the angles were MEA=27.79°, DA=56.70°, and CA=43.54°, with maximum values of 68.78°, 93.55°, and 83.01°, and minimum values of 0.01°, 27.51°, and 12.35°, respectively. The overall median IoU was 0.835, while the median precision, recall, and F1 score were 0.946, 0.942, and 0.91, respectively, across the 20 teeth. Conclusion: The validation of AI must evolve to include clinical parameters beyond digital metrics. Visual parameters used to validate the design of implant crowns are not universal but rather supplementary measures for assessing the real clinical value of newly generated crowns. The present findings indicate that even in cases where the IoU, precision, recall, and F1 scores are not perfect (<1), clinically significant parameters such as MEA can still demonstrate an excellent mean value (27.79°), which is a predictive factor for peri-implant tissue health.

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DOI: 10.3897/folmed.68.e169836

Authors: Sonakshi Sharma, Amol Patil, Shruti Biyani, Shivangini Swarnkar, Meydha Gera

Abstract: Aim: Functional mandibular advancement appliances are widely used in orthodontics, but their molecular and histological effects on masticatory muscles remain underexplored. This study evaluated gene expression and tissue-level adaptations in response to mandibular advancement and a subsequent recovery period in young male Wistar rats. Materials and methods: Thirty rats were randomly assigned to three groups: control (Group A), functional mandibular advancement for four weeks (Group B), and functional mandibular advancement followed by a one-month recovery period (Group C). The expression of myostatin and myosin-1c genes was determined using quantitative real-time reverse transcription polymerase chain reaction. Histological analyses were performed to examine muscle fiber morphology in the masseter and lateral pterygoid muscles. Results: Mandibular advancement produced a significant downregulation of myostatin and upregulation of myosin-1c (p<0.05), most prominent in the lateral pterygoid muscle. Histological evaluation revealed hypertrophic changes in muscle fibers consistent with increased mechanical loading. After the recovery phase, altered gene expression and hypertrophic features persisted partially, indicating sustained molecular and structural adaptations. The masseter and lateral pterygoid muscles exhibited distinct, muscle-specific responses at both the genetic and histological levels. Conclusion: Mandibular advancement induces molecular and histological adaptations in masticatory muscles, with partial persistence following a one-month recovery period. These results suggest the potential for long-term functional and morphological changes after orthodontic intervention and provide biological evidence to inform personalized treatment and retention strategies in growing individuals.

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DOI: 10.3897/folmed.68.e152126

Authors: Varvara-Velika G. Rogova, Desislava A. Konstantinova, Tihomir D. Georgiev

Abstract: Abstract Dentoalveolar trauma is a common cause of tooth loss, especially in the anterior region of the maxilla. The restoration of teeth in this area is invariably challenging due to aesthetic considerations. A variety of treatment modalities are available for clinicians to select from. These include tooth-supported solutions, such as fixed (dental bridges) or removable (partial dentures) prosthodontics, as well as implant-supported restorations. Implant dentistry is an evolving field with expanding indications. The case under consideration is that of head trauma, accompanied by injuries to the soft intra- and extraoral tissues, as well as fractures to teeth #11, #12, and #13. The patient underwent a surgical procedure involving the immediate placement of two implants, accompanied by simultaneous guided bone regeneration. A provisional removable partial denture was fabricated. The placement of the implants occurred six months prior to the subsequent extraction of the teeth. The dentition was subsequently restored with an implant-supported metal-ceramic bridge.

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DOI: 10.3897/folmed.68.e147880

Authors: Prema Anbarasu, Saravana Kumar Subramanian, M. Gokilla Priya, Dhanush Sakthivel, Harini Saravanan, R. Pravin

Abstract: This case report emphasizes the role of a customized chin cup in the management of Class III malocclusion in pediatric patients, emphasizing its contribution to improved compliance and treatment outcomes. Class III malocclusion, often characterized by maxillary retrusion and mandibular prognathism, presents unique challenges in orthodontics, particularly in young patients. Reverse pull facemask therapy is a well-established method to correct maxillary retrusion, but the success of this approach heavily depends on patient compliance. Prefabricated chin cups, commonly used in facemasks, frequently lead to discomfort and irritation, negatively affecting adherence. In this report, we present a simple, cost-effective technique to customize chin cups using polyvinyl siloxane (PVS) for enhanced comfort, stability, and compliance. By improving the fit of the chin cup, this method addresses a critical barrier to successful Class III treatment in pediatric cases.

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DOI: 10.3897/folmed.68.e161534

Authors: Iurii Mochalov, Marina Kryvtsova, Serhii Tsuperiak, Bogdan Mykhailychenko, Nutsu Guzo, Alla Kizim

Abstract: Introduction: Lateral sinus lift is a common procedure in the field of dentistry, employed for the purpose of preparing the maxilla for subsequent dental implantation. This procedure is associated with a significant risk of intra- and postoperative complications, largely attributable to the presence of pathogenic microorganisms within the oral cavity and maxillary sinus. Aim: The aim of the present study was to determine the species composition of the microorganisms (pathogenic and opportunistic) in four biotopes in the maxillofacial region (Schneiderian membrane, pharynx, nasal passage, and oral mucosa) during a planned sinus lift and detect their sensitivity to antibiotics. Materials and methods: Biological material (swabs) was examined bacteriologically by cultivating it on standard and differential diagnostic nutritional media; antibiotic sensitivity of the isolated strains was assessed using the disk diffusion method. Results: The ambiguous picture of microorganism persistence in the various biotopes of the maxillofacial region was identified. , Pseudomonas aeruginosa, and Candida were detected in clinically significant amounts in the maxillary sinuses of healthy patients. Ceftriaxone and cefoperazone/sulbactam were the most effective antibiotics against microorganisms isolated in clinically significant concentrations across all biotopes. Cefuroxime was effective against 75% of all bacteria tested. Gatifloxacin was effective, with no cases of resistance reported. The fungi in the maxillary sinus mucoperiosteum were sensitive to fluconazole, ketoconazole, and clotrimazole, but only moderately sensitive to itraconazole and nystatin. Conclusion: The findings suggest that patients undergoing sinus lift surgery may have fewer options for prophylactic antibacterial therapy. Bacteriological studies on oral and nasal mucosa do not predict the presence of pathogenic microorganisms in the maxillary sinus.

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DOI: 10.3897/folmed.68.e157615

Authors: Anıl Özgün Karatekin, Ergün Yücel

Abstract: Finite element analysis (FEA) and photoelasticity are frequently utilized methods in biomechanical research to examine stress distribution within dental structures and materials. This review provides a comprehensive examination of the historical evolution, clinical applications, and comparative advantages of these methods and limitations of FEA with a particular emphasis on endodontic research. While photoelasticity offers intuitive, real-time visualization of stress patterns, it remains limited in analyzing complex three-dimensional (3D) structures. In contrast, FEA enables the simulation of complex 3D anatomical structures and multidirectional loading conditions through numerical computations, making it a powerful tool across various dental specialties. However, FEA presents significant limitations including unrealistic modeling assumptions, oversimplified anatomical geometries with insufficient representation of diversity and lack of material long-term material degradation models. The review proposes recommendations to enhance FEA’s clinical relevance including incorporating anisotropic tissue and material properties, patient-specific parameters, dynamic loading scenarios, and advanced techniques for crack propagation analysis.

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DOI: 10.3897/folmed.68.e161188

Authors: Valeriya Aleksandrova, Neshka Manchorova, Veselina Todorova, Lyubomir Vangelov, Svetlin Alexandrov

Abstract: Aim: The study of the tribological properties of dental materials is a growing and rapidly expanding field. The aim of our research is to investigate the micro-scratch and wear resistance of different restorative dental materials. Materials and methods: Three restorative materials indicated for the treatment of dental caries in the distal area of the dentition were used: dental amalgam without γ2 phase, with high Ag content (Cavex Non Gamma-2); a microhybrid resin-based composite material (Gradia Direct posterior); a metal alloy (Duceralloy C) was used as a positive control. All specimens were subjected to micro-scratch resistance test in 1 N, 5 N, 9 N mode, a ball-on-flat wear resistance test at 120,000/240,000 cycles loaded at 50 N. The examined surfaces of the specimens were visualized by optical microscopy and by 3D profilometry of all the specimens tested after 240,000 wear cycles. Results: The results are presented in the form of graphs - for each specimen, for each individual test, and for each individual cycle. The wear resistance of Duceralloy C increases after 240,000 cycles. The wear resistance of Cavex Non Gamma-2 and Gradia Direct posterior decreases with increasing time and friction cycles. Conclusion: The results of this study may help to elucidate the wear mechanisms and provide additional information on the expected changes in the materials tested in clinical practice.

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DOI: 10.3897/folmed.67.e158421

Authors: Maria Stoyanova Manolova, Neshka Atanasova Manchorova, Donka Keskinova, Veselina Ivanova Todorova, Lyubomir Stefanov Vangelov, Desislava Krasteva Petkova

Abstract: Abstract Introduction: Tooth enamel has a high specific electrical resistance due to its mineral-rich composition. The decreased electrical resistance is associated with the low mineral content of the enamel tissue and can be used as a method for early diagnosis of incipient caries. This indicates compromised enamel protection in the absence of clinically evident enamel damage, permitting reactions to irritants without direct dentin exposure. Aim: The study aims to investigate the relationship between reduced enamel electrical resistance measured using the CarieScanPro device and the presence of tooth hypersensitivity and varying levels of caries risk. Materials and methods: The study involved a total of 60 patients ranging in age from 25 to 45 years, who were categorized into two distinct groups based on their caries risk and the presence or absence of tooth hypersensitivity. The risk of developing dental caries was assessed using an American Dental Association (ADA) questionnaire. This questionnaire was translated and validated in Bulgarian. A total of twenty teeth were examined for each patient, with the teeth being categorized into four groups based on their location within the oral cavity: the first group consisted of the upper central incisors, the second group consisted of the upper lateral incisors, the third group consisted of the lower central incisors, and the fourth group consisted of the lower lateral incisors. The electrical resistance of the enamel on the vestibular cervical surface was measured on each tooth. To this end, a CarieScanPro device was utilized, which shows the result as both a numerical value and a letter on a display. Results: A statistically significant difference in the value of electrical resistance was found between patients with and without tooth hypersensitivity, but there is no such difference in patients with different degrees of caries risk. Conclusions: Tooth hypersensitivity is significantly associated with a higher prevalence of teeth with reduced electrical resistance, regardless of caries risk level.

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DOI: 10.3897/folmed.67.e161643

Authors: Zeena Tariq Abdulhadi, Shareef Radhi Jawad, Thuraya K. Alwandawi, Zainab Y. Muhsin

Abstract: Introduction: Apical periodontitis (AP) is a chronic inflammatory condition resulting from microbial infection of the dental pulp. The host immune response and microbial interactions play a significant role in the disease’s progression. Gingival crevicular fluid (GCF) provides a valuable, non-invasive source for detecting inflammatory biomarkers involved in AP, such as IL-1β, IL-10, and IL-23. Aim: To evaluate the levels of IL-1β, IL-10, and IL-23 in GCF among individuals with symptomatic apical periodontitis (SAP), asymptomatic apical periodontitis (AAP), and healthy controls, and to assess their potential as diagnostic biomarkers. Materials and methods: This cross-sectional study included 90 participants aged 20–50 years, divided into three groups: SAP (n=30), AAP (n=30), and healthy controls (n=30). GCF samples were collected using Periostrips, and cytokine levels were measured using enzyme-linked immunosorbent assay (ELISA). Statistical analysis was performed using SPSS version 26, with significance set at p<0.05. Results: IL-1β, IL-10, and IL-23 levels were significantly elevated in the SAP group compared to the AAP and control groups (p<0.01). IL-10 showed the highest diagnostic accuracy (AUC=0.806), followed by IL-1β (AUC=0.714). IL-23, although significantly elevated in SAP, had lower diagnostic value (AUC=0.636). Strong positive correlations were observed between IL-1β and IL-10, as well as IL-1β and IL-23. Conclusion: The elevated levels of IL-1β, IL-10, and IL-23 in GCF reflect their involvement in the inflammatory processes of apical periodontitis. IL-10 demonstrated the greatest potential as a diagnostic biomarker. These findings support the clinical utility of GCF cytokine profiling for non-invasive diagnosis and monitoring of AP progression.

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DOI: 10.3897/folmed.67.e154202

Authors: Iliyana Stoeva, Zlatina Tomova

Abstract: Introduction: Titanium dental implants are the most common type of dental implants. Although titanium and its alloys are considered biocompatible, there are concerns about the induction of metal allergy with dental implants. Aim: To evaluate the presence of titanium sensitization by patch testing in patients who intend to have titanium dental implants. Materials and methods: A retrospective study was performed in which data on sensitization to titanium collected from the Allergy Office at the Faculty of Dentistry in Plovdiv from January 2022 to April 2024 were analyzed. We analyzed data from 95 patients who had patch testing done before their dental implant surgery. Results: Thirty-eight (40.0%) patients exhibited positive patch test reactions to at least one metal. The most common allergen was nickel (32.6%). Titanium (IV) oxalate was the only one with a positive rate (7.4%) among titanium reagents. Almost one-half (42.9%) of the patients were monosensitized to titanium (IV) oxalate. No association between positive reaction to titanium (IV) oxalate and history of suspected metal allergy was identified (p=0.064). Conclusions: The absence of positive reactions to other titanium reagents, as well as a correlation with a history of metal allergy and other allergies in patients who tested positive for titanium oxalate, makes determining the clinical relevance of the positive reactions difficult. Standardization in titanium allergy research is required to ensure the accuracy of the findings.

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DOI: 10.3897/folmed.67.e153378

Authors: Denitsa Zaneva-Hristova, Tsvetelina Borisova, Slavena Svetlozarova, Mariyana Kirova, Boris Valkov

Abstract: Introduction: Primary endodontic treatment and retreatment involves a number of stages and materials which are all crucial for the final result. Irrigation and the reduction of the microbial count in the root canal system represent a critical phase of the treatment process, contributing significantly to the overall success of the procedure. It was found that conventional methods and irrigants do not show satisfactory results. For this reason, different lasers are entering endodontics to combine with traditionally accepted materials. Aim: This literature review aims to examine the various aspects of laser applications in endodontics and their clinical significance. Materials and methods: In this literature review, related articles and publications are reviewed and research findings on the topic are summarized. Results: Review of all included articles and publications indicates that most types of lasers can be used in the course of endodontic treatment. Lasers are also used to remove pins, fractured instruments and old root canal filling. Conclusion: In this review, we have provided an overview of the emerging applications of lasers in endodontics and various common dental procedures, highlighting laser-based therapy as a promising approach in dental treatment.

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DOI: 10.3897/folmed.67.e150425

Authors: Zlatina Tomova

Abstract: Introduction: The corrosion of dental alloys can have undesirable consequences. The corrosion properties may be modified by the alloy production method, composition, method of prosthetic restoration manufacturing, and oral conditions. Aim: The aim of this study was to assess the corrosion resistance of three cobalt-based alloys produced by different methods and indicated for different manufacturing techniques. Materials and methods: Three groups of specimens were created. Group 1 consisted of 35 specimens produced using direct metal laser sintering (DMLS) with EOS CobaltChrome SP2 (EOS, Germany). Groups 2 and 3 each consisted of 30 specimens produced by a conventional casting technique using Marranium CC (Sintal, Bulgaria) and Wirobond C (Bego, Germany). The former was obtained by powder metallurgy methods, while the latter was obtained by conventional thermal melting and alloying. The specimens were placed in artificial saliva with pH adjusted to 7.4. Open circuit potentials were measured at two time points: two hours and seven days after placement in the medium, using a Dentotest Six apparatus (Atlantis, Bulgaria). Results: After two hours in artificial saliva, significant differences in the open circuit potential (Eocp) values were observed between the groups. However, after seven days, no significant differences in Eocp were observed. Conclusion: Corrosion behavior of cobalt-based dental alloys depends on the type of the alloy and the manufacturing methods.

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DOI: 10.3897/folmed.67.e153322

Authors: Krasimir Hristov, Ralitsa Bogovska-Gigova, Nedana Georgieva

Abstract: Introduction: Marginal integrity can be defined as the ability of a sealant to establish a robust and resilient bond at the interface between the sealant and the tooth surface, preventing microleakage, discoloration, the formation of voids and cracks, and the subsequent development of caries lesions. Aim: To make a scanning electron microscopy (SEM) evaluation of the marginal integrity of resin sealant applied on the occlusal surfaces of permanent molars, using different techniques. Materials and methods: The study involved 80 non-carious human third molars that were subjected to three different sealant application methods: conventional, heating, and the use of a vibrating instrument. Epoxy resin replicas were created from each occlusal surface of the teeth. The teeth underwent thermocycling, after which new replicas were made. All replicas were coated with gold powder and observed under scanning electron microscopy. Marginal integrity of the replicas was assessed and compared before and after the thermocycling process. The extent of gaps was measured as a percentage of the restoration edge’s total length. Results: The data show that marginal adaptation ranges from 90% to 94% before thermocycling. Sealants’ marginal adaptation was compromised in all study groups and decreased between 81% and 88% after thermocycling. There were statistically significant differences between the control and the other three groups in the study (heating and application of vibrations) before and after thermocycling (p<0.001). The best sealant adaptation was observed when vibrations were applied along the fissure system. Conclusion: The method of sealant application plays a crucial role in determining its marginal integrity and sealing ability.

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DOI: 10.3897/folmed.67.e154338

Authors: Atanu Mukhopadhyay, Santanu Mukhopadhyay, Raju Biswas

Abstract: Aim: This study aimed to evaluate the performance of three large language models (LLMs)—ChatGPT-4.0, Claude 3.5 Sonnet, and DeepSeek R1—in answering multiple-choice questions (MCQs) related to pediatric dentistry. Accuracy and justification quality were analyzed using Bloom’s taxonomy. Materials and methods: A total of 90 MCQs were developed based on the American Academy of Pediatric Dentistry (AAPD) guidelines, ensuring cognitive diversity across Bloom’s taxonomy levels. The models were assessed for answer accuracy and required to provide justifications, which were scored using a structured 4-point rubric by two independent pediatric dentistry experts. Statistical analyses, including Kruskal-Wallis tests and one-way ANOVA, were used to compare performance. Results: DeepSeek R1 demonstrated the highest accuracy (92.2%), followed by Claude 3.5 sonnet (86.6%) and ChatGPT-4.0 (72.2%). Significant differences in accuracy were observed at the “Understanding” level (p=0.009). Justification quality also varied significantly among models, with DeepSeek R1 outperforming the others (p<0.001). Inter-rater reliability was high (ICC: 0.615–0.848), showing the reliability of the evaluation. Conclusion: The study shows variations in LLM performance, with DeepSeek R1 excelling overall. It holds promise for pediatric dentistry education and AI decision-making, but further improvements are needed for better reasoning and clinical use.

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DOI: 10.3897/folmed.67.e143587

Authors: Reem Hanna, Ioana Cristina Miron, Stefano Benedicenti

Abstract: Root canal system decontamination is recognized as one of the main pillars of successful endodontic treatment, although variations in the efficacy of current disinfection methods have been reported. In light of this, the present study investigated the activation of 5.25% sodium hypochlorite (NaOCl) using a 980 nm diode laser (laser-activated irrigation) as an adjunct to conventional decontamination, with the addition of photobiomodulation therapy. The objectives were to achieve optimal clinical outcomes over long-term follow-up, to alleviate post-endodontic pain, and to propose effective decontamination treatment protocols. A 57-year-old female patient presented with a perio-endo lesion of the lower second premolar teeth, which was associated with Grade III mobility. The treatment strategies included conventional decontamination, laser-activated irrigation, and photobiomodulation. Periodontal parameters, tooth mobility, and periapical healing were assessed at baseline and then at 3, 6, and 12 months. The results showed a significant improvement in these clinical variables, as well as a reduction in post-endodontic pain following photobiomodulation irradiation. The combination of 980 nm laser-activated irrigation and conventional decontamination was found to be significant in optimizing treatment outcomes. However, the study concludes that extensive comparative studies with larger datasets are needed to further validate these results.

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DOI: 10.3897/folmed.67.e149216

Authors: Juman Alkhayoun, Heba Yassin, Muna Saleem, Federica Canfora

Abstract: Introduction: Salivary melatonin is a critical antioxidant that contributes to oral health by mitigating oxidative stress. Psychological stress linked to thumb sucking may disrupt oral homeostasis, leading to conditions such as dental caries and fungal infections. Aim: This study explores the relationships between thumb sucking, salivary melatonin levels, dental caries, and the presence of Candida albicans (CA) in children. Materials and methods: A case-control study was conducted with 60 children aged 4-5 years at the University of Baghdad’s College of Dentistry. Participants were divided into thumb-sucking (n=30) and non-thumb-sucking (n=30) groups. Salivary melatonin levels were measured using enzyme-linked immunosorbent assays (ELISA), dental caries were assessed via the dmfs index, and CA counts were quantified on Sabouraud dextrose agar (SDA). Statistical analyses were performed, including t-tests, ANOVA, and correlation assessments. Results: Thumb-sucking children exhibited significantly lower salivary melatonin levels (28.620±2.278 pg/mL) compared to controls (34.525±2.142 pg/mL; p=0.044). The thumb-sucking group also had higher dmfs scores (15.033±1.449 vs. 8.667±0.899; p=0.000) and greater CA counts (18.900±1.048 vs. 13.583±0.549; p=0.000). Negative correlations were observed between salivary melatonin levels and the severity of dental caries, while positive correlations linked CA with dental caries. Conclusions: Thumb sucking adversely affects pediatric oral health by reducing salivary melatonin, increasing dental caries risk, and promoting fungal overgrowth. Early intervention to curb thumb-sucking behaviors may mitigate these risks and improve oral health outcomes.

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DOI: 10.3897/folmed.67.e151396

Authors: Irina Uzunova-Raycheva, Tanya Nihtyanova, Ralitsa Raycheva, Dancho Danalev, Petya Romanova, Ani Belcheva-Krivorova

Abstract: Aim: The aim of this study was to compare the lesion depth and level of penetration of CPP-ACFP, SAP P11-4 and 2 newly synthesized self-assembling peptides by measuring the linear depth of fluorescence. Materials and methods: A total of 30 enamel samples were prepared from orthodontically extracted permanent premolars. Three zones were provided: a sound enamel surface (SC), a demineralization zone (DC), and a remineralization zone (TA). The samples were randomly divided into five groups (n=6): group 1 – Gr V (MI Varnish™), group 2 – Gr CR (Curodont™ Repair), group 3 – IU1, group 4 – IU2, and group 5 – Gr NT (control group, no treatment). Lesion depth was assessed by measuring the linear penetration depth of the fluorescent dye by laser confocal microscopy. Results: A statistically significant reduction in the depth of the lesion was found in the experimental groups compared to the control group, which was not treated (p<0.001). The depth of the lesion reveals the degree of mineralization and the cariostatic effect in the experimental groups. When measuring the confocal images, the results showed that there was a similar degree of remineralization for CPP-ACFP and for SAP P11-4, IU1, and IU2 for the two time points DC and TA, but without statistical significance between them (p=1.00). The samples treated with IU2 showed the highest degree of remineralization, followed by CPP-ACFP, SAP P11-4 and IU1. Conclusion: The self-assembling peptides have a significant level of infiltration and potential for remineralization of artificial carious lesions in permanent teeth. The combination of SAP with fluoride has an additive effect.

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DOI: 10.3897/folmed.67.e152720

Authors: Atanas Chonin, Radka Cholakova, Zlatina Tomova, Angelina Vlahova, Mariana Dimova-Gabrovska

Abstract: Recent EU regulations recommend restriction of the use of medical devices in which cobalt content exceeds 0.1%. Commercially pure titanium (cpTi) and titanium alloys appear to be excellent alternatives to cobalt-based alloys in the fields of implantology and prosthodontics. The narrative review summarizes the structure and types of titanium alloys and the methods of their processing. The high biocompatibility of titanium is explained in terms of corrosion, ion release, and interaction with the biological environment. An analysis of existing studies on the mechanical properties of titanium prosthetic restorations is presented, and future perspectives are outlined.

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DOI: 10.3897/folmed.67.e142966

Authors: KS Sachin, K Shibani Shetty, KB Jeyalakshmi, S Harishma, S Harshini

Abstract: Aim: The objective of the present study was to assess and compare the antibacterial activity of two bioceramic sealers, BioRoot RCS and CeraSeal RCS, against Enterococcus faecalis with and without the addition of two herbal extracts, Psidium guajava and Azadirachta indica. Materials and methods: We formed two experimental groups, group 1 included CeraSeal RCS sealers and group 2 included BioRoot RCS sealers. These groups were further subdivided into subgroup 1A (controls) with CeraSeal RCS sealers, subgroup 1B with CeraSeal RCS sealers plus ethanolic extract of neem, subgroup 1C: CeraSeal RCS + ethanolic extract of guava, subgroup 2A (controls): BioRoot RCS root canal sealers (controls), subgroup 2B: BioRoot RCS root canal sealer plus ethanolic extract of neem, and subgroup 2C including BioRoot RCS root canal sealers plus ethanolic extract of guava. To prepare the subgroups containing ethanolic extract of neem and guava, 20 µL of extract were mixed with the powder and liquid and spatulated well to form a homogenous paste. Direct contact test was performed and the colonies were counted using a digital colony counter and the colony forming units (CFU) per microliter were calculated based on the dilutions used. Results: The mean CFUs in the BioRoot RCS group without extract, with guava and with neem extracts showed significantly lesser values (1.305±0.038; 0.852±0.051; 1.097±0.072) as compared to CeraSeal RCS group without extract, with guava; neem extracts showed significantly lesser values (1.392±0.057, 1.073±0.064; 1.201±0.055). Multiple comparisons between groups revealed that the guava extract demonstrated significantly fewer CFUs as compared to the no-extract and the neem-extract groups, and the difference was statistically significant at p<0.001. Conclusion: Adding herbal extracts increased the antimicrobial activity which can be inferred from the comparison of the mean number of colony forming units after direct contact test and the reduction in mean optical density of both the subgroups to their respective control groups. The ethanolic extract of guava displayed better antimicrobial efficacy than the ethanolic extract of neem.

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DOI: 10.3897/folmed.67.e143137

Authors: Esra Hassan Abd Ali, Suzan Mohammed Abdul Raheem, Hussain Owaid Muhammed, Alzahraa Jabbar Jassim, Abdullah J. Jasem

Abstract: Introduction: A substantial body of research has underscored the intricate nature of diagnosing oral disorders in conjunction with chronic inflammatory diseases. Aim: Multiple sclerosis (MS) and rheumatoid arthritis (RA) are chronic autoimmune diseases, which are usually difficult to distinguish in the early stage of the diseases. The objective of this study was to explore the differences of immune mechanism and diagnostic markers through bioinformatics analysis of the pro-inflammatory cytokine’s markers (IL-1β, IL-6, and TNF-α) to evaluate the role of immunological markers in patients with MS and RA with oral diseases. Materials and methods: This study enrolled 54 patients with oral disorders and chronic inflammatory diseases admitted to our hospital between January 2020 and December 2022, among 587 patients who had MS or RA and 50 healthy controls without oral disorders, with age, sex, and familial and genetic factors matching. Oral disorders were diagnosed and staged according to the method of dental examination. Blood (IL-1β, IL-6, and TNF-α) levels were measured using ELISA to detect chronic inflammatory diseases. Results: Important changes were found in RA and MS patients in terms of their age at onset of disease: RA patients exhibited a higher average age of onset (47.29 years) compared to MS patients (30.56 years), with both conditions showing a female predominance. Genetic factors did not differ significantly between the two conditions. Patients with both chronic inflammatory diseases and oral disorders had elevated levels of the studied markers (IL-1β, IL-6, and TNF-α) compared to those without oral disorders, indicating a substantial impact of oral diseases on immunological responses. Conclusions: RA typically affects older individuals, while MS onset occurs at a younger age with a higher female prevalence. Xerostomia was more common in RA, while oral candidiasis was more common in MS. Both active MS and patients with oral disorders exhibit high concentrations of IL-1β, IL-6, and TNF-α markers. These outcomes may have inferences for understanding the immune reaction and inflammation in these conditions.

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DOI: 10.3897/folmed.67.e143232

Authors: Hadeel Mazin Akram, Rand Zaidoon, Rusul Alaa

Abstract: Background: Periodontal diseases include gingivitis, periodontitis, and peri-implant disease. There are different ways to treat these diseases, such as surgical and non-surgical periodontal treatments like gingivectomy, open flap debridement, and crown lengthening. Aim: This study aimed to determine the most common periodontal surgery procedures performed in postgraduate periodontic clinics and to identify the associated periodontal diagnoses and patient demographics. Materials and methods: This study is a retrospective cross-sectional study carried out at the postgraduate periodontic clinics in the College of Dentistry, University of Baghdad. Various information, such as demographic data, medical and dental history, periodontal diagnoses, and types of periodontal surgery that the subjects underwent, was collected from the periodontal records. The collected data were then analyzed statistically. Results: A total of 271 patient records were included in this study, with a mean age of 38.7±11.9 years. The most frequently performed periodontal surgery procedures were open flap debridement (29.2%), followed by gingivectomy (19.1%) and guided tissue regeneration (17.5%). Regarding diagnosis, the most prevalent periodontal diagnoses were gingivitis (31%), followed by periodontitis (28.04%) and gingival enlargement (8.86%). Statistically significant associations were observed between periodontal diagnoses and types of periodontal surgeries performed. Sex-specific differences were noted in the selection of surgical treatments. Conclusion: This study sheds light on periodontal surgery epidemiology in a postgraduate periodontic clinic. The data show that periodontal diseases and patient-specific characteristics require personalized treatment techniques.

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DOI: 10.3897/folmed.67.e137670

Authors: Ankit Shah, BC Sikkerimath, Yash Merchant, Santosh Gudi, Satyajit Dandagi, Dinesh Shah

Abstract: Aim: Maxillofacial space infection refers to infections in the potential spaces and fascial planes of the maxillofacial region. The primary objective was identifying predictive variables associated with increased hospital stay in patients with odontogenic maxillofacial space infections. Materials and methods: A retrospective chart review of all patients treated for odontogenic maxillofacial space infections from January 2001 to December 2012 at the P.M.N.M. Dental College and Hospital, Bagalkot, was conducted. Results: Out of 141 patients identified, 59.6% were females, and the mean age of our study group subjects was 36.81±15.76 years. 9.93% of the patients had diabetes, and the most common space involved was the buccal space. The mean white blood cell (WBC) count was 12329.93 cells/mm3, and the most common bacteria isolated were Staphylococcus aureus. The average length of hospital stay was 6.06±2.96 days. Space involvement, severity of infection (presenting WBC count in the CBC), and pre-morbid medical status increased the length of in-patient stay post-operatively with a statistical significance. Conclusion: The results of our retrospective study noted a higher prevalence of maxillofacial space infections due to odontogenic etiology in the age group of 31-50 years with the buccal space being implicated the most. The predictors associated with an increased length of hospital stay were spaces involved, treatment regimen, severity of infection (indicated by presenting WBC count in the CBC), and pre-morbid medical status.

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DOI: 10.3897/folmed.67.e144621

Authors: Kalina Georgieva-Bozhkova, Desislava Konstantinova, Anna Nenova-Nogalcheva, Dimo Nedelchev

Abstract: Introduction: The faculty of speech in humans is a distinguishing trait that sets them apart from all other biological species. Speech production is typically achieved through the processes of phonation and articulation. The acoustic method of studying speech is an individual auditory approach based on hearing as a biological analyzer. Aim: The present study aims to conduct a speech assessment of patients with single frontal maxillary defects, divided into two stages: an initial speech assessment before prosthetic treatment and a secondary speech assessment after temporary prosthetic restorations. The study will also investigate the factors influencing the improvement of sound articulation. Materials and methods: A total of 40 patients (17 men and 23 women) with diastema and healthy vocal cords were included in the study for primary and secondary speech assessments. 60 speech therapy indicators were examined. Results: In our study, improvement was observed in 30 out of 60 speech therapy indicators. The greatest improvement was noted in the pronunciation of alveolodental consonants (‘S’, ‘TS’, ‘L’). A moderate negative linear correlation suggested that as age increased, the degree of improvement decreased (p=0.343). Conclusions: The distortion of consonants in Bulgarian among patients with diastema remains within normal parameters. The richness of sounds in the Bulgarian language, in conjunction with the capabilities of contemporary dental prosthetics, underscores the necessity for subsequent in-depth studies of speech function following prosthetic rehabilitation in future research with a larger sample size.

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DOI: 10.3897/folmed.67.e140934

Authors: Krasimir Hristov, Ralitsa Bogovska-Gigova, Nedana Georgieva

Abstract: Introduction: Sealants prevent the development of dental caries by forming a protective barrier that reduces bacterial growth and food retention. The morphology of the pits and fissures and the material of the sealant can affect the depth to which it penetrates into the fissures and the longevity and durability of the sealant. Aim: To compare the depth of penetration into fissures and pits of different types of sealants in primary molars using micro-CT assessment. Material and methods: Forty intact primary molars were extracted just prior to their physiologic exfoliation. They were sealed with glass ionomer cement (GIC) and resin sealant. The samples were scanned with a desktop X-ray microtomograph. The fissure profile, sealant penetration depth, and depth of the unfilled part of the fissure were measured. Descriptive and inferential statistics were used to analyze the data. Results: The median penetration depth of GIC was 89% (IQR 81.31%–100.00%) in U-type fissures and 66% (IQR 55.64%–76.77%) in V-type fissures. The deepest median penetration with resin sealant was found in U-type fissures 89% (IQR 73.16%–100.00%) and the shallowest median depth was found in IK-type fissures 34% (IQR 25.39%–41.73%). Penetration depths ranged from 34% to 43% in the I and IK fissure types. No statistically significant difference was found in the penetration of the two types of sealants in the different types of fissures (p>0.05), except for those classified as other types. There, a significantly greater depth of penetration was found in the group of teeth sealed with GIC - median 56%, compared to the resin sealant, which reached only 40% of the fissure depth (p=0.003). Conclusion: The morphology of the fissure plays a more important role in determining the depth to which the sealant will penetrate the fissure than the type of sealant material used.

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DOI: 10.3897/folmed.67.e127609

Authors: Hachko Giragosyan, Ivan Filipov, Emiliya Simeonova, Nikolay Zahariev, Stela Kasabova

Abstract: Aim: The aim of the present study was to evaluate the surface changes in two different systems of rotary instruments before and after use by means of scanning electron microscopy (SEM) and energy dispersive analysis (EDA). Materials and methods: We selected thirty files and divided them equally into two groups of 15 files each based on their manufacturing technology. Each file was used to prepare 5 root canals of freshly extracted human teeth. All the files were subjected to SEM and EDS before and after being used and the results compared to evaluate the surface changes. The results were then compared between the two groups using the t-test. Results: The SEM images showed a greater mean difference in the surface changes before and after use for the system that employed only the M-wire manufacturing technology (1.46±1.68) vs. (3.07± 2.01), compared with the system that combined the M-wire and Gold manufacturing technologies (2.06±1.62) vs. (3.33±2.19). The most common observation in both systems was debris accumulation. Other notable findings included microfractures and file separation. The EDS results suggest that the more modern system has a higher loss of chemical composition after use compared to the system using only M-wire technology. Conclusion: The present study provides evidence confirming that the use of Ni-Ti rotary file systems leads to the progression and possible creation of new surface changes. They increase the likelihood of iatrogenic errors and treatment failure in both file systems. Long-term use of files with gold manufacturing technology is not recommended, but for single use they outperform those with M-wire technology.

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DOI: 10.3897/folmed.66.e135281

Authors: Mihail Z. Tanev, Georgi T. Tomov, Kostadin G. Georgiev, Ekaterina D. Georgieva, Kamelia V. Petkova-Parlapanska, Galina D. Nikolova, Yanka D. Karamalakova

Abstract: Introduction: Antimicrobial photodynamic therapy (aPDT) utilizes light-sensitive materials to inactivate pathogens. Indocyanine green (ICG) is an FDA-approved photosensitizer known for its effective photo-thermal and photo-chemical properties. Aim: This study evaluates the efficacy of ICG-based aPDT in eliminating reactive species compared to methylene blue (MtB) using electron paramagnetic resonance (EPR) spectroscopy. Materials and methods: Solid samples of ICG and MtB were prepared at 0.33% concentrations. Solutions were irradiated with lasers at 810 nm and 630 nm, respectively. EPR spectroscopy measured reactive oxygen species (ROS) and reactive nitrogen species (RNS). Spin-trapping agents assessed alkyl radicals, superoxide, and singlet oxygen. Results: ICG demonstrated higher scavenging activity for ROS/RNS compared to MtB. Under PDT, ICG significantly enhanced the reduction of photooxidative stress markers in vitro. Conclusions: ICG combined with aPDT is more effective than MtB in reducing ROS/RNS, indicating its potential for enhanced antimicrobial applications.

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DOI: 10.3897/folmed.66.e135584

Authors: Shila Kahalian, Marieh Rajabzadeh, Melisa Öçbe, Mahmut Sabri Medisoglu

Abstract: Introduction: ChatGPT has the ability to generate human-like text, analyze and understand medical images using natural Language processing (NLP) algorithms. It can generate real-time diagnosis and recognize patterns and learn from previous cases to improve accuracy by combining patient history, symptoms, and image characteristics. It has been used recently for learning about maxillofacial diseases, writing and translating radiology reports, and identifying anatomical landmarks, among other things. Materials and methods: In this study, 52 radiographic images were queried on the OpenAI application ChatGPT-4.0. The responses were evaluated with and without using clues for specific radiographs to see if adding clues during prompting improved diagnostic accuracy. Results: The true prediagnosis rate without any clue was 30.7%. By adding one clue this rate significantly increased to 56.9%. There was not a significant difference in accurate diagnosis of anatomical landmarks, cysts, and tumors (p>0.05). However, including internal structure information improved the diagnostic accuracy (p<0.05) Conclusion: GPT-4.0 showed a tendency to misdiagnose closely located anatomical structures and by adding additional clues its performance showed improvement, while its ability to recognize diverse differential diagnoses remains limited.

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DOI: 10.3897/folmed.66.e130813

Authors: Swapnil Junnarkar, Anand Sabane, Amol Patil, Meenal Tepan, Tanisha Rout, Sonakshi Sharma, Arati Gholap

Abstract: Aim: We aim to assess and contrast the mechanical stability of two mini-implant designs, featuring larger diameters and shorter lengths, for orthodontic anchorage against a conventional group of implants. Materials and methods: Three groups of mini-implant underwent testing: the implants in Group 1 were 2.5 mm in diameter and 4 mm in length; the implants in Group 2 were 3 mm in diameter and 3 mm in length; and the conventional group implants were 1.3 mm in diameter and 7 mm in length. Both types were Abso Anchor mini-implants (Dentos Inc.). The implants’ mechanical stability was assessed using the maximum insertion torque (MIT), the maximum removal torque (MRT), and the angulated lateral displacement tests for compression and tension force vectors. Fourteen mini-implants of each design were used to measure MIT and MRT. Seven mini-implants of each design were tested for lateral displacement. Results: Torque tests - Group 2 mini-implants showed superior primary stability with higher MIT and MRT values compared to Group 1 and the conventional group implants. Lateral displacement tests - Group 2 mini-implants required significantly greater compressive force than those in Group 1 and the conventional group. Tension force for lateral displacements was similar between the three groups. Conclusion: Group 2 mini-implants, with larger diameters and shorter lengths, demonstrated superior primary stability over Group 1 implants. Despite the differences in compressive force, all three groups performed similarly under tension in lateral displacement tests.

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DOI: 10.3897/folmed.66.e137447

Authors: Nataliya Emelyanova, Dmitry Emelyanov

Abstract: Introduction: In recent years, non-invasive screening methods for diagnosing various human conditions, including those corresponding to biological age, have attracted great interest, one of the sources for non-invasive research of which is oral fluid. Aims: To study the age-related features of oral fluid facies in patients with non-alcoholic fatty liver disease. Materials and methods: Sixty-one patients with non-alcoholic fatty liver disease and 57 somatically healthy patients were selected for study. An oral fluid sample was taken into a plastic tube in the quantity of 1.5-2 ml. The supernatant fluid was collected using a laboratory pipette, and 4 drops of 0.02 ml were formed on a glass slide. After that, the drop was subjected to natural dehydration. The facies study has been carried out using an electron microscope. Results: Normally, during the phase OF drop transition, the formation of 2 zones is characteristic – the marginal zone having the “colloidal glass” form, and the central organized by crystals in the “fern leaf” or “tree branch” form. The metabolic dysfunction negatively affect the organization of protein molecules and the formation of marginal zone in which pathology markers are spread – fissures, wrinkles, pigment inclusions. Conclusion: Accordingly, elements of crystal destruction appear in the salt part, and the number of chaotically oriented dendrites increases.

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DOI: 10.3897/folmed.66.e139442

Authors: Zlatina Tomova, Atanas Chonin, Radka Cholakova, Iliyana Stoeva

Abstract: The aim of this literature review was to provide a brief perspective over the scientific research of the condition known as burning mouth syndrome. Information from review articles, original studies, and dissertations was gathered using keywords describing etiological factors, clinical, laboratory findings and treatment protocols. We compiled information on potential etiological factors, symptoms, and potential treatments from the fifty-three included studies on dental and general health issues in patients complaining of burning sensations in their mouths. Despite the numerous attempts by dental and medical professionals to diagnose and treat mouth burning, the etiology and pathogenesis of this disorder remain rather unclear. In most cases, it is concluded that further research is needed with the inclusion of more patients, administering a long-term therapy, and monitoring the results.

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DOI: 10.3897/folmed.66.e136356

Authors: Ehab Qasim Talib, Ghada Ibrahim Taha, Dhuha Mahmood Ali, Sahar Hashim Al-Hindawi, Fadia Abd Almuhsin Al-Khayat, Israa Amer Hasan

Abstract: In the field of implantology, peri-implantitis is still a common complication of implant failure. Similar to periodontal disease, this kind of pathological condition is characterized by inflammation of the tissues surrounding dental implants or fillings. The sources of infection have been shown to be chronic periodontitis and poor maintenance of the communion. A thorough examination of the intricate components of peri-implantitis was sought in this review in order to identify common characteristics of the disease with regard to bacteria, biofilm formation, host immunological responses, diagnostic tools, and therapeutic treatments. The aim of this study was to provide a detailed overview of the different bacterial species associated with peri-implantitis, a clinical condition similar to periodontitis, characterized by a higher prevalence of staphylococci and enteric bacteria. The study underscores the importance of employing sophisticated diagnostic methods like cone beam computed tomography. It covers a range of therapeutic approaches including surgical and non-surgical techniques as well as strategies stressing host-modification and photodynamic treatment. The study was conducted using pertinent publications from scientific databases, including Scopus, Google Scholar, PubMed, and Web of Science. We searched these databases using the following terms: periodontitis, microbial, dental implants, peri-implantitis, and biofilm formation.

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DOI: 10.3897/folmed.66.e123762

Authors: Krikor Giragosyan, Lyubomir Chenchev, Vasilena Ivanova

Abstract: Reduction of the bone dimensions after tooth loss leads to complications during dental implant placement and prosthetic rehabilitation of the patient. Ridge augmentation procedures aim to increase the available bone volume and provide adequate surface area for the following treatment. Different methods and materials are suggested for the purposes of guided bone regeneration. This case report represents the management of a severe bone atrophy with a 3D printed titanium mesh.

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DOI: 10.3897/folmed.66.e117367

Authors: Amba Esakki, Anitha Pandi, Smiline A S Girija, Vijayashree Priyadharsini Jayaseelan

Abstract: Introduction: Transformer (TRA2B) is a serine/arginine-rich (SR)-like protein family that regulates the alternative splicing of several genes in a concentration-dependent manner. Amplification of the TRA2B gene, which codes for TRA2B, occurs in several malignancies, including those of the lung, cervix, head and neck, ovary, stomach, and uterine. Materials and methods: The present study design follows a computational approach to predict the molecular mechanisms underlying TRA2B alterations in two cancer phenotypes, viz., lung and head and neck squamous cell carcinoma. The genetic alteration in the TRA2B gene was identified using the cBioportal database. The gene expression pattern in both the cancer types and their survival pattern concerning the expression profile was demonstrated using UALCAN. The microRNA targets of the TRA2B gene were identified using the miRDB database. Results: Genetic alteration was found to be 27% and 48% in HNSCC and LUSC datasets, respectively. The alterations included gene amplification, missense, nonsense, and splice site mutations. The gene expression profile of TRA2B correlated well with the gene amplification demonstrated by patients in both groups. However, the upregulation of TRA2B did not correlate well with the survival profile in LUSC patients. The downregulation of TRA2B markedly affected the survival of HNSCC patients, which can be attributed to the functions of microRNAs targeting TRA2B transcripts. Conclusion: Although TRA2B was found to be a potential diagnostic marker exhibiting a differential expression pattern for HNSCC, the employability of this gene as a prognostic marker needs more experimentation. Also, the influence of microRNAs on dysregulated gene expression should be considered to gain a better understanding of the underlying molecular mechanisms precipitating the disease.

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DOI: 10.3897/folmed.66.e119060

Authors: Harpreet Singh, Pinaki Roy, Raj Kumar Maurya, Poonam Sharma, Pranav Kapoor, Tanmay Mittal

Abstract: Skeletal class III malocclusion is a therapeutic challenge in orthodontic practice. Reverse functional appliances such as reverse twin block (RTB) are used to correct class III skeletal and occlusal disharmonies associated with functional anterior shift in growing patients. However, treatment options become limited with increasing age, especially when patients desire nonsurgical and nonextraction camouflage treatment. This report illustrates the successful nonsurgical treatment of class III malocclusion during adolescence and adulthood, exacerbated by a functional anterior shift that resulted in overclosure of the mandible. A modified fixed RTB was utilized to posture the mandible backwards, thereby inducing active clockwise rotation of the mandible. After treatment, patients demonstrated significantly improved maxillomandibular relationships, well-maintained stable occlusion, and facial esthetics. Satisfactory occlusal, esthetic, and functional outcomes achieved in the present cases underline the fact that dentoalveolar changes induced by fixed RTB can be utilized even past a patient’s peak pubertal growth period to obtain changes that aid in correcting a class III malocclusion. A synergistic combination of modified fixed RTB therapy accompanied by comprehensive fixed mechanotherapy is a viable treatment alternative for the correction of aptly selected mild to moderate skeletal class III malocclusions associated with functional anterior shift, anterior crossbites, and mandibular overclosure.

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DOI: 10.3897/folmed.66.e129047

Authors: Anish Doke, Anand Sabane, Amol Patil, Jayesh Rahalkar, Tulsi Subramaniam, Monali Nikalje

Abstract: Introduction: Mandibular prognathism (MP) patients present with aesthetic concerns and functional issues, including difficulties in mastication and pronunciation. Studies revealed that mandibular prognathism had definitive Mendelian inheritance patterns. This study aimed to ascertain distinct genetic markers associated with mandibular prognathism in individuals of Indian descent, focusing on exploring the prevalent genetic variations associated with certain genes. This study sought to identify the association of the following gene markers with mandibular prognathism: 1) Matrilin-1 (MATN1) (rs1065755), 2) Bone morphogenic protein 3 (BMP-3) (Tyr67Asn), 3) Homeobox protein hox-A2 (HOXA2) (Val327Ile), 4) Rho-GTPase activating protein (ARHGAP 21) (Gly1121Ser), 5) Myosin 1H (MYO1H) (rs10850110) Materials and methods: Forty subjects (age group 18–30 years) were chosen based on their clinical examination, study model, and lateral cephalogram. Ten subjects had normal skeletal jaw-base relationships, and 30 had prognathic mandibles (skeletal class III jaw-base relationships). Two milliliters of blood were taken from each person. The genes, as mentioned above, associated with mandibular prognathism were studied. To assess the association between genetic markers and mandibular prognathism, the following statistical tests were used: an unpaired t-test was used to compare the mean values of continuous variables between the normal and prognathic groups; a chi-square test was used to evaluate the association between genetic markers and the jaw-base relationship; and an odds ratio was used to assess the strength of association between genetic markers and the prognathic mandible. Statistical analyses were conducted using SPSS software. Results: Out of five single nucleotide polymorphisms (SNP) selected in the study, namely rs10850110, rs1065755, rs111419738, rs143043350, and rs74764079, three SNPs—rs111419738, rs143043350, and rs74764079—did not show differences in the genotypes among the study and control samples. Thus, this indicates that these three SNPs may be related to mutations seen in MP in other populations but do not exhibit any association with the people covered in this study. The other two SNPs, rs10850110 and rs1065755, showed variant genotypes in control and study samples. Conclusions: Our research found that rs10850110 and rs1065755 positively correlated with mandibular prognathism. Further studies are needed to see the association between these two restriction sites in MP subjects.

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DOI: 10.3897/folmed.66.e126997

Authors: Panchatcharam Barkavi, Mohamed Iqbal, Priyanka Gandhi, Harishma Sivakumar, Kavitha Mathivanan, Kothandaraman Thirivikhraman

Abstract: Introduction: Mixed dentition analyses are used to determine possible tooth-size and arch-length discrepancies during the transition from primary to permanent dentition. Prediction methods using a probability table or linear regression equation use the sum of the mesiodistal widths of mandibular permanent incisors to predict the mesiodistal width of unerupted permanent teeth. Racial and sexual variations and sexual dimorphism in tooth size have been reported. The objective of this study is to validate Moyer’s and Tanaka Johnston’s mixed dentition analyses in a contemporary South Indian population. Materials and methods: 100 pairs of permanent dentition models belonging equally to both sexes with an age range of 12–21 years comprised the sample in which both analyses were done. The predicted width of permanent canines and premolars was compared to the actual width in the study models. Results: There was a statistically significant difference between the two values for Moyer’s analysis in the mandibular teeth of females (p=0.04), 95% CI −0.605 to −0.969. There was a statistically significant difference between the two values for Tanaka Johnston’s analysis of maxillary teeth (p=0.001), 95% CI 0.863 to 1.370. Conclusions: Moyer’s analysis shows a statistically significant underestimation in the mandibular arch of females. Tanaka Johston’s analysis shows a statistically highly significant overestimation in the maxilla. Both analyses cannot be reliably applied to the South Indian population.

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DOI: 10.3897/folmed.66.e123181

Authors: Ausama Fathallh, Fouad Al-Sudani, Sabreen Almuhssen, Shaymaa Hassoon

Abstract: Introduction: Malnutrition in children is epidemic in developing countries. Several health issues and consequences are believed to develop due to this phenomenon. Children’s oral health is also affected by malnutrition. The main aspects of oral health status are caries experience, the existence of cariogenic bacteria, and salivary immunoglobulin A. Materials and methods: This comparative study included 87 school children aged 12 years. Participants with systemic disease were excluded. An oral examination was conducted to record the DMFT score, then saliva samples were collected in the morning using an unstimulated method. Salivary IgA were analyzed using Sandwich ELISA technology. Malnutrition was based on body mass index (BMI) which was computed as weight/height2 (kg/m2). Ethical approval was granted by the ethical committee at the Faculty of Dentistry. Informed consents from children’s parents were gained prior to the start of the study. Results: Compared to the normal weight group, the results of this study showed that overweight and obesity are inversely correlated with the mean DMFT and the number of S. mutans and S. sobrinus. Salivary IgA was negatively correlated with overweight and obesity, compared to normal weight group. Conclusions: Children suffering from malnutrition are at risk of developing oral health diseases. Treating malnutrition will therefore improve children’s overall oral health.

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DOI: 10.3897/folmed.66.e128602

Authors: Desislava A. Konstantinova, Dimo K. Nedelchev, Anna K. Nenova-Nogalcheva

Abstract: Introduction: A maxillary diastema (MD) is identified when the gap between the central incisors exceeds 0.5 mm. It poses an a and phonetic concern, often seen in mixed dentition and occasionally continuing into permanent dentition. Aim: The aim was to conduct a retrospective study on the epidemiology of maxillary diastema among patients in northeastern Bulgaria. Materials and methods: We analyzed 149 diagnostic plaster models of individuals with maxillary diastema with a mean age of 39.50±1.70 years. To ensure accuracy, we divided the patients into two age groups. People 35 years of age or younger were in the first age group. The second group consisted of those who were older than 35. Results: Size of maxillary diastema according to sex: the derived 95% confidence interval shows that in the group of patients who met the selection criteria in the study, with 95% certainty, the width of the maxillary diastema was expected to be in the range of 1.389 mm to 1.754 mm. The median maxillary diastema width in males was 1.45±0.78 mm. The median maxillary diastema width in females was 1.41±0.24 mm. Size of maxillary diastema according to age: data analysis indicates that the average size of a maxillary diastema was 1.43±0.24 mm among those under 35. In such individuals, the maxillary diastema width ranged from 1.07 mm to 2.20 mm, with 1.07 mm being the lowest recorded value. Maxillary diastema in those over 35 had a maximum measurement of 7.88 mm and a minimum of 1.05 mm. The median width of maxillary diastema in the analyzed 149 models was 1.46±0.23 mm. Conclusion: Patients’ smiles and dental as are subject to the strict a standards set by modern society. This causes one to examine small details like the distance between one’s central incisors and feel compelled to have them adjusted. Examining the maxillary diastema width in relation to age and sex facilitates a prompt selection of materials and fabrication methods, leading to outstanding functional and a results from the treatment that is performed.

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DOI: 10.3897/folmed.66.e127454

Authors: Muna Saleem Khalaf, Alhan Ahmed Qasim, Zainab Juma Jafar, Ahlam Taha Mohammad

Abstract: Introduction: Streptococcus mutans and lactobacilli are most important bacteria in the pathogenesis of dental caries. Cariogenic microflora has been associated to the primary caregiver transmission and sugary diets. Aim: This study aimed to relate S. mutans and lactobacilli in the plaque to demographic factors in Iraqi children. Materials and methods: The study included 135 children aged 3-10 years. Samples of their dental plaque were taken from the upper second primary molars on the buccal surfaces using a clean toothpick. Each sample was stored in 1 ml of normal saline followed by dispersion for 30 seconds using Vortex mix. Before inoculation, serial dilutions were done. Inoculation was done in the selective media for each microorganism: mitis salivarius-bacitracin agar for S. mutans and Rogosa agar for lactobacilli. The bacterial count was estimated by counting CFU and a dissection microscope (×15). A questionnaire on the demographic factors was sent to each child to be filled in by their parents. Results: S. mutans was demonstrated to be greater in the dental plaque of 3-6-year-old children whose mothers are housewives, groups that add sugar to milk, groups without any history of systemic disease, mother’s age, and normal-weight children, whereas lactobacilli increased in the plaque of children aged 7–10 years, women, children with fathers who are government employees, mother’s occupation, children who were not nursed during sleep, father’s age, normal weight, and times of teeth brushing. Conclusion: S. mutans and lactobacilli are clearly associated with different demographic factors. Education of parents and children has an effective impact on controlling their number, reducing dental caries.

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DOI: 10.3897/folmed.66.e123766

Authors: Krikor Giragosyan, Ivan Chenchev, Vasilena Ivanova

Abstract: Aim: The aim of this randomized clinical trial was to compare the qualitative (linear alveolar ridge changes) and quantitative (healing complications) outcomes after guided bone regeneration (GBR) using a custom-made 3D printed titanium mesh versus titanium reinforced dense PTFE membrane for vertical and horizontal augmentation of deficient alveolar ridges. Materials and methods: Forty patients (40 defect sites) were included in the analysis. The patients were divided into two groups – a test group that received custom made Ti mesh and a control group which received a titanium reinforced dense polytetrafluoroethylene membrane. This case series documented consecutive patients treated with vertical bone augmentation to facilitate the future placement of dental implants. The procedure was performed using xenograft and autograft in a ratio of 1:1. Baseline vertical and horizontal deficiencies, acquired bone height and width as well as absolute bone gain (height and width) were recorded radiographically; postoperative complication rate was recorded clinically. Results: The absolute bone height acquired for the test group was 3.65±1.73 mm, and for the control group - 4.24±2.19 mm; the absolute bone width acquired for the test group was 2.48±1.03 mm and for the control group - 2.60±0.82 mm. Postop complication rate was 33.3% for the test group and 38.9% for the control group. Conclusion: The use of a custom-made 3D printed titanium mesh for needs of vertical and horizontal guided bone regeneration showed results comparable to those of – Ti d-PTFE both in terms of height and width gain and complication rate.

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DOI: 10.3897/folmed.66.e116056

Authors: Zlatina Tomova, Yanko Zhekov, Angelina Vlahova

Abstract: Fractures in esthetic ceramic veneering are one of the potential failure modes during prosthetic treatment. Depending on the type of chipping fracture, there are three possible outcomes: replacement, restoration repair, or polishing of the fractured area. Computer-aided design and manufacturing (CAD/CAM) technologies provide new methods to the maintenance and repair of fixed metal-ceramic restorations. Here, we report the case of a 68-year-old patient who came to the dentist with comcerns about his appearance due to spontaneous gingival bleeding and a fracture in the ceramic veneering of a metal-ceramic restoration. The patient reported occurrences of bruxism. The proposed treatment plan included consultation with a cardiologist, periodontal treatment, polishing of the chipped areas, repair of the fractured zone with an exposed metal core, and fabrication of a mouth guard. Once the ceramic veneering on the palatal and buccal sides of the retainers had been completely removed, a digital impression was obtained and sent to the dental lab so that milled zirconium veneer could be manufactured. The veneering was cemented the next day using the standard prosthetic field preparation process and resin-modified glass ionomer cement. In conclusion, fixed metal-ceramic restorations that have fractured can be successfully repaired using CAD/CAM methods and materials.

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DOI: 10.3897/folmed.66.e119114

Authors: Asel Usdat Ozturk, Ekin Dogan, Venus Seyedoskuyi, Berk Senguler, Asli Topaloglu-Ak

Abstract: Aim: The aim of this study was to compare the effectiveness of filling pastes in resin prototype primary molars by cone beam computed tomography (CBCT) and 3D modeling. Materials and methods: The canals of 27 primary second molar teeth models were shaped with a rotary endodontic motor to file No. 30/04. The samples were randomly divided into three groups and filled with calcium hydroxide-distilled water, Viopex, and calcium hydroxide-propylene glycol, respectively (n=9). Pre-filling and post-filling CBCT images of the shaped canals were obtained, 3D models were reconstructed with MiMiCS® software and volume measurements were made in cubic millimeters (mm3). Differences between the volume of the shaped canals and filling materials were calculated as the miss-filling areas of various filling materials were also recorded. Dependent 2-group I-test, Bonferroni test, and one-way analysis were used for statistical analysis. Data were statistically analyzed at p<0.05 significance level by IBM SPSS 25 software. Results: Among the three root canal sealers, the filling capacity of the calcium hydroxide-propylene glycol group was found to be the highest (p=0.001). Conclusion: When calcium hydroxide mixed with propylene glycol was compared to calcium hydroxide alone, calcium hydroxide demonstrated a greater potential for root canals in primary maxillary second molar models. It is clear that clinical studies with follow-ups of the subjects will contribute to literature and clinical success.

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DOI: 10.3897/folmed.66.e115709

Authors: Prashant Sharma, Amol Patil, Sonakshi Sharma, Tanisha Rout, Pragati Hemgude, Anand Sabane

Abstract: Aim: The aim of this study was to evaluate specific single nucleotide polymorphisms (SNP) of transforming growth factor-beta (TGF-β) (rs1800469) and insulin-like growth factor-1 (IGF-1) (rs17032362) genes in Class II individuals with a normal maxilla and retrognathic (short) mandible. Materials and methods: The study had 25 participants: 5 were assigned to the control group, which had a normal maxilla and mandible, and 20 to the experimental group, which had a structurally retrognathic mandible and a normal maxilla. The polymerase chain reaction was used with preselected primers after which Sanger sequencing was used to identify individual mutations. Results: SNP at rs1800469 (TGF-β) in the study and control groups showed significant difference (p=0.009). The Odds Ratio of 5.28 signified that the individuals with SNP at rs1800469 were at 5.28 times higher risk of developing mandibular retrognathism. The IGF SNP showed its presence in experimental group but was not statistically significant. Conclusion: Our study reports for the first time on the association between TGF-β SNP and mandibular retrognathism. Other SNP also showed its presence in the study group and its complete absence from control group directs us for further research.

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DOI: 10.3897/folmed.66.e122678

Authors: Lyubomir I. Chenchev, Vasilena V. Ivanova, Ivan L. Chenchev, Hristo I. Daskalov

Abstract: Introduction: Tooth extraction is still one of the most common dental procedures, routinely performed for a variety of reasons. Tooth extraction forceps and elevators are well-known extraction instruments which have been the standard in tooth extraction procedures for well over a hundred years. Physics forceps are one possible alternative, aiming to perform less traumatic and more predictable extractions. Aim: The aim of study was to compare the effectiveness of physics forceps as an alternative, less traumatic, tool to the conventional extraction forceps. Materials and methods: All patients in the study were split into two groups: 26 patients in whom conventional extraction forceps were used (a control group) and 28 patients in whom we used physics forceps (a study group). For each group, we assessed the success of the extraction, the buccal cortical plate preservation, pain experience, and early wound healing. Results: There was no statistically significant difference in extraction success scores between the two groups. Physics forceps extractions preserved the buccal cortical plate in 81.1% of instances, while traditional forceps extractions did so in 71.8%. The patients in the study group reported less pain on the seventh day. At 10 days, the study group had a marginally higher proportion of completely healed extraction wounds. Conclusions: Atraumatic extractions preserve more hard and soft tissues at the extraction site. Physics forceps are a tool similar to the well-known conventional extraction forceps. They provide for somewhat better results in most extractions.

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DOI: 10.3897/folmed.66.e115083

Authors: Ayser Najah, Raghad Fadhil, Hadeel Mazin Akram, Rasha Salah

Abstract: Introduction: Specific bacterial plaque and environmental factors cannot be considered the only cause of periodontitis. Still, several genetic factors affect the host response to the bacteria, like gene polymorphisms in anti-inflammatory cytokines. Several studies have reported that clones of T-helper 2 lymphocytes (TH2) are generated in response to dental plaque in periodontitis patients, while in healthy individuals, they are regulated by T-helper 1 (TH1) lymphocytes. Accordingly, such patients consistently produce more IL-4 (TH2) in response to bacterial stimulation, whereas healthy controls with intact periodontal tissues produce a significantly higher level of TH1. Aim: The current work aimed to investigate the association between variations in IL-4 gene polymorphisms and susceptibility to periodontitis. Materials and methods: The current study employed a case-control observational methodology involving 120 Iraqi participants. These participants were divided into two groups: the periodontitis group, consisting of 63 subjects, and the control group, consisting of 57 subjects. Clinical periodontal parameters were assessed for all participants, and subsequent genetic analysis of IL-4 was conducted using DNA sequencing. Venous blood samples were collected from each participant enrolled in the study. SPSS was used to conduct descriptive and inferential statistical analyses, including odds ratio, Hardy-Weinberg equilibrium, and Pearson correlation. Results: The Hardy-Weinberg equilibrium for study groups regarding the rs1801275 and rs1805016 polymorphisms of IL-4 showed a non-significant difference between the observed and expected genotypes in both groups involved in the study and the overall sample. Moreover, there was no significant association between the IL-4 gene polymorphism and the clinical periodontal parameters. Conclusion: The research conducted revealed a lack of correlation between IL-4 gene polymorphism and the susceptibility to periodontitis in individuals from Iraq. More research with a bigger sample size is required to validate these findings.

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DOI: 10.3897/folmed.66.e119961

Authors: Edon Behluli, Enis Veseli, Argjira Veseli

Abstract: Aim: This study aimed to analyze the oral health conditions of pregnant women. The analysis involves evaluating two key indices: the decayed, missing, and filled teeth (DMFT) index and the basic erosive wear examination (BEWE) index. Furthermore, this study investigated potential correlations between calcium (Ca) and phosphate (P) levels within specific time intervals and the aforementioned oral health indices. Materials and methods: This study included 66 women. The examination consisted of assessing the condition of the teeth by using the DMFT index. Additionally, the erosive decay of the teeth was evaluated according to the BEWE index. Salivary concentrations of Ca and P were determined using a colorimetric method. These measurements were performed during the first (T1) and third (T3) trimesters of pregnancy. Results: The study results showed that the DMFT index value in T3 was significantly higher compared to that in T1. However, there were no significant differences in BEWE index values between the two time intervals. Furthermore, notable differences were observed in the levels of Ca and P between T1 and T3 (Z=4.87, p=0.000 and Z=2.95, p=0.003, respectively). Nevertheless, the analysis of the relationship between DMFT/BEWE indices and Ca and P levels found no significant correlation. Conclusions: The results suggest that the third trimester poses a greater oral health burden. Additionally, there were notable fluctuations in the Ca and P levels during pregnancy. These findings shed light on the correlation between pregnancy phases and oral health indicators, emphasizing the significance of the salivary composition.

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DOI: 10.3897/folmed.66.e118377

Authors: Mariya Dimitrova, Angelina Vlahova, Raycho Raychev, Bozhana Chuchulska, Rada Kazakova

Abstract: Introduction: The worldwide application of digital technology has presented dentistry with transformative opportunities. The concept of digital dentures, incorporating computer-aided design (CAD) and computer-aided manufacturing (CAM) techniques, holds the promise of improved precision, customization, and overall patient satisfaction. However, the shift from traditional dentures to their digital counterparts should not be taken lightly, as the intricate interplay between oral physiology, patient comfort, and long-term durability requires thorough examination. Aim: The aim of the present study was to evaluate and compare the dimensional changes of 3D printed (NextDent, 3D Systems, The Netherlands) and conventional heat-cured (Vertex BasiQ 20, 3D Systems, The Netherlands) denture base resin after immersion in artificial saliva for different periods (7, 14, and 30 days) and then applying 3D simulated deformation, tensional strength, and stress, using the ANSYS software (ANSYS Inc., Pennsylvania, USA). Materials and methods: For the manufacturing of the test specimens, an STL file was created, using the Free CAD Version 0.19 (Free CAD, Stuttgart, Germany). The dimensions of each specimen were 20 mm in width, 20 mm in length, and 3 mm in thickness. Two hundred experimental bodies were created and divided into two groups (n=100), with half fabricated using a 3D printer (NextDent 5100, NextDent, 3D Systems, The Netherlands) and the other half prepared using the traditional method of heat-curing polymerization in metal flasks. The test samples were then weighed using an analytical balance, immersed in artificial saliva for three periods (7, 14, and 30 days), and reweighed after water absorption. After desiccation at 37°C for 24 hours and then at 23±1°C for 1 hour, the samples were weighed again. Then the data were entered into the specialized program ANSYS and the 3D simulation tests for deformation, tension, and stress were performed. Statistical analysis was performed using the IBM SPSS Statistics Version 0.26 statistical software, which includes descriptive statistics and one-way ANOVA analysis. Results: The findings weren’t statistically significant and indicated that the average metrics for the 3D-printed experimental test samples were marginally greater than those recorded for the conventional samples. Conclusions: Within the limitations of this study, it is possible to conclude that 3D-printed resin has a lower capacity to withstand deformation, tension, and stress under simulated conditions than conventional dental resin. However, they do not exceed the values accepted by the ISO standard for clinical application of this type of material.

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DOI: 10.3897/folmed.66.e115790

Authors: Antonia Palankalieva, Ani Belcheva-Krivorova

Abstract: Silver compounds have been used in medicine and dentistry for centuries. Their use in pediatric dentistry has long been restricted because of some drawbacks, chief among them being the discoloration of teeth with black stains. However, recent advances in technology have resulted in the development of new silver agents that do not have the limitations of previously used ones. This led to the reintroduction of silver compounds in pediatric dentistry. The aim of the present review was to examine the evidence supporting the therapeutic use of silver compounds in pediatric dentistry for caries arrest, as well as the mode of action and biocompatibility, characteristics, advantages, and disadvantages of different silver-containing agents.

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DOI: 10.3897/folmed.65.e100418

Authors: Janet Kirilova, Dimitar Kirov, Dimitar Yovchev, Elitsa Deliverska

Abstract: Apical cysts are typically caused by dental pulp disease and are difficult to treat. In the majority of cases, surgical intervention is required. The rate of success after apical osteotomy varies between 60% and 91%. The introduction of platelet concentrates in treating chronic apical periodontitis is a promising direction for achieving quick and secure results. This article examines the healing of a sizable apical cyst after conservative surgical intervention and the application of platelet concentrate. We present the case of a patient with a large apical cyst (0.799 cm3) of teeth 24 and 25 which was treated in this study. The precise endodontic treatment was performed with regenerative components such as gaseous ozone and EDTA irrigation. Apical osteotomy was performed, followed by inserting advanced platelet-rich fibrin plus (A-PRF+) into the surgical wound. Nine months after treatment, the bones of teeth 24 and 25 were fully healed without any changes to the sinus and nine months after surgically removing the radicular cyst, rapid and complete tissue repair was demonstrated.

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DOI: 10.3897/folmed.65.e111609

Authors: Nikolay Kanazirski, Deyan Neychev, Ralitsa Raycheva, Nikolay Zahariev

Abstract: Introduction: Various rotary and mechanical instruments are used in conventional oral surgery for osteotomies. Despite the implementation of effective cooling systems, it is difficult to prevent thermal damage to the adjacent bone caused by heat generated during the procedure. A smear layer forms on the surface, which can impede the interaction of blood elements with the underlying tissue, resulting in a delayed healing process. Aim: This study explores the possibility of overcoming these drawbacks by combining conventional methods with a pulsed Er:YAG laser. By examining the osteotomy surfaces using scanning electron microscopy (SEM), we investigated the potential synergistic effects that could benefit conventional implantology. Materials and methods: Split osteotomies were performed on mandibles of freshly euthanized domestic pigs (Sus scrofa domestica). With osteotomy surface examination, the experimental comparison involved two groups: group A - standard technique, and group B - surface ablation using an Er:YAG laser by applying our own method. The samples from both groups were examined using scanning electron microscopy (SEM). Results: In group A samples, the bone surface was smooth, with an amorphous layer and microcracks all over it. The thickness of this layer ranged from 21.77 µm to 136.2 µm, completely obstructing the Volkmann’s and Haversian canals. In group B, the borders were smooth and well defined. The bone structure remained unchanged, with empty intratrabecular spaces, no signs of carbonization, and open canals reaching the surface. The smear layer measured between 3.054 µm and 47.26 µm, with complete absence observed in some places. Conclusions: The present study provides evidence that ablation of the osteotomy surface using an Er:YAG laser leads to biomodification by eliminating the smear layer without altering the parameters of the bone bed.

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DOI: 10.3897/folmed.65.e107299

Authors: Yoan Y. Stoev, Todor Ts. Uzunov, Nikolina S. Stoyanova, Raya G. Grozdanova-Uzunova, Dimitar N. Kosturkov, Iva K. Taneva

Abstract: Aim: The purpose of this study was to compare the mechanical properties of materials used for orthodontic retainers made by direct 3D printing and thermoforming. Materials and methods: Twenty-one specimens (n=7) from 3 different materials (Formlabs Dental LT Clear V2 - Formlabs Inc., Somerville, Massachusetts, USA; NextDent Ortho Flex - Vertex-Dental B.V., Soesterberg, The Netherlands, and Erkodent Erkodur - ERKODENT, Germany) were manufactured and their mechanical properties were evaluated. Two of the specimen groups were 3D printed and the other one was fabricated using a material for thermoforming. The statistical methods we applied were descriptive statistics, the Kruskal-Wallis and Dunn’s post-hoc tests. Results: With respect to Young’s modulus (E), the Kruskal-Wallis test (df=2, χ2=17.121, p=0.0002) showed a significant difference between the materials for direct 3D printing of orthodontic retainers (E=2762.4 MPa±115.16 MPa for group 1 and 2393.05 MPa±158.13 MPa for group 2) and thermoforming foils (group 3, E=1939.4 MPa±74.18 MPa). Statistically significant differences were also found between the flexural strength (FS) (Kruskal-Wallis test, df=2, χ2=17.818, p=0.0001) and F(max) (Kruskal-Wallis test, df=2, χ2=17.818, p=0.0001). Conclusions: The materials tested in the current study showed statistically significant differences in their Young’s modulus, flexural strength, and F(max).

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DOI: 10.3897/folmed.65.e107180

Authors: Vladimir Bogdanov

Abstract: Introduction: Maximal bite force is an important determinant of masticatory function and is essential for the estimation of dental status. Bite force is usually measured by gnathodynamometry. Aim: The aim of the study was to investigate the type of correlation between the electromyographic activity of the masticatory muscles and the bite force during simultaneous measurement and to evaluate the use of EMG activity as an option for indirect determination of the bite force. Materials and methods: The study included 68 people (33 men and 35 women) with a mean age of 18.4±6.1 years. The bite force and the sEMG were measured in all 68 subjects consecutively on the right and the left side during maximal (1) and submaximal (2/3 and 1/3) clenching. Statistical analysis was performed by IBM SPSS Statistics, version 23.0. Results: EMG activity and maximal bite force values did not show significant differences on the left and right side. Linear relationship was found for the association bite force: EMG activity for the masseter muscle during maximal and submaximal (2/3) clenching, while for 1/3 clenching force the association was lost. For the temporalis muscle, this relationship was linear for the left side during maximal and submaximal 2/3 clenching and non-linear for the right side. During 1/3 clenching, the linearity was lost on both left and right sides. Conclusions: The masseter muscle shows stable linear relationship between BF and EMG on both sides and can be considered reliable for indirect estimation of the bite force by measuring the EMG potentials. During low occlusal forces (1/3) the linearity of both masseter and temporalis muscles is decreased or lost.

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DOI: 10.3897/folmed.65.e102907

Authors: Mihail Zh. Tanev, Iliyan N. Dobrev

Abstract: Introduction: In dental medicine, photodynamic therapy is a promising treatment for bacterial infections. Oral biofilms, on the other hand, can produce an extracellular matrix that provides protection and stability against external forces. Materials and methods: In this pilot study, we investigate the relationship between a prototype extracellular matrix and the efficacy of photodynamic therapy with three different photosensitizers. To assess the efficacy of the photodynamic therapy, we use culture analysis of the colony-forming units (CFU) and diffusion kinetics microscopy using fluorescence recovery after photobleaching (FRAP). Results: Our results show evidence of decreased efficacy of the photodynamic process in the presence of extracellular matrix, as observed in experimental culture models and in direct FRAP observation. Additionally, the mathematically modeled diffusion coefficients of the used photosensitizers suggest low diffusion of these molecules in the prototype extracellular matrix. Conclusions: The presence of an extracellular matrix in oral biofilms may reduce the efficacy of photodynamic therapy in dentistry. These findings highlight the need for further investigation into the development of photosensitizers with better diffusion properties in extracellular matrix. Overall, this study provides valuable insights into the potential limitations of photodynamic therapy in dental medicine.

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DOI: 10.3897/folmed.65.e90085

Authors: Azam Akhavan, Sepideh Arab, Negin Eslamiamirabadi, Ahmad Sodagar, Fatemeh Safari

Abstract: Aim: Nanopropolis has become the subject of interest in medicine and dentistry as a natural product due to its outstanding properties, particularly antimicrobial activity. This study aimed at investigating the effect of nanopropolis on flexural strength of polymethyl methacrylate (PMMA). Materials and methods: Three groups of two acrylic resin brands namely Acropars and Triplex containing 0 (control group), 0.5%, and 1% of nanopropolis were prepared in 64×10.0×3.3 mm according to ISO 20795-2 (2013). Fifteen samples were allocated to each concentration. Flexural strength was determined following immersion in water and incubation at 37°C for 50±2 hours using a universal testing machine at a crosshead speed of 5±1 mm/min. Data were analyzed using ANOVA, Tukey HSD, and t-test. P<0.05 was set as statistical significance. Results: Control groups of Acropars and Triplex showed the highest mean flexural strength within their own group which both were higher than the recommended 50 MPa. The mean flexural strength of Triplex incorporated with 0.5 and 1% of nanopropolis was higher than that of Acropars with the same percentage. Conclusions: The mean flexural strength of Triplex remained above the recommended value of 50 MPa after incorporation of both 0.5 and 1% nanopropolis. However, that of Acropars dropped below it.

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DOI: 10.3897/folmed.65.e94741

Authors: Vladimir Bogdanov, Miroslava Dinkova, Diana Tsakova

Abstract: Introduction: Myofunctional appliances have been shown to have a positive effect on the muscles in the facial area. Surface electromyography (sEMG) is one of the reliable methods used to investigate these effects. Aim: The aim of this follow-up study is to evaluate the effect of a myofunctional appliance T4K on the perioral and masticatory muscles in patients with class II subdivision 1 malocclusion by sEMG. Materials and methods: Sixteen children were treated with a Trainer appliance (T4K) for 9 months. The appliance should be worn every day for 1 hour and overnight. The EMG recordings were performed at the beginning and at the end of the Trainer therapy. The anterior temporal and masseter muscles were examined during maximal clenching. The orbicularis oris and mentalis muscles were examined during swallowing and sucking. Statistical analysis was performed using IBM SPSS Statistics version 23.0. Results: The EMG values of the anterior temporal and masseter muscles during clenching increased significantly as a result of the treatment (p<0.05). At the end of the observation period, the EMG values of the mentalis muscle did not change during both sucking and swallowing (p>0.05), while the values of the orbicularis oris muscle increased significantly during sucking and swallowing (p<0.05). Conclusions: As a result of the treatment with Trainer appliance, the EMG activity of the perioral and masticatory muscle significantly increased, while no change was observed in the electrical activity of the mentalis muscle.

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DOI: 10.3897/folmed.65.e97183

Authors: Egemen Sezen, Umut Kaya, Asli Topaloglu Ak, Miray Ay

Abstract: Introduction: Silver diamine fluoride (SDF) is a topical agent that has recently gained popularity for its ability to stop and prevent dental caries. Aim: The aim of this study was to evaluate the effect of SDF applied to class I cavities of extracted non-caries molar teeth on the fracture resistance of CAD/CAM block. Materials and methods: Twenty eight extracted noncarious molars were selected for the study. They were divided into two groups (n=14 per group). In each tooth, a diamond head was used to create Class I cavities that were 2 mm deep and 2 mm wide. The fracture strength test was carried out by applying a force at a speed of 5 mm/min, while continuously increasing the long axis of the tooth at the point corresponding to the central fossa. Results: SDF application did not have a statistically significant effect on fracture resistance in teeth restored with Class I cavities CAD/CAM blocks. The two groups did not differ statistically significantly according to the two-way ANOVA [mean fracture force (N) ± standard deviation: without SDF 1138.19±581.65 and with SDF 1067.93±555.65; p=0.712]. Conclusions: This study showed that SDF did not have either a positive or negative effect on the fracture resistance for restoration or easy application in cavities. Long-term clinical studies with different mechanical tests are needed for the safe use of SDF in pre-restoration cavities with CAD/CAM blocks.

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DOI: 10.3897/folmed.65.e98856

Authors: Maksym Skrypnyk, Tatiana Petrushanko, Karine Neporada, Nataliia Vynnyk, Margarita Skikevych, Igor Skrypnyk

Abstract: Aim: The aim of the study was to examine the association between periodontal health in young patients with various body mass indexes and psychological traits such as temperament, level of anxiety, and autonomic nervous system tone. Materials and methods: The study included 132 male and female subjects aged 18–22 years with different body mass indexes (BMI). They were allocated into four groups by their BMIs: normal weight, overweight, and first- and second-degree obesity. We completed periodontal charts for all patients and evaluated basic oral hygiene and periodontal indexes, such as the Green-Vermillion index (OHI), the approximal plaque index by Lange (API), and papilla bleeding index by Saxer & Mühlemann (PBI). Eysenck personality questionnaire, the state-trait anxiety inventory of Spielberger-Khanin, and Wayne questionnaire were used to determine the psychological characteristics. Results: Patients with the first and second degrees of obesity were found to have the highest prevalence and severity of generalized gingivitis (up to 90%). Patients with normal BMI had significantly lower levels of extraversion and higher levels of neuroticism than the obese individuals, while subjects with extra weight and normal BMI were more emotionally stable. We found no evidence that choleric or melancholic temperament had an impact on BMI or periodontal health. However, phlegmatic temperament was found to be linked to a normal BMI, good oral hygiene, and an intact periodontium, while sanguine temperament was linked to obesity and gingivitis in young adults. A significantly higher level of state and trait anxiety was observed in obese individuals. Fifty percent of the obese subjects had disturbances of the functional state of the cardiovascular system and the tone of the autonomic nervous system. Conclusions: Because obesity and periodontal pathology are multifactorial diseases linked to lifestyle, stress tolerance, and habits, personality temperament may play a causal role in their development.

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DOI: 10.3897/folmed.65.e99682

Authors: Gergo Mitov, Roman Kilgenstein, Philipp Partenheimer, Serge Ricart, Dennis Ladage

Abstract: Introduction: Infective endocarditis is a serious infection of the endocardium, especially the heart valves, which is associated with a high mortality rate. It generally occurs in patients with altered and abnormal cardiac architecture combined with exposure to bacteria from trauma and other potentially high-risk activities with transient bacteremia. Aim: The aim of the study was to develop a reproducible periodontitis-endocarditis model in a rat that can be used to answer the question of how the administration of antibiotic prophylaxis before tooth extraction affects the prevalence of bacteremia and the incidence of endocarditis. Materials and methods: Thirty-five female Wistar rats were divided into three groups: periodontitis group (PG): ligatures were placed bilaterally on maxillary first molars, and the maxillary molars were extracted after 30 T; endocarditis group (EG): in addition to PG, aortic valve injury was performed with simulated prosthetic material before extraction; antibiotic prophylaxis group (AG): in addition to EG, a single-shot antibiotic administration was performed 30–60 minutes before extraction. Periodontal indices were collected, blood samples were microbiologically analyzed. Hearts were examined histologically after euthanasia. Results: On the day of extraction, 93% of the ligatures were still in situ. The average approximal plaque index of maxillary first molars was 92%. The average papilla bleeding index according to Saxer and Mühlemann of the first molar in the first quadrant was grade 3, in the second quadrant – grade 2. The average probing depth of the first molar in the first quadrant was 3 mm, in the second – 2 mm. Endocarditic changes were identified in 20% in the AG group, 60% in the EG, and 0% in the PG control group. A successful model was developed by reliably developing endocarditis and periodontitis. Specific marker germs for periodontitis could be detected in blood cultures. The effectiveness of antibiotic prophylaxis prior to tooth extraction in groups at risk of endocarditis has been demonstrated in animal models. Conclusions: In the present experimental animal study, a reproducible model could be developed by creating a manifest periodontal lesion, which, in connection with an aortic valve lesion and a tooth extraction, triggers bacteremia. Clinical relevance The model could act as a basis for further studies on the topic to answer remaining questions related to oral pathogens and IE.

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DOI: 10.3897/folmed.65.e73531

Authors: Zlatina Tomova, Atanas Chonin, Iliyana Stoeva, Angelina Vlahova

Abstract: Introduction: CAD/CAM technologies are becoming widely used for the production of metal ceramic dental restorations. Powder Co-based alloys are developed for selective laser melting. The corrosion resistance of the dental alloy affects the biocompatibility, functional suitability, and longevity of the prosthetic restoration. Aim: The aim of this study was to evaluate and compare the corrosion resistance of a cobalt-chromium dental alloy for porcelain-fused-to-metal (PFM) crowns produced for selective laser melting technique in clinical and laboratory conditions. Materials and methods: PFM crowns were made for 35 patients using CAD/CAM technology. The metal copings of the crowns were made of the EOS CobaltChrome SP2 alloy (EOS, Germany). Eocp measurements were conducted 2 hours and 7 days after fixing the restorations in oral cavity. The digital files of patients’ designed copings were used for the production of another 35 specimens, which were placed in artificial saliva. Eocp measurements were conducted after the same periods. Results: In vitro studies showed high corrosion resistance after the short 2-hour stay. After 7 days in artificial saliva, the corrosion resistance became even higher probably due to strong passivation. In clinical conditions, Eocp values were slightly higher than the normal range 2 hours after fixing the crowns. Seven days after fixing, the Eocp values showed a decrease of corrosion resistance of the PFM crowns. The cause of the decrease may be interaction with other metal objects or specific conditions of the oral cavity. Conclusions: The investigated alloy showed high corrosion resistance in in vitro settings. Clinical research revealed that PFM crowns had lower corrosion resistance. Further observation and research are required.

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DOI: 10.3897/folmed.65.e90408

Authors: Lilyana Shtereva, Veselina Kondeva

Abstract: Introduction: The majority of researchers agree that sealants need to be monitored and kept in good condition because even a small amount of sealant loss raises the possibility of developing caries lesions. The first year after application is when sealant loss is reported to be at its highest. This motivated us to monitor silanized patients who received resin-based sealant for a full year. Aim: The aim of this study was to monitor the retention of resin-based sealant on fully erupted first permanent molars in children aged 7-8 years. Materials and methods: Prior to sealant application, all first permanent molars included in the study were subjected to visual diagnostics using the ICDAS II system and diagnostics with VistaCamiX Macro using the same system. Silanization was performed according to the indications. The follow-up checks were performed at 3, 6, and 12 months in accordance with the accepted methodology. Results: At the end of the first year, completely lost sealant was reported in approximately 8%-9% of the monitored surfaces using various diagnostic methods. Conclusions: Resin-based sealants are suitable for application on occlusal surfaces of teeth when it is possible to properly isolate the field of work. They provide both an excellent prophylactic effect of caries and very good retention.

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DOI: 10.3897/folmed.65.e85525

Authors: Manoela Kalaydzhieva, Silviya Krasteva, Mariya Stoilova-Todorova, Katya Todorova-Plachyiska, Konstantin Georgiev

Abstract: Introduction: The main goal of orthodontic retention is to keep the teeth in their corrected positions. Fixed or removable retainers are the most common types of retainers used during the retention phase. For the maxilla, various types of retainers have been described, including the vacuum-formed retainers and Hawley retainers. Fixed retainers are used for the lower jaw. Aim: The aim of the present study was to assess the retention characteristics of Hawley retainers, vacuum-formed retainers, and fixed retainers in preserving dental arch dimensions and tooth alignment. Materials and methods: Seventy subjects were examined and distributed into two retention groups. One of the groups received maxillary Hawley retainers and bonded retainers in the mandible. The other group received maxillary vacuum-formed retainers and bonded retainers in the mandible. The mean retention period was two years. Maxillary and mandibular casts were analyzed at pretreatment, debonding, and two years in retention. The assessed measurements were the arch length, intercanine width, interpremolar width, intermolar width and Little’s irregularity index. Results: Vacuum-formed retainers maintained maxillary anterior teeth alignment more effectively than Hawley retainers did. No differences in transversal dimensions were found between the two retention protocols. Hawley retainers showed superior retention characteristics in maxillary arch length preservation compared to vacuum-formed retainers. Even with bonded retainers, relapse could still happen. All measured variables showed a tendency to relapse to the pretreatment values in the two groups. Conclusions: Vacuum-formed retainer maintained maxillary incisor position more effectively than Hawley retainers did. No differences were observed in the transversal dimensions between the two groups. A greater decrease in the mandibular intermolar width was measured between T1 and T2 in both groups where bonded retainers were used.

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DOI: 10.3897/folmed.65.e80275

Authors: Zdravka Pashova-Tasseva, Antoaneta Mlachkova, Ekaterina Tosheva

Abstract: Aim: The aims of the present study were to explore the relations between the gingival phenotype (GP) and the periodontal health status and find the prevalence of a specific gingival phenotype in a small Bulgarian population. Materials and methods: We recruited 50 patients attending our dental practice with different periodontal diagnoses. A detailed periodontal status was taken to assess the diagnosis of each participant. Several clinical methods for evaluation of the gingival thickness and keratinized tissue width, including the TRAN method, transgingival probing, and direct measurement, were used. The data were summarized and analyzed statistically. Results: We found a significant prevalence of the thick gingival phenotype, in particular the thick flat type. The patients with periodontitis had a higher distribution of the thick gingival phenotype, while in those with gingivitis, the thin scalloped gingival phenotype was noted. In regards to the gingival thickness (GT), 36 participants were found to have GT >1 mm, and the remaining 14 had GT ≤1 mm. Statistically significant differences were found in the keratinized tissue width and the width of attached gingiva in the different gingival phenotypes. No significant differences were found in the age and sex of participants. Conclusions: We found a significant prevalence of the thick (with a mild prevalence of thick flat to thick scalloped) versus thin gingival phenotype in the studied sample. The highest relative proportion of patients with periodontitis was among the subsample of individuals with thick flat gingival phenotype. Regarding gingivitis, the highest proportion was in the thin scalloped phenotype subsample – 42.9%. The highest prevalence of periodontal health was among the individuals with thick scalloped GP (50%), followed by the thin scalloped GP (35.7%).

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DOI: 10.3897/folmed.65.e80063

Authors: Krasimir Hristov, Liliya Doitchinova, Natalia Gateva

Abstract: Introduction: The traditional treatment of immature permanent teeth with necrotic pulp involves creating an apical barrier by using calcium hydroxide or an MTA plug for an extended period of time. A novel therapeutic approach called regenerative endodontic procedures (REP) is used to allow root development to continue. Aim: To investigate the response of immature permanent teeth and necrotic pulp to REP using a modified clinical protocol involving minimal mechanical instrumentation and irrigation with 10% citric acid. Materials and methods: We treated 30 immature permanent teeth with necrotic pulp in 28 patients aged 7-14 years using a modified protocol for regenerative endodontics. The protocol included mechanical instrumentation of the root canal with the appropriate file for 2 minutes in total and irrigation with 10% citric acid. Results: The root walls increased their thickness in 28 (93%) of the treated cases. In 16 (53%) cases, we found radiographic signs of continued root development; in six (20%), there was thickening of the canal walls and closure of the apex but no elongation; in four (13%), there was obliteration of the root canal; in two (7%), there was healing of the periapical lesion without any change in the length of the root walls or closure of the apex; and only two cases (7%) showed no signs of healing, but the teeth remained asymptomatic. Conclusions: The use of mechanical instrumentation with the appropriate files in REP shortens the clinical protocol, which is advantageous when treating children’s dental issues.

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DOI: 10.3897/folmed.65.e76606

Authors: Nikolay Simeonov, Vesela Stefanova

Abstract: Aim: The purpose of this study was to analyze and compare the micromorphology of the hybrid layer and the dentinal surface when the dentin was prepared with an Er:YAG laser or burs, and to find if there was any difference if the time of application of the self-etching primer on the dentin prepared with an Er:YAG laser was doubled. Materials and methods: Fifteen freshly extracted human teeth with preserved crowns were selected. Three cavities were prepared on each extracted tooth. Two of the cavities were prepared with an Er:YAG dental laser, and the third with burs. A self-etching adhesive system was applied. The primer of the adhesive was labeled with Rhodamine B, and the bond was labeled with fluorescein prior to application. The teeth were sectioned mesiodistally through the cavities and the cavity of each sample was examined using a confocal laser scanning microscope. The infiltration and micromorphology were determined qualitatively on ninety samples. Results: The dentinal surface in the samples prepared with burs was smoother and with shorter resin tags than the surface prepared with an Er:YAG laser. When using an Er:YAG laser for preparation, crater-like irregularities of the surface were observed. In five of the samples prepared with burs, no resin tags were found. We could not detect any difference in the hybrid layer when the time of application of the adhesive system was increased. Conclusions: The clinical significance of the tag length and quality, as well as the infiltration ratio, needs to be further studied.

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DOI: 10.3897/folmed.65.e83093

Authors: Desislava R. Makakova, Svetlin Alexandrov, Angelina Vlahova

Abstract: Introduction: Gingival retraction is the withdrawal of the marginal gingiva away from the tooth. This procedure creates a space between the prepared tooth and the gingival tissues to catch more fine details of the impression material. The most common retraction device used in clinical practice is the retraction cord. Aim: The study aims to evaluate the tensile strength of retraction cords designed with different braiding technology. Materials and methods: A total of 150 experimental units were studied. They were divided into 3 groups of 50 each according to the type of retraction cord (Ultrapak #00, braided cord without core, and braided cord with monofilament core). We tested the tensile strength in the LMT 100 micro-tensile apparatus. The data were analyzed using SPSS v. 21. A critical significance level of p<0.05 is used. Results: The comparative analysis of the tensile strength of the retraction cords shows a statistically significant difference between the braided and the knitted threads (Ultrapak #00) (p<0.001). The results indicated the highest tensile strength of the cord with monofilament 41.95 N/mm2, followed closely by the cord with the same cotton braid without monofilament with average strength of 39.80 N/mm2, and last came the Ultrapak cord 22.11 N/mm2. Conclusions: The braided retraction cords show higher tensile strength compared to the Ultrapak #00 cord, which is made using knitting technology.

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DOI: 10.3897/folmed.65.e78138

Authors: Chris S. Ivanoff, Bogomil Andonov, Timothy L. Hottel

Abstract: Aim: The study queries a sample of dentists and dental assistants in Bulgaria about their understanding and perceptions of Expanded Function Dental Auxiliaries (EFDA). The study considers whether expanding the skillset of dental assistants to function in specific scenarios without personal supervision by the dentist may be a viable strategy to address various oral health inequities in the country. Materials and methods: An anonymous survey was conducted among 103 practicing dentists and 100 dental assistants throughout the country. The questionnaire consisted of 20 questions that probed respondents’ understanding about the duties performed by EFDAs and their potential to increase productivity and efficiency of the dental workforce. Sociological (poll) and statistical (alternative analysis) methods were used in the survey. Results: The majority of respondents were female. Most worked in the larger cities. One worked in a village. Most were ethnic Bulgarians and none were Roma, reflecting the racial imbalance in the national workforce. Two-thirds (67%) believed that dental assistants with appropriate training are capable of doing expanded dental procedures without personal supervision by a dentist. The majority (83.7%) believed that EFDAs could improve efficiency of a dental practice, while 58.1% indicated that with appropriate training, they could perform expanded duties as well as the dentist. However, only one third believed that EFDAs could increase practice output (38.9%); enhance the quality of the dentist’s work (37.4%); or decrease patient anxiety (31.5%). Though most respondents (78.3%) believed that a patient would not be receptive to an EFDA placing a restoration without personal supervision by the dentist, two thirds of respondents (66.5%) would like to see dental assistants trained to perform expanded duties otherwise reserved for dentists. Most respondents felt that EFDAs could help to build a well-functioning dental team. Conclusions: Most respondents believed that EFDAs can benefit the efficiency of a practice, suggesting that Bulgarian dental professionals would respond favorably to enhancing the skillset of assistants with expanded functions. The study suggests they are skeptical about “general” versus “personal” supervision. EFDAs may potentially provide improved access by underserved communities, while building a more inclusive oral healthcare workforce reflective of the population.

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DOI: 10.3897/folmed.65.e78621

Authors: Ülkü Tuğba Kalyoncuoğlu, Sara Samur Ergüven

Abstract: Introduction: The success of implant therapy is strongly related to the perceptions and expectations of the patients. Aim: This study aimed to assess the level of social appearance anxiety and oral health-related quality of life in middle-aged adults with implant-supported fixed prostheses and compare with individuals who have tooth loss without any prosthetic rehabilitation or who have natural teeth. Materials and methods: The participants (n=292) were divided into three groups: group 1, individuals with implant-supported fixed dental prostheses; group 2, individuals with tooth loss; and group 3, individuals with totally natural teeth. A questionnaire form including basic questions, Social Appearance Anxiety Scale (SAAS), and Oral Health Impact Profile-14 (OHIP-14) was distributed among patients. Results: Group 2 showed a significantly higher level of SAAS and OHIP-14 scores compared with groups 1 and 3 (p<0.001). The SAAS scores were similar between groups 1 and 3, with no significant differences. The median OHIP-14 score was the lowest in group 3. For all groups, education was related to SAAS and OHIP-14 scores (p=0.037 and 0.002, respectively). The SAAS and OHIP-14 scores were significantly and positively related (p<0.001, r=0.501). Conclusions: It was concluded that patients with tooth loss had higher levels of SAAS and OHIP-14 scores. Besides, the SAAS scores were similar for patients with implant-supported fixed prostheses and those with natural teeth. Middle-aged adults with higher educational levels tended to present better oral health-related quality of life and lower social appearance anxiety.

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DOI: 10.3897/folmed.65.e74030

Authors: Elka Radeva, Tsonko Uzunov

Abstract: Introduction: Successful periapical surgery requires appropriate root resection, preparation, and adequate sealing. Aim: The aim of the present study was to assess the marginal adaptation of MTA and Biodentine after apical resection with an Er:YAG laser and a diamond turbine bur using a scanning electron microscope (SEM). Materials and methods: The crown part of forty-eight extracted single-root human teeth was removed, and the root canal length of 15 mm was standardized. The root canals were prepared using rotary Ni-Ti Revo-S files up to an apical stop – AS40 and filled with MTA Fillapex and gutta-percha points (cold lateral condensation). The teeth are divided into 2 main groups: group 1 (n=24) after apical resection with a turbine bur, ultrasonic preparation of the retrograde cavity at 3 mm depth and retrograde obturation with Biodentine and MTA; group 2 (n=24) after apical resection with an Er:YAG laser, ultrasonic preparation of the retrograde cavity at a depth of 3 mm and retrograde obturation with MTA and Biodentine. A SEM was used for assessment of the marginal adaptation of the material to the root dentin. The data was entered into and analyzed with IBM SPSS Statistics 22.0. Results: In the group with apical resection with a turbine bur, a statistically significant difference in the gap size between the material and dentin was found in both materials we studied (MTA and Biodentine). The higher mean value was in MTA (1.72 µm), in Biodentine it was 1.08 µm. In the group with apical resection with Er:YAG laser, no statistically significant difference in the gap size between the material and dentin was found in both studied materials: MTA – 1.88 µm, Biodentine – 1.32 µm. Conclusions: In the present study, MTA and Biodentine showed good sealing capabilities after apical resection. Biodentine displayed better marginal adaptation when resecting the root tip using a turbine bur. The Er:YAG laser-assisted apical resection shows sealing of the open dentinal tubules around the resected root surface.

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DOI: 10.3897/folmed.65.e75621

Authors: Mehrak Amjadi, Soolmaz Heidari, Maryam Jafari, Amin Jabbari

Abstract: Introduction: Developments in dental materials, CAD/CAM technologies and adhesive dentistry have improved the application of conservative restorations such as endocrowns and onlays. Among ceramics, zirconia has properties such as high strength, transformation toughening, chemical and structural durability, and biocompatibility, which enable zirconia to be used in the posterior area. Aim: This study is a comparative evaluation of fracture resistance and failure modes in endodontically treated molars restored with zirconia endocrown and onlays. Materials and methods: This study was performed on 20 human mandibular first molars with similar dimensions. After root canal treatment, the samples were divided into two groups: endocrowns and onlays (n=10). Restorations were made using a CAD-CAM milling machine with zirconia CAD blocks and, after cementation, subjected to 10,000 thermocycling and 500,000 fatigue cycle procedures, respectively. Each specimen was placed on a Universal Testing Machine and subjected to axial compressive force applied at a crosshead speed of 0.5 mm/min. The mean loads of failure of each group were statistically compared using the Student t-test. Chi-square tests were used to compare frequencies of failure modes among groups. Results: Fracture resistance showed a statistically significant difference between endocrown (5374.6810±670.03445 N) and onlay (3312.5000±804.01428 N) (p<0.001). No statistically significant difference was detected in the distribution of failure types among the groups (p>0.05). Conclusions: The fracture resistance of endocrown is substantially higher than that of onlay, and failure type does not differ in both restorations. Zirconia is a reliable material to use in conservative restorations.

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DOI: 10.3897/folmed.65.e77442

Authors: Viktor Hadzhigaev, Angelina Vlahova, Gergo Mitov, Stefan Zlatev

Abstract: Introduction: Masticatory pressure increases in the distal areas of the dentition. This should be considered when restoring partially edentulous patients with a metal-free fixed partial denture (FPD). An alternative abutment preparation design can be used in order to increase the materials’ volume in the most fracture-prone “connector area” of an FPD. The increased size of the connection might positively influence the constructions’ mechanical durability, thereby increasing its success and survivability. Aim: The aim of the present study was to investigate the influence of two preparation designs of the distal abutment on the fracture resistance of three-unit, monolithic, ZrO2 FPDs. Materials and methods: 3D printed replicas of a partially edentulous mandibular segment and a ZrO2, milled in full-contour, three-unit FPDs were used for this investigation. Two experimental groups (n=10) were defined based on the preparation design of the distal abutment tooth – classical shoulder preparation 0.8 mm deep, and endocrown preparation with a 2-mm retention cavity. The bridge – mandibular segment replica assembly was done with relyXU200(3M ESPE, USA), light-cured for 10 seconds per side with D-light Duo (GC, Europe). After cementation the test specimens were subjected to loading in a universal testing machine Zwick (Zwick-Roell Group, Germany). Statistical analysis was performed using R and includes descriptive statistics, t-test for quantitative and chi-squared test for qualitative variables. Results: The results showed no difference between the two studied groups in the maximum force required to fracture the test specimens [t=−1.8088 (17.39), p-value=0.087; P>0.05]. 95% of the fracture lines were located in the distal connector. Conclusions: Within the limitations of this study, it can be concluded that both tested preparation designs show similar results in terms of the load required to fracture the test specimens. Furthermore, it is confirmed that the distal connector is the weakest area of an all-ceramic 3-unit FPD in the posterior area.

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DOI: 10.3897/folmed.65.e71970

Authors: Andrii Demkovych

Abstract: Introduction: Excessive lipoperoxidation is accompanied by accumulation of peroxidation products and depletion of antioxidant reserves, which cause hyperenzymemia and the accumulation of toxic substances. The level of endotoxicosis is determined by the content of hydrophilic and hydrophobic products in the blood. Aim: To define the pathogenetic role of endogenous intoxication in the dynamics of development of experimental periodontitis of bacterial-immune genesis. Materials and methods: The experiment was conducted on rats. The animals were divided into three groups: group 1 – control group/intact; group 2 – model periodontitis at 7 days; group 3 – model periodontitis at 30 days. The experimental bacterial-immune periodontitis was induced by injection into the tissue of the periodontal complex of the microorganisms’ mixture diluted with egg’s albumin. For the study, we selected the blood serum in which the content of middle molecular weight molecules and erythrocyte intoxication index were determined. The results were statistically analyzed by means of non-parametric indices methods. Results: The development of generalized periodontitis is characterized by the occurrence of oxidative stress, which leads to violation of the metabolism in the mucous membrane of the oral cavity resulting in the accumulation of toxic products and the development of endogenous intoxication. The results show that the content of middle molecular weight molecules (aromatic amino and chain amino acids) determined on day 7 of the experiment was 1.11 times higher than that of the control group (p<0.01) and by 1.16 times (p<0.01), respectively. Comparing the levels of the above hydrophilic components of endogenous intoxication at 30 days of experimental periodontitis, we found a probable increase in these indicators compared with those at 7 days of the experiment. Studying the level of erythrocyte intoxication index, we found that at 7 days of experimental periodontitis this index was 1.28 times higher (p<0.01) than that of the intact group and continued to increase at 30 days. Conclusions: The dynamics of experimental periodontitis of bacterial-immune genesis show that the highest rates of endogenous intoxication are found in the late stages of the dynamics of the inflammatory process in the periodontium, namely at 30 days of the experiment, which may indicate chronic inflammation.

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DOI: 10.3897/folmed.65.e72920

Authors: Ivan Nachkov, Plamen Zagorchev, Blagovesta Yaneva

Abstract: Introduction: Peri-implantitis is a relatively new and difficult disease that is becoming more common. Of the different therapeutic options to manage this condition, lasers show certain advantages over other therapeutic alternatives because of their antibacterial potential. Aim: The aim of the present study was to investigate the temperature rise of implant surfaces, soft tissues, and bone during irradiation with diode, CO2, and Er:YAG lasers. Materials and methods: Ten implants inserted in biological models were irradiated with three laser systems with different parameters: a diode laser (980 nm) with power levels of 0.75 W and 1.6 W; a CO2 laser (10600 nm) with power levels of 252 W and 241 W; and an Er:YAG laser (2940 nm) with power levels of 1.5 W, 6.8 W, and 7.5 W. The temperature rise was measured using a specially designed thermal probe (type K thermocouple) with accuracy of ±0.1°C over the range from 20°C to 80°C. The temperature was measured at 5 points – in the implant body, in the mucosa, in the middle part of the implant, in the implant apex, and in the bone around the implant apex. Measurements were obtained at 1 minute working interval. Results: Diode and CO2 lasers with both parameters used increased significantly the temperature of more than 46°C, whereas the temperature in the Er:YAG laser group was less than 30°C. There was a statistically significant difference between diode, CO2, and Er:YAG lasers in favor of the erbium laser. Conclusions: The Er:YAG laser demonstrates the best thermal properties during irradiation of the implant surface. The three working modes tested – 1.5 W, 6.8 W, and 7.5 W – provide safe intervention on both the soft and bone tissues of the implant interface and on the implant itself.

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DOI: 10.3897/folmed.65.e67782

Authors: Zeinab Imani, Ahmad Sodagar, Maryam Pourhajibagher, Armin Hosseinpour Nader, Abbas Bahador

Abstract: Aim: The present study aimed to assess the antimicrobial effects of orthodontic primer containing nano-propolis against the cariogenic bacteria in а rat model. Materials and methods: Transbond XT orthodontic primer containing 0%, 1%, 5%, and 10% nano-propolis was experimentally prepared in-house. The Wistar rats we used in the study were randomly divided into four groups and their oral cavities were colonized with Streptococcus mutans, Streptococcus sanguinis, and Lactobacillus acidophilus. After anesthetizing the rats, one drop (10 µL) of primer containing different concentrations of nano-propolis was applied to the labial surface of the maxillary incisor and light-cured. The orthodontic composite was applied on the primer and light-cured. One drop (10 µL) of primer containing the same concentrations of nano-propolis was again applied on the surface of composite and light-cured. The number of S. mutans, S. sanguinis, and L. acidophilus colonies in the saliva of rats was quantified at 24 h, at days 4 and 7 using plate counting. Results: Primer containing 1%, 5%, and 10% of nano-propolis significantly reduced the S. mutans colony count at 24 h compared with the control group (p<0.05). At day 4, the mean S. mutans colony counts in the 5% and 10% nano-propolis groups were significantly lower than that in the control group (p<0.05). Primer containing 1%, 5%, and 10% (all (p<0.05) of nano-propolis significantly reduced the L. acidophilus at 24 hours. Also, at day 4 the mean L. acidophilus colony counts in the 5% and 10% nano-propolis groups were significantly lower than that in the control group (p<0.05). At 24 h and 4 days, the mean S. sanguinis colony count in the 1%, 5%, and 10% nano-propolis group was significantly lower than that in the control group (p<0.05). No significant difference was observed in the presence of all concentrations of nano-propolis at day 7 (p>0.05). Conclusions: Orthodontic primer containing nano-propolis significantly reduced the colony count of cariogenic bacteria in a rat model.

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DOI: 10.3897/folmed.65.e71784

Authors: Athena E. Ivanoff, Chris S. Ivanoff

Abstract: Introduction: Ring chromosome 14 syndrome, or r(14), is a rare genetic disorder characterized by distinctive facial features, intractable epilepsy, delayed development, intellectual disability, and autism spectrum disorder. With less than 100 documented cases worldwide, the disease is not well known or fully studied. Furthermore, the literature offers little guidance to aid dentists in the management of these patients as r(14) remains undocumented in the dental literature. Aim: To investigate the manifestations and challenges faced by a group of subjects suffering from r(14), to raise awareness of this syndrome, and to provide tips and suggestions that dentists may find helpful to manage r(14) children effectively. Materials and methods: A voluntary survey was administered to the caretakers of 13 r(14) patients who, as of 2019, were registered in the NORD (National Organization for Rare Diseases) global data bank (Ring 14 USA Outreach). The patients were assessed for age, gender, geographic distribution, phenotype, physical appearance, maxillofacial characteristics, presence of oral conditions and abnormalities, malocclusion, epileptic seizures, cognitive abilities, speech, muscle tone, nutrition, autism, and other developmental and behavioral points of interest. Results: Of the 13 patients queried, 7 were male and 6 were female. The age of the patients ranged from 5 to 49 years. Ten patients were of European ancestry and three were Hispanic, all residing across the U.S. The majority of patients were diagnosed as infants, shortly after commencement of uncontrollable seizures. All the patients had microcephaly and presented with Class II malocclusions. More frequent occlusal anomalies and conditions included diastemata of the anterior teeth, congenitally missing teeth, crowding, and drooling. The majority of subjects was unable to speak, suffered from intractable seizures, and frequently exhibited behavioral outbursts. Conclusions: A child with r(14) may present a considerable challenge to the dentist and staff, but the dental problems of r(14) children are, for the most part, like those of any other patient and can often be handled by the dentist. Depending on the severity of symptoms, some children with r(14) may be as treatable in the dental office as any other child.

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DOI: 10.3897/folmed.64.e68427

Authors: Ivan Ivanov, Antoaneta Mlachkova

Abstract: The interrelationship between periodontium and pulp makes the treatment of combined endo-periodontal lesions (EPL) more challenging. It involves successful elimination of both periodontal and endodontic lesion. The current case report represents the efficacy of regenerative potential of enamel matrix derivates (Emdogain®) in endo-periodontal lesion after successful endodontic treatment. A 39-year-old woman presented with EPL on a left first mandibular molar. After the initial 3 months of healing, the clinical examination showed that the furcation involvement still prevailed. A decision was made to use a regenerative procedure using Emdogain®. Fourteen months after the procedure, full periodontal regeneration can be seen on the X-ray. The results demonstrated the synergetic effect of the endodontic and periodontal therapy that changed the prognosis for the tooth.

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DOI: 10.3897/folmed.64.e68508

Authors: Bogomil Andonov, Silviya Dimitrova, Plamen Zagorchev, Milena Draganova-Filipova

Abstract: Aim: The aim of the present in vitro study was to analyze the endodontic cavity walls for presence of remnants of conventional glass ionomer cement and flowable light cure composite used as temporary restorative materials of endodontically treated teeth. The dentine surface of the access cavity was observed with scanning electron microscopy after the final removal of the temporary restoration using high-speed turbine and diamond bur or ultrasonic device and diamond tip. Materials and methods: Twenty-one extracted intact human molars were selected for this study. Endodontic access, enlargement of the coronal one third of the root canals and standard irrigation were performed. Teeth were then restored with two different materials – conventional glass ionomer cement (Ketac Molar Easymix, 3M ESPE, USA) and flowable light cure composite (Vertise flow, KERR, USA) and divided in four groups according to the method of removal and type of material used for temporary restoration. One sample, positive for temporary material remnants, was used as a control group. After the removal of the restorative material, all specimens were prepared for SEM examination. Scanning Electron Microscopy (Prisma E SEM, Thermo Scientific, Eindhoven, The Netherlands) was used to examine the surface morphology of the samples. The samples were sputter-coated with gold using vacuum evaporator (JEOL JFC-1200). The images were recorded at 20 kV acceleration using various magnifications (×150, ×500, and ×1000). Results and conclusions: Remnants were detected in all specimens, regardless of the material for temporary restoration or method of removal.

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DOI: 10.3897/folmed.64.e68223

Authors: Zohreh Moradi, Sara Valizadeh, Elham Farhadi, Yasaman Asadollahi, Mohammad Noroozian, Nasim Chiniforush

Abstract: Aim: Since the introduction of bleaching treatments in the office, different lights have been suggested to accelerate the bleaching reaction. This study aimed to evaluate the microhardness of tooth enamel after office bleaching using different materials. Materials and methods: Thirty-three sound human upper premolars were randomly divided into 3 groups as follows (n=11): Group 1: Whitesmile HP40% gel with R&B LED light source with 3 W power output; Group 2: HP 35% Dr Smile gel with a 980 nm diode laser, 2 W power and continuous wavelength; Group 3: HP 40% Ultra boost gel according to factory instructions. Enamel surface microhardness was measured before and after the bleaching procedure in each group using the Vickers microhardness test. One-way ANOVA and Tukey post hoc tests were used for statistical analysis. We used a SEM microscope to examine the surface of one sample from each group and one sample as a negative control. Results: In group 1, enamel microhardness increased remarkably (p=0.013) whereas in group 2 and group 3 enamel microhardness decreased. Enamel microhardness decreased in group 3 significantly (p=0.00) but its reduction in group 2 was not significant (p=0.833). SEM examination of the enamel surfaces after bleaching revealed erosion and surface porosities in group 1, enamel structure melting, and shallow porosities in group 2, and enamel prism exposure and etching in group 3. Conclusions: Due to the limitations of the present study, power bleaching with HP40% Whitesmile gel with LED Monitex increases microhardness, so it can have better results for treatment in the clinic. Additionally, using Dr Smile gel with a 980 nm diode laser does not reduce surface microhardness.

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DOI: 10.3897/folmed.64.e66695

Authors: Marjan Bolbolian, Atefeh Hamzei, Navid Mohammadi, Maryam Tofangchiha

Abstract: Introduction: A sealer’s ability to effectively and stably penetrate the dentinal tubules is an essential factor for selecting an effective root canal obturation material. Evaluation of the sealers’ penetration into the dentinal tubules provides valuable data in the endodontic treatment outcome. Aim: To compare the dentin penetration of AH Plus, Endoseal MTA, and Syntex endodontic sealers in the presence and absence of the smear layer. Materials and methods: Thirty single-rooted teeth were selected in the present in vitro study and randomly assigned to three experimental groups (n=10). Half of the samples were prepared by removing the smear layer in each group, and the remaining samples were prepared without removing the smear layer. Root canal preparation was carried out with the Perfect Rotary system up to file T3. The root canals were obturated with gutta-percha and AH Plus, Endoseal MTA, or Syntex endodontic sealers. The samples were incubated at 100% relative humidity at 37°C for one week. Each root was sectioned at 2-, 5-, and 8-mm distances from the apex, and sealer penetration depth at each section was determined under a scanning electron microscope (SEM). ANOVA was used to compare penetration depths. Results: There were significant differences in sealer penetration between the samples with and without smear layer removal in each group. The maximum and minimum sealer penetration was at the coronal and apical sections, respectively. The maximum sealer pe-netration depths in descending order were observed with AH Plus, Syntex, and Endoseal MTA sealers (p<0.05). Conclusions: Elimination of smear layer increased three sealers’ dentin penetration depth, with the deepest penetration for the AH Plus sealer in the coronal section without the smear layer.

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DOI: 10.3897/folmed.64.e67842

Authors: Behrad Tanbakuchi, Sharmin Kharrazi, Matin Nikfarjam, Mohammad Sadegh Ahmad Akhoundi, Atefe Saffar Shahroudi

Abstract: Introduction: In orthodontic treatment with sliding technique, reduction of frictional forces could result in a more effective treatment. Recently, wire coating with nanoparticles were proposed to reduce frictional forces. Aim: The aim of this study was to evaluate the effect of coating wires with zinc oxide nanoparticle by two methods of chemical precipitation and direct hydrothermal process on the wire-bracket frictional force. Materials and methods: In this study, 30 pieces of stainless-steel arch wire with and without zinc oxide nanoparticles and 30 metal brackets with a 0.022-inch slot were divided into three groups: group 1 – control (uncoated wires); group 2 – wires coated with zinc oxide nanoparticles, and group 3 – wires with a thin layer of nanostructured zinc oxide. In the first method, the nanoparticles were made by chemical precipitation method, and in the second method, nanostructure was directly formed on wires. Additionally, SEM observations were used to confirm the presence of nanoparticles on the wires. Friction between wires and brackets was measured using Universal Testing Machine. SPSS v. 20 and ANOVA test was used in order to analyze the data. The significance level was considered as p<0.05. Results: The mean value of frictional forces were 1.73 N, 1.52 N, and 1.56 N in the control group, chemical precipitation method group and thin layer of nanostructured zinc oxide group, respectively. There was no significant difference in friction rate between brackets and stainless-steel wire coated by any of these two methods (p=0.555). Conclusion: Coating of orthodontic wires with zinc oxide nanoparticles can reduce friction with brackets during sliding. There was no difference in the established value of friction between coating of orthodontic wires with chemical precipitation method and thin layer coating method.

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DOI: 10.3897/folmed.64.e64542

Authors: Farhad Sobouti, Ardavan Etemadi, Sara Seifi, Maryam Bakhshi, Nasim Chiniforush, Sepideh Dadgar

Abstract: Aim: Clinicians and researchers have always made every effort to achieve proper bonding between the surface of the tooth and the rebonded orthodontic brackets in order to prevent the re-fracture failure of orthodontic pressures throughout treatment. The aim of this study was to determine the bond strength of rebonded brackets by four adhesive removal methods. Materials and methods: Seventy-five orthodontic brackets were bonded to the extracted first premolar teeth and then debonded. Fifteen of these teeth were rebonded to new brackets after adhesive removal and were named as the control group. Sixty debonded brackets were divided into four groups by means of resin-removal: laser, burr, sandblast, and direct flame. These recycled brackets were re-bonded to the teeth with the same basic bonding methods. The shear bond strength (SBS) was measured at the speed of 0.5 mm/min and the data were analyzed using ANOVA and post hoc tests (α=0.05). Results: SBS was significantly different in all four groups compared to the control group (p<0.05). The burr and sandblast groups had the lowest levels of SBS. Although the laser and flame groups had the highest levels of SBS, they did not show a significant difference (p=0.99). Conclusions: 5W Er:YAG irradiation and direct flame due to relatively good bond strength can be recommended as proposed methods for orthodontic brackets recycling.

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DOI: 10.3897/folmed.64.e67475

Authors: Shabnam Aghayan, Asma Yazdanfar, Ehsan Seyedjafari, Mohammad Noroozian, Roxana Ioana Bordea, Nasim Chiniforush

Abstract: Introduction: Antimicrobial photodynamic therapy (aPDT) is an adjunctive non-invasive procedure for the management of periodontal tissue infection and deep periodontal pocket decontamination. However, the effects of this procedure on periodontal cells like osteoblasts that play a role in periodontal tissue repair and regeneration is not yet clear. Aim: This study aimed to investigate aPDT based on indocyanine green (ICG) on MG-63 osteoblast-like cells in vitro. Materials and methods: MG-63 cells were treated in 9 different groups: 1) Control (untreated cells), 2) ICG alone at a concentration of 1000 µg/mL, 3) ICG alone at a concentration of 2000 µg/mL, 4) diode laser irradiation alone for 30 s, 5) laser irradiation for 30 s combined with ICG with a concentration of 1000 µg/mL, 6) laser irradiation for 30 s combined with ICG at a concentration of 2000 µg/mL, 7) laser irradiation alone for 60 s, 8) laser irradiation for 60 s combined with ICG at a concentration of 1000 µg/mL, and 9) laser irradiation for 60 s combined with ICG at a concentration of 2000 µg/mL. Cell viability was assessed by MTT assay in different groups. Results: In groups that were treated with 2000 µg/mL of ICG or diode laser irradiation at fluency of 39 J/cm2 for 60 s alone or in combination during ICG-aPDT, osteoblast-like cells viability decreased, remarkably. Conclusions: IGC-mediated aPDT with 1000 µg/mL of ICG combined with diode laser irradiation at fluency of 39 J/cm2 for 30 s is safe for MG-63 human osteoblast-like cells; however, higher concentration of ICG or laser irradiation time will increase cells death. There is still a need for more in vivo studies.

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DOI: 10.3897/folmed.64.e64714

Authors: Mahin Bakhshi, Mohammad Kamalinejad, Mehdi Shokri, Gelareh Forouzani, Faezeh Heidari, Maryam Tofangchiha

Abstract: Introduction: Pimpinella anisum is a medicinal plant with antimicrobial, antifungal, and anti-oxidative properties. Limited studies have assessed the antibacterial properties of Pimpinella anisum on oral and dental pathogens. Aim: This in vitro study aimed to assess the antibacterial effect of Pimpinella anisum essential oil on Enterococcus faecalis, Lactobacillus casei, Actinomyces naeslundii, and Aggregatibacter actinomycetemcomitans. Materials and methods: After obtaining the essential oil of Pimpinella anisum, its antimicrobial activity was evaluated using the agar disc diffusion test. The minimum inhibitory concentration and minimum bactericidal concentration of the essential oil were also determined; 0.2% chlorhexidine was used as the positive control. Results: The mean diameter of growth inhibition zone was 39 mm for Enterococcus faecalis, 40 mm for Lactobacillus casei, 42 mm for Actinomyces naeslundii, and 18.5 mm for Aggregatibacter actinomycetemcomitans. The mean diameter of the growth inhibition zones for Enterococcus faecalis, Lactobacillus casei, and Actinomyces naeslundii was significantly greater than that of Aggregatibacter actinomycetemcomitans (p=0.001). Also, the mean diameter of the growth inhibition zone of Actinomyces naeslundii was significantly larger than that of Enterococcus faecalis (p=0.05). The minimum inhibitory concentration and minimum bactericidal concentration of the essential oil for Enterococcus faecalis were 4.88% and 4.88%, respectively. These values were 9.76% and 9.76% for Lactobacillus casei, 9.76% and 4.88% for Actinomyces naeslundii, and 9.76% and 9.76% for Aggregatibacter actinomycetemcomitans, respectively. Conclusions: Pimpinella anisum essential oil was effective against all four microorganisms evaluated in this study. Since the lowest minimum inhibitory concentration and minimum bactericidal concentration were recorded for Enterococcus faecalis, this essential oil has maximum effects on Enterococcus faecalis. Future clinical studies are required to assess the antimicrobial efficacy of Pimpinella anisum essential oil in clinical samples.

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DOI: 10.3897/folmed.64.e68631

Authors: Safoura Ghodsi, Soroush Sef Omrani, Sara Mogharrabi, Sara Valizadeh

Abstract: Introduction: Occlusal plane orientation affects the esthetic, function, and success of removable or fixed prostheses. The most prevalent index for determination of this plane is the ala-tragus line while there are controversies in the exact location of tragus reference point. Aims: This study aimed to determine the best point on tragus as the posterior reference of ala-tragal line in relation to occlusal plane according to age and sex. Materials and methods: The study included 136 participants of both sexes who were randomly divided into three age groups: 20-35, 36-50, and older than 50. Fox plane was stabilized on incisal edge-occlusal table of maxillary teeth. A lateral photograph was obtained from each participant sitting in predetermined standard position. Using Auto-Cad software, three lines were traced from nasal ala base to superior, middle, and inferior borders of the tragus, and evaluated for being parallel to occlusal plane. Results: The coordination between occlusal plane and ala was 20.5% for superior, 35.6% for middle, and 43.9% for inferior border of tragus. There was a significant difference in the relationship between sex and plane position (p=0.003), while the relationship between age and plane could not reach statistical significance (p=0.65). The results were analyzed using chi-square test, and ANOVA (p<0.05). Conclusions: Ala-inferior border of tragus line was the most parallel, and ala-superior border of tragus line was the least parallel line to the occlusal plane. The parallelism between occlusal plane and ala-superior border was more prevalent in women, while the men demonstrated significantly more parallelism with inferior border of tragus.

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DOI: 10.3897/folmed.64.e72254

Authors: Atanas Doshev, Vasko Doshev

Abstract: It is assumed that most cleft lip and palate are due to a combination of genetic and environmental factors (maternal diseases, smoking, alcohol intake, infections, and ionizing treatment) that alter morphogenesis. Treatment of these cases begins from birth to adulthood and requires a number of interventions depending on the period of development of the maxillofacial area and teeth. We present the case of a patient with unilateral cleft lip and palate. Surgery and orthodontic treatment were carried out subsequently, and then a metal-ceramic bridge was made to correct the defect. In the course of the treatment, we made decisions that were determined by the available space. The construction restored the dentition, the aesthetics, speech, and masticatory functions of the patient. The treatment of such defects requires good collaboration between individual specialists in order to achieve optimally good results. We believe that in such cases of crucial importance is the contribution of a prosthetic dentistry expert since surgical and orthodontic treatments alone are insufficient to achieve complete recovery and rehabilitation of patients.

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DOI: 10.3897/folmed.64.e63623

Authors: Deyan Neychev, Bozhidar Pilichev, Denitsa Serteva, Petya Kanazirska

Abstract: Reparative giant cell granulomas are benign masses of multi-etiological nature, which account for 1%–7% of all benign lesions of the jaws. The objective of this case report is to present the relationship between isolated vitamin D deficiency and the development of reparative giant cell granuloma. Herein, we present the case of a 70-year-old female patient with a painless mass of increased mobility in the mandibular region, and pain in the involved teeth. After histological confirmation and laboratory screening, а reparative giant cell granuloma caused by serious deficiency of vitamin D3 - (25-OH)D was diagnosed. The treatment protocol included surgical removal of the lesion and vitamin D replacement therapy. In rare cases, this type of lesion can be a primary manifestation of vitamin D deficiency; therefore, it is extremely important to be aware of this pathology.

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DOI: 10.3897/folmed.64.e63528

Authors: Blagovesta K. Yaneva, Yana B. Dermendzhieva, Maria Z. Mutafchieva, Nikola V. Stamenov, Lilia B. Kavlakova, Mihail Z. Tanev, Emiliya Karaslavova, Georgi T. Tomov

Abstract: Aim: The present clinical study aimed to investigate the clinical efficacy of 5 types of mouthwash based on different active substances. Materials and methods: The study included 180 patients divided into 6 groups of 30 patients, each group rinsing with one of the following types of mouthwash based on: essential oils, combination of essential oils and 0.12% chlorhexidine, hydrogen peroxide (0.8%), prebiotic, 0.2% chlorhexidine, and placebo. All participants underwent professional mechanical plaque removal after which they were instructed to rinse with 15 ml mouthwash 2 times a day for 21 days. During the study period, patients were monitored at days 0, 14, and 21, examining oral hygiene index, gingival index, bleeding index, and presence of side effects. Results: Gingival index, bleeding index, and oral hygiene index were reduced statistically significantly in all treatment groups. Adjunctive use of mouthwashes demonstrated better clinical effectiveness compared to mechanical plaque control (and placebo mouthwash). The gingival index and the plaque index were reduced most significantly in the group using mouthwash with hydrogen peroxide. The bleeding index decrease was most significant in the group using 0.2% chlorhexidine. Conclusions: All tested mouthwashes demonstrated significant clinical effectiveness in different degrees in gingivitis treatment. New formulas with prebiotic and combination of essential oils and chlorhexidine indicate promising effectiveness.

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DOI: 10.3897/folmed.64.e62408

Authors: Muhammet Kerim Ayar

Abstract: Abstract Aim: The aim of the present study was to assess the effects of rotary brush active application technique on the ultramorphological changes induced by self-etching adhesive systems on ground enamel. Materials and methods: Three application methods were deployed: (1) passive application; (2) manual active application; (3) rotary-brush active application. Two self-etching adhesive systems were used: (1) Optibond All-in-one; (2) Nova Combo Plus. Acid-etching of the ground enamel surface with phosphoric acid was used as control. Labial surfaces of bovine incisors were separated into four pieces. One of three application methods including phosphoric acid-etching was used to apply one of self-etch adhesive systems to enamel surface of each enamel piece respectively. Treated enamel samples were then processed for evaluation under scanning electron microscope (SEM). Results: SEM findings showed that acid-etching completely removed the smear layer from the ground enamel surface. None of the active application techniques, however, were able to eliminate the smear layers. Conclusions: Active application of self-etch adhesives to enamel with a rotary brush may not have an effect on the interaction of the tested self-etch adhesives with smear layers on the enamel surface.

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DOI: 10.3897/folmed.64.e62851

Authors: Lilia Kavlakova

Abstract: Abstract Introduction: Oral lichen planus (OLP) is a chronic inflammatory mucocutaneous disorder with unknown etiology. Numerous treatment options have been reported, with topical corticosteroids being very often used as the first-line therapy for gingival lesions. However, a relatively novel therapeutic option is provided by tacrolimus. Aim: To compare the clinical effectiveness of topical tacrolimus 0.1% and clobetasol propionate 0.05% in the management of desquamative gingivitis, a distinct clinical manifestation of OLP. Materials and methods: This comparative study included 20 patients with histologically proven symptomatic OLP with gingival manifestation. The participants were divided into 2 groups: group A (clobetasol propionate 0.05% cream) and group B (topical tacrolimus 0.1% ointment). They were instructed to apply topical medications twice daily for three consecutive weeks. Custom trays have been used for better drug delivery. The patients were recalled at 1, 2, and 3 months after cessation of therapy for a follow-up control of any relapse. Results: The subjects in both groups showed a significant reduction in the burning sensation/pain and discomfort according to the visual analog scale (VAS). Similarly, both groups showed reduction in the efficiency index, and moderate improvement especially was seen in the tacrolimus 0.1% group (53%) and the clobetasol propionate group 0.05% (47%). Patients treated with clobetasol propionate 0.05% didn’t have a relapse at 2 and 3 months after cessation of treatment. In contrast, 30% of the patients treated with tacrolimus 0.1% had a relapse of the condition at 2 and 3 months. Conclusions: Tacrolimus can be considered as a good alternative topical medication in the treatment of OLP, especially in those patients that do not respond to topical corticosteroids.

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DOI: 10.3897/folmed.64.e62532

Authors: Denislav K. Emilov, Elitsa G. Deliverska-Aleksandrova

Abstract: Introduction: The main goal of root coverage procedure is complete coverage of the recession defect with good esthetic results related to the adjacent soft tissues and minimal probing depth after the healing process. Aim: The aim of this study was to compare the efficiency of surgical and nonsurgical treatment options in patients with gingival recession and dentin hypersensitivity. Materials and methods: Sixty patients with gingival recession Miller Class I and II with hypersensitivity and esthetic concerns were included. Of these, 30 patients were treated with free soft-tissue graft procedures and 30 people as controls were treated with anti-hypersensitivity gel. The surgically treated patients were allocated into two groups: 20 of them with coronally advanced flap with subepithelial connective tissue graft and 10 with free gingival graft. Results: We achieved full coverage on the exposed root surfaces in 19 patients treated with coronally advanced flap and de-epithelized graft and partial root coverage in one of them. Patients treated with free gingival graft procedure achieved full root coverage in 7 of them and partial in 3 of them (gingival recession = 1 mm after surgery). The surgical treatment allowed resolution of the esthetic issues of patients and elimination or reduction of the dentin hypersensitivity. In the control group, there was partial elimination of root sensitivity. Conclusions: In the surgically treated group with both techniques, we achieved resolution of dentin hypersensitivity and coverage of the root surface with healthy keratinized tissues. These techniques can be considered as treatment options for dentin hypersensitivity depending on the indications.

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DOI: 10.3897/folmed.64.e64841

Authors: Maria Shindova, Ani Belcheva-Krivorova

Abstract: Abstract Aim: The objective of the present study was to investigate the influence of dentists’ age, gender, working experience, and practitioner type on the use of non-pharmacological behaviour management techniques in the treatment of paediatric dental patients. Materials and methods: An anonymous, self-completion survey was mailed to 200 randomly selected dentists. The recorded information included items on practitioner’s gender, age, working experience, specialty status, and frequency of using different non-pharmacological behaviour management techniques as well as the factors influencing the choice for specific behaviour guidance techniques. Results: Significant differences between age/gender distributions were seen in the use of the basic non-pharmacological behaviour management techniques. Younger females were more likely to indicate that they were comfortable using communicative guidance techniques. The respondents in the over-40 age group did not rely at all on negative reinforcement and parental presence/absence techniques during the dental treatment of children (p<0.05). Dental practitioners with working experience of fewer than 10 years were more likely to utilize behaviour guidance techniques in attending paediatric dental patients compared to their older colleagues. No significant difference by practitioner types was seen in the use of the basic behaviour management techniques (p>0.05). Conclusions: The present study showed age, gender, working experience, and practitioner type statistically significant differences in the use of behaviour management techniques during the dental treatment of children. The choice of a technique was influenced mainly by personal factors associated with the physical and psychological health of the child.

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DOI: 10.3897/folmed.64.e60418

Authors: Maryam Pourhajibagher, Abbas Bahador

Abstract: Introduction: White spot lesions around orthodontic brackets may lead to the formation of dental caries during and following fixed orthodontic treatment. Aim: This study aimed to evaluate the physico-mechanical properties and antimicrobial potencies of orthodontic adhesive doped with cerium oxide nanoparticles (CeO2-NPs) against Streptococcus mutans. Materials and methods: After synthesis and conformation of CeO2-NPs by transmission electron microscope (TEM), shear bond strength (SBS) and adhesive remnant index (ARI) of modified orthodontic adhesive containing different concentrations of CeO2-NPs (0, 1, 2, 5, and 10 wt%) were measured. The antimicrobial effects of modified orthodontic adhesive were evaluated by disk agar diffusion method and biofilm formation inhibition assay. Results: The pseudo-spherical shapes of CeO2-NPs were observed in TEM micrographs. The physico-mechanical finding showed that 5 wt% CeO2-NPs showed the highest concentration of CeO2-NPs and SBS value (18.21±9.06 MPa, p<0.05) simultaneously with no significant differences in ARI compared with the control group (p>0.05). There was a significant reduction in cell viability of S. mutans with increasing CeO2-NPs concentration. The 3.1 Log10 and 4.6 Log10 reductions were observed in the count of treated S. mutans with 5 and 10 wt% CeO2-NPs, respectively (p<0.05). Conclusions: Overall, an orthodontic adhesive containing 5 wt% CeO2-NPs had antimicrobial properties against S. mutans without adverse effects on SBS and ARI.

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DOI: 10.3897/folmed.64.e61540

Authors: Kostadin Georgiev, Ivan Filipov, Aleksandra Pecheva

Abstract: Introduction: The majority of biodegradation studies of composite materials use simplified models of microbial biofilm despite the apparent diversity of the oral microbiota. The use of in vitro systems of “artificial mouth” design is a step towards clarifying the synergistic effect that microbial plaque and human saliva have on composite degradation. Aim: Establishment of functional parameters for in vitro reproduction of oral biofilms via biofilm reactor systems. Materials and methods: The CDC Biofilm Reactor system consists of eight polypropylene sticks. The rod cover and the retaining plates are mounted in a 1-dm glass cylinder with an outlet side opening. The laboratory bioreactor has a working volume of 340 ml. The device is equipped with a four-blade magnetic stirrer. The system also includes gauging appliances and executive mechanisms for controlling and adjusting the basic parameters of the process. Results: Determination of the operating volume of the reactor is performed prior to the experiment along with the time of reach and stabilization of the set temperature in the design which is 60 min at 120 rpm. A mathematical model is used to calculate the rate of delivery of growth medium - 11 millilitres per minute. The bioreactor is sterilized by 0.3% neomycin solution for 24 hours. Prior to the experiment the system is cleansed (via passage) with sterile water for 60 minutes. Conclusions: The pre-calibration of a bioreactor system allows specification and refinement of its working parameters, thus engaging for accurate reproduction of the environmental conditions in the oral cavity.

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DOI: 10.3897/folmed.64.e69136

Authors: Maria P. Shindova, Ani Belcheva-Krivorova, Zdravko Taralov

Abstract: Pulse oximetry is a technique used to measure the levels of blood oxygen saturation. Because this technique is regarded as non-invasive, easy to apply, and accurate technology, the number of possible applications in general dentistry practice has been gradually increasing. The aim of the present study was to summarise the contemporary research literature concerning the use of pulse oximetry in paediatric dentistry. We made a critical evaluation of the clinical applications of pulse oximetry and the advantages and disadvantages of this technique. Knowledge of innovative methods and techniques for treatment and diagnostics by paediatric dentists is a valuable advantage in dealing with the functional problems in attending dental patients. The expository analysis allows reviewing the succession of this diagnostic approach.

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DOI: 10.3897/folmed.64.e60553

Authors: Krikor Giragosyan, Ivan Chenchev, Vasilena Ivanova, Stefan Zlatev

Abstract: Here we review the knowledge on the local biological immunological response (formation of “pseudo periosteum” of the host) to two types of nonresorbable membranes used in the horizontal and vertical alveolar ridge augmentation: the titanium-reinforced polytetrafluoroethylene membrane and the titanium mesh membrane. A literature search was conducted including available in vitro, in vivo, and clinical studies on cellular and molecular immunological response to these two types of nonresorbable membranes, in particular the formation of “pseudo periosteum”. Emerging data demonstrates that despite barrier membranes being considered as bioinert, they still elicit an immunological response from the body. The outcome of this reaction is the formation of a thin fibrous capsule referred to as “pseudo periosteum”. There are almost no biomaterials that are truly bioinert and this makes no exception for the nonresorbable membranes used in the guided bone regeneration. This iatrogenically made tissue is hypothesized to have a number of advantages and drawbacks. However, more research is needed in that area to truly understand its nature and importance to the guided bone regeneration process.

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DOI: 10.3897/folmed.64.e58877

Authors: Kostadin Georgiev, Aleksandra Pecheva

Abstract: Numerous cases of aberrant root and root canal morphology have been described, still diversion occurs more frequently in premolars and molars. To the dental researcher, the aberrations in the mandibular second premolars afford a vast field of interest. The current report presents a clinical case which demonstrates a simplified therapeutic protocol for re-treatment of Vertucci type V root canals. Endodontic access is gained by expanding the endodontic cavity. The instrumentation (preflaring and final preparation) of the root canal system is performed using predominantly hand files in order to preserve to the maximum the tactile feedback in the apical part of the ramification. Obturation is performed through hydraulic condensation. Postoperative radiographs show sufficient three-dimensional sealing of all portals of exit with excellent healing result.

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DOI: 10.3897/folmed.64.e58178

Authors: Vijay Yadav, Sidhartha Sharma, Vijay Kumar, Amrita Chawla, Ajay Logani

Abstract: Stevens-Johnson syndrome (SJS) is a rare medical condition with severe mucocutaneous reaction due to infection or adverse drug reaction. The present case reports the impact of chloroquine-induced SJS on the tooth root development. A 20-year-old Indian male reported to conservative dentistry and endodontics speciality clinic with the chief complaint of food lodgement and sensitivity in maxillary and mandibular posterior teeth. He had a past medical history of severe cutaneous reaction after taking Tab. Lariago (chloroquine) for treatment of malarial fever at the age of 8 years. The acute inflammatory immune response was managed by hospitalization and administration of steroids and anti-inflammatory drugs. Clinical examination revealed dry mucosa, carious teeth with adequate oral hygiene. Panoramic X-ray showed multiple teeth with short roots. A detailed cone beam computed tomographic scan (CBCT) demonstrated a healthy bone trabecular pattern with the absence of any periapical radiolucency. Short, blunt roots with immature apex were seen in many teeth. Based upon the measurement of root to the crown ratio on the CBCT scan and correlating the development status of teeth with the medical history, a diagnosis of short root anomaly (SRA) after chloroquine-induced SJS was made. This is the first report to describe the three-dimensional features of teeth with SRA in a patient with SJS. Diagnostic, restorative, and endodontic implications of SJS are highlighted.

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DOI: 10.3897/folmed.64.e59099

Authors: Nikolay Kanazirski, Petya Kanazirska

Abstract: We present some clinical cases of autogenous tooth graft – a modern method in which the extracted teeth are processed into a demineralised dentin matrix (DDM) and are then immediately transplanted into the post-extraction sockets or bone defects. We included patients with jaw lesions due to chronic inflammatory conditions, cystic formations, or peri-implantitis. After removing the pathological processes and tissues, we performed curettage with an Er-YAG laser and treated the bone structures in the borderline area. Then auto-tooth bone (ATB) graft material was applied. The clinical results showed favourable wound healing and good bone integration of implants. Radiological studies showed stimulation and acceleration of bone regeneration with alveolar crest resorption of graft material of no more than 10%. Histological examination found new bone formation which was induced by the osteo-inductive material. On the basis of the clinical outcomes and the favourable healing process with a very good bone integration of the DDM, we can recommend this method as an option for bone defect reconstruction. The satisfactory quantity (up to 3 grams per molar) and quality of the demineralised dentin matrix determine a relatively low cost of bone grafting.

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