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Item Are new dentists prepared for clinical practice? A survey of the clinical abilities of new dental graduates in the U.S. military(2024) Chiodo, Kathleen; Cook, N. Blaine; Capin, Oriana; Diefenderfer, Kim; Adcook, RichardObjective: This study aimed to identify new dentists’ competence in preventive and restorative procedures, as self-assessed by the new dentists and evaluated by their clinical supervisors. Justification: Preventive and restorative dental procedures constitute the majority of treatment provided daily in a general dentistry practice. Exploring new dentist proficiency in these foundational skills within one year of dental school graduation provides crucial information regarding the knowledge and skills new dentists attain during dental school. The military dental system is structured so that all new dentists receive close clinical oversight during their first year following graduation. Hypotheses: (1) The majority of dentists who have graduated less than one year prior to this survey will self-assess their skills in basic preventive and restorative dental procedures as “competent” or higher. (2) The majority of supervisor evaluations of new dentists will also average a level of “competent” or higher. (3) New dentists will self-assess their competence levels higher than their supervisors will evaluate them. Methods: An electronic, anonymous Qualtrics survey was sent to U.S. Air Force, Army and Navy new dentists and their clinical supervisors November 2022. Using a modified-Dreyfus model of skill acquisition, new dentists completed a self-assessment of 20 preventive and restorative procedures. Their clinical supervisors also completed a survey evaluating the proficiency level of the new dentists they oversaw. Results: 60 new dentists and 25 supervisors, accounting for 151 new dentists, responded. The proportion of competence ratings at a level of “competent” or higher (“proficient,” “expert”) was estimated, along with a 95% confidence interval, and one-sample chi-square tests were used to compare the proportion against 50%. Supervisors’ ratings of the new dentists’ skill levels were significantly lower than the new dentists’ ratings for 19 of the 20 dental procedures. Supervisors’ ratings of competent or higher were significantly greater than 50% in caries diagnosis and treatment planning, caries risk assessment, Class III anterior composite resins and posterior composite resins. Overall, supervisors rated 71.3% of new dentists at Novice or Beginner skill level. Conclusion: Supervisor ratings of the new dentists’ skill levels were significantly lower than the dentists’ ratings for the majority of procedures. New dentists and supervisors significantly disagreed on new dentists’ skill levels in the treatment of class I and II amalgams, endodontically treated teeth without a post, and crown preparation and delivery. Overall, 28.7% of new dentists were evaluated as competent in preventive and restorative procedures during their first year following dental school graduation.Item Chlorhexidine-modified nanotubes and their effects on the polymerization and bonding performance of a dental adhesive(Elsevier, 2020-05) Kalagi, Sara; Feitosa, Sabrina A.; Münchow, Eliseu A.; Martins, Victor M.; Karczewski, Ashley E.; Cook, N. Blaine; Diefenderfer, Kim; Eckert, George J.; Geraldeli, Saulo; Bottino, Marco C.; Cariology, Operative Dentistry and Dental Public Health, School of DentistryObjectives: The purpose of this study was to synthesize chlorhexidine (CHX)-encapsulated aluminosilicate clay nanotubes (Halloysite®, HNTs) and to incorporate them into the primer/adhesive components of an etch-and-rinse adhesive system (SBMP; Scotchbond Multipurpose, 3M ESPE) and to test their effects on degree of conversion, viscosity, immediate and long-term bonding to dentin. Methods: CHX-modified HNTs were synthesized using 10% or 20% CHX solutions. The primer and the adhesive components of SBMP were incorporated with 15wt.% of the CHX-encapsulated HNTs. Degree of conversion (DC) and viscosity analyses were performed to characterize the modified primers/adhesives. For bond strength testing, acid-etched dentin was treated with one of the following: SBMP (control); 0.2%CHX solution before SBMP; CHX-modified primers+SBMP adhesive; SBMP primer+CHX-modified adhesives; and SBMP primer+CHX-free HNT-modified adhesive. The microtensile bond strength test was performed after immediate (24h) and long-term (6 months) of water storage. Data were analyzed using ANOVA and Tukey (α=5%) and the Weibull analysis. Results: DC was greater for the CHX-free HNT-modified adhesive, whereas the other experimental adhesives showed similar DC as compared with the control. Primers were less viscous than the adhesives, without significant differences within the respective materials. At 24h, all groups showed similar bonding performance and structural reliability; whereas at the 6-month period, groups treated with the 0.2%CHX solution prior bonding or with the CHX-modified primers resulted in greater bond strength than the control and superior reliability. Significance: The modification of a primer or adhesive with CHX-encapsulated HNTs was an advantageous approach that did not impair the polymerization, viscosity and bonding performance of the materials, showing a promising long-term effect on resin-dentin bonds.Item Combined effects of soft drinks and nicotine on Streptococcus mutans metabolic activity and biofilm formation(J-STAGE, 2021-01) Mokeem, Lamia S.; Willis, Lisa H.; Windsor, L. Jack; Cook, N. Blaine; Eckert, George; Gregory, Richard L.; Cariology, Operative Dentistry and Dental Public Health, School of DentistryThe purpose of this study was to explore the effects of nicotine on the activity of Streptococcus mutans (S. mutans) in soft drinks. Regular soft drinks contain large proportions of high-fructose corn syrup (HFCS), which increases the activity of S. mutans resulting in high-caries risk compared with sugar-free soft drinks. Nicotine use exhibits a strong correlation with increased S. mutans biofilm formation. The soft drinks chosen were (Coca-Cola Classic, Diet Coke, Coca-Cola Zero Sugar, Caffeine-Free Coca-Cola, Caffeine-Free Diet Coke, Caffeine-Free Coca-Cola Zero Sugar). S. mutans was grown overnight in tryptic soy broth; nicotine was diluted in tryptic soy broth supplemented with 1.0% sucrose followed by soft drinks in dilution of 1:3. Total growth absorbance and biofilm growth were determined by spectrophotometry, absorbance measured to determine biofilm formation, and metabolic activity quantified. One-way ANOVA showed a considerable effect for HFCS and caffeine in the presence of nicotine and their interaction in all measures. Results showed sugar-free caffeinated colas demonstrated significant effect in inhibiting S. mutans biofilm formation and metabolic activity with nicotine. Nicotine-induced S. mutans increased biofilm formation and metabolic activity in the presence of HFCS and caffeine in soft drinks. In conclusion, smokers should consider sugar-free caffeinated versions to minimize the chance of developing dental caries dut to the reduction of biofilm formation.Item Comparison of Internal Adaptation of Bulk-fill and Increment-fill Resin Composite Materials(2019-01) Alqudaihi, Fatema Sabri; Cook, N. Blaine; Diefenderfer, Kim E.; Bottino, Marco C.; Platt, Jeffrey A.; Cariology, Operative Dentistry and Dental Public Health, School of DentistryObjectives: To evaluate 1) the internal adaptation of a light-activated incremental-fill and bulk-fill resin-based composite (RBC) materials by measuring the gap between the restorative material and the tooth structure and 2) the aging effect on internal adaptation. Methods and Materials: Seventy teeth with class I cavity preparations were randomly distributed into five groups; four groups were restored with bulk-fill RBCs: Tetric EvoCeram Bulk Fill (TEC), SonicFill (SF), QuiXX Posterior Restorative (QX), and X-tra fil (XF); the fifth group was restored with incremental-fill Filtek Supreme Ultra Universal Restorative (FSU). One-half of the specimens of each group were thermocycled. Each tooth was sectioned, digital images were recorded, and the dimensions of any existing gaps were measured. Data were analyzed using analysis of variance (α=0.05). Results: FSU had the smallest gap measurement values compared with the bulk-fill materials except QX and TEC (p≤0.008). FSU had the smallest sum of all gap category values compared with the bulk-fill materials, except QX (p≤0.021). The highest gap incidence and size values were found at the composite/adhesive interface. All aged groups had greater gap values in regard to the gap measurement and the sum of all gap categories compared with non-aged groups. Significance: The incrementally placed material FSU had the highest internal adaptation to the cavity surface, while the four bulk-fill materials showed varied results. Thermocycling influenced the existing gap area magnitudes. The findings suggest that the incremental-fill technique produces better internal adaptation than the bulk-fill technique.Item Effect of Bottled Water and Fluoride Toothpaste Usage on Caries Lesion Remineralization.(2023) Qaw, Masoumah Samir; Lippert, Frank; Al Dehailan, Laila; Hara, Anderson T; Cook, N. BlaineBackground: The importance of fluoride in the prevention of dental caries has been well documented in the literature, as it inhibits demineralization of the tooth structure and enhances remineralization. One of the major public health policies to prevent caries is to provide the population with an adequate amount of fluoride through community water fluoridation. Nowadays many people drink bottled water instead of tap water due to its easy access, convenience, and low cost. Besides fluoride, other minerals present in tap and bottled water, such as calcium and magnesium, are also important in decreasing dental caries prevalence. However, our knowledge of the role of bottled water in caries prevention and especially when combined with fluoride toothpaste usage is still poor. Objectives: The aim of this in-vitro study was to evaluate the effects of some bottled waters on fluoride toothpaste efficacy in enhancing caries lesion remineralization. Methodology: Early caries lesions were created in bovine enamel specimens and stratified into treatment groups based on Vickers surface microhardness (VHN). The present study followed a two (fluoride and fluoride-free toothpaste) by five (four bottled waters and tap water) factorial design. The treatment groups were bottled water with the following attributes: a) 309.9 ppm Ca/1.20 ppm F; b) 118.4 ppm Ca/0.16 ppm F; c) 1.00 ppm Ca/1.01 ppm F; d) 0.1 ppm Ca/0.04 ppm F, and tap water (48.7 ppm Ca/0.7 ppm F). The five water groups were paired either with 1100 ppm fluoride or fluoride-free toothpaste, yielding 10 groups. Specimens were pH-cycled for 10 days with the daily regimen comprised of twice daily toothpaste slurry, with four exposures to water in between. VHN was measured, again, and the difference calculated (ΔVHN). Data were analyzed using two-way ANOVA at a 5-percent significance level. Results: The two-way interaction between water and toothpaste was significant (p < 0.001). All groups except fluoride-free toothpaste/bottled water with 0.1 ppm Ca/0.04 ppm F (p = 0.411) had significant increases in VHN after pH cycling (p ≤ 0.023). Fluoridated toothpaste resulted in a higher rate of remineralization compared to fluoridefree toothpaste (all p < 0.001). Bottled water with 1.20 ppm F/309.9 ppm Ca exhibited the greatest extent of remineralization within fluoride toothpaste groups (p < 0.001) and higher remineralization than lower fluoride water in fluoride-free toothpaste groups (p ≤ 0.006). Within the fluoridated toothpaste group, tap water exhibited significantly less remineralization compared to all bottled waters (all p < 0.001). Conclusion: Within the limitation of this study, bottled water with higher fluoride and calcium concentrations might improve fluoridated toothpaste efficacy by enhancing remineralization of early enamel caries-like lesions.Item Effect of Chlorhexidine-Encapsulated Nanotube-Modified Adhesive System on the Bond Strength to Human Dentin(2019) Kalagi, Sara Arfan; Cook, N. Blaine; Diefenderfer, Kim; Bottino, Marco; Feitosa, SabrinaIntroduction: The resin-dentin interface undergoes degradation by endogenous matrix metalloproteinases (MMPs) after adhesive procedures. Application of several MMP inhibitors such as chlorhexidine (CHX) to the demineralized collagen dentin matrix after acid-etching has been suggested to be a successful approach to prevent degradation of the hybrid layer. Further, nanotubes (HNT) have been used as a reservoir for encapsulation and controlled delivery for several therapeutic drugs with sustained release. Therefore, HNT can be encapsulated with CHX and incorporated into dentin adhesives for the possibility of enhancing the longevity and durability of the hybrid layer. Objective: To evaluate the effect of a CHX-encapsulated nanotube-modified primer/PR and adhesive/ADH on the microtensile resin bond strength (µTBS) to dentin. Materials and Methods: A commercial adhesive and its respective primer were modified by adding CHX-encapsulated nanotubes at two distinct concentrations (10 and 20 wt.%). The experimental adhesives were evaluated by degree of conversion (DC) and viscosity. Meanwhile, only viscosity was determined for the experimental primers. The prepared HNT-encapsulated with CHX (10 and 20 wt.%) powders were incorporated into the primer and/or adhesive according to the groups: ADH (control); HNT (control); 0.2% CHX; PR+CHX10%; PR+CHX20%; ADH+CHX10%; ADH+CHX20%. Human molars were selected and autoclaved; mid-coronal dentin surfaces were exposed for bonding purposes. Dentin surfaces were etched, followed by primer and adhesive application, and restored with a resin composite. After 24 hours, the teeth were sliced into beams for µTBS testing; beams collected for each tooth were equally assigned into two testing condition groups: 24 hours and 6 months. Microtensile bond strength was tested using a universal testing machine, and the types of failure were classified as adhesive, mixed, and cohesive failure. Data from DC and viscosity tests were analyzed using one-way ANOVA. Bond strength data were analyzed by pair-wise comparisons using the Sidak method to control the overall significance level at 5% for each aging time separately. Weibull-distribution survival analysis was used to compare the differences in the microtensile bond strength results among the groups after 24 hours and 6 months. Results and Conclusion: DC analysis revealed no significant differences among adhesive groups. However, ADH group had a significantly lower viscosity than modified adhesive groups, and a significantly higher viscosity than modified primer groups. Test results of stress value (MPa) by each group for each aging time revealed no significant differences among groups after 24 hours. However, after 6-month storage, modified primer groups (PR+CHX10%, PR+CHX20%) and 0.2%CHX group showed a significant difference in µTBS compared to control groups (ADH, HNT) and modified adhesive groups (ADH+CHX10%, ADH+CHX20%) in the same aging time testing (p < 0.05). When comparing the µTBS after 24 hours and 6 months, there were no significant differences among the groups except for the ADH+CHX20% group, for which MPa values were higher after 24 hours than 6 months (p = 0.0487). In conclusion, this study has demonstrated the great potential of modified dental primers with CHX-encapsulated nanotubes in preservation of the resin-dentin bond strength over a 6-month time period. Additionally, modification of dental primers and adhesives was a successful approach that didn’t compromise the characteristics or the mechanical properties of the materials and has a promising long-term effect on resin-dentin bond strength.Item Effect of full-contour Y-TZP zirconia surface roughness on wear of glass-based ceramics(2011) Luangruangrong, Palika, 1983-; Bottino, Marco C.; Hara, Anderson T.; Cochran, Michael A.; Cho, Sopanis D.; Cook, N. BlaineThe use of yttria-stabilized tetragonal zirconia polycrystal (Y-TZP), normally employed as a framework for all-ceramic restorations, has now started to be used without any veneering ceramics in patients with parafunctional activities. The aims of this study were to evaluate the influence of Y-TZP surface roughness on the wear behavior (volume/height loss) against glass-based ceramics (i.e., IPS Empress CAD and IPS e.max CAD, Ivoclar-Vivadent). Thirty-two Y-TZP full-contour zirconia (Ardent®) sliders (ϕ=2 mm, 1.5 mm in height) were milled in a CAD/CAM unit and sintered according to the manufacturer instructions. Sliders were embedded in brass holders using acrylic resin and then randomly allocated into 2 groups according to the surface treatment (n=16): G1-as-machined and G2-glazed (Diazir®). Empress and e.max antagonists were cut into tabs (13×13×2 mm) wet-finished and also embedded in brass holders. Two-body pin-on-disc wear testing was performed at 1.2 Hz for 25,000 cycles under a 3-kg load. Non-contact profilometry was used to measure antagonist height (μm) and volume loss (mm3). Qualitative data of the testing surfaces and wear tracks were obtained using SEM. Statistics were performed using one- and two-way ANOVAs (α=0.05). The results indicated that G1 yielded significantly higher mean roughness values (Ra=0.83 μm, Rq=1.09 μm) than G2 (Ra=0.53 μm, Rq=0.78 μm). Regarding antagonist loss, G1 caused significantly less antagonist mean height and volume loss (68.4 μm, 7.6 mm3) for Empress than G2 (84.9 μm, 9.9 mm3) while no significant differences were found for e.max. Moreover, Empress significantly showed lower mean height and volume loss than e.max (p<0.0001). SEM data revealed morphological differences on wear characteristics between the two ceramics against Y-TZP. Within the limitations of this study, e.max wear was not affected by Y-TZP surface roughness. However, Empress wear was greater when opposing glazed Y-TZP. Overall, based on our findings, surface glazing on full-contour Y-TZP did not minimize glass-ceramic antagonist wear when compared with as-machined group.Item Longevity of Crown Margin Repair Using Glass Ionomer: A Retrospective Study(International Association for Dental Research, 2020) Watson, Justin; Tang, Qing; Patel, Jay; Diefenderfer, Kim E.; Thyvalikakath, Thankam; Cook, N. BlaineObjectives: Repair of crown margins may extend the functional life of existing crowns. However, the longevity of such treatment is unknown. This study determined the survival time of crown margin repairs (CMR) with glass-ionomer (GI) and resin-modified glass-ionomer cements. Methods: We queried axiUm (Exan Group, Coquitlam, BC, Canada) database for permanent teeth that underwent CMR in the Graduate Operative Dentistry Clinic, Indiana University School of Dentistry (IUSD), Indianapolis, Ind., USA, from January 1, 2006 through January 1, 2018. Since there is no CDT code for the CMR procedure, CDT codes for resin-composite and GI restorations (D23XX) were queried; these patients also had treatment notes that indicated CMR. The final data set included patient ID, birth date, gender, dates of treatments, CDT codes, tooth type, tooth surface and existing findings. Two examiners developed guidelines for record review and manually reviewed the clinical notes of patient records to confirm CMR. Only records that were confirmed with the presence of CMR were retained in the final dataset for survival analysis. Survival time was calculated by Kaplan-Meier statistics and a Cox Proportional Hazards model was performed to assess the influence of selected variables (p < 0.05). Results: 214 teeth (115 patients) with CMR were evaluated. Patient average age was 69.4 11.7 years old. Posterior teeth accounted for 78.5 percent (n = 168) of teeth treated. CMRs using GI had a projected 5-year survival rate of 62.9 percent (K-M Analysis) and an 8.9 percent annual failure rate. Cox Proportional Hazards Regression analysis revealed that none of the factors examined (age, gender, tooth type) affected time to failure. Conclusion: CMRs may extend the longevity of crowns with defective margins. Larger EHR studies or case control studies are needed to investigate other variables, such as the caries risk status or the severity of defects that may affect the survival rate of CMR.Item Longevity of Crown Margin Repairs Using Glass Ionomer: A Retrospective Study(2020) Watson, Justin I.; Cook, N. Blaine; Thyvalikakath, Thankam; Diefenderfer, Kim E.; Capin, OrianaObjectives: Repair of crown margins may extend the functional life of existing crowns. However, the longevity of such treatment is unknown. This study determined the survival time of crown margin repairs (CMR) with glass-ionomer (GI) and resin-modified glass-ionomer cements. Methods: We queried axiUm (Exan Group, Coquitlam, BC, Canada) database for permanent teeth that underwent CMR in the Graduate Operative Dentistry Clinic, Indiana University School of Dentistry (IUSD), Indianapolis, Ind., USA, from January 1, 2006 through January 1, 2018. Since there is no CDT code for the CMR procedure, CDT codes for resin-composite and GI restorations (D23XX) were queried; these patients also had treatment notes that indicated CMR. The final data set included patient ID, birth date, gender, dates of treatments, CDT codes, tooth type, tooth surface and existing findings. Two examiners developed guidelines for record review and manually reviewed the clinical notes of patient records to confirm CMR. Only records that were confirmed with the presence of CMR were retained in the final dataset for survival analysis. Survival time was calculated by Kaplan-Meier statistics and a Cox Proportional Hazards model was performed to assess the influence of selected variables (p < 0.05). Results: 214 teeth (115 patients) with CMR were evaluated. Patient average age was 69.4 11.7 years old. Posterior teeth accounted for 78.5 percent (n = 168) of teeth treated. CMRs using GI had a projected 5-year survival rate of 62.9 percent (K-M Analysis) and an 8.9 percent annual failure rate. Cox Proportional Hazards Regression analysis revealed that none of the factors examined (age, gender, tooth type) affected time to failure. Conclusion: CMRs may extend the longevity of crowns with defective margins. Larger EHR studies or case control studies are needed to investigate other variables, such as the caries risk status or the severity of defects that may affect the survival rate of CMRs.Item Longitudinal In Vitro Effects of Silver Diamine Fluoride on Early Enamel Caries Lesions(2020) Thompson Alcorn, Alice-Anne; Lippert, Frank; Al Dehailan, Laila; Cook, N. BlaineObjective: This study aimed to evaluate surface microhardness changes in early, incipient, non-cavitated white-spot, enamel caries lesions treated with silver diamine fluoride (SDF) longitudinally. The utilization of silver nitrate and potassium fluoride test groups served as additional controls to assist in evaluating if the remineralization effects were due to the silver or fluoride component in SDF. Hypotheses: 1. SDF treatment will result in increased surface microhardness of early, incipient, non-cavitated white-spot, enamel caries lesions compared to all other tested interventions. 2. Specimen storage for 2-weeks in artificial saliva will result in greater surface rehardening in lesions treated with SDF compared to other tested interventions. Design: This laboratory study had 5 intervention groups (SDF, silver nitrate (AgNO3), potassium fluoride (KF), 5.0-percent sodium fluoride varnish (FV), deionized water (DI)) × 2-time intervals after intervention (immediate & delayed pH-cycling), resulting in 10 groups (n = 18). Early, incipient, non-cavitated white-spot, enamel caries lesions were created in bovine enamel and extent of demineralization was determined using Vickers surface microhardness (VHNlesion). Intervention treatments were applied. Half the specimens from each group underwent immediate 5-day pH-cycling and half were stored in an incubator with artificial saliva for two weeks before undergoing 5-day pH-cycling. After pH-cycling, lesion hardness was evaluated using VHNpost. Specimens were then exposed to a second demineralization challenge and lesion softening was evaluated using VHNsecdem. Surface rehardening was calculated: ΔVHN =VHNpost - VHNlesion. Surface softening was calculated: ΔVHNsecdem =VHNsecdem – VHNpost. Data was analyzed using two-way ANOVA. Results: Immediately cycled, SDF had significantly (p < .0001) greater remineralization than DI, AgNO3, and FV. All delayed cycling groups had significantly (p < .0001) greater remineralization than FV. Significantly greater remineralization was noted in delayed AgNO3 (p < .0001), DI (p = .0003), and FV (p = .0006) compared to immediately cycled. After the second demineralization challenge, FV had significantly less surface softening than AgNO3 (p = 0.0002), DI (p = 0.0003), KF (p = 0.0225), and SDF (p = 0.0388) intervention groups. No significant difference was found between the pH-cycle timings. Conclusion: Based on our findings, FV maybe better suitable than SDF to treat early, incipient, non-cavitated white-spot, enamel caries lesions. Longitudinally, SDF exhibited greater remineralization than both FV and DI groups, though not statistically significant. However, upon a second demineralization challenge, FV significantly outperformed SDF in preventing surface softening.