Dexamethasone Use in Periodontal Surgery: Pros & Cons

Dexamethasone use in periodontal surgery has been investigated as a perioperative strategy to reduce the inflammatory response associated with surgical manipulation of periodontal tissues.

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Because postoperative pain and edema can affect comfort, mastication, and recovery, corticosteroids may provide an adjunctive benefit when appropriately selected.

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Current evidence suggests that perioperative dexamethasone can reduce postoperative pain and swelling, particularly during the first several days after periodontal flap surgery.
However, its benefits should be balanced against patient-specific contraindications, potential adverse effects, and the limited number of high-quality periodontal studies.

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✅ How Dexamethasone Works in Periodontal Surgery
Dexamethasone is a potent glucocorticoid with anti-inflammatory activity. It suppresses multiple inflammatory pathways, including the production of prostaglandins and other mediators involved in vascular permeability, tissue edema, and postoperative pain.
In periodontal surgery, this mechanism may attenuate the acute inflammatory response produced by flap elevation, tissue manipulation, and surgical trauma.
Importantly, dexamethasone is an adjunct to surgical and analgesic management, not a substitute for atraumatic surgical technique or appropriate postoperative analgesia.

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✅ Benefits of Dexamethasone in Periodontal Surgery

1. Reduction of postoperative pain
Randomized clinical trials have demonstrated a reduction in postoperative pain following periodontal flap surgery when dexamethasone is administered perioperatively.
A randomized trial involving 60 patients undergoing open-flap debridement found that an 8-mg preoperative dose of dexamethasone provided greater pain control and reduced the need for rescue acetaminophen compared with placebo.
More recently, a randomized crossover trial found that 8 mg of intravenous dexamethasone administered before periodontal flap surgery significantly reduced pain during the first 72 hours compared with placebo.

2. Reduction of postoperative swelling
The anti-inflammatory effect of dexamethasone may also reduce postoperative edema.
In the 2022 randomized trial, intravenous dexamethasone was associated with significantly less swelling during several postoperative assessment periods, including the early postoperative phase.
A 2024 randomized clinical study also reported less swelling on the first postoperative day after submucosal administration of 8 mg dexamethasone during periodontal flap surgery.

3. Potential improvement in early postoperative function
Reduction of inflammatory edema may facilitate early oral function. The 2024 submucosal study reported improved chewing efficiency and less reduction in mouth opening during the early postoperative period. However, these findings should be interpreted cautiously because the study included only 25 patients.

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✅ Routes and Timing of Administration
Dexamethasone has been studied through several administration routes, including oral, intravenous, and submucosal administration.

Approach	Evidence in Periodontal Surgery	Main Consideration
Preoperative oral	Evidence of reduced postoperative pain	Convenient; evidence remains limited
Intravenous	Reduced pain and swelling in randomized clinical trials	Useful when IV access is already established
Submucosal	Recent evidence suggests reduced pain and swelling	Avoids the need for IV access
Repeated postoperative dosing	Less consistently studied	Greater exposure is not necessarily associated with greater benefit

Factor	Clinical implication
Timing	Preoperative or perioperative administration is the approach most consistently investigated.
Dose	Studies have commonly evaluated single doses of 4–8 mg, but no universally established periodontal surgery regimen exists.
Route	IV and submucosal administration have demonstrated clinical effects; the optimal route remains uncertain.

The evidence should therefore not be interpreted as establishing 8 mg as a universal standard dose. The 8-mg regimen has been studied in clinical trials, but patient characteristics, surgical extent, route of administration, and local prescribing regulations must be considered.

✅ Limitations and Safety Considerations

1. Evidence remains limited
A 2024 systematic review identified only six randomized clinical trials involving 250 participants evaluating preemptive steroidal and nonsteroidal analgesia in periodontal surgery. The authors noted substantial methodological limitations, including risk of bias and heterogeneity in drugs and doses.
Consequently, dexamethasone should be regarded as a selective adjunct rather than routine therapy for every periodontal surgical procedure.

2. Hyperglycemia
Systemic corticosteroids can transiently increase blood glucose concentrations. This is particularly relevant in patients with diabetes or impaired glucose regulation.
Patient-specific risk assessment is therefore important before administration, especially when systemic corticosteroids are being considered.

3. Infection considerations
Corticosteroids suppress immune responses and can potentially exacerbate or mask infection. Current prescribing information warns that corticosteroids may reduce resistance to infection and obscure clinical signs of infection.
This does not mean that a single perioperative dose inevitably causes infection. Indeed, a large Cochrane review of perioperative dexamethasone in surgical patients found no evidence of increased postoperative wound infection with a single perioperative steroid exposure.
Nevertheless, dexamethasone should not be used to mask an inadequately controlled infection or as a substitute for appropriate antimicrobial or surgical management.

4. Not a replacement for conventional analgesia
Dexamethasone primarily modifies the inflammatory component of postoperative morbidity. It should not automatically replace evidence-based analgesic therapy.
Current dental pain guidelines support NSAIDs, alone or combined with acetaminophen, as first-line pharmacologic therapy for acute dental pain when not contraindicated.

5. Limited evidence regarding long-term periodontal outcomes
Most studies evaluate short-term outcomes such as pain, swelling, trismus, and analgesic consumption. There is insufficient evidence to conclude that perioperative dexamethasone improves long-term periodontal healing, attachment gain, or regenerative outcomes.

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💬 Discussion
The current evidence supports a potential role for perioperative dexamethasone as an adjunct in periodontal surgery, particularly when postoperative inflammation is expected to be clinically significant.
The strongest periodontal evidence concerns reduction of early postoperative pain and swelling. Both intravenous and submucosal administration have demonstrated beneficial effects in randomized trials, while a recent systematic review supports the potential effectiveness of preemptive dexamethasone for postoperative pain.
However, the evidence base remains relatively small and heterogeneous. The 2024 systematic review specifically highlighted methodological limitations and the need for additional well-designed randomized trials.
Therefore, the clinical decision should be individualized rather than protocol-driven. Dexamethasone may be particularly reasonable when substantial postoperative inflammation is anticipated, while routine administration for uncomplicated periodontal procedures offers less clearly established incremental benefit.

✍️ Conclusion
Dexamethasone can reduce postoperative pain and swelling following periodontal surgery, with evidence supporting both systemic and local administration. Its anti-inflammatory effect makes it a potentially useful perioperative adjunct, particularly for procedures associated with greater tissue trauma.
Nevertheless, dexamethasone is not universally indicated. The relatively limited periodontal evidence, potential systemic effects, glucose elevation, infection-related considerations, and absence of demonstrated long-term periodontal benefits support a selective, patient-centered approach.
The most appropriate use is therefore as an adjunct to atraumatic surgical technique and evidence-based analgesia, rather than as routine medication for all periodontal surgical patients.

🎯 Clinical Recommendations
▪️ Consider perioperative dexamethasone selectively when postoperative pain or edema is expected to be clinically significant.
▪️ Do not interpret the commonly studied 8-mg dose as a universal periodontal protocol; dosing should be individualized according to the clinical situation and route of administration.
▪️ Consider submucosal administration when an IV route is unnecessary; current evidence suggests it can provide postoperative benefits without clear superiority of IV administration for pain or analgesic consumption.
▪️ Evaluate diabetes, infection, immunosuppression, corticosteroid exposure, and other relevant medical conditions before prescribing.
▪️ Maintain conventional evidence-based analgesia; dexamethasone should generally be considered an adjunct rather than a replacement for NSAID-based analgesic strategies when these are appropriate.
▪️ Avoid routine corticosteroid use when the expected inflammatory burden is low and the potential benefit is unlikely to justify systemic exposure.
▪️ Explain to patients that the principal expected benefit is short-term reduction of postoperative inflammatory symptoms, not improvement of long-term periodontal healing.

📚 References

✔ Altindal, D., Alsafadi, A., Alshujaa, B., Talmac, A. C., Ege, B., Calisir, M., & Alpaslan, N. Z. (2024). Effect of submucosal dexamethasone on postoperative pain, swelling and trismus after periodontal surgery: A randomized clinical study. Clinical Oral Investigations, 28(12), 681. https://doi.org/10.1007/s00784-024-06076-5
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., Pilcher, L., Shirey, M., Tampi, M., & Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Lages, L. P. de D., Bergamaschi, C. de C., Lopes, L. C., da Frota, E. G., Silva, M. T., Monte, T. L., & Motta, R. H. L. (2024). Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: A systematic review. Frontiers in Pharmacology, 15, 1385401. https://doi.org/10.3389/fphar.2024.1385401
✔ Vieth, M. P., Deas, D. E., Palaiologou, A. A., Diogenes, A., Mader, M. J., & Mealey, B. L. (2022). Effect of intravenous dexamethasone on postoperative pain and swelling following periodontal flap surgery: A randomized controlled trial of patient-centered outcomes. Journal of Periodontology, 93(2), 237–245. https://doi.org/10.1002/JPER.21-0153
✔ Wagner, J. C., Johnson, T. M., & Gilbert, W. A. (2022). Should periodontists prescribe postoperative oral corticosteroids to control pain and swelling? A systematic review. Clinical Advances in Periodontics, 12(2), 134–142. https://doi.org/10.1002/cap.10169
✔ Sauerland, S., Nagelschmidt, M., Mallmann, P., & Neugebauer, E. A. M. (2019). Adverse side-effects of dexamethasone in surgical patients—An abridged Cochrane systematic review. Anaesthesia, 74(8), 1013–1020. https://doi.org/10.1111/anae.14610
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054

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Teeth Whitening Overuse: Risks and Consequences

Teeth whitening is a popular and generally safe cosmetic dental treatment when used according to professional or manufacturer instructions. Most whitening products contain hydrogen peroxide or carbamide peroxide, which break down compounds responsible for tooth discoloration.

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However, repeated treatments, excessive exposure, higher-than-recommended concentrations, or unsupervised use can increase the risk of adverse effects.

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The consequences of teeth whitening overuse are usually related to tooth sensitivity and soft-tissue irritation, while evidence regarding permanent enamel damage is more complex.

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✅ What Happens When You Overuse Teeth Whitening?
The main problem with excessive whitening is not simply that the teeth become "too white." Repeated exposure to peroxide can increase temporary changes in the tooth surface and make adverse effects more likely.
The most important consequences include:

1. Increased Tooth Sensitivity
Tooth sensitivity is the most common adverse effect of dental bleaching. Patients may experience short, sharp pain when consuming cold, hot, sweet, or acidic foods and drinks.
Sensitivity is generally temporary, but repeated bleaching sessions without adequate intervals may prolong or intensify symptoms. Higher concentrations and longer exposure times are also associated with a greater risk.

2. Gum Irritation and Chemical Burns
Whitening gel can irritate the gingiva when it comes into direct contact with soft tissues. Poorly fitting trays, excessive gel application, or inappropriate use of whitening products can increase this risk.
Mild irritation usually resolves after stopping exposure. More intense or persistent burning, ulceration, or white areas on the gingiva should be evaluated by a dentist.

3. Changes to Enamel Surface Properties
This is an area where the evidence requires careful interpretation.
Laboratory studies have reported changes in enamel microhardness, surface morphology, and permeability after exposure to peroxide. However, these findings do not necessarily mean that routine clinical whitening causes clinically significant enamel destruction.
A 2026 systematic review and meta-analysis found a statistically detectable but small reduction in enamel microhardness in laboratory studies. Importantly, the authors concluded that there was no clear evidence of clinically meaningful damage to enamel integrity when bleaching is performed according to recommended protocols.
Therefore, the greatest concern is not occasional, properly performed whitening, but repeated or inappropriate exposure.

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4. Greater Visibility of Yellow Dentin
Over-whitening does not make teeth infinitely whiter. Natural tooth color is influenced by both enamel and the underlying dentin.
When enamel becomes thinner or more translucent, the naturally yellowish dentin may become more visible. As a result, some patients may perceive their teeth as becoming less attractive and attempt additional whitening, creating a cycle of repeated treatment.

5. Uneven Tooth Color
Whitening agents affect natural tooth structure, but they do not whiten existing restorations such as composite fillings, crowns, veneers, or ceramic restorations.
Repeated whitening may therefore make the difference between natural teeth and restorations more noticeable.

6. Greater Risk From DIY Whitening
Home-made whitening methods involving acidic fruits, vinegar, abrasive powders, or poorly tested products should not be considered safer alternatives.
Some DIY approaches may combine chemical irritation with abrasion, potentially increasing enamel surface wear without providing predictable whitening results.

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✅ Common Consequences of Whitening Overuse

Problem	What Patients May Notice	Typical Response
Tooth sensitivity	Pain with cold, heat, sweets, or air	Usually temporary; reduce or stop bleaching
Gingival irritation	Redness, burning, or white irritated areas	Remove peroxide exposure and assess persistent lesions
Surface changes	Possible changes in enamel surface properties	Avoid excessive concentration or exposure time
Color mismatch	Restorations appear darker than natural teeth	Evaluate restorations before further whitening

✅ Who Should Be More Careful?
Whitening should be approached cautiously in patients with:

▪️ Untreated dental caries
▪️ Significant pre-existing tooth sensitivity
▪️ Exposed root surfaces
▪️ Gingival inflammation or recession
▪️ Cracked or structurally compromised teeth
▪️ Large existing restorations in the visible smile
▪️ Poorly controlled oral disease
A dental examination before whitening can identify problems that may become more uncomfortable during treatment.

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💬 Discussion
The evidence does not support the idea that every whitening treatment damages enamel permanently. In fact, current evidence suggests that appropriately performed tooth bleaching has a generally favorable safety profile.
The distinction between appropriate treatment and overuse is important. A 2018 Cochrane review found that tooth sensitivity and oral irritation were the most common adverse effects of home bleaching and tended to be more frequent with higher concentrations, although they were generally mild and temporary.
More recent evidence also supports caution with unsupervised over-the-counter use. A 2024 systematic review and network meta-analysis found that OTC whitening products can produce effective short-term color changes, but emphasized the need to counsel patients about potential risks when these products are used without professional supervision.
The newest evidence on enamel is particularly useful because a 2026 systematic review and meta-analysis detected small changes in enamel microhardness in laboratory studies but found no clear evidence of clinically meaningful enamel damage when recommended bleaching protocols are followed.
Thus, the primary clinical message is not that patients should avoid whitening altogether. Rather, they should avoid the misconception that more frequent or more concentrated bleaching produces a healthier or permanently whiter smile.

✍️ Conclusion
Excessive teeth whitening can increase the risk of tooth sensitivity, gingival irritation, and temporary changes in enamel surface properties. These effects are generally more closely associated with concentration, exposure time, frequency, and inappropriate use than with properly performed whitening itself.
For most patients, the safest approach is to use an evidence-based whitening protocol, follow product instructions, and obtain a dental evaluation when sensitivity, gum irritation, or persistent discoloration occurs.

🎯 Clinical Recommendations
▪️ Do not increase the concentration, application time, or frequency of a whitening product to obtain faster results.
▪️ For patients with sensitivity, consider reducing exposure or pausing treatment rather than continuing through significant discomfort.
▪️ Examine patients for caries, gingival problems, recession, cracks, and existing restorations before whitening.
▪️ Use dentist-supervised whitening when patients have significant sensitivity, complex discoloration, or extensive restorations.
▪️ Advise patients to avoid DIY acidic or highly abrasive whitening methods because their safety and effectiveness are not well established.
▪️ If sensitivity or soft-tissue irritation persists after stopping whitening, investigate other dental causes rather than assuming the symptoms are simply a normal whitening reaction.

📚 References

✔ American Dental Association. (2024). Whitening. American Dental Association. https://www.ada.org/resources/ada-library/oral-health-topics/whitening
✔ Eachempati, P., Kumbargere Nagraj, S., Kiran Kumar Krishanappa, S., Gupta, P., & Yaylali, I. E. (2018). Home-based chemically-induced whitening (bleaching) of teeth in adults. Cochrane Database of Systematic Reviews, 2018(12), CD006202. https://doi.org/10.1002/14651858.CD006202.pub2
✔ Márton, P., Antal, M., Kiss-Dala, S., Agócs, G., Qian, X., Hegyi, P., Varga, G., & Ábrám, E. (2026). Enamel damage from tooth-whitening—A systematic review and meta-analysis. Journal of Dentistry, 172, 106786. https://doi.org/10.1016/j.jdent.2026.106786
✔ Zanolla, J., Marques, A. B. C., da Costa, D. C., de Souza, A. S., & Coutinho, M. (2017). Influence of tooth bleaching on dental enamel microhardness: A systematic review and meta-analysis. Australian Dental Journal, 62(3), 276–282. https://doi.org/10.1111/adj.12494
✔ Toledo, F. L., et al. (2024). Assessment of color changes and adverse effects of over-the-counter bleaching protocols: A systematic review and network meta-analysis. Clinical Oral Investigations. https://doi.org/10.1007/s00784-024-05595-5

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Cracked Tooth Treatment: Causes, Diagnosis & Care

Cracked tooth treatment requires more than simply covering a visible crack. A dental crack represents a structural disruption that may progress under repeated occlusal loading and may eventually affect the dentin, dental pulp, or periodontal tissues.

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The clinical objective is to identify the cause, determine the extent of the crack, assess pulpal and periodontal status, and stabilize the remaining tooth structure.

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Early management is particularly important because an untreated crack may progressively extend and compromise tooth survival.

✅ Dental Crack vs. Dental Fracture
A dental crack is a structural discontinuity that does not necessarily separate the tooth into segments. In current endodontic terminology, a cracked tooth involves a crack extending into dentin, with its depth and extension often initially uncertain.
A fracture generally indicates a more extensive structural disruption and may involve separated or partially separated tooth segments. A split tooth represents a more advanced stage in which the tooth is completely separated into two or more segments.
A superficial craze line, by contrast, is confined to enamel and generally does not represent a clinically significant structural crack. Treatment is usually unnecessary unless esthetic concerns exist.

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✅ Why Does a Dental Crack Develop?
The etiology is usually multifactorial rather than attributable to a single event. Important predisposing and contributing factors include:
▪️ Occlusal overload and parafunctional habits, particularly clenching and bruxism.
▪️ Unfavorable occlusal contacts or interferences.
▪️ Extensive restorations or loss of tooth structure.
▪️ Tooth morphology and cusp anatomy.
▪️ Repeated masticatory loading, particularly with hard foods.
▪️ Age-related changes in dentin.
▪️ Stress generated during restorative procedures.
The current evidence emphasizes that both the structural condition of the tooth and the magnitude and direction of applied forces influence crack development and propagation.
Identifying the Causative Factors
Treatment should not focus exclusively on the visible crack. The mechanical environment responsible for crack initiation or progression should also be evaluated.
Occlusal examination should assess wear facets, premature contacts, functional cusp loading, parafunctional activity, and other conditions capable of repeatedly stressing the affected tooth. When appropriate, management of these factors should accompany restorative treatment.

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✅ Diagnosis of a Cracked Tooth
Diagnosis requires correlation of clinical findings because early cracks may not be visible radiographically or even under direct examination.
Important diagnostic procedures include:
▪️ Pulp sensibility testing to establish pulpal status.
▪️ Bite testing to reproduce pain associated with crack movement. ▪️ Transillumination to identify crack lines. ▪️ Magnification with loupes or an operating microscope. ▪️ Periodontal probing, particularly to identify isolated narrow defects. ▪️ Occlusal analysis. ▪️ Periapical radiographs when indicated. ▪️ CBCT in selected inconclusive cases, recognizing that CBCT does not reliably visualize all dental cracks.
A crack may produce cold sensitivity, sharp pain during biting or release of pressure, or persistent discomfort. However, some cracks remain asymptomatic, making clinical examination particularly important.

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✅ How Is a Cracked Tooth Treated?
Treatment should be individualized according to crack extension, tooth structure, symptoms, pulpal diagnosis, periodontal status, and risk of further propagation.

Clinical Condition	Preferred Approach	Main Objective
Superficial enamel craze line	Observation; esthetic treatment only when indicated	Avoid unnecessary intervention
Vital tooth with shallow, low-risk crack	Monitoring and control of etiologic factors	Prevent progression while preserving tooth structure
Vital tooth with symptomatic crack	Adhesive composite stabilization or cuspal coverage according to structural risk	Reduce tooth flexure and protect the crack
Cracked tooth with irreversible pulpitis or necrosis	Root canal treatment followed by definitive restorative protection	Manage pulpal disease and stabilize the tooth
Extensive non-restorable crack	Extraction when predictable restoration is not possible	Prevent progression and further biological complications

✅ Is Fluoride Useful for a Dental Crack?
Fluoride should not be considered a treatment that repairs a true dentinal crack.
Fluoride can promote remineralization of demineralized enamel and is valuable in caries prevention. However, a structural crack extending into dentin is a mechanical defect and cannot be biologically “sealed” or regenerated with fluoride.
Therefore, fluoride may be appropriate when the tooth also presents an indication for caries prevention or enamel remineralization, but it should not replace mechanical stabilization and restorative management when a clinically significant crack is present.

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✅ Restorative Treatment in a Vital Cracked Tooth
When the pulp is normal or affected by reversible pulpitis, preservation of pulp vitality should be prioritized whenever the tooth remains restorable.
Depending on crack extension and structural risk, treatment may include:
▪️ Direct bonded composite restoration in appropriately selected cases.
▪️ Cuspal coverage with an onlay or other indirect restoration when greater structural protection is required.
▪️ Interim stabilization with bonded composite or a provisional restoration when pulpal response needs to be reassessed before definitive treatment.
The 2025 systematic review by Gavriil et al. found high one-year tooth survival in symptomatic vital cracked teeth, although the certainty of evidence was very low. Indirect restorations, particularly onlays, showed favorable pulp outcomes compared with some alternative approaches.
Current consensus also emphasizes that there is no single restorative protocol appropriate for every cracked tooth. The extent of the crack, remaining tooth structure, symptoms, occlusal forces, existing restorations, and parafunctional habits should influence the choice of restoration.

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✅ Monitoring and Prevention of Crack Progression
A crack with a normal pulp, minimal symptoms, limited extension, and low structural risk may sometimes be monitored rather than immediately restored.
However, active treatment becomes more appropriate when there is significant structural compromise, persistent symptoms, extensive restorations, unfavorable occlusal loading, or a high risk of crack propagation.
Preventive management should include:
▪️ Reduction of excessive occlusal loading when clinically indicated.
▪️ Management of parafunctional habits.
▪️ Avoidance of repeated excessive forces on the affected tooth.
▪️ Periodic clinical and pulpal reassessment.

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💬 Discussion
The management of a cracked tooth is fundamentally a structural and biological problem, rather than simply a cosmetic one. A crack may provide a pathway for bacterial penetration and may progressively affect the pulp and periodontal tissues under continued mechanical loading.
The current evidence supports a conservative philosophy when appropriate: preserve pulp vitality, preserve sound tooth structure, control etiologic factors, and stabilize the tooth according to its structural risk.
Importantly, direct composite restoration can be appropriate in selected vital cracked teeth, but it should not be considered universally equivalent to cuspal coverage. Treatment selection must remain case-specific because the evidence does not establish a single superior restorative protocol for every presentation.

✍️ Conclusion
Cracked tooth treatment should be directed at both the structural defect and the factors responsible for its progression. Fluoride may support enamel remineralization when indicated, but it does not repair a dentinal crack.
For a vital and restorable tooth, treatment may range from monitoring and etiologic control to adhesive composite stabilization or cuspal coverage, depending on the extent and mechanical risk of the crack. When irreversible pulpal disease or necrosis develops, root canal treatment followed by definitive restorative protection may be indicated.
Early diagnosis, preservation of tooth structure, control of occlusal forces, and appropriate restoration are central to improving the long-term prognosis.

🎯 Clinical Recommendations
1. Do not treat a dental crack with fluoride alone. Fluoride supports remineralization but does not repair structural dentinal disruption.
2. Identify and control contributing mechanical factors, particularly parafunction and unfavorable occlusal loading.
3. Preserve pulp vitality whenever clinically possible in a restorable cracked tooth.
4. Select direct composite or cuspal coverage according to structural risk, rather than applying a uniform restorative protocol.
5. Do not perform root canal treatment solely because a crack is present; establish the pulpal diagnosis first.
6. Reassess cracks periodically when observation is selected, because progression may occur despite an initially favorable presentation.

📚 References

✔ Gavriil, D., Kakka, A., & Del Fabbro, M. (2025). The effect of single versus multiple-stage restorative approaches on the pulp outcomes of symptomatic vital cracked teeth: A systematic review and meta-analysis. Journal of Endodontics, 51(10), 1362–1375. https://doi.org/10.1016/j.joen.2025.06.013
✔ Kakka, A., Gavriil, D., & Whitworth, J. (2022). Treatment of cracked teeth: A comprehensive narrative review. Clinical and Experimental Dental Research, 8(5), 1218–1248. https://doi.org/10.1002/cre2.617
✔ Krell, K. V., & Rivera, E. M. (2018). A study of crack lines in posterior teeth. Journal of Endodontics, 44(4), 611–614.
✔ Li, F., Diao, Y., Wang, J., Hou, X., Qiao, S., Kong, J., Sun, Y., Lee, E.-S., & Jiang, H. B. (2021). Review of cracked tooth syndrome: Etiology, diagnosis, management, and prevention. Pain Research and Management, 2021, 3788660. https://doi.org/10.1155/2021/3788660
✔ Patel, S., Teng, P.-H., Liao, W.-C., Davis, M. C., Fidler, A., Haupt, F., Fabiani, C., Ordinola-Zapata, R., & Bose, R. (2025). Position statement on longitudinal cracks and fractures of teeth. International Endodontic Journal, 58(3), 379–390. https://doi.org/10.1111/iej.14186
✔ Zhang, S., Xu, Y., Ma, Y., Zhao, W., Jin, X., & Fu, B. (2024). The treatment outcomes of cracked teeth: A systematic review and meta-analysis. Journal of Dentistry, 142, 104843. https://doi.org/10.1016/j.jdent.2024.104843
✔ Kaur, S., Puzhankara, L., Shenoy, N., Kini, K. S., & Singhal, D. K. (2026). Saving the split: An umbrella review on therapeutic approaches for cracked tooth syndrome. Journal of Conservative Dentistry and Endodontics, 29(1), 11–19. https://doi.org/10.4103/JCDE.JCDE_796_25

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What Is Peri-Implantitis? How Does It Affect Dental Implants?

Peri-implantitis is an inflammatory disease that affects the tissues surrounding a dental implant. Unlike peri-implant mucositis, which is limited to inflammation of the soft tissues, peri-implantitis is associated with progressive loss of the bone supporting the implant.

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The condition is mainly associated with the accumulation of dental plaque and bacterial biofilm, although several patient-, implant-, and prosthesis-related factors can increase the risk. If left untreated, peri-implantitis may progressively compromise implant stability and, in advanced cases, lead to implant failure.

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✅ What Is Peri-Implantitis?
Peri-implantitis is a plaque-associated inflammatory disease characterized by inflammation of the tissues around a dental implant and progressive loss of supporting bone.
It should be distinguished from peri-implant mucositis:

Condition	Main feature	Bone loss
Peri-implant health	No clinical signs of inflammation	No progressive bone loss
Peri-implant mucositis	Inflammation and bleeding around the implant	No progressive bone loss
Peri-implantitis	Inflammation with bleeding and/or suppuration	Progressive supporting bone loss

The distinction is clinically important because peri-implant mucositis can often be controlled before bone destruction occurs, whereas peri-implantitis requires assessment of both the soft tissues and the supporting bone.

✅ How Does Peri-Implantitis Develop?
The process usually begins with the accumulation of bacterial biofilm around the implant. This can trigger inflammation in the surrounding soft tissues.
If the inflammatory process persists, it may extend deeper and contribute to loss of the bone supporting the implant.
However, plaque is not the only consideration. Current evidence indicates that peri-implantitis results from the interaction of biofilm, patient susceptibility, implant characteristics, and local conditions.
Important Risk Factors
Recent AO/AAP evidence identifies several factors that may increase the risk of peri-implant diseases:
▪️ Previous periodontitis
▪️ Smoking
▪️ Poor plaque control
▪️ Uncontrolled diabetes
▪️ Obesity
▪️ Poorly positioned implants
▪️ Prosthetic factors that make cleaning difficult
▪️ Certain unfavorable peri-implant soft-tissue conditions
Among these, a history of periodontitis and cigarette smoking have particularly strong evidence as risk factors for peri-implantitis.

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✅ Signs and Symptoms of Peri-Implantitis
Peri-implantitis may not always cause pain, so patients can have disease progression without obvious symptoms.
Possible warning signs include:
▪️ Bleeding when brushing or during professional probing
▪️ Redness or swelling around the implant
▪️ Suppuration or pus
▪️ Increasing probing depth
▪️ Gum recession around the implant
▪️ Unpleasant taste or odor in some cases
▪️ Progressive radiographic bone loss
▪️ Mobility of the implant in advanced cases
A particularly important point is that implant mobility is generally a late finding. An implant that becomes mobile may already have experienced substantial loss of supporting bone.

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✅ How Is Peri-Implantitis Diagnosed?
Diagnosis requires more than simply observing redness around an implant.
The clinician evaluates the peri-implant tissues through:
1. Clinical examination
2. Gentle periodontal probing
3. Assessment of bleeding and/or suppuration
4. Comparison of probing depths with previous records
5. Radiographic evaluation of bone levels
6. Evaluation of prosthetic and implant-related factors
Whenever possible, baseline probing and radiographic measurements should be recorded after completion of the implant-supported restoration. These measurements make future changes easier to identify.
When previous records are unavailable, the 2017 classification proposed the combination of bleeding and/or suppuration, probing depths of ≥6 mm, and bone levels ≥3 mm apical to the most coronal portion of the intraosseous implant as criteria consistent with peri-implantitis.
These numerical criteria should not, however, replace clinical judgment and comparison with previous examinations.

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✅ How Does Peri-Implantitis Affect a Dental Implant?
The main concern is progressive loss of the bone that supports the implant.
As bone is lost, the implant may become increasingly exposed and its long-term stability can be compromised. Advanced disease may also create deeper areas that are more difficult for the patient to clean, potentially sustaining the inflammatory process.
The clinical consequence can therefore be summarized as:
Biofilm accumulation → inflammation → progressive bone loss → reduced implant support → possible implant failure.
Importantly, peri-implantitis does not automatically mean that an implant must be removed. Treatment depends on disease severity, bone defects, implant position, prosthetic design, patient risk factors, and the response to treatment. Current consensus recommendations emphasize individualized management rather than a single treatment protocol for every case.

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✅ How Is Peri-Implantitis Treated?
Treatment aims to control inflammation, reduce bacterial contamination, manage contributing risk factors, and preserve or restore peri-implant tissues when possible.

1. Non-Surgical Management
Initial treatment may include:
Professional mechanical debridement
Improvement of the patient's oral hygiene
Management of modifiable risk factors
Correction of local factors that interfere with plaque control
A personalized supportive maintenance program
For some patients, nonsurgical therapy can reduce inflammation, but established peri-implantitis may require additional treatment when inflammation and bone loss persist.

2. Surgical Management
More advanced cases may require surgical treatment to obtain access to the affected implant surface and manage the bone defect.
Depending on the defect and clinical situation, treatment may involve:
▪️ Access-flap surgery
▪️ Resective procedures
▪️ Regenerative procedures
▪️ Soft-tissue augmentation when indicated
▪️ Implant removal in selected cases where the implant cannot be predictably maintained
The 2025 AO/AAP consensus emphasizes that treatment should be individualized according to disease severity and patient- and site-specific factors, followed by supportive peri-implant maintenance.

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💬 Discussion
Peri-implantitis is one of the most important biological complications associated with long-term implant therapy. Current evidence supports viewing it as a multifactorial inflammatory disease, rather than simply an infection caused by poor oral hygiene.
Its clinical importance lies in the potential for progressive bone destruction around an otherwise functional implant. Prevention and early detection are therefore essential.
Recent AO/AAP evidence estimated patient-level prevalence of peri-implantitis at approximately 21%, although prevalence varies substantially according to diagnostic criteria, study populations, and follow-up periods.
The most important practical message is that implant therapy does not end when the prosthesis is delivered. Long-term maintenance, plaque control, management of risk factors, and periodic clinical and radiographic monitoring are essential components of implant care.

✍️ Conclusion
Peri-implantitis is a plaque-associated inflammatory disease that causes progressive loss of bone around a dental implant. It differs from peri-implant mucositis because bone destruction is a defining feature.
Although peri-implantitis can threaten the long-term stability of an implant, early diagnosis and appropriate management can help control disease progression. Patients with a history of periodontitis, smokers, and individuals with inadequate plaque control or other risk factors require particular attention.
Successful implant therapy therefore depends not only on implant placement and restoration, but also on lifelong peri-implant maintenance and risk-factor management.

🎯 Clinical Recommendations
▪️ Establish baseline probing and radiographic records after implant restoration whenever possible.
▪️ Do not wait for pain or implant mobility before investigating suspicious peri-implant changes.
▪️ Bleeding on probing should be taken seriously, particularly when it is persistent or accompanied by increasing probing depths.
▪️ Identify and manage modifiable risk factors, especially smoking, poor plaque control, and uncontrolled diabetes.
▪️ Assess whether the prosthesis or implant position makes effective plaque removal difficult.
▪️ Treat peri-implant mucositis early to reduce the risk of progression.
▪️ For established peri-implantitis, use a severity- and defect-specific treatment plan and maintain the patient in supportive peri-implant care.

📚 References

✔ Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J., Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E., Hämmerle, C. H. F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V., Koo, K.-T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., Salvi, G. E., Schwarz, F., Tarnow, D., Tomasi, C., Wang, H.-L., & Zitzmann, N. (2018). Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of Periodontology, 89(Suppl. 1), S313–S318. https://doi.org/10.1002/JPER.17-0739
✔ Fiorellini, J. P., Mojaver, S., Sarmiento, H., & Aghaloo, T. (2025). Clinical translation of the 2024 AO/AAP consensus on prevention and management of peri-implant diseases and conditions. The International Journal of Periodontics & Restorative Dentistry, 45(4), 1–30. https://doi.org/10.11607/prd.7658
✔ Galarraga-Vinueza, M. E., Pagni, S., Finkelman, M., Schoenbaum, T., & Chambrone, L. (2025). Prevalence, incidence, systemic, behavioral, and patient-related risk factors and indicators for peri-implant diseases: An AO/AAP systematic review and meta-analysis. Journal of Periodontology, 96(6), 587–633. https://doi.org/10.1002/JPER.24-0154
✔ Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. Journal of Periodontology, 89(Suppl. 1), S304–S312. https://doi.org/10.1002/JPER.17-0588
✔ Wang, H.-L., Avila-Ortiz, G., Monje, A., Kumar, P., Calatrava, J., Aghaloo, T., Barootchi, S., Fiorellini, J. P., Galarraga-Vinueza, M. E., Kan, J., Lin, G.-H., Ravida, A., Saleh, M. H. A., Tavelli, L., & Rosen, P. S. (2025). AO/AAP consensus on prevention and management of peri-implant diseases and conditions: Summary report. Journal of Periodontology, 96(6), 519–541. https://doi.org/10.1002/JPER.25-0270

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Space Maintainer Classification: Types & Clinical Uses

Space maintainers are orthodontic appliances designed to preserve the position of adjacent teeth and maintain available arch space following the premature loss of primary teeth.

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Their primary objective is to prevent unwanted tooth migration that may compromise the eruption path of the permanent successor.

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The American Academy of Pediatric Dentistry (AAPD) currently classifies space maintainers primarily according to their method of retention and distribution within the dental arch.
Contemporary clinical decision-making also considers the tooth lost, dental age, eruption status of the permanent successor, occlusion, existing crowding, oral hygiene, and patient cooperation.

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🔹 Classification of Space Maintainers
Space maintainers can be broadly classified as fixed or removable. Fixed appliances can be further categorized as unilateral or bilateral according to their extension and anchorage.

Classification	Examples	Typical Clinical Use
Fixed unilateral	Band and loop, crown and loop, distal shoe	Premature loss of a single primary tooth or localized space
Fixed bilateral	Lower lingual holding arch, Nance appliance, transpalatal arch	Bilateral space management and preservation of arch length
Removable	Removable partial denture, Hawley-type appliance	Selected cases requiring appliance removal or replacement of multiple teeth

The AAPD specifically describes fixed unilateral appliances as including band-and-loop, crown-and-loop, and distal-shoe designs, while fixed bilateral appliances include the lower lingual holding arch, Nance appliance, and transpalatal arch. Removable options include partial dentures and Hawley-type appliances.

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1. Fixed Unilateral Space Maintainers
These appliances generally preserve space on one side of the arch.
Band and loop is one of the most commonly used designs following premature loss of a primary molar. It is particularly useful when a single primary first molar has been lost and the adjacent teeth provide suitable anchorage.
Crown and loop follows the same basic principle but uses a stainless-steel crown as the abutment. It can be advantageous when the abutment tooth has extensive structural loss and requires full-coverage restoration.
Distal shoe is a specialized appliance used primarily when a second primary molar is lost prematurely before eruption of the permanent first molar. Its intra-alveolar extension guides the eruption of the permanent molar and helps prevent mesial migration. Recent evidence suggests favorable eruption outcomes, although case selection and technical execution remain important.

2. Fixed Bilateral Space Maintainers
These appliances provide bilateral anchorage and are particularly useful when space must be controlled across a larger portion of the dental arch.
Common examples include:
▪️ Lower lingual holding arch (LLHA): commonly used in the mandibular arch during the mixed dentition.
▪️ Nance appliance: primarily used in the maxillary arch, with acrylic support against the anterior palatal tissues.
▪️ Transpalatal arch (TPA): connects the maxillary molars and provides transverse and anteroposterior control.
These appliances are especially relevant when bilateral primary molar loss or preservation of leeway space requires greater arch-wide control.

3. Removable Space Maintainers
Removable space maintainers are typically acrylic-based appliances that can be removed by the patient or clinician. Examples include removable partial dentures and Hawley-type appliances.
Their principal advantages include easier cleaning and the possibility of replacing multiple missing primary teeth. However, their effectiveness depends substantially on patient compliance, making them less predictable in children who do not consistently wear the appliance. Recent clinical evidence has reported higher failure rates for removable appliances than fixed appliances in some clinical populations, particularly because of appliance loss.

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🔹 Classification by Clinical Location
Space maintainers may also be described according to the location and extent of the space being preserved:

▪️ Unilateral: maintains space in one quadrant.
▪️ Bilateral: provides space control on both sides of the arch.
▪️ Maxillary: designed for space management in the upper arch.
▪️ Mandibular: designed for the lower arch.
This anatomical classification should complement, rather than replace, the fixed-versus-removable classification, because appliance selection ultimately depends on the clinical circumstances.

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🔹 How to Select a Space Maintainer
The choice of appliance should not be based solely on the identity of the missing primary tooth. The AAPD recommends considering several variables, including the tooth lost, time since extraction, occlusion and space analysis, dental age, development of the permanent successor, alveolar bone coverage, oral habits, oral hygiene, and patient cooperation.
Recent systematic reviews demonstrate that premature primary molar loss can produce measurable space changes, although the magnitude varies according to the tooth involved, arch, eruption status, and occlusal characteristics. Therefore, individualized assessment is preferable to routine appliance placement after every premature extraction.

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💬 Discussion
The traditional classification of space maintainers remains clinically useful because it provides a practical framework for selecting an appliance according to retention, extension, and location. However, classification alone does not determine treatment necessity.
Current evidence indicates that space loss following premature primary tooth extraction is variable and that the effectiveness of space maintainers is not equally established for every clinical situation. A 2023 systematic review of premature second primary molar loss found that space maintainers may preserve arch length, but also identified limited evidence regarding their broader clinical effects and potential periodontal complications.
Similarly, a 2024 systematic review found that fixed space maintainers had significantly lower failure rates than removable appliances in the evaluated clinical population, although both categories required continued maintenance, repair, or replacement.
Consequently, the modern approach is not simply to classify an appliance and place it automatically. Risk assessment, space analysis, eruption monitoring, and periodic clinical evaluation should guide treatment.

🎯 Clinical Recommendations
1. Perform a space analysis before selecting a space maintainer, particularly when the permanent successor is developing normally.
2. Consider fixed appliances when predictable retention and minimal dependence on patient compliance are priorities.
3. Consider a distal shoe when a second primary molar is lost before eruption of the permanent first molar and preservation of its eruption path is indicated.
4. Reassess cementation, appliance integrity, plaque accumulation, abutment teeth, and eruption of the permanent successor at regular intervals.
5. Do not assume that every premature primary tooth extraction requires space maintenance; base the decision on individual space-loss risk and occlusal development.

✍️ Conclusion
Space maintainer classification is primarily based on whether the appliance is fixed or removable, with fixed appliances further divided into unilateral and bilateral designs. Band-and-loop, crown-and-loop, distal shoe, lingual holding arch, Nance, and transpalatal appliances represent the principal fixed categories, while removable partial dentures and Hawley-type appliances represent the removable group.
Although classification facilitates appliance selection, contemporary pediatric dentistry emphasizes individualized diagnosis and risk assessment. The decision to maintain space should integrate the location and timing of tooth loss, dental development, occlusion, space analysis, eruption status, oral hygiene, and patient cooperation.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Management of the developing dentition and occlusion in pediatric dentistry. In The Reference Manual of Pediatric Dentistry (pp. 497–515). American Academy of Pediatric Dentistry.
✔ Abdin, M., Ahmed, E., Hamad, R., Splieth, C., & Schmoeckel, J. (2024). Success rates and failures of fixed and removable space maintainers after the premature loss of primary molars. Quintessence International, 55(4), 304–312. https://doi.org/10.3290/j.qi.b4984249
✔ Durward, C. S. (2000). Space maintenance in the primary and mixed dentition. Annals of the Royal Australasian College of Dental Surgeons, 15, 203–205.
✔ Tabatabai, T., & Kjellberg, H. (2023). Effect of treatment with dental space maintainers after the early extraction of the second primary molar: A systematic review. European Journal of Orthodontics, 45(4), 462–467. https://doi.org/10.1093/ejo/cjad006
✔ Zhao, J., Jin, H., Li, X., & Qin, X. (2023). Dental arch spatial changes after premature loss of first primary molars: A systematic review and meta-analysis of split-mouth studies. BMC Oral Health, 23, 430. https://doi.org/10.1186/s12903-023-03111-x

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