Common Complications of Dental Implants: Diagnosis and Treatment Guide

Dental implants have become the gold standard for replacing missing teeth due to their high success rate and ability to restore function and aesthetics. However, like any surgical procedure, implant placement is not free of complications.

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Understanding the nature of these complications—ranging from peri-implant diseases to mechanical failures—is crucial for timely diagnosis and appropriate management. This article reviews the most common problems associated with dental implants, including their definitions, clinical characteristics, diagnostic strategies, and current treatment options.

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✅ 1. Peri-Implant Mucositis

➤ Definition:
° Peri-implant mucositis is a reversible inflammatory reaction of the soft tissues surrounding a dental implant without accompanying bone loss.
➤ Clinical Features:
° Redness and swelling of peri-implant mucosa
° Bleeding on probing (BOP)
° No radiographic bone loss
° Patient may report mild discomfort or sensitivity
➤ Diagnosis:
° Probing depth measurement
° Presence of BOP
° Radiographs confirm absence of bone loss
° Exclusion of other causes such as food impaction or residual cement
➤ Treatment:
° Mechanical debridement with plastic or titanium curettes
° Antimicrobial mouth rinses (e.g., chlorhexidine)
° Improved patient oral hygiene
° Re-evaluation after 2–4 weeks

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✅ 2. Peri-Implantitis

➤ Definition:
° Peri-implantitis is a progressive inflammatory disease affecting both the soft and hard tissues around an osseointegrated implant, leading to bone loss.
➤ Clinical Features:
° BOP and/or suppuration
° Increased probing depth (>5 mm)
° Progressive radiographic bone loss
° Possible implant mobility in advanced cases
➤ Diagnosis:
° Periodontal charting (baseline comparison)
° Radiographic bone level analysis
° Microbial analysis in severe or refractory cases
➤ Treatment:
° Mechanical debridement and antiseptic therapy
° Local or systemic antibiotics (e.g., amoxicillin + metronidazole)
° Surgical intervention (e.g., resective or regenerative surgery)
° Implant surface decontamination with lasers or air abrasives

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✅ 3. Implant Failure (Early and Late)

➤ Definition:
° Implant failure is classified as early (before osseointegration) or late (after functional loading), resulting in implant mobility or loss.
➤ Clinical Features:
° Pain or discomfort on function
° Mobility of implant
° Radiographic evidence of peri-implant radiolucency
° Soft tissue inflammation
➤ Diagnosis:
° Clinical mobility testing
° Percussion and tactile evaluation
° Radiographs to assess integration and bone levels
➤ Treatment:
° Removal of failed implant
° Management of infection or bone defects
° Possible delayed or immediate re-implantation depending on case

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✅ 4. Mechanical Complications

a. Screw Loosening or Fracture
➤ Definition:
° Mechanical dislodgment or breakage of abutment or prosthetic screws.
➤ Clinical Features:
° Mobility of crown or prosthesis
° Clicking or instability during function
° Possible pain or soft tissue trauma
➤ Diagnosis:
° Clinical inspection
° Radiographs to detect screw fracture or misfit
➤ Treatment:
° Retightening or replacement of screws
° Use of torque-controlled drivers
° Avoidance of occlusal overload

b. Prosthetic Fracture (e.g., Crown or Bridge)
➤ Definition:
° Fracture of the prosthetic components due to stress, fatigue, or poor design.
➤ Clinical Features:
° Fractured ceramic or acrylic visible
° Aesthetic compromise
° Patient may report altered bite or discomfort
➤ Diagnosis:
° Clinical examination
° Assessment of occlusal forces and design flaws
➤ Treatment:
° Repair or replacement of prosthesis
° Occlusal adjustment
° Use of more durable materials (e.g., zirconia)

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✅ 5. Neurological Complications

➤ Definition:
° Nerve injury typically occurs during implant placement in the mandibular region, resulting in temporary or permanent paresthesia.
➤ Clinical Features:
° Numbness or tingling of lower lip, chin, or tongue
° Burning sensation
° Pain or discomfort during healing
➤ Diagnosis:
° Clinical sensory testing (light touch, pinprick)
° Radiographic assessment of implant proximity to nerve canal
° Cone beam computed tomography (CBCT) if needed
➤ Treatment:
° Immediate implant removal if impingement is suspected
° Corticosteroids to reduce inflammation
° Referral to a neurologist for persistent symptoms

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💬 Discussion
Dental implant complications can significantly impact treatment outcomes and patient satisfaction. Peri-implant diseases, including mucositis and peri-implantitis, are among the most common biological complications and share many features with periodontal diseases. Mechanical and neurological complications, although less frequent, require early recognition and targeted management. Preventive strategies such as accurate surgical planning, patient education, and regular maintenance therapy play a vital role in minimizing the occurrence of complications.

💡 Conclusion
While dental implants are highly predictable, complications—both biological and mechanical—can arise. Timely identification and management based on clinical and radiographic findings are essential for preserving implant function and health. Clinicians must stay updated on the latest diagnostic protocols and treatment strategies to ensure long-term success and patient safety.

📚 References

✔ Lang, N. P., Berglundh, T., & Working Group 4 of the Seventh European Workshop on Periodontology. (2011). Periimplant diseases: Where are we now? – Consensus of the Seventh European Workshop on Periodontology. Journal of Clinical Periodontology, 38(s11), 178–181. https://doi.org/10.1111/j.1600-051X.2010.01674.x

✔ Heitz-Mayfield, L. J., & Mombelli, A. (2014). The therapy of peri-implantitis: A systematic review. The International Journal of Oral & Maxillofacial Implants, 29(Suppl), 325–345. https://doi.org/10.11607/jomi.2014suppl.g5.3

✔ Esposito, M., Hirsch, J. M., Lekholm, U., & Thomsen, P. (1998). Biological factors contributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. European Journal of Oral Sciences, 106(1), 527–551. https://doi.org/10.1046/j.0909-8836.1998.eos106111.x

✔ Misch, C. E. (2020). Dental Implant Prosthetics (3rd ed.). Mosby.

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Oral Manifestations of STDs: Diagnosis, Signs, and Dental Management

Sexually transmitted diseases (STDs) remain a global health concern. Several infections, including syphilis, HIV, herpes simplex virus (HSV), gonorrhea, and human papillomavirus (HPV), present oral signs that may be the first indication of systemic illness.

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Dentists are in a unique position to detect and refer these cases early.

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✅ Diagnosis in dental practice
A thorough medical and sexual history should be taken. Diagnostic tools include:

° Biopsy and exfoliative cytology
° PCR testing for viral identification (HPV, HSV)
° Serologic testing (VDRL, ELISA, Western Blot)
° Referral to specialists for confirmatory diagnosis

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✅ Common oral manifestations of STDs

✅ Dental management
A thoughtful and professional approach is essential when treating patients with oral manifestations of STDs. Management includes:

1. Thorough clinical examination:
° Detailed intraoral inspection to identify ulcers, warts, vesicles, leukoplakia, or other lesions.
° Clinical photography (with consent) for documentation and follow-up.
2. Detailed medical history:
° Focus on systemic conditions, sexual history, and risk behaviors (e.g., smoking, drug use, multiple partners).
3. Symptomatic management:
° Topical anesthetics or systemic analgesics for pain.
° Antiviral therapy (e.g., Acyclovir, Valacyclovir) for herpes infections.
° Systemic antibiotics for bacterial STDs (e.g., syphilis or gonorrhea)—in coordination with medical treatment.
° Antifungal therapy for HIV-related oral candidiasis (e.g., Nystatin, Fluconazole).
4. Patient education and counseling:
° Clarify the link between STDs and oral health.
° Promote safer sex practices and regular testing.
° Encourage communication with physicians and follow-up care.
5. Referral and interdisciplinary care:
° Timely referral to infectious disease specialists or physicians.
° Collaboration with medical teams for systemic management.

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✅ Basic biosafety protocols in dental practice
To ensure safety for both dental personnel and patients, the following standard precautions must be implemented:

➤ Personal Protective Equipment (PPE):
° Gloves, surgical mask or N95 respirator (if aerosol is generated), protective eyewear, and disposable gowns.
➤ Strict hand hygiene:
° Follow the WHO's five moments of hand hygiene protocol before and after patient contact.
➤ Surface and instrument sterilization:
° Proper cleaning and disinfection of all equipment and environmental surfaces between patients.
➤ Aerosol minimization:
° Use low-speed instruments or hand techniques when possible, especially with active lesions or immunocompromised patients.
➤ Biological waste management:
° Proper segregation and disposal of contaminated materials per regulations.
➤ Informed consent:
° Secure written consent before biopsy, photo documentation, or referral procedures.

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💡 Conclusion
Oral signs may be the first or only indication of STDs. Dentists must stay updated on their recognition and management to improve public health outcomes through early diagnosis and referral.

📚 References

✔ Fatahzadeh, M., & Schwartz, R. A. (2007). Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management. Journal of the American Academy of Dermatology, 57(5), 737–763. https://doi.org/10.1016/j.jaad.2007.06.020

✔ Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2015). Oral and Maxillofacial Pathology (4th ed.). Elsevier Health Sciences.

✔ Centers for Disease Control and Prevention (CDC). (2023). Sexually Transmitted Infections Treatment Guidelines. https://www.cdc.gov/std/treatment-guidelines/default.htm

✔ Reznik, D. A. (2006). Oral manifestations of HIV disease. Topics in HIV Medicine, 14(5), 143–148. https://pubmed.ncbi.nlm.nih.gov/17133174/

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Oral Manifestations of Systemic Diseases: Updated Clinical Review

Systemic diseases affect more than internal organs—they often present oral signs that can be essential for early diagnosis.

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Due to its high vascularity and immune role, the oral cavity frequently reflects systemic conditions. In modern dentistry, recognizing these signs is key to preventive care and interdisciplinary treatment.

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✅ Systemic Diseases and Their Oral Manifestations

1. Diabetes Mellitus
➤ Definition: A chronic metabolic disorder characterized by persistent hyperglycemia.
➤ Oral manifestations:
° Xerostomia (dry mouth)
° Advanced periodontal disease
° Delayed wound healing
° Oral candidiasis
➤ Common signs and symptoms: Gingival bleeding, tooth mobility, halitosis, recurrent oral infections.

2. Iron Deficiency Anemia
➤ Definition: A lack of iron leading to decreased oxygen-carrying capacity of the blood.
➤ Oral manifestations:
° Pale oral mucosa
° Atrophic glossitis (smooth, sore tongue)
° Angular cheilitis
➤ Common signs and symptoms: Burning sensation in the mouth, altered taste, oral ulcers.

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3. HIV/AIDS
➤ Definition: Infection caused by the human immunodeficiency virus, impairing the immune system.
➤ Oral manifestations:
° Pseudomembranous candidiasis
° Kaposi's sarcoma
° Oral hairy leukoplakia
° Necrotizing gingivitis/periodontitis
➤ Common signs and symptoms: White lesions, persistent ulcers, oral pain, gingival bleeding.

4. Systemic Lupus Erythematosus (SLE)
➤ Definition: A multisystem autoimmune disease affecting connective tissues.
➤ Oral manifestations:
° Painless oral ulcers
° Erythematous or purpuric lesions
° Xerostomia (often secondary to Sjögren’s syndrome)
➤ Common signs and symptoms: Mild pain, difficulty chewing, mucosal and lingual changes.

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5. Chronic Kidney Disease (CKD)
➤ Definition: Progressive, irreversible loss of kidney function.
➤ Oral manifestations:
° Uremic breath odor
° Oral ulcerations
° Gingival bleeding
Enamel hypoplasia (especially in children)
➤ Common signs and symptoms: Metallic taste, oral pain, delayed tooth eruption in children.

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✅ Recommendations for Dental Practice

° Conduct thorough medical histories that screen for systemic illnesses.
° Treat oral signs as potential indicators of undiagnosed systemic disease.
° Work collaboratively with physicians for interdisciplinary care.
° Educate patients on the oral-systemic health connection.
° Schedule frequent cleanings and periodontal evaluations for at-risk patients.

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💡Conclusions
Oral signs of systemic diseases serve as critical indicators for early diagnosis and comprehensive treatment. Timely recognition of these signs can improve patient outcomes, reduce complications, and enhance quality of life. Dentists play a key role in identifying these manifestations and guiding patients to appropriate medical care.

📚 References

✔ Chávez, E. M., et al. (2022). Oral health considerations in patients with chronic kidney disease. Journal of Clinical Nephrology and Renal Care, 8(1), 110. https://doi.org/10.23937/2572-3286.1510110

✔ Kottoor, R., et al. (2020). Oral manifestations in patients with systemic lupus erythematosus. Lupus, 29(3), 274–281. https://doi.org/10.1177/0961203320903073

✔ López-López, J., et al. (2021). Oral manifestations of iron deficiency anemia: A clinical approach. Clinical Oral Investigations, 25(1), 123–130. https://doi.org/10.1007/s00784-020-03418-z

✔ López-Pintor, R. M., et al. (2020). Diabetes mellitus and oral health: A bidirectional relationship. Medicina Oral, Patología Oral y Cirugía Bucal, 25(4), e559–e566. https://doi.org/10.4317/medoral.24012

✔ Patton, L. L., et al. (2021). Oral manifestations of HIV infection and treatment: A clinical guide. Oral Diseases, 27(S1), 59–68. https://doi.org/10.1111/odi.13742

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Lingual Coating: Causes, Characteristics, Bacterial Profile, Consequences, and Treatment

Lingual coating, also known as tongue biofilm or tongue plaque, is a common condition in the oral cavity characterized by a whitish, yellowish, or brownish layer on the dorsal surface of the tongue.

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This layer is primarily composed of desquamated epithelial cells, food debris, leukocytes, mucins, and a significant number of microorganisms, especially anaerobic bacteria. Often underestimated, lingual coating can indicate poor oral hygiene, systemic disorders, or imbalances in the oral microbiome.

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✅ Clinical Characteristics of Lingual Coating
The main clinical features include:

° Whitish or yellowish appearance on the dorsal surface of the tongue.
° Pastelike or sticky texture.
° Halitosis (bad breath) present in most cases.
° Dry mouth sensation or unpleasant taste.
° Possible dysgeusia (altered taste) or burning tongue sensation.

The most commonly affected area is the posterior dorsal region, where filiform papillae are more abundant, facilitating retention of debris and microorganisms.

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✅ Microbiota Involved in Lingual Coating
The tongue harbors a complex microbiota of both aerobic and anaerobic bacteria. Lingual coating is especially associated with a high concentration of Gram-negative anaerobic bacteria that produce volatile sulfur compounds (VSCs), the main cause of halitosis.

➤ Key bacterial species identified:
° Porphyromonas gingivalis
° Fusobacterium nucleatum
° Prevotella intermedia
° Treponema denticola
° Tannerella forsythia
° Solobacterium moorei

These bacteria break down proteins from food and epithelial cells, producing VSCs such as hydrogen sulfide (H₂S), methyl mercaptan, and dimethyl sulfide, which are highly volatile and malodorous.
A recent metagenomic study by Seerangaiyan et al. (2017) confirmed that the tongue is one of the most microbiologically diverse sites in the oral cavity.

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✅ Causes of Lingual Coating
Several factors contribute to the development of lingual coating:

1. Poor oral hygiene
Failure to brush the tongue promotes debris and microbial buildup.
2. Xerostomia (dry mouth)
Reduced salivary flow impairs the self-cleansing ability of the tongue.
3. Tobacco and alcohol use
These habits disrupt the oral flora and irritate the tongue’s surface.
4. Systemic diseases
Conditions like diabetes, chronic kidney disease, or gastrointestinal infections can manifest with tongue coating.
5. Use of antibiotics or antiseptic mouthwashes
Certain medications can alter the oral microbiome.

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✅ Clinical Consequences of Lingual Coating
Though often considered minor, lingual coating can lead to significant consequences:

° Chronic halitosis: The primary source of intraoral bad breath (Morita & Wang, 2001).
° Taste alterations: Due to mechanical obstruction of taste buds.
° Psychological discomfort: Bad breath may lead to social anxiety or isolation.
° Risk of periodontal disease: Lingual bacteria can colonize the gums.
° Indicator of systemic conditions: May be an early sign of candidiasis or immunosuppression.

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✅ Prevention of Lingual Coating
Effective preventive strategies include:

° Daily tongue cleaning: Using tongue scrapers or brushes with a cleaner surface.
° Proper oral hygiene: Brushing and flossing to reduce overall biofilm.
° Antimicrobial mouth rinses: Chlorhexidine 0.12% or zinc lactate in severe cases.
° Adequate hydration: To stimulate saliva production.
° Avoidance of tobacco and alcohol.
° Regular dental visits: For professional evaluation and monitoring.

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✅ Treatment of Lingual Coating
Treatment should be multifactorial and individualized, addressing the underlying cause:

1. Tongue scraping
° Mechanical removal of coating using specialized tools—highly effective and affordable.
2. Antimicrobial therapy
° Rinses with chlorhexidine, cetylpyridinium chloride, or chlorine dioxide to reduce microbial load.
° Antibacterial toothpastes may support overall reduction of pathogens.
3. Correction of predisposing factors
° Manage dry mouth and systemic conditions (e.g., diabetes, kidney failure).
° Eliminate irritants such as smoking or alcohol.
4. Complementary therapies
° Oral probiotics (e.g., Lactobacillus reuteri) to modulate microbiota.
° Patient education on hygiene techniques and healthy lifestyle choices.

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💡 Conclusion
Lingual coating is more than an aesthetic concern. It reflects microbial imbalances in the oral ecosystem and can impact systemic and psychosocial health. Its prevention and treatment are simple yet require consistency and patient education. A comprehensive approach—addressing both local and systemic factors—is essential for effective management.

📚 References

✔ Morita, M., & Wang, H. L. (2001). Association between oral malodor and adult periodontitis: a review. Journal of Clinical Periodontology, 28(9), 813–819. https://doi.org/10.1034/j.1600-051x.2001.028009813.x

✔ Seerangaiyan, K., Jüch, F., Winkel, E. G., & Winkelhoff, A. J. V. D. (2017). Tongue Microbiome in Healthy Subjects and Patients with Intra-Oral Halitosis. Journal of Breath Research, 11(3), 036010. https://doi.org/10.1088/1752-7163/aa6f9e

✔ Takeshita, T., Suzuki, N., Nakano, Y., & Yamashita, Y. (2008). Relationship between oral malodor and the global composition of indigenous bacterial populations in saliva. Applied and Environmental Microbiology, 74(2), 562–569. https://doi.org/10.1128/AEM.02039-07

✔ Tangerman, A., & Winkel, E. G. (2010). Intra- and extra-oral halitosis: findings of a new classification. Journal of Clinical Periodontology, 37(9), 807–814. https://doi.org/10.1111/j.1600-051X.2010.01699.x

✔ Faveri, M., Gonçalves, L. F., Feres, M., Figueiredo, L. C., & de Figueiredo, C. A. (2006). Prevalence and microbiological diversity of tongue coating in subjects with and without halitosis. Revista da Associação Paulista de Cirurgiões Dentistas, 60(2), 150–155.

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Prosecco Teeth: The Growing Dental Concern at Celebrations

As festive seasons approach, Prosecco often becomes the drink of choice for many. However, dental professionals are raising alarms about a condition termed "Prosecco teeth," highlighting the potential oral health risks associated with this sparkling beverage.

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✅ Understanding 'Prosecco Teeth'
"Prosecco teeth" refers to dental issues such as enamel erosion, increased sensitivity, and discoloration resulting from the consumption of Prosecco. This phenomenon is particularly prevalent during holidays and celebrations when Prosecco consumption surges.

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✅ Why Is Prosecco Harmful to Teeth?
Several factors contribute to the detrimental effects of Prosecco on dental health:

1. High Acidity
Prosecco has a pH level around 3.25, making it highly acidic. Such acidity can erode tooth enamel, leading to increased sensitivity and vulnerability to cavities.
2. Sugar Content
A standard flute of Prosecco contains approximately one teaspoon of sugar. This sugar feeds oral bacteria, producing acids that further erode enamel.
3. Carbonation
The carbonation in Prosecco introduces carbonic acid, which can weaken enamel and exacerbate erosion.
4. Alcohol-Induced Dry Mouth
Alcohol can reduce saliva production, leading to dry mouth. Saliva is essential for neutralizing acids and protecting teeth; its reduction increases the risk of decay.

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✅ Recognizing the Signs
Early indicators of "Prosecco teeth" include:

➤ Increased sensitivity to hot or cold foods and beverages.
➤ Yellowing or discoloration of teeth.
➤ A white line near the gum line, indicating the onset of decay.

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✅ Preventative Measures
To enjoy Prosecco while minimizing dental risks:

1. Moderation
Limit Prosecco intake and avoid prolonged sipping to reduce acid exposure.
2. Pair with Food
Consuming Prosecco alongside food, especially cheese, can help neutralize acids and protect enamel.
3. Use a Straw
Drinking through a straw can minimize contact between Prosecco and teeth, reducing erosion risk.
4. Rinse with Water
After drinking, rinse your mouth with water to help wash away acids and sugars.
5. Delay Brushing
Wait at least 30 minutes after consuming Prosecco before brushing to allow enamel to re-harden.

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✅ Conclusion
While Prosecco adds sparkle to celebrations, it's essential to be aware of its potential impact on dental health. By understanding the risks and taking preventative steps, you can enjoy your favorite bubbly without compromising your smile.

📚 References

✔ Alshahrani, A., Al Zahrani, M., & Alhaddad, A. (2023). Erosive effects of commercially available alcoholic beverages on enamel. PubMed. https://pubmed.ncbi.nlm.nih.gov/36624075/
✔ The Drinks Business. (2017, August 30). Dentist warns of the prosecco smile. https://www.thedrinksbusiness.com/2017/08/dentist-warns-of-the-prosecco-smile/
✔ Patient.info. (n.d.). What is a prosecco smile? Tips to protect your teeth this Christmas. https://patient.info/news-and-features/what-is-a-prosecco-smile-tips-to-protect-your-teeth-this-christmas
✔ Decanter. (2018, November 16). Prosecco teeth: How to combat the risks. https://www.decanter.com/learn/advice/prosecco-teeth-how-to-combat-375405/
✔ Hermitage Dental Practice. (2023, December 15). The hidden dental dangers of Prosecco. https://www.hermitagedental.co.uk/post/the-hidden-dental-dangers-of-prosecco

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Occlusal Splints: Types, Benefits, and Who Needs Them

Occlusal splints, also known as bite guards, night guards, or dental orthotics, are removable dental devices that cover the occlusal (biting) surfaces of teeth. They are used to manage conditions such as bruxism (teeth grinding), temporomandibular joint disorders (TMDs), and excessive dental wear.

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A. Purpose of Occlusal Splints
Occlusal splints serve several key functions:
° Protecting Teeth from Wear: They act as a protective barrier between the upper and lower teeth, preventing enamel erosion and fractures caused by grinding.
° Reducing Jaw and Muscle Pain: By repositioning the jaw and alleviating pressure on the TMJ, they help relieve pain and muscle tension.
° Preventing Further Dental Damage: Patients with bruxism or TMD can experience cracked or worn-down teeth; splints help mitigate this risk.

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B. Types of Occlusal Splints
There are different types of occlusal splints, depending on the patient’s needs:
° Stabilization Splints – Also called flat-plane splints, these are used to prevent bruxism and relieve muscle tension.
° Repositioning Splints – These are designed to reposition the lower jaw to relieve TMJ discomfort.
° Soft Splints – Made of a softer material, these are typically used for mild bruxism cases.
° Dual-Laminate Splints – A combination of hard and soft materials, offering comfort and durability.

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C. Materials Used in Occlusal Splints
Occlusal splints are typically made from the following materials:
° Hard Acrylic Resin (PMMA - Polymethyl Methacrylate): The most common material, it is highly durable and provides excellent stability.
° Thermoplastic Materials: Softer and flexible, these materials offer more comfort but are less durable.
° EVA (Ethylene Vinyl Acetate): Used in softer night guards, providing a balance between comfort and protection.
Dual-Layered Materials: Some splints combine a hard outer shell with a soft inner lining for both protection and comfort.

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D. Who Needs an Occlusal Splint?
Patients who may benefit from occlusal splints include:
° Bruxism Sufferers – Those who grind or clench their teeth, especially at night.
° Patients with TMD – Individuals experiencing jaw pain, clicking sounds, or limited movement of the jaw.
° People with Dental Restorations – Those with veneers, crowns, or implants that need extra protection from excessive force.

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Conclusion
Occlusal splints are essential devices for protecting teeth, managing jaw disorders, and preventing long-term dental complications. Their effectiveness depends on proper diagnosis and professional customization by a dentist.

References
1. Crout, D. K. (2017). Anatomy of an occlusal splint. General Dentistry, 65(2), 52-56. AGD
2. Okeson, J. P. (2014). Management of Temporomandibular Disorders and Occlusion (7th ed.). Elsevier.
3. Jagger, R. (2003). The effectiveness of occlusal splints for sleep bruxism. Evidence-Based Dentistry, 4(2), 39-40.
4. Wright, E. F. (2014). Occlusal Appliance Therapy. In Manual of Temporomandibular Disorders (pp. 149–222). Wiley-Blackwell.
5. Clark, G. T., & Minakuchi, H. (2006). Oral Appliances. In Laskin, D. M., Greene, C. S., & Hylander, W. L. (Eds.), Temporomandibular Disorders: An Evidence-based Approach to Diagnosis and Treatment (pp. 377–390). Quintessence Publishing.

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