Interventions for tobacco cessation in the dental setting. A systematic review.

UNLABELLED: Oral health professionals have a unique opportunity to increase tobacco abstinence rates among patients who use tobacco. OBJECTIVE: To assess the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. RESEARCH DESIGN: We searched standard electronic retrieval systems and databases including the specialized registers of the Cochrane Tobacco Addiction Group and the Cochrane Oral Health Group through 2006. Selection criteria included randomised and pseudo-randomised clinical trials assessing tobacco cessation interventions for tobacco users conducted by oral health professionals in the dental office or community setting. The most rigorous abstinence outcome reported with at least six months of follow-up was recorded. Data collection and analysis involved two authors who independently reviewed abstracts for inclusion and abstracted data from included trials. RESULTS: Six clinical trials assessing the efficacy of interventions in dental office or school community settings were included. All studies assessed the efficacy of interventions for smokeless tobacco users, one also included cigarettes smokers, all employed oral exam and behavioral components, and one offered pharmacotherapy. The results showed that interventions conducted by oral health professionals increase tobacco abstinence rates (OR 1.44; 95% CI: 1.16-1.78) at 12 months or longer. Heterogeneity was evident and could not be adequately explained through subgroup or sensitivity analyses. CONCLUSIONS: Available evidence suggests that behavioral interventions for tobacco use conducted by oral health professionals incorporating an oral exam component in the dental office and community setting increase tobacco abstinence rates.

Interventions for tobacco cessation in the dental setting.

BACKGROUND: Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users. OBJECTIVES: This review assesses the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction group Specialized Register (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1982-2004), Healthstar (1975-2004), ERIC (1967-2004), PsycINFO (1984-2004), National Technical Information Service database (NTIS, 1964-2004), Dissertation Abstracts Online (1861-2004), Database of Abstract of Reviews of Effectiveness (DARE, 1995-2004), and Web of Science (1993-2004). SELECTION CRITERIA: We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow up. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus. MAIN RESULTS: Six clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or a school community setting. All studies assessed the efficacy of interventions for smokeless tobacco users, one of which included cigarettes smokers. All studies employed behavioural interventions and only one offered pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling of the studies suggested that interventions conducted by oral health professionals increase tobacco abstinence rates (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.16 to 1.78) at 12 months or longer. Heterogeneity was evident (I(2) = 75%) and could not be adequately explained through subgroup or sensitivity analyses. AUTHORS' CONCLUSIONS: Available evidence suggests that behavioural interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice.

Histomorphometric comparison of implant anchorage for two types of dental implants after 3 and 6 months' healing in baboon jaws.

STATEMENT OF PROBLEM: A complete understanding of dental implant prognosis requires better knowledge of the bone anatomy after implant healing. Such baseline data are necessary to compare against load-induced changes in anatomy. PURPOSE: The purpose of this article is to describe and compare measures of implant support (percentage [%] integration and percentage [%] bone area) for various implants in baboon jaws after healing times of 3 and 6 months. MATERIAL AND METHODS: Commercially pure titanium (cpTi) and titanium alloy (Ti-alloy) screw-shaped implants were placed in the posterior jaws of 9 female baboons after 2 months of postextraction healing. Specimens were harvested after 3 months (5 baboons: 8 cpTi, 7 Ti-alloy) and after 6 months (4 baboons: 8 cpTi, 8 Ti-alloy). Each implant provided 6 polished horizontal sections for data collection, which was accomplished from digitized images with the IMAGE analysis system (reliability at 1.6%). Three- and six-month data for each parameter were compared with the use of ANOVA (P<.01). RESULTS: The results revealed a significant increase in the % integration (cpTi 39.1 to 56.2; Ti-alloy 40.0 to 55.2) and the % bone area (cpTi 38.8 to 47.9; Ti-alloy 38.9 to 49.2) from 3 to 6 months for both implants. This significant increase was also true for comparisons by jaw for each implant material (P<.01 for overall and by jaw comparisons). CONCLUSION: A time-dependent increase in jawbone anchorage was measured in this nonhuman primate population, and it was shown that the 6-month maxillary data were comparable to the 3-month mandibular data. These results lend support to the clinical strategy of waiting longer to load implants in the maxilla.

Hierarchy of research design used to categorize the "strength of evidence" in answering clinical dental questions.

The purpose of this article is to highlight important features of research design that clinicians can use to determine which articles are useful when attempting to answer clinical questions and determine the best therapy for a particular patient. This article offers a systematic means of categorizing the quality of research reports for clinicians and clinical investigators. A recurring clinical theme of hygiene education is used to exemplify how phrasing the clinical question determines the type of study design that could be used. The article describes the continuum of research reports, and categorizes them by their inherent strengths and weaknesses. The report describes why the research designs in the supreme position of the research hierarchy, are the most valuable to clinicians seeking evidence that defines the best therapy for their patients.

Histomorphometric analysis of implant anchorage for 3 types of dental implants following 6 months of healing in baboon jaws.

In an effort to better understand the supporting anatomy for unloaded endosseous dental implants, this study focused on the histomorphometric analysis of 3 different types of implants placed into non-human primate jaws and allowed to heal for 6 months. This report describes data from 24 screw-type dental implants placed in edentulated (2 months healing time) posterior arches of 4 adult female baboons. Three different implants were placed and allowed to heal for 6 months prior to processing for evaluation: commercially pure titanium (n = 8), titanium alloy (n = 8), and titanium plasma-sprayed (n = 8). Circumferential bone-implant interface sampling from 6 regions along the entire length of each implant was obtained for evaluation of percent bone-implant contact (%BIC) and percent bone area (%BA), within 3 mm of the implant. Data were collected (reliability of 1.6% for both parameters) and analyzed by an observer blinded to implant material using IMAGE analysis software for differences between jaws, implant biomaterials, and jaw/biomaterial (analysis of variance, pairwise comparison using least squares method with Bonferroni adjustment). The results indicated that the overall mean %BIC was 55.8 and mean %BA was 48.1. Maxillary and mandibular differences for both parameters were statistically significantly different: %BIC in maxilla 50.8, in mandible 60.8; %BA in maxilla 43.6, in mandible 52.6 (both significant at the P < .05 level). The biomaterial analyses revealed no significant differences between the different implants for %BIC or %BA. The trend observed--that mandibular values were greater than maxillary values for the overall jaw comparisons--was found to be consistent at the jaw/biomaterial level, although the small sample size limited statistical power. These data, along with data from a previous 3-month study, provide insight into baseline supporting anatomy for dental implants.

Distortion of three-unit implant frameworks during casting, soldering, and simulated porcelain firings.

PURPOSE: The aim of this study was to assess distortion inherent in casting, soldering, and simulated porcelain firings of screw-retained, implant-supported three-unit fixed partial dentures (FPDs). MATERIALS AND METHODS: Ten wax patterns were fabricated on a die-stone cast containing two implants, 20 mm apart from center to center. Five specimens were cast in a high-palladium alloy, exposed to simulated porcelain firings, sectioned, and then soldered with low-fusing solder. Five specimens were cast, sectioned, soldered with high-fusing solder, and then exposed to simulated porcelain firings. For each specimen, two horizontal and six vertical distances between appropriately scribed reference points were measured with a traveling microscope. Comparisons were made among the various measurements taken after wax-pattern fabrication, casting, high- and low-fusing soldering, and each porcelain firing. Data were analyzed using a repeated-measures factorial ANOVA (alpha = 0.05). RESULTS: Significant difference was detected in the amount of horizontal distortion during casting (53 +/- 24 microns) and high-fusing soldering (-49 +/- 50 microns), as well as in the amount of horizontal distortion during high-fusing soldering (-49 +/- 50 microns) and low-fusing soldering (17 +/- 26 microns). However, no clinically significant difference was found in the amount of horizontal distortion during casting, low-fusing, and high-fusing soldering. The greatest amount of distortion during the simulated porcelain firings took place during the oxidizing cycle. CONCLUSIONS: Soldering did not improve the casting misfit of a three-unit implant-retained FPD model. Metal-ceramic implant frameworks should be oxidized before intraoral fit evaluation.

Effects of dental laboratory processing variables and in vitro testing medium on the porcelain adherence of high-palladium casting alloys.

PURPOSE: This study assessed the effects of dental laboratory processing variables and testing medium on porcelain adherence of representative high-palladium alloys. MATERIAL AND METHODS: The processing variables were recasting two and three times, porcelain stripping with hydrofluoric acid and rebuilding, and changing the recommended oxidation procedures. The testing medium was air for these four groups and the nontreatment group. In the last group, the specimens were stored and tested in artificial saliva. The metal ceramic specimens were fractured with biaxial flexure in constant strain. The area fraction of adherent porcelain (%) was calculated with a standardized spectrometric technique. A gold-palladium alloy served as the control. RESULTS: Recasting without adding new alloy negatively affected some high-palladium alloys. Porcelain stripping did not cause a decrease in adherence of the tested alloys. The alternate oxidation treatment reduced significantly the porcelain adherence of the Au-Pd and one Pd-Cu-Ga alloy. Storage and testing in artificial saliva did not significantly affect the porcelain adherence of the alloys. The Au-Pd alloy exhibited the highest porcelain adherence.

Successful long-term treatment outcomes in the field of osseointegrated implants: prosthodontic determinants.

PURPOSE: Because existing implant success criteria have not met with widespread use, consensus is needed among professionals working in the field as to what constitutes implant success. This article discusses implant success within the context of prosthesis success, and argues that successful use of implants cannot be judged without prosthesis consideration. RESULTS AND DISCUSSION: A framework for evaluating clinical success of prosthodontic treatment is presented. A context for judging success by presenting related topics that include contrasting process and outcome measures, and consideration of long-term outcomes that have a tangible meaning to the patient (i.e., are patient-based), is argued for. A hierarchy of outcomes is proposed for a better understanding of the relative strengths associated with various outcomes. Emphasis is given to the concept of prosthodontic treatment being prescribed to reduce the patient-specific burden associated with the missing tooth condition. CONCLUSION: The challenge is to define the best applications of dental implants within the broad context of prosthodontic options through demonstrated advantages over more conventional options. A broad understanding of "success" from multiple outcome domains is most likely to give the truest measure for implant application within the context of possible prosthodontic options for all patients.

Reverse-torque failure of screw-shaped implants in baboons after 6 months of healing.

Mechanical testing of the implant-tissue interface has been the focus of numerous investigations concerning the anchorage capacity of implants. The purpose of this study was to measure reverse-torque failure after 6 months of healing for three different biomaterials in the posterior jaws of four adult female baboons. The animals had all of their posterior teeth surgically extracted and, following 10 weeks of healing, 7 implants were placed in each quadrant. The biomaterials included titanium plasma-sprayed surfaces, titanium-aluminum-vanadium surfaces (both 3.8 mm x 10 mm), and a commercially pure titanium surface (3.75 mm x 10 mm). After 6 months, torque data were collected using a counterclockwise computerized torque driver and were analyzed by repeated measures analysis of variance for differences related to biomaterial, jaw, and biomaterial/jaw. Post-hoc Tukey Kramer analysis was also performed for within-group differences (alpha = .05 level). The biomaterial comparison revealed a significant difference between the titanium plasma-sprayed and the combined commercially pure titanium/titanium -aluminum-vanadium groups (analysis of variance, Tukey Kramer, P < .05). The jaw comparison showed no significant difference, although the data suggest that higher forces may be required for mandibular torsional failure. The biomaterial/jaw comparison revealed that jaw differences for the mean values of commercially pure titanium and titanium-aluminum-vanadium implants were greater than jaw differences for mean values of titanium plasma-sprayed implants, although these differences were not statistically significant. Because of the lack of correlation between single-cycle biomechanical tests and clinical performance, it is necessary to be selective in assigning usefulness to data of this type.

Effect of prosthetic superstructure accuracy on the osteointegrated implant bone interface.

OBJECTIVE: This study evaluated the biologic result of forces induced by a misfitting prosthetic superstructure on implants placed in a New Zealand white rabbit tibia model. STUDY DESIGN: Nine rabbits had two dental implants placed in both right and left proximal tibias. After 6 weeks, one animal was sacrificed for baseline integration data, and the remaining animals had fitting or misfitting prosthetic superstructures attached to the implants for 12 weeks. Implants were evaluated clinically, radiographically, and histomorphometrically at the scanning electron microscopic level. RESULTS: No clinical, radiographic, or histomorphometric evidence exists of integration failure with implants subjected to superstructure strain, although bone remodeling is noted. CONCLUSIONS: Given the limitations of sample size, animal model used, duration of prosthetic superstructure attachment, and loading confounders possible, the study of prosthetic framework misfit must be evaluated with another animal model, such as an intraoral primate model, to determine the relationship between clinical performance and histologic findings.

Quantitative histomorphometric description of implant anchorage for three types of dental implants following 3 months of healing in baboons.

Important to the understanding of the dynamics associated with dental implant anchorage over time is a knowledge of the supporting anatomy for common endosseous implants prior to being placed into function. This study followed 20 screw-shaped dental implants placed in edentulated (2 months' healing time) posterior jaws of five adult female baboons. Implants made of three biomaterials were placed and allowed to heal for 3 months prior to processing for evaluation. Percentage integration and bone area data from six horizontal sections along the entire length of each implant were collected and analyzed for differences between jaws, implant biomaterials, jaw/biomaterial, and sections of the implants (ANOVA, pairwise comparison using LSM with Bonferroni adjustment). The results indicated that overall mean percentage integration was 46.5 and mean percentage bone area was 39.9. Maxillary and mandibular differences for both parameters were statistically different (integration: maxillary = 38.1%, mandibular = 56.7%; bone area: maxillary = 35.8%, mandibular = 44.9%; both were significant at the P < .05 level). The biomaterial analyses revealed significant differences for percentage integration between the metal implants and the hydroxyapatite-coated implant (commercially pure titanium = 39.1%, titanium-aluminum-vanadium = 40.0%, hydroxyapatite-coated = 61.5%), but no such difference was noted for percentage bone area (commercially pure titanium = 38.8%, titanium-aluminum-vanadium = 38.9%, hydroxyapatite-coated = 42.3%). Discussion of the relative importance of the two parameters highlights the fact that resistance to functional loads requires establishing and then maintaining an adequate volume of bone, which may have a functionally specific structure based on the mechanical properties of the local jaw environment.

The accuracy of implant verification casts compared with casts produced from a rigid transfer coping technique.

PURPOSE: Prosthodontic techniques for implant-supported prostheses continue to evolve in an effort to facilitate treatment and minimize costs. Because research has shown no impression transfer technique to be without error, some clinicians have attempted to control the fit of prosthetic frameworks by reorienting sections of patterns or frameworks intraorally, fabricating a verification cast, and completing the prosthesis to fit such a cast. One manufacturer has attempted to meet both impression-making and verification-cast objectives by providing metallic impression copings (MICS) with extensions that allow contact between the copings for rigid fixation with acrylic resin before impression making. The purpose of this study was to determine the accuracy of casts produced from the MICS transfer process compared with casts produced from sectioned frameworks, where both techniques used a low-polymerization-shrinkage acrylic resin polymer to rigidly join the sections. MATERIALS AND METHODS: Using stainless steel measurement spheres as a reference point on each implant analog, the distances between analogs on the experimental casts were compared with the distances measured on the master cast. Seven casts were produced for each group and measured with a machinist's microscope at a 4-micron level of precision. RESULTS: The results revealed that the MICS transfer exhibited a mean error of 41 microns, which was significantly less than the verification-cast group mean error of 57 microns (p < .01, Student's t test). CONCLUSIONS: Given these results, clinicians can consider the rigid transfer technique as provided in the MICS transfer to be more accurate than the verification technique as outlined in this study.

The response of bone in primates around unloaded dental implants supporting prostheses with different levels of fit.

Implant failure as a consequence of prosthetic loading following clinical determination of successful stage I healing is poorly understood. A basic premise of accepted prosthetic protocol is passive connection of multiunit prostheses to the implant support. To better understand mechanical factors related to implant failure, this basic passivity premise was experimentally tested prior to study of functional loading research. The purpose of this preliminary study was to measure the bone response around implants placed in the mandible of baboons that supported prostheses exhibiting two levels of fit and not loaded occlusally. Screw-retained prostheses that exhibited a mean linear distortion of 38 microns and 345 microns made up the fit and misfit groups respectively. The results failed to distinguish a difference in bone response between the two levels of prosthetic fit. Although the finding can be argued as a sample size limitation, the data strongly suggest an opposite response than is clinically expected and, consequently, does not warrant the use of additional animals in this initial study. Because the design of this study does not mimic the clinical application of misfitting prostheses (where dynamic functional loads are superimposed with misfit loads), it cannot be inferred that, in clinical application, fit does not alter the osseointegrated interface. Ongoing investigation of failure due to nonpassive connections under dynamic loading conditions of mastication will help clarify the clinical significance of passivity.

Effects of fabrication, finishing, and polishing procedures on preload in prostheses using conventional "gold' and plastic cylinders.

This study reviews fundamental concepts related to the use of screws and presents data describing the effect of fabrication, finishing, and polishing procedures on as-received preload for implant cylinders. Specifically, this study measured and compared preload produced when using as-received gold cylinders (the reference or gold standard), and cast cylinders produced from premade gold and plastic cylinders in the as-cast condition and following postcast finishing and polishing manipulations. The results reveal that preload in the gold screw-gold cylinder-abutment joint can be affected by the casting process, and that the choice of cylinder type, casting alloy, investment, and finishing/polishing technique may affect the resultant preload as compared to as-received joint conditions. The data from this study indicate that when plastic patterns are used as part of the framework, finishing and polishing of implant cylinder components should provide an increased preload compared to no such manipulations. Also, if maximum preload is desired, the use of premade metal cylinders offers an advantage over plastic patterns in both preload magnitude and precision.

Comparison of strains transferred to a bone simulant between as-cast and postsoldered implant frameworks for a five-implant-supported fixed prosthesis.

PURPOSE: To measure and compare the strains transferred by screw-fastening one-piece full-arch prostheses as cast and after sectioning and soldering. MATERIALS AND METHODS: Photoelastic resin was applied directly to five 3.75 x 13-mm Brånemark implants, situated 7 mm apart, in a silicone mold of an edentulous mandible. Four strain gauge rosettes were also incorporated in the resin to allow strain measurements at four locations. Three frameworks were made from a single master cast produced from an impression of the five-implant model with 4-mm abutments. These frameworks were sequentially secured to the master model with five gold slot screws tightened to 10 N cm. Strain indicator readings were recorded at a standardized time following the initial fastening of each prosthesis. The test was repeated three times. Each of the three castings were subsequently sectioned and soldered in two locations, mesial to the two terminal fixtures. After soldering, the three superstructures were returned to the master model for measurement of postsolder strains three times each. A one-way repeated-measures ANOVA was performed to determine differences between mean principal strains between the as-cast and postsoldered groups. RESULTS: A statistically significant difference was found in the principal strains between the as-cast and soldered frameworks. Overall, there was a decrease in the magnitude of strain for the soldered frameworks. CONCLUSIONS: Sectioning and soldering improved the as-cast accuracy as far as the amount of strain transferred to the bone simulant.

New high-palladium casting alloys: studies of the interface with porcelain.

This investigation studied the metal ceramic interface for two representative high-palladium alloys each of the Pd-Cu-Ga and Pd-Ga systems, using scanning electron microscopy and x-ray energy dispersive spectroscopy. The Pd-Cu-Ga alloys produced complex subsurface oxidation regions with thickness ranging from 15 to 20 microns for one alloy and 5 to 10 microns for the other alloy. Ga, In, and Sn accumulated at the interfaces, and Ga-rich deposits were found in the subsurface scale. One Pd-Ga alloy presented a surface oxidation region which dissolved in the ceramic, producing "islands" rich in Pd and Ga with a width that ranged from 1 to 2 microns. These islands were separated from the alloy by a band rich in Ga and Si which was 1 to 2.5 microns thick. While the other Pd-Ga alloy presented similar interfacial microstructures, the "islands" formed for this alloy were relatively sparse. The Pd-Cu-Ga alloys had a more favorable interface for metal ceramic bonding, which agrees with previous characterization of bond failures between these alloys and dental porcelain.

Characterization of noble metal implant cylinders: as-received cylinders and cast interfaces with noble metal alloys.

A common procedure in the fabrication of implant prostheses is the use of premade wrought cylinders in cast frameworks. Although manufacturers outline some precautions in the use of these components, detailed information about the metal interface between cylinders and cast alloys is lacking. This article, following a previous report that compared titanium-based implant cylinders used with two different classes of cast alloys, compares conventional noble metal cylinders from three different manufacturers combined with these two classes of cast noble alloys. Analysis of the as-received cylinders revealed that the implant cylinders as a group are predominantly composed of metals commonly found in noble dental alloys, namely, platinum, palladium, gold, and silver. The interfaces created by casting both high-fusing and low-fusing alloys around the cylinders exhibited a general elemental concentration variability compared with the bulk alloy regions, but continuous concentrations for shared elements suggested alloy-cylinder compatibility. Vickers hardness values, which ranged from 212 to 276 for the as-received cylinders, decreased from 12% to 43% for the various cylinders after casting. This study suggests characteristics of an ideal cast interface that include maintenance of the cylinder and casting alloy microstructures up to the interface, absence of interfacial reaction regions, lack of porosity created by volatilization of components from either alloy or the casting process, and sufficient strength to maintain anticipated loads.

Comparison of strains transferred to a bone simulant among implant overdenture bars with various levels of misfit.

PURPOSE: To measure and compare strains transferred to a bone simulant by screw-fastening implant overdenture bars with various levels of fit or misfit. MATERIALS AND METHODS: Photoelastic resin was cast directly to two 3.75 X 13-mm Branemark fixtures (Nobelpharma USA Inc, Chicago, IL) situated 20 mm apart in a silicone mold of an edentulous mandible. Two strain-gauge rosettes were also incorporated in the resin to allow precise determination of principal stresses at two locations. Four groups of three overdenture bars with 0-, 180-, 360-, and 500-micrometer vertical gaps were fabricated. These bars were sequentially secured to the abutments with gold slot screws tightened to 10 N-cm. Strain indicator readings were recorded at a standardized time following the initial fastening of each bar. The test was repeated three times for each overdenture bar. RESULTS: Mean principal stresses and strains at the location of the rosettes were determined. The magnitude of these stresses and strains increased significantly with each increase in gap size. Strains were several times larger mesial to the fixture than they were distal. CONCLUSIONS: Strains are transferred to the bone when misfitting prostheses were secured. Some of the strains mesial to the fixture appeared to be unfavorable for regions of lower bone density when the groups with designed gaps were secured. These data will be compared with those in ongoing animal studies regarding the cellular response to prosthesis misfit.