Apicoectomy in Children and Adolescents: When Is It Truly Indicated?

Apicoectomy is a well-established endodontic surgical procedure in adult patients; however, its indication in children and adolescents remains controversial due to ongoing root development, anatomical variability, and high regenerative potential.

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This article critically analyzes when apicoectomy is truly indicated in pediatric and adolescent patients, highlighting biological considerations, clinical justifications, and key differences compared to adult procedures, based on current scientific evidence.

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✅ Introduction
Endodontic surgery aims to eliminate persistent periapical pathology when conventional root canal treatment fails. While apicoectomy is widely accepted in adults, its use in younger patients must be approached with caution. Immature apices, open root canals, proximity to tooth germs, and superior healing capacity significantly influence decision-making in pediatric cases.

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✅ Biological and Anatomical Considerations in Children and Adolescents
Developing teeth present distinct characteristics:

▪️ Incomplete root formation
▪️ Wide apical foramina
▪️ High vascularization and cellular activity
▪️ Proximity to permanent tooth buds
These factors often favor conservative and regenerative approaches over surgical intervention.

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✅ Indications for Apicoectomy in Pediatric and Adolescent Patients
Apicoectomy should be considered only when less invasive treatments have failed or are contraindicated. Accepted indications include:

▪️ Persistent periapical lesions after adequate nonsurgical retreatment
▪️ Apical pathology associated with fractured instruments inaccessible via orthograde access
▪️ Anatomical obstructions preventing complete canal disinfection
▪️ Symptomatic lesions compromising adjacent structures
Importantly, apicoectomy is not a first-line treatment in immature permanent teeth.

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✅ Differences Between Pediatric and Adult Apicoectomy
Key differences include:

Higher healing potential in younger patients
Greater risk of disrupting root development
Lower tolerance for surgical trauma
Preference for regenerative endodontics in children
Adults typically present with fully developed apices, making surgical outcomes more predictable.

📊 Comparative Table: Apicoectomy in Pediatric vs. Adult Patients

Clinical Factor	Pediatric / Adolescent Patients	Adult Patients
Root development	Often incomplete, open apex	Fully developed roots
Healing capacity	High regenerative potential	Moderate regenerative capacity
Preferred treatment	Conservative or regenerative approaches	Surgical intervention acceptable
Risk profile	Higher risk of affecting tooth development	Lower developmental risk

💬 Discussion
Recent literature emphasizes that regenerative endodontic procedures (REPs) and apexification techniques should be prioritized in immature teeth. Surgical intervention may compromise continued root maturation and periodontal attachment. Therefore, apicoectomy must be justified by clear clinical failure of conservative therapy, supported by radiographic and clinical findings.

🎯 Clinical Recommendations
▪️ Exhaust nonsurgical and regenerative options before considering surgery
▪️ Avoid apicoectomy in teeth with active root development unless absolutely necessary
▪️ Use CBCT imaging for accurate diagnosis and surgical planning
▪️ Ensure multidisciplinary evaluation in complex pediatric cases

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✍️ Conclusion
Apicoectomy in children and adolescents should be regarded as a last-resort intervention. The unique biological characteristics of young patients demand a conservative, evidence-based approach. When properly indicated and carefully executed, apicoectomy can be successful; however, its indiscriminate use may compromise long-term dental development. Clinical judgment, supported by current scientific evidence, remains essential.

📚 References

✔ American Association of Endodontists. (2021). AAE clinical considerations for regenerative endodontic procedures. Journal of Endodontics, 47(5), 811–820. https://doi.org/10.1016/j.joen.2021.02.010
✔ Bjørndal, L., Reit, C., Bruun, G., Markvart, M., Kjaeldgaard, M., Näsman, P., & Thordrup, M. (2019). Treatment of deep caries lesions in adults: Randomized clinical trials comparing stepwise vs direct excavation. Journal of Endodontics, 45(9), 1107–1115. https://doi.org/10.1016/j.joen.2019.06.002
✔ European Society of Endodontology. (2016). Position statement on surgical endodontics. International Endodontic Journal, 49(3), 211–221. https://doi.org/10.1111/iej.12564
✔ Torabinejad, M., & White, S. N. (2016). Endodontic surgery: Past, present, and future. Journal of Endodontics, 42(9), 1293–1300. https://doi.org/10.1016/j.joen.2016.06.002

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Why Does the Jaw “Click”? Causes, TMJ Disorders, and Treatment Options

Many people notice that their jaw “clicks,” “pops,” or “cracks” when opening the mouth, chewing, or yawning. While these sounds are often harmless, they can sometimes be a sign of a temporomandibular joint (TMJ) disorder.

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Understanding why the jaw makes noise, what conditions are involved, and how they are treated helps reduce anxiety and supports early care.

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✅ What Is the Temporomandibular Joint (TMJ)?
The temporomandibular joint (TMJ) connects the lower jaw (mandible) to the skull. It works like a hinge and a sliding joint at the same time, allowing us to talk, chew, swallow, and yawn. Inside the joint, a small cartilage disc helps movements stay smooth and quiet.
When this system loses coordination or becomes irritated, joint sounds may appear.

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✅ Main Causes of Jaw Clicking
Jaw noises usually occur due to changes in joint mechanics, muscle tension, or disc position. The most common causes include:

▪️ Disc displacement
▪️ Joint inflammation
▪️ Muscle overload or tension
▪️ Degenerative joint changes
▪️ Joint hypermobility
Not all clicking is painful or dangerous, but persistent noise, pain, or limited movement should be evaluated.

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✅ Common TMJ Disorders: Definition and Treatment

1. Disc Displacement With Reduction
Definition:
The joint disc moves out of its normal position but returns during mouth opening, producing a clear clicking sound.
Treatment:
▪️ Patient education and reassurance
▪️ Jaw exercises and physical therapy
▪️ Occlusal splints (night guards)
▪️ Stress management

2. Disc Displacement Without Reduction
Definition:
The disc does not return to its normal position, often causing limited mouth opening and discomfort, usually without clicking.
Treatment:
▪️ Physical therapy
▪️ Anti-inflammatory medication
▪️ Occlusal appliances
▪️ Referral to a specialist if needed

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3. Myofascial Pain (Muscle-Related TMJ Disorder)
Definition:
Pain and tension in the jaw muscles, often linked to stress, clenching, or grinding.
Treatment:
▪️ Muscle relaxation techniques
▪️ Physical therapy
▪️ Behavioral counseling
▪️ Occlusal splints

4. TMJ Inflammation (Capsulitis or Synovitis)
Definition:
Inflammation of the joint tissues, commonly associated with pain during movement.
Treatment:
▪️ Anti-inflammatory medication
▪️ Rest and soft diet
▪️ Cold or warm compresses

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5. Degenerative Joint Disease (TMJ Osteoarthritis)
Definition:
Gradual wear of joint surfaces, more common with aging or long-term overload.
Treatment:
▪️ Conservative pain management
▪️ Physical therapy
▪️ Occlusal stabilization
▪️ Specialist care for advanced cases

📊 Comparative Table: Treatments for Temporomandibular Joint Disorders

TMJ Condition	Main Treatment Options	Expected Outcome
Disc displacement with reduction	Exercises, splints, stress control	Reduced clicking and improved comfort
Disc displacement without reduction	Physical therapy, medication	Improved jaw movement and pain relief
Muscle-related TMJ pain	Muscle relaxation, splints	Pain reduction and functional recovery
TMJ inflammation	Anti-inflammatory therapy, rest	Decreased inflammation and pain
Degenerative joint disease	Conservative management, monitoring	Symptom control and slower progression

💬 Discussion
Jaw clicking is very common and, in many cases, not a sign of serious disease. Scientific evidence shows that most TMJ disorders respond well to conservative, non-invasive treatment. Early education and simple behavioral changes often prevent progression.
Importantly, absence of pain usually means no urgent treatment is required, but monitoring is still recommended.

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✍️ Conclusion
A clicking jaw is often related to temporary changes in joint coordination rather than permanent damage. Understanding the cause allows patients to feel reassured and make informed decisions. When symptoms persist or worsen, early professional evaluation leads to better outcomes and avoids unnecessary interventions.

🎯 Recommendations for Patients
▪️ Avoid excessive mouth opening (yawning widely, biting hard foods)
▪️ Reduce clenching and grinding, especially during stress
▪️ Maintain good posture, especially when using screens
▪️ Seek dental evaluation if pain, locking, or limited movement appears

📚 References

✔ American Academy of Orofacial Pain. (2020). Orofacial pain: Guidelines for assessment, diagnosis, and management (6th ed.). Quintessence Publishing.
✔ Okeson, J. P. (2020). Management of temporomandibular disorders and occlusion (8th ed.). Elsevier.
✔ Schiffman, E., Ohrbach, R., Truelove, E., et al. (2014). Diagnostic criteria for temporomandibular disorders (DC/TMD). Journal of Oral & Facial Pain and Headache, 28(1), 6–27. https://doi.org/10.11607/jop.1151
✔ Manfredini, D., Guarda-Nardini, L., Winocur, E., Piccotti, F., Ahlberg, J., & Lobbezoo, F. (2011). Research diagnostic criteria for temporomandibular disorders. Journal of Oral Rehabilitation, 38(9), 631–640. https://doi.org/10.1111/j.1365-2842.2011.02210.x

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Principles for the Management of Odontogenic Infections: An Evidence-Based Clinical Approach

Odontogenic infections remain a significant clinical challenge in dental practice due to their potential for rapid progression and life-threatening complications. These infections originate from dental or periodontal tissues and may spread to adjacent fascial spaces if not managed appropriately.

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The cornerstone of effective management lies in the early recognition, accurate diagnosis, and adherence to well-established treatment principles.

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The management framework proposed by Peterson et al. continues to be widely accepted and serves as a systematic, evidence-based protocol for controlling odontogenic infections while minimizing morbidity and mortality.

✅ Conceptual Framework for the Management of Odontogenic Infections
Although Peterson et al. originally proposed an eight-step protocol for the management of odontogenic infections, Velasco and Soto later introduced a simplified and clinically oriented adaptation. In their article Principles for the Management of Odontogenic Infections with Different Levels of Complexity, the authors condensed the original framework into seven core principles, maintaining diagnostic rigor and therapeutic effectiveness while improving clinical applicability.
This simplified model emphasizes sound clinical decision-making, prioritization of surgical intervention, and patient-centered care, making it particularly valuable in routine dental practice and academic training. Accordingly, the present article adopts the seven-step protocol proposed by Velasco and Soto, which remains firmly grounded in Peterson’s original principles while offering a more streamlined and practical approach for managing odontogenic infections across varying levels of severity.

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I. Determining the Etiology and Severity of the Infection
The first and most critical step is identifying the source and extent of the infection. Odontogenic infections typically arise from:

▪️ Pulpal necrosis
▪️ Periapical pathology
▪️ Periodontal infections
▪️ Pericoronal infections
Severity assessment must include evaluation of pain, swelling, fever, trismus, dysphagia, airway compromise, and fascial space involvement. Severe or rapidly spreading infections require urgent intervention due to the risk of systemic involvement.

II. Evaluation of Medical History and Immune Status
A comprehensive medical history is essential to identify conditions that may alter disease progression or treatment response. Patients with diabetes mellitus, immunosuppression, malignancies, or chronic systemic diseases are at higher risk for complications.
Understanding the patient’s immune status allows clinicians to anticipate aggressive disease behavior and tailor treatment accordingly.

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III. Decision on the Appropriate Setting of Care
The decision to manage the infection on an outpatient or inpatient basis depends on:

▪️ Severity and anatomical spread
▪️ Presence of systemic signs
▪️ Airway involvement
▪️ Patient’s general health status
Hospitalization is mandatory when there is airway compromise, systemic toxicity, dehydration, or involvement of deep cervical or fascial spaces.

IV. Surgical Management
Surgical intervention is the primary treatment modality for odontogenic infections. This includes:
▪️ Elimination of the infection source (tooth extraction or endodontic treatment)
▪️ Incision and drainage of abscesses
▪️ Adequate debridement of necrotic tissue
Antibiotics alone are insufficient without proper surgical management, especially in established abscesses.

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V. Medical and Nutritional Support
Supportive care plays a crucial role in recovery. Patients with severe infections often require:

▪️ Hydration therapy
▪️ Pain control
▪️ Nutritional support to maintain immune function
Adequate caloric intake and fluid balance are essential, particularly in patients with fever, dysphagia, or prolonged infection.

VI. Appropriate Selection and Prescription of Antibiotics
Antibiotic therapy should be adjunctive, not a substitute for surgical treatment. Selection must be based on:

▪️ Likely causative microorganisms
▪️ Local antimicrobial resistance patterns
▪️ Patient allergies and systemic condition
Empirical therapy often targets aerobic and anaerobic oral flora, with adjustments made based on clinical response. Rational antibiotic use is critical to prevent antimicrobial resistance.

VII. Periodic Patient Evaluation
Continuous monitoring is essential to assess treatment effectiveness. Follow-up should include evaluation of:

▪️ Reduction in swelling and pain
▪️ Improvement in systemic symptoms
▪️ Restoration of function
Failure to improve within 48–72 hours necessitates reassessment of diagnosis, surgical adequacy, and antimicrobial therapy.

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💬 Discussion
The principles proposed by Peterson et al. provide a structured and reproducible approach to managing odontogenic infections. Their strength lies in emphasizing early surgical intervention, patient-centered care, and judicious antibiotic use. In the context of rising antimicrobial resistance, adherence to these principles is more relevant than ever in contemporary dental practice.

✍️ Conclusion
The successful management of odontogenic infections depends on strict adherence to evidence-based principles, including accurate diagnosis, timely surgical intervention, appropriate antibiotic selection, and close patient monitoring. Applying the Peterson protocol systematically reduces complications and improves clinical outcomes.

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🎯 Clinical Recommendations
▪️ Always identify and eliminate the primary source of infection
▪️ Assess systemic and immune status before treatment planning
▪️ Do not rely solely on antibiotics without surgical intervention
▪️ Re-evaluate patients regularly to ensure clinical resolution
▪️ Refer or hospitalize promptly when airway or systemic involvement is suspected

📚 References

✔ Peterson, L. J., Ellis, E., Hupp, J. R., & Tucker, M. R. (2012). Contemporary Oral and Maxillofacial Surgery (6th ed.). St. Louis, MO: Mosby Elsevier.
✔ Flynn, T. R. (2011). Principles and surgical management of head and neck infections. Oral and Maxillofacial Surgery Clinics of North America, 23(3), 355–365.
✔ Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and Maxillofacial Surgery (7th ed.). Elsevier.
✔ Brook, I. (2017). Microbiology and management of odontogenic infections. Oral and Maxillofacial Surgery Clinics of North America, 29(4), 435–444.
✔ Velasco M., I., & Soto N., R. (2012). Principios para el tratamiento de infecciones odontogénicas con distintos niveles de complejidad. Revista Chilena de Cirugía, 64(6), 586–598.

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Management of Bruxism with Night Guards: An Updated Guide for Dental Professionals

Bruxism is a common parafunctional activity characterized by involuntary clenching or grinding of teeth, occurring during sleep or wakefulness. It is associated with tooth wear, temporomandibular disorders (TMD), muscle pain, and restorative complications.

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Current evidence indicates that bruxism has a multifactorial etiology, including central nervous system regulation, psychosocial factors, and sleep-related mechanisms.

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Night guards (occlusal splints) are widely used in dental practice as a conservative management approach. However, it is essential to emphasize that night guards do not cure bruxism; instead, they protect oral structures and reduce the clinical consequences of excessive occlusal forces.

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✅ Understanding Bruxism: Clinical Considerations
Bruxism is classified as:

▪️ Sleep bruxism, a sleep-related movement disorder.
▪️ Awake bruxism, often associated with stress and behavioral factors.
Clinical diagnosis relies on patient history, clinical signs (wear facets, fractures), muscle tenderness, and, in selected cases, instrumental assessments. Accurate diagnosis is essential to avoid overtreatment and to select appropriate management strategies.

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✅ Role of Night Guards in Bruxism Management
Night guards act as protective and biomechanical devices, reducing direct tooth-to-tooth contact and redistributing occlusal forces. Their main clinical roles include:

▪️ Prevention of enamel wear and fractures
▪️ Reduction of muscle hyperactivity
▪️ Protection of restorations and prostheses
▪️ Symptom relief in TMD-related discomfort
Importantly, night guards do not modify the central mechanisms responsible for bruxism, reinforcing the need for patient education and realistic expectations.

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✅ Types of Night Guards
Commonly used appliances include:

▪️ Hard acrylic stabilization splints, typically fabricated for the maxilla
▪️ Soft or dual-laminate splints, often used for short-term protection
▪️ Anterior bite appliances, indicated in selected cases under strict monitoring
Material selection and design should be based on occlusal stability, symptom severity, and patient compliance.

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✅ Clinical Indications and Limitations
Night guards are indicated for patients with:

▪️ Moderate to severe tooth wear
▪️ Recurrent restoration failure
▪️ Muscle-related pain associated with bruxism
▪️ Temporomandibular discomfort

Limitations include:
▪️ Lack of effect on bruxism frequency
▪️ Possible occlusal changes if poorly designed or improperly monitored
▪️ Dependence on patient adherence

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✅ Multidisciplinary Management Approach
Optimal bruxism management requires a multimodal strategy, combining:

▪️ Occlusal protection (night guards)
▪️ Behavioral counseling and stress management
▪️ Sleep hygiene optimization
▪️ Referral to medical professionals when sleep disorders are suspected

💬 Discussion
Current literature supports night guards as an effective method for damage control rather than etiologic treatment. Their value lies in preventing irreversible dental damage and improving patient comfort. Dentists must clearly communicate their protective role and integrate them into a broader management plan tailored to individual risk factors.

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✍️ Conclusion
Night guards remain a cornerstone in the conservative management of bruxism, offering significant protection against dental and muscular complications. However, they should be prescribed with a clear understanding of their limitations and supportive role within a comprehensive, evidence-based treatment strategy.

🎯 Clinical Recommendations
▪️ Perform a thorough clinical assessment before prescribing a night guard
▪️ Educate patients that night guards control consequences, not causes
▪️ Ensure regular follow-up to monitor occlusion and appliance wear
▪️ Integrate behavioral and medical interventions when indicated

📊 Comparative Table: Treatment Options for Bruxism

Treatment Approach	Clinical Benefits	Limitations
Night Guards (Occlusal Splints)	Protect teeth and restorations; reduce muscle load; improve comfort	Do not eliminate bruxism; require patient compliance
Behavioral Therapy	Addresses stress-related triggers; useful in awake bruxism	Limited effect on sleep bruxism; requires long-term commitment
Pharmacological Management	May reduce muscle activity in selected cases	Not recommended for routine use; potential side effects
Physiotherapy	Improves muscle function and reduces pain	Supportive role only; does not prevent tooth wear

📚 References

✔ Lobbezoo, F., Ahlberg, J., Glaros, A. G., et al. (2018). Bruxism defined and graded: An international consensus. Journal of Oral Rehabilitation, 45(11), 837–844.
✔ Manfredini, D., Winocur, E., Guarda-Nardini, L., Paesani, D., & Lobbezoo, F. (2013). Epidemiology of bruxism in adults. Journal of Orofacial Pain, 27(2), 99–110.
✔ Klasser, G. D., & Greene, C. S. (2009). The changing field of temporomandibular disorders. Journal of the Canadian Dental Association, 75(7), 507–512.
✔ Dao, T. T. T., & Lavigne, G. J. (1998). Oral splints: The crutches for temporomandibular disorders and bruxism? Critical Reviews in Oral Biology & Medicine, 9(3), 345–361.

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Tongue Cancer: Early Warning Signs, Prevention, and the Role of Self-Examination

Tongue cancer is one of the most common malignancies of the oral cavity and represents a significant global health concern. Early detection remains a decisive factor for patient survival and quality of life.

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Dentists play a critical role in identifying early warning signs, promoting preventive strategies, and educating patients about oral self-examination. This article reviews the clinical features, risk factors, prevention measures, and pre- and post-treatment care related to tongue cancer.

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✅ Etiology and Risk Factors
Tongue cancer is predominantly classified as oral squamous cell carcinoma (OSCC). Its development is multifactorial and strongly associated with:

▪️ Tobacco use (smoked and smokeless)
▪️ Excessive alcohol consumption
▪️ Human papillomavirus (HPV), especially HPV-16
▪️ Chronic mechanical irritation
▪️ Poor oral hygiene
▪️ Immunosuppression
▪️ Nutritional deficiencies (iron, folate, vitamin B12)
The synergistic effect of tobacco and alcohol significantly increases carcinogenic risk.

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✅ Early Warning Signs and Clinical Manifestations
Early recognition is essential for improving prognosis. Warning signs of tongue cancer include:

▪️ Persistent ulceration lasting more than two weeks
▪️ Indurated or non-healing lesions
▪️ Red (erythroplakia) or white (leukoplakia) patches
▪️ Pain or burning sensation
▪️ Difficulty chewing, swallowing, or speaking
▪️ Unexplained bleeding
▪️ Palpable cervical lymphadenopathy
Lesions often appear on the lateral borders and ventral surface of the tongue, areas that require meticulous clinical examination.

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✅ Importance of Oral Self-Examination
Oral self-examination is a simple and cost-effective strategy that empowers patients to identify suspicious changes at an early stage. Patients should be instructed to:

▪️ Inspect the tongue under good lighting
▪️ Palpate both lateral borders
▪️ Observe color changes, ulcers, or masses
▪️ Seek professional evaluation if abnormalities persist beyond 14 days
Self-examination complements professional screening but does not replace routine dental examinations.

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✅ Pre-Treatment Care
Before initiating oncologic treatment, dental management aims to minimize complications:

▪️ Comprehensive oral examination
▪️ Elimination of active infections
▪️ Extraction of non-restorable teeth
▪️ Oral hygiene instruction
▪️ Fluoride therapy to reduce post-treatment caries risk
Pre-treatment dental care is essential in patients scheduled for surgery, radiotherapy, or chemotherapy.

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✅ Post-Treatment Care and Oral Management
Post-treatment complications may significantly affect oral function and quality of life. Dental professionals should monitor and manage:

▪️ Xerostomia
▪️ Mucositis
▪️ Dysgeusia
▪️ Trismus
▪️ Osteoradionecrosis
Long-term follow-up includes regular oral examinations, salivary substitutes, topical fluoride use, and reinforcement of oral hygiene practices.

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✅ Prevention Strategies
Primary prevention focuses on reducing exposure to known risk factors:

▪️ Smoking cessation and alcohol moderation
▪️ HPV vaccination
▪️ Nutritional counseling
▪️ Regular dental check-ups
▪️ Public education on early signs of oral cancer
Secondary prevention emphasizes early diagnosis through routine screening and self-examination.

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Dental Article 🔽 Differences and Relationship Between Leukoplakia, Erythroplakia, and Oral Lichen Planus ... While each has distinct clinical and histopathological features, they share an underlying risk of epithelial dysplasia and malignant transformation to oral squamous cell carcinoma (OSCC).

💬 Discussion
Despite advances in oncologic therapies, tongue cancer continues to present diagnostic challenges due to late patient presentation. Dentists are strategically positioned to detect early lesions and initiate timely referral. Integrating patient education, preventive counseling, and systematic oral examination significantly improves outcomes.

🎯 Recommendations
▪️ Perform systematic tongue examination during every dental visit
▪️ Educate patients on oral self-examination techniques
▪️ Refer suspicious lesions promptly for biopsy
▪️ Collaborate with oncologists in pre- and post-treatment dental care
▪️ Promote preventive public health strategies

✍️ Conclusion
Tongue cancer remains a potentially life-threatening condition, yet it is highly curable when detected early. Dentists play a fundamental role in prevention, early diagnosis, and long-term oral management. Emphasizing self-examination, risk factor control, and regular dental screening is essential to reducing morbidity and mortality associated with this disease.

📚 References

✔ Warnakulasuriya, S. (2020). Oral potentially malignant disorders: A comprehensive review. Oral Oncology, 102, 104550. https://doi.org/10.1016/j.oraloncology.2019.104550
✔ World Health Organization. (2023). WHO classification of head and neck tumours (5th ed.). IARC Press.
✔ National Comprehensive Cancer Network. (2024). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. NCCN.
✔ Rivera, C. (2015). Essentials of oral cancer. International Journal of Clinical and Experimental Pathology, 8(9), 11884–11894.

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Recurrent Oral Ulcers in Children: Etiology and Management (Recurrent Aphthous Stomatitis)

Recurrent aphthous stomatitis (RAS) is the most common cause of recurrent oral ulcers in children, characterized by painful ulcerations affecting oral mucosa without systemic disease.

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This article reviews etiology, clinical characteristics, treatment strategies, and differential diagnosis relevant to pediatric dental practice.

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✅ Introduction
Recurrent oral ulcers in children, clinically known as recurrent aphthous stomatitis (RAS), represent a frequent complaint in pediatric dentistry. Although benign and self-limiting, RAS significantly affects oral function, nutrition, and quality of life. Early recognition and accurate diagnosis are essential to distinguish RAS from systemic or infectious diseases presenting with similar lesions.

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✅ Etiology of Recurrent Aphthous Stomatitis
The exact etiology of RAS remains multifactorial and incompletely understood. Proposed contributing factors include:
▪️ Genetic predisposition, particularly a positive family history
▪️ Immune dysregulation, involving T-cell–mediated responses
▪️ Nutritional deficiencies, especially iron, folate, vitamin B12, and zinc
▪️ Local trauma to the oral mucosa
▪️ Psychological stress
▪️ Food hypersensitivity and sodium lauryl sulfate exposure
RAS is not considered infectious and is not associated with viral replication.

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✅ Clinical Characteristics
Recurrent aphthous ulcers typically present on non-keratinized oral mucosa, including the labial mucosa, buccal mucosa, floor of the mouth, and ventral tongue.
Clinical Types
▪️ Minor RAS: Small (less than 10 mm), shallow ulcers healing within 7–14 days without scarring
▪️ Major RAS: Larger, deeper ulcers with prolonged healing and possible scarring
▪️ Herpetiform RAS: Multiple small ulcers occurring in clusters
Common symptoms include pain, burning sensation, and difficulty eating or speaking.

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✅ Treatment and Management
There is no definitive cure for RAS; treatment focuses on symptom control, lesion duration reduction, and recurrence prevention.

Local Therapies
▪️ Topical corticosteroids (e.g., triamcinolone acetonide)
▪️ Topical anesthetics for pain relief
▪️ Antimicrobial mouth rinses (chlorhexidine) to prevent secondary infection

Systemic and Adjunctive Approaches
▪️ Nutritional supplementation when deficiencies are identified
▪️ Avoidance of known triggers
▪️ Maintenance of optimal oral hygiene
Systemic therapy is rarely indicated in children and should be reserved for severe cases.

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💬 Discussion
Despite its benign nature, recurrent aphthous stomatitis may indicate underlying systemic or nutritional disorders. Accurate diagnosis is essential to prevent overtreatment and to differentiate RAS from viral, autoimmune, or hematologic diseases. Pediatric dentists play a critical role in early identification and appropriate referral when systemic involvement is suspected.

🎯 Recommendations for Pediatric Dental Practice
▪️ Perform thorough medical and dietary history assessments
▪️ Educate caregivers on trigger avoidance and oral hygiene practices
▪️ Use topical therapy as first-line treatment
▪️ Refer patients with atypical or severe lesions for medical evaluation

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✍️ Conclusion
Recurrent aphthous stomatitis is the leading cause of recurrent oral ulcers in children, with multifactorial etiology and characteristic clinical presentation. Evidence-based diagnosis and conservative management allow effective symptom control while minimizing unnecessary interventions.

📊 Comparative Table: Differential Diagnosis of Recurrent Oral Ulcers in Children

Condition	Key Clinical Features	Distinguishing Factors
Recurrent Aphthous Stomatitis	Painful, shallow ulcers on non-keratinized mucosa	No systemic symptoms, recurrent pattern
Primary Herpetic Gingivostomatitis	Multiple vesicles progressing to ulcers	Fever, lymphadenopathy, viral etiology
Behçet Disease	Recurrent oral and genital ulcers	Systemic involvement, ocular lesions
Traumatic Ulcers	Single ulcer at trauma site	History of mechanical injury

📚 References

✔ Edgar, N. R., Saleh, D., & Miller, R. A. (2017). Recurrent aphthous stomatitis: A review. Journal of Clinical and Aesthetic Dermatology, 10(3), 26–36.
✔ Preeti, L., Magesh, K. T., Rajkumar, K., & Karthik, R. (2011). Recurrent aphthous stomatitis. Journal of Oral and Maxillofacial Pathology, 15(3), 252–256.
✔ Scully, C., & Porter, S. (2008). Oral mucosal disease: Recurrent aphthous stomatitis. British Journal of Oral and Maxillofacial Surgery, 46(3), 198–206.
✔ Shulman, J. D. (2004). An epidemiologic study of recurrent aphthous ulceration in U.S. children. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 98(4), 405–410.

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Recognizing Life-Threatening Odontogenic Infections: Emergency Protocols for Dentists

Odontogenic infections are common in dental practice; however, under certain conditions, they may progress rapidly and become life-threatening medical emergencies. Failure to recognize early warning signs can result in severe complications such as airway obstruction, sepsis, mediastinitis, or intracranial spread.

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Dentists play a crucial role in the early identification, risk stratification, and timely referral of these infections. This article reviews the clinical characteristics of severe odontogenic infections, outlines emergency management protocols, and emphasizes the importance of prompt intervention.

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✅ Pathophysiology of Life-Threatening Odontogenic Infections
Most severe odontogenic infections originate from:

▪️ Untreated dental caries
▪️ Pulpal necrosis
▪️ Periodontal infections
▪️ Pericoronitis of third molars
The spread occurs through fascial spaces of the head and neck, facilitated by anatomical pathways and virulent polymicrobial flora dominated by anaerobic bacteria. Once deep cervical spaces are involved, the risk of systemic dissemination and airway compromise increases significantly.

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✅ Clinical Warning Signs and Red Flags
Dentists must recognize early indicators of severe infection, including:
▪️ Rapidly progressing facial or cervical swelling
▪️ Trismus (limited mouth opening)
▪️ Dysphagia or odynophagia
▪️ Voice changes or drooling
▪️ Fever with systemic toxicity
▪️ Dyspnea or stridor
▪️ Elevated heart rate and hypotension
These findings may indicate involvement of critical spaces such as the submandibular, sublingual, parapharyngeal, or retropharyngeal spaces, commonly associated with Ludwig’s angina and other deep neck infections.

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✅ Emergency Protocols for Dentists
When a life-threatening odontogenic infection is suspected, the following steps are essential:

1. Do not delay referral for imaging or outpatient antibiotic trials.
2. Assess airway patency immediately.
3. Initiate urgent referral to a hospital setting with maxillofacial and medical support.
4. Avoid definitive dental procedures in unstable patients.
5. Communicate clearly with emergency physicians regarding the odontogenic source.
6. Document all clinical findings thoroughly.
Antibiotic therapy alone is insufficient in advanced cases; surgical drainage and airway management are often required.

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💬 Discussion
Despite advances in dentistry, severe odontogenic infections remain a significant clinical challenge. Delayed diagnosis, inappropriate antibiotic use, and underestimation of severity contribute to poor outcomes. Dentists must maintain a high index of suspicion, particularly in patients with systemic diseases, immunosuppression, or limited access to care. Early recognition and interdisciplinary collaboration are critical to reducing morbidity and mortality.

✍️ Conclusion
Life-threatening odontogenic infections require immediate recognition and decisive action. Dentists are often the first healthcare providers to encounter these patients and must be prepared to identify danger signs, initiate emergency protocols, and ensure timely referral. Adhering to evidence-based clinical criteria can be lifesaving.

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🎯 Clinical Recommendations
▪️ Always assess systemic symptoms in patients with odontogenic infections.
▪️ Consider deep space involvement when swelling extends beyond the alveolar process.
▪️ Do not rely solely on oral antibiotics in severe cases.
▪️ Educate patients on the importance of early dental infection management.
▪️ Maintain updated emergency referral pathways.

📊 Comparative Table: Step-by-Step Oral Self-Examination

Step	What to Observe	Warning Signs
Lips and cheeks	Color, symmetry, swelling	Persistent swelling or asymmetry
Tongue	Surface texture and mobility	Restricted movement or painful enlargement
Floor of the mouth	Firmness and tenderness	Hard swelling or elevation of the tongue
Gingiva	Redness, discharge, bleeding	Suppuration or rapidly spreading inflammation
Neck region	Palpable lymph nodes	Painful, enlarging cervical masses

📚 References

✔ Flynn, T. R. (2011). Severe odontogenic infections, part 1: Prospective report. Journal of Oral and Maxillofacial Surgery, 69(11), 2715–2723. https://doi.org/10.1016/j.joms.2011.02.015
✔ Hupp, J. R., Ellis, E., & Tucker, M. R. (2019). Contemporary oral and maxillofacial surgery (7th ed.). Elsevier.
✔ Marioni, G., Rinaldi, R., Staffieri, C., Marchese-Ragona, R., & Staffieri, A. (2008). Deep neck infection with dental origin: Analysis of 85 consecutive cases. Acta Oto-Laryngologica, 128(2), 201–206. https://doi.org/10.1080/00016480701488511
✔ Wang, L. F., Kuo, W. R., Tsai, S. M., & Huang, K. J. (2003). Characterizations of life-threatening deep cervical space infections. Journal of Otolaryngology, 32(6), 400–404.

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Night Guards for Bruxism: A Complete Dental Guide for Symptom Prevention and Control

Bruxism is a condition in which a person grinds or clenches their teeth, often without noticing it. It usually happens during sleep but can also occur while awake. Many people are surprised to learn that night guards do not treat bruxism itself.

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Instead, they are designed to protect the teeth and jaw from the damage caused by bruxism. This guide explains, in simple terms, how night guards work, what they can and cannot do, and why they are an important part of symptom control—not a cure.

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✅ What Is Bruxism?
Bruxism is a repetitive jaw activity involving tooth grinding or clenching. It is now understood as a condition related to the brain and nervous system, not a problem caused by how the teeth fit together.

Common factors linked to bruxism include:
▪️ Stress and emotional tension
▪️ Sleep disturbances
▪️ Anxiety or concentration habits
▪️ Certain medications
Because bruxism starts in the brain, there is no device that can completely stop it.

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✅ What Are Night Guards and How Do They Work?
Night guards (also called occlusal splints) are removable dental appliances worn during sleep. They are usually made of acrylic or flexible materials and are custom-made by a dentist.

Their main function is to:
▪️ Create a protective barrier between the teeth
▪️ Reduce pressure on teeth and jaw joints
▪️ Limit muscle overload during clenching
It is important to understand that night guards do not eliminate bruxism. They simply contain its harmful effects.

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✅ What Night Guards Can and Cannot Do

What They Can Do
▪️ Protect teeth from excessive wear
▪️ Lower the risk of tooth fractures
▪️ Reduce jaw muscle discomfort
▪️ Help prevent damage to dental restorations

What They Cannot Do
▪️ Stop tooth grinding
▪️ Treat the neurological cause of bruxism
▪️ Replace stress or sleep management
This distinction is essential for setting realistic expectations.

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💬 Discussion
Night guards are often misunderstood as a treatment for bruxism. Scientific evidence shows that they act as protective tools, not curative solutions. Their value lies in preventing long-term damage, especially to teeth, muscles, and jaw joints. For best results, night guards should be used as part of a broader approach, which may include stress reduction, sleep improvement, and regular dental follow-up.

✍️ Conclusion
Night guards play a crucial role in protecting oral structures from the consequences of bruxism, but they do not cure the condition. When patients understand their real purpose, night guards become a safe and effective way to control symptoms and preserve oral health over time.

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🎯 Recommendations
▪️ Use night guards as a protective measure, not as a cure.
▪️ Have the appliance custom-made and regularly checked by a dentist.
▪️ Address contributing factors such as stress and poor sleep quality.
▪️ Seek professional advice if symptoms worsen or persist.
▪️ Maintain routine dental visits to monitor wear and jaw health.

📊 Comparative Table: Consequences of Bruxism and Their Impact on Oral Health

Bruxism Consequence	Main Effect on Oral Health	Potential Long-Term Outcome
Tooth wear	Gradual loss of enamel	Tooth sensitivity and structural damage
Tooth fractures	Cracks or broken teeth	Need for crowns or root canal treatment
Jaw muscle pain	Muscle fatigue and soreness	Chronic facial discomfort
Jaw joint stress	Overload of the temporomandibular joint	Joint pain and limited jaw movement

📚 References

✔ American Academy of Sleep Medicine. (2014). International classification of sleep disorders (3rd ed.). Darien, IL: AASM.
✔ Lobbezoo, F., Ahlberg, J., Raphael, K. G., et al. (2013). International consensus on the assessment of bruxism. Journal of Oral Rehabilitation, 40(1), 2–12. https://doi.org/10.1111/joor.12021
✔ Manfredini, D., & Lobbezoo, F. (2010). Relationship between bruxism and temporomandibular disorders. Journal of Oral Rehabilitation, 37(6), 413–419. https://doi.org/10.1111/j.1365-2842.2010.02065.x
✔ Shetty, S., Pitti, V., Babu, C. L., Kumar, G. S., & Deepthi, B. C. (2010). Bruxism: A literature review. Journal of Indian Prosthodontic Society, 10(3), 141–148. https://doi.org/10.1007/s13191-011-0041-5

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What Are the Oral Manifestations in Oncology Patients? : Early and Advanced Manifestations

Patients undergoing cancer treatment frequently develop oral manifestations that significantly impact quality of life, nutrition, and treatment adherence. These manifestations may appear early during oncologic therapy or progress to severe, potentially life-threatening complications in advanced stages.

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Oral changes are mainly associated with chemotherapy, radiotherapy, targeted therapies, and hematopoietic stem cell transplantation, as well as with cancer-related immunosuppression.

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Understanding the chronological progression of oral manifestations is essential for early diagnosis, preventive care, and multidisciplinary management.

✅ Early Oral Manifestations in Oncology Patients
Early oral changes often develop within days to weeks after initiation of cancer therapy and may be subtle but clinically significant.

➤ Oral Mucositis
Oral mucositis is one of the most common and debilitating early complications, characterized by:
▪️ Erythema and mucosal inflammation
▪️ Painful ulcerations
▪️ Burning sensation and hypersensitivity
It is primarily induced by chemotherapy and head-and-neck radiotherapy, resulting from epithelial cell damage and inflammatory cytokine release.

➤ Xerostomia
Reduced salivary flow is frequently observed, especially in patients receiving radiotherapy involving salivary glands. Early xerostomia leads to:
▪️ Dry mouth
▪️ Difficulty swallowing and speaking
▪️ Increased risk of dental caries

➤ Taste Alterations (Dysgeusia)
Taste disturbances may appear early due to damage to taste buds or salivary changes, often resulting in:
▪️ Metallic or bitter taste
▪️ Reduced appetite
▪️ Nutritional deficiencies

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✅ Intermediate Oral Manifestations
As oncologic treatment continues, oral alterations may progress in severity.

➤ Opportunistic Infections
Immunosuppression increases susceptibility to infections, including:
▪️ Oral candidiasis (pseudomembranous or erythematous forms)
▪️ Herpes simplex virus reactivation
▪️ Bacterial infections
These conditions may exacerbate pain and delay oncologic therapy.

➤ Dental and Periodontal Complications
Reduced salivary protection and poor oral hygiene can lead to:
▪️ Radiation-induced caries
▪️ Gingivitis and periodontitis
▪️ Tooth sensitivity and enamel demineralization

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✅ Advanced Oral Manifestations
Advanced stages are often associated with long-term or high-dose oncologic treatments and may have permanent consequences.

➤ Osteoradionecrosis
Osteoradionecrosis is a severe complication mainly affecting irradiated jawbones, characterized by:
▪️ Exposed necrotic bone
▪️ Chronic pain and infection
▪️ Impaired wound healing

➤ Severe Trismus
Fibrosis of masticatory muscles and temporomandibular joint structures may result in:
▪️ Limited mouth opening
▪️ Difficulty eating and maintaining oral hygiene

➤ Chronic Ulcerations and Tissue Necrosis
Persistent ulcerations may occur due to:
▪️ Vascular damage
▪️ Impaired immune response
▪️ Secondary infections
These lesions significantly compromise oral function and patient comfort.

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💬 Discussion
Oral manifestations in oncology patients are multifactorial and progressive, reflecting both the direct effects of cancer therapy and the systemic condition of the patient. Early recognition allows for preventive and supportive interventions, reducing complications and improving overall outcomes. Dental professionals play a crucial role within the multidisciplinary oncology care team, particularly in prevention, monitoring, and management of oral complications.

🎯 Recommendations
▪️ Perform comprehensive dental evaluation before initiating cancer therapy
▪️ Implement preventive oral care protocols, including fluoride application
▪️ Monitor patients regularly throughout oncologic treatment
▪️ Manage oral infections promptly to avoid systemic spread
▪️ Educate patients on meticulous oral hygiene and symptom reporting

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✍️ Conclusion
Oral manifestations in oncology patients range from early inflammatory changes to advanced destructive complications. Their impact on quality of life and treatment continuity underscores the importance of early diagnosis, preventive strategies, and interdisciplinary collaboration. Proactive dental management is essential to minimize morbidity and support successful oncologic outcomes.

📚 References

✔ Lalla, R. V., Bowen, J., Barasch, A., Elting, L., Epstein, J., Keefe, D. M., … Sonis, S. T. (2014). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer, 120(10), 1453–1461. https://doi.org/10.1002/cncr.28592
✔ Sonis, S. T. (2009). Mucositis: The impact, biology and therapeutic opportunities of oral mucositis. Oral Oncology, 45(12), 1015–1020. https://doi.org/10.1016/j.oraloncology.2009.08.006
✔ Jansma, J., Vissink, A., Spijkervet, F. K. L., Roodenburg, J. L. N., & Panders, A. K. (1993). Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiotherapy. Cancer, 72(10), 2895–2903. https://doi.org/10.1002/1097-0142(19931115)72:10

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Night Guards: Do They Really Help with Bruxism?

Bruxism is a common parafunctional activity characterized by repetitive jaw muscle activity, including clenching or grinding of the teeth. It can occur during sleep (sleep bruxism) or while awake (awake bruxism) and is associated with tooth wear, temporomandibular disorders, and orofacial pain.

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Among the most widely recommended treatments are night guards, also known as occlusal splints. However, an important clinical question remains: do night guards truly help manage bruxism, or do they simply protect the teeth from its consequences?

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✅ What Is Bruxism?
Bruxism is defined as a repetitive masticatory muscle activity characterized by clenching, grinding, or bracing of the mandible. It is considered a multifactorial condition, influenced by biological, psychological, and neurological factors rather than occlusal discrepancies alone.

Types of Bruxism
▪️ Sleep bruxism: A sleep-related movement disorder associated with micro-arousals.
▪️ Awake bruxism: A behavioral condition often linked to stress or concentration.

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✅ Causes of Bruxism
The etiology of bruxism is complex and multifactorial:

▪️ Psychological factors, such as stress, anxiety, and emotional tension
▪️ Central nervous system regulation, including sleep arousal mechanisms
▪️ Medications, particularly selective serotonin reuptake inhibitors (SSRIs)
▪️ Sleep disorders, such as obstructive sleep apnea
▪️ Lifestyle factors, including caffeine, alcohol, and tobacco use
Current evidence indicates that bruxism is centrally mediated, rather than caused by dental occlusion alone.

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✅ Night Guards: Definition and Mechanism of Action
Night guards are custom-made or prefabricated intraoral appliances designed to cover the occlusal surfaces of the teeth, usually fabricated from acrylic or thermoplastic materials.

Their primary functions include:
▪️ Redistributing occlusal forces
▪️ Reducing tooth-to-tooth contact
▪️ Protecting dental structures from wear
▪️ Decreasing muscle hyperactivity in some patients
Importantly, night guards do not eliminate bruxism, but they may reduce its harmful effects.

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✅ Clinical Effectiveness of Night Guards
Scientific evidence supports that night guards:

▪️ Protect teeth from further wear
▪️ May reduce muscle pain and morning discomfort
▪️ Can improve patient awareness of parafunctional habits
However, they do not consistently reduce the frequency of bruxism episodes, particularly in sleep bruxism. Their effectiveness is primarily protective rather than curative.

📊 Comparative Table: Bruxism Treatment Options

Treatment Approach	Clinical Benefits	Limitations
Night Guards (Occlusal Splints)	Protect teeth, reduce wear, may decrease muscle discomfort	Do not eliminate bruxism activity
Behavioral Therapy	Addresses stress-related and awake bruxism factors	Requires patient compliance and time
Botulinum Toxin Injections	Reduces muscle hyperactivity and pain	Temporary effect, invasive, higher cost
Pharmacological Management	May help in selected neurological or sleep-related cases	Limited evidence, potential side effects

💬 Discussion
Night guards remain a cornerstone in the management of bruxism due to their non-invasive nature and protective benefits. Nevertheless, their role should be clearly explained to patients: they manage the consequences, not the underlying neurological or behavioral causes.
Optimal management often requires a multidisciplinary approach, combining occlusal therapy with behavioral strategies, stress management, and, when indicated, pharmacological or adjunctive therapies.

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Dental Article 🔽 Is Bruxism a Medical or Dental Problem? Causes, Risks, and Treatments ... Dental professionals can manage the manifestations, while medical specialists address underlying contributing factors. This interplay underpins why bruxism should be viewed as both a dental and medical issue.

🎯 Recommendations
▪️ Use custom-fabricated night guards for better fit and compliance
▪️ Combine occlusal splints with behavioral and stress-reduction therapies
▪️ Monitor patients regularly for appliance wear and symptom progression
▪️ Address contributing factors such as sleep disorders or medication use
▪️ Educate patients that night guards protect teeth but do not cure bruxism

✍️ Conclusion
Night guards are an effective and evidence-based tool for protecting teeth and reducing symptoms associated with bruxism. While they do not eliminate the condition itself, they play a critical role in preventing irreversible dental damage. Comprehensive bruxism management should extend beyond occlusal appliances to address the multifactorial nature of the disorder.

📚 References

✔ Lobbezoo, F., Ahlberg, J., Raphael, K. G., Wetselaar, P., Glaros, A. G., Kato, T., & Manfredini, D. (2018). International consensus on the assessment of bruxism. Journal of Oral Rehabilitation, 45(11), 837–844. https://doi.org/10.1111/joor.12663
✔ Manfredini, D., Serra-Negra, J., Carboncini, F., & Lobbezoo, F. (2017). Current concepts of bruxism. International Journal of Prosthodontics, 30(5), 437–438. https://doi.org/10.11607/ijp.5210
✔ Macedo, C. R., Silva, A. B., Machado, M. A., Saconato, H., & Prado, G. F. (2007). Occlusal splints for treating sleep bruxism. Cochrane Database of Systematic Reviews, (4), CD005514. https://doi.org/10.1002/14651858.CD005514.pub2

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