April 2015 - New York State Dental Association

Transcription

the new york state dental journal
Volume81 Number 3
April 2015
19 Clearing up the Confusion about Medicare and Dentistry
Judith L. Shub, Ph.D.; Lance Plunkett, J.D., LL.M.
Dentists have until December to properly enroll in Medicare to satisfy regulatory changes to
the system. What they need to know.
22 Barotrauma: Tooth under Pressure
Satheesh Kumar, B.D.S., M.D.S.; Preeti Satheesh Kumar, B.D.S., M.D.S.; Jins John, B.D.S.,
M.D.S.; Ruchi Patel, M.D.S.
Modern dental encounters include patients whose pain symptoms coincide with air travel or
underwater exploration. A review of literature on classification, etiology and manifestations
of barodontalgia, along with clinical considerations for its management.
27 TMJ Changes in Adolescent TMD Patients Seen on MRI in Clinical Setting
Cover: Underwater divers, as well as air crew
and aircraft passengers, are prime targets for
barodontalgia, or painful teeth due to changes
in pressure gradients. Because pre-existing oral
disease can play a role in development of the
symptom, a thorough dental exam before being
exposed to pressure changes is recommended.
Correction: We heard from several readers
regarding the cover of the March Journal.
They pointed out, correctly, that the dentist
pictured was not properly masked. We regret
the oversight. Most of the images for our cov
ers are stock photos, secured from online
photo sources. We promise to do a better job
of vetting our covers before printing.
2
Editorial
Special patients
4
Attorney on Law
Antitrust safe harbor
8
Letters
9
Association Activities
Nan Su, B.Sc.; Renee Poon, B.Sc.; Lawrence Friedman, M.B., B.Ch., FRCP(C), FACR; Mark
Darling, B.Ch.D., M.Sc. (Med), M.Ch.D.; Miriam Grushka, M.Sc., D.D.S., Ph.D.
Retrospective chart review was undertaken to determine if temporomandibular joint changes
are similar between adolescent and older TMJ disorder patients. It was determined that both
displayed comparable disc/bone changes in their TMJ.
31 Evaluation of Orthodontic and Triple-headed Toothbrushes When Used Alone or in Conjunction
with Single-tufted Toothbrush in Patients with Fixed Lingual Orthodontic Appliances
Malka Ashkenazi, D.M. D.; Nurit Flaisher Salem, D.M.D.; Silvia Garon, D.M.D., Liran Levin, D.M.D.
Randomized clinical trial is undertaken to determine effectiveness of brushing with singletufted toothbrush in conjunction with manual toothbrush, as widely recommended. While
triple-headed toothbrush appeared to remove plaque more effectively than orthodontic
toothbrush, adding single-tufted toothbrush eliminated differences between them.
38 Management of a Dental Implant with Internal Thread Damage
Barry S. Rubel, D.M.D.; Edward E. Hill, D.D.S., M.S.
Patient treatment report illustrates clinical intervention needed to prevent possible misalign
ment and damage to internal aspect of implant body when confronted with implant in
which internal threads are damaged.
41 Lack of Correlation between Benign Brain Tumors and Markers of Oral Health
51 General News
Steven Lehrer, M.D.; Sheryl Green, M.B.BCh.; Kenneth E. Rosenzweig, M.D.
Examination of association of benign brain tumor incidence with number of dentists and
other correlates of oral health was undertaken to determine what risk, if any, dental X-rays
posed to development of intracranial meningioma.
52 Component News
44 Oral Cavity Lymphoid Neoplasms: A Fifteen-year Single Institution Review
59 Read, Learn, Earn
61 Classifieds
64 Index to Advertisers
68 Addendum
Use your smartphone to scan this
QR Code and access the current
online version of The New York
State Dental Journal.
Elizabeth Philipone, D.M.D.; Govind Bhagat, M.B.B.S.; Bachir Alobeid, M.D.
Retrospective search of surgical pathology database at New York City teaching hospital reviewed all oral
biopsy specimens diagnosed as either lymphoma or plasma cell neoplasm over past 15 years. Fortyseven cases of oral cavity lymphoid neoplasms were identified. A report of those cases is presented.
48 Diagnosing the Parotid Lipoma
Ashely Houle, B.S.; Louis Mandel, D.D.S.
Clinical features of rarely reported and diagnostically challenging parotid gland lipoma are
described. Case report.
The New York State Dental Journal is a peer reviewed publication. Opinions expressed by the authors of material included in The New York State Dental
Journal do not necessarily represent the policies of the New York State Dental Association or The New York State Dental Journal. EZ-Flip version of The
NYSDJ is available at www.nysdental.org and can be downloaded to mobile devices.
editorial
Treating Special Needs Patients is Rewarding Experience
May summit aimed at increasing the number of providers caring for the disabled.
A
s an orthodontist, I have treated many
special needs patients. They all present with situa
tions you don’t see ordinarily in the day-to-day
practice of dentistry. Their malocclusions, for
example, seem to be much worse than what I see
in my other patients. However, I have always
found treating these special needs patients to be
very rewarding. They are challenging to be sure,
but they appreciate all that I do for them. And
they make you think about treatment beyond the
typical plan.
Because of their disabilities, it takes longer
than usual to treat special needs patients. Some
treatments, for example, can involve a more diffi
cult orthodontic-surgical approach. Nevertheless, I
never regretted having them as patients. Their suc
cessful treatment gives me a sense of fulfillment
that is greater than what I experience when treating
someone without a disability.
Special needs patients need dental treatment,
just like all other patients. However, during a typical
dental education, students aren’t exposed much to
special needs patients—which may be one reason
these patients find it hard to find a dentist who will
care for them. It might be also that dentists feel
uncomfortable providing treatment, because of their
limited knowledge and experience, so they avoid tak
2
APRIL 2015 • The New York State Dental Journal
ing special needs patients into their practices—to the
detriment of both the patient and the dentist.
As I said, I have found treating special needs
patients to be very rewarding. The Down syndrome
patients I have treated are the friendliest and most
caring people you could ever encounter. One of my
Down syndrome patients was an amateur comedian;
he had us laughing at every appointment, telling us
new jokes whenever he came in. Another was a sweet
little girl, who just wanted to have straight teeth.
When her braces came off, her smile melted my heart.
You may not feel comfortable treating patients
with special needs. You may think you don’t have the
proper education to undertake such a task. In that
case, I have a suggestion to make. NYSDA and the
New York State Dental Foundation are sponsoring a
summit to address the future of special needs den
tistry, hospital dentistry and dental education on
May 14 and 15 in Albany. The event is titled “The
Impending Oral Health Crisis: Ensuring Quality
Dental Care and Access for New York’s Most
Vulnerable Patients,” and it’s taking place in the
Legislative Office Building on the Empire State Plaza.
The summit is the brainchild of NYSDA
President Elect David Miller and Carl Tegtmeier,
chair of NYSDA’s Council on Dental Health
Planning and Hospital Dentistry. It is expected to
THE NEW YORK STATE DENTAL JOURNAL
EDITOR
Kevin J. Hanley, D.D.S.
bring together a broad spectrum of knowledgeable presenters who will discuss var
ied topics concerning the treatment of special needs patients. The keynote address
will be given by Robert Lewando, executive dental director of Blue Cross/Blue Shield
of Massachusetts. The title of his presentation is “Linking Oral Health and General
Health: How Oral Health Care Can Help Medical Costs.”
Richard Speisman, chair of the Department of Dentistry, Rochester Regional
Health System, Rochester General Hospital, will discuss “Dental Care for Patients
with Complex Treatment Needs.” John Morgan, associate professor at Tufts
University School of Dental Medicine, will detail the “Challenges in Providing
Preventive Care to Residents in Long-Term Care.” And Elizabeth Smith-Boivin,
executive director of the Northeast New York Chapter of the New York State
Alzheimer’s Association, will describe future challenges in “Preparing for Increases
in Alzheimer’s disease and Dementia Patients.”
“A Collaborative Model to Reduce Health Costs” will be offered by Fred
Ferguson, director of pediatric dentistry at Stony Brook University School of Dental
Medicine. Gary Goldstein, director of the dental program for Emblem Health
Family Dental Practice, and Carl Tegtmeier finish the first day with a report on the
New York State Office of Persons with Developmental Disabilities Task Force on
Special Needs Dentistry in “Transitioning Patients with Developmental Disabilities
into Managed Care.” The second day of the symposium has equally relevant topics
and speakers.
This promises to be an excellent, fact-filled, educational two days about a topic
with which not many of us are familiar. Special needs patients deserve the best
treatment we can give. This symposium will give us the knowledge and background
we need to accomplish just that. I will be attending. I suggest if special needs
patients are part of your practice, you do the same.
MANAGING EDITOR
Mary Grates Stoll
ADVERTISING MANAGER
Jeanne DeGuire
ART DIRECTORS
Kathryn Sikule / Ed Stevens
EDITORIAL REVIEW BOARD
Frank C. Barnashuk, D.D.S.
David A. Behrman, D.M.D.
Michael R. Breault, D.D.S.
Ralph H. Epstein, D.D.S.
Daniel H. Flanders, D.D.S.
Joel M. Friedman, D.D.S.
Chester J. Gary, D.D.S., J.D.
G. Kirk Gleason, D.D.S.
John T. Grbic, D.M.D., M.S., MMSc.
Brian T. Kennedy, D.D.S.
Stanley M. Kerpel, D.D.S.
Elliott M. Moskowitz, D.D.S., M.Sd
Francis J. Murphy, D.D.S.
Eugene A. Pantera Jr., D.D.S.
Robert M. Peskin, D.D.S.
Georgios Romanos, D.D.S., D.M.D., Ph.D., Prof.Dr.med.dent
Robert E. Schifferle, D.D.S., MMSc., Ph.D.
PRINTER
E-prescribing Delayed One Year
On another topic, NYSDA achieved legislative success in March when, working
with the Medical Society of the State of New York, it persuaded the State Legislature
and Gov. Cuomo to delay implementation of e-prescribing regulations for one year
to ease what has been a difficult implementation. Scheduled to go into effect on
March 27 of this year, the requirement that every dentist, physician and other
health care personnel who write prescriptions, transmit those prescriptions elec
tronically, will now take effect on March 27, 2016.
Even though NYSDA was ahead of the curve on implementation, recommend
ing that its members subscribe to an e-prescribing service and securing such a
service at a reduced rate, members were encountering technical glitches that made
it difficult to sign up. Now we have another year to complete the process. My advice
is not to wait until next year, but to complete the process as soon as you can. March
27, 2016, will be here before you know it, and there won’t be another extension.
Please, don’t be like my son, who waits until April 14 to fill out and file his
tax forms. Every year I admonish him to get his taxes filed early, but that never
seems to happen. Sign up now, so that your transition to e-prescribing will be a
smooth one.
Fort Orange Press, Albany
NYSDJ (ISSN 0028-7571) is published six times a year,
in January, March, April, June/July, August/ Septem
ber and November, by the New York State Dental As
sociation, 20 Corporate Woods Boulevard, Suite 602,
Albany, NY 12211. In February, May, October and De
cember, subscribers receive the NYSDA News. Periodi
cals postage paid at Albany, NY. Subscription rates $25
per year to the members of the New York State Dental
Association; rates for nonmembers: $75 per year or $12
per issue, U.S. and Canada; $135 per year foreign or $22
per issue. Postmaster: Please send change of address to
the New York State Dental Association, Suite 602, 20
Corporate Woods Boulevard, Albany, NY 12211. Edito
rial and advertising offices are at Suite 602, 20 Corpo
rate Woods Boulevard, Albany, NY 12211. Telephone
(518) 465-0044. Fax (518) 465-3219. E-mail info@
nysdental.org. Website www.nysdental.org. Microform
and article copies are available through National Ar
chive Publishing Co., 300 N. Zeebe Rd., Ann Arbor, MI
48106-1346.
D.D.S.
The New York State Dental Journal • APRIL 2015
3
Clearing Up the Confusion about Medicare and Dentistry
Dentists have until December to properly enroll in Medicare to satisfy regulatory changes to the system.
M
Judith L. Shub, Ph.D.; Lance Plunkett, J.D., LL.M.
ost dental practices that treat patients over 65 years
of age will be affected by a significant change to the Medicare reg
ulations. Medicare recipients who purchase supplemental Medi
care insurance policies (that is, Part D drug plans) will be eligible
for benefits from those plans only when the ordering doctor has
enrolled in Medicare by opting in, opting out or enrolled using
the 8550. The Centers for Medicare and Medicaid Services (CMS)
has delayed enforcement of this regulation until Dec. 1.
It is advisable for dentists to enroll now as Medicare provid
ers or to submit affidavits indicating that they wish to opt out
of the program. Because enrollment is not immediate, dentists
should file the necessary documentation—or register online—to
opt in, opt out or submit an 8550 form with Medicare as soon as
possible. If a dentist takes no action, patients with Part D cover
age will not receive benefits when their dentist writes a prescrip
tion for them. The important things to note are:
1. Regardless of your decision (to opt in, opt out or submit an
8550), your patients with Medicare Part D plans will have
coverage for any prescriptions covered by their Part D plans.
2. Dentists who elect to opt out are not required to provide indi
vidual notification to patients in their practices, as dentistry
is not included in the Medicare program.1 However, dentists
who have opted out of Medicare are required to enter into a
1.
It is advisable that dentists inform their patients that Medicare does not cover dental treat
ment. They may wish to include this information with instructions given to patients about
the practice and its billing policies. Example: “Medicare does not cover dentistry. Our prac
tice does not participate in Medicare. Nonetheless, if you have a Part D supplemental drug
plan, your plan will cover your prescriptions because we have registered with the Medicare
program.”
written agreement with a patient advising the patient that
they are not Medicare providers only when and if they are
performing a procedure covered by Medicare Part B.
Dentistry is excluded from the Medicare benefit package with
limited exceptions. Opting out of Medicare has no real impact
for most dentists because they do not perform medical treatment
services covered by Medicare Part B. The only drawback to opting
out is that it is in force for only two years.
Recently, in addition to opting in or out, CMS has estab
lished a third option that would enable patients with Medicare
Part D Supplemental Drug Plans to receive coverage for their
dentists’ prescriptions. Dentists now may choose to submit the
Form 8550 to be placed on the Medicare Ordering and Referring
Registry, which will deem them eligible to order and refer patients
to Medicare enrolled providers and suppliers and for prescribing.
The ability to utilize the 8550 is a desirable alternative for most
dentists, given that Medicare does not cover dental treatment and
resubmitting opt out affidavits biannually is inconvenient. Sub
mitting the 8550 is not a form of opting in, because it does not al
low the practitioner to bill Medicare. But it is also not opting out,
because it does not trigger any other obligations in that regard.
The new regulations do not change anything with respect to
the relationship between dental specialists who do perform medi
cal services covered by Medicare Part B and Medicare. Dentists
who bill Medicare can simply continue to do what they have al
ways done with respect to enrolling. That is, if they opt in, they
are compelled to accept Medicare reimbursement when they per
form a medical service covered by Medicare Part B. If they opt out,
they can bill their patients and collect their usual fees.
19
Medicare and Dentistry
Again, Medicare does not
include coverage for routine
dental treatment. Nonethe
less, to refer or order services
for a Medicare patient (where
the service provider expects to
be paid by Medicare), practi
tioners must be on record
as known to the Medicare
program. Medicare will not
pay a second provider if the
referring provider is not en
rolled as a Medicare provider
or has opted out. Do not be
confused by the terminology.
Opting out is different from
completely ignoring Medicare
by doing nothing. Opting out is a status that Medicare recognizes
even though it means a doctor will not be billing and will not be
reimbursed by Medicare.
Dentists are not required to provide written notification to
their patients that they do not participate as Medicare providers
unless they are providing services that are covered by Medicare
Part A or B. Because dental care is excluded from Medicare gen
erally, it is exempt from the advance beneficiary notice of noncoverage requirements.
Section 1862 (a)(12) of the Social Security Act states:
“where such expenses are for services in connection with the care,
treatment, filling, removal, or replacement of teeth or structures di
rectly supporting teeth, except that payment may be made under part
A in the case of inpatient hospital services in connection with the pro
vision of such dental services if the individual, because of his underly
ing medical condition and clinical status or because of the severity of
the dental procedure, requires hospitalization in connection with the
provision of such services.”
Most of the procedures performed by dentists who do
qualify for Medicare reimbursement typically are performed
by specialists—biopsies, including brush biopsies, for example.
Medicare Part B excludes the following two categories of services
from coverage:
1. A primary service (regardless of cause or complexity) provid
ed for the care, treatment, removal or replacement of teeth
or structures directly supporting teeth—for example, prepara
tion of the mouth for dentures or removal of diseased teeth
in an infected jaw.
2. A secondary service that is related to the teeth or structures
directly supporting the teeth unless it is incidental to and an
integral part of a covered primary service that is necessary to
treat a non-dental condition (for example, tumor removal)
20
and it is performed at the
same time as the covered pri
mary service and by the same
physician/dentist.
In cases where these
requirements are met and
the secondary services are
covered, Medicare does not
make payment for the cost
of dental appliances, such
as dentures, even though
the covered service resulted
in the need for the teeth to
be replaced; the cost of pre
paring the mouth for den
tures; or the cost of directly
repairing teeth or structures
directly supporting teeth (for
example, alveolar process).
Certain dental services are always covered, including the ex
traction of teeth to prepare the jaw for radiation treatment of
neoplastic disease, and an oral or dental examination performed
on an inpatient basis as part of a comprehensive workup prior to
renal transplant surgery or performed in a rural health center/
federally qualified health center prior to a heart valve replace
ment. Dentists should contact Medicare directly with questions
about whether a service will or will not be covered. A key thing to
remember is that Medicare is not really paying for a dental service
but, rather, is either paying for a covered medical service that a
dentist can perform or is paying for a dental service that is a nec
essary adjunct to a covered medical service.
Understanding Medicare Part B and
Supplemental Plan Coverage
There are two key issues to understand with respect to Medicare
in deciding which enrollment option is best for an individual
dentist. The first issue pertains to the scope of coverage of Medi
care Part B. The second is the impact of the regulatory changes to
the Part D supplemental plans taking effect this year.
Billing for Medicare Part B Covered Services
If a dentist has not opted out of the Medicare program and that
dentist performs Medicare-covered services for patients eligible
for Medicare, the dentist has only three options:
1. Enroll as a Medicare provider and submit a claim for the
treatment in accordance with the Medicare fee schedule.
2. Refer the patient for services covered by Medicare to a dentist
who is a Medicare provider.
3. Not charge the patient for the treatment provided.
Unless the dentist has opted out, the dentist legally cannot
charge a Medicare recipient for a treatment service covered under
the Medicare Part B schedule.
Coverage for Prescription Drugs under Medicare Part D
Supplemental Coverage
As a result of new CMS regulations, in December, patients who
purchase Medicare Part D prescription drug coverage will only
receive benefits for prescriptions issued by prescribers who have
enrolled with Medicare by opting in, opting out or submitting an
8550 enrollment application. Thus, it is beneficial for dentists to
enroll with CMS to assure that their patients will be eligible for
benefits when the dentist prescribes a covered drug.
Medicare Dental Advantage Plans
Medicare Advantage plans are part of Medicare. They are issued
by private insurers contracted to administer Medicare benefits. A
provider who opts out cannot be paid any Medicare dollars for
Part B Medicare services. This does not affect dentists who con
tract with Medicare supplemental dental plans because Medicare
Part B does not pay for dental services.
As with Part B, Medicare Advantage plans are prohibited
from paying anyone who is opted out of Medicare for services
that Medicare Part B otherwise pays for. Since Medicare Part B
basically does not pay for dental services, these dentists are not
affected directly by this.2 However, it is important for anyone
contracted as a Medicare Advantage provider to review whether
he or she is contracted to provide medical services and consider
this in making any enrollment decision. Nonetheless, it would be
virtually anomalous for this to make any difference with a supple
mental dental plan under Medicare Advantage.
Sleep Apnea Devices
There is one other type of service for which dentists are eligible
for Medicare reimbursement. Dentists who fabricate sleep ap
nea/snoring devices for patients over 65 years of age must enroll
with CMS as providers of durable medical equipment (CMS form
855S). This is unrelated to the dentist’s status as a Medicare pro
vider for the purpose of billing for medical/dental treatment. It
is completely unrelated to the doctor’s status as a practitioner. A
dentist who enrolls using form 855S would still need to opt in or
opt out as a dentist provider.
Treatment for sleep apnea is outside of the scope of prac
tice for dentistry in New York State. Because dentists do not treat
sleep apnea, they cannot submit claims to Medicare for such
treatment. Nevertheless, dentists can fabricate sleep apnea ap
pliances on the order of a physician. Dentists who fabricate such
appliances must be registered with Medicare as a DME (durable
2.
If a dentist opts out of Medicare, then he/she cannot get paid by a Medicare Advantage plan
for any service that Medicare Part B might pay for. Since payment for any dental service is
rare, the net effect is virtually zero.
medical equipment) provider to bill Medicare or Medicare Advan
tage for any sleep apnea device. Medicare is billed for the DME
service, not for the dental/medical service by the DME provider—
in this instance, the DME provider just coincidentally happens to
also be a dentist. Dentists who fabricate sleep apnea appliances
can enroll as DME providers on the CMS website.
A dentist may enroll as a Medicare DME provider and opt out
of Medicare Part B. DME suppliers cannot opt out of Medicare
with respect to payment for durable medical equipment, that is,
sleep apnea devices. No Medicare dollars can be paid by anyone
to a DME supplier who is not registered with Medicare. A den
tist who makes sleep apnea devices cannot be paid with Medicare
monies if the person is not registered as a DME provider.
How to Enroll or Opt Out
Patients’ ability to obtain benefits from the program and supple
mental insurers is not affected—as long as the dentist opts in or
out (or completes the 8550). In order to opt out, the dentist must
notify the contractor handling Medicare claims for New York
State that he or she intends to contract privately with Medicare
patients. This is done by filing an affidavit in which the dentist
attests to certain specific terms. Affidavits must be filed within
10 days of entering the first private contract and are valid for two
years. Non-Medicare enrolled dentists wanting to opt out must
obtain and use a Unique Physician Identifier Number (UPIN)
provided by the Medicare carrier.
Information and forms to enroll are available at:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certifi
cation/MedicareProviderSupEnroll/EnrollmentApplications.html.
Alternately, practitioners can file an opt out affidavit with the
contractor for New York State, National Government Services,
Inc. To opt out of Medicare, you must file a Medicare Opt Out
Affidavit. The required form is available on the NYSDA website,
www.nysdental.org, in the “members only” section.
Contact information for National Government Services, Inc., is as follows:
National Government Services, Inc., (888) 379-3807,
http://www.ngsmedicare.com.
For additional information regarding opting out, log onto:
http://www.cms.gov/Outreach-and-Education/Medicare-Learn
ing-Network-MLN/MLNMattersArticles/downloads/SE1311.pdf.
For general information, call the Medicare provider customer
service number, 1 (866) 837-0241. p
Dr. Shub is NYSDA Assistant Executive Director for Health Affairs. Mr. Plunkett is NYSDA General
Counsel.
21
clinical dentistry
Barotrauma
Tooth under Pressure
Satheesh Kumar, B.D.S., M.D.S.; Preeti Satheesh Kumar, B.D.S., M.D.S.;
Jins John, B.D.S., M.D.S.; Ruchi Patel, M.D.S.
ABSTRACT
With the growing number of air passengers, flight at
tendants, leisure pilots, as well as military and airline
pilots, dentists may encounter physiological and patho
logical phenomena precipitated by high altitude. With
the introduction of the self-contained breathing appa
ratus (SCUBA), many of these manifestations caused
by changes in atmospheric pressure were reported in
association with diving as well. Limited literature ex
ists on this subject. Hence, this article aims to review
literature concerning the classification, etiology and
manifestations of barodontalgia, as well as important
clinical considerations for its management.
Barodontalgia, which affects air crew and aircraft passengers, as
well as underwater divers, is pain or injury affecting teeth due to
changes in pressure gradients.1 It has been reported also as a con
sequence of air bag rupture and the high pressure air inhaled by
the car driver during an accident.2 It is sustained from the failure
to equalize the pressure of an air-containing cavity to that of the
surrounding environment.
In general, barotrauma is defined as pressure-induced dam
age that can occur at both high and low pressures. Changes in
ambient pressure, for example, during flying, diving or hyperbaric
oxygen therapy, can lead to barotrauma. Flying and diving are
usually associated with different types of pressure changes. Dur
ing commercial flights, for example, aircraft personnel are ex
22
posed to only minor pressure differences, but this exposure lasts
for a relatively long period of time.
By contrast, military and aerobatic pilots are subjected to
rapid pressure changes and strong acceleration forces. As a re
sult of the higher density of the surrounding medium, divers are
exposed to very high ambient pressures. Compared with aircraft
personnel, however, the duration of exposure is usually short. De
pending upon diving depth and technique, there are considerable
differences in the breathing gases used. This causes further physi
ological and metabolic changes in the human body, in addition to
changes in ambient pressure.3
Etiology
Barodontalgia is a symptom rather than a pathological condition
and in most cases reflects a flare-up of pre-existing oral disease;
hence, most common oral pathologies have been reported as pos
sible sources of barodontalgia.4,5,6
The chief prerequisite for toothache at high altitude is the
presence of some pre-existing pathological disturbance of the
pulp. The environmental changes associated with high altitudes
may cause an exacerbation of symptoms. High altitude environ
ment does not affect a normal pulp.
From an analysis of more than 1,000 case histories by the
army/air force dental research group,6 toothaches at altitude were
grouped into the following three categories on the basis of clinical
findings:
Group I: Pain in teeth with irreparable damage to the pulp.
Clinical findings included pulp destruction and periapical lesions.
Treatment includes root canal therapy or extraction.
Group II: Pain in teeth with a reversible disturbance of the
pulp. These could be attributed to recently done fillings, defective
fillings, recurrent caries and hypersensitive dentin. They respond
to restorative treatment or do not recur after a few flights.
Group III: Pain referred to the teeth from aerosinusitis, ae
rootitis, or unerupted or partially erupted third molars.6
Barodontalgia affects 11.9% of divers and 11.0% of military
air crews, with a rate of 5 episodes/1,000 flight-years. Upper and
lower dentitions were affected equally in flight, but more upper
than lower dentitions were affected in diving. The most prevalent
etiologic pathologies for in-flight dental pain were faulty dental
restorations (including dental barotrauma) and dental caries
without pulp involvement (29.2%), necrotic pulp/periapical in
flammation (27.8%), vital pulp pathology (13.9%), recent dental
treatment or “postoperative barodontalgia”(11.1%). Barosinus
itis was the main cause of pain in 9.7% of the cases.4,7
Barodontalgia was most prevalent in the third decade of life
and showed no gender preference
Classification
Barodontalgia is subgrouped into direct (dental-induced) and in
direct (nondental-induced) pain. The currently accepted classifi
cation of direct barodontalgia consists of four classes according to
pulpal/periapical conditions and symptoms.4,8,9
Strohaver10 has advocated the differentiation of barodontal
gia into direct and indirect types. In the direct type, reduced at
mospheric pressure contributes to a direct effect on a given tooth.
In the indirect type, dental pain is secondary to stimulation of the
superior alveolar nerves by a maxillary barosinusitis.
Direct barodontalgia is generally manifested by moderate-to
severe pain, which usually develops during ascent, is well local
ized, and the patient can frequently identify the involved tooth.
Indirect barodontalgia is a dull, poorly defined pain that generally
involves the posterior maxillary teeth and develops during descent.
If pain occurs during descent, indirect barodontalgia attributable
to barosinusitis should be suspected. If indirect barodontalgia is
diagnosed, the patient should be referred to a medical practitio
ner or an ear, nose and throat specialist for treatment.11,12
Pathology
The pathology of barotrauma is directly related to Boyle’s law,
which states, if temperature remains constant, the volume of a
fixed mass of an ideal gas is inversely proportional to the pressure
of the gas. As pressure increases, the volume of a confined gas
decreases. Specifically, as a person descends deeper and deeper be
low the water surface, pressure exerted on the diver by the water
increases and reduces the volume of gases in enclosed spaces such
as teeth and sinuses.
TABLE 1
Classification of Direct (dental-induced) Barodontalgia4
Class Pathology Features
1.
Irreversible pulpitis: Sharp transient (momentary) pain on ascent.
2.
Reversible pulpitis: Dull throbbing pain on ascent.
3.
Necrotic pulp: Dull throbbing pain on descent.
4.
Periapical pathology: Severe persistent pain (on ascent/descent).
The same law applies if a person climbs to high altitudes (in flight);
in this case, outside pressure decreases, permitting the volume of
gases to increase.1,14,15 Pain during ascent can indicate the presence
of a disease of vital pulp tissue (pulpitis). Pain during descent can
be indicative of pulp necrosis or facial barotraumas.3,15
Pathogenesis
There was no published research regarding the pathogenesis of
barodontalgia in the past decade. Some theories exist, but most
were offered in the first half of the 20th century.4 Kollmann5 re
fers to three important hypotheses to explain this phenomenon:
expansion of trapped air bubbles under a root filling or against
dentin that activates nociceptors; stimulation of nociceptors in
the maxillary sinuses, with pain referred to the teeth; and stimula
tion of nerve endings in a chronically inflamed pulp.1 He strongly
supports the last two hypotheses and states, for the latter, that
histologic evidence shows that chronic pulpal inflammation can
still be present even when a thin dentin layer covers the pulp—for
example, as in a deep cavity preparation.1 Yet the pathogenesis of
this unique dental pain remains occult.
Diagnosis
Certain generalities have been established to help with the diag
nosis of direct barodontalgia. Posterior teeth are more frequently
involved than anterior teeth, while maxillary teeth are affected
more often than mandibular teeth. Teeth with amalgam restora
tions are more likely to be involved than unrestored teeth; and re
cently restored teeth are particularly susceptible. Examination of
a patient complaining of barodontalgia should include an estima
tion of the age of restorations in the suspected area, exploration
for caries or defective restorations, percussion of any suspected
tooth, the patient’s response to the application of electrical
stimulation and/or cold and heat, and radiographic examina
tion.11,16,17 Appropriate radiographs of the suspected teeth should
be obtained, with the understanding that a negative radiograph
does not rule out pulpitis.16
Barodontalgia has been found to occur during diving in teeth
with carious lesions, or where there are periapical lesions, periodon
tal abscesses, maxillary sinus congestion and recently crowned teeth.
23
Strohaver has recommended that diving drills be restricted for 48
to 72 hours to allow time for the dental pulp to “quiet down” or
stabilize. Overall, regular dental examinations are essential for div
ers. And any dental problem that might predispose to barodontalgia
should be corrected to prevent the development of symptoms.11
Exposure to reduced barometric pressure is evidently a pre
cipitating factor, with disease of the pulp a probable cause. Fer
jentsik et al.8 stated that normal pulp tissue would not produce
pressure-associated pain, regardless of whether restorations or
caries were present. However, Hodges19 has reported that den
tal pain could be produced in apparently healthy teeth when the
atmospheric pressure was increased to a level corresponding to a
depth of three atmospheres.
The clinician has to discover the offending tooth, which could
be any tooth with an existing restoration or with endodontic treat
ment (often clinically acceptable) and/or adjacent anatomical
structures (e.g., maxillary sinus). The clinician usually cannot re
produce the pain trigger (i.e., barometric pressure change) in or
dinary dental facilities and, even in a diagnostic altitude chamber
simulation, sometimes it is impossible to reproduce the pain.
Discussion
The first description of pressure-related disease was written by
Paul Bert in 1978, when he noted symptoms of Caisson disease in
bridge workers who, after finishing their shifts and returning to
the surface, presented with dizzy spells, difficulty in breathing and
pain of the abdomen and joints.2
During World War II, as aircraft began to fly at altitudes
greater than 25,000 feet, the number of dental emergency visits
by flight crewmen increased.20 The name of this dental pain was
given the prefix ‘‘aero’’ (i.e., aerodontalgia) and was reported for
the first time as an in-flight physiologic and pathologic phenom
enon at the beginning of the 20th century. In the 1940s, with the
appearance of SCUBA, many in-flight manifestations caused by
barometric changes were found to be associated with diving as
well. Consequently, the prefix was changed to ‘‘baro,’’ a broader,
more appropriate term, barodontalgia. In the diving environ
ment, this pain is commonly called “tooth squeeze.”
Barodontalgia, which affects air crews and aircraft passen
gers, as well as underwater divers, is pain or injury affecting teeth
due to changes in pressure gradients.1,14,22 The prevalence of bar
odontalgia was 1% to 3% of all military flights and was ranked
fifth for in-flight physiological complaints of U.S. pilots and third
as a causative factor of premature landing.6,20,23 Barodontalgia
was reported to occur during flying at altitudes of 600m to 1500m
and during diving at depths of 10m to 25m.3,15 It is well known
that as one rises in the atmosphere, air density and pressure fall.
The drop in pressure is such that at 6,000 meters, the air pressure
is around half that at sea level. At about 10,000 meters, it is a
quarter of its sea level value.2
TABLE 2
Dental-Related (Direct) Versus Non–Dental-Related (Indirect) Barodontalgia1,13
Characteristic
Pulp disease-induced
(direct) barodontalgia
Periapical disease-induced
(direct) barodontalgia
Facial barotrauma-induced
(indirect) barodontalgia
Cause
Pulp disease
Periapical disease
Barosinusitis, barotitis media
Appearance
During ascent
Pain usually ceases during descent
at the appearance-level
Periapical periodontitis: usually at
high altitude (38,000 ft) during
ascent or descent
During descent
Pain usually continues on ground
Symptoms
Nonreversible pulpitis:
sudden sharp penetrating pain, reversible
pulpitis or necrotic pulp: dull beating pain
Continuous intense or dull beating pain, swelling
Dental pain in maxillary molar or
premolar region
Dental History
Recent dental work, Recent dental thermal
sensitivity (eg, during hot or cold drinking)
Recent dental percussion sensitivity
(e.g., during eating)
Present upper respiratory infection
Past sinusitis illness
Clinical Findings
Extensive dental caries lesion or
(defective) restoration, Acute pain upon
cold (40 o C) test
Extensive caries lesions or (defective) restoration,
Acute pain upon percussion test
Pain on sinus palpation
Pain upon acute change in head position
Radiological
Findings
Pulpal caries lesions
Restoration close to pulp chamber
Pulpal caries lesions
Restoration close to pulp chamber
Periapical radiolucency
Inadequate endodontic obturation
Opacity (fluid) on maxillary
sinus image
24
The physical properties of the gas mixture used during deep sea
diving may also contribute to barodontalgia. In scuba tanks, oxy
gen’s natural diluent gas, nitrogen, is replaced by helium, result
ing in a gas of lower viscosity. This gas can enter tissues, including
teeth, and can sometimes become trapped in closed spaces, such
as the pulp chamber and root canal. There are two mechanisms by
which gases can be trapped in spaces: if there is a space between a
tooth and its restoration, gas may be forced into it during an in
crease in pressure; and dissolved gas may diffuse from tissues into
spaces as pressure decreases. Consistent with Boyle’s Law, trapped
gas will expand and the resulting stress may cause tooth fracture.1
Calder and Ramsey studied tooth fracture at high altitude and
have coined the term “odontecrexis” (Greek for tooth explosion)
to describe this physical disruption of teeth with leaking restora
tions due to barometric pressure change.24
Clinically, people affected by barodontalgia were found to
have one or more of the following: acute or chronic periapical
infection; caries; deep restorations; residual dental cysts; sinus
itis; and a history of recent surgery.1,12 The latter is of particular
concern for people wearing oxygen regulators when diving, using
self-contained underwater breathing apparatus (scuba) or when
wearing oxygen masks during high performance aircraft flights,
due to the risk of air being pushed into the tissues. Sinusitis may
also contribute to barodontalgia, although it may not be related
to any tooth pathology.1
Kennebeck et al.6 have suggested that decreased atmospheric
pressure plays a role in the development of apical lesions and in
the dissemination of focal infection. Hence, apical periodontitis
due to necrosis of the dental pulp tissue can also be considered a
causative pathology of the pain.21 In the literature,15 pulpitis with
periapical inflammation or after dental restoration is reported to
be the most common cause of barodontalgia.
Ear-nose-throat disorders account for more than 50% of
cases of flying-associated diseases. The middle ear is the most
common structure to be subjected to barotrauma, whenever the
Eustachian tube is functionally impaired because of mucosal con
gestion or edema. Symptoms may include clogging of the ear, ear
pain, dizziness, tinnitus and hemorrhage. The paranasal sinuses
may also be affected if the sinus orifices are occluded.
The Fédération Dentaire Internationale (FDI) has classified
barodontalgia into four groups according to its signs and symp
toms. From moderate to severe, they are: acute pulpitis; chronic
pulpitis; necrosis of the pulp; and periapical abscess or a cyst. The
FDI also recommends an annual checkup for divers, submariners
and pilots, with oral hygiene instructions from dentists.1,7
addition, screening panoramic radiographs are recommended for
these populations at three- to five-year intervals.1,17 When deal
ing with patients involved in diving or aviation, clinicians should
pay close attention to areas of dentin exposure, caries, fractured
cusps, periapical pathology, defective (fractured or cracked) res
torations, restorations with poor retention, secondary carious le
sions and signs of attrition.1,13,14,15,18
Retrospective studies showed that most patients with clini
cal manifestations of barodontalgia had carious lesions or de
fective restorations extending into the dentin.6 The clinical im
plication of this finding is that patients who have carious lesions
or who have undergone dental treatment, including the expo
sure of dentin, for example, during prosthetic tooth prepara
tion, should avoid exposure to pressure changes until definitive
treatment is completed.15
As a rule, individuals should undergo a thorough dental exam
ination before being exposed to pressure changes. Treatment must
include the restoration of all carious lesions, the removal of all
defective restorations and the management of inflammation. Vital
ity testing of all teeth is required for the detection and treatment
of asymptomatic pulp necrosis.3 Dentists should advise patients
to avoid exposure to pressure changes until all necessary surgical,
conservative and prosthetic procedures have been completed.15
Prevention
Periodic oral and dental examinations, including periapical radio
graphs and vitality tests, are recommended for the prevention of
barodontalgia in high-risk populations (e.g., aircrews, divers). In
25
Based on the results of the study conducted by Khanna,11 dental
surgeons should consider cementing fixed prosthetics with resin ce
ments for patients who are exposed to marked variations in environ
mental pressure, such as divers and submariners during escape drills.
The placement of a zinc oxide eugenol (ZOE) base was found
to prevent barodontalgia when reversible pulpitis was the under
lying cause. This is attributed to the well-known sedative effects
of zinc-oxide eugenol.1,7,22
Rossi dictates the grounding of military aircrews from the
time of diagnosing the need for endodontic treatment until com
pletion of treatment. He recommends against direct pulp capping
in the military aircrew patient and for pulpectomy and endodon
tic treatment in all caries management in which exposure of the
pulp chamber is evident or suspected.1,4,7,13
Stoetzer et al. suggest that warm gutta-percha obturation
techniques are preferred to cold lateral condensation or warm
carrier-based Resilon obturation techniques in the endodontic
treatment of patients such as professional divers or parachutists,
who are often exposed to changes in atmospheric pressure.25
Temporary flight restriction (grounding) after dental and
surgical procedures is still a powerful tool for prevention of post
operative barodontalgia.13
REFERENCES
1.
2.
3.
4.
5.
6.
7.
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9.
10.
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18.
Recommendations
Although barodontalgia is not common, it should not be dismissed
as unimportant, as it can pose a serious safety risk to divers, sub
mariners, pilots and airline passengers. It may be prevented by reg
ular dental examinations, with adequate attention paid to existing
dental restorations. The flight population would be better served by
a more comprehensive understanding of the issues and awareness
of the limitations of our current knowledge base.
Patients should not dive or fly in non-pressurized cabins
within 24 hours of dental treatment requiring aesthetic or seven
days following surgical treatment.1 A subject of aviation dentistry
needs to be incorporated into the dental curriculum. Continuing
dental education programs should be conducted to educate den
tal and healthcare professionals about the prevalence, diagnosis
and treatment of barodontalgia.
Summary
The article presented here reviews available literature regarding
barodontalgia. Although it may seem that barodontalgia was al
most neglected in dental education and research in the second
half of the 20th century, reports appearing during the past decade
were gathered to draw an updated image of this pain entity. The
efforts of more researchers, educators and clinicians are need
ed for further enhancement of theoretical, as well as practical,
knowledge of barodontalgia. p
19.
20.
21.
22.
23.
24.
25.
Robichaud R, McNally ME. Barodontalgia as a differential diagnosis: symptoms and find
ings. J Can Dent Assoc 2005;71(1):39–42.
Macaluso GM, Galli C. Flight associated inferior alveolar nerve paresthesia: a case report.
Oral Surg Oral Med Oral Path Oral Radiol Endod 2005;99:165-7.
Stoetzer M, Kuehlhorn C, Ruecker M, Ziebolz D, Nils Claudius Gellrich NC, von See C.
Pathophysiology of Barodontalgia: A Case Report and Review of the Literature. Case Reports
in Dentistry Volume 2012, Article ID 453415.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2010;109:e65-e69.
Kollmann W. Incidence and possible causes of dental pain during simulated high altitude
flights. J Endod 1993;19(3):154–9.
Kennebeck R, Knudtzon KF, Goldhush AA. Symposium on problems of aviation dentistry.
JADA 1946;33(13):827-844.
Gaur TK, Shrivastava TV. Barodontalgia: a clinical entity. J Oral Health Comm Dent
2012;6(1)18-20.
Ferjentsik E, Aker F. Barodontalgia: a system of classification. Military Medicine
1982;147(4):299–304.
Ingle JI, Dudley HG. Differential diagnosis and treatment of dental pain. In: Ingle JI, Bak
land LK, editors. Endodontics. 4th ed. Baltimore: Williams and Wilkins; 1994, p. 444.
Strohaver RA. Aerodontalgia: dental pain during flight. Med Serv Dig 1972;23:35-41.
Khanna A. Crown cementing strategy for naval divers. MJAFI 2010;66:46-49.
Rauch JW. Barodontalgia: dental pain related to ambient pressure change. Gen Dent
1985;33:313.
Zadik Y. Aviation dentistry: current concepts and practice. Br D J 2009;206(1):11-16.
Kieser J, Holborow D. The prevention and management of oral barotrauma. NZ Dent J
1997;93(414):114–6.
Zadik Y., Barodontalgia. J Endodontics 2009; 359(4):481–485.
Rauch JW. Barodontalgia: dental pain related to ambient pressure change. Gen Dent
1985;33:313.
Zadik Y, Einy S. Aviation dentistry. In: Goldstein L, editor. Aviation Medicine. Tel Aviv:
Israeli Ministry of Defense 2006, p. 197-208.
Senia ES, Cunningham KW, Marx RE. The diagnostic dilemma of barodontalgia: report of
two cases. Oral Surg Oral Med Oral Pathol 1985;60:212–7.
Hodges FR. Barodontalgia at 12,000 feet. J Am Dent Assoc1978 97:66-73.
Rai B, Kaur J. The history and importance of aeronautic dentistry. J Oral Science
2011;53(2):143-146.
Zadik Y. Barodontalgia due to odontogenic inflammation in the jawbone. Aviat Space Envi
ron Med 2006;77:864–6.
Holowatyj R. Barodontalgia among flyers: a review of seven cases. J Can Dent Assoc 1996;
62(7):578–84.
Zadik Y, Chapnik L, Goldstein L. In-flight barodontalgia: analysis of 29 cases in military.
Aircrew Aviation, Space, and Environmental Medicine 2007;78(6).
Zadik Y, Einy S, Pokroy R, Dayan Yb, Goldstein L. Dental fractures on acute exposure to
high altitude. Aviat Space Environ Med 2006;77:654-7.
Stoetzer M, Ruecker M, Koch A, Ziebolz D, Kokem¨uller H, Kaempf C, Gellrich NC, von
See C. In Vitro Effects of External Pressure Changes on the Sealing Ability under Simulated
Diving Conditions. ISRN Dentistry Volume 2012, Article ID 418609, 5 pages.
Dr. Satheesh
Kumar
Dr. Preeti
Kumar
Dr. John
Dr. Patel
Satheesh Kumar, B.D.S., M.D.S., is associate professor in the Department of Prosthodontics at
The Oxford Dental College & Hospital, Bangalore, India.
Preeti Satheesh Kumar, B.D.S., M.D.S., is associate professor in the Department of Prosth
odontics at The Oxford Dental College & Hospital, Bangalore, India.
Jins John, B.D.S., M.D.S., is associate professor in the Department of Prosthodontics at The
Oxford Dental College & Hospital, Bangalore, India.
Ruchi Patel, M.D.S., is an assistant professor at Ahmedabad Dental College, Gujarat, India.
Queries about this article can be sent to Dr. Satheesh Kumar at [email protected].
26
treatment planning
TMJ Changes in Adolescent TMD
Patients Seen on MRI in Clinical Setting
Nan Su, B.Sc.; Renee Poon, B.Sc.; Lawrence Friedman, M.B., B.Ch., FRCP(C), FACR;
Mark Darling, B.Ch.D., M.Sc. (Dent); M.Sc. (Med), M.Ch.D., Miriam Grushka, M.Sc., D.D.S., Ph.D.
ABSTRACT
To determine whether temporomandibular joint
(TMJ) changes are similar between adolescent and
older TMJ disorder (TMD) patients, a retrospective
chart review for TMJ MRIs was done for disc and bone
changes. Patients were divided into adolescent, adult
and elderly groups. Results: The groups had similar
prevalence of joint changes and number of joints
involved. Disc changes were more prevalent in ado
lescents (p=0.008), while bone changes were more
prevalent in the elderly group (p=0.10). Anterior disc
displacement was the most common finding and was
most prevalent in adolescents (p<0.001). Conclusion:
Adolescents display similar disc/bone changes in their
TMJ as older TMD patients.
The temporomandibular joint (TMJ) is a synovial joint composed
of the mandibular condyle, articular disc, the glenoid fossa and
articular eminence of the temporal bone.1 The articular disc is a
biconcave disc consisting of three zones: an anterior band, inter
mediate zone and posterior band. The thinnest is the intermedi
ate zone, which sits between the mandibular condyle and man
dibular fossa and eminence. On normal opening, the condyle and
disc both translate forward to the articular eminence, with the
intermediate zone of the articular disc remaining between the
condyle and eminence.1-2 Anatomical disorders of the TMJ can
occur when disc and/or condyle fails to translate properly.
Clinically, signs and symptoms of temporomandibular
joint disorder (TMD) include joint noises, locking, pain, mus
cle tightness/tenderness, tinnitus and psychosocial effects.3
The pain and discomfort resulting from TMD may restrict the
daily activities of children and adolescents, including talking,
eating and sleeping, with these restrictions increasing with age
in the adolescent population.4 Pain caused by TMD has been
found to have an impact on behavioral and psychosocial fac
tors. It is more prevalent in girls than boys.5-6 This increased
likelihood of females having TMD signs and symptoms com
pared to males has been found to be similar to the higher prev
alence in females compared to males of having TMD in later
stages of life.4
Disc displacement, osteoarthritis and myofascial syndromes
are the major classes of TMD, the first two of which can be seen
on MRI.2 MRI is the current gold standard in diagnosis of TMD,
although diagnosis of disc displacement can be up to 83% accu
rate based only on clinical signs and symptoms.7
Many MRI studies have been performed to determine the
prevalence of changes occurring in TMD patients, but these
studies tend to look at all patients as a single population.8-10
MRI studies have also been performed to determine the type
of specific changes that can be seen in children and adoles
cents,11-12 but these often lack comparison to the adult TMD
27
TABLE 1
TMD Patients by Gender
Group
Female
Male
n
Adolescent
31
9
40
Adult
53
11
64
Elderly
48
7
55
Total
132
27
159
TABLE 2
Number of Patients with Changes Found on MRI
Group
MRI with Changes Found
One Joint
Both Joints
Adolescent
12 (30.0%)
22 (55.0%)
Adult
12 (18.7%)
36 (56.3%)
Elderly
13 (23.6%)
34 (61.8%)
TABLE 3
Types of Changes Found on MRI
Group
Disc Changes
Only
Bone Changes
Only
Both Disc and
Bone Changes
Adolescent
25 (62.5%)
1 (2.5%)
8 (20.0%)
Adult
28 (43.8%)
2 (3.1%)
16 (25.0%)
Elderly
19 (25.0%)
3 (5.5%)
24 (43.6%)
TABLE 4
Number of Patients with Anterior Disc Displacement and Disc
Reduction Status Found on MRI
Anterior Disc Displacement
With Reduction
Without Reduction
Both with and with
out Reduction (Two
Joints Affected)
Adolescent
7 (18.9%)
14 (37.8%)
3 (8.1%)
Adult
21 (34.4%)
4 (6.6%)
11 (18.0%)
Elderly
12 (21.8%)
14 (25.5%)
5 (9.1%)
Group
Graph 1. Distribution of Changes Seen on MRI by Age Group
28
population, which has been well studied. Therefore, this study
aims to compare the pattern of changes found on MRIs of chil
dren and adolescent TMD patients compared to those of TMD
patients in the later stages of life to determine whether there are
similarities.
Material and Method
Medical charts were reviewed for patients who were seen between
July 2009 and July 2012 at a private oral medicine clinic. Patients
were included in the study if they complained of TMD symptoms,
including popping/clicking, pain and locking at the initial assess
ment, and had an MRI done subsequently. A total of 159 MRI
reports from various hospitals in Ontario, Canada, were reviewed
and grouped by patient age into adolescent group (8-18 years
old), adult group (30-39 years) and elderly group (>50 years old).
MRIs were reviewed for disc changes, including displacement,
tear, morphological changes and degenerative and morphological
bone changes, for each group.
The Mantel-Haenszel test was performed to look for a lin
ear trend across categories. The Chi-square test was performed
to look for any differences between the study groups. Pairwise
comparisons were performed if the overall test was statistically
significant. Bonferroni correction was performed, and compari
sons were considered statistically significant at 0.05/3=0.0167.
Fisher’s Exact test was performed for bone changes due to the low
number of subjects.
Results
There were no differences among the three groups in terms of
gender distribution (p=0.456) (Table 1). The prevalence of
changes found on MRI were not significantly different (p=0.268)
among the three groups, nor were the number of joints affected
(p=0.757) (Table 2). The Chi-square test was significant for disc
changes (p=0.025), and disc and bone changes (p=0.023); how
ever, pairwise comparison with Bonferroni correction at a signifi
cance of p<0.0137 did not demonstrate significant differences in
prevalence of disc and bone changes among the different groups
except for anterior displacement of the disc without reduction,
which was significantly higher in the adolescent group compared
to the adult group (p <0.001), and disc changes, which were sig
nificantly higher in the adolescent compared to the elderly group
(p=0.007) (Table 3).
Anterior displacement of the disc was the most prevalent
change noted on MRI in all three groups, with 75.0% in the ado
lescent group, 62.5% in the adult group and 43.6% in the elderly
group. Anterior displacement without reduction was significant
ly higher in the adolescent group compared to the adult group
(p<0.001) (Table 4).
The Mantel-Haenszel test demonstrated a linear correlation
between age and the prevalence of disc changes (p=0.008) and
bone changes (p=0.10). This trend can also be seen in Graph 1.
Discussion
Three study groups were formed based on the process of matura
tion of the mandibular condyle. The adolescent group included
children from 8 years up to 18 years, since subchondral cortical
bone formation begins at the age of 13 to 14 in boys and 12 to
13 in girls and is usually completed by the early 20s.13 The adult
groups consisted of patients between the ages of 30 and 39, as
their cortical bone has completed formation and has not been af
fected by the onset of osteoporosis. Patients ages 50 and over were
grouped into one group, since by the age of 50, more than 55% of
the population will have osteoporotic changes.14
MRI studies of the TM joints were prescribed because of the
MRI’s sensitivity compared to clinical diagnosis based on signs and
symptoms in identifying soft tissue changes, as well as its ability to
demonstrate bone changes. Although CT scans are better at identify
ing bone changes, MRI has an advantage in that it is a relatively safe
imaging study that does not expose patients to radiation and is, there
fore, an appropriate screening device in children and adolescents.
All three groups showed a female predominance of TMD,
which is consistent with current literature.4 All three groups show
similar proportions of the number of patients with changes found
on MRI, indicating that disc and joint change occurrence is not
related to age but may be due to other factors, such as gender, an
terior crossbite, condylar displacement, sleep bruxism, etc.4,15-16
However, the type of changes seems to be affected by the age of
patients. The Mantel-Haenszel test showed a linear trend between
age and disc changes, as well as age and bone changes. As the pa
tient population increased in age, the prevalence of disc changes
decreased, while the prevalence of bone changes increased, which
was consistent with the finding of Guarda-Nardini et al. (2012) of
a decrease in internal derangement with increased age and increased
inflammatory-degenerative changes with increase in age.17 Disc
changes were significantly more prevalent in the adolescent group
than in the elderly group suggesting that disc changes may be induc
ing bone remodeling of the TM joints.18 The elderly group displayed
more bone changes consistent with the onset of osteoarthritis.
The prevalence of having both joints showing changes was
more predominant in all groups, with anterior disc displacement
the most commonly found change noted on MRIs in all three
groups: 75.0% (30/40) in adolescents; 62.5% (40/64) in adults;
and 61.8% (32/55) in the elderly group. Lateral, medial and pos
terior disc displacement was not examined due to lack of details
on the majority of the MRI reports. In all groups, the prevalence of
having a disc that reduces is the highest, with the adolescent group
29
having a significantly higher prevalence of fixed discs than the adult
population, consistent with the Guarda-Nardini et al. (2012) find
ing of a decrease in internal derangement with increased age.17
The results of the study suggest that children and adolescent
TMD patients show similar patterns in terms of changes found on
MRI. However, the study is limited in its retrospective design with
the lack of strict control in location and reading of the MRI. The
design of the study also did not take into account the experiences
of radiologists in terms of reading a TMJ MRI. In addition, MRI is
limited when it comes to visualizing bone changes, with CT scan a
better choice; therefore, many bone changes may have been missed.
Although there are several limitations in the designs of this
study, the results describe what may be presented on TMJ MRIs in
a clinical setting, as not all TMD patients can attend the same hos
pital for MRIs and have the same radiologist read the MRI. A future
study with a well-controlled, prospective design will help in better
understanding the changes in TMJ in adolescent TMD patients.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Conclusions
Based on the results of this study, young TMD patients would
benefit from both clinical examination and imaging study before
treatment planning to allow for the best possible outcome. Further,
prior to orthodontic or other dental treatment, including extrac
tion of wisdom teeth, pre-screening with MRI in young TMD pa
tients may be helpful in factoring in the presence of jaw changes
while undergoing these treatments, thereby preventing aggravation
of the joint that may eventually lead to TMJ surgery. p
Queries about this article can be sent to Dr. Grushka at [email protected].
Nan Su, B.Sc., is an M.B.B.S. student at Norman Bethune College of Medicine, Jilin University, China.
Renee Poon, B.Sc., is a senior research associate, oral medicine private practice, Toronto, Ontario, Canada.
Lawrence Friedman, M.B., B.Ch., FRCP(C), FACR, is a radiologist at North York General
Hospital, Toronto, Ontario, Canada.
Mark Darling, B.Ch.D., M.Sc. (Dent), M.Sc. (Med), M.Ch.D., is an associate professor,
Division of Oral Pathology, Department of Pathology, Schulich School of Medicine and Dentistry, Uni
versity of Western Ontario, Canada.
Miriam Grushka, M.Sc., D.D.S., Ph.D., is a certified specialist in oral medicine in Ontario, and
a diplomate, American Board of Oral Medicine and American Board of Orofacial Pain, and is on active
staff at William Osler Health Centre, Etobicoke, Ontario, Canada.
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Wang E, Fleisher K. MRI of temporomandibular joint disorders. Applied Radiology
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Durham J. Temporomandibular disorders (TMD): an overview. Oral Surgery 2008;1(2):60-68.
Karibe H, Goddard G, Aoyagi K, Kawakami T, Warita S, Shimazu K, et al. Comparison of
subjective symptoms of temporomandibular disorders in young patients by age and gender.
Cranio 2012;30(2):114-20.
List T, Wahlund K, Wenneberg B, Dworkin SF. TMD in children and adolescents: prevalence
of pain, gender differences, and perceived treatment need. J Orofac Pain 1999;13(1):9-20.
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Usumez S, Oz F, Guray E. Comparison of clinical and magnetic resonance imaging diagno
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Moen K, Hellem S, Geitung JT, Skartveit L. A practical approach to interpretation of MRI of
the temporomandibular joint. Acta Radiol 2010;51(9):1021-7.
Almasan OC, Hedesiu M, Baciut G, Leucuta DC, Baciut M. Disk and joint morphology
variations on coronal and sagittal MRI in temporomandibular joint disorders. Clin Oral
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Gil C, Santos KC, Dutra ME, Kodaira SK, Oliveira JX. MRI analysis of the relationship
between bone changes in the temporomandibular joint and articular disc position in symp
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Nebbe B, Major PW. Prevalence of TMJ disc displacement in a pre-orthodontic adolescent
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Hasegawa H, Saitoh I, Nakakura-Ohshima K, Shigeta K, Yoshihara T, Suenaga S, et al. Condylar
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Lei J, Liu MQ, Yap AU, Fu KY. Condylar subchondral formation of cortical bone in adoles
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Vilela P, Nunes T. Osteoporosis. Neuroradiology 2011;53 Suppl 1:S185-9.
Fernandes G, Franco AL, Siqueira JT, Goncalves DA, Camparis CM. Sleep bruxism increases
the risk for painful temporomandibular disorder, depression and non-specific physical
symptoms. J Oral Rehabil 2012;39(7):538-44.
Barrera-Mora JM, Espinar Escalona E, Abalos Labruzzi C, Llamas Carrera JM, Ballesteros EJ,
Solano Reina E, et al. The relationship between malocclusion, benign joint hypermobility
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Guarda-Nardini L, Piccotti F, Mogno G, Favero L, Manfredini D. Age-related differences in
temporomandibular disorder diagnoses. Cranio 2012;30(2):103-9.
Major PW, Kinniburgh RD, Nebbe B, Prasad NG, Glover KE. Tomographic assessment of tem
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orthodontics
Evaluation of Orthodontic and Triple-headed
Toothbrushes When Used Alone or in Conjunction
with Single-tufted Toothbrush in Patients with
Fixed Lingual Orthodontic Appliances
A Randomized Clinical Trial
Malka Ashkenazi, D.M.D.; Nurit Flaisher Salem, D.M.D.; Silvia Garon, D.M.D.; Liran Levin, D.M.D.
ABSTRACT
Brushing with a single-tufted toothbrush in conjunction
Results: After one month of brushing with the orth
with a manual toothbrush has been widely recommend
odontic toothbrush, the mean plaque index for tooth
ed, although its effectiveness has not been proven. This
and bracket, bleeding index and gingival index were
study investigated the effectiveness of orthodontic and
higher by 74.4% (0.68 vs. 0.39, p=0.026), 54.2%
triple-headed toothbrushes when used alone or in con
(0.37 vs. 0.24), 15.4% (0.15 vs. 0.13) and 30% (0.26
junction with the single-tufted toothbrush in patients
vs. 0.20), respectively, than after brushing with the
with fixed lingual orthodontic appliances.
triple-headed toothbrush. After combined brushing
Methods: In this randomized, single-blinded, con
trolled clinical trial, orthodontic patients (N=26,
with the single-tufted toothbrush, no additional sta
tistical differences were found between groups.
mean age 27.3 years) with lingual fixed appliances
Conclusion: When used alone, the triple-headed
were asked to brush with a triple-headed or an orth
toothbrush seems to remove plaque more effectively
odontic toothbrush alone for one month, followed by
than the orthodontic toothbrush. The addition of the
brushing in conjunction with the single-tufted tooth
single-tufted toothbrush eliminates differences be
brush for an additional month. Teeth were profes
tween groups.
sionally cleaned at baseline and one month later. A
clinician blinded to group assignments examined the
patients and evaluated tooth plaque index, bracket
plaque index, modified gingival index and bleeding on
probing at baseline at one month and two months.
Orthodontic brackets and wires tend to trap food and debris and
increase plaque retention, hampering toothbrushing and increas
ing enamel decalcification and gingivitis.1,4 Regular toothbrush
ing reduces caries and gingivitis by reducing dental plaque and is
of utmost importance during orthodontic treatment.
31
In patients undergoing treatment with lingual fixed orthodontic
appliances, the proximity of the brackets, ligatures and wires to the
gingival margin, and the small inter-bracket distance, might also
promote accumulation of plaque and calculus on the teeth, further
impeding access of the toothbrush and obscuring the detection of
plaque. These individuals suffer frequently from gingival inflam
mation5 and, therefore, are required to increase their toothbrush
ing skill and effort to maintain an adequate level of oral hygiene.6,7
Several toothbrushes have been designed to assist tooth
brushing performance in individuals with labial fixed appliances,
including a manual orthodontic brush, manual triple-headed
toothbrush, electric brushes and interproximal brushes.5,8,9-11 A
recently published systematic review concluded that the evidence
supporting the use of powered toothbrushes for orthodontic pa
tients is insufficient.12 Further, studies measuring the effective
ness of orthodontic compared to conventional toothbrushes in
reducing plaque and gingivitis in teeth with labial fixed appliances
have produced conflicting results.9,10 The triple-headed tooth
brush was shown to be more effective than the conventional or
orthodontic toothbrush in reducing plaque and improving gin
gival health in patients with labial fixed orthodontic appliances,
and in removing plaque from the lingual aspect of teeth in chil
dren and adults.11,13,14
Some practitioners advocate the use of inter-dental brushes
for improving plaque removal in patients undergoing orthodontic
treatment with fixed appliances.15,16 In 2008, a systematic review
evaluated the evidence-based benefit of using inter-dental brush
es in addition to standard toothbrushes in increasing plaque re
moval and improving dental health of patients undergoing fixed
orthodontic appliance therapy. The authors did not identify any
studies that met their search criteria.17
Despite the fact that effective toothbrushing of teeth with
lingual fixed orthodontic appliances requires higher skill and ef
fort, we could not find in an English language literature search
any studies that evaluated the effectiveness of different tooth
brushes in patients with lingual appliances.
The aims of the present study were to evaluate orthodontic
and triple-headed toothbrushes when used alone or in conjunc
tion with the single-tufted toothbrush in patients with fixed lin
gual orthodontic appliances.
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32
Material and Methods
Ethics
The Ethics Committee of Tel Aviv University approved the study,
participation was voluntary and written consent was obtained
from the participants.
cal trial were healthy patients without periodontal disease who
received orthodontic treatment at the Department of Orthodontics, School of Dental Medicine, Tel Aviv University, or at
the private practice of one of the authors (SG), and who were
treated by lingual fixed appliances. The subjects were asked per
sonally to participate in the study. They were told that participation would require toothbrush prophylaxis and scaling every
Study Population
month for a two-month period, free of charge, and that the ex
Participants in this randomized, single-blinded, controlled cliniamination would be performed during
their regular appointments.
TABLE 1
Inclusion criteria were patients who
Plaque Index Tooth at Baseline and at One- and Two-month Follow-up
received
orthodontic treatment using lin
Plaque Index
Baseline
1 Month
2 Month*
Base-1M
1M-2M
Base-2M
Tooth
(n=26, 13 in Gingival Index (n=24, 12 in Paired
Paired
Paired T-test
gual fixed appliances and agreed to par
each group)
(n=26, 13 in
each group)
T-test
T-test
p-value
ticipate in the study. Exclusion criteria
each group)
p-value
p-value
(n=24)
were non-lingual orthodontic treatment
(n=24)
(n=24)
and an unwillingness to participate.
THTB maxilla
0.64±0.47
0.36±0.19
0.18±0.21
0.014
0.078
0.010
OTB maxilla
0.95±0.75
0.53±0.33
0.27±0.26
Between groups
p-value
P=NS
P=NS
P=NS
THTB mandibule
1.17±0.58
0.42±0.26
OTB mandibule
1.46±0.80
0.85±0.57
Between groups
p-value
P=NS
P=0.02
P=NS
THTB total
0.91±0.41
0.39±0.17
OTB total
1.15±0.67
0.68±0.40
Between groups
p-value
P=NS
P=0.02
P=NS
*Two patients dropped from study
0.072
0.034
0.012
0.27±0.15
<0.001
0.089
0000
0.30±0.36
0.018
0.029
0.002
0.23±0.13
<0.001
0.031
0.000
0.28±0.27
0.033
0.022
0.002
THTB- Triple-headed toothbrush
OTB- Orthodontic toothbrush
TABLE 2
Plaque Index Bracket at Baseline and at One- and Two-month Follow-up
Plaque Index
Bracket
Baseline
(n=26, 13
in each
group)
1 Month
(n=26, 13
in each
group)
2 Month*
(n=24, 12 in
each group)
Base-1M
Paired T-test
p-value
(n=24)
1M-2M
Paired T-test
p-value
(n=24)
Base-2M
Paired T-test
p-value
(n=24)
THTB maxilla
0.37±0.40
0.20±0.17
0.11±0.15
0.150
0.332
0.131
OTB maxilla
0.63±0.76
0.34±0.40
0.16±0.24
0.170
0.360
0.104
Between groups
p-value
P=NS
P=NS
P=NS
THTB mandibule
0.66±0.66
0.28±0.34
0.11±0.15
0.024
0.176
0.011
OTB mandibule
1.20±0.80
0.34±0.34
0.16±0.24
0.001
0.125
0.005
Between groups
p-value
P=NS
P=NS
P=NS
THTB total
0.52±0.45
0.24±0.21
0.11±0.15
0.032
0.155
0.015
OTB total
0.88±0.63
0.37±0.40
0.16±0.23
0.010
0.206
0.012
Between groups
p-value
P=NS
P=NS
P=NS
Study Design
At baseline, before assignment to the groups, the lingual aspects of teeth with brackets were evaluated for:
l Tooth plaque index (0-no plaque; 1-islands of plaque; 2-continuous
line of plaque < 1 mm; 3-continuous
line of plaque $ 1 mm).18
l Bracket plaque index (indexed be
tween 0 and 3).19
l Modified gingival index (0-absence of
inflammation; 1-mild inflammation,
slight change in color, little change
in texture of any portion of marginal or papillary gingival unit; 2-mild
inflammation as above but involv
ing the entire marginal or papillary
gingival unit; 3-moderate inflamma
tion, glazing, redness, edema and/or
hypertrophy of marginal or papillary
gingival unit; 4-severe inflamma
tion, marked redness, edema and/or
hypertrophy of marginal or papillary
gingival unit, spontaneous bleeding,
congestion or ulceration).20-21
l Bleeding on probing index (0-no
bleeding within 15 seconds; 1-point
bleeding within 15 seconds; 2abundant bleeding within 15 sec
onds),21-22 as described previously.5
All evaluations were performed and
recorded by one calibrated dentist (NFS).
Teeth without brackets and banded mo
33
Statistical Analysis
lars were excluded from the study. Immediately after examina
Statistical analysis was performed using SPSS. Fisher’s exact
tion, teeth were professionally cleaned to obtain a plaque-free
test was calculated for descriptive statistics; the paired T-test
condition at baseline. The patients were then randomly assigned
(2-tailed) was used to compare indices at different points in the
to use one of two toothbrushes. Thirteen (nine females and four
study (baseline to one-month evaluation and one- to two-month
males) were assigned to use a triple-headed toothbrush (regular
evaluation). ANOVA with repeated measures was used to com
size, Dr. Barman Superbrush, Dentaco AS, Norway) and 13 (nine fe
pare the improvement of indices with time (at baseline and at
males and four males), an orthodontic toothbrush (Ortho Brush,
one- and two-month evaluations) between groups. Statistical sig
Paro, Switzerland).
nificance was set at 5%. Due to the limited number of patients
Each participant was personally instructed by the same den
in this cohort, it might be considered as underpowered. Subjects
tist (NFS) regarding toothbrushing using the toothbrush he/she
were served as the unit of analysis. Descriptive statistics were used
was assigned. Instruction for toothbrushing included an expla
for the questionnaire analysis.
nation of the purpose of brushing and a demonstration of the
technique on a plastic model and on their own teeth.11,23 To
Results
improve plaque removal around the orthodontic brackets, the
Overall, 29 patients were approached to participate in the present
patients were instructed to brush 15 strokes for each group of
study. Of these, two refused to participate and were not examined
tooth surfaces. They were further instructed to brush their teeth
at all. Another one refused to participate in the study immedi
twice daily—in the morning and in the evening, immediately after
ately after completion of the baseline examination. These three
meals—and to use the same toothpaste (Elmex, Teva 1400ppm F- ,
patients were not included in the present report. Two patients
Gaba International, Switzerland), which they received free of charge.
declined to participate in the study immediately before the sec
To avoid bias, patients were asked to abstain from using oral rins
ond-month assessment when they realized that they would have
es and gels during the study.
to spend additional time at the dental office for the study. One
For the follow-up visits, patients were asked to brush their
was in the triple-headed toothbrush group and one in the orth
teeth immediately before arriving to the dental appointment; and
odontic toothbrush group. Thus, a total of 26 patients completed
they were screened immediately at their arrival.
the study.
After one month, plaque, gingival and bleeding indices were
The mean patient age was 27.3 years; 18 were female (69.2%)
re-evaluated by the same dentist, who was blinded at that time to
and 8 male (30.8%), with no difference between groups (25.99±
the information in the patient’s file regarding the type of toothbrush
4.26 and 28.6± 6.47 years). Twenty-five patients were treated in
group. The patient was identified during the follow-up assessment
both their maxillary and mandibular arches, and one patient was
only by a serial number that was given at the first appointment.
Participants were then asked to add a sin
gle-tufted toothbrush (Paro interdental clean- TABLE 3
Blood on Probing Index at Baseline and at One- and Two-month Follow-up
ing toothbrush, Switzerland) in conjunction
with the toothbrush they used during the
Blood on
Baseline
1 Month
2 Month*
Base-1M
1M-2M
Base-2M
previous month. Each participant received
Paired T-test Paired
Probing Index
(n=26, 13 in (n=26, 13 in (n=24, 12 in Paired
T-test
each group)
each group)
each group) T-test
p-value
instruction on how to use the single-tufted
p-value
(n=24)
p-value
toothbrush, including rotator movements
(n=24)
(n=24)
around and between the brackets. Imme
THTB maxilla
0.09±0.72
0.09±0.072 0.07±0.54
0.150
0.226
0.695
diately after instruction, their teeth were
OTB maxilla
0.12±0.23
0.08±0.12
0.06±0.07
0.170
0.262
0.213
professionally cleaned. Toothpaste was
Between groups P=NS
P=NS
P=NS
provided again.
p-value
At the two-month assessment, all in
THTB mandibule 0.27±0.29
0.17±0.11
0.11±0.08
0.024
0.098
0.110
dices (plaque tooth and bracket, gingival
OTB mandibule 0.24±0.24
0.25±0.22
0.15±0.17
0.001
0.105
0.465
and bleeding) were re-evaluated.
Between groups P=NS
P=NS
P=NS
At the one- and two-month assess
p-value
ments, participants were asked to rate, on
THTB total
0.17±0.16
0.13±0.07
0.09±0.05
0.141
0.028
0.105
a five-point scale, their satisfaction with
OTB total
0.17±0.16
0.15±0.13
0.10±0.11
0.480
0.044
0.181
the toothbrush(es) used during the pre
Between groups P=NS
P=NS
P=NS
vious month regarding three aspects of
p-value
brushing: the time required; convenience;
and the subsequent feeling of freshness.
34
treated only in his maxillary arch. All patients had at least 10
treated teeth. The total number of evaluated teeth was 584.
First Month (Triple-headed and Orthodontic Toothbrush)
At the one-month assessment, the average reduction in plaque
index tooth for the triple-headed toothbrush and orthodontic
groups was 57.14% and 40.87%, respectively, and 53.90% and
57.96% in plaque index brackets, respectively; in bleeding on
probing index 57.58% and 11.77%, respectively; and in gingival
index 45.94% and 55.17%, respectively, compared to baseline
(Tables 1-4).
Second Month (Additional Use of Single-tufted Toothbrush)
One month after brushing with the single-tufted toothbrush, the
mean plaque index tooth, plaque index brackets, gingival index
and bleeding on probing index were decreased by an additional
34.29% and 45.00%, 86.36% and 25.00%, respectively, in the
triple-headed toothbrush, and by 56.92%, 44.83%, 44.44% and
37.50%, respectively, in the orthodontic toothbrush group.
Triple-headed vs. Orthodontic Toothbrush
At one month, the total plaque index tooth, plaque index brack
ets, bleeding on probing index and gingival index were higher
by 85.71%, 45.00%, 33.33% and 22.73%, respectively, among
patients in the orthodontic toothbrush
TABLE 4
group compared with those in the tripleGingival Index at Baseline and at One- and Two-month Follow-up
headed toothbrush group. After using the
(Number of evaluated patients in parenthesis)
single-tufted toothbrush, the differences
Gingival Index
Baseline
1 Month
2 Month*
Base-1M
1M-2M
Base-2M
between groups were 21.74%, 45.45%,
(n=26, 13 in (n=26, 13 in (n=24, 12
Paired
Paired
Paired T-test
11.11% and 400%, respectively.
each group)
each group)
in each
T-test
T-test
p-value
group)
p-value
p-value
(n=24)
To investigate if the improvements in
(n=24)
(n=24)
all indices during the second study period
THTB maxilla
0.10±0.17
0.09±0.07
0.03±0.11 0.880
0.086
0.192
were related more to the duration of the
OTB maxilla
0.25±0.34
0.08±0.12
0.08±0.19 0.032
0.910
0.077
study or to the type of toothbrush used,
Between groups
P=NS
P=NS
P=NS
ANOVA with repeated measures (general
p-value
linear model) was run. It was found that
THTB mandibule 0.64±0.72
0.30±0.38
0.03±0.08 0.155
0.037
0.012
the improvement in both groups was re
OTB mandibule
0.95±0.59
0.45±0.36
0.21±0.29 0.004
0.108
0.004
lated mainly to the duration of the study
Between groups
P=NS
P=NS
P=NS
(for bleeding in probing p=0.021, plaque
p-value#
index brackets p=0.0001, plaque index
THTB total
0.37±0.41
0.20±0.27
0.03±0.07 0.232
0.063
0.009
tooth p=0.0001, gingival index p=0.0001).
OTB total
0.58±0.31
0.26±0.17
0.15±0.19
Between groups
p-value
P=NS
P=NS
P=NS
0.002
0.082
0.001
TABLE 5
Patient Satisfaction after Using Triple-headed and Orthodontic Toothbrushes
With or Without Additional Use of Single-tufted Toothbrush
Triple-headed
Type of variable
Duration of toothbrushing
Toothbrushing convenience
Feeling of freshness
following toothbrushing
Months after
study initiation
Mean± SD
One month
3.27±0.90
Two months
3.46±1.04
One month
3.27±1.01
Two months
3.46±1.04
One month
3.18±0.98
Two months
3.73±0.65
Orthodontic
P
T- test
2-tailed
0.341
0.167
0.025
Mean± SD
3.18±0.87
2.73±0.79
3.27±0.64
3.09±0.83
3.27±0.65
3.64±0.51
P
T--test
2-tailed
0.176
0.553
0.104
Patient Satisfaction
One and two months after study initia
tion, differences in mean satisfaction scores
reported by the participants in the tripleheaded and orthodontic toothbrush groups
did not differ significantly (Table 5).
Discussion
In this study, the mean plaque index tooth
decreased more after one month of brush
ing with the triple-headed toothbrush
than with the orthodontic toothbrush.
The mean plaque index bracket, bleeding
on probing index and gingival index re
ductions did not differ significantly after
one month brushing with the two types
of toothbrushes. Enhanced effectiveness
of the triple-headed toothbrush may be
due to its unique inclination of bristles,
enabling access to the gingival margins of
35
the brackets around which the plaque is trapped without requir
ing special manual skills. This is important, especially in patients
with lingual fixed appliances.
Interestingly, at the one-month assessment, significant im
provement in plaque index was observed also in patients using
the orthodontic toothbrush, though its design is similar to that
of a conventional toothbrush. It can be assumed that the im
provement in this group resulted from increasing awareness and
guidance for correct toothbrushing. Another possible contributor
to the improved gingival health in this cohort is the professional
prophylaxis that was performed as part of the study.
The lesser improvement in the plaque index of the maxilla in the
orthodontic group may reflect difficulty accessing the palatal aspect
with the orthodontic toothbrush. These results concur with those of
Rafe et al.,11 which showed that the triple-headed toothbrush was
more effective than a conventional toothbrush in removing plaque
in patients with buccal fixed appliances by 48.8% for plaque index
total and by 38.2% for plaque index brackets. The study conducted
by Rafe et al.11 has shown no statistical differences in the PIT, PIB,
GI or BOP indices scores before and after instruction between the
orthodontic toothbrush and the regular toothbrush.
In the current study, the statistical similarity in other indices at
the one-month assessment, regardless of toothbrush, may be due to
the fact that only patients with high motivation who had good oral
hygiene and high esthetic awareness were candidates for lingual fixed
orthodontic appliances. This is further reinforced by the relatively low
er basic scores (by 30%-86%) of PIT, PIB, BI and GI of the patients in
the present study as compared with previously published data about
children (mean aged 15.6) undergoing orthodontic treatment.11
Moreover, in the present study most participants were females (18 vs.
7). Zadik et al. have shown that females reported significantly higher
frequencies of toothbrushing and flossing than males did.24
The major limitation of the present study is the small cohort
of participants; thus, further larger-scale studies are warranted.
The duration of each phase of the present study was one month.
According to Trimpeneers et al., it is sufficient to assess the effect of
toothbrushing on plaque and gingival indices.8 Even one week has
been considered sufficient for estimating the effectiveness of tooth
brushing on plaque removal, since after meticulous plaque removal,
it takes only a few hours for new visible plaque to develop.25
The addition of the single-tufted toothbrush to the tripleheaded or orthodontic toothbrush was found to further improve
the plaque, gingival and bleeding indices. One month after using
the triple-headed or the orthodontic toothbrush, and immediate
ly before adding the single-tufted toothbrush, the mean bleeding
on probing and gingival indices in the orthodontic toothbrush
group were 28.7% and 23.6% higher, respectively, than those in
the triple-headed toothbrush group. After using the single-tufted
toothbrush for one month, the differences in bleeding on probing
decreased, though without statistical significance. However, the
36
difference in gingival index between groups increased, and was
five-times higher in the orthodontic group.
The differences between groups in gingival index at the secondmonth assessment, as well as the significant improvement in bleeding
on probing in both groups, may be due not only to the effectiveness of
the single-tufted toothbrush, but also to the fact that improvement in
gingival health requires a longer time for clinical presentation.
The similarity in assessed indices between those using tripleheaded and orthodontic toothbrushes in conjunction with the
single-tufted toothbrush suggests that the high effectiveness of
the single-tufted toothbrush may, at least partially, obscure dif
ferences between toothbrush types. Therefore, the main advan
tage of using the triple-headed toothbrush in conjunction with
the single-tufted toothbrush in highly motivated patients is the
shorter time required for toothbrushing. The main advantage of
the triple-headed toothbrush is the need to perform fewer strokes
per quadrant of teeth (one instead of three for buccal, occlusal
and lingual) as compared to a conventional toothbrush; thus, it
takes a shorter period to perform fewer strokes.
These findings concur with those of others who reported that
for individuals with high oral hygiene motivation who receive oral
hygiene instruction, the type of toothbrush is less significant.5 Nev
ertheless, the improvement in most indices’ scores following two
months justifies recommending using the single-tufted toothbrush
in addition to OTB or THTB. Generally, it can be stated that the
better the oral hygiene, the better the oral health. It is difficult to
draw a line when the magnitude of improvement is relevant from a
clinical point of view. However, since the orthodontic treatment is
prolonged, and good oral hygiene is challenging, it can be assumed
that all effort should be put to improve oral hygiene.
It should be noted in this context that early diagnosis and treat
ment are essential for successful long-term prognosis in patients
with caries and periodontal diseases. The role of the orthodontist
in diagnosis and referral for adequate treatment is crucial, since
most orthodontic patients are adolescents and caries and aggressive
periodontitis may affect them greatly.26 Many patients undergoing
orthodontic treatment believe that their regular and frequent visits
to the orthodontic office are sufficient to monitor their dental and
periodontal needs. Orthodontists should be aware of this notion.26
Conclusion
At the one-month assessment, the triple-headed toothbrush was
more effective than the orthodontic toothbrush in plaque remov
al among patients undergoing orthodontic treatment with lingual
fixed appliances. Overall improvements were observed and the
differences dependent upon toothbrush type decreased follow
ing the second month of additional brushing with a single-tufted
toothbrush. The improvement may be due, at least in part, to the
increased duration of the follow-up period. Further large scale
study is warranted to confirm those results. p
No conflict of interests is reported by the authors. No external funding was
provided for this study; toothbrushes were provided by Dr. Malka Ashkenazi
and were purchased by her personal research fund. Queries about this article
can be sent to Dr. Ashkenazi at [email protected].
REFERENCES
1,
2.
3.
4.
5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Lovrov S, Hertrich K, Hirschfelder U. Enamel demineralization during fixed orthodontic
treatment - incidence and correlation to various oral-hygiene parameters. J Orofac Orthop
2007;68(5):353-363.
Zachrisson BU. Oral hygiene for orthodontic patients: current concepts and practical ad
vice. Am J Orthod 1974;11:487-497.
Levin L, Samorodnitzky-Naveh GR, Machtei EE. The association of orthodontic treatment
and fixed retainers with gingival health. J Periodontol 2008;79(11):2087-2092.
Pender N. Aspects of oral health in orthodontic patients. Br J Orthod. 1986;13(2):95-103.
Thienpont V, Dermaut LR, Van Maele G. Comparative study of 2 electric and 2 manual
toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofacial Or
thop 2001;120:353-360.
Ciancio SG, Cunat JJ, Mather ML, Harvey DH. A comparison of plaque accumulation in
bonded versus banded teeth. J Dent Res 1985;64(suppl 1): Abstract number 1664.
Miyawaki S, Yasuhara M, Koh Y. Discomfort caused by bonded lingual orthodontic appli
ances in adult patients as examined by retrospective questionnaire. Am J Orthod Dentofa
cial Orthop 1999;115(1):83-88.
Trimpeneers LM, Wijgaerts IA, Grognard NA, Dermaut LR, Adriaens PA. Effect of electric
toothbrushes versus manual toothbrushes on removal of plaque and periodontal status
during orthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111(5):492-497.
Williams P, Fenwik A, Schou L, Adams W. A clinical trial of an orthodontic toothbrush. Eur
J Orthod 1987; 9:295-304.
Kiliço
lu H, Yildirim M, Polater H. Comparison of the effectiveness of two types of tooth
brushes on the oral hygiene of patients undergoing orthodontic treatment with fixed appli
ances. Am J Orthod Dentofacial Orthop 1997;111:591-594.
Rafe Z, Vardimon A, Ashkenazi M. Comparative study of three types of toothbrushes in pa
tients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2006;130:92-95.
Huang GJ. Insufficient evidence to conclude that orthodontic patients derive benefits from
using power toothbrushes. J Am Dent Assoc 2009;140:914-915.
Levin L, Marom Y, Ashkenazi M. Brushing skills and plaque reduction using single- and
triple-headed toothbrushes. Quintessence Int 2012;43(6):525-531.
Kiche MS, Fayle SA, Curzon ME. A clinical trial comparing the effectiveness of a three-tufts ver
sus a conventional toothbrush for oral hygiene in children. Eur J Paediatric Dent 2002;3:33-38.
Berglund LJ, Small CL. Effective oral hygiene for orthodontic patients. J Clin Orthod
1990;24(5):315-320.
Casey GR. Maintenance of oral hygiene and dental health during orthodontic therapy. Clin
Prev Dent 1988;10(1):11-13.
Goh HH, Fernandez Mauleffince LM. Interspace/interdental brushes for oral hygiene in orth
odontic patients with fixed appliances. Cochrane Database Syst Rev 2007;18(3):CD005410.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl ana
logue of Victamine C. J Periodontol 1970;41:41-3.
Clerehugh V, Williams P, Shaw WC, Worthington HV, Warren P.A practice-based random
ized controlled trial of the efficacy of an electric and a manual toothbrush on gingival
health in patients with fixed orthodontic appliances. J Dent 1998; 26(8):633-639.
Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L. A modified gingival index for
use in clinical trials. Clin Prev Dent 1986;8(1):3-6.
Fischman SL. Clinical index systems used to assess the efficacy of mouth rinses on plaque
and gingivitis. J Clin Periodontol 1988;15(8):506-510.
Muhelmann HR. Psychological and chemical mediators of gingival health. J Prev Dent 1977;4:6-17.
Weinstein P, Milgrom P, Melnick S, Beach B, Spadafora A. How effective is oral hygiene
instruction? Results after 6 and 24 weeks. J Public Health Dent 1989;49(1):32-38.
Zadik Y, Galor S, Lachmi R, Proter N. Oral self-care habits of dental and healthcare provid
ers. Int J Dent Hyg 2008;6(4):354-360.
Newman HN. The development of dental plaque in primary preventive dentistry. N. O.
Harris and A. G. Christen, ed. 4th ed. Norwalk: Appleton & Lange, 1994, p. 19.
Levin L, Einy S, Zigdon H, Aizenbud D, Machtei EE. Guidelines for periodontal care and
follow-up during orthodontic treatment in adolescents and young adults. J Appl Oral Sci
2012;20(4):399-403.
Dr. Ashkenazi
Dr. Salem
Dr. Garon
Dr. Levin
Malka Ashkenazi, D.M.D., is in the Pediatric Dentistry Dental Clinic, Petach-Tikva, Israel.
Nurit Flaisher Salem, D.M.D., is a graduate student at The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel.
Silvia Garon, D.M.D., is in the Department of Orthodontics, The Maurice and Gabriela Gold
schleger School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel.
Liran Levin, D.M.D., is professor and head, Division of Periodontology, Faculty of Medicine and
Dentistry, University of Alberta, Canada.
37
implants
Management of a Dental Implant with
Internal Thread Damage
A Patient Treatment Report
Barry S. Rubel, D.M.D.; Edward E. Hill, D.D.S., M.S.
ABSTRACT
When a patient presents with an implant with the
internal threads damaged (or cross-threaded), a de
finitive restorative challenge may be faced. By having
a difference in hardness between an abutment screw
and the implant to which it is to be attached, there is
potential for internal thread damage to the implant
if the opposing threads do not interface properly. As
such, the operator must use care when positioning the
abutment and engaging the threads to prevent pos
sible misalignment and damage to the internal aspect
of the implant body. This article describes such a situ
ation and the action taken to overcome the problem.
When a patient presents with an implant with the internal threads
damaged (or cross-threaded), a definitive restorative challenge may
be faced. Non-one-piece dental implant systems use an internal
screw to hold the healing abutment, definitive abutment or an at
tachment abutment to the implant body. A problem associated with
these types of implant systems is loosening of abutment screws.1,2,3
To help counter the problem, abutment screws are often made of
alloys different from the implants in which they are placed, to al
low for a preload torque to be established. By having a difference
in hardness between an abutment screw and the implant to which
it is to be attached, there is potential for internal thread damage to
the implant if the opposing threads do not interface properly.
A definitive abutment on which a crown or retainer will be
placed usually sits in some form of internal slot or hex, or on
38
an external hex so that the abutment itself helps position the
screw for proper thread alignment. But the initial horizontal
alignment and angulation of a healing abutment or an attach
ment abutment (where the screw is actually part of the abut
ment) is determined solely by the dexterity of the dentist and
restrictions imposed by the surrounding soft tissue. As such,
the operator must use care when positioning the abutment and
engaging the threads to prevent possible misalignment and
damage to the internal aspect of the implant body. This article
describes such a situation and the action taken to overcome
the problem.
Case Description
An 84-year-old male patient presented for evaluation to have
new maxillary complete and mandibular partial removable dental
prostheses made. Because of tooth loss, he required a Kennedy
Class II mod 2 classification mandibular prosthesis. Also, several
teeth needed crowns to provide rest seats and adequate retentive
clasp undercuts and to improve the occlusal alignment (Figure 1).
Significant bilateral mandibular tori were present, which posed a
potential problem for the planned prosthesis. After considering
the patient’s age, his desire to avoid excessive oral surgery and
the size of the bilateral tori, it was decided not to pursue their re
moval. Instead, the plan was to place two Zimmer Dental Tapered
Screw-Vent implants (Zimmer Dental, Warsaw, IN), one on each side
of the mandibular arch, to improve the retention and support for
the planned prosthesis.
The implants were placed by a periodontist. Four to six
months healing time was allowed. After four months, the rootform implants appeared to have bone approximating each fixture
in radiographs and so they were uncovered by the
same periodontist and healing abutments placed.
Upon attempting removal of the healing abut
ments by the restorative dentist to measure for Locator
(Zimmer Dental) attachment abutments, it was noticed
that the healing abutment on the left side “caught”
at a certain point during unscrewing. It was theorized
that the abutment was either not seated correctly or
was somehow forced into the implant body at the time
of placement, resulting in cross-threading or damage
to the internal threads of the implant body and/or
abutment screw (Figure 2). Eventually, after repeated
attempts, the healing abutment was removed. Exami
nation with 3X magnification showed an area near the
apex where the thread was nicked and blunted (Fig
ures 3, 3a). After selecting the appropriate size Loca
tor abutments, the right attachment abutment was
screwed to place passively; the left one would not seat
after an initial twist. A radiograph demonstrated that
the abutment was not fully seating into the implant
body (Figure 4).
A Zimmer 3.25 OMNI/SPL TAP (Zimmer Dental)
specific for re-threading the Tapered Screw-Vent im
plant placed in this patient (Figures 5, 5a) was used
to correct the internal thread damage in the implant.
Following Zimmer’s directions, the tap was inserted
into the implant and turned slightly, a quarter turn,
clockwise. It was then turned counter-clockwise and
removed. Copious irrigation with water and with high
vacuum suction was accomplished to remove any fil
ings and clean out the internal implant chamber.
The tap was inserted again and turned another
quarter turn past the previous point. This was followed
by irrigation and evacuation. The process was continued
until the tap was fully seated into the implant. Finally,
the Locator attachment abutment was able to be screwed
into the implant body without any evidence of resis
tance. A radiograph was made to verify that the abut
ment was fully seated. After verification, the abutment
screw was torqued to the recommended preload (Figure
6). Re-tapping of the internal threads of the implant fa
cilitated fabrication of the definitive partial removable
dental prosthesis as designed, producing a highly accept
able functional and esthetic result (Figures 7, 7a).
Discussion
When a patient presents with damage to the internal
threads of a dental implant, a restorative problem oc-
Figure 1. Crowns delivered on RPD abut
ments with large mandibular tori present.
Figure 2. Initially placed healing collar in
left implant body.
Figure 3. Left healing abutment.
Figure 3a. Close-up of damaged threads on
healing abutment.
Figure 4. Attachment abutment not fully
seated by hand tightening.
Figure 5. Zimmer 3.25 OMNI/SPL TAP.
Figure 5a. Zimmer 3.25 OMNI/SPL TAP
and radiograph of tapping tool in place.
Figure 6. Left Locator attachment abutment
fully seated and verified.
Figure 7. Definitive prostheses delivered.
Figure 7a. Case complete.
39
curs that can complicate or even negate planned treatment. Re
generation of the internal threads in the implant body may be
necessary by re-tapping. If the internal threads cannot be correct
ed, there are few options except to bury or replace the implant.
Although the authors could not find a report or discussion in
the literature regarding this unique dental implant complication,
the maker of this particular implant system (Zimmer Dental) must
have anticipated a need since a tool for re-tapping was available.
(A tapping tool is used to initially generate the internal threads
on most titanium dental implants after they are milled during
fabrication.4) Platform reshaping followed by internal re-tapping
was used by Mendonca in 2009 to salvage a horizontally fractured
dental implant.5
It is hoped that this report will make others aware of this
corrective option and avoid the possible need for implant removal
and replacement. p
Queries about this article can be sent to Dr. Rubel at [email protected].
REFERENCES
1.
2.
3.
4.
5.
Jeong Y, Chung C, Lee H. Screw joint stability according to abutment screw materials. J
Korean Acad Prosthodont 2001;39:297-305.
Pjetursson B, Bragger U, Lang N, Zwahlen M. Comparison of survival and complication
rates of tooth-supported fixed dental prostheses (FPDs) and implant-supported FPDs and
single crowns (SCs). Clin Oral Implants Res 2008;19:326-8.
Theoharidou A, Petridis H, Tzannas K, Garefis P. Abutment screw loosening in single im
plant restorations: a systematic review. Int J Oral Maxillofac Implants 2008;23:681-90.
Araujo A, Fromentin G, Poulachon G. Analytical and experimental investigations on thread
milling forces in titanium alloy. International Journal of Machine Tools and Manufacture
2013;67:28-34.
Mendonca G, Mendonca DB, Fernandes-Neto AJ, Neves FD. Management of fractured den
tal implants: a case report. Implant Dent 2009;18:10-6.
Dr. Rubel
Dr. Hill
Barry S. Rubel, D.M.D., is professor of care planning and restorative sciences at the University of
Mississippi School of Dentistry, Jackson, MS.
Edward E. Hill, D.D.S., M.S., is professor of care planning and restorative sciences at the Univer
sity of Mississippi School of Dentistry, Jackson, MS.
40
statistical analysis
Lack of Correlation between Benign Brain
Tumors and Markers of Oral Health
Steven Lehrer, M.D.; Sheryl Green, M.B.BCh.; Kenneth E. Rosenzweig, M.D.
ABSTRACT
Case control studies implicating dental X-rays in the
Conclusion: Our finding of a total lack of correlation
genesis of intracranial meningiomas have yielded con
between benign brain tumors and markers of oral
flicting results. To further evaluate what risk, if any, that
health and, by implication, dental X-rays, suggests
intracranial meningioma might be associated with den
there may be no relationship between dental X-rays
tal X-rays, we examined the association of benign brain
and meningioma or other benign brain tumors. This
tumor incidence with the number of dentists and other
conclusion is strengthened by our demonstration of
correlates of oral health in U.S. states and the District of
the known negative correlation between Alzheimer’s
Columbia. We compared these correlations to the asso
and dental care.
ciation of the same markers of oral health with Alzheim
er’s death rates. Poor oral health, especially periodontal
disease, is a well-established risk factor for dementia.
Results: Pearson correlations, number of cases (49,
no data from Kansas or Maryland) and significance (2
tailed p values) of benign brain tumor incidence and
parameters of oral health are presented. None of the
correlations approached statistical significance. In
contrast, Alzheimer’s deaths by state were negatively
correlated with number of dentists and other mark
ers of oral health.
Meningioma is the most frequently occurring brain tumor,
comprising more than a third of all benign and malignant brain
neoplasms.1 But case control studies implicating dental X-rays
in the genesis of intracranial meningiomas have yielded con
flicting results.2-7 Longstreth et al. found that dental X-rays in
volving full-mouth series performed 15 to 40 years before their
2005 study, when radiation exposure from a full-mouth series
was much greater than in 2005, were associated with an in
creased risk of meningioma.8 They did not observe an increased
risk with bitewings, lateral cephalometric or panoramic radio
graphs. Claus et al. also reported that exposure to dental X-rays
performed in the past, especially bitewings, increased the risk of
intracranial meningioma.9
41
TABLE 1
Pearson Correlations, Number of Cases (49, no data from
Kansas or Maryland) and Significance (2 tailed p values) of
Benign Brain Tumor Incidence and Parameters of Oral Health.
(None of the correlations approached significance.)
CLEANED TEETH YES
CLEANED TEETH NO
LOST ALL TEETH YES
LOST ALL TEETH NO
DENTAL VISITS YES
DENTAL VISITS NO
DENTISTS PER POPULATION
Pearson Correlation
0.058
Sig. (2-tailed)
0.691
N
49
Pearson Correlation
-0.128
Sig. (2-tailed)
0.382
N
49
Pearson Correlation
0.134
Sig. (2-tailed)
0.359
N
49
Pearson Correlation
-0.056
Sig. (2-tailed)
0.7
N
49
Pearson Correlation
0.056
Sig. (2-tailed)
0.7
N
49
Pearson Correlation
-0.089
Sig. (2-tailed)
0.545
N
49
Pearson Correlation
0.089
Sig. (2-tailed)
0.545
N
49
TABLE 2
Pearson Correlations, Number of Cases and Significance (2
tailed p values) of Age-adjusted Alzheimer’s Death Rate and
Parameters of Oral Health in 50 U.S. States and District of
Columbia. (All of the correlations were significant.)
CLEANED TEETH YES
CLEANED TEETH NO
LOST ALL TEETH YES
LOST ALL TEETH NO
DENTAL VISITS YES
DENTAL VISITS NO
DENTISTS PER POPULATION
Pearson Correlation
-.311(*)
Sig. (2-tailed)
0.027
N
51
Pearson Correlation
.311(*)
Sig. (2-tailed)
0.027
N
51
Pearson Correlation
.408(**)
Sig. (2-tailed)
0.003
N
51
Pearson Correlation
-.408(**)
Sig. (2-tailed)
0.003
N
51
Pearson Correlation
-.313(*)
Sig. (2-tailed)
0.025
N
51
Pearson Correlation
.313(*)
Sig. (2-tailed)
0.025
N
51
Pearson Correlation
-.483(**)
Sig. (2-tailed)
<0.001
N
51
*Correlation is significant at 0.05 level, 2-tailed. **Correlation is significant
at 0.01 level, 2-tailed.
42
To further evaluate what risk, if any, that intracranial menin
gioma might be associated with dental X-rays, we examined the
association of benign brain tumor incidence with the number of
dentists and other correlates of oral health in U.S. states and the
District of Columbia. People who have the least access to pre
ventive services and dental treatment have greater rates of oral
diseases.10,11
We compared these correlations to the association of the
same markers of oral health with Alzheimer’s death rates. Poor
oral health, especially periodontal disease, is a well-established
risk factor for dementia.12-15
Methods
Age-adjusted data on benign brain tumor incidence by state are
from CBTRUS Statistical Report: Primary Brain and Central Ner
vous System Tumors Diagnosed in the United States in 2005–
2009.1 Data on number of dentists per 10,000 population in 50
U.S. states and the District of Columbia are from Table 1.12 (Ac
tive dentists, by state, 1993-2008, US Centers for Disease Con
trol and Prevention, National Center for Health Statistics, http://
www.cdc.gov/nchs.)
Data on Dental Visits: Percent adults aged 18+ who have
visited a dentist or dental clinic in the past year (yes and no).
Teeth Cleaning: Percent adults aged 18+ who have had their
teeth cleaned in the past year (among adults with natural teeth
who have ever visited a dentist or dental clinic, yes and no).
Complete Tooth Loss: Percent adults aged 65+ who have lost
all of their natural teeth due to tooth decay or periodontal disease
(yes and no).
Lost Six or More Teeth: Percent adults aged 65+ who have
lost six or more teeth due to tooth decay or periodontal disease
(yes and no) are from BRFSS (Behavioral Risk Factor Surveil
lance System 2008), the US Centers for Disease Control and
Prevention survey, which tracks health risks in the United States
(www.cdc.gov/brfss). Survey methods have been described in
detail elsewhere.16
Age-adjusted Alzheimer’s death rates by state are from the
Alzheimer’s Association.17
Results
Pearson correlations, number of cases (49, no data from Kansas or
Maryland) and significance (2 tailed p values) of benign brain tu
mor incidence and parameters of oral health are listed in Table 1.
None of the correlations approached statistical significance.
In contrast, Alzheimer’s deaths by state were negatively cor
related with number of dentists (Figure 1). Pearson correlations,
number of cases and significance (2 tailed p values) of age-adjust
ed Alzheimer’s death rates and parameters of oral health are listed
in Table 2. All of the correlations were significant.
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1. Figure 1. Number of Dentists per 10,000 population in 50 U.S. States and District of Colum
bia vs. Age-adjusted Alzheimer’s Deaths per 100,000 population. Correlation is significant (p
< 0.001).
2. 3. 4. 5. 6. 7.
8. 9. 10. 11. 12. Discussion
White et al. noted that radiation exposure from dental X-rays
is too low to cause tumors.18 Calnon found multiple inconsis
tencies in the Claus et al. study and that the odds ratios Claus
et al. calculated were small and of borderline statistical signifi
cance.19 Jorgensen concluded that radiation-induced meningio
ma risks cannot possibly be as high as Claus et al. suggested.20
Our finding of lack of correlation between benign brain tumor
and markers of oral health is in agreement with White et al.,
Jorgensen and Calnon.
A weakness in our analysis is possible confounding by the
ecological fallacy (or ecological inference fallacy), a logical fal
lacy in the interpretation of statistical data where inferences
about the nature of individuals are derived from inference for
the group to which those individuals belong.21 In this case, in
ferences about individuals are being drawn from the character
istics of the U.S. states where they reside, rather than from the
individuals themselves.
Nevertheless, our finding of a total lack of correlation be
tween benign brain tumors and markers of oral health and, by
implication, dental X-rays, suggests that there may be no rela
tionship between dental X-rays and meningioma or other benign
brain tumors. This conclusion is strengthened by our demonstra
tion of the known negative correlation between Alzheimer’s and
dental care. p
13. 14. 15. 16. 17. 18.
19. 20. 21. Dolecek TA, Propp JM, Stroup NE, Kruchko C. CBTRUS Statistical Report: Primary Brain
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consequences. Am J Public Health 1994;84(5):819-24.
Steven Lehrer, M.D., is associate professor of radiation oncology, Department
of Radiation Oncology, Icahn School of Medicine, Mount Sinai, New York, NY.
Dr. Lehrer
Sheryl Green, M.B.BCh., is assistant professor of radiation oncology, De
partment of Radiation Oncology, Icahn School of Medicine, Mount Sinai, New
York, NY.
Kenneth E. Rosenzweig, M.D., is professor and system chair, radiation oncology, Department of
Radiation Oncology, Icahn School of Medicine, Mount Sinai, New York, NY.
Queries about this article can be sent to Dr. Lehrer at [email protected].
43
oral pathology
Oral Cavity Lymphoid Neoplasms
A Fifteen-Year Single Institution Review
Elizabeth Philipone, D.M.D.; Govind Bhagat, M.B.B.S.; Bachir Alobeid, M.D.
ABSTRACT
Although relatively rare, lymphomas can and do pres
ent within the oral cavity and can represent either the
initial presentation or secondary involvement in the
setting of systemic disease. Our objective was to con
duct a retrospective search of the surgical pathology
database at our institution to review all oral biopsy
specimens diagnosed as either a lymphoma or plasma
cell neoplasm over the past 15 years. Based on our
search, we identified 47 cases. We report here the type
of neoplasm, location, patient age and gender, and
available pertinent clinical information.
Despite being the second most common malignancy of the head
and neck, lymphoid neoplasms of the oral cavity are relatively in
frequent, as the vast majority of oral malignancies are squamous
cell carcinomas.1 Whereas lymphoma is a neoplastic proliferation
of mature lymphocytes, often initially involving the lymph nodes,
plasma cell neoplasms are clonal expansions of terminally differ
entiated B-cells (plasma cells). Both lymphomas and plasma cell
neoplasms can involve either the soft tissues of the mouth or bone
and be either a primary occurrence or manifestation of dissemi
nated disease.
In this study we reviewed all biopsies from the oral soft tis
sues or jaw bones diagnosed as a lymphoma or plasma cell neo
44
plasm. Our goal is to provide practitioners with a summary of the
prevalence, types and relevant clinicopathologic findings for cases
seen at our institution.
Materials and Methods
Following institutional review board approval, a 15-year
(1/1/1997-6/1/2012) retrospective search of the surgical pa
thology database at our institution was performed to identify all
intra-oral biopsies diagnosed as lymphoma or plasma cell neo
plasm. Myeloid neoplasms were excluded for this study.
H&E sections prepared from formalin-fixed and paraffinembedded tissue were used for morphologic analysis. A compre
hensive panel of immunohistochemical (IHC) stains and in situ
hybridization (ISH) was performed on all cases for confirmation
of diagnosis and proper classification of the neoplasm. In addi
tion, results of cytogenetic and polymerase chain reaction (PCR)
analyses were reviewed when available.
We provide a descriptive analysis. All cases were diagnosed
and classified according to the current WHO 2008 classification
of hematopoietic neoplasms. We restricted our review to biopsies
submitted by dentists and/or oral surgeons and did not include
cases occurring in the palatine tonsils or nasopharynx.
Results
A total of 47 patients—22 males and 25 females—had intraoral
biopsies in which a diagnosis of either lymphoma or plasma cell
neoplasm was rendered. No cases of oral Hodgkin lymphoma
were found. The most to least frequently rendered diagnoses are
listed in Table 1, with diffuse large B-cell lymphoma (n=13) be
ing the most frequent. Forty-six patients were adults ranging in
age from 23 to 94 years (median – 66 years); one patient was a
7-year-old child.
Location
Thirty-five of the lesions presented in soft tissue, most frequently
involving the buccal mucosa. Twelve patients presented with in
traosseous lesions, seven cases occurring in the maxilla and five
in the mandible. Nine of the intraosseous cases were diagnosed
as lymphoma and three as plasma cell neoplasm. The sites of in
volvement are summarized in Table 2.
Clinical Impression
A clinical differential diagnosis and/or adequate clinical history
were provided for 35 of the 47 patients. Lymphoma was the ren
dered clinical diagnosis in nine cases. In eight of these cases, the
submitting clinician was aware of a prior history of lymphoma
elsewhere (implying the patient had systemic lymphoma with
secondary involvement of the oral cavity or, as in one of the
cases, the lymphoma was a recurrence at the same site). Plasma
cell neoplasm was the suspected clinical diagnosis in one case in
which the clinician was aware of a history of such.
The next most common clinical diagnosis was squamous cell carci
noma (n=4), followed by salivary gland tumor (n=3) and mucocele
(n=2). A simple statement of “rule out neoplasm” was the clini
cal diagnosis for three of the cases. Peripheral odontogenic tumor,
radicular cyst, sarcoma, granulomatous inflammation, granulation
tissue, periapical lesion, lymph node osteonecrosis and ameloblas
toma comprised the clinical diagnoses for the remaining cases.
Clinical Presentation
A description of the clinical presentation was provided for only
14 of the cases. The most commonly reported presentation was of
an enlarging soft tissue mass (n=7). This was followed by a pain
less nodule (n=4). Gingival overgrowth, persistent swelling and
ulceration were reported for one case each.
Past Medical Histories
We were aware of a prior history of lymphoma for 16 of the lym
phoma cases. A history of HIV was provided in two of the three
cases of plasmablastic lymphoma. A history of metastatic papil
lary thyroid carcinoma was provided in one case of diffuse large
B-cell lymphoma clinically described as a mass at the base of the
tongue. A history of metastatic breast cancer was provided in a
case of diffuse large B-cell lymphoma that presented intraosse
ously within the mandible. Both of the patients diagnosed with
TABLE 1
Subtype, Number of Cases, Age and Gender
Subtype
Diffuse large B-cell lymphoma
TABLE 2
No. of
cases
Age range
(years) [Mean](years)
M:F
Location of Lesions
13
36-94 [70.8]
2:3
Site
No. of cases (%)
Chronic lymphocytic leukemia/small
lymphocytic lymphoma
8
71-86 [77.3]
1:1
Buccal Mucosa
8 (17.0%)
Follicular lymphoma
6
59-79 [66.6]
3:2
Maxilla
7 (14.9%)
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue
5
23-85 [60]
1:1
Palate
7 (14.9%)
Plasma cell neoplasms
5
42-71 [61.4]
1:3
Tongue
6 (12.8%)
Plasmablastic lymphoma
3
29-49 [37.7]
2:1
Mantle cell lymphoma
2
88,84
1:1
Gingiva
6 (12.8%)
CD30+ T-cell lymphoproliferative
disorder
2
34,84
1:1
Mandible
5 (10.6%)
Post-transplant lymphoproliferative
disorder (PTLD)
Vestibule
5 (10.6%)
2
7,31
0:2
Lip
2 (4.3%)
B-Cell lymphoma not otherwise
classified
1
66
0:1
Floor of Mouth
1 (2.1%)
45
post-transplant lymphoproliferative disorder had received a car
diac transplant. Three of the patients with a diagnosis of plasma
cell neoplasm had a known history of plasma cell myeloma. Ex
posure to bisphosphonates was reported in one case of plasma
cell myeloma of the mandible in which the clinician suspected
osteonecrosis.
Additional Testing
The presence of Epstein-Barr virus (EBV) was evaluated in 16 cas
es using Epstein-Barr virus-encoded small RNAs (EBER) in situ
hybridization. Five cases were found to be positive. These included
all three cases of plasmablastic lymphoma, as well as the two cas
es of post-transplant lymphoproliferative disorder.
Discussion
Lymphomas
Lymphomas comprise the second most common malignancy
within the oral cavity.1 Despite this ranking, the occurrence of
lymphoma within the oral cavity is relatively rare, since the vast
majority—over 90% of oral malignancies—represent squamous
cell carcinomas.1 In a large population-based review, Epstein et
al. reported that lymphomas of the oral cavity account for only
3.5% of all oral malignancies.2
In reviewing cases diagnosed over a 15-year period at our
institution, 42 intraoral biopsies were diagnosed as lymphoma.
This is in comparison to over 500 oral squamous cell carcinoma
diagnoses rendered at this institution during the same time pe
riod. We found that lymphoma comprised just over 5% of oral
malignant lesions diagnosed at our institution.
Up to 48% of non-Hodgkin lymphomas occur at extra nodal
locations and 3% to 5% involve the oral cavity.3 Often the oral
lesions are not the initial presentation of disease.4 Although the
amount of information provided on the biopsy requisition form
by the submitting clinician was limited, approximately one-half
of the cases had a prior history of non-Hodgkin lymphoma, im
plying that the oral lymphoma was a secondary manifestation
or, as revealed in one case, a recurrence at the same site. No di
agnoses of intraoral Hodgkin lymphoma were made during the
period reviewed. A literature search revealed only 10 case reports
of Hodgkin lymphoma occurring within the oral cavity, three of
which occurred in the tonsils.5
Non-Hodgkin lymphoma primarily affects adults.1,2 All of
our cases, except for one post-transplant lymphoproliferative dis
order case, occurred in adult patients. Based on the Surveillance,
Epidemiology and End Results (SEER) report from 2004-2008,
the median age at diagnosis of non-Hodgkin lymphomas in the
U.S. was 66 years.6 In our series, the median age of patients with
non-Hodgkin lymphoma at time of biopsy was 71. This is slightly
older than the SEER mean; however, our mean represents the age
at which the oral lesions were biopsied and as mentioned above,
46
at least half of our patients had a prior history of lymphoma.
Therefore, the true median age at diagnosis was likely younger.
In our series, the vast majority of patients were over 60 years
of age, except cases of plasmablastic lymphomas where the ages
of the three patients were 29, 35 and 49 years, and five nonHodgkin lymphoma cases occurring in patients # 40 years. Two
of these patients, one of which was a child, age 7, were status
post-iatrogenic immunosupression secondary to heart transplan
tation, which is a known risk factor for developing lymphoma.7
Non-Hodgkin lymphoma is also known to show a slight male
predilection.1 Our non-Hodgkin lymphoma patients were almost
equally divided based on gender, with 19 males and 17 females.
Our results with regard to gender and prior history of lymphoma
correlated with a similar review of 31 cases reported by L. Eisen
bud et al.4 In their review, the male-to-female ratio was almost
equal; 19 of their patients had a prior history of lymphoma. How
ever, these authors included lymphomas involving the tonsils in
their series, which accounted for three cases. Interestingly, Bur
kett’s lymphoma was the diagnosis in four of their cases, and in
six cases, patients were under 16 years of age.
The presence of Epstein-Barr virus (EBV) was evaluated in
15 of our cases using Epstein-Barr virus-encoded RNAs (EBER)
in situ hybridization. All three cases of plasmablastic lymphoma
were positive for EBV. Two of these patients were known to be HIV
positive. In addition, both patients who were immunosuppressed
secondary to organ transplant also had EB-positive lymphomas.
EBV infection is a known cooperating event in the pathogenesis
of post-transplant lymphoproliferative disorder.7 Our results were
in accordance with prior studies, which reported a lack of EBV
infection in oral non-Hodgkin lymphoma of immunocompetent
individuals.8
Within the oral cavity, non-Hodgkin lymphoma can pres
ent either within soft tissue or bone. When affecting the soft tis
sues of the oral cavity, the most common locations have been
reported to be the buccal vestibule, posterior hard palate and
gingiva.9 In the U.S., 5% to 10% of all cases of primary or sec
ondary non-Hodgkin lymphoma have been reported to involve
Waldeyer’s ring, which includes the lymphoid tissue on the base
of the tongue (lingual tonsil).10 We found the buccal mucosa,
base of tongue and palate to be the most common soft tissue sites
of involvement; however, as stated previously, tonsils were not
analyzed in our series.
Plasma Cell Neoplasms
Extramedullary plasmacytoma, solitary osseous plasmacytoma
and plasma cell myeloma comprise a clinical spectrum of clonally
expanded, terminally differentiated B-cells. Plasma cell myeloma
is the most common plasma cell neoplasm, and up to 30% of
patients develop manifestations within the jaw bone.11 The occur
rence of either extraosseous (extramedullary) or solitary osseous
plasmacytoma within the oral cavity is much rarer.12,13 Similar to
non-Hodgkin lymphoma, plasma cell neoplasms primarily affect
adults, albeit of an older age.1 All of our plasma cell neoplasm
cases occurred in adult patients. In our series the median age at
time of biopsy for patients was 65.8
Although extramedullary plasmacytoma has a predilection
for the head and neck, it has been reported to comprise fewer
than 1% of head and neck tumors, with the nasopharynx, paranasal sinuses and tonsils the most common sites.14 Solitary osse
ous plasmacytoma is less common in the head and neck than ex
tramedullary plasmacytoma. In a review conducted by Kanazawa
et al., solitary osseous plasmacytoma was found to account for
4% of myelomatous diseases of the mandible.13 Many cases of
solitary plasmacytoma of bone eventually progress to plasma cell
myeloma. It has been reported that approximately 30% of plasma
cell myeloma cases show manifestations within the oral cavity.15
Within the oral cavity, plasma cell neoplasm can present either
within soft tissue or bone. When affecting bone, the mandible
is the most frequent site of oral involvement.15 Three of our five
cases occurred within the jaws, two within the mandible and one
within the maxilla. Two of these cases had a disclosed prior his
tory of plasma cell myeloma. The remaining three cases were lo
calized as a soft tissue mass within the oral cavity, two occurring
within the buccal mucosa and one within the gingiva. One of our
patients presenting with a soft tissue lesion had a known history
of plasma cell myeloma.
Within the oral cavity, both lymphoma and plasma cell neo
plasm can have a variety of clinical manifestations that clinicians
need to be aware of. Only slightly more than one-third of cli
nicians provided clinical description/information at the time of
biopsy, but in most cases it was limited. An enlarging soft tissue
mass was the most common description provided. The presence
of surface ulceration can lead clinicians to suspect squamous cell
carcinoma. Therefore, it is not surprising that squamous cell car
cinoma was the second most frequent clinical diagnosis provided
by the clinicians in our review; after all, it is the most common
malignant lesion to occur within the oral cavity.
A total of 12 cases occurred within bone. Despite having lim
ited clinical data, the jaw lesions were confirmed as secondary
manifestations in 7 of the 12 cases. Jaw lesions often present as
ill-defined radiolucencies and can cause pain and/or paresthe
sia often leading clinicians to suspect inflammatory processes,
odontogenic tumors and/or metastases. Radicular cyst, periapi
cal pathology and ameloblastoma were suspected in three of the
intraosseous cases for which the clinician provided a clinical di
agnosis. Osteonecrosis was the suspected clinical diagnosis in a
patient with a reported history of intravenous bisphosphonate
exposure and plasma cell myeloma.
Despite being relatively uncommon in the oral cavity, lym
phoma and plasma cell neoplasm do manifest in soft tissues of
the mouth and within the jaws, typically in adult patients over
60 years of age. The clinical presentation may be variable and
the disease can be either primary or secondary. Clinicians need
to be aware of this in order to better evaluate patients with oral
lesions and to consider lymphoma when formulating differen
tial diagnoses. p
Queries about this article can be sent to Dr. Philipone at [email protected].
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Barnes L, Everson JW, Reichart P, Sidransky D. Pathology and Genetics of Head and Neck
Tumours, World Health Organization, Lyon, France: IARC Press, 2005;168,199.
Epstein JB, Epstein JD, Le ND, Gorsky M. Characteristics of oral and paraoral malignant
lymphoma: a population-based review of 361 cases. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2001;92:519-25.
Söderholm AL, Lindqvist C, Heikinheimo K, Forssell K, Happonen RP. Non-Hodgkin’s lym
phomas presenting through oral symptoms. Int J Oral Maxillofac Surg 1990;19(3):131-4.
Eisenbud LL, Sciubba JJ, Mir RR, Sachs SA. Oral presentations in non-Hodgkin’s lymphoma:
a review of thirty-one cases. Oral Surg 1983;56(2):151-6.
Kämmerer PW, Schiegnitz E, Hansen T, Draenert GF, Kuffner HD, Klein MO, et al. Multiple
primary enoral soft tissue manifestations of a Hodgkin lymphoma-case report and litera
ture review. Oral Maxillofac Surg 2013;17(1):53-7.
SEER Research Data 1973-2009 Surveillance, Epidemiology, and End Results (SEER) Pro
gram (www.seer.cancer.gov) SEER Cancer Statistics Review 1975-2009 (Vintage 2009 Popu
lations). Updated April 30, 2012 (accessed May 10, 2012).
Carbone A, Gloghini A, Dotti G. EBV-associated lymphoproliferative disorders: classifica
tion and treatment. Oncologist 2008;13(5):577-85.
Leong IT, Fernandes BJ, Mock D. Epstein-Barr virus detection in non-Hodgkin’s lymphoma
of the oral cavity: an immunocytochemical and in situ hybridization study. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2001 Aug;92(2):184-93.
Neville B, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St.
Louis MS:W. B. Saunders Co., 2008;595-98.
Shvero J, Morgenstern S, Shvili I, Hadar T. Non-Hodgkin lymphoma presenting as a base of
tongue mass: clinicopathological study. Medical Connections 2009;1:7-10.
Pisano JJ, Coupland R, Chen S, Miller A. Plasmacytoma of the oral cavity and jaws: a
clinicopathologic study of 13 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;83:265-71.
Dimopoulolos MA, Kiamouris C, Moulopoulos LA. Solitary plasmacytoma of bone and
extramedullary plasmacytoma. Hematol Oncol Clin North Am 1999;13:1249-57.
Kanazawa H, Shoji A, Yokoe H, Midorikawa S, Takamiya Y, Sato K. Solitary plasmacy
toma of the mandible. Case report and review of the literature. J Craniomaxillofac Surg
1993;21:202-206.
Nofsinger YC, Mirza N, Rowan P, Lanza D, Weinstein G. Head and neck manifestations of
plasma cell neoplasms. The Laryngoscope 1997;107(6):741–46.
Epstein JB, Voss NJ, Stevenson-Moore P. Maxillofacial manifestations of multiple my
eloma. An unusual case and review of the literature. Oral Surg Oral Med Oral Pathol
1984;57(3):267-71.
Dr. Philipone
Dr. Bhagat
Dr. Alobeid
Elizabeth Philipone, D.M.D., is in the Division of Oral Pathology at Columbia University College
of Dental Medicine, New York, NY.
Govind Bhagat, M.B.B.S., is in the Division of Hematopathology, Department of Pathology and
Cell Biology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY.
Bachir Alobeid, M.D., is in the Division of Hematopathology, Department of Pathology and Cell
Biology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY.
47
oral diagnosis
Diagnosing the Parotid Lipoma
Case Report
Ashley Houle, B.S.; Louis Mandel, D.D.S.
ABSTRACT
The clinical features of the rarely reported and diagnos
tically challenging parotid gland lipoma are described.
Presurgical diagnosis is aided by CT scan imaging.
Lipomas are benign tumors of adipose tissue that usually involve
the upper back, shoulder and abdomen.1 These benign growths
represent the most commonly occurring mesenchymal soft tis
sue tumors,2-4 with 13% to 20% involving the head and neck re
gions.5-9 Only 5% of benign oral tumors are classified as lipoma.2-4
Fat tissue tumors are found more frequently in males than
females, in a 5:1 ratio,10 and tend to become clinically apparent
in the fifth to sixth decades of life.4,7,8
Initially, the lipoma was thought to originate after trauma.
However, development of a true neoplastic lipoma following
trauma is now discounted. Those that develop following trauma,
usually in the thigh or pelvis area,11 are not true neoplasms and
are not encapsulated. These masses are pseudolipomas and result
from a prolapse of normal adipose tissue through a deficiency
in Scarpa’s fascial layer following a traumatic incident.12 It has
also been theorized that trauma causes an inflammation with fat
necrosis that incites a proliferation of pre-adipocytes to form the
pseudolipoma.12
Lipomas of the parotid salivary gland are relatively rare
findings, with the reported incidence varying from .6% to 4.4%
48
of benign parotid neoplasms.1,4,6,7,9,13-16 Those that involve the
parotid gland are usually located in the superficial lobe and
rarely occur in the gland’s deep lobe.7,10,16 A specific preopera
tive diagnosis can be difficult because the lipoma has no unique
clinical features. The lipoma is known to be painless and slow
growing. When close to the surface, palpation indicates that it
is soft and doughy in tone, circumscribed and freely movable.
Head and neck lipomas average 3 cm in size, although some can
be as large as 8 cm.5,8 Because they are painless, patients often
seek attention only when functional problems or cosmetic is
sues become a concern.
A presurgical diagnosis of a lipoma is facilitated with CT scan
imaging. The density value of the tumor corresponds to that of
fat and has been reported to vary from −50 to −150 Hounsfield
units.1-3,5-7 There is no contrast enhancement, and the growth
will be noted to have well-defined margins.2 The displacement of
the surrounding soft tissue serves as an indication of tumor ex
pansion and differentiates the lipoma from the infiltrating pres
ence of normal fat accumulations. The CT scan can only suggest
a diagnosis because no specific characteristic signs are available.
Final diagnosis awaits histologic examination of a presurgical bi
opsy or the excised surgical specimen.
From the Salivary Gland Center, Columbia University College of Dental Medi
cine, New York, NY.
Histologically, the true parotid lipoma is surrounded by a thin
fibrous capsule that serves to isolate this neoplasm from the sur
rounding normal parotid gland tissue. Connective tissue septa
can be observed partitioning the lipoma into a lobular configura
tion, which is helpful in distinguishing the lipoma from simple
fat aggregations.2 Sheets of mature adipocytes with a clear cyto
plasm are seen, with little variation in cell size. Small flattened
nuclei are located peripherally.4,7
Because of its rarity and the absence of significant diagnostic
features, the authors wish to call attention, via a case report, to
the existence of and diagnostic challenge associated with a pa
rotid gland lipoma.
Case Report
A 53-year-old male was referred to the Salivary Gland Center of Co
lumbia University College of Dental Medicine because of the pres
ence of a left parotid area swelling (Figure 1). A medical history in
dicated that the patient was in excellent health. He had no systemic
medical problems, and his only medication was the daily use of 81
mg aspirin. Questioning indicated that the left facial swelling had
been present for at least eight years. During this period, it had grown
slowly, but was always painless. Recently, because of its continued
growth, the patient has become concerned about his appearance.
Extraorally, a visible swelling, measuring 3 cm x 3 cm, was
apparent, involving the left parotid area. Palpation revealed that
the mass was soft, circumscribed and painless, and involved the
superficial lobe of the parotid gland. When palpated, the other
salivary glands proved to be normal in tone and painless. There
was no facial palsy or cervical lymphadenopathy. Intraorally,
the mucosa was normally moist, and a normal salivary return
through the left parotid duct orifice was observed when the left
parotid gland was aggressively massaged. A panoramic radiograph
added no diagnostic information related to the swelling. A CT
scan was ordered. The report stated that a circumscribed, poor
ly hypodense mass (-110 Hounsfield units) was present in the
parotid’s superficial lobe, consistent with a diagnosis of lipoma
(Figure 2).
The patient was referred for surgical removal of the patholog
ic lesion. Careful dissection resulted in enucleation of the tumor,
along with a narrow rim of parotid tissue. The microscopic find
ings confirmed the presence of a thin fibrous capsule separating a
tumor of fat from normal parotid gland tissue (Figure 3). Lobules
of mature adipocytes were observed, with the lobules separated
from each other by thin fibrous connective tissue bands. The final
diagnosis was lipoma.
Discussion
Because confusion with other pathologic entities exists, differential
diagnosis of a lipoma must include the possible presence of a pseu-
Figure 1. Clinical view of left parotid gland swelling.
Figure 2. CT scan (axial view) demonstrates large hypodense area (-110 Hounsfield units)
involving left parotid gland (arrows).
Figure 3. Microscopic view of lipoma (L) surrounded by thin fibrous capsule and rim of
normal parotid gland tissue (H and E stain, magnification x 100).
49
dolipoma or lipomatosis. As indicated, the pseudolipoma has its
origin in a traumatic event. Its differentiation from a true lipoma
rests in the fact that it is not encapsulated and usually is located
in the thigh and pelvic areas.11 Lipomatosis of the parotid gland
is also characterized by the absence of a capsule. In lipomatosis, a
diffuse fat infiltration of the parotid tissues, often bilateral, is seen.
The condition, also called sialadenosis, is frequently associated with
alcoholism, diabetes, malnutrition or an underlying metabolic or
hormonal abnormality.6 Variants of the lipoma have also been re
ported and include sialolipoma, angiolipoma and fibrolipoma.17,18
These entities probably represent entrapment of normal adjacent
tissues and are not true neoplastic variants.17-19
Differential diagnosis also must include consideration of the
existence of the malignant liposarcoma. Malignant transforma
tion from a benign lipoma is rare.17 Imaging features of the malig
nant liposarcoma include its large size and absence of a capsule.20
The margins of the liposarcoma are irregular, with the growth
infiltrating into the surrounding tissues. A heterogeneous density
is usually seen on the CT scan.10 Nevertheless, final diagnosis de
mands a histologic diagnosis of an excised specimen. Fine-needle
aspiration biopsy may be helpful preoperatively in identifying a
malignant lipoma.21
Treatment
Removal of a parotid lipoma is most frequently achieved via a
superficial parotidectomy.6,7,22 However, because the lipoma is
benign and well-circumscribed by its capsule, enucleation of the
tumor with incorporation of a rim of normal parotid gland tissue
is an option.7,22 When the parotid’s deep lobe is involved, surgery
becomes difficult because a meticulous dissection with preserva
tion of the facial nerve becomes mandatory. p
Queries about this article can be sent to Dr. Mandel at [email protected].
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Ozcan C, Unal M, Talas D, Gorur K. Deep lobe parotid gland lipoma. J Oral Maxillofac Surg
2002;60:449.
Chikui T, Yonetsu K, Yoshiura K, et al. Imaging findings of lipomas in the orofacial region
with CT, US and MRI. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:88.
Munk PL, Lee MJ, Janzen DL, et al. Lipoma and liposarcoma: evaluation using CT and MR
imaging. AJR 1997;169:589.
Furlong MA, Fanburg-Smith JC, Childers ELB. Lipoma of the oral and maxillofacial region:
site and subclassification of 125 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004; 98:441.
deJong AL, Park A, Taylor G, Forte V. Lipomas of the head and neck in children. Int J Pediatr
Otorhinolaryngol 1998;43:53.
Ethunandan M, Vura G, Anand R, et al. Lipomatous lesions of the parotid gland. J Oral
Maxillofac Surg 2006;64:1583.
Gooskens I, Manni JJ. Lipoma of the deep lobe of the parotid gland: report of 3 cases. ORL
2006; 68:290.
El-Monem MHA, Gaafar AH, Magdy EA. Lipomas of the head and neck: presentation of
variability and diagnostic work-up. J Laryngol Otol 2006;120:47.
Dispenza F, DeStefano A, Romano G, Mazzoni A. Post-traumatic lipoma of the parotid
gland: case report. Acta Otorhinolaryngol Ital 2008;28:87.
Fakhry N, Michel J, Varoquaux A, et al. Is surgical excision of lipomas arising from the
parotid gland systematically required? Eur Arch Otorhinolaryngol 2012;269:1839.
David L, DeFranzo A, Marks M, Argenta L. Posttraumatic pseudolipoma. J Trauma
1996;40:396.
Copcu E, Sivrioglu NS. Posttraumatic lipoma: analysis of 10 cases and explanation of pos
sible mechanisms. Dermatol Surg 2003;29:215.
Debnath SC, Saikia A. Lipoma of the parotid gland extending from the superficial to the
deep lobe: a rarity. Br J Oral Maxillofac Surg 2010;48:203.
Esposito C, Califano L, D’Armiento M, Longo F. Lipomatosis of the parotid gland in a child.
Br J Plast Surg 2000;53:699.
Gritzmann N, Macheiner P. Lipoma in the parotid gland; typical US and CT morphology.
Ultraschall Med 2003;24:195.
Ansari MH. Case report: superficial lobe parotid gland lipoma. J Craniomaxillofac Surg
2006;34:47.
Signorini M, Campiglio GL. Posttraumatic lipomas: where do they really come from? Plast
Reconstr Surg 1998;101:699.
Nagao T, Sugano I, Ishida Y, et al. Sialolipoma: a report of seven cases of a new variant of
salivary gland lipoma. Histopathology 2001;38:30.
Fritzsche FR, Bode PK, Stinn B, Huber GF, Noske A. Sialolipoma of the parotid gland. Patho
loge 2009;30:478.
Kransdorf MJ, Bancroft LW, Peterson JJ, Murphey MD, Foster WC, Temple HD. Imaging of
fatty tumors: distinction of lipoma and well-differentiated liposarcoma. Radiology 2002;
224:99.
Stewart CJR, MacKenzie K, McGarry GW, Mowat A. Fine-needle aspiration cytology of sali
vary gland: a review of 341 cases. Diagn Cytopathol 2000;22:139.
Kim D-S, Kwon H, You G, Jung S-N. Surgical treatment of a giant lipoma in the parotid
gland. J Craniofac Surg 2009;20:1601.
Ashley Houle, B.S., is fourth-year student at Columbia University College of Dental
Medicine, New York, NY, and a research assistant in the Salivary Gland Center there.
Dr. Mandel
50
Louis Mandel, D.D.S., is director of the Salivary Gland Center and associate
dean and professor, oral and maxillofacial surgery, Columbia University College
of Dental Medicine, New York, NY.

April 2015 - New York State Dental Association

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