Discussion.—The clinical guideline developed is basedon five predictors andwas able to differentiate well betweenpersons who are at varying risks for having undiagnoseddiabetes. For certain subgroups, persons with periodontaldisease ran amuch high risk of having undiagnosed diabetescompared to persons without periodontal disease.

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Clinical Significance.—Dentists could usethis tool to identify patients who may haveundiagnosed diabetes. Finding these cases andreferring them to medical care providers for

4 Dental Abstracts

treatment can improve the general health of thepatient, reduce morbidity, and lower healthcare costs.

Li S, Williams PL, Couglass CW: Development of a clinical guidelineto predict undiagnosed diabetes in dental patients. J Am Dent As-soc 142:28-37, 2012

Reprints available from CW Douglass, Harvard School of DentalMedicine, 188 Longwood Ave, Boston, MA 02115; e-mail:chester_douglass@hsdm.harvard.edu

OrthodonticsChewing gum to relieve pain

Background.—Fixed orthodontic appliances are associ-ated with a decline in the oral health-related quality of life(OHRQoL) of both adolescents and adults, especially in thefirst month after placement. Functional and social discom-fort, physical discomfort, and pain may adversely affect pa-tients’ compliance and willingness to complete treatment.Systemic analgesics are the most common intervention, butlocal pharmaceutical agents andnonpharmacologicmethodssuch as transcutaneous electrical nerve stimulation and lasershave also beenused. The act of chewing increases pulpal sen-sory thresholds to electrical stimulation andmay increase theblood flow into and around the periodontal membrane,restore lymphatic circulation, and prevent or relieve inflam-mation and edema. Chewing also stimulates salivary flow,which increases bicarbonate concentration and the pH andbuffering capacity of saliva. The rate of clearance of oral sugarand plaque acid is also increased, which reduces demineral-ization and caries incidence.Whether chewing gum can posi-tively affect the impact and pain caused by fixed orthodonticappliances was investigated.

Methods.—Participants were between ages 11 and 18years and about to begin treatment with a fixed orthodonticappliance in at least one dental arch. A total of 57 subjectswere randomly assigned to two groups. The chewing gum(CG) group received chewing gum to use when requiredat the bonding/separator appointment and subsequent ap-pointments up to the visit after the working arch wire wasplaced. The non-chewing gum (NG) group participantswere asked not to chew gum for the duration of the study.After each visit up to and including the arch wire placementappointment, participants were asked to complete a diarythat included an Impact of Fixed Appliances (IFA) question-naire to quantify the impact of a fixed appliance on daily life.

The IFA included one global question and 32 questions innine subscales. The responses to the 32 questions weresummed to yield a Total Impact Score (TIS). Participantswere to complete the diary 24 h and 1 week after placementor adjustment of the appliance. They were also asked toindicate how much their teeth hurt at those times using a100-mm visual analogue scale (VAS). Those in the CG groupwere also asked to note how many sticks of gum they used.The primary outcome was TIS after 24 h and 1 week. Sec-ondary outcomemeasures included pain assessments usingthe VAS, reported use of oral analgesics, and recorded appli-ance breakage.

Results.—Analysis of responses to the global rating ofimpact question indicated that the frequency of impactswas significantly lower for the CG group at 24 h, but notat 1 week. After 24 h the median TIS was 89 for the NCgroup and 73 for the CG group, which was a significant dif-ference. After 1 week the median TIS was 78 for the NCgroup and 70 for the CG group, a difference that was notsignificant.

Median VAS was 45 mm for the NC group and 20 mm forthe CG group after 24 h, which were significantly differentvalues. Median VAS was 21 mm for the NC group and 9mm for the CG group after 1 week, a difference that wasno longer significant.

No significant differences were noted between the twogroups’ use of pain medications at either 24 h or 1 week.The CG group chewed a median of 5 sticks of gum after24 h and 6 after 1 week. No significant differences werefound between the two groups with respect to the numberof appliance failures that occurred.

Discussion.—Chewing gum significantly diminished theimpact and pain related to appliance placement or adjust-ment but did not lead to a higher incidence of appliancebreakage. When young people receive a fixed appliance orundergo an adjustment of the appliance, they can be encour-aged to use a sugar-free chewing gum to relieve discomfort.

Clinical Significance.—Patients usuallyreport the highest pain levels 24 h after fixedappliance placement or adjustment. The painthen declines over the course of the followingweek. Most of the participants in this study indi-cated that chewing gum helped them deal withthe pain and discomfort. Some mentioned thatthe chewing distracted them. Others found that

chewing gum did not help when the teeth werevery sore. The effects of chewing gum on sali-varyflow, cleansing the appliance, and reducingdemineralization were not explored but wouldbe interesting topics for future research.

Benson PE, Razi RM, Al-Bloushi RJ: The effect of chewing gum onthe impact, pain and breakages associated with fixed orthodonticappliances: A randomized clinical trial. Orthod Craniofac Res; firstpublished online June 22, 2012

Reprints available from PE Benson, Academic Unit of Oral Health andDevelopment, School of Clinical Dentistry, Univ. of Sheffield, ClaremontCrescent, Sheffield S10 2TA, UK; e-mail: p.benson@sheffield.ac.uk

Pain ManagementNeurosensory deficit after third molar surgery

Background.—Third molar surgery is a common oralsurgical procedure, but can be accompanied by neuro-sensory deficit affecting the lingual nerve (LN) or inferioralveolar nerve (IAN). Patients experience anesthesia, hyp-esthesia, hyperesthesia, or dysesthesia in the distribu-tions of the affected nerve, with or without tastedisturbance. A third of these deficits can become perma-nent. Various treatments are available, but their efficaciesseem to vary. The treatments and their outcomes werediscussed.

Methods.—A systematic review was done, identifying10 studies that fulfilled all selection criteria. Nine wereretrospective and one was prospective in design. Nonewere randomized controlled clinical trials. Six treatmentmodalities—four surgical and two nonsurgical—were iden-tified. The surgical treatments included external neurolysis,nerve repair by direct suturing, and bridging the nervedefect using an autogenous vein graft or Gore-Tex tube.The nonsurgical treatments were acupuncture and low-level laser therapy (LLLT).

Results.—Results indicate that surgery is the mainstayof treatment for neurosensory deficits after third molar sur-gery. Most of the subjects who had surgery had LN injuries,perhaps because LN injury related to taste disturbance maylead to a higher demand for nerve repair. IAN injury has aslightly better prognosis, with a higher chance for sponta-neous reinnervation and nerve recovery.

The indications for surgical repair were moderate to se-vere hypesthesia or anesthesia, hyperesthesia, or dysesthe-sia along the IAN or LN distribution without or without tastedisturbance with LN injury. External neurolysis was usedwhen the injury was less severe or the nerve appeared tobe in continuity during surgical exploration. Reanastomosiswas required when the nerve damage was more severe,with extensive fibrosis and neuroma formation. Bridgeswere needed when the nerve endings could not opposewithout tension or a sizable gap. A small gap within 5 mmwas the suggested threshold for a reasonable chance forneurosensory recovery.

For IAN injury, external neurolysis tends to have apoorer outcome than with LN injury. Some IAN injuriesmay be severe enough to form a neuroma, but, becausethis nerve is confined to its canal, it may macroscopicallyresemble a nerve in continuity. Because a less severelyinjured nervemay fool less experienced surgeons to chooseto perform external neurolysis alone, its clinical result iscompromised. Excision of the neuroma and direct suturingpermit better recovery of the IAN. Sensory recovery is alsobetter with conduits when the nerve defect gap is 5 mm orless.

Full recovery of sensation through surgical interven-tions is uncommon, achieved by fewer than 30% of patientsafter external neurolysis of the injured nerve and 5.7% orfewer patients after suturing with or without a conduit.

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