# data[].attributes.headline
Orofacial Myofunctional Therapy for Patients with Obstructive Sleep Apnea — A Mixed Methods Study of Facilitators and Barriers to Treatment Adherence

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Orofacial Myofunctional Therapy for Patients with Obstructive Sleep Apnea — A Mixed Methods Study of Facilitators and Barriers to Treatment Adherence

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Summery:

Orofacial myofunctional therapy (OMT) was tested in adults with obstructive sleep apnea using a 12-week exercise program guided by a therapist. Participants reported improved sleep quality and daytime function, but adherence varied widely. Common barriers included the fixed protocol, difficulty with exercises, and diary burden, while motivators included therapist support and belief in health benefits. The study concludes that OMT may improve symptoms, but success depends heavily on adherence and supportive guidance.

# data[].attributes.attachment_link.title
Orofacial Myofunctional Therapy for Patients with Obstructive Sleep Apnea—A Mixed Methods Study of Facilitators and Barriers to Treatment Adherence

# data[].attributes.attachment_link.description
Orofacial myofunctional therapy (OMT) for obstructive sleep apnea (OSA) is a promising, new treatment. We aimed to study patients’ experiences and adherence to OMT. Twelve patients with OSA were included in the study, and they engaged in OMT exercises three times daily for 12 weeks. Participants tracked their sleep and OMT exercise activities in an electronic diary. Exercise techniques were guided by a certified therapist. Patients’ experiences with OMT were assessed through semi-structured individual interviews conducted after a 12-week intervention, and the transcripts were analyzed using thematic analysis. The findings revealed an overarching theme that captured both facilitators of and barriers to OMT, organized into three subthemes: (1) motivation, (2) perceived support, and (3) perceived effects. Motivation was driven by a desire to improve general health and avoid continuous positive airway pressure treatment, and was supported by a sense of mastery and perceived effectiveness. Key facilitators included a trusting patient–therapist relationship, as well as developing routines and a sense of control. Barriers involved managing the comprehensive treatment protocol, insecurities around exercise execution and the potential impact of OMT, sickness burden, and previous negative healthcare experiences. These themes were supported by quantitative findings, which demonstrated high treatment adherence, while sleep data indicated modest individual improvements in subjective sleep quality and efficiency. By recognizing facilitators and barriers and addressing the individual differences among OSA patients, healthcare providers can better tailor their approach to meet diverse patient needs. This personalized approach, supported by emerging sleep improvements, may enhance patient engagement and improve adherence to OMT.

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Effectiveness of Orofacial Myofunctional Therapy for Speech Sound Disorders (SSD) in Children: A Systematic Review

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Effectiveness of Orofacial Myofunctional Therapy for Speech Sound Disorders (SSD) in Children: A Systematic Review

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Summary: This systematic review examined OMT for children with organic speech sound disorders across 13 studies. Results showed that high-quality studies generally did not find clear improvements in speech from OMT alone, though lower-quality studies sometimes reported positive effects. The best outcomes were seen when OMT was combined with traditional articulation therapy. Overall, evidence suggests OMT may be a useful adjunct but not an effective stand-alone treatment for speech sound disorders.

# data[].attributes.attachment_link.title
Effectiveness of Orofacial Myofunctional Therapy for Speech Sound Disorders in Children: A Systematic Review

# data[].attributes.attachment_link.description
Orofacial myofunctional therapy (OMT) is an intervention approach used to remediate orofacial myofunctional disorders (OMDs). OMDs are abnormal patterns involving the oral and orofacial musculature that can subsequently interfere with the normal growth, development, or function of orofacial structures, including speech production. Historically, articulation therapy is used to remediate speech sound disorders (SSDs). Currently, there is a dearth of literature on the use of OMT to treat non-developmental (organic) SSDs in children. The aim of this systematic review is to examine the effectiveness of OMT in treating organic SSDs in children and adolescents between 4 and 18 years of age. A search of five electronic databases (ProQuest, Scopus, Ovid, CINAHL, and Embase) was conducted, including backward (identifying and reviewing references from earlier studies from sources) and forward searching (reviewing newer studies that have cited a source). Only primary research including OMT with post-treatment outcome measures for speech production were included. Thirteen studies were reviewed, including a total of 397 participants between 4 and 17 years of age. A range of study designs, diagnoses, and intervention approaches were discussed. Studies yielded mixed results on the effectiveness of OMT to treat organic SSDs. OMT alone, and in combination with articulation therapy, was not found to be more effective than articulation therapy alone. The methodological quality of the studies ranged from limited to strong. Findings from high quality studies showed no improvement to speech that could be directly attributed to OMT, and lower quality studies yielded mixed results. This review found no conclusive evidence supporting the use of OMT as a standalone treatment for the effective remediation of SSDs. This is attributed to significant variability in speech outcomes, small sample sizes, limited comparison groups, diverse participant diagnoses, and inconsistent methodologies and treatment protocols, yielding mixed results. In addition, while the term OMT was used in the papers to designate treatment methodology, an analysis of the exercise descriptions revealed that some reported OMT exercises were non-speech oral motor exercises (NSOMEs) and oral motor therapies. Overall, many of the techniques utilized across studies did not provide speech-like movements in their therapeutic interventions based on their description. Finally, traditional articulation therapy, including speech drills to work on articulation disorders, was not included in many of the included studies. SLPs using OMT as a modality would typically combine this with articulation practice to treat the SSD. This study highlights the need for robust future studies including prospective cohort studies to compare OMT, combined OMT and articulation therapy, and articulation therapy alone to provide clearer guidance for future clinical practice.

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Impact of myofunctional therapy on orthodontic management and orthognathic surgery outcomes: a scoping review

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Impact of myofunctional therapy on orthodontic management and orthognathic surgery outcomes: a scoping review

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Summary: Within this article, they take two different groups of people, those with myofunctional disorders, and try myofunctional therapy on one group to see if therapy makes a difference. They found that there was a difference and a better occlusion in the group with therapy, and that the group without therapy stayed the same or got worse. Concluding that there is a true benefit with myofunctional therapy.

# data[].attributes.attachment_link.title
Impact of myofunctional therapy on orthodontic management and orthognathic surgery outcomes: a scoping review

# data[].attributes.attachment_link.description
Orofacial myofunctional disorders (OMDs) are conditions or behaviors that negatively affect oral postures and functions. These behaviors can interfere with normal orofacial growth and development and related functions. Map the available evidence…

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Summary: This study compared image quality between the

handheld Nomad Pro 2 and the wall-mounted Heliodent

Plus using a maxillofacial phantom. Results showed

comparable quality across anterior teeth, premolars, molars,

and bitewing

# data[].attributes.attachment_link.readable_text
Abstract

Objectives

The aim of this study was to determine whether a handheld (HH) X-ray device (Nomad Pro 2) is capable of producing equivalent or even superior X-ray image quality in comparison to a wall-mounted (WM) dental X-ray unit (Heliodent Plus) on the basis of objectifiable image quality parameters.

Methods

Anatomical, radiological and biological dental X-ray image quality parameters of a handheld dental X-ray device (Nomad Pro 2, Kavo Kerr, Biberach, Germany) were compared to a standard wall-mounted dental X-ray unit (Heliodent Plus, Sirona Dental Systems, Bensheim, Germany) using a maxillofacial phantom. In addition, the effect of different operators (dentists, dental students, dental assistants) on the dental X-ray image quality was measured.

Results

HH and WM devices showed comparable image quality for anterior teeth, premolars, molars and bitewing images. During the two-month investigational period, the radiation exposure level for the operator of the Nomad Pro 2 was 0.1 mSv for 203 images. Dentists as the highest trained personnel enrolled in the study achieved better image quality with the Nomad Pro 2 as compared to dental students and dental assistants, especially in the molar region.

Conclusions

A HH device delivers a comparable image quality to a WM device. In addition, there seem to be short learning curves with regard to image acquisition when using a handheld device, which is further minimised by the previous training of the operating personnel. HH dental X-ray devices, such as the Nomad Pro 2 are a promising adjunct for dental radiology in cases where WM units are of limited practicability.

Keywords: Handheld, Device, Dental, Radiology, X-ray

Introduction

In contemporary clinical dentistry, the use of X-ray images fundamentally increases diagnostic and therapeutic quality. Accordingly, orthopantomograms and dental X-rays are the preferred radiographical examinations not only in cases of dental trauma, but also in conservative dentistry and prosthodontics. Therefore, dental diagnostic imaging remains one of the most commonly performed radiological procedures worldwide [ 1]. This might have an impact on the lifetime radiation exposure of the general population, promoting malignancies, such as thyroid cancer [ 2].

Today, intraoral dental X-ray units are typically wall mounted (WM). Such configuration or design goes back to the original technical constraint in which a high voltage cable, attached to the so-called scissor arm, is needed to connect the X-ray tube assembly to the high voltage generator. This basic design of using a scissor type arm has not been changed once it became feasible to embed the high voltage generation into the X-ray tube head [ 3]. This WM design allows for positioning of the dental X-ray tube and has been the base of teaching intra-oral X-ray acquisition for multiple decades. The obvious disadvantage is the immobility of such devices, unless being fixed on a wheeled stand [ 4]. In cases of immobile, severely ill or disabled patients, it has proven difficult, if not impossible, to obtain dental X-ray images. This often leads to the problem of insufficient diagnostic statements and might lead to incorrect therapeutic decisions. Recently, handheld (HH) dental X-ray devices, such as the Nomad Pro 2 (Kavo Kerr, Biberach, Germany), were introduced as an alternative to the conventional WM units [ 5]. These devices claim to offer a convenient and portable size and are supposed to be easily operated even under difficult conditions, such as bedside dental X-ray imaging in hospitals and nursing homes, while offering equivalent operator doses to standard WM units [ 6]. This new class of devices is, in some regions, covered by regulatory guidance [ 7].

The guidelines of the German Federal Medical Association for quality assurance in radio diagnostics require dental X-ray images to fully capture the examined tooth from crown to apex, the periodontal bony structure as well as the border of the inner alveolar cortex to the periodontal space [ 8]. Furthermore, standards for dental X-ray diagnostics authored by the German Federal Association of Dentists dictate imaging voltages of ≥ 60 kilovolts (kV), a resolution of ≥ 5 line pairs per millimeter (mm) as well as a distance between the focus and the end of the X-ray tube of ≥ 200 mm [ 9]. The average radiation effective dose determined for analogue dental X-ray images is approximately 0.005 millisieverts (mSv) and 0.003 mSv for digital dental X-ray imaging. Whether portable handheld X-ray devices are capable of providing all of the required image quality parameters on a reproducible and safe basis is currently being debated, limiting the use of handheld X-ray devices in Western Europe [ 10].

Hence, the aim of this study was to determine whether the HH X-ray device Nomad Pro 2 (Kavo Kerr, Biberach, Germany) is capable of producing equivalent X-ray image quality compared to the WM dental X-ray unit Heliodent Plus (Sirona Dental Systems, Bensheim, Germany) on the basis of objectifiable image quality parameters using a real tooth phantom. Furthermore, dependence of different operators (dentists, dental students and dental assistants) on the X-ray image quality parameters of the Nomad Pro 2 and the Heliodent Plus was assessed.

Methods and materials

In this study, the HH Nomad Pro 2 (Kavo Kerr, Biberach, Germany) was used to conduct fully hand-guided dental X-ray images by means of a digital dental X-ray sensor (GXS 700, size 1 and 2, Gendex, Kavo Kerr, Biberach, Germany). X-ray image quality parameters (according to the current statutes of the German Dental Association; [ 9]) of the Nomad Pro 2 were then compared to a typical WM X-ray unit (Heliodent Plus, Sirona Dental Systems, Bensheim, Germany) with the same digital dental X-ray sensors (GXS 700, size 1 and 2, Gendex, Kavo Kerr, Biberach, Germany). Quality parameters were distortion, level of detail, image size, overlay, resolution, radiation field, and technical parameters, such as distance from tube end to focus and receiver dose (see Table 1).

Table 1.

Variable

Dichotomic scale

Display of the periodontal gap and the lamina dura

Yes/no

Display of the periradicular bone structure

Yes/no

Display of the alveolar crest

Yes/no

Display of the pulp cavity and root canals

Yes/no

Overlay effect on relevant structures

Yes/no

Blanking to film format, if possible and reasonable

Yes/no

Spatial resolution: ≥ 5 line pairs/mm [ 11] a

Yes/no

In order to record these X-ray image quality parameters, dental X-ray images as well as bite wing images (mandatory criteria for bite wing images are marked with an asterisk in Table 1) of the anterior teeth, premolars and molars of the left and right maxilla and mandible were conducted with a real tooth phantom (DXTTR mannequin, Densply, Ontario, USA). All shots were taken using a positioning ring with a metal rod (Fig. 1b). Images were taken holding the HH device first (Fig. 1 a). Afterwards, all images were taken again using the WM device. Each image was positioned and shot individually.

Fig. 1.

Experimental setup: a placed sensor inside the real tooth phantom and Nomad Pro 2 before image triggering. b Gendex digital X-ray sensor with positioning device

All examinations were carried out and controlled by the study leader (specialist for oral and maxillofacial surgery) and a medical student in her 5th year of study.

Furthermore, three dental students (having taken dental X-ray images supervised for 2 years), three dental assistants (> 5 years of work experience) and three dentists (> 5 years of work experience) were instructed to use the Nomad Pro 2 and conduct X-ray images with the real tooth phantom. The dental students had to be in their clinical study phase, the dental assistants had to have completed their vocational training and the dentists had to have two years of experience on the job after graduation. Everyone received a 20-min introduction and training with the HH device before the X-ray images were taken. The following images had to be taken independently: Ten dental X-ray images of (1) the anterior teeth (Fig. 2), (2) ten of the premolars and (3) ten of the molars of the maxilla and mandible in each quadrant ( n = 120) Additionally, ten bite wing images (4) (of molars/premolars) were taken on each side with the Nomad Pro 2 ( n = 20, in total n = 140) (Table 2). They were compared and analysed using the image quality parameters described above as well (Table 1).

Fig. 2.

Radiological images of the maxillary anterior teeth taken by the HH Nomad Pro 2 ( a) and the WM Heliodent Plus ( b)

Table 2.

Conducted series of X-ray images

10 dental X-ray images of (1) the anterior teeth, (2) premolars, (3) molars and (4) bite wing images of the maxilla and mandible with the Nomad Pro 2 and the Gendex Sensor (total = 140 X-ray exposures)

10 dental X-ray images of (1) the anterior teeth, (2) premolars, (3) molars and (4) bite wing images of the maxilla and mandible with the Heliodent Plus and the Gendex Sensor (total = 140 X-ray exposures)

After every X-ray image Nomad Pro 2 and Heliodent Plus were newly repositioned from starting position

Calibration of the Nomad Pro 2 and Heliodent Plus with a dosimeter (Thermo Eberline ESM, ThermoFisher Scientific, Waltham, MA, USA) to obtain equivalent radiation doses at the sensor:

Handheld Nomad Pro 2: 60 kV, 0.12 s, 2.5 mA

Wall-mounted unit Heliodent Plus: 60 kV, 0.06 s, 7 Ma

The real tooth phantom used in this study has been used for approximately 20 years in numerous scientific international studies and has been validated to physiologically represent the dentoalveolar anatomy [ 11, 12].

Viewing conditions

Only an accepted and constancy checked diagnostic monitor approved according to German standards (DIN standard 6868-157) was used for the examination and diagnosis of the generated dental film images of both the HH and the WM system.

Image receptor alignment and recording space

Sensor alignment has been identical for both WM and HH device generated images. The prescribed and approved sensor holders for the GXS 700-sensor, size 1 and 2 (Gendex, Kavo Kerr, Biberach, Germany) were used. The experimental setup is shown as an example in Fig. 1. The images were taken in the approved X-ray room, in which the remaining standard dental X-ray units are also located.

Radiation protection aspects

Throughout this study, a shared film-based X-ray dosimeter (whole-body dosimeter; radiation type: X-ray s and gamma rays; measurement: depth person dose; measuring range 0.1 mSv-1 Sv, 13 keV-1.4 MeV) was worn by all investigating personnel in order to measure released radiation (carried at chest height on an X-ray apron approved for dental radiology) for each taken image (separate dosimeters for HH and WM devices). Between active image acquisition it was stored in a radiation protected room (image release chamber for dental X-ray devices). After the acquisition sequence, the X-ray dosimeter was read according to the routine praxis of radiation dose monitoring once a month by local material testing office (the reading of the dosimeter was corrected for natural, background dose).

Ethics approval and trial registration

This study was approved by the Ethics Committee of the University of Duesseldorf (Study number: 2018-162-KFogU). Trial registration of prospective trials: Central Study Register of Duesseldorf University Hospital, Registration-ID: 2018064716. Additionally, this study was approved by the district government of North Rhine-Westphalia due to the use of X-ray radiation (approval 772/18).

Statistical methods

A statistical power analysis was used to determine a significant sample size (G*Power open source software [ 13]. Data analysis was performed using IBM SPSS statistics for Mac version 26 (SPSS Inc., Chicago, IL USA) and Microsoft Excel for Mac version 16.16.3 (Microsoft, Redmond, WA, USA). Frequency distributions for the analyses of image quality parameters were examined with the help of cross-tabs (Pearson's Chi-square test). Due to skewed/abnormal distribution, nonparametric tests were used, additionally, to compare the image quality parameters between the HH Nomad Pro 2 and the WM Heliodent Plus (Mann-Whitney U, Kruskal-Wallis H). The level of significance was set to p ≤ 0.05. Values of p  ≤ 0.01 were considered highly significant.

Results

Percentage of cases/pictures with all mandatory diagnostic criteria fulfilled

Analysis of the image quality parameters between the HH Nomad Pro 2 and the WM Heliodent Plus of all dental regions taken together (anterior teeth, premolars, molars) show an insignificant trend in favour of the Nomad Pro 2 in the maxilla (40.0-33.3%; p > 0.05) and mandible (45.0-31.7%; p > 0.05). Combining the values of maxilla and mandible, p value is also insignificant with a trend towards Nomad Pro 2 (36.4-27.9%; p  > 0.05).

Individual analysis of the image quality parameters of the respective dental regions reveals a significant difference between the Nomad Pro 2 and the Heliodent Plus in favour of the Nomad Pro 2 for the front teeth of the maxilla (55-15%, p = 0.005) and the front teeth of the mandible and the maxilla together (30.0-7.5%, p = 0.034). No significant differences in the image quality parameters between the Nomad Pro 2 and the Heliodent Plus were found in the analysis of the bite wing X-ray images (0%; p  > 0.05).

Percentage of criteria fulfilled absolutely

Due to the skewed distribution of the percentage of fulfilled criteria, nonparametric tests were used to compare the percentage of fulfilled criteria between the Nomad Pro 2 and the Heliodent Plus. These data show a significant difference in favour of the Nomad Pro 2 ( p = 0.044) as compared to the Heliodent Plus for total taken images. No significant differences could be found within the specific dental regions (anterior teeth, premolars, molars). On the contrary, analysis of the bite wing X-ray images showed a significant difference between the Nomad Pro 2 and the Heliodent Plus in favour of the Nomad Pro 2 ( p  < 0.001).

X-ray image quality differences of the Nomad Pro 2 handled by different occupational groups

When the HH Nomad Pro 2 was operated by the three dentists included in this study image quality parameters were significantly better in the maxillary molar region ( p = 0.047) and the mandibular premolar region ( p = 0.028) compared to the WM Heliodent Plus. Furthermore, the Nomad Pro 2 showed significantly better image quality parameters in the entire mandible ( p = 0.037) and all premolar regions of the maxilla and mandible ( p  = 0.014). In all other regions examined, equivalent image quality parameters of the Nomad Pro 2 and the Heliodent Plus were demonstrated.

When the HH Nomad Pro 2 was operated by the dental students, statistically significant differences ( p  = 0.046) between the Nomad Pro 2 and the WM Heliodent Plus were exclusively seen for all molar regions in the maxilla and mandible in favour of the Nomad Pro 2. There were no significant differences in image quality parameters for images of the anterior teeth or premolars.

Dental assistants operating the HH Nomad Pro 2 showed significant differences ( p  = 0.033) in favour of the Nomad Pro 2 solely for the images of the entire mandible (anterior teeth, premolars and molars). In the maxilla, there were no differences between the Nomad Pro 2 and the WM Heliodent Plus.

Comparing the outcomes of image quality parameters of the Nomad Pro 2 for dentists, dental students and dental assistants only the group of dentists showed a significant advantage ( p = 0.050) of the Nomad Pro 2 in the premolar region as compared to dental students and dental assistants. Comparing outcomes for dentists, dental students and dental assistants operating the wall-mounted Heliodent Plus, dentists and dental assistants showed a significant advantage ( p  = 0.050) over dental students in taking X-ray images of the premolar region in the maxilla. In all other areas, no significant differences were observed.

Total amount of X-ray radiation released in the course of this study

Within the study period between 01.08.2018 and 30.09.2018, released (stray) radiation dose for all operating participants was 0.1 mSv as measured by the used dosimeter all together for all HH conducted images ( n  = 203). There was no radiation dose detected for WM devices.

Discussion

The results of the present study indicate an equivalent X-ray image quality when using a HH Nomad Pro 2 device in comparison to the WM X-ray unit Heliodent Plus in X-ray images of the premolars, molars and bitewing images. Since the same digital sensors and identical examination conditions have been used for the Nomad Pro 2 and the Heliodent Plus to acquire comparable results these findings are in accordance with a study by Ulusu et al., who found equivalent image quality of handheld devices on digital and conventional bitewing radiographs [ 14]. The Nomad Pro 2 even surpassed image quality parameters of the Heliodent Plus in dental X-ray images of the anterior/front teeth (counting only images fulfilling all necessary criteria) as well as the percentage of fulfilled criteria for all dental regions together and the bite wings in particular. A reason could be difficult alignment of the wall-mounted tube central ray perpendicular to the image receptor. The finding that especially dental X-ray images of the anterior teeth region showed superior image quality of the Nomad Pro 2 compared to the Heliodent Plus supports the hypothesis that angulation and adequate positioning of the handheld Nomad Pro 2 might be easier than the wall-mounted X-ray tube head of the Heliodent Plus. Pittayapat et al., also found that the image quality of handheld dental X-ray devices was adequate for forensic use [ 15]. In our study, we found no evidence that the dental X-ray image quality of the Nomad Pro 2 was lower compared to the wall-mounted unit. It might, therefore, be useful when treating immobile, disabled or severely ill patients. In an ageing, less mobile population the need for portable devices will on the long run be necessary to provide adequate diagnostic and therapeutic options. The use of a portable device, such as the Nomad Pro 2 could be imaginable in nursing homes or intensive care units.

Furthermore, the "as low as reasonably achievable; ALARA" principle could be regarded as higher for the Nomad Pro 2, compared to a wall-mounted dental X-ray unit considering radiation exposure for the wall-mounted unit being between 0 and 0.1 mSv (yearly full-body effective dose) taken from a radiation protected area at a distance or behind shielding [ 7, 16]. However, with a radiation dose of 0.1 mSv for about 2 months and 203 taken images, still corrected for natural background radiation and including potential use errors (e.g., one of the users standing unprotected or too close to the phantom while taking HH images) for all personnel enrolled in the study together the operator exposure levels remain below recommended levels of the Ionizing Radiation Regulations of 1999 as described in other studies [ 16] and the measured scattered radiation values of dental HH X-ray units of a current study, which indicates limit values of 1.32-2.55 mSV annually [ 7]. A study by Rottke et al. [ 17] showed similar results. The radiation was measured using a film dosimeter as whole-body dosimetry. The dosimeter was protected by shielding. Scatter above and below the Nomad shield can reach the operator and, in these areas, the reduction in scatter intensity due to the inverse square law is offset by the absence of shielding. When using a WM device, the operator took the image from a 2 m distance and behind shielding, therefore, no radiation could be detected while using WM devices. Training of operating personnel might influence radiation when using a HH device. In order for the operator's body to be parallel and behind the scatter shield, the head of the patient must be tipped down for anterior maxillary imaging and up for anterior mandibular imaging. When this step is not taken, the required downward angle of maxillary imaging results in increased operator abdominal/gonadal exposure while upward angulation of mandibular imaging results in increased exposure of the clinician's thyroid gland from patient backscatter.

It was stated in earlier studies that training of the operator also has a higher effect on the precision of aim than the type of device (HH vs. WM) [ 6]. In part, we support this statement since dentists as the highest trained personnel included in this study achieved better results with the Nomad Pro 2 compared to dental students and dental assistants, especially in the molar and premolar region. No differences, however, were found for anterior teeth, presumably because sensor and handheld device can be positioned more easily in this area. On the whole, our results in this respect are similar to those of a recent study by Hoogeveen et al., who do not see any difference in target precision between HH and WM devices. In contrast to our study, however, they only used dental students as operators [ 5]. Collectively, additional studies with more personnel in different stages of training need to be conducted to test for operator-dependent differences in dental X-ray image quality.

Conclusion

The Nomad Pro 2 delivers an image quality that is at least as good as that of a WM device. In addition, there seems to be an easy learning curve with regard to the HH image acquisition procedure. The use of HH dental X-ray devices might be advantageous in daily clinical routines.

Acknowledgements

Open Access funding provided by Projekt DEAL. The authors thank punkt05 Statistik (Duesseldorf, Germany) for power analysis and statistical analysis.

Compliance with ethical standards

Conflict of interest

Funding was provided by KavoKerr (KaVo Dental GmbH Head Office, Bismarckring 39, 88400 Biberach/Riß, Germany) in contributing the digital dental sensors, the real tooth phantom as well as the Nomad Pro 2 handheld X-ray device as a loan for this investigation. There was no funding in the form of monetary payments for this study. Uwe Zeller has an active consulting agreement with KaVoKerr in the field of regulatory affairs and standardisation. Authors, Julia Nitschke, Lara Schorn, Henrik Holtmann, Jörg Handschel, David Sonntag and Julian Lommen declare that they have no conflict of interest.

Human rights statement and informed consent

This study was approved by the Ethics Committee of the University of Duesseldorf (Study number: 2018-162-KFogU). Trial registration of prospective trials: Central Study Register of Duesseldorf University Hospital, Registration-ID: 2018064716. Additionally, this study was approved by the district government of North Rhine-Westphalia due to the use of X-ray radiation (approval 772/18).

Footnotes

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Julia Nitschke, Email: Julia.Nitschke@med.uni-duesseldorf.de.

Lara Schorn, Email: Lara.Schorn@med.uni-duesseldorf.de.

Henrik Holtmann, Email: Henrik.Holtmann@malteser.org.

Uwe Zeller, Email: uwe.zeller@z-idl.de.

Jörg Handschel, Email: handschel@klinikamkaiserteich.de.

David Sonntag, Email: David.Sonntag@med.uni-duesseldorf.de.

Julian Lommen, Email: julian.lommen@med.uni-duesseldorf.de.

References

Articles from Oral Radiology are provided here courtesy of Springer

# data[].attributes.attachment_link.title
Image quality of a portable X-ray device (Nomad Pro 2) compared to a wall-mounted device in intraoral radiography

# data[].attributes.attachment_link.description
The aim of this study was to determine whether a handheld (HH) X-ray device (Nomad Pro 2) is capable of producing equivalent or even superior X-ray image quality in comparison to a wall-mounted (WM) dental X-ray unit (Heliodent Plus) on the basis of ...

# data[].attributes.body
Summary: This study assessed positioning accuracy

specifically centering and angulation accuracy between the

Nomad Pro 2 and a wall-mounted unit using a phantom.

Findings revealed that the wall-mounted device produced

significantly better centering (horizontal and vertical), while

the Nomad Pro 2 achieved significantly better

perpendicularity (angulation) in both axes (p < 0.001)

# data[].attributes.attachment_link.readable_text
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Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

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Affiliation

¹ 1 Department of Oral and Maxillofacial Radiology, Academic Center for Dentistry Amsterdam (ACTA) University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan , Amsterdam , The Netherlands.

Affiliation

¹ 1 Department of Oral and Maxillofacial Radiology, Academic Center for Dentistry Amsterdam (ACTA) University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan , Amsterdam , The Netherlands.

Abstract

Methods and materials: 20 operators obtained intraoral radiographs of four regions (bitewing, upper molar, lower molar and upper anterior) in five mannequins, using HH and WM devices. Beam-aiming devices were fitted with metal cross-wires to project on image sensors. Deviation from ideal perpendicular incidence of beam was calculated, based on positions of cross-wires relative to gold-standard positions ( i.e. average of 10-fold precise aiming by authors via WM system). Analytic models relied on Wilcoxon signed-rank test and mixed model analyses.

Results: Mean deviations from perfect aim were 2.88˚ (± 1.80˚) for WM and 3.06˚ (± 1.90˚) for HH methods. The difference among all operators (HH vs WM) was 0.17˚ (± 2.48˚), which was not significant. Seven operators showed better aim by HH device (13 by WM system); and in one instance, this difference was significant.

Conclusions: Aiming precision proved similar for HH and WM methods of intraoral radiography, although individual operators may perform better using one of these modalities. Aim is not an expected limiting factor for image quality in HH ( vs WM) diagnostics.

Keywords: dental equipment; dental radiography; diagnostic equipment; diagnostic imaging.

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Hoogeveen RC, Ouchene S, Berkhout W. Hoogeveen RC, et al. Dentomaxillofac Radiol. 2021 Jul 1;50(5):20200471. doi: 10.1259/dmfr.20200471. Epub 2021 Jan 8. Dentomaxillofac Radiol. 2021. PMID: 33417507 Free PMC article. Clinical Trial.

References

Pittayapat P, Oliveira-Santos C, Thevissen P, Michielsen K, Bergans N, Willems G, et al. . Image quality assessment and medical physics evaluation of different portable dental X-ray units. Forensic Sci Int 2010; 201(1-3): 112-7. doi: 10.1016/j.forsciint.2010.04.041 - DOI - PubMed

Pittayapat P, Thevissen P, Fieuws S, Jacobs R, Willems G. Forensic oral imaging quality of hand-held dental X-ray devices: comparison of two image receptors and two devices. Forensic Sci Int 2010; 194(1-3): 20-7. doi: 10.1016/j.forsciint.2009.09.024 - DOI - PubMed

Tyson R, Smiley DC, Pleasant RS, DANIEL GB. Estimated operator exposure for hand holding portable X-ray units during imaging of the equine distal extremity. Vet Radiol Ultrasoun 2011; 52: 121-4. doi: 10.1111/j.1740-8261.2010.01754.x - DOI - PubMed

Coy J, Vandre RH, Davidson WR. Use of the hand-held dental X-ray machine during joint operation, NATO exercise display Determination-92. Mil Med 1997; 162: 575-7. doi: 10.1093/milmed/162.8.575 - DOI - PubMed

Drage N. Hand-held dental X-ray equipment-an update. Dental Update 2017; 2017: 146-50.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Precision of aiming with a portable X-ray device (Nomad Pro 2) compared to a wall-mounted device in intraoral radiography - PubMed

# data[].attributes.attachment_link.description
Aiming precision proved similar for HH and WM methods of intraoral radiography, although individual operators may perform better using one of these modalities. Aim is not an expected limiting factor for image quality in HH ( vs WM) diagnostics.

# data[].attributes.body
Summary: This dosimetry study measured radiation

exposure to operators and patients using the Nomad Pro 2

and other handheld devices. Thermoluminescent dosimeters

placed on a mannequin captured doses to sensitive organs

(eyes, thyroid, gonads, hands, etc.). The Nomad Pro 2 showed

doses within safety limits, and use of protective measures

(like shielding) reduced exposure by 11%–93%, depending on

body region (p < 0.05) .

# data[].attributes.attachment_link.title
Evaluation of Operator and Patient Doses after Irradiation with Handheld X-ray Devices

# data[].attributes.attachment_link.description
This study aimed to evaluate radiation doses from handheld X-ray devices, specifically NOMAD Pro 2TM (DvcN), Rextar X (DvcRX), and Diox 602 (DvcD), targeting operator and patient’s critical organs and tissues. Calibrated TLD-100H dosimeters were placed on a mannequin and phantom head, focusing on the eyes, thyroid, gonads, hands, and salivary glands. Using a TLD reader, absorbed equivalent doses post irradiation were assessed. Conventional systems yielded higher radiation doses than phosphor plates and digital systems. Notably, implementing protective measures resulted in significant (p < 0.05) dose reductions to the operator. Peak measurements without protection included: gonad 24.4 (DvcN) μGy; thyroid 30.5 (DvcN) μGy; right eye 31.9 (DvcN) μGy; left eye 27.9 (DvcN) μGy; right hand 111.6 (DvcRX) μGy; and left hand 71.7 (DvcD) μGy. Radiation dose reductions ranged from 11.49% to 93.25%, depending on the region and device. It is imperative to adhere to radiological protection protocols, particularly when employing handheld X-ray devices; optimally, these should be used with digital systems.

# data[].attributes.body
Advantages

portiliably

improve work flow

high quality of images

Disadvantages

higher exposure risk

costly

operator exhaustion

# data[].attributes.body
The price of the Nomad Pro 2 handheld X-ray system depends on the supplier and the package included.

Most U.S. retailers list the unit between $2,500 and $3,000, which usually covers the device, charger, and

standard accessories. Some distributors advertise higher bundled prices, reaching $6,000 to $7,000,

especially when additional features, warranties, or veterinary models are included. On the lower end,

international suppliers may offer units for $1,200 to $2,000, although shipping costs, taxes, and limited

warranty coverage often make these options less practical for dental offices in North America. While the

Nomad Pro 2 requires a larger upfront investment than many wall-mounted X-ray units, its portability,

flexibility, and ability to serve patients in diverse settings often make the cost justifiable.

# data[].attributes.body
Summary: This article compares impressions with iOS and examines the pros and cons of both. With the long wait times and discomfort of traditional impressions, IOSs offer an easier way for dental professionals. It also allows accuracy to the dental atomey in a better way than impressions do. that iOSs are more comfortable and accepted by the patients than impressions due to their shorter wait time.

# data[].attributes.body
Summary: This article discusses the accuracy of iOS devices and how they compare with the impressions of implants. With the importance of knowing where an implant is and ensuring it isn't moving or failing, IOSs allow for an accurate depiction of an implant's position. Also, combining the usage of iOS and implant scan bodies gives extreme accuracy.

# data[].attributes.body
advantages:

easy to use

pateint comforablilty

shorter wait time than traditional impressions

more accurate than impressions

disadvantages:

costly

routinely maintenance needed

heavy and big

# data[].attributes.body
Intraoral scanners are costly, ranging around 10 thousand to 30 thousand, which can be costly for many clinics, making IOSs not easily accessible. Like all products, many different brands and companies sell iOSs.

# data[].attributes.body
Summary: This article talks about recent advances with intraoral scanners (IOSs). IOSs have the caries detection within their software using light waves to detect areas of decalcification. It also looks into enamel defects by assessing tooth wear and gingival recession.

# data[].attributes.body
Summary: With the new advances in oral microbial testing, lots of studies, including this one, talk about the benefits of testing and its impact on a patient's overall health. One being patients with diabetes with the connection of periodontal disease, and how patients with a history of perio may have undiagnosed diabetes, which may be the reason for their current oral health. It also talks about caries and other underlying health issues.

# data[].attributes.attachment_link.title
Advances in the oral microbiota and rapid detection of oral infectious diseases

# data[].attributes.attachment_link.description
Several studies have shown that the dysregulation of the oral microbiota plays a crucial role in human health conditions, such as dental caries, periodontal disease, oral cancer, other oral infectious diseases, cardiovascular diseases, diabetes,…

# data[].attributes.body
Summary: This article talks about how microorganisms impact our oral and systemic health, and that by using oral microbial testing, patients are truly able to have dental care that is personalized to themselves and their dental care to improve, as well as their systemic health.

# data[].attributes.attachment_link.readable_text
Vibrant Sciences LLC, Santa Clara, CA 95054, USA

Vibrant America LLC, Santa Clara, CA 95054, USA

Author to whom correspondence should be addressed.

1. Introduction

The human oral cavity harbors a diverse and complex microbial community, collectively known as the oral microbiome [ 1]. It has diverse microorganisms, including bacteria, archaea, fungi, and viruses [ 2]. It exists in the form of a biofilm and contributes significantly to maintaining oral homeostasis by fostering a harmonious balance within the oral environment [ 1]. Through its natural defense mechanisms, the oral microbiome acts as a protective barrier, preventing the colonization of harmful pathogens and preventing potential infections in the oral cavity [ 3]. Furthermore, a balanced oral microbiome is instrumental in preventing the development of oral diseases, such as dental caries and periodontal diseases, as it helps control the growth and activity of pathogenic bacteria [ 1, 3]. Understanding the diverse roles of the oral microbiome is essential for devising effective preventive and therapeutic strategies to promote oral health.

Interestingly, various civilizations have shown an extensive understanding of the vitality of oral health in the past. Remarkably, in ancient Egypt, the arid climate and special burial customs led to the preservation of well-kept skeletons and mummies. Researchers have learned a great deal about the historical dental practices of ancient civilizations by examining these remnants [ 4]. In antiquity, societies likely employed wooden toothpicks, chew sticks, tree twigs, and animal bones as implements for oral hygiene. Impressively, traces of caries and periodontal disease date back thousands of years to the upper Paleolithic era. As opposed to their prevalent occurrence in current times, dental caries were notably infrequent in ancient Egypt due to a lack of fermentable carbohydrates in their diet, impeding plaque buildup. Additional factors, such as tooth wear, including occlusal and interproximal wear, further contributed to the scarcity of caries by smoothing surfaces and discouraging plaque proliferation [ 4]. The increased availability and consumption of sugar-rich foods and beverages over the past few decades has resulted in a substantial shift in dietary patterns and an increase in dental problems. The rise in metabolic illnesses such as obesity, non-alcoholic fatty liver disease, cardiovascular disease, and diabetes is partly attributable to this increased consumption of sugars [ 5].

This historical perspective underscores the importance of dietary choices and their impact on oral and overall health.

In the past decade, significant progress has been made in understanding the impact of the oral microbiome on health and disease, propelled by innovative genomic technologies such as Next-Generation Sequencing (NGS) and advanced bioinformatic tools. NGS is an umbrella term that encompasses various methods like 16S rRNA sequencing, metagenomics, shotgun metagenomics, and quantitative Real-Time PCR (RT-PCR), all of which have replaced conventional culture-based techniques in unravelling the complexities of the oral microbiome [ 9, 10]. In this context, stimulated saliva collection offers a controlled and comprehensive method for investigating the oral microbiome, providing valuable insights into its composition, functions, and implications for human health. (Detailed techniques for the analysis of the oral microbiome are provided in Supplementary Materials File S1 ([ 1, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22]).) It is important to acknowledge that the oral microbiome is molded by various factors, such as diet, oral hygiene practices, smoking, systemic illnesses, and changes in the oral environment [ 23]. Therefore, emphasizing the importance of promoting good oral hygiene practices, adopting a healthy diet, and making positive lifestyle changes can play a pivotal role in nurturing a balanced oral microbiome ecosystem.

This review extensively examines the diverse microbial composition and its role in maintaining oral equilibrium, outlining the significance of various bacterial genera. Additionally, it delves into the oral-gut axis and microbial translocation, unravelling the interconnection between the mouth and gut. We also explore how dysbiosis can instigate a cascade of consequences, not only leading to various oral diseases such as dental caries, periodontitis, halitosis, and oral candidiasis but also exerting a profound impact on systemic health, encompassing conditions like gastrointestinal diseases, CVD, diabetes, neurological diseases, and autoimmune diseases. Lastly, understanding the pivotal role of daily dental care practices is essential for maintaining oral hygiene and preventing oral diseases, thus contributing to the preservation of a balanced oral microbiome ecosystem and good systemic health.

Search methods: To provide a comprehensive review of the oral microbiome, we conducted an extensive literature search. We used the following keywords: "Oral Microbiome", "Oral Diseases", "Systemic oral diseases", "oral care", "dental practices", "oral probiotics", and many more. Our search spanned multiple databases including PubMed, Google Scholar, and Web of Science.

Inclusion and exclusion criteria: This review paper includes case-control studies, cross-sectional studies, retrospective and prospective cohort studies, and randomized controlled trials that examined the composition of, role of, and factors that influence oral microorganisms, connections between oral and systemic diseases, and personalized oral care strategies.

This thorough methodology ensures that our review encompasses a broad and relevant range of studies, providing a robust overview of the current state of knowledge in this field.

2. The Composition and Role of the Oral Microbiome

With over 700 known bacterial species, the oral microbiome is the second most diverse microbiota within the human body [ 1]. Principally, this vibrant ecosystem encompasses a wide range of bacterial phyla, including Actinobacteria, Bacteroidetes, Chlamydia, Euryarchaeota, Fusobacteria, Firmicutes, Proteobacteria, Spirochaetes, and Tenericutes [ 24]. In a healthy oral cavity, the prevailing bacterial genera primarily encompass both Gram-positive and Gram-negative species. Within the realm of Gram-positive cocci, the genera Abiotrophia, Peptostreptococcus, Streptococcus, and Stomatococcus assume pivotal roles. Notably, some bacterial species, including Streptococcus sanguinis and salivarius, are known for producing antimicrobial compounds, making a significant contribution to the maintenance of oral health, and protecting dental structures from the damaging effects of enamel erosion. [ 25]. However, it is important to note that the full extent of each bacterium's role in this complex interaction has not yet been fully elucidated.

Gram-positive rods, such as Actinomyces, Bifidobacterium, Corynebacterium, Eubacterium, Lactobacillus, Propionibacterium, Pseudoramibacter, and Rothia, contribute to the microbial consortium. Considering recent research, Actinomyces naeslundii has been discerned as proficient in utilizing urea as a nitrogen source, thereby strengthening its resistance against environmental acidification within the oral cavity. Consequently, it assumes a dominant role among dental plaque organisms, exerting a pronounced influence on the ecological processes of the plaque community [ 26]. Furthermore, Lactobacillus, Bifidobacterium, Streptococcus, and Weissella are all acknowledged as helpful probiotics in treating periodontal diseases, boosting oral health, and improving oral care as a whole [ 27].

In addition to the Gram-positive taxa, the Gram-negative cocci genera Moraxella, Neisseria, and Veillonella are prevalent inhabitants of the healthy oral cavity. Among the Gram-negative rods, the following genera are commonly observed: Campylobacter, Capnocytophaga, Desulfobacter, Desulfovibrio, Eikenella, Fusobacterium, Hemophilus, Leptotrichia, Prevotella, Selemonas, Simonsiella, Treponema, and Wolinella [ 28]. Many oral inhabitants are known for their ability to produce biofilms. Fusobacterium nucleatum exemplifies this capability through its unique role in mediating intergeneric coaggregation within oral biofilms. This involves its ability to bring diverse bacteria together, enabling them to create a well-organized community known as a biofilm. Furthermore, the involvement of F. nucleatum extends to the subsequent growth and development of these biofilms [ 29]. Within these biofilms, Prevotella organisms have a unique role. They are capable of regulating host residence and immune cell responses without requiring direct contact with the host. While Prevotella spp. are generally considered to be aerotolerant, their ability to thrive in aerated environments appears to be significantly influenced by their coaggregation with F. nucleatum. This coaggregation not only contributes to the structural maintenance of oral biofilms but also allows Prevotella spp. to benefit from the multispecies character of these biofilms [ 30]. The precise functions carried out by each bacterial genus offer a field for exploration and deeper study.

Fungi are estimated to constitute less than 0.1% of the total microbial population in the oral cavity [ 31]. The oral cavity is frequently associated with Candida spp., making it the most prevalent fungus observed. Additionally, other notable fungi identified in this environment include species belonging to the Cladosporium, Aureobasidium, Saccharomycetales, Aspergillus, Fusarium, and Cryptococcus groups [ 23]. When the host's defense mechanism is weakened, fungi in the oral microbiome may still modulate immune responses or even develop into opportunistic infections [ 32]. Physical interactions between fungi and bacteria in the oral cavity influence the oral microbiota. Candida and other oral fungi act as bridging organisms, facilitating bacterial adhesion to their surfaces and epithelial cells. This leads to distinct sets of bacteria adhering to Candida-covered vs. non-covered cells. Additionally, these interactions contribute to bacterial resilience against antimicrobial agents, modulating the diversity of the oral microbiome [ 33]. Oral archaea exhibit significantly lower abundance and diversity compared to oral bacteria. In the oral cavity, all known archaeal species belong to the phylum Euryarchaeota and are characterized as methanogens, organisms that produce methane [ 2]. Studies have indicated that these archaea are found in higher quantities in individuals affected by periodontitis [ 34, 35]. The composition of the oral microbiome is summarized in Table 1, showcasing the predominant phyla/genera of bacteria, fungi, and archaea, along with other notable genera.

In addition to the three primary domains of life-bacteria, fungi, and archaea-the oral microbiome also encompasses viruses. Oral microbiomes harbor extensive populations of viruses, predominantly bacteriophages (phages) that target specific bacterial species. These phages can exist either as free phage particles (virions) or as dormant prophages integrated within bacterial lysogens [ 36]. The phage population in dental regions, more indicative of periodontal disease and dental caries than the salivary phage population influenced by multiple oral surfaces, primarily includes Caudovirus families: Siphoviridae (generally lysogenic with intermediate host ranges), Myoviridae (typically lytic with broad host ranges), and Podoviridae (typically lytic with narrow host ranges). However, information on the periodontal phageome remains sparse [ 36, 37, 38].

Common eukaryotic viruses in the oral cavity of healthy adults include Herpesviridae, Papillomaviridae, Anelloviridae, and Redondoviridae [ 31, 39]. Anelloviridae are the most common, with the newly discovered Redondoviridae as the second most common [ 31]. Prevalence measures depend on sampling methods, and amplification steps may favor small DNA circles, potentially boosting Anelloviridae and Redondoviridae detection. Redondoviridae prevalence ranges from 2 to 15% in various populations, and increased levels are observed in periodontitis patients and those with severe illnesses, though no evidence links them to disease causation [ 37, 40]. Both viruses appear to be common commensals, detectable due to advancements in viral metagenomic sequencing [ 37]. Despite viruses being the dominant infectious agents, we have limited research on the complex viral communities in the human mouth, even though some now believe they could be commensals (23-25). However, it is critical to emphasize that while this hypothesis is gaining attention, substantial empirical evidence or explicit validation within the scientific literature is currently lacking to substantiate this assertion.

3. Factors Influencing the Oral Microbiome

3.1. Diet

Emerging research brings out the profound influence of dietary macronutrients and diet types on the composition and equilibrium of the oral microbiome. The presence of nutrients plays a crucial role, as seen in the notable impact of fermentable carbohydrates like sugars and starches, which strongly influence the proliferation of acid-producing bacteria, particularly Streptococcus mutans. These microbes drive the development of dental caries-generating acids that erode tooth enamel and initiate cavities [ 41]. Remarkably, the oral microbiome not only responds to dietary components, indicating its ability to change in response to the types of food consumed, but also actively participates in nutrient breakdown. This process involves specialized bacteria that degrade glycoproteins and sugars, a crucial step in nutrient utilization [ 42].

However, the impact of diet extends beyond nutrient breakdown. The influence of food choices on oral microbiome functions is shown by the fact that a nitrate-rich diet can promote the proliferation of nitrate-reducing bacteria. Dietary nitrate changes the salivary microbiome in people of various ages, with Prevotella and Veillonella populations declining and Rothia and Neisseria populations rising [ 43]. Notably, this modification in the salivary microbiota can affect the control of blood pressure and nitric oxide levels [ 44]. Furthermore, the complex relationship intertwines with immune responses and bacterial interactions. Antioxidants and anti-inflammatory compounds found in fruits and vegetables can modulate the immune response in the oral cavity, influencing the balance of various bacterial species [ 45].

3.2. Smoking

The influence of smoking on the oral microbiome is a multifaceted phenomenon with far-reaching implications for oral health. The relationship between smoking and the oral microbiome involves mechanisms such as the creation of anerobic conditions, compromised immune responses, altered salivary pH, and the antibacterial effects of cigarette smoke's toxic compounds [ 46, 47]. Nicotine, a substance found in tobacco leaves, has been shown to boost the virulence of oral microorganisms, possibly by stimulating the expression of virulence-related genes or promoting increased biofilm formation. Its influence on human cells is primarily through nicotine acetylcholine receptors (nAChRs) [ 48]. These alterations can disrupt the equilibrium within indigenous oral microbial communities, including beneficial species, while also creating a more favorable environment for the colonization of harmful microbes associated with oral diseases. Consequently, individuals who smoke may be at an increased risk of infections and oral health complications.

Tobacco smoke has a dual impact on the oral microbiome. First, it decreases oxygen levels, creating an environment ideal for anerobic bacteria that thrive without oxygen. Simultaneously, it increases free iron levels while inhibiting oral peroxidase activity, further promoting conditions favorable for anerobic bacterial growth. As a result of this, exposure to tobacco smoke prompts salivary cells to switch to anerobic glycolysis for energy production [ 49]. The alteration in the oral microbiota due to smoking is marked by a decrease in Proteobacteria and an increase in Firmicutes and Actinobacteria. These changes collectively contribute to the significant shifts observed in the composition of the oral microbiome in response to smoking [ 47]. Comprehensive studies utilizing advanced techniques are needed to illuminate the full scope of smoking's impact, particularly on passive smokers, shedding light on potential interventions to counteract these effects and enhance oral health outcomes [ 23].

3.3. Alcohol Consumption

Excessive alcohol consumption can lead to an imbalance within the oral microbiome [ 50], causing potential repercussions for both oral and systemic health. Prolonged alcohol intake has been shown to impact various aspects of the oral environment, including the oral mucosa, salivary glands, and saliva composition [ 51]. Exposure to ethanol, whether acute or chronic, can result in significant changes in salivary function, characterized by the decreased flow rate and impaired secretion of crucial components like total protein and amylase [ 52, 53]. Moreover, alcohol can impair the function of neutrophils, potentially leading to bacterial overgrowth and increased bacterial infiltration [ 54]. It can also reduce the production of inflammatory cytokines by monocytes, creating an environment conducive to microbial proliferation [ 55]. Additionally, ethanol's adverse effects extend to dental health by promoting bone resorption and suppressing bone formation [ 56], impacting teeth, and supporting periodontal structures [ 57].

Notably, research has underscored a correlation between alcohol use and alterations in the oral microbiota, characterized by a diminished Lactobacillales abundance and an increased presence of Neisseria, Streptococcus, and Prevotella [ 58, 59]. Interestingly, the oral microbiota has exhibited potential as an indicator of alcohol-induced liver damage [ 60]. Furthermore, diurnal changes within the oral microbiota, crucial for maintaining microbial balance, are reportedly disrupted by alcohol consumption, potentially contributing to disturbances within the microbial ecosystem and subsequent functional impairments [ 60]. Intriguingly, studies by Thomas et al. and Liao et al. have revealed distinct variations in the oral microbiota of alcohol consumers, including reduced bacterial richness and shifts in the prevalence of specific genera such as Prevotella and Moryella. Conversely, genera like Lautropia, Haemophilus, and Porphyromonas were found to be significantly diminished [ 61, 62].

3.4. Other Factors That Influence the Oral Microbiome

In addition to diet, smoking, and alcohol consumption, several other factors significantly influence the composition and equilibrium of the oral microbiome. Poor oral hygiene practices, medical conditions, and medications play pivotal roles in shaping this complex ecosystem. Poor oral hygiene, characterized by inadequate brushing and flossing, promotes the accumulation of dental plaque-a biofilm predominantly composed of bacteria. This plaque buildup provides a conducive environment for the proliferation of pathogenic species, leading to an imbalance in the oral microbiome [ 63]. Moreover, various medical conditions exert substantial effects on oral microbial communities. Systemic diseases such as diabetes, CVD, neurological conditions, gastrointestinal diseases, and autoimmune disorders can disrupt immune responses and alter oral pH, creating favorable conditions for the overgrowth of pathogenic bacteria [ 64]. Furthermore, medications, notably antibiotics and immunosuppressants, can disturb microbial homeostasis by directly impacting bacterial populations or weakening host defenses [ 65]. Consequently, dysbiosis may arise, contributing to oral health issues. The use of broad-spectrum antibiotics can potentially disrupt the natural balance of beneficial oral microorganisms. In people without health issues, helpful microorganisms keep Candida in check by competing for nutrients and attaching to epithelial cells. Changes in these microorganisms might lead to the unchecked growth of Candida. Additionally, the broader effects of systemic antibiotic treatment could also contribute to oral candidiasis by affecting the immune system [ 66]. Moreover, the oral microbiome is a known site for the acquisition and transfer of resistance via horizontal gene transfer (HGT), which can contribute to the systematic development of antimicrobial-resistant infections [ 67]. HGT in the oral microbiome enables the rapid sharing of antibiotic resistance genes among microorganisms, leading to the emergence of antibiotic-resistant strains, reducing antibiotic efficacy and contributing to the overall problem of antibiotic resistance.

4. Oral Microbiome Dysbiosis

Oral microbiome dysbiosis refers to an imbalance or disruption in the composition and functioning of the oral microbial community [ 1]. Various factors, such as poor oral hygiene, dietary habits, medical conditions, medications, and lifestyle choices, can lead to this disturbance. This imbalance disrupts the previously harmonious interactions between different bacteria, altering the overall microbial ecology. The repercussions of oral microbiome dysbiosis are significant, contributing to common oral health issues like dental caries (cavities), periodontal diseases (gum infections), halitosis (bad breath), and oral candidiasis (oral thrush). Emerging research also indicates potential links between oral microbiome dysbiosis and systemic health conditions such as cardiovascular disease (CVD), diabetes, and cognitive disorders [ 8]. A key characteristic of oral microbiome dysbiosis is the overgrowth of harmful bacteria and a decline in beneficial microorganisms [ 68]. This imbalance fosters an environment where pathogens can thrive, causing inflammation and damage to oral tissues. Moreover, dysbiosis can disrupt the natural processes that maintain and repair tissues, further aggravating oral health problems.

5. Oral-Gut Axis

The oral and gut microbiomes play crucial roles in human health, each harboring a distinct microbial community. These communities are typically separated by barriers such as the oral-gut barrier, physical distance, and chemical obstacles like gastric acid and bile [ 69]. However, recent research has shed light on the potential microbial translocation between these two ecosystems, highlighting the interconnected nature of the oral-gut microbiome axis. Several factors can influence the translocation of oral microbiota to the gut. Individuals at the extremes of life, such as neonates and the elderly, may have fewer effective barriers, allowing for increased microbial movement [ 70, 71]. Certain bacteria, like Bifidobacterium, have been detected in the neonatal gut and oral fluids [ 72]. Additionally, decreased gastric acidity can shift the gut microbiota composition to resemble the oral microbiome. This suggests that under certain conditions, oral microbes can bypass barriers and successfully translocate to the gut [ 73]. Microbial translocation is not limited to physiological states. Pathological conditions, such as IBD and colon cancer, have shown evidence of oral bacteria colonizing the gut mucosa [ 74]. This suggests that disruptions in mucosal homeostasis can lead to the invasion of oral commensals into the gut, potentially contributing to disease progression.

Two main hypotheses have been proposed for the transmission of oral bacteria to the gut: the hematogenous route and the enteral route ( Figure 1). The hematogenous route suggests that oral bacteria enter the bloodstream, circulate, and colonize the gut mucosa. Meanwhile, the enteral route proposes that bacteria from the mouth travel through the stomach to the intestines. Although the human body possesses defenses against microbial invasion, instances can arise where these barriers are compromised, allowing for bacterial movement [ 75]. The findings of oral-to-gut microbial translocation implicate human health. Antibiotic use and conditions like achlorhydria (absence of hydrochloric acid in the gastric secretions) can diminish barriers, facilitating the colonization of oral bacteria in the gut [ 76, 77]. Certain pathogens, like Klebsiella spp. and Porphyromonas gingivalis, possess antibiotic resistance and acid-resistant properties, respectively, enhancing their ability to translocate to the gut [ 76, 78]. The occurrence of oral commensal bacteria in the gut is an uncommon and abnormal event, resulting from a process known as ectopic colonization, where these bacteria are found in a location where they do not typically belong. This presence of oral commensals in the gut is considered a characteristic feature of various diseases, including IBD [ 79]. Several known oral bacterial species belonging to genera such as Staphylococcus, Porphyromonas, Veillonella, Fusobacterium, Actinomyces, and Parvimonas have been detected within the gut of patients with gastrointestinal disorders [ 77]. The emerging understanding of oral-gut microbial translocation deepens the complex interplay between these two microbial ecosystems.

6. Oral Microbiome and Oral Diseases

6.1. Dental Caries

Dental caries stand as the most prevalent infectious disease within the oral environment [ 80] primarily driven by bacterial pathogens and characterized by progressive dental hard tissue deterioration [ 81]. Recent investigations have unveiled the pivotal role of the oral microbiome in caries onset and progression. Prevotella spp., Lactobacillus spp., Dialister spp., and Filifactor spp. have surfaced as potential contributors to caries pathogenesis and advancement [ 82]. Caries development is attributed to the acidic by-products of sugar metabolism by acidogenic bacteria, inducing demineralization and cavitation [ 83]. All these factors, such as ecological imbalances, trends towards acidogenic environments, and the acidification of biofilms, contribute to the emergence of caries [ 84]. The caries biofilm, a complex and highly active ecosystem, initiates the accumulation of dental plaque on the tooth's surface. Within this environment, various microorganisms colonize, with S. mitis and S. mutans being among the initial colonizers [ 85, 86].

The formation of the biofilm begins when a salivary glycoprotein film (dental pellicle) coats a tooth surface [ 87]. These initial colonizers create extracellular polymers (EPSs) that enhance the adherence of other microorganisms to the biofilm. EPS-rich environments provide ideal binding sites for acid-producing bacteria. Acid-producing bacterial species, such as Veillonella, Lactobacillus, and Propionibacterium, become part of the dental biofilm. They contribute to cariogenic conditions in the mouth by producing acids [ 88]. S. mutans has cariogenic potential; excels in acid production, allowing it to metabolize a wide range of carbohydrates into organic acids; and exhibits remarkable acid resistance, enabling it to thrive even in low-pH environments. Additionally, it can synthesize EPSs that not only promote its growth but also offer protection to its cells in challenging and harsh conditions. These attributes collectively underscore the significant role of S. mutans in the pathogenesis of dental caries [ 89]. S. mutans utilizes a crucial virulence factor, specifically three enzymes known as glucosyltransferases (GtfBCD), to initiate and establish cariogenic biofilms [ 90]. Bacterial diversity within caries-associated microbiota is modulated by competitiveness, as evidenced by varying compositions across different carious sites [ 90, 91]. S. mutans [ 92], long considered a key player, has been joined by acidogenic species like Bifidobacterium [ 93] and Lactobacillus [ 94]. The multifaceted cariogenic consortia include Prevotella, Corynebacterium, Veillonella, and Capnocytophaga, collectively contributing to local pH reduction and tissue demineralization [ 93, 95].

6.2. Gingivitis

Gingivitis is described as inflammation of the gums, typically caused by the accumulation of microbial plaque, or bacteria, on the surface of the teeth due to ineffective tooth brushing. Thus, the importance of effective tooth brushing cannot be overstated, as it is essential for removing food debris and preventing the further growth of plaque [ 96]. Bacteria present in accumulated plaque on the tooth surface can penetrate the gingival tissue, particularly the gingival sulcus, making the marginal area prone to microbial infection. Common microbial species associated with gingivitis include P. gingivalis, A. actinomycetemcomitans, Streptococcus sp., Fusobacterium sp., Actinomyces sp., Veillonella sp., Treponema denticola, and Prevotella intermedia [ 97]. If untreated, gingivitis has the potential to advance to periodontitis, a condition that can lead to irreversible damage not only to the gums but also to the surrounding bone that supports the teeth [ 96].

6.3. Periodontitis

The oral microbiome plays a pivotal role in the development and progression of periodontal diseases, encompassing gingival diseases and periodontitis [ 98]. Chronic periodontitis, a prevalent form of periodontal disease, spans a wide age range and evolves from gingivitis to deeply affecting periodontal tissues. Dental plaque bacteria emerge as the principal culprits in the onset of periodontal disease [ 99]. Plaque exists in both supragingival and subgingival areas, fostering microbial biofilms that thrive on tooth surfaces. The crevicular epithelium and gingival crevice act as pivotal habitats for microbial initiation, supported by gingival crevicular fluid and a favorable anerobic environment [ 10]. The subgingival plaque, comprising more than 500 species, undergoes compositional shifts during disease progression [ 100]. In healthy conditions, Gram-positive cocci and rods dominate as early colonizers, while F. nucleatum bridges bacterial coaggregation [ 100]. However, as gingivitis advances, Gram-negative bacteria like Prevotella spp. and F. nucleatum ss. polymorphum surge, associated with elevated inflammatory cytokines such as IL-1, IL-6, IL-17, TNF-α, and IL-23 [ 98, 101, 102].

IL-17 plays a stimulatory role in activating T helper (Th)-17 and B cells, which, when activated, elevate the expression of receptor activator of nuclear factor kappa-B ligand (RANKL). RANKL is also directly activated by the neutrophils that have migrated to the site. RANKL, in turn, triggers the activation and maturation of osteoclast precursors into active osteoclasts, which are responsible for bone resorption. Simultaneously, the recruited neutrophils contribute to tissue degradation by inducing the production of enzymes like matrix metalloproteinases (MMPs) and cytotoxic substances, including reactive oxygen species (ROS). These interactions among microbes, the innate immune response, and the adaptive immune response illustrate key mechanisms involved in the persistence of inflammation, which, if left unresolved, leads to tissue destruction [ 103]. The red complex bacteria-P. gingivalis, Treponema denticola, and Tannerella forsythia [ 24]-emerge as keystone pathogens, triggering an imbalance in host-bacterial interactions and resulting in bone loss [ 104, 105]. Furthermore, recent investigations highlight the systemic implications of periodontal diseases. Periodontitis not only poses local health risks but also acts as a potential risk factor for systemic conditions like CVD, diabetes, and cancer [ 9].

6.4. Halitosis

Halitosis, commonly referred to as oral malodor or bad breath, is a frequent oral condition marked by an unpleasing or disagreeable odor that originates within an individual's mouth [ 106]. This widespread condition impacts a significant portion of the worldwide population, ranging from 15% to 60%, and is characterized by the emission of an offensive odor from the mouth, nasal passages, and throat regions [ 107]. Intra-oral halitosis (IOH), closely tied to microbial interactions within the oral environment, is a prominent facet of this condition. Anerobic bacteria give rise to volatile compounds, with key volatile sulfur compounds (VSCs) including hydrogen sulfide, dimethyl sulfide, dimethyl disulfide, and methyl mercaptan [ 107, 108]. Oral bacteria, such as Prevotella spp. [ 109], Bacteroides spp., and Actinomyces spp. play vital roles in halitosis by producing VSCs during the biodegradation of sulfur-containing amino acids [ 108, 109]. These sulfur-containing amino acids, such as L-cysteine and L-methionine, originate from the saliva, the blood, the oral mucosa, and epithelial cell debris. The enzymatic reactions involving L-cysteine and L-methionine are crucial in sulfur-containing amino acid metabolism. L-cysteine undergoes desulfhydration, catalyzed by the L-cysteine desulfhydrase enzyme, resulting in the formation of pyruvate, ammonia, and hydrogen sulfide. On the other hand, L-methionine is acted upon by the L-methionine α-deamino-γ-mercaptomethane-lyase enzyme, leading to the generation of α-ketobutyrate, ammonia, and methyl mercaptan [ 110]. In addition, VSCs, particularly hydrogen sulfide and methyl mercaptan, exhibit significant toxicity. These observations imply that VSCs not only play a role in causing bad breath but could also be involved in the development of periodontitis [ 111].

Gram-negative bacteria, including Prevotella (Bacteroides) melaninogenica, Treponema denticola, Porphyromonas gingivalis, Porphyromonas endodontalis, and others like Enterobacteriaceae, Tannerella forsythia, Eikenella corrodens, and various Fusobacterium species, are implicated as likely contributors to oral malodor. However, the lack of a clear association between a specific bacterial infection and halitosis suggests that malodor is the result of intricate interactions among multiple oral bacterial species [ 112].

Earlier studies by Persson and collaborators highlighted the production of H ₂S by bacteria such as Treponema denticola and Bacteroides intermedius, alongside Peptostreptococcus, Eubacterium, and Fusobacterium [ 113]. Additionally, investigations by other researchers revealed the dominance of Veillonella spp., Actinomyces spp., and Prevotella spp. in patients experiencing oral malodor [ 114]. Conversely, Neisseria spp., Fusobacterium spp., and Porphyromonas spp. were noted to be most prevalent in individuals with elevated H ₂S concentrations, while Veillonella spp., Prevotella spp., Megasphaera, and Selenomonas predominated in those exhaling primarily CH ₃SH [ 115]. Notably, lower levels of Streptococcus and Granulicatella were evident, while higher proportions of Leptotrichia, Peptostreptococcus, Eubacterium, and Fusobacterium were detected across both (H ₂S and CH ₃SH) malodor groups [ 115].

6.5. Taste Impairment

Taste ability is notably compromised in acutely hospitalized elderly individuals who exhibit decayed teeth, elevated levels of oral bacteria linked to caries, poor oral hygiene, and dry mouth [ 116]. It has been proposed that the loss of taste associated with poor oral health may be attributed to toxins and inflammatory products produced by oral bacteria [ 117]. A study revealed that patients with high Lactobacilli growth experienced particularly impaired sour taste perception [ 116]. Lactobacilli thrive in acidic environments and produce acid themselves, potentially causing an adaptation in sour taste perception and increasing the taste threshold for sour flavors. Additionally, we found that inadequate oral hygiene correlated with a reduced total taste score and diminished perception of salty taste [ 118, 119]. Saliva plays a crucial role in transporting food particles and taste stimuli to the taste buds in the oral cavity, and reduced saliva flow has been linked to taste impairment [ 120]. Hospitalized elderly individuals frequently consume a high number of medications, which can induce xerostomia (dry mouth) and hypo-salivation [ 121], resulting in the loss of taste. Findings by [ 122] and [ 123] reveal reduced taste sensitivity in individuals with Sjøgren's syndrome, characterized by oral dryness, compared to controls.

6.6. Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a condition characterized by a persistent burning sensation in the mouth without any apparent lesions [ 124]. Recent research suggests a potential association between BMS and the oral microbiota, shedding light on the role of oral bacteria in the etiology of this syndrome. A study investigating the oral microbiota signature of BMS patients found marked differences in microbial profiles between BMS patients and healthy controls [ 125]. The composition of bacterial strains, including dominant genera, was distinct in BMS patients compared to controls. Streptococcus, Rothia, Bergeyella, and Granulicatella were prevalent in the BMS group, while Prevotella, Haemophilus, Fusobacterium, Campylobacter, and Allorevotella were more common in healthy controls [ 125]. This correlation between the oral microbiome composition and BMS suggests a potential role of oral bacteria in the pathogenesis of BMS.

6.7. Oral Thrush

Oral thrush, also known as oral candidiasis, is a fungal infection that affects the oral mucosa. It is caused by an overgrowth of Candida albicans [ 126]. Candida krusei, Candida stellatoidea, Candida tropicalis, Candida glabrata, Candida guilliermondii, and Candida dubliniensis are other species seen in oral candidiasis lesions [ 127]. The symptoms of oral thrush can include white patches on the tongue, inner cheeks, and roof of the mouth, as well as redness and soreness in the affected areas. In severe cases, it can cause difficulty swallowing and a burning sensation in the mouth [ 128]. Factors such as poor oral hygiene, a weakened immune system, or certain medical conditions like diabetes or HIV/AIDS can increase the risk of oral thrush [ 129]. These factors can create an imbalance in the natural flora of the mouth, allowing the Candida fungus to overgrow and cause an infection. Several processes contribute to Candida albicans pathogenicity ( Figure 2). Initially, it adheres to host surfaces through weak and reversible interactions that are influenced by both hydrophobic and electrostatic forces [ 130]. The process of adhesion is facilitated through the presence of specific host tissue receptors, notably the glycoproteins ALS (agglutinin-like sequence) [ 131] and HWP1 (hyphal wall protein) (100). C. albicans can adhere to epithelial cells using various host cell receptors, such as EphA2 (through β-glucan) and E-cadherin (through ALS3).

Additionally, host cell transglutaminases create direct links between C. albicans and the epithelial surface by interacting with HWP1. Among the family of eight glycosylphosphatidylinositol (GPI)-linked Als proteins, ALS3 stands out as a pivotal player in mediating the attachment of fungal hyphae to epithelial cells and facilitating their subsequent penetration into host cells [ 132, 133]. HWP1 exhibits elevated expression levels during oral infections in humans [ 134], and it serves as a target for epithelial transglutaminases, facilitating robust and covalent connections with various epithelial proteins [ 135]. The interaction with oral bacteria can promote biofilm formation. Candida spp. readily forms biofilms, microbial communities encased in an extracellular matrix. Biofilms contribute to increased virulence and resistance to antimicrobial agents. In oral candidiasis, biofilms on dentures are a major factor [ 136]. For instance, Streptococcus gordonii is a common resident that interacts with C. albicans in the oral cavity, promoting the formation of hyphal structures and biofilms. This interaction is facilitated by the direct binding of ALS3 on C. albicans to the surface protein SspB (cell-wall-associated protein) on S. gordonii, highlighting the complex interactions between microbes in the oral environment that impact biofilm formation and colonization [ 137]. C. albicans can change into an invasive filamentous form after adhering to host surfaces, which significantly improves its ability to penetrate epithelial tissue [ 138, 139].

Candida can phenotypically switch between its yeast and hyphal states. C. albicans worsens host tissue damage by releasing enzymes outside the cell. Candida secretes enzymes like secreted aspartyl proteinases (SAPs), phospholipases, and lipases. These enzymes can degrade host immune factors, such as antibodies and antimicrobial peptides, reducing the effectiveness of host defenses [ 140]. For tissue invasion, the shift to the hyphal form is crucial [ 141]. Hyphae can infiltrate and harm the epithelial cells, resulting in inflammation and distinctive white patches that appear in oral thrush. Thigmotropism, a directional growth response to surface contact, is a characteristic of hyphal cells and aids in their ability to successfully explore and infiltrate host tissues [ 142]. Candida can release candidalysin, a hypha-specific toxin that promotes immunological activation and tissue destruction [ 143]. Candidalysin, when acting upon oral epithelial cells, triggers the entry of calcium ions and the release of lactate dehydrogenase (LDH), both of which are indicative of cellular harm and the destabilization of the cell membrane [ 144]. In addition to this, Candida engages in a complementary, passive process called endocytosis. ALS3 plays a dual role as both an adhesin and an invasin, and it collaborates with Ssa1, a heat shock protein. Together, they facilitate the endocytosis of C. albicans into epithelial cells through their interaction with E-cadherin. In this process, fungal enzymes and invasins on the hyphae bind to and degrade inter-epithelial cell junctional proteins like E-cadherin, enabling the yeast to penetrate and enter host epithelial cells [ 145].

7. Oral Microbiome and Systemic Diseases

7.1. Gastrointestinal Disorder: Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), a chronic inflammatory condition affecting the gut, is known to be associated with oral microbial dysbiosis [ 74]. In healthy conditions, the mucosal barrier largely prevents microbial translocation from the oral cavity to the gut [ 146]. However, IBD's altered gut epithelial permeability allows oral-resident bacterial strains to infiltrate the gut microbiome [ 147, 148]. F. nucleatum, typically an oral inhabitant, has been detected in the intestines of IBD patients, underscoring the potential oral-gut axis in disease pathogenesis [ 149]. This notion is supported by in vivo studies wherein oral microbiota transplantation led to gut dysbiosis and exacerbated visceral hypersensitivity, further accentuating the role of oral microbes in influencing gut health [ 76, 150]. Periodontitis exhibits a strong association with IBD. Keystone pathogen P. gingivalis disrupts intestinal barrier function, impacting the gut microbiome composition and inciting inflammation [ 101, 104]. P. gingivalis enters the gastrointestinal tract and triggers an inflammatory response in the ileum. This inflammation is a localized immune reaction intended to combat the invading pathogen. During the inflammatory response, there is an activation and proliferation of a particular subset of immune cells known as IL9+ CD4+ lamina propria T cells. These T cells are known for their production of interleukin-9 (IL-9), a cytokine that plays a role in immune responses [ 151] ( Figure 1).

Moreover, pediatric Crohn's Disease (CD) patients, a type of IBD, exhibited an enrichment in resident oral bacteria, including Enterobacteriaceae, in the gut [ 76]. Klebsiella spp. derived from the oral cavity have been identified as potent inducers of Th1-mediated inflammation in the gut. This implies a potential contribution of oral bacteria to CD pathogenesis [ 77]. Collectively, the oral microbiome manifests in IBD's complex etiology. The oral-gut axis suggests that oral dysbiosis can influence IBD pathogenesis, while alterations in gut health reciprocally impact the oral microbiome [ 74]. It is promising that further research into the precise mechanisms and microbes responsible for these interactions will lead to new strategies for treating IBD.

7.2. Cardiovascular Diseases: Atherosclerosis

Studies have revealed the connection between oral dysbiosis and cardiovascular disease (CVD), as well as the impact of CVD on the oral microbiota. In the context of periodontal diseases, an increase in Gram-negative bacterial populations, such as P. gingivalis, T. denticola, and T. forsythia, can exacerbate CVD by triggering local inflammation, which in turn stimulates systemic inflammatory responses, oxidative stress, immune activation, and platelet aggregation factors associated with CVD [ 152, 153]. Pathogens such as S. mutans [ 154] and P. gingivalis [ 155] are increased in patients with both periodontal disease and atherosclerosis. Emerging evidence suggests that the relationship between oral microbiota and CVD is bidirectional, with CVD impacting the oral microbiota through systemic inflammation and immune activation. Microbial invasion of the bloodstream [ 156], facilitated by oral-gut microbiota transfer [ 79, 157] and bacteremia, may exacerbate systemic inflammation, leading to a cascade of effects that further disrupt the oral microbial balance.

Metabolites produced by the oral microbiota are gaining recognition for their potential to influence cardiometabolic health. Elevated concentrations of bacterial surface molecules like lipopolysaccharides (LPSs) and bacterial flagellins stimulate the production of pro-inflammatory mediators and cytokines [ 158, 159]. These molecules trigger inflammatory pathways such as the nuclear factor kappa-B (NF-κB) and matrix metalloproteinase 9 (MMP9) pathways, contributing to inflammation and immunoreactivity [ 155]. Aggregatibacter actinomycetemcomitans, linked to chronic periodontitis, releases leukotoxin A (LtxA), which kills white blood cells by causing cofilin dephosphorylation and actin depolymerization [ 160]. LtxA disrupts enzyme function in neutrophils, causing hypercitrullination and releasing altered proteins that could trigger autoimmune responses, possibly contributing to atherosclerosis [ 161]. Several additional bacterial species have also been implicated in the interaction between disrupted oral microbial balance and CVD. These species, including Prevotella intermedia, Prevotella nigrescens, Campylobacter rectus, Parvimonas micra, P. endodontalis, Eubacterium timidum, Eubacterium brachy, and Eubacterium saphenum, have been linked to both oral dysbiosis and the development of CVD [ 162, 163, 164].

Apart from this, autoimmune processes constitute a crucial mechanism in the development of atherosclerosis. One intriguing aspect of this immune response involves heat shock proteins (HSPs), which are part of a family of molecular chaperones that protect cells during stress [ 165]. These proteins are present in the host as well as in bacteria, including P. gingivalis. In the case of P. gingivalis, its HSP60 equivalent, known as GroEL, can trigger both a humoral and cellular immune response in humans [ 166]. This immune response can lead to chronic activation, as antibodies originally primed for bacterial HSPs may cross-react with human HSP60 due to structural similarities. This chronic immune activation fuels inflammation within arterial walls, promoting the accumulation of plaque composed of cholesterol, immune cells, and debris. Over time, the plaque buildup narrows arteries, reducing blood flow and raising the risk of cardiovascular events like heart attacks and strokes when unstable plaques rupture [ 161].

7.3. Endocrine Disorders: Diabetes Mellitus

Diabetes mellitus, marked by hyperglycemia and inflammation coupled with elevated oxidative stress, creates an environment conducive to microbial dysbiosis. Subsequently, alterations within the oral microbiome have been reported, with distinct bacterial shifts observed in diabetic subjects [ 167]. Elevated proportions of Capnocytophaga [ 168], P. gingivalis, T. forsythia [ 169, 170], and others have been noted, hinting at potential microbial contributors to diabetic-associated oral complications. However, the findings remain diverse and inconsistent, partly due to limited bacterial profiling and confounding factors. A newly gained understanding of the underlying mechanisms has revealed how diabetes-induced changes in host responses play a significant role [ 171]. Individuals with diabetes experience elevated inflammatory reactions, impaired neutrophil activity, and a diminished ability to clear bacteria. This cascade of events contributes to exacerbated periodontal inflammation and tissue damage. Moreover, the dysregulated cytokine environment, including tumor necrosis factor (TNF), fuels inflammation, exacerbating periodontal degradation [ 172, 173]. Oral microbes in diabetic individuals exhibit high virulence, potentially fueling disease progression. Diabetes-induced IL-17 elevation further amplifies oral microbial pathogenicity, intensifying the risk of periodontal deterioration [ 167]. Insightfully, interventions targeting IL-17 have shown promise in mitigating the pathogenic potential of the oral microbiome in diabetes.

7.4. Obesity

Obesity is characterized by chronic low-grade inflammation, recognized as a key link between obesity and metabolic dysfunction [ 174, 175]. This interaction, termed "meta inflammation", is particularly notable in adipose tissue [ 176]. Recent research indicates a connection between obesity and the oral microbiome, suggesting oral bacteria might play a role in obesity's development and progression [ 177]. Distinct shifts in the composition of the oral microbiome have been observed in individuals with obesity compared to non-obese individuals [ 178]. Intriguingly, lean (non-obese) individuals showcase elevated populations of Firmicutes, Bacteroidetes, and Spirochaetes [ 179, 180] in sublingual plaque, while their obese counterparts exhibit increased levels of Proteobacteria, Chloroflexi, and Firmicutes [ 181, 182]. Alterations in bacterial populations have been associated with changes in metabolic homeostasis. An area of investigation focuses on the migration of oral bacteria to the gut, subsequently influencing the composition of the gut microbiome. This "oral-gut-axis" hypothesis suggests that oral microbes can influence distant organs, potentially contributing to systemic inflammation and metabolic perturbations. Additionally, the concept of an "oral-blood axis" highlights the potential for oral bacteria and inflammatory molecules to enter the bloodstream, further propagating inflammation and metabolic dysfunction [ 175]. Moreover, studies have identified a significant link between periodontal disease, oral dysbiosis, and obesity-associated inflammation [ 183]. Intriguingly, overweight individuals exhibit altered salivary bacterial composition, possibly serving as an early indicator of developing obesity.

7.5. Neurological Disorders: Alzheimer's Disease

Alzheimer's disease (AD) is a progressive and neurodegenerative disorder predominantly affecting individuals aged over 65 years, characterized by significant cognitive decline that impairs daily activities [ 184]. Recent research has unveiled a robust connection between AD and the composition of the oral microbiota. Notably, specific pathogens within this microbial array, namely P. gingivalis, T. forsythia, and T. denticola, play central roles in periodontitis, inciting a cascade of inflammatory responses that have been implicated in AD progression [ 185, 186, 187, 188]. The oral microbiota's production of inflammatory agents introduces a novel perspective on systemic infection and inflammation. These mediators can traverse the bloodstream, influencing remote tissues and organs, including the brain. This suggests that the oral microbiota may act as a potential primary agent for AD, provoking neuroinflammation and contributing to the disease's etiology [ 189]. Interestingly, P. gingivalis, an oral pathogen, has been detected in brain tissue [ 184]. It can directly impact AD through various mechanisms. These microbes gain access to the brain via routes such as transient bacteremia, root canal pathways, or gingival crevices, where they provoke direct damage to the central nervous system (CNS), initiating an immune cascade characterized by microglial activation and inflammatory responses [ 190]. This process may induce the production of Aβ protein, which, while normally protective, could be overproduced in response to oral microbes, potentially contributing to the formation of Aβ plaques in AD [ 191].

Furthermore, the blood-brain barrier (BBB) may become more permeable in elderly AD patients, aiding oral microbe entry. Some oral microorganisms and their secreted substances can even directly alter BBB permeability. Indirectly, chronic oral diseases weaken the oral mucosal barrier, permitting cytotoxins and pro-inflammatory factors to enter the bloodstream and trigger systemic inflammation. These factors can then reach the CNS, indirectly influencing AD by inciting neuroinflammation and cognitive impairment associated with the disease [ 192]. While Aβ peptides have demonstrated antimicrobial efficacy against a range of bacteria and Candida albicans, their prolonged accumulation due to persistent colonization by pathogenic oral bacteria might lead to the formation of amyloid plaques and tau protein hyperphosphorylation, ultimately culminating in brain tissue damage [ 190, 193].

7.6. Parkinson's Disease

Parkinson's Disease (PD), a prevalent neurodegenerative disorder primarily recognized for its impact on movement control, poses significant challenges to the aging population [ 194, 195]. It is a disorder that affects memory. PD's core manifestation lies in compromised fine and gross motor skills. The onset of PD, frequently late in life, may not exclusively stem from genetic inheritance but rather a combination of multifactorial contributors, including genetic predisposition, environmental risks, and aging [ 196]. Recently, many studies have shown a correlation between P. gingivalis infection and PD [ 197, 198, 199, 200]. Studies have revealed that gingipain R1 (RgpA), a virulence factor produced by P. gingivalis, can be detected in the bloodstream, indicating systemic dissemination of the bacterium [ 197]. Additionally, PD patients exhibit a hypercoagulable state characterized by hyperactivated platelets and fibrinogen amyloid features, which may be influenced by P. gingivalis and its products [ 197, 201]. Furthermore, P. gingivalis is implicated in inducing systemic inflammation, as evidenced by the presence of its lipopolysaccharides (LPSs) and gingipain in circulation [ 201]. This systemic inflammation is known to play a role in the pathogenesis of PD. Animal studies have provided further insights into the potential mechanisms linking P. gingivalis to PD. The oral administration of live P. gingivalis to mice with a genetic mutation associated with PD leads to neurodegeneration in the substantia nigra, the activation of microglia, and the upregulation of IL-17A secretion and its receptor IL-17RA [ 199]. These findings suggest that P. gingivalis may contribute to PD pathogenesis by inducing systemic inflammation, promoting hypercoagulability, and exacerbating neurodegeneration. However, further research is needed to fully elucidate the complex interplay between the oral microbiota, systemic inflammation, and neurodegenerative diseases like PD.

7.7. Autoimmune Conditions: Rheumatoid Arthritis

Rheumatoid arthritis (RA), a chronic autoimmune disease characterized by symmetrical inflammation and joint pain, has a complex etiology involving genetic and environmental factors [ 202]. Recent research has unveiled a compelling connection between the oral microbiota and RA pathogenesis, shedding light on the role of specific microorganisms and their molecular mechanisms in triggering and exacerbating the disease. Among the key players, P. gingivalis stands out as a significant pathogen implicated in both periodontitis and RA [ 203]. P. gingivalis is equipped with virulent factors, including the bacterial protein arginine deiminase (PPAD), capable of citrullinating host proteins [ 204]. This citrullination has been postulated to initiate an autoimmune response, culminating in the production of anticitrullinated protein antibodies (ACPAs) that are characteristic of RA. Neutrophil extracellular traps (NETs) generated during infection further contribute to the citrullination of proteins catalyzed by PAD4 enzymes and ACPA production [ 205, 206]. The presence of ACPAs has been correlated with P. gingivalis exposure and has been proposed as a crucial link between periodontal inflammation and RA onset ( Figure 3).

Beyond P. gingivalis, a broader dysbiosis of the oral microbiota has appeared as a potential factor in RA development. Elevated levels of Prevotella, Veillonella, and anerobic species, such as Lactobacillus salivarius, have been observed in RA patients [ 207]. Conversely, decreased levels of beneficial microbes, such as Haemophilus spp., have been noted. This dysbiosis can lead to altered immune responses, including the overactivation of T helper 17 (Th17) cells, which play a pivotal role in autoimmune processes. Th17 cells produce pro-inflammatory cytokines like IL-17 [ 208]. Elevated levels of IL-17 have been found in the synovium of RA patients and are associated with disease severity [ 209]. Moreover, the interplay between microbial communities and immune cells can exacerbate joint inflammation and bone destruction in RA [ 210]. Recent investigations have also implicated A. actinomycetemcomitans, a periodontal bacterium, in RA pathogenesis. Leukotoxin A (LtxA) secreted by A. actinomycetemcomitans triggers neutrophil hypercitrullination and the subsequent release of citrullinated autoantigens, further fueling the ACPA response [ 211]. Some oral microbiome molecules structurally resemble human self-antigens, potentially leading to cross-reactivity with host proteins. For instance, P. gingivalis' α-enolase protein shares homology with human α-enolase, an autoantigen in RA. Antibodies against citrullinated α-enolase (anti-CEP-1) have been found in individuals with chronic PD, suggesting a connection [ 212].

7.8. Systemic Lupus Erythematosus

Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease that impacts various organs and tissues, disproportionately affecting women of reproductive age [ 207]. Although its etiology remains elusive, recent research has shed light on the potential involvement of the oral microbiome in SLE pathogenesis. Numerous studies have demonstrated alterations in the oral microbiota composition in individuals with SLE. This microbial dysbiosis extends beyond the oral cavity, possibly contributing to the systemic inflammation characteristic of SLE [ 213]. A study conducted by Pessoa et al. made a significant observation regarding the oral microbiota in individuals with SLE compared to healthy controls. Fourteen distinct subgingival bacteria in SLE patients were enriched, suggesting a distinct microbial profile associated with the disease. Interestingly, this elevated microbial abundance was particularly evident in certain bacteria, specifically T. denticola and T. forsythia [ 214]. Moreover, an increased diversity of oral microbiota was observed in SLE patients' saliva, with Veillonella, Streptococcus, and Prevotella as the dominant species [ 215].

Periodontitis may exacerbate SLE through activation of the Toll-like receptors (TLRs), such as TLR2 and TLR4. These receptors are pivotal in recognizing microbial components and initiating immune responses [ 216]. The interesting concept of molecular mimicry arises in the context of SLE. Cross-recognition between self-antigens, like Ro60, and homologous peptides from oral bacteria suggests a potential role for bacterial antigens in triggering autoimmune responses. These observations highlight the oral microbiota's capacity to induce and perpetuate aberrant immune reactions in SLE [ 216]. Elevated levels of pro-inflammatory cytokines, such as interleukin-6 (IL-6), IL-17A, and IL-33, have been detected in the saliva of SLE patients with chronic periodontitis. These cytokines play a pivotal role in promoting immune cell activation and differentiation, thereby intensifying autoimmune responses and tissue damage [ 217, 218, 219]. The complicated relationship between oral microbial dysbiosis, periodontitis-induced inflammation, and systemic immune dysregulation emphasizes the potential impact of the oral microbiota on SLE progression.

7.9. Cancer

Within the realm of cancer research, specific bacterial strains have emerged as influential contributors to cancer progression, shedding light on the intricate connections between the oral microbiome and this complex disease. Notably, two bacterial strains, particularly F. nucleatum and P. gingivalis, have been recognized as agents that contribute to cancer progression. F. nucleatum employs a range of surface proteins to infiltrate diverse cell types, potentially initiating tumor development in the mouth, colon, and esophagus. Similarly, P. gingivalis is connected to periodontal harm and can support tumor formation by invading neighboring tissues. This bacterium can also travel to other sections of the oral and digestive systems, and its association with pancreatic cancer has been observed [ 220]. Certain bacteria produce specific substances with potent cancer-causing properties. For instance, lipopolysaccharide, which is generated by numerous anerobic oral microorganisms, including S. oralis, S. mitis, S. sanguinis, Lactobacillus fermentum, Lactobacillus acidophilus, and Bifidobacterium adolescentis, can induce inflammatory mechanisms linked to the development of cancer [ 221].

A comprehensive overview of the associations between the oral microbiome and various diseases is mentioned in Table 2. It is noteworthy that the organisms discussed are referred to as commensal when they are present at low levels, typical of a healthy microbiome.

8. Oral Health and Dental Care Practices

8.1. Probiotics

Dental probiotics contribute to the balance of the oral microbiota by colonizing the oral mucosa, producing specialized metabolites to maintain the host microbiota's ecological equilibrium, and promoting a healthy level of immunity [ 222]. Scientifically studied probiotic strains such as Streptococcus salivarius M18, Streptococcus salivarius K12, Lactobacillus plantarum, Bifidobacterium lactis, Lactobacillus reuteri, and Lactobacillus salivarius have demonstrated their efficacy in supporting oral health. These strains are known to combat the bacteria responsible for bad breath and gum inflammation. S. salivarius can generate powerful antibacterial proteins known as bacteriocins, which can be harmful for the growth of various bacterial species [ 223]. Furthermore, laboratory investigations have revealed that S. salivarius engages directly with the gingival epithelium [ 224], exhibiting anti-inflammatory characteristics and fostering a harmonious immune response [ 225, 226].

Specifically, two strains of L. reuteri (DSM 17938 and ATCC PTA 5289) have been shown to significantly reduce halitosis [ 227]. L. salivarius (WB21 and TI 2711) may reduce dental caries through mechanisms including coaggregation and growth inhibition of S. mutans, as well as reducing plaque acidogenicity [ 228]. The probiotic strain Bifidobacterium animalis subsp. lactis (B. lactis) HN019 showed significant improvement in clinical periodontal indicators, a more efficient reduction in periodontal pathogens, and a decrease in pro-inflammatory cytokine levels within the gingival crevicular fluid [ 229]. Moreover, L. plantarum exhibited notable effectiveness in inhibiting the growth of S. mutans and C. albicans, disrupting the formation of virulent biofilms, and influencing gene expression related to crucial metabolic pathways, fungal resistance, and oxidative stress. These findings underscore the potential of L. plantarum as a promising candidate for controlling cariogenic biofilms and, consequently, for the prevention of dental caries [ 230].

8.2. Peptides in Oral Health and Their Role in Oral Care

Peptides, short chains of amino acids, play critical roles in various biological processes, including promoting health and healing [ 231]. In the past twenty years, peptides have gained significant attention in the dental field [ 232, 233]. These peptides have been applied across various dental specialties, including endodontic therapy, restorative dentistry, caries control, bone and dental tissue remineralization, and an enhancement in dental materials [ 232, 234]. The integration of peptides in oral care is an emerging area of research with the potential to revolutionize oral health practices.

Antimicrobial peptides (AMPs) such as defensins and cathelicidins are known for their ability to inhibit the growth of oral bacteria, fungi, and viruses [ 235]. These peptides disrupt the integrity of microbial cell membranes, providing a natural defense against oral pathogens [ 236]. AMPs exhibit a range of mechanisms to target and inhibit microbes. Primarily, they interact electrostatically with negatively charged microbial membranes due to their cationic nature. This leads to the formation of pores, disrupting membrane integrity and increasing permeability. AMPs allow the leakage of ions, metabolites, and other vital cellular components, ultimately causing microbial cell death. The interfacial activity of AMPs enables them to partition into the membrane-water interfaces, modifying lipid structures. While eukaryotic cell membranes remain unaffected due to their neutral charge, the specific interactions with microbial membranes make AMPs selective and effective in combating pathogens [ 235].

Naturally occurring peptides in saliva, such as histatins, play a key role in oral health. They possess antimicrobial properties and contribute to maintaining oral tissue integrity, helping to prevent infections and inflammation [ 237]. Histatins interact with the plasma membrane of pathogens, forming pores that disrupt membrane integrity. This action allows for the leakage of ions such as potassium, as well as other intracellular components, ultimately impairing the pathogen's cellular functions and leading to cell death. Histatins bind to the Trk1 potassium transporter on yeast cells, causing potassium efflux and further destabilizing the cell's internal environment. Histatins exhibit both fungistatic (inhibiting fungal growth) and fungicidal (killing fungi) effects, particularly against Candida albicans [ 238]. Among the histatins, Histatin-5 is the most effective, followed by Histatin-3 and then Histatin-1 [ 239].

Enamel strengthening peptides, such as peptide P11-4, are an innovative development in dental health, designed to support the remineralization and strengthening of tooth enamel [ 240]. The biomimetic nature of P11-4 allows it to closely resemble the mineral structure of enamel, aiding the regeneration and remineralization of dental hard tissues [ 240]. Once applied to the tooth surface, P11-4 forms scaffold-like structures with negative-charge domains that attract calcium ions, inducing the precipitation of hydroxyapatite, the mineral essential for tooth enamel [ 241]. Combined with fluoride, P11-4 enhances the remineralization process by incorporating calcium and phosphate ions into the enamel structure [ 240]. Studies, including randomized clinical controlled trials, have demonstrated the safety and efficacy of P11-4 in promoting enamel health [ 240].

8.3. Personalized Oral Care Approaches

In addition to probiotics, a comprehensive oral care regimen can support the natural healing of teeth and gums, aligning with the body's inherent mouth chemistry for enhanced oral health. In this regimen, xylitol is a vital component that helps rebalance mouth acidity. The regular use of xylitol mints and gums has been associated with decreased counts of S. mutans, potentially reducing the adherence of plaque [ 242]. These products consist of xylitol, natural peppermint flavor, magnesium stearate, and natural menthol. Xylitol, being the crucial component, is the one that decreases the presence of S. mutans, which is responsible for tooth decay. Xylitol, once taken up by S. mutans, significantly disrupts the bacterium's usual energy production pathways, fundamentally altering its growth and survival mechanisms. Unlike other sugars, xylitol cannot be processed by S. mutans for energy, initiating a futile energy cycle that derails the bacterium's normal metabolic processes. This disruption results in the conversion of xylitol to xylitol-5-phosphate within the bacterial cell, causing the formation of vacuoles and damaging the cell membrane. These alterations impede the bacterium's growth and viability. Furthermore, the attempt by S. mutans to expel the dephosphorylated xylitol-5-phosphate from the cell, with no energy yield from xylitol metabolism, essentially starves the bacterium, hindering its growth and contributing to its eventual death [ 243].

Following in the regimen is the mouth rinse, comprising stabilized chlorine dioxide (ClO ₂), trisodium phosphate, and citric acid. This distinct formulation highlights its capacity to offer therapeutic advantages, making it an attractive option for patients concerned about taste preferences and tooth discoloration during oral health treatment [ 244]. ClO ₂, being the compound of interest, acts on volatile sulfur compounds (VSCs), the chief contributors to oral malodor, through a sequential mechanism. Initially, ClO ₂ reacts with thiol compounds like L-cysteine, generating ClO 2− and thiol radicals (RS.), subsequently converting thiol compounds into disulfides like cystine. This reduction of thiol compounds progresses through reactions involving the formation of disulfides, addressing malodorous thiols. Simultaneously, ClO ₂ showcases bactericidal properties by permeating bacterial cells and disrupting cytoplasmic amino acids and membrane proteins, leading to microbial cell death. The chemical reactions involved underline the efficacy of ClO ₂ in neutralizing malodor-causing compounds and eradicating odor-producing bacteria, essential for combating oral malodor [ 245].

9. Chemical Reactions

9.1. Reaction 1

This reaction includes thiol compounds (e.g., L-cysteine), chlorine thiol, chlorine dioxide, hydrogen, and a dioxide radical ion.

9.3. Reaction 3

This reaction includes thiol compounds, chlorine dioxide, disulfides, chloride, and water.

The reaction also includes compounds (e.g., L-cysteine) and radical (e.g., cystine) ions.

The results from Shinada et al.'s study [ 245] confirm that a seven-day regimen using a ClO ₂ mouth rinse significantly reduced morning oral malodor and lowered VSCs in healthy subjects. Additionally, it effectively reduced plaque, tongue coating, and F. nucleatum counts in the saliva.

Alternatively, individuals can incorporate a mouth rinse into their oral care routine, which includes thymol, eucalyptol, menthol, and methyl salicylate dissolved in ethanol (27%) [ 246]. Thymol, derived from Thyme essential oil, is an essential component in antiseptic mouthwashes due to its potent antifungal properties. Its mechanism involves altering the membrane lipids' fluidity and permeability, disrupting the production of hyphae, which are essential structures for the pathogenicity of C. albicans. Additionally, thymol significantly reduces the adhesion of C. albicans to epithelial cells, an initial step in infection development [ 247]. Eucalyptol, a primary constituent of Eucalyptus essential oil, features prominently in oral hygiene products due to its potent antimicrobial properties. Its efficacy extends to combating various oral pathogens like P. gingivalis and S. mutans, commonly associated with periodontitis and dental issues. Eucalyptol operates by disrupting bacterial cell membranes, notably the cytoplasmic membrane. Components like 1.8-cineole and terpinolene modify membrane permeability, compromising its integrity and allowing the increased passage of ions and molecules, leading to cellular dysfunction and eventual bacterial demise [ 248]. The combined action of these ingredients aims to support oral health by targeting bacteria and promoting a clean and refreshed feeling in the mouth after use [ 249].

A fluoride toothpaste is an essential part of oral care, featuring sodium fluoride among other vital components like hydrated silica, cellulose gum, and glycerin. These ingredients collectively contribute to fortifying tooth enamel, preventing cavities, and promoting oral hygiene. Fluoride's action in preventing tooth decay involves multiple mechanisms and chemical reactions. Fluoride ions (F −) can replace hydroxyl ions (OH −) in the hydroxyapatite crystal structure of enamel, forming fluorapatite (FAP) [ 250]. This substitution creates a more acid-resistant structure, making the enamel less susceptible to acids produced by plaque bacteria.

The chemical reaction can be represented as follows:

Hydroxyapatite (HA) + Fluoride ions (F −) → Fluorapatite (FAP) + Hydroxyl ions (OH −)

Fluoride deposition is higher in the outer enamel layers, enhancing their acid resistance and conferring caries resistance to the tooth. In an acidic environment, fluoride can form hydrogen fluoride (HF), an undissociated weak acid that can penetrate bacterial cell membranes. HF's penetration into bacterial cells leads to two physiological impacts: interference with fluoride-sensitive enzymes and intracellular acidification, hindering essential enzymes necessary for cell growth. Fluoride, when present, combines with calcium to form calcium fluoride (CaF ₂) on plaque and enamel surfaces. CaF ₂ acts as a reservoir for fluoride. When the pH drops due to acid, fluoride and calcium ions are released into plaque fluid. Fluoride then diffuses into enamel pores, forming FAP. FAP is more acid-resistant than hydroxyapatite, reducing the demineralization and enhancing the remineralization of enamel between pH 4.5 and 5.5. This process shortens the demineralization period and helps in maintaining enamel health [ 250, 251]. Combinations such as using toothpaste containing fluoride concentrations ranging from 1100 ppm to 1500 ppm, either on its own or paired with a 0.05% sodium fluoride mouth rinse, have demonstrated considerable effectiveness in reducing the progression of root caries [ 252].

Fluoride has long been relied upon for its role in preventing dental cavities, yet the growing concerns regarding public acceptance and the potential risk of fluorosis in children highlight the need for alternative solutions. Toothpastes incorporating hydroxyapatite (HA) have emerged as fluoride-free options and have demonstrated promising efficacy as anti-cavity agents in recent research [ 253]. HA toothpaste works by replenishing lost minerals in enamel and restoring its structure. It binds to damaged enamel, filling in surface irregularities and promoting deeper penetration into lesions for comprehensive repair. Mimicking natural enamel, HA particles effectively remineralize teeth, offering an alternative to fluoride-based products [ 253].

Cetylpyridinium chloride (CPC), a quaternary ammonium compound, is a prevalent antiseptic found in various oral care formulations like mouthwashes and toothpaste [ 254]. CPC serves as a potent antimicrobial in oral care by engaging in a multifaceted role in bacterial membranes and cellular functions, ensuring its efficacy in combating plaque-forming bacteria for maintaining oral hygiene. Its positive charge enables interaction with negatively charged bacterial membranes, disrupting the balance of ions like Mg ²⁺ and Ca ²⁺ and integrating its hydrophobic tail into the lipid bilayer. At lower concentrations, CPC disrupts bacterial osmoregulation, causing the leakage of vital cellular components and potentially activating autolytic enzymes. Higher concentrations lead to extensive membrane disintegration, resulting in the leakage of cytoplasmic contents and damage to proteins, nucleic acids, and cell walls. CPC's effectiveness extends to Gram-negative bacteria, bypassing their complex cell walls due to its molecular size and leveraging damaged cell walls to enhance its penetration. Additionally, CPC's surfactant properties facilitate the uniform coverage of irregular surfaces, aiding in biofilm disruption [ 254].

Clove oil, primarily composed of eugenol, eugenyl acetate, carvacrol, and other compounds, has gained attention in dental health due to its therapeutic properties. Clove oil demonstrates potent antibacterial effects against multi-resistant Staphylococcus species. Its action inhibits the growth and proliferation of these bacteria, aiding in controlling oral infections. With its antifungal activity, clove oil impedes the growth of fungi like C. albicans. It reduces ergosterol levels, a crucial component of fungal cell membranes, and inhibits germ tube formation by C. albicans, essential for its pathogenicity. The oil exhibits strong radical scavenging activity, indicating its antioxidant potential. This property helps combat oxidative stress in the oral cavity, contributing to overall oral health [ 255]. In dentistry, clove oil finds application in various forms, including mouth rinses or gels. Its mode of action involves disrupting microbial cell membranes, inhibiting essential cellular processes, and interfering with the structural integrity of pathogens. These actions collectively contribute to its efficacy in preventing and managing oral infections and inflammation.

Oil pulling is a traditional oral hygiene technique involving swishing oil, typically coconut, sesame, or sunflower oil, in the mouth for around 15-20 min [ 256]. Oil pulling generates antioxidants that damage the cell walls of microorganisms, killing them effectively. The oils attract the lipid layer of bacterial cell membranes, causing them to stick to the oil and eventually get removed from the oral cavity. The oil gets emulsified during the swishing process, increasing its surface area and efficacy. The oil coats the teeth and gums, hindering bacterial coaggregation and plaque formation. It effectively removes plaque-building bacteria responsible for various oral issues like dental caries, gingivitis, and bad breath. Coconut oil, particularly due to its lauric acid content, exhibits potent antimicrobial properties. It effectively fights Streptococcus mutans and Candida albicans in biofilm models. The lauric acid in coconut oil reacts with the saliva's alkalis to form a substance that reduces plaque adhesion and accumulation, aiding in cleansing the oral cavity. Lauric acid also prevents dental caries, possesses anti-inflammatory properties, and promotes overall oral health. Its pleasant taste adds to its appeal [ 256, 257] ( Table 3).

o-Cymen-5-ol exhibits antibacterial qualities without adversely altering the oral microbiome, making it an important component of oral care [ 258]. It has been discovered to specifically target possible oral pathogens while encouraging the development of advantageous bacteria like Rothia, which helps control blood pressure [ 258]. Furthermore, it has been demonstrated that o-Cymen-5-ol increases the efficacy of colistin against multidrug-resistant Klebsiella pneumoniae without producing cell toxicity or resistance [ 259]. According to recent research, o-cymen-5-ol and zinc salts together can effectively lower the development of plaque, gingival inflammation, bleeding gums, and halitosis in toothpastes and mouthwashes [ 260, 261]. It is already known that the o-cymen-5-ol/zinc system directly inhibits oral infections such Fusobacterium nucleatum, Actinomyces viscosus, Porphyromonas gingivalis, Streptococcus mutans, and Candida albicans [ 261]. Moreover, o-Cymen-5-ol prolongs substantivity when paired with cetylpyridinium, which makes it a viable substitute for conventional antimicrobials in mouthwash formulations like triclosan and chlorhexidine [ 262].

Practicing daily dental care ( Supplementary Materials File S2 ([ 263, 264, 265, 266, 267, 268, 269, 270, 271])) with the above-mentioned key components and strategies may ensure the removal of plaque, resolution of gingivitis, prevention of cavities, treatment of periodontal disease, and management of gum issues, all while fostering a harmonious and healthy oral microbiome.

10. Conclusions

In conclusion, the oral microbiome is a diverse and complex ecosystem that plays a significant role in maintaining oral and systemic health. Comprising a plethora of bacterial, fungal, and archaeal species, the oral microbiome's composition and dynamics are intricately linked to various physiological processes. Disruptions in this delicate balance, leading to oral dysbiosis, can precipitate a spectrum of oral ailments like dental caries, gingivitis, periodontitis, halitosis, and oral candidiasis, while also exerting profound effects on systemic health, including gastrointestinal disorders, cardiovascular diseases, endocrine imbalances, and neurological conditions. The interplay between the oral and gut microbiomes, underscored by microbial translocation, emphasizes the bidirectional relationship between oral and systemic health, wherein disturbances in either ecosystem can cascade into the other, exacerbating disease states. Recent research illuminating connections between specific oral bacteria, such as P. gingivalis, and systemic diseases like IBD, cancer, Alzheimer's, and RA, bring out the far-reaching impact of oral health on overall health outcomes.

As our understanding of the oral microbiome expands, it becomes increasingly evident that fostering a balanced oral microbial ecosystem is paramount for holistic health. Embracing evidence-based dental care practices, such as integrating dental probiotics like S. salivarius and Lactobacillus strains, alongside utilizing oral ingredients like xylitol, fluoride toothpaste, and essential-oil-based mouth rinses, presents a comprehensive approach to oral health maintenance. One could test for these problems and arrive at a personalized dental care plan to address specific needs. These interventions, rooted in scientific validation, offer promising avenues for preventing oral dysbiosis and tackling common oral health issues like bad breath, gum inflammation, and dental caries. By adopting these strategies, individuals can actively contribute to nurturing a balanced oral microbiome, thus safeguarding not only their oral health but also their systemic well-being. Researchers should conduct long-term studies to track changes in the oral microbiome over time and map out the entire oral microbiome in future investigations, including less-studied archaea and fungi. Finding biomarkers for individualized dental treatment and comprehending how mouth microorganisms impact general health are crucial. To develop new health strategies, we must evaluate novel oral health products and apply methods from other disciplines to increase our understanding of the oral microbiota and its impacts.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/microorganisms12091797/s1, File S1: Oral Microbiome and Techniques for Analysis. File S2: Practices for Daily Dental Care. References [ 1, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 263, 264, 265, 266, 267, 268, 269, 270, 271] have been cited in the Supplementary Materials.

Author Contributions

Conception: H.K.K., J.J.R., and V.J. Manuscript preparation: H.K.K., J.B., V.J., K.K., T.W., K.B., and J.J.R. All authors have read and agreed to the published version of the manuscript.

Funding

Vibrant America provided funding for this study in the form of salaries for the authors [H.K.K., J.B., V.J., K.K., T.W., K.B., and J.J.R.]. The specific roles of these authors are articulated in the 'Author Contributions' section. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of this manuscript.

Acknowledgments

We acknowledge Vibrant America LLC for supporting this research.

Conflicts of Interest

The authors have read the journal's policy, and the authors of this manuscript have the following competing interests: H.K.K., V.J., K.K., T.W., K.B., and J.J.R. are paid employees of Vibrant Sciences LLC. J.B. is a paid employee of Vibrant America LLC. Vibrant Sciences or Vibrant America is a commercial lab which performs saliva testing for oral micro-organisms. Vibrant Sciences or Vibrant America could benefit from increased testing based on the observations. There are no patents, products in development, or marketed products to declare. This does not alter our adherence to Microorganisms' policies on sharing data and materials.

References

1. Morillo, J.M.; Lau, L.; Sanz, M.; Herrera, D.; Silva, A. Quantitative real-time PCR based on single copy gene sequence for detection of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. J. Periodontal Res. 2003, 38, 518-524. [Google Scholar] [CrossRef]

2. Rathee, M.; Jain, P. Gingivitis. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: http://www.ncbi.nlm.nih.gov/books/NBK557422/ (accessed on 3 May 2024).

3. Arya, N.R.; Rafiq, N.B. Candidiasis. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: https://www.ncbi.nlm.nih.gov/books/NBK560624/ (accessed on 20 September 2023).

4. Oral Thrush: Overview; Institute for Quality and Efficiency in Health Care: Cologne, Germany, 2022. Available online: https://www.ncbi.nlm.nih.gov/books/NBK367586/ (accessed on 20 September 2023).

5. Zeng, Y.; Fadaak, A.; Alomeir, N.; Wu, T.T.; Rustchenko, E.; Qing, S.; Bao, J.; Gilbert, C.; Xiao, J. Lactobacillus plantarum Disrupts S. mutans-C. albicans Cross-Kingdom Biofilms. Front. Cell Infect. Microbiol. 2022, 12, 872012. [Google Scholar] [CrossRef]

6. Forbes, J.; Krishnamurthy, K. Biochemistry, Peptide. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: https://www.ncbi.nlm.nih.gov/books/NBK562260/ (accessed on 3 May 2024).

7. Vlachojannis, C.; Chrubasik-Hausmann, S.; Hellwig, E.; Al-Ahmad, A. A Preliminary Investigation on the Antimicrobial Activity of Listerine®, Its Components, and of Mixtures Thereof. Phytother. Res. PTR 2015, 29, 1590-1594. [Google Scholar] [CrossRef]

8. Alshehri, F.A. The use of mouthwash containing essential oils (LISTERINE®) to improve oral health: A systematic review. Saudi Dent. J. 2018, 30, 2-6. [Google Scholar] [CrossRef] [PubMed]

Figure 1. Oral-Gut pathways to IBD and systemic diseases: Oral microbes such as Porphyromonas gingivalis can take two distinct routes to enter the body. The first is the hematogenous route (shown on the left), often associated with dental problems like tooth decay, periodontitis, gingivitis, oral thrush, and halitosis, which can further lead to systemic conditions such as CVD, neurological disorders, autoimmune diseases, diabetes, IBD, and cancer. On the other hand, the enteral route (shown in the right) allows these oral microbes to travel from the stomach to the intestines. P. gingivalis, which possesses resistance to antibiotics and can survive stomach acid, moves from the stomach into the gut. Changes in gastric acidity can alter the gut microbiota, making it resemble the oral microbiome. Upon entering the gastrointestinal tract, P. gingivalis disrupts the intestinal barrier, compromising gut integrity. This disruption, along with changes in the microbiome, initiates inflammation, typically occurring in the ileum. Within this inflammatory response, specific immune cells known as IL9+ CD4+ lamina propria T cells become active and produce IL-9, a cytokine that fuels immune responses and inflammation. While inflammation serves as a defense against invaders, excessive or chronic inflammation can lead to conditions like IBD. Abbreviations: IL-9: Interleukin-9; IL9+ CD4+ lamina propria T cells: immune cells producing IL-9; IBD: inflammatory bowel disease.

Figure 2. Mechanisms of Candida albicans pathogenicity. ( A) Adhesion to host surfaces: Candida albicans initially adheres to host surfaces through weak and reversible interactions influenced by hydrophobic and electrostatic forces, facilitated by host tissue receptor glycoproteins ALS and HWP1. ( B) Phenotypic switch: C. albicans can phenotypically switch between yeast and hyphal states. ( C) Host cell receptor interaction: C. albicans can adhere to epithelial cells using various host cell receptors, such as EphA2 (through β-glucan) and E-cadherin (through ALS3). Host cell transglutaminases create a cross-linking between C. albicans and the epithelial surface by interacting with HWP1. ( D) Biofilm formation: Interaction with oral bacteria, such as Streptococcus gordonii, promotes the formation of biofilms. ALS3 on C. albicans binds to surface protein SspB on S. gordonii, facilitating biofilm formation. ( E) Hyphal penetration into epithelial cells: The shift to the hyphal form is crucial for tissue invasion. Hyphae infiltrate and harm epithelial cells, causing inflammation and white patches in oral thrush. Abbreviations: ALS: agglutinin-like sequence; HWP1: hyphal wall protein; SspB: surface protein SspB; EphA2: Eph receptor A2.

Figure 3. Mechanisms linking oral pathogens to RA. Porphyromonas gingivalis and RA link: P. gingivalis possesses virulent factors, including the PPAD, which citrullinates host proteins. This citrullination is thought to trigger autoimmune responses, leading to the production of ACPAs characteristic of RA. NETs and ACPA production: NETs formed during periodontitis contribute to protein citrullination catalyzed by PAD4 enzymes, further enhancing ACPA production. Aggregatibacter actinomycetemcomitans and RA: A. actinomycetemcomitans secretes LtxA, triggering neutrophil hypercitrullination and the release of citrullinated autoantigens, further fueling the ACPA response. Citrullinated autoantigens can trigger an autoimmune response, wherein Th17 cells in the immune system become overactivated. Th17 cells are known for producing pro-inflammatory cytokines, notably IL-17. IL-17 stimulates B cells to produce antibodies, including ACPAs. These antibodies can target citrullinated proteins, contributing to the autoimmune processes and inflammation seen in RA. Abbreviations: PPAD: protein arginine deiminase of P. gingivalis; ACPAs: anticitrullinated protein antibodies; PAD4: peptidylarginine deiminase 4; LtxA: leukotoxin A; Th17: T helper 17; IL 17: interleukin-17; RA: rheumatoid arthritis.

Table 1. The composition of the oral microbiome.

Table 2. Oral microbes and disease associations.

Oral diseases

Dental caries

↑

Acidogenic bacteria produce acidic by-products, leading to demineralization and cavitation; dysbiosis-driven disorder.

Gingivitis

Streptococcus sp., Actinomyces sp., and Veillonella sp.

↑

Caused by the accumulation of microbial plaque on the tooth surface, which penetrates the gingival tissue and leads to inflammation.

Periodontitis

Prevotella melaninogenica

↑

Pathogenic bacteria induce inflammation, oxidative stress, immune activation, and tissue damage; potential systemic implications.

Halitosis

Treponema denticola, P. gingivalis, P. endodontalis, and Tannerella forsythia

↑

Anerobic bacteria produce VSCs causing malodor; bacterial degradation of sulfur-containing amino acids.

Taste impairment

Lactobacilli

-

↑

High levels of acid produced by the bacteria impair taste, affecting taste perception.

Burning mouth syndrome (BMS)

-

↑

Alteration in bacterial strains may contribute to the development of BMS influencing pathways involved in inflammation, immune responses, and sensory perception.

Oral thrush

Candida parapsilosis, Candida krusei, and
Candida tropicalis

Candida albicans,
Candida glabrata,
Candida dubliniensis, and
Candida guilliermondii

↑

Overgrowth of Candida species due to factors like poor oral hygiene, weakened immune system, or underlying medical conditions; adhesion to host surfaces and tissue invasion through various mechanisms; hyphal formation, biofilm production, and secretion of enzymes that degrade host immune factors.

Systemic diseases

IBD

-

↑

Oral-resident bacteria may infiltrate the gut microbiome; gut dysbiosis due to altered gut epithelial permeability.

Atherosclerosis

↑

Oral dysbiosis triggers local inflammation, systemic inflammatory responses, oxidative stress, immune activation, and platelet aggregation.

Diabetes

Capnocytophaga

↑

Hyperglycemia and oxidative stress create a conducive environment for microbial dysbiosis;
elevated inflammatory reactions.

Obesity

-

↑

Potential migration of oral bacteria to the gut; alterations in bacterial populations impact metabolic homeostasis.

AD

-

↑

Oral microbiota's production of inflammatory agents potentially contributes to neuroinflammation and AD progression.

PD

-

P. gingivalis

↑

P. gingivalis infection is correlated with PD, with studies demonstrating the presence of gingipain R1 (RgpA) in the bloodstream, indicating systemic dissemination. P. gingivalis may contribute to PD pathogenesis by inducing systemic inflammation, promoting hypercoagulability, and exacerbating neurodegeneration.

RA

↑

P. gingivalis implicated in RA onset via citrullination and ACPA production; dysbiosis of oral microbiota exacerbates joint inflammation.

SLE

↑

Oral microbial dysbiosis and periodontitis may exacerbate SLE via immune activation; potential contribution to autoimmune responses.

Cancer

↑

Specific bacteria infiltrate cells, initiate tumor development, and produce cancer-promoting substances like lipopolysaccharides.

Table 3. Summary of oral health compounds: mechanisms of action and formulations.

Probiotics

Support balance of oral microbiota, produce specialized metabolites for maintaining microbiota equilibrium, and
promote healthy immunity

Probiotic supplements containing strains such as Streptococcus salivarius M18, Streptococcus salivarius K12, Lactobacillus plantarum, Bifidobacterium lactis, Lactobacillus reuteri, and Lactobacillus salivarius help maintain oral microbiota balance, combat bad breath and gum inflammation, and enhance immune responses

Xylitol

Rebalances mouth acidity, reduces S. mutans counts, and disrupts S. mutans energy production

Xylitol mints and gums contain xylitol, natural peppermint flavor, magnesium stearate, and natural menthol

Chlorine dioxide mouth rinse

Neutralizes volatile sulfur compounds (VSCs), kills odor-producing bacteria, and reduces plaque and F. nucleatum counts

Stabilized chlorine dioxide (ClO ₂), trisodium phosphate, and citric acid; typically found in commercially available mouth rinses

Thymol mouth rinse

Antifungal properties; disrupts C. albicans hyphae production and adhesion to epithelial cells

Thymol, eucalyptol, menthol, and methyl salicylate dissolved in ethanol (27%); available in various commercial mouthwash formulations

Clove oil

Has antibacterial and antifungal effects, inhibits multi-resistant Staphylococcus species growth, and reduces C. albicans ergosterol levels

Clove oil containing eugenol, eugenyl acetate, and carvacrol, available in various oral care products such as mouth rinses and gels

Oil pulling

Generates antioxidants to damage microbial cell walls, removes bacteria by attracting them to oil, and hinders bacterial coaggregation and plaque formation

Coconut, sesame, or sunflower oil, typically used as a standalone oral hygiene technique

Antimicrobial peptides

Antimicrobial peptides (AMPs) such as defensins and cathelicidins disrupt microbial cell membranes through electrostatic interactions, forming pores that lead to ion leakage and cell death, providing natural defense against oral pathogens

Antimicrobial peptides (AMPs) like defensins and cathelicidins are integrated into oral care products to combat oral bacteria, fungi, and viruses

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# data[].attributes.attachment_link.title
Oral Microbiome: A Review of Its Impact on Oral and Systemic Health

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Purpose of review: This review investigates the oral microbiome's composition, functions, influencing factors, connections to oral and systemic diseases, and personalized oral care strategies. Recent findings: The oral microbiome is a complex ecosystem consisting of bacteria, fungi, archaea, and viruses that contribute to oral health.

# data[].attributes.body
Summary: This article talks about how oral microbial testing can be used for periodontal disease. Even though there are a lot of good forms of oral testing. This article does highlight some of the limitations of oral testing. Some being missing, other pathogens, testing being site-specific, and external factors not being considered. Also talks about how testing alone can only do so much. Using clinical assent and testing can improve a patient's health.

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early disease detection

improving patient health

more effective treatment planning

no painful

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costly

complicated results that need understanding, that can be hard for a patient

limited testing types

inconsistent sampling

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Testing can vary in cost depending on how much offices may charge for them and what tests you purchase. The cost can vary from 70-200 dollars.

How To:

The patient will swish and gargle sterile saline for 30 seconds and spit it back into a tube, and send it to an oral testing lab, and will receive results within 2 weeks.

# data[].attributes.headline
Oral Irrigation Devices: A Scoping Review

# data[].attributes.subject
Oral Irrigation Devices: A Scoping Review

# data[].attributes.body
This review analyzed nearly 275 studies on oral irrigators. Findings show they consistently reduce gingival inflammation and may influence the oral microbiome, though results on plaque removal are mixed. Oral irrigators are well-tolerated by most patients, including those with implants or special needs. The authors highlight research gaps on long-term outcomes, cost-effectiveness, and environmental impact.https://www.researchgate.net/publication/381472452_Oral_Irrigation_Devices_A_Scoping_Review?utm_source=chatgpt.com

# data[].attributes.headline
Efficacy of oral irrigators compared to other interdental aids

# data[].attributes.subject
Efficacy of oral irrigators compared to other interdental aids

# data[].attributes.body
This meta-analysis compared oral irrigators with brushing, flossing, and other interdental aids in preventing peri-implant disease. Oral irrigators used with brushing showed significant reductions in plaque, bleeding, and harmful bacteria compared to brushing alone. With chlorhexidine, oral irrigators reduced peri-implant mucositis to 5%, compared with 35% (irrigator + water) and 50% (brushing only).https://www.nature.com/articles/s41405-025-00301-3?utm_source=chatgpt.com

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Abstract

Objective

Peri-implant diseases (peri-implant mucositis and peri-implantitis) are inflammatory conditions that affect the peri-implant tissues and are induced by microbial biofilms (dental plaque) formed around the implant. Removal of biofilm is the fundamental step in managing peri-implant diseases. Interdental cleaning aids such as interdental brush, unitufted brush, or oral irrigation along with regular toothbrushing are recommended for effective plaque control around implants. The present systematic review aims to evaluate the efficacy of home use of oral irrigators compared to other plaque control methods for managing peri-implant diseases.

Method

This systematic review has been prepared using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) checklist. Five databases were searched using the following keywords: "Peri-implantitis" OR Periimplantitis OR "Peri-implant disease" OR "Peri-implant Mucositis" AND "Oral irrigation" OR "Oral Irrigator" OR Waterpik OR "Interdental irrigation" OR "Oral Spray" OR "Oral Irrigants".

Results

Oral irrigator along with mechanical brushing was found to be more effective than mechanical brushing alone in reducing the plaque index (PI), gingival index (GI), and bleeding on probing (BOP). No statistically significant difference in improvement in quality of life and patient satisfaction with regard to comfort and ease of use was noted upon using mechanical toothbrushing alone and an oral irrigator. Implant sites where an oral irrigator was used showed more reduction in BOP (81.8% vs 33.35%) compared to sites where the floss was used (P = 0.0018). The levels of the red and orange complex bacteria in the peri-implant biofilm were lower with the use of an oral irrigator than with toothbrushing alone.

Conclusion

Oral irrigators along with toothbrushing were found to be more effective in removing microbial plaque around implants and controlling peri-implant inflammation compared to mechanical brushing alone. The reduction in BOP was better with the use of oral irrigation compared to floss and interdental brush.

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Article Open access

Introduction

Peri-implant diseases, which include peri-implant mucositis and peri-implantitis, are one of the most common biological complications seen in patients with dental implants [ 1, 2]. The prevalence of peri-implantitis is rapidly increasing due to an increase in the replacement of teeth with dental implants [ 3, 4]. According to the 11th European Workshop in Periodontology in 2014, a patient-level prevalence of 43% for peri-implant mucositis and 22% for peri-implantitis was reported [ 5]. Another systematic review, including 47 studies, reported a prevalence similar prevalence of 46.83% for peri-implant mucositis and 19.83% for peri-implantitis [ 6, 7]. Peri-implant diseases are inflammatory in origin, caused primarily by the formation of peri-implant biofilms on the implant surface [ 8]. The peri-implant inflammation begins as an inflammation of the soft tissues surrounding the implant as peri-implant mucositis, which clinically manifests as swelling, color change, and bleeding from the peri-implant mucosa without any marginal bone loss [ 3, 9]. If left untreated, peri-implant mucositis progresses to peri-implantitis with the spread of inflammation to the underlying bone. Peri-implant mucositis manifests as bone loss, swelling, pocket formation, mobility of implant, and pus discharge from the peri-implant sulcus [ 10]. Progression of peri-implantitis will most likely lead to the loss of the affected implant and the implant-supported prosthesis.

The existing evidence explores the efficacy of oral irrigators for managing gingivitis and periodontitis, with limited reviews exploring the role of oral irrigators in managing peri-implant disease (peri-implant mucositis and peri-implant). Hence the present systematic review aims to explore the efficacy of oral irrigators at home compared to other mechanical plaque control methods for managing peri-implant diseases. With the marked rise in the use of dental implants for prosthetic rehabilitation, this review is timely and important for both the public and dentists. The review will help to understand the efficacy of oral irrigators compared to other plaque control methods for implant maintenance.
Focus question
How effective are home use of oral irrigators compared to other mechanical plaque control methods in managing peri-implant diseases?

Objectives

Primary objective

To evaluate and compare the efficacy of home use of oral irrigators compared to other mechanical plaque control methods (floss/ interdental brush) in reducing the BOP, gingival inflammation, probing pocket depth (PPD), and clinical attachment loss (CAL).

Secondary objective

1. a.
To evaluate and compare the efficacy of oral irrigators compared to other mechanical plaque control methods in reducing biofilm formation and improving soft and hard tissue healing.

2. b.
To evaluate and compare patient satisfaction, improvement in quality of life, ease of use, and patient-reported adverse events/effects after the use of oral irrigators for managing peri-implant diseases.

Methodology

This systematic review has been prepared using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) checklist [ 31]. The protocol has been registered in the International Prospective Register of Systematic Review PROSPERO with registration number CRD42023469319 ON 14/10/2023. The study was under the exempt category of the ethical approval of the Institutional Ethics Committee of Kasturba Medical College and Kasturba Hospital, Manipal.

Eligibility criteria

The eligibility criteria for screening the articles followed the Participant-Intervention-Comparison-Outcome-Study Design (PICOS) framework as follows:

Participants/condition: Patients above 18 to 70 years with peri-implantitis or peri-implant mucositis in any type or design of dental implant placed in either maxilla or mandible were included.

Intervention: Use of oral irrigators either with or without any chemical plaque control agent or mechanical toothbrushing to manage peri-implant mucositis or peri-implantitis.

Comparators: Any other mechanical plaque control methods (mechanical toothbrush, dental floss, interdental brush) with or without any chemical plaque agents

Outcomes: The following primary and secondary outcomes were reported:

Primary outcome: PPD, CAL, gingival inflammation (measured by any gingival index (GI), bleeding on probing (BOP) as measured by any index, plaque scores (as measured by any plaque index (PI)).

Secondary outcome: Bone loss around the implant; degree of osseointegration, recession around peri-implant mucosa, soft tissue healing (measured by any index), ease of use and patient satisfaction (measured by any index/ scale/ tool), cost-effectiveness, and improvement in quality of life (measured by any index/ scale/ tool) after using the oral irrigator.

Study design: All non-randomized and randomized clinical studies, cross-sectional, prospective, case-control, and case series with more than 8 cases were included in this review. All case reports letters to the editor, narrative reviews, scoping reviews, and in-vitro/animal studies were excluded. No restrictions were placed on language or date of publication.

Search strategy

Five databases (Medline (via PubMed), Scopus, Web of Science, EMBASE, and Cochrane along with the clinical trial registry ( https://clinicaltrials.gov/) were searched electronically by four authors (GG, AN, BM, NS) using the following MeSH terms ("Peri-Implantitis"[Mesh]; "Oral Irrigator" "Endosseous Implants") and Boolean operators as follows: "Peri-implantitis"[Title/Abstract] OR Periimplantitis[Title/Abstract] OR "Peri-implant disease"[Title/Abstract] OR "Peri-implant Mucositis"[Title/Abstract] AND "Oral irrigation"[Title/Abstract] OR "Oral Irrigator"[Title/Abstract] OR Waterpik [Title/Abstract] OR "Interdental irrigation"[Title/Abstract] OR "Oral Spray"[Title/Abstract] OR "Oral Irrigants"[Title/Abstract]. The preliminary search to check for the possibility of articles was done on 29-06-2023 and the final search was completed and updated on 8-2-2024. The search was complemented by hand searching of the reference list of included relevant articles. The corresponding authors for the ongoing clinical trials were requested to share the results (if available). All the articles were compiled in Microsoft Excel spreadsheet version 2308 and duplicates were removed.

Data screening and data collection process

After removing duplicates manually in the Microsoft Excel spreadsheet, four authors (GG, AN, BM, NS) independently screened the studies using the above-mentioned eligibility criteria. In the first stage, the titles and abstracts screening for all the studies were independently done by four authors (GG, AN, BM, NS). Studies that did not qualify for the eligibility criteria and those with inadequate data or information were excluded. In the second stage, the four authors (GG, AN, BM, NS) independently screened the full texts of the included studies. Any disagreements regarding the inclusion of a study were discussed between the reviewers and, if unresolved, the subject expert (AC) was consulted and a final decision was made. Any articles whose full text was not available either online, in print, or even after requesting the corresponding authors were excluded. All studies that were selected after the full-text screening were reviewed by the supervisor (AC) before data extraction.

Data item

The following data was collected from each study: author, year of study, site of study, study design, sample size, age range (mean age), male to female, type of peri-implant disease (peri-implant mucositis or peri-implantitis), nature of the intervention (Type of oral irrigator, frequency of use and nature and dose of chemical agent use with oral irrigator), Nature of the comparator (Type of mechanical plaque control agent, frequency, duration of use), Total no. of implants assessed, Type of implants in the study (Endosseous implants/ overdentures); Outcomes and method to assess the outcome (mean score ± standard deviation for GI, Plaque score, BOP, PPD, CAL, bone levels, Microbial profile, inflammatory biomarker); Patient-reported outcomes (ease of use, adverse events or problem reported while using oral irrigators).

Risk of bias assessment

The risk of bias was assessed using the revised Cochrane Risk of Bias Assessment Tool (ROB2) [ 32]. The following domains were assessed for risk of bias: 1. Randomization process; 2. Bias resulting from deviations from intended interventions; 3. Bias resulting from missing outcome data; 4. Bias resulting from measurement of the outcome; 5. Bias resulting from selection of the reported result; 6. Bias in the identification or recruitment of individual participants within clusters. The identified risk was categorized as low risk, high risk, and risk with some concern. The 'effects of assignment' were considered as the effect of principal interest to assess the risk of bias. The quality assessment of non-randomized studies was performed using the 'Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I)' tools. The following seven domains were used for Risk of Bias analysis: a) bias due to confounding; b) bias in the selection of participants into the study; c) bias in the classification of interventions; d) bias due to deviations from intended interventions; e) bias due to missing data; f) bias in the measurement of outcomes; g) bias in the selection of the reported result. The scores equal to or less than 4 were considered a high risk of bias; scores between 5-7 were considered a moderate risk of bias and scores above than or equal to 8 were considered a low risk of bias.

Assessment of heterogeneity and reporting bias

Clinical and methodological heterogeneity was assessed by comparing the specifications of intervention and control used, outcome measures, and measurement tools used in each included study.

Effect measures and data synthesis

Data synthesis was performed by qualitatively summarizing and comparing each included article for its study characteristics: study population, intervention and controls, outcome measures, tools of measurement, and results. The mean and standard deviation for PI, GI, BOP, PD, CAL, Microbial count, and levels of biomarkers were noted along with the P-value. A Summary of Findings (SoF) for narrative reviews was prepared using GradeProGDT. The SoF has been prepared to identify the effectiveness of oral irrigators in reducing the PPD, plaque index, gingival index, and BOP.

Results

Studies included

Study characteristics

Table 1 Detailed list of articles retrieved from different databases and search strings used for data collection.

Quality (risk of bias) assessment

Four studies were found to have a low risk of bias [ 33, 34, 43, 45]; one study had some concerns [ 47] and two studies had a high risk of bias [ 46, 48]. The main concern was that no baseline data was provided for the clinical parameter (gingival index) in one study [ 46]. The uncertainty in the randomization process and blinding of the patient and investigator was noted in all the studies. The self-administered questionnaire which was developed by a qualified committee is also not specified. Salles et al did not state whether patients with peri-implantitis and peri-implant mucositis or both were included in the inclusion criteria. In the study by Azim and Artur, the reduction in plaque accumulation was assessed by the patients themselves, which is of concern as to how the patient differentiates between debris, plaque, and calculus (Supplementary Table 2).

Table 2 Characteristics of the included studies.

Table 3 Quantitative data for Oral hygiene status, plaque scores, Gingival Index, Bleeding on Probing, Mucositis severity index, Periodontal probing Depth, Clinical attachment Loss, Microbial profile, Width of keratinized tissue, Systemic effect (levels of inflammatory mediator, patient satisfaction score for all the included studies).

Results from individual studies (Table 2 and Table 3)

Oral irrigator along with mechanical brushing was found to be more effective in reducing the PI, GI, and BOP than the use of oral irrigator alone or mechanical brushing alone [ 43] (Table 2). Oral irrigator when paired with a manual toothbrush was found to be 2.45-fold (145%) more effective than floss in reducing bleeding around implants. Implant sites where an oral irrigator (water flosser) was used showed more reduction in BOP (81.8% vs 33.35%) compared to sites where the floss was used (P = 0.0018) [ 47, 48]. The use of oral irrigators was effective in increasing the width of keratinized gingiva around implants and the increase in keratinized gingiva was found to be comparable to the floss (oral irrigator: 2.02 ± 2.33 mm and floss: 2.19 ± 2.17 mm) (Table 2) [ 48]. When oral irrigators were combined with a manual toothbrush and interdental brush, the reduction in PI and GI was better compared to the use of interdental brush and oral irrigator alone (Table 2). The control of gingival inflammation was more for patients who only used mechanical toothbrushes (1.7 ± 0.05) compared to those who used interdental brushes along with toothbrushes (0.95 ± 0.05) and oral irrigators along with interdental brushes and toothbrush (0.08) [ 46]. The PI and BOP were also significantly lower in the oral irrigator group compared with the toothbrush alone group (p < 0.05). No significant differences were noted for BOP scores for oral irrigator, mechanical brushing, and interdental brush at the end of 12 weeks (p > 0.05). Oral irrigators are also found to be effective in reducing the levels of proinflammatory cytokines (IL-I β and T-PA) compared to the toothbrushing group (p < 0.001) [ 33]. This evidence is low as only one study has reported the changes in the levels of the proinflammatory cytokine around implants with the use of oral irrigators.

The efficacy of oral irrigators is improved when used along with antimicrobial agents such as chlorhexidine. The use of an oral irrigator along with 0.06% chlorhexidine was found to be more effective compared to plain/ tap water as an adjunct to toothbrushing for managing peri-implant mucositis. The prevalence of peri-implant mucositis was found to be 5% when an oral irrigator was used with 0.06% chlorhexidine compared to 35% with plain water and 50% for toothbrushing alone. Upon comparison between the use of plain water and chlorhexidine, less reduction in BOP with water was noted compared to the use of chlorhexidine (Table 2). The patients who used chlorhexidine along with oral irrigation showed significantly lower BOP-positive sites after 12 weeks when compared to those who used toothbrushing alone (−0.75 [95% CI − 1.26; −0.25], p = 0.004) [ 45].

Oral irrigators were also found to be effective in reducing the microbial load compared to tooth brushing. Only one study that found changes in the levels of the microbial complexes (orange (P < 0.001), purple (P = 0.012), and green (P = 0.030) complexes) were more with the use of an oral irrigator compared to toothbrushing alone in patients with implant-supported overdentures [ 34, 43]. A reduction in the levels of Campylobacter rectus (P = 0.001), V eillonella parvula (P = 0.012), and Porphyromonas endodontalis (P = 0.003) was noted after the use of an oral irrigator compared to the toothbrush alone. No pathogenic bacteria like Aggregatibacter actinomycetemcomitans, Bacteroides fragilis, Enterococcus faecalis, Lactobacillus casei, Staphylococcus pasteuri, Streptococcus constellatus, Streptococcus mutans were not identified in the biofilm after the use of oral irrigator. (Table 2). No study was found to report any changes in the bone level after the use of an oral irrigator.

When assessing the patient-reported outcomes and ease of use of oral irrigators compared to other mechanical plaque control agents, no statistically significant differences in the ease of use and preference for using an oral irrigator or floss were reported by patients with dental implants No statistically significant difference in improvement in quality of life and patient satisfaction in patients using mechanical toothbrushing alone and oral irrigator with regards to comfort (P = 0.108); cleaning sensation around implants (P = 0.123), and overdentures (P = 0.983). No difference was noted concerning the ease of use by patients with endosseous implants (P = 0.665) and for those with overdentures (P = 0.687). No difference was noted in the ease of use and cleaning efficacy between the use of an oral irrigator and toothbrush (for cleansing sensation: Z = −1.540; P = 0.123) [ 34, 43]. No difference was noted in the level of satisfaction and cleanliness around implants (P = 0.614), overdentures (P = 0.922), and continuity of use in daily hygiene (P = 0.845). Only, one study reported the presence of pain in the gums and difficulty using oral irrigators by five patients.

Results syntheses

A quantitative synthesis was not performed due to wide heterogeneity among studies in terms of intervention and comparator groups. The clinical heterogeneity was noted in terms of variations in the characteristics of the study population and outcome assessed. For example, a study by Bunk et al. mentions that both periimplantitis and peri-implant mucositis patients were included; while other studies did not differentiate between periimplantitis and peri-implant mucositis or provide any specific inclusion criteria for disease [ 45]. The nature of the implant and the number of implant prostheses were not mentioned. One study also included patients with implant-supported overdenture. The nature of the comparator group (floss, interdental brush, mechanical tooth brushing) was different in the included. There are wide variations in the type of irrigants used with oral irrigators. In some studies, oral irrigators were used with tap water, while in others they used saline or chlorhexidine. The methods of assessing the clinical outcomes such as gingival inflammation and plaque score were measured using different indices and the results were reported with varying follow-up periods.

GRADE profile

A grade profile for systematic reviews with narrative results was undertaken using the new GradePro software (Supplementary Table 3). Due to wide heterogeneity in the studies, serious concerns about the risk of bias, inconsistency, indirectness, and imprecision were noted. The certainty of the evidence was very low for bleeding on probing, modified plaque index, and gingival index, and low for probing pocket depth. The Grade Summary of Findings table for systematic review gives reasons for downgrading the evidence is provided as Supplementary Table 3.

Discussion

Additionally, we would like to highlight that the current evidence is based on a limited number of studies with only six months of follow-up. Additionally, in all the included studies comparing the use of oral irrigators on peri-implant inflammation, there was a significant heterogenicity in the comparator group used for assessing the efficacy of oral irrigators. While only one study has evaluated the additional benefit of using chlorhexidine over water for peri-implant tissues, previous studies comparing the use of oral irrigators with antimicrobial agents on periodontal tissues have shown better results than plain water. It is therefore essential that future studies compare the effect of different antimicrobial solutions and water in the maintenance of peri-implant health. No studies have assessed the effect of oral irrigators on the microbial profile, marginal bone levels, and the degree of osseointegration. Also, no clinical studies have compared the use of oral irrigators with different antimicrobial agents and different regimes. Based on the heterogenicity of the studies included, the certainty of evidence regarding the effects of oral irrigators on individual parameters of inflammation is low. Combining the overall effect of oral irrigators, we can conclude that the addition of oral irrigators to mechanical brushing would be beneficial in managing peri-implant disease by providing better plaque control and reducing bleeding sites. Future studies must assess the effect of oral irrigators on PD, CAL, and microbial profile around implants. Studies must also analyze and compare the nature and pressure of oral irrigation devices on the macro-design and micro-design of the implant surface and implant-supported prosthesis. Patients must be taught how to use the oral irrigator correctly to avoid damaging soft tissues and interdental papillae. Incorrect angulation and excessive water pressure can damage the junctional epithelium, dislodge the prosthesis, and lead to bacteremia in some patients. A pressure of 70-90 psi is considered safe for non-ulcerated attached gingiva, and 50-70 psi is safe for ulcerated oral soft tissues [ 39, 55].

Conclusion

Peri-implant mucositis can be managed effectively by reinforcing good oral hygiene and plaque control. Oral irrigators are a good adjunct to mechanical toothbrushing for effectively removing microbial biofilm and controlling the inflammation around the implants. Based on the results of the included studies in this review, oral irrigation was found to be comparable to other interdental aids in managing peri-implant diseases. Oral irrigators when combined with mechanical toothbrushing are more effective in controlling inflammation and BOP compared to mechanical brushing alone. The decrease in inflammation, plaque scores, and BOP was noted irrespective of the nature of the solution used with an oral irrigator.

References

1. Orjonikidze A, Mgebrishvili S, Orjonikidze M, Barbakadze I, Kipiani NV, Sanikidze T. New approaches to the treatment of periimplantitis (Review). Georgian Med News. 2020 May; 28-33.

2. Derks J, Tomasi C. Peri‐implant health and disease. A systematic review of current epidemiology. J Clin Periodontol [Internet]. 2015 Apr;42. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12334

3. Lee C-T, Huang Y-W, Zhu L, Weltman R. Prevalences of peri-implantitis and peri-implant mucositis: systematic review and meta-analysis. J Dent [Internet]. 2017 Jul;62:1-12. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0300571217300957

4. Pokrowiecki R, Mielczarek A, Zaręba T, Tyski S. Oral microbiome and peri-implant diseases: where are we now? Ther Clin Risk Manag. 2017;13:1529-42.

Article CAS PubMed PubMed Central Google Scholar

5. Roccuzzo A, De Ry SP, Sculean A, Roccuzzo M, Salvi GE. Current approaches for the non-surgical management of peri-implant diseases. Curr Oral Heal Reports [Internet]. 2020;7:274-82. https://link.springer.com/10.1007/s40496-020-00279-x

Article Google Scholar

6. Cheung MC, Hopcraft MS, Darby IB. Dental implant hygiene and maintenance protocols: a survey of oral health practitioners in Australia. J Dent Hyg JDH. 2021;95:25-35.

PubMed Google Scholar

7. Chopra A, Sivaraman K, Narayan AI, Balakrishnan D. Etiology and classification of food impaction around implants and implant-retained prosthesis. Clin Implant Dent Relat Res. 2019;21.

8. Mensi M, Scotti E, Calza S, Pilloni A, Grusovin MG, Mongardini C. A new multiple anti-infective non-surgical therapy in the treatment of peri-implantitis: a case series. Minerva Stomatol. 2017;66:255-66.

PubMed Google Scholar

9. Worthington HV, MacDonald L, Poklepovic Pericic T, Sambunjak D, Johnson TM, Imai P, et al. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database Syst Rev [Internet]. 2019;. Available from: https://doi.org/10.1002/14651858.CD012018.pub2

10. Sambunjak D, Nickerson JW, Poklepovic Pericic T, Johnson TM, Imai P, Tugwell P, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev [Internet]. 2019; Available from: https://doi.org/10.1002/14651858.CD008829.pub3

11. Ng E, Lim LP. An overview of different interdental cleaning aids and their effectiveness. Dent J. 2019;7:56.

Article Google Scholar

12. Lyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on plaque removal: a single-use pilot study. J Clin Dent [Internet]. 2016;27:23-6. http://www.ncbi.nlm.nih.gov/pubmed/28390213

PubMed Google Scholar

13. Gomes SC, Corvello P, Romagna R, Müller LH, Angst PDM, Oppermann RV. How do peri-implant mucositis and gingivitis respond to supragingival biofilm control - an intra-individual longitudinal cohort study. Eur J Oral Implantol [Internet]. 2015;8:65-73. http://www.ncbi.nlm.nih.gov/pubmed/25738180 Available from

PubMed Google Scholar

14. Elemek E, Almas K. Peri-implantitis: etiology, diagnosis and treatment: an update. NY State Dent J. 2014;80:26-32.

Google Scholar

15. Sarkisova F, Morse Z, Lee K, Bostanci N. Oral irrigation devices: a scoping review. Clin Exp Dent Res [Internet]. 2024 Jun 16;10. Available from: https://onlinelibrary.wiley.com/doi/10.1002/cre2.912

16. Teughels W, Seyssens L, Christiaens V, Temmerman A, Castro AB, Cosyn J. Adjunctive locally and systemically delivered antimicrobials during surgical treatment of peri-implantitis: a systematic review. J Clin Periodontol. 2023 Jan;

17. Azim OV, Artur KM, Olimov AB, Khaydarov AM. Comparative evaluation of the efficiency of conducting individual and professional hygiene in prosthetics for dental implants. Eur J Mol Clin Med [Internet]. 2020;7:6273-8. https://www.scopus.com/inward/record.uri?eid=2-s2.0-85098160428&partnerID=40&md5=e0151f7c724e61c8c3e684fd2746a738 Available from

Google Scholar

18. Magnuson B, Harsono M, Stark PC, Lyle D, Kugel G, Perry R. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: a 30-day randomized clinical trial. Compend Contin Educ Dent. 2013;34:2-17.

PubMed Google Scholar

19. Sgarbanti, C, Hala, G, Stavropoulou Chrysi, D, Michelle K-CA. A comparison of the efficacy of water flosser to interdental floss around dental implants: a randomized controlled trial and a qualitative study of patients' perceptions. 2021; Available from: https://mspace.lib.umanitoba.ca/server/api/core/bitstreams/8d10fd17-7dc7-4522-9f24-9afc63231918/content

20. Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol. 1987;2:145-51.

21. Löe H. The Gingival Index, the Plaque Index, and the Retention Index Systems. J Periodontol. 1967;38:610-6.

22. Matthes R, Jablonowski L, Pitchika V, Holtfreter B, Eberhard C, Seifert L, et al. Efficiency of biofilm removal by combination of water jet and cold plasma: an in-vitro study. BMC Oral Health. 2022;22:157.

Article CAS PubMed PubMed Central Google Scholar

23. Löe H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta odontologica scandinavica. 1963;21:533-51.

24. Grischke J, Karch A, Wenzlaff A, Foitzik MM, Stiesch M, Eberhard J. Keratinized mucosa width is associated with severity of peri-implant mucositis. A cross-sectional study. Clin Oral Implants Res. 2019;30:457-65.

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Funding

Open access funding provided by Manipal Academy of Higher Education, Manipal.

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Authors and Affiliations

1. Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Gargi Gandhi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair & Nidhi Semani

2. Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Aditi Chopra

3. Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, India

Venkitachalam Ramanarayanan

Contributions

Concept/Design: Gargi Gandi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair, Nidhi, Aditi Chopra; Data analysis/interpretation: Gargi Gandi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair, Nidhi, Aditi Chopra, Venkitachalam Ramanarayan; Drafting article: Gargi Gandi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair, Aditi Chopra, Venkitachalam Ramanarayan; Critical revision of the article: Gargi Gandi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair, Venkitachalam Ramanarayan Approval of article, Statistics: Venkitachalam Ramanarayan; Data collection: Gargi Gandi, Bhoomika Sai Laxmi Masanam, Ananya Sudhakaran Nair, Nidhi, Aditi Chopra.

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Correspondence to Aditi Chopra.

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The study was under the exempt category of the ethical approval of the Institutional Ethics Committee of Kasturba Medical College and Kasturba Hospital, Manipal.

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Gandhi, G., Masanam, B.S.L., Nair, A.S. et al. Efficacy of oral irrigators compared to other interdental aids for managing peri-implant diseases: a systematic review. BDJ Open 11, 7 (2025). https://doi.org/10.1038/s41405-025-00301-3
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# data[].attributes.attachment_link.title
Efficacy of oral irrigators compared to other interdental aids for managing peri-implant diseases: a systematic review - BDJ Open

# data[].attributes.attachment_link.description
Peri-implant diseases (peri-implant mucositis and peri-implantitis) are inflammatory conditions that affect the peri-implant tissues and are induced by microbial biofilms (dental plaque) formed around the implant. Removal of biofilm is the fundamental step in managing peri-implant diseases. Interdental cleaning aids such as interdental brush, unitufted brush, or oral irrigation along with regular toothbrushing are recommended for effective plaque control around implants.

# data[].attributes.headline
The effectiveness of oral irrigators on periodontal health status of orthodontic patients

# data[].attributes.subject
The effectiveness of oral irrigators on periodontal health status of orthodontic patients

# data[].attributes.body
This systematic review looked at orthodontic patients, who often struggle with traditional flossing. Oral irrigators improved gingival inflammation, bleeding scores, and microbial reduction in some studies. However, results were inconsistent, with several trials showing little advantage over brushing alone. More research is needed to determine their effectiveness in orthodontic populations.https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-024-05255-w?utm_source=chatgpt.com

# data[].attributes.attachment_link.title
The effectiveness of oral irrigators on periodontal health status and oral hygiene of orthodontic patients: a systematic review and meta-analysis - BMC Oral Health

# data[].attributes.attachment_link.description
Background An Oral irrigator, known as a dental waterjet (DWJ), is an adjunctive oral hygiene tool to remove dental plaque. The aim of this study was to systematically evaluate the effectiveness of oral irrigators on orthodontic patients’ oral hygiene and periodontal status. Methods A comprehensive search was undertaken in five electronic databases (PubMed, EMBASE, Web of Science, Scopus, and Cochrane) up to 1 May 2024. Clinical trials comparing DWJ with other adjunctive tools or no adjunctive in healthy orthodontic patients were included. The outcome was periodontal health condition measured by periodontal indexes. The risk of bias of the included studies was assessed using the Cochrane risk of bias tool. Random- effects meta- analyses of mean differences (MD) with their 95% confidence intervals (CI) were conducted and the overall quality of evidence was evaluated by GRADE approach. Results Seven trials were included in the meta-analysis (Two with low, and others with unclear risk of bias). There was no statistically significant difference between automatic toothbrush (ATB) with DWJ and ATB alone in the gingival index (GI) (MD = 0.00; 95% CI -0.17- 0.18) (low quality of evidence). No statistically significant differences were found between (ATB + DWJ) and manual toothbrush (MTB) alone in the GI (MD= -0.11; 95% CI -0.31- 0.09) (very low quality of evidence). Also, no significant difference was detected between the two groups in the Plaque index (PI) (MD= -0.12; 95% CI -0.36- 0.11) (very low quality of evidence). There was no statistically significant difference between (MTB + DWJ) and MTB alone in the GI (MD= -0.06; 95% CI -0.16- 0.03) (very low quality of evidence). No statistically significant differences were revealed between the two groups in the PI (MD= -0.33; 95% CI -0.97- 0.32) (very low quality of evidence). No statistically significant improvements were found between these two groups in bleeding index (BI) (MD= -0.05; 95% CI − 0.12 − 0.01) (low quality of evidence). Conclusions Adding DWJ to either manual or automatic toothbrushes did not significantly enhance oral health of orthodontic patients. Orthodontists could recommend their patients to use either of these toothbrushes with or without DWJ. Further clinical trials are needed. Trial registration number The protocol of this study was registered on PROSPERO with the ID # CRD42023465849.

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Advantages

Reduce gingival inflammation and bleeding more effectively than floss in some cases.

Helpful for patients with implants, orthodontic appliances, bridges, or dexterity issues.

Easy and well-tolerated by most patients.

Can deliver antimicrobial solutions (e.g., chlorhexidine) directly to gingival pockets.

Disadvantages

Evidence on plaque removal is mixed not always superior to floss.

Some studies show inconsistent results, especially in orthodontic patients.

Cost and need for electricity/water make them less convenient than floss.

Lack of strong long-term evidence compared to traditional methods.

# data[].attributes.body
Oral irrigators (water flossers) vary in price depending on features and design. Countertop models like the Waterpik Ultra or Aquarius typically cost $60–$100 and offer stronger water pressure, larger reservoirs, and multiple tips for home use. Cordless rechargeable options such as the Waterpik Cordless Enhance range around $40–$70, making them convenient for travel or small spaces. For those on a budget, brands like Nicwell, H2ofloss, or GuruNanda offer portable irrigators priced between $20–$40, providing a more affordable entry point. Overall, patients can choose a model based on their needs, lifestyle, and budget.

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steps on how an oral irrigator (water flosser) works:

1. Fill the reservoir with lukewarm water (or mouthrinse if recommended).

2. Select a tip and attach it to the handle.

3. Place the tip in your mouth, leaning over the sink.

4. Turn on the device and close your lips slightly to avoid splashing.

5. Aim the water stream at the gumline and between teeth, moving slowly tooth by tooth.

6. Empty the reservoir, then rinse and dry the device after use.

# data[].attributes.body
advantages

better sleep

improved orthodontic outcomes

better breathing

less tension

disadvantages

require consistency

not much evidence

lack of insurance coverage, making it pricey

# data[].attributes.body
Tongue exercise:

tongue clicks

tongue pressing

Breathing exercises:

deep nasal breathing

ballon breathing

- also doing lip and cheek massages can be a simple way of creating simple habits to better occlusion

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Orofacial myofunctional therapy (OMT) typically ranges in cost depending on the provider, location, and number of sessions needed. An initial evaluation usually costs between $100 and $400, while individual therapy sessions can range from $90 to $250 each. Comprehensive treatment programs, which may involve several months of therapy, often fall between $1,400 and $3,000 or more. Most providers operate on an out-of-network basis, meaning they do not bill insurance directly, though some may provide a superbill for patients to seek reimbursement. Insurance coverage is inconsistent and often depends on whether a medical diagnosis supports the therapy, so many patients end up paying out of pocket.

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Velscope guided oral cancer screening: A ray of hope in early diagnosis

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Velscope guided oral cancer screening: A ray of hope in early diagnosis

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Summary: This article assesses the diagnostic utility of VELScope, a handheld autofluorescence device, for detecting dysplastic and malignant lesions in the oral cavity. The authors report that VELScope can reveal fluorescence loss in abnormal tissues that may be missed under conventional white-light examination, and suggest that it may improve early detection of oral neoplasia. However, they caution that the device should be used as an adjunct (not a replacement) to standard clinical and histopathologic evaluation.

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Velscope guided oral cancer screening: A ray of hope in early oral cancer diagnosis

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Early oral cancer diagnosis is an important factor in reducing cancer-associated mortality and morbidity. Traditional oral cancer screening by Conventional Oral Examination (COE) is limited. A new approach in this regard is the use of “optical…

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Diagnostic value of objective VELscope fluorescence methods in distinguishing oral cancer from oral potentially malignant disorders (OPMDs)

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Diagnostic value of objective VELscope fluorescence methods in distinguishing oral cancer from oral potentially malignant disorders (OPMDs)

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Summary: This study compares subjective and objective VELScope autofluorescence methods in their ability to distinguish malignant lesions from potentially malignant ones (OPMDs). The authors find that the objective (quantitative) fluorescence method offers improved specificity for separating high-risk from low-risk lesions, though sensitivity remains moderate, and that the diagnostic performance varies depending on anatomic site (lining mucosa vs masticatory mucosa). They conclude that combining subjective and objective fluorescence may enhance discrimination of malignancy.

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Diagnostic value of objective VELscope fluorescence methods in distinguishing oral cancer from oral potentially malignant disorders (OPMDs)

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Diagnostic value of objective VELscope fluorescence methods in distinguishing oral cancer from oral potentially malignant disorders (OPMDs)

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VELscope as an Adjuvant Chairside Diagnostic Tool

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VELscope as an Adjuvant Chairside Diagnostic Tool

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Summary: This review (with case reports) describes how VELScope can function as a noninvasive, adjunctive tool alongside conventional oral examination to help detect dysplastic changes, guide biopsy site selection, assess surgical margins, and monitor suspicious lesions over time. The authors discuss both the advantages (portability, fluorescence visualization, non-contact) and limitations (such as false positives in inflammation, inability to provide histologic diagnosis on its own), emphasizing that VELScope is best used to assist rather than replace standard diagnostic pathways

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“VELscope as an Adjuvant Chairside Diagnostic Tool” – A... : Archives of Medicine and Health Sciences

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The use of VELscope in dentistry is contributory as it aids in the detection of dysplastic changes in oral potentially malignant disorders and appropriate surgical margins for resection, VELscope-guided biopsy procedures, indicative of bacterial, fungal, and viral infections, and also inflammatory lesions. The cases discussed in the report are clinical cases where VELscope has been used as an accessory tool to enhance the clinical efficacy of diagnosis. There are different domains of cases where the use of VELscope has been assessed, also cases where VELscope can be beneficial to identify most preferred site of biopsy, aiding in the identification of fungal, bacterial presence, and evaluation of premalignant lesions and different oral carcinomas. Both the advantages, limitations, and significance of the device in each clinical condition have been discussed. VELscope is a handheld, noninvasive adjuvant device which can be used along with conventional clinical conditions for enhanced diagnostic accuracy. It can also be used as a screening tool for the early detection of oral carcinoma and dysplastic lesions in mass screening and tertiary centers. Further studies are required to establish the efficacy of VELscope in the clinical practice of oral medicine and radiology. Increasing incidence of oral carcinoma is a worrying scenario. Early detection of these conditions can be assessed by various diagnostic methods which broadly includes conventional staining dyes such as Lugol’s iodine, methylene blue, toluidine blue, or light-based detection such as chemiluminescence, VELscope, Vizilite, or optical-based system such as colposcopy and optical coherence tomography. VELscope can be one of the tool for assessing dysplastic lesions at an early stage. Due to its portability, cost-effectiveness, and noninvasive advantages, it can be a promising tool for screening mass population for oral carcinomas.…

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Advantages

Helps detect lesions not visible under white light.

Quick, painless, and non-invasive.

Guides biopsy site selection and surgical margins.

Useful for patient education and follow-up monitoring.

Disadvantages

Cannot confirm diagnosis (needs biopsy).

Low specificity (many false positives).

Requires training and interpretation.

Costly and not always covered by insurance.

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Cost

VELscope unit: $3,000–7,000 (depending on model).

Disposables: ≈ $2–3 per patient.

Patient fee (if charged): $10–65, avg. ~$35.

How to Use

1. Dim lights, give protective eyewear.

2. Do a normal oral exam first.

3. Shine VELscope blue light—healthy tissue glows green, abnormal looks dark.

4. Record findings, recheck or biopsy if suspicious.

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Summary: This article talks about how AI holds so much potential in dentistry by improving diagnoses and personalizing treatments.

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Hiroj Bagde hirojbagde8gmail.com ✉Corresponding author.

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Smart Smile: Revolutionizing Dentistry With Artificial Intelligence

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Artificial intelligence (AI) has emerged as a transformative technology in various industries, and its potential in dentistry is gaining significant attention. This abstract explores the future prospects of AI in dentistry, highlighting its…

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Summary: This article talks about the use of AI in detecting caries for bitewings. They use an AI-powered smartphone that gives real-time detection of caries. This tool is exceptionally quick and convenient.

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Artificial intelligence enabled smart phone app for real-time caries detection on bitewing radiographs

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Diagnosis of proximal caries is a difficult task. Artificial intelligence (AI) enabled diagnosis is gaining momentum. Therefore, it is of interest to evaluate the effectiveness of an artificial intelligence (AI) smart phone application for bitewing…

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AI-Driven denalt caries mangement strategies

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AI-Driven denalt caries mangement strategies

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Summary: AI is a powerful and evolving tool in the fight against dental caries. It helps with diagnosis, personalizing risk assessment, and improving patient education. Despite current limitations, AI's integration into dentistry holds promise for more effective and efficient caries management in the near future.

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Abstract

Dental caries is one of the most prevalent chronic diseases among both children and adults, despite being largely preventable. This condition has significant negative impacts on human health and imposes a substantial economic burden. In recent years, scientists and dentists have increasingly started to utilize artificial intelligence (AI), particularly machine learning, to improve the efficiency of dental caries management. This study aims to provide an overview of the current knowledge about the AI-enabled approaches for dental caries management within the framework of personalized patient care. Generally, AI works as a promising tool that can be used by both dental professionals and patients. For dental professionals, it predicts the risk of dental caries by analyzing dental caries risk and protective factors, enabling to formulate personalized preventive measures. AI, especially those based on machine learning and deep learning, can also analyze images to detect signs of dental caries, assist in developing treatment plans, and help to make a risk assessment for pulp exposure during treatment. AI-powered tools can also be used to train dental students through simulations and virtual case studies, allowing them to practice and refine their clinical skills in a risk-free environment. Additionally, AI tracks brushing patterns and provides feedback to improve oral hygiene practices of the patients and the general population, thereby improving their understanding and compliance. This capability of AI can inform future research and the development of new strategies for dental caries management and control.

Key words: Dental caries; Artificial intelligence; Risk assessment; Diagnosis and therapeutics; Education, Dental; Self care

Introduction

Dental caries remains a global public health challenge for quite a long time. The Global Burden of Disease from 1990 to 2015 showed that its prevalence in permanent dentition ranked top among 328 investigated diseases.¹ The estimated age-standardized incidence rate of dental caries in permanent teeth in 2019 was 39200.36/100,000, and 3.09 billion incident cases were detected in that year.² The high prevalence of dental caries highlights the importance of a modern dental caries management strategy that differs from the traditional "drill and fill" model. The core of modern dental caries management at the individual level is a patient-centered, dental caries risk-based philosophy that prioritizes prevention, early detection, noninvasive and micro-invasive treatments.³,⁴ In accordance with this principle, good oral hygiene, precise prediction of the dental caries occurrence, timely preventive intervention, early diagnosis, and appropriate treatment are all essential for preventing dental caries. Meanwhile, dental intervention in the clinic alone is far from successful dental caries prevention, and successful dental caries management needs dentist-patient cooperation. Therefore, innovative tools that both improving dental professionalism and enhancing patients' compliance will undoubtedly help prevent dental caries.

With the development of computer science and the advent of the big data era, artificial intelligence (AI) has entered all aspects of the medical community with an extremely strong posture. In recent years, the use of artificial intelligence in various fields of dentistry has been extensively explored.⁵ The present work specifically focuses on the progress of AI in aiding dental caries management to clarify its achievements and future trends. Being different from previously published reviews which concentrate on specific aspects (e.g. AI algorithms tested for dental caries detection⁶ and AI in dental caries diagnosis)⁷, it delves into multiple directions of AI's application, including how AI may assist dental professionals, dental students, patients, and the general population in preventing dental caries ( Figure 1), considering all of them have crucial responsibilities in the "war" against this common oral disease.

Fig. 1.

Applications of artificial intelligence in caries management.

Artificial intelligence

The concept of AI was first proposed by John McCarthy of Dartmouth University in 1956.⁸ It is also called machine intelligence, with the aim of developing a machine mimicking the cognitive behavior of the human brain. It has evolved into a new field over the past few decades, intending to develop theories, methodologies, technologies, and application systems to simulate, enhance, and expand human intelligence.⁹

Machine learning (ML) is the main branch of AI ( Figure 2). Its basic concept is that a system or machine can learn from data, identify the patterns of these data, make decisions, and perform tasks at human intelligence levels with minimal human intervention.¹⁰ The basic elements of ML are massive data and algorithms. Algorithms learn patterns and structures in the data ("training"), and then apply the learned patterns to make predictions on unseen data. Algorithms are the virtual component of AI, and they usually present as computer codes or software. When a machine is equipped with algorithms and can autonomously perform tasks, it becomes the physical component of AI. ML can be further divided into supervised learning, self-supervised learning, unsupervised learning, and semi-supervised learning. Supervised learning uses annotated data to train the algorithm, which is manually labeled by experts.¹¹ Manually annotating data is cumbersome and time-consuming, and there are also ethical risks involved. Consequently, significant efforts have been made to move forward. A special example is self-supervised learning. When fed with unlabeled data, it generates data labels automatically, and then the labels are used to train the algorithms, like supervised learning. Unsupervised learning is a type of ML where algorithms are trained on data without labeled inputs. It analyzes datasets without human interference, and the algorithms find the internal patterns of the data themselves.¹² Self-supervised learning can be taken as a branch of unsupervised learning since there is no manual label involved.¹³ Semi-supervised learning is a combination of supervised and unsupervised learning.¹⁴,¹⁵ It utilizes both labeled and unlabeled data for algorithm training.

Fig. 2.

Concept set diagram of artificial intelligence, machine learning, neural networks, and deep learning.

(Abbreviations: CNN, convolutional neural networks; RNN, recurrent neural networks; LSTM, long short-term memory networks; GAN, generative adversarial networks; TN, transformer networks; DBN, deep belief networks; DQN, deep Q-networks; VAEs, variational autoencoders; GNN, graph neural networks).

The algorithms used in conventional ML are mainly derived from classical statistics, such as random forest¹⁶ and decision trees¹⁷ (shown in Figure 2). Conventional ML algorithms have limited data requirements, making them suitable to solve simple tasks. To tackle complex tasks, algorithms must mimic the operations of the biological neural network in the human brain. The breakthrough in neuroscience and the expansion of computational power paved the way for the development of a sophisticated algorithmic structure known as an artificial neural network (ANN). Like the biological neural network, an ANN consists of multiple interconnected nodes or "neurons" that can process information and pass it among each other efficiently. The development of ANN has gone from the beginning of single-layer to 2-layer (containing a hidden layer), and then to multi-layer networks. The presence of multi-layer ANN brings ML into a new era named deep learning (DL, shown in Figure 2). The term "deep" refers to the number of layers through which the data is transformed. The more layers it has, the deeper it is. The word "learning" indicates that feature learning is the goal.

A multitude of DL algorithms have been developed and refined, including but not limited to convolutional neural networks (CNN),¹⁸ recurrent neural networks (RNN),¹⁹ long short-term memory (LSTM),²⁰ generative adversarial networks (GAN),²¹ transformer networks,²² deep belief networks (DBN),²³ deep Q-networks (DQN),²⁴ variational autoencoders (VAE) and graph neural networks (GNN)²⁵ ( Figure 2). The most widely used algorithm in the medical field is CNN.¹⁸ CNN consists of the input layer, convolutional layer, pooling layer, fully connected layer, and output layer, through which data features are extracted and classified.²⁶ Each layer of a CNN applies operations called convolutions to every pixel of an image, enabling the extraction of important features.²⁷ Typical CNN architectures include GoogLeNet Inception, Xception, ResNet, DenseNet, U-Net, VGG16, etc.²⁸

AI in dental caries management

AI in dental caries risk assessment and prediction

Dental caries risk assessment predicts the likelihood of developing new cavities or incipient lesions within a specified time frame, as well as the probability of changes in the size or activity of existing lesions.²⁹ It helps to tailor specific preventive measures to the highest-risk persons, identifying low-risk patients to delay restorations and preventing unnecessary surgical intervention.³⁰ Different systems have been suggested for dental caries risk assessment, including CAMBRA, Cariogram, and CAT. These systems predict future dental caries development by selectively analyzing combinations of dental caries risk and protective factors, while their predictive performance is still under debate.³¹ Dental caries is a multi-factorial disease. Logically, the more risk/protector factors that are considered, the more accurate risk assessment and prediction can be generated. At the same time, the more factors are considered, the more powerful tools are needed to find patterns of these factors for downstream risk prediction.

In recent years, AI has shown its power in developing dental caries risk assessment and prediction systems.³² AI-based dental caries risk assessment could be divided into oral microbiota-independent, -related, and -based systems. Oral microbiota -independent system emphasizes the importance of demographic and environmental factors without considering oral microbiota. 33, 34, 35 Among these systems is the 1 introduced by Qu et al.³³ It was developed on the child's age, height, weight, family dental caries status, duration of brushing per session, fluoride toothpaste usage, frequency of brushing, parental supervision of brushing, mother's mode of delivery, daily brushing routine, number of children, and frequency of nocturnal feeding in the last month. Systems that consider oral microbe as an indicator for dental caries risk assessment, among other non-bacterial factors, are oral microbiota-related. For example, Pang et al. generated a system by using variants in gene loci, cario-state score, plaque index, and past dental caries experience.³⁵ Efforts have also been made to predict the risk of dental caries by analyzing the features of the oral microbiome via AI. The first attempt was made by Teng et al.³⁶ Through evaluating the oral microbial shift before, during, and after the occurrence of dental caries, a prediction algorithm named MiC (i.e., Microbial Indicators of Caries) was built with random forest method, and MiC predicts future new dental caries among kids with 81% accuracy.

The AI-driven dental caries risk assessment systems are mainly constructed by conventional ML algorithms to date. There are few systems really driven by DL. Future advances in this field may provide more precise assessments through "deep learning" of oral microbiome, demographic characteristics, lifestyle habits, genetic information, medical history, radiographic images, intra-oral images, as well as other data simultaneously.

AI in dental caries detection and diagnosis

AI-powered dental caries detection from radiographic images

Early detection and diagnosis enable the avoidance of invasive treatment and reduce healthcare costs. Radiographic images, including bitewing, periapical, panoramic X-rays, and CBCT, are among the major tools for dental caries detection. However, detecting dental caries from radiographic images is dentist-dependent, with limitations of subjectivity and instability. Hence, the urgent need arises for novel techniques that can help make precise and objective diagnoses.

At the early stage, engineers attempted to construct AI themselves, followed by testing the effectiveness of these algorithms in detecting dental caries.³⁷,³⁸ As DL advances, various algorithms were developed, and efforts concentrate on how these algorithms could be applied with or without modifications to diagnose dental caries. The most intensively tested DL algorithm is CNN⁷ because it is good at processing grid-like matrix datasets¹⁸. Supervised learning is predominant for AI-driven automatic dental caries detection. It requires large amounts of high-quality training data with labels during training.³⁹ To tackle the annotation difficulty, certain groups tried semi-supervised and self-supervised learning methods, aiming to minimize the dependency on labeled datasets and clinicians' support. In this area, Qayyum et al. proposed a semi-supervised learning system, and it exhibited significant computational and performance improvements over the supervised and self-supervised learning models.⁴⁰ Hopefully, innovative and effective algorithms belonging to semi-supervised and self-supervised learning would provide novel directions to improve the effectiveness of AI-assisted dental caries diagnosis in the future.

AI algorithms that have been trained and tested for dental caries detection include but are not limited to ResNet, 41, 42, 43 RetinaNet, As You Only Look Once (YOLO) v5, EfficientDet,⁴⁴ EfficientNet-B0, DenseNet, ResNet-50,⁴⁵ DeeplabV3 and visual geometry group (VGG)16,⁴⁶ YOLOv3,⁴⁷,⁴⁸ U-Net, 49, 50, 51, 52 and GoogLeNet Inception⁴³,⁵³ ( Table 1). Zhu et al. constructed CariesNet, a model specifically designed to detect dental caries.⁵⁴ Metrics used to assess the accuracy and reliability of their performance, including sensitivity, specificity, precision, F1 scores, receiver operating characteristic curve analysis, and intersection-over-union (IoU) scores. AI has shown great potential in detecting dental caries from radiographs. However, the performance of different algorithms varies. Taking the accuracy as an example, it ranges from 82% to 99% on periapical and panoramic radiographs, and from 68.7% to 94.59% on bitewing radiographs ( Table 1). A key constraint inherent in these investigations stems from the limited sample sizes and substantial heterogeneity of the datasets. Future studies should prioritize the utilization of standardized, population-diverse cohorts with robust clinical annotations to accurately represent the true performance of AI.⁶

The management of a dental caries lesion depends primarily on its depth or severity. Therefore, some studies go further by using AI to delineate the severity of dental caries lesions.⁴⁷,⁵¹,⁵⁴ DenseNet121 showed an overall detection accuracy of 0.957, 0.832, and 0.863 from panoramic radiographs for lesions affecting the outer, middle, and inner third dentin, respectively.⁵¹ The International Dental Caries Classification and Management System™ (ICCMS TM) provides a standard for defining the severity of carious lesions. Although YOLOv3 was unable to classify all dental caries lesion types included in ICCMS TM, it accurately classified the enamel caries and initial dentin caries.⁴⁷ There was significant variability in the accuracy of AI in classifying caries depth. Ahmed et al. found that, the IoU scores of the AI performance gradually improved with increasing lesion depth: 21% for lesions within the outer half of the enamel, 23% for lesions within the inner half of the enamel, 35% for lesions within the inner half of the dentin, and 41% for lesions within the inner half of the dentin,⁵⁵ suggesting that deeper caries lesions are, the more accurate the AI assessment.

When faced with so many kinds of algorithms, a question arises as to the optimal choice for dental caries detection. Studies have been carried out to answer it. One of these studies was conducted to compare the performance of EfficientNet-B0, DenseNet-121, and ResNet-50, with results suggesting that ResNet-50 exhibited the best performance with high accuracy and reliability.⁴⁵ However, when Pérez de Frutos et al. evaluated the performance of RetinaNet (ResNet-50), YOLOv5 (M size), and EfficientDet (D0 and D1 sizes), they found that YOLOv5 excelled ResNet-50 and EfficientDet in detection accuracy.⁴⁴ Interestingly, Zhu et al. proposed an AI model based on Faster-RCNN and compared its performance with that of YOLOv5. Faster-RCNN showed higher detection accuracy, although YOLOv5 outperforms in terms of speed.⁵⁶ Due to the use of different image datasets, unstandardized comparison procedures, and comparison being conducted on only few algorithms, no consensus has been reached so far on the best algorithm for dental caries diagnosis. Generally, each AI algorithm comes with its own strengths and weaknesses; probably the selection of an algorithm for dental caries detection should depend on the specific task goals and requirements.⁶ For instance, ResNet and DenseNet are renowned for their high accuracy and stability, making them well-suited for handling complex features in high-resolution images. However, their computational costs are relatively high, which may limit their use in resource-constrained environments.⁵⁷ EfficientNet strikes a balance between accuracy and efficiency through its compound scaling method, making it an ideal choice for scenarios with limited computational resources.⁵⁸ Although the detection time of Faster-RCNN is 0.13 seconds slower than that of YOLOv5 when processing a single sample,⁵⁶ considering the significance of detection accuracy in clinical applications, this time difference is acceptable when dealing with non-big data volumes.

Although AI has shown its capabilities in dental caries detection and severity assessment, its clinical application ultimately depends on a key determinant: whether AI can outperform or at least match the diagnostic performance of human experts. Studies have shown that AI can detect caries lesions as well as or better than professionals.⁵⁰ Lian et al observed that nnU-Net and DenseNet121 performed at a level similar to expert dentists,⁵¹ while a study carried out by Moran et al. showed the CNN-based models exhibited significantly higher sensitivity and accuracy in dental caries detection compared to the reference test.⁴³ Cantu et al. reported that CNN outperformed dentists with 3 to 14 years of experience in diagnosing initial carious lesions.⁵²

AI-powered dental caries detection from optical images

In addition to radiographic examination, optical-based techniques have been used to aid the dental caries detection. These techniques include Quantitative Light-Induced Fluorescence (QLF), Near-Infrared Light Transillumination (NILT), Laser-Induced Fluorescence, Optical Coherence Tomography, and Fiber Optic Transillumination.⁶⁶ Efforts have been made to develop AI-based automatic dental caries detection systems by analyzing images captured using these techniques. AI had a good performance in detecting dental caries from QLF images, with 83.2% of accuracy, 85.6% of precision, and 86.9% of sensitivity.⁶⁷ A cascade region-based CNN also showed its applicability in detecting dental caries from full intraoral NILT images.⁶⁸

Intra-oral images taken by digital cameras or smartphones could also serve as resources for AI-powered dental caries detection. Studies have been conducted on the use of red, green, and blue (RGB)-based images in AI-powered dental caries diagnosis. 69, 70, 71, 72 A prospective clinical trial used an AI algorithm integrating MobileNet-v3 with U-net to detect dental caries in digital intraoral images. This system showed remarkable diagnostic performance, achieving an overall accuracy of 93.40% in dental caries identification.⁷³ Notably, the sensitivity of the AI diagnostic system using intraoral RGB images varied greatly depending on the type of affected tooth and the severity of caries lesions, indicating the need for further improvement.⁷³,⁷⁴

AI-powered dental caries detection systems: more than codes

AI algorithms have been integrated into the software. Up to now, many software programs have been approved by authorities, including the US FDA, and are prepared to be used routinely in clinical diagnosis. Commercially available software and services include Overjet, Pearl, Dentrix, VideaHealth, Carestream, etc. Small-scale randomized controlled trials have been conducted to validate the effectiveness of these AI software tools in assisting dentists. A recent publication evaluated the roles of dentalXrai Pro 1.0.4 in aiding dentists in proximal dental caries detection, and the results showed that it increased dentists' diagnostic accuracy for enamel caries.⁶² Another randomized controlled study found that the use of AssistDent AI software resulted in a 71% increase in the ability to detect enamel-only proximal caries with an 11% decrease in specificity.⁷⁵ AI-enabled smartphone applications for real-time dental caries detection from bitewing radiographs are also available.⁷⁶ Mobile applications that utilize AI to analyze intraoral digital photos have been developed to offer tele-consultation, simple examination, assessment, and appointment booking for dental caries patients.⁷⁷,⁷⁸ More recently, AICaries was developed by Xiao et al to detect dental caries from photos taken by smartphones.⁷⁸ Hopefully, it will simplify dental caries screening for patients, leading to early detection and treatment, and improved patient engagement. AI-equipped machines that can autonomously detect dental caries are also commercially available at present. Optical dental caries detection tools and AI-based scoring systems have been implemented in modern 3D intraoral scanners, enabling automated dental caries assessment and detection. 79, 80, 81

Cost-effectiveness of AI-powered dental caries detection

AI enhances dentists' diagnostic capabilities and influences their treatment decisions.⁶² Therefore, the cost-benefit of applying AI in dental caries diagnosis needs to be carefully evaluated. Current evidence shows that higher accuracy of AI does not lead to higher cost,⁸²,⁸³ and AI-assisted diagnosis results in better retention of the affected teeth compared to conventional assessment by dentists.⁸⁴ A potential reason for the cost-effectiveness of applying AI for caries diagnosis might be due to fewer lesions remaining undetected, and this cost-effectiveness requires dentists to perform non-restorative treatment for early lesions that are detected.⁸⁴

AI in dental caries treatment

Studies exploring AI's application in dental caries treatment are quite few. The limited studies focus on utilizing AI to predict pulp exposure risk during deep dental caries treatment. Dentists rely heavily on preoperative radiographs to get pulp exposure clues currently. However, the image acquisition angle, as well as the experience and expertise of the dentists, affect their assessments. AI can extract more information than human eyes, allowing it to make more accurate predictions. A pioneer study suggested that AI holds the potential of predicting pulp exposure.⁸⁵ Another group further compared the effectiveness of different AI algorithms in predicting pulp exposure risk.⁸⁶ Among the 3 CNN models tested, DenseNet emerged as the most effective, and its predictive effect was comparable to that of senior experts.⁸⁶ Although the published results are exciting, the clinical efficacy validation studies are still absent. Furthermore, the cost-effectiveness of AI-powered pulp exposure prediction also needs to be evaluated, as a predicted outcome without pulp exposure risk may place the involved tooth at higher risk due to reduced vigilance by dentists.

AI-enabled robotics has started to perform surgery without human input. At present, dental robotics is mainly used in orthodontics and implantology.⁸⁷ AI-enabled robotics for dental caries treatment is not yet available. In 2011, Ortiz Simon et al. took an initial step in this direction.⁸⁸ The mechatronic assistant system they developed can hold a dental drill, perform precise positioning, and drill under the guidance of a dentist.⁸⁸

Generally, the application of AI in dental caries treatment is still underdeveloped. In the future, AI is likely to automatically formulate treatment plans for patients. AI could also streamline the assessment of treatment difficulty when factors influencing treatment difficulty are provided. Future directions for AI in dental caries treatment may also encompass the advancement of AI-enabled robots, as they have the potential to augment the efficiency, precision, and cost-effectiveness.

AI in oral hygiene guidance

Effective prevention and control of dental caries requires the participation of patients and the general public. The adoption of AI may increase their confidence in the diagnosis and foster their understanding of dentists' decisions.⁸⁹ In addition, expanding oral health care beyond the clinical setting can help patients maintain long-term oral health, reduce the likelihood of developing dental diseases, and increase satisfaction with the dental visit.

AI-enabled health applications are becoming more integrated with family oral health care. Dentists can leverage AI to monitor and provide feedback to patients and the general population, aiding in the maintenance of good oral health habits. Tooth brushing is the most effective way to prevent dental caries. Dentists' inability to oversee patients' brushing habits exacerbates the disparity between ideal oral hygiene and individuals' actual practices.⁹⁰ By combining front-end oral healthcare devices like electronic toothbrushes and smartphones with back-end risk prediction and personalized intervention algorithms, oral health can be effectively measured and managed. Smart toothbrushes equipped with sensors can collect data about brushing habits, then transmit to a cloud server for AI-based analysis, and then provide real-time feedback to continually optimize their brushing technique.⁹¹. In this area, Chen et al.⁹² used a Recurrent Probabilistic Neural Network to recognize toothbrush posture and brushing position and to monitor the correctness and integrity of the volunteers' Bass brushing technique. Another system developed by Kim et al.⁹³ consists of a device identifying plaque through light-induced fluorescence technology and a mobile app displaying the location of dental plaque over time. By employing a deep learning-based algorithm, the app can automatically predict plaque distribution and present the results as time series data. Smartphone app WhiteTeeth has been developed and tested for its effectiveness in improving oral hygiene.⁹⁴,⁹⁵ With the help of WhiteTeeth, adolescents wearing fixed orthodontic appliances improved their oral hygiene, demonstrating the positive influence of intelligent software in oral hygiene management.

AI in dental caries-related education

The incorporation of AI into dental caries-related education might become commonplace in the future, considering the alarming development speed of AI. Dental education helps students learn scientific knowledge and clinical skills, and then apply them in clinical situations, including the management of dental caries. Mapping dental students' preferred learning styles to suitable instructional strategies by educators enhances their academic performance. AI-powered tools can tailor instructional strategies to students' specific needs.⁹⁶ They provide paths to plan student-centered lessons and to improve the learning experience of the students.

Pre-clinic training prepares students to become qualified dental practitioners. In recent years, virtual reality and augmented reality simulators have been extensively applied to reproduce the physiological responses of real patients. However, assessing students' performance automatically on a simulator remains challenging. ML may offer potential solutions.⁹⁷ A virtual patient called Julia (which is a conversational AI chatbot as a fact) was created to develop dental students' diagnostic skills.⁹⁸ Through meticulous design, Julia effectively addressed the students' inquiry about dental issues, guiding them towards a precise diagnosis. This interaction helps students to enhance their diagnostic skills.

AI can assist in forecasting the prognosis for interns through the Case-based reasoning (CBR) system. This AI-enabled tool integrates various ML methodologies to realize its functions. CBR can predict the likelihood of restoration failure performed by dental students.⁹⁹ Notably, a significant correlation was found between the predicted failure and the grades assigned by the supervisor, suggesting this system is also a useful teaching tool able to adequately assess the competencies of dental students.⁹⁹

Concerns and prospects

Despite the exciting progress to date, the application of AI in dental caries management is still in its early stages and has not yet been fully integrated into standard dental practice. Large-scale clinical trials validating its efficacy and reliability remain absent, and most existing studies are small-scale and conducted in controlled settings with relatively limited sample sizes. These studies have mainly focused on the diagnostic performance of AI in detecting carious lesions from radiographic images, often comparing AI to human dentists in retrospective datasets rather than in real-world clinical settings. Future research should prioritize multi-institutional collaborations to validate the effectiveness of AI-driven tools across diverse demographic and geographical settings, complemented by longitudinal studies to assess long-term impacts on prevention and treatment outcomes.

Besides, numerous obstacles need to be addressed before AI can be seamlessly incorporated into dental caries management. One major challenge is the reliance on patient data to train AI. It is important to recognize that these data may reflect biases and inequalities present in society. If the training data contains racial discrimination or prejudice, AI is likely to learn and perpetuate these undesirable traits in its decision-making process.¹⁰⁰ Interpretability is another crucial aspect. Dental professionals require a clear understanding of how AI arrives at its decisions to facilitate accurate diagnostic and treatment options. However, AI frequently lacks the ability to articulate the rationale behind its conclusions. Third, the integration of AI in dentistry elicits ethical and legal considerations. Issues such as patient privacy, confidentiality, and informed consent must be meticulously managed when using patient data for AI purposes. It is also important to understand that poorly designed algorithms can lead to misinterpretations by healthcare providers. Therefore, the cooperation between experienced dentists and computer engineers is critical to reduce potential risks. Last but not least, AI is not a 1-size-fits-all technology, and infrastructure, economic, and ethical barriers that vary across regions and countries may hinder the general applicability of AI for dental caries management. However, targeted efforts can make AI a cornerstone of equitable global caries management, such as developing context-specific solutions tailored to regional needs, investing in infrastructure and affordable AI tools for resource-poor settings, ensuring diverse training data to minimize bias, and prioritizing ethical frameworks for data use and accountability.

Conclusions

AI has shown great potential in dental caries management, including risk assessment, diagnosis, treatment planning, home-based oral health monitoring, and dental education. Through interdisciplinary collaboration and continued technological advancements, it is expected to transform dental caries management, making dental care more efficient, precise, and accessible.

Author contributions

L.C. and J.H. conceived of the presented idea, Y.L., D.L., L.C., and J.H. collected the data and drafted the manuscript. All authors discussed, commented, and revised the manuscript.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This study was supported by 2024 Talent Development Program, West China Hospital of Stomatology, Sichuan University (RCDWJS2024-2), Technology Project of Health Commission of Sichuan Province (Clinical Research Special, 23LCYJ016) and Research Project on Graduate Education and Teaching Reform at Sichuan University (GSSCU2023036).

Contributor Information

Jinzhi He, Email: hejinzhi@scu.edu.cn.

Lei Cheng, Email: chenglei@scu.edu.cn.

References

14. Ouali Y., Hudelot C., Tami M. An overview of deep semi-supervised learning. arXiv preprintc. 2020 doi: 10.48550/arXiv.2006.05278. [DOI] [Google Scholar]

Articles from International Dental Journal are provided here courtesy of Elsevier

# data[].attributes.attachment_link.title
AI-Driven Dental Caries Management Strategies: From Clinical Practice to Professional Education and Public Self Care

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Dental caries is one of the most prevalent chronic diseases among both children and adults, despite being largely preventable. This condition has significant negative impacts on human health and imposes a substantial economic burden. In recent ...

# data[].attributes.body
advantages:

improving diagnosis

efficient

personalizing treatment

improving patient experience

disadvantages:

expensive

data security

information quality issues

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With the growing technquies, there are many different ways AI is used in dentistry

used in X-rays to dectect bone loss and caries

used to note probing scores

making a personalized treatment plan

Recording notes while the hygienist is talking to the patient to improve time management

oral cancer and lesion detection

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Many software programs used in dental offices have AI already embedded into their systems, but to get products that can help with probing and note-taking, there are additional costs to the office. Many of these companies hold subscriptions allowing offices to customize what they want in their office. One like Denti AI, which helps with charting, can cost an office up to 140 dollars for its services. Dentrix Detect AI, which is already embedded in the system of Dentrix, helps with bone loss and caries detection.

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Summary: This article gives a nice introduction to teledentistry and how it can be used. Teledentistry was first used in 1997 to define the use of technologies to diagnose and provide advice about treatment over a distance. Since the first introduction in the 70s, teledentistry has been used to expand the scoupe of dentristy and makes providers have more time to see patients.

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Applications of teledentistry: A literature review and update

# data[].attributes.attachment_link.description
Teledentistry is a combination of telecommunications and dentistry involving the exchange of clinical information and images over remote distances for dental consultation and treatment planning. Teledentistry has the ability to improve access to…

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Summary: This article talks about how there has been such a big improvement in the patient and the provider. It also talks about the usage of teledentistry getting more popular during COVID-19. Also, it is really helpful for older patients, patients without the ability to go to a dental clinic, and those without insurance.

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Abstract

Teledentistry is an online dental care service that allows patients and dentists to meet in real time, safely, without being at the same location. During the COVID-19 pandemic, real-time videoconferencing has gained popularity in the field of teledentistry, with numerous benefits for both patients and dentists. Online consultations can minimize costs, maximize time, and provide more convenient care options for both patients and dentists. When practicing teledentistry, a dentist must establish a good doctor-patient relationship. Dentists must ensure that the telecommunication solution that they choose meets their clinical requirements and complies with privacy laws. Dentists should provide adequate information to patients about the limitations, advantages, and disadvantages that may occur during online consultation. Dentists must follow guidelines and procedures regarding informed consent, patient details, personal communications, and consultancies' privacy and confidentiality. The patient should be aware of the limitations of teledentistry, and dentists will provide the best advice possible in the absence of a face-to-face consultation. This article discusses how teledentistry could be an effective tool for dentists and patients.

Keywords: teledentistry, healthcare, real-time videoconferencing, digital dentistry, digital health, COVID-19

1. Introduction

With the era of technology and telecommunication, the healthcare system is changing rapidly. Several telecommunications systems have been implemented for hospitals and, with the passage of time, a new term for it has emerged, namely "telemedicine" [ 1]. As a branch of telehealth, telemedicine employs communications networks from one regional area to another to deliver healthcare facilities and medical education, especially to solve problems such as unequal access and a lack of infrastructure and human resources [ 2]. Teledentistry is a subfield of telehealth, along with telemedicine, that focuses on dentistry, derived from interactive tools, telecommunications, and dentistry combinations [ 2]. Teledentistry uses information technology to facilitate remote dental care, advice, education, or treatment rather than direct face-to-face communication with patients [ 3]. The first study on teledentistry was conducted in 1994. It was conducted by the US Army as part of the US Army's Total Dental Access Project [ 4]. Cook et al. defined the term teledentistry in 1997, as "the practice of diagnosing and providing treatment advice over a distance using video-conferencing technology" [ 5] ( Figure 1).

Figure 1.

Evaluation timeline of teledentistry.

It can be used as a service modality in three primary ways [ 6]. These include the following: (i) consultations among dentists-for example, a general dentist and a specialist dentist can exchange patient photos and records, followed by a review and treatment planning discussion; (ii) a real-time face-to-face video conference consultation between a general dentist or specialist and a patient or family member in a distant, remote location; (iii) remote patient monitoring, collecting data in real time and transmitting them to the dentist in a remote location for examination and action as required [ 6]. It also assists in providing patients with basic knowledge about dental healthcare and improving patients' healthcare facilities [ 7, 8]. This facilitates the efficient exchange of information and knowledge between the patient and the doctor and among different specialists to achieve better treatment planning and outcomes [ 9]. Most dentists or specialists prefer synchronous or real-time videoconferencing with the patient through teledentistry systems [ 10]. In the healthcare system, real-time interactive consultations are now integrated [ 11]. Several studies have indicated that real-time video consultations play an important role in the healthcare setting and, in these cases, they also demonstrate advantages over simple mobile consultations [ 11, 12]. Recent studies showed that video consultations were thought to be useful for general practitioners but perhaps more suitable for particular groups of patients [ 13]. The demand for online video consultation is likely to increase, but it is essential to improve the technical infrastructure and to select cases [ 14]. Therefore, real-time interactive video consultation is the most authentic means of communicating with patients and conducting a teledentistry examination. During online consultation, a dentist must establish a doctor-patient relationship with the patient. When establishing relationships between dentist and patient, it is crucial to maintain the proper guidelines or recommendations for online consultation from both sides. In this article, we discuss how teledentistry could be an effective solution for dentists and patients.

2. Technologies Used in Teledentistry

Information and communication technology (ICT) is being developed day by day. Teledentistry can help in oral healthcare almost in every corner of the world. It connects the patient, dentist, and specialist from the relevant fields, where exchanges and interactions are established for diagnosis and treatment. "Store-and-forward" and "real-time" are the two main types of interaction. "Store-and-forward" is commonly referred to as pre-recorded media or asynchronous systems, whereas real-time interactions are known as synchronous systems [ 15].

Clinical information, including clinical images, can be gathered in a virtual storage place in the store-and-forward system, which can be further used as a diagnostic reference and treatment plan [ 16]. Moreover, it can be a valuable tool in patient counseling, even if the patient is far from the consultation process [ 17]. Dentists and specialist clinicians can easily exchange patient information, radiographic images, pathological images and laboratory findings, treatment modalities, and other information related to oral and general health status. They may seek help from a different specialist for their opinions and counseling. Usually, low-bandwidth internet is suitable for such kinds of systems.

In real-time methods, a consultation can take place via video calling or conferencing between a dentist, specialist clinicians, and a patient. They can quickly review clinical and general information, medical history, radiographic images, and laboratory findings for diagnosis. This interactive approach allows real-time images and better understanding from the doctor's side to the patient's side [ 1, 17, 18, 19, 20, 21].

Remote patient management is a recent addition to this field. In this method, dentists or other clinical experts can obtain detailed information directly from patients' homes about their health conditions and easily send them to clinical centers. The main advantage of this method is that it reduces healthcare costs.

Moreover, recently, mobile communication devices have gained attention in the field of public health education and promotion, especially cell phones and tablets.

3. Applications of Teledentistry

3.1. In Diagnosis

The most significant aspect of teledentistry is its ability to minimize healthcare disparities, improve patients' access to professional advice, shorten the treatment duration without sacrificing quality, and drastically reduce waiting times [ 15, 22]. With the introduction of teledentistry into oral health services, patients might have easy access to diagnosis and management of their oral health concerns [ 10]. One of the possible reasons for the delayed diagnosis of oral cancer is the improper diagnosis of oral lesions [ 23]. In this regard, teledentistry aids in the early detection of malignant lesions, enabling faster measures for the treatment of oral cancer and enhancing the effectiveness and safety of the therapy [ 24] by facilitating communication between dentists and clinical specialists. In addition, remote diagnosis can be a useful method for detecting oral lesions [ 4, 25, 26]. Involving many specialists in the diagnostic process seems to be a promising approach for increasing the precision of remote diagnosis [ 8, 25, 27].

3.2. In Oral and Maxillofacial Surgery

Previous research has demonstrated that teledentistry can be an effective technique for the purposes of consultation, assessment of the patient, treatment planning, and follow-up care in maxillofacial surgery [ 28, 29, 30, 31, 32]. Patients' and dental surgeons' acceptability regarding teledentistry performed through telephone appointments for different patient categories in maxillofacial surgical practice in comparison with the on-site evaluation was highly appreciated [ 33]. This study also showed that most of the patients with conditions such as temporomandibular disorder, salivary gland disorders, head and neck cancer, and orthognathic surgery require further assessment owing to the difficulty of carrying out a standard "face-to-face" consultation. Other studies revealed the overall perspectives of both dentists and patients on teledentistry [ 34, 35]. They reported that teledentistry was generally well accepted by patients with trauma, whereas the lowest acceptance was found in patients with temporomandibular joint disorder. Concerning how dentists and clinicians perceive teledentistry, most of the dentists were happy with it. However, some of them expressed concern about its effectiveness because the inability to perform physical examinations can lead to an incomplete diagnosis.

3.3. In Orthodontics

Teledentistry is becoming more popular in orthodontics as a means to consult with and monitor patients without visiting dentists due to technological advancements. Virtual consultation and artificial intelligence (AI)-based treatment monitoring methods with photos or videos are currently the main forms of online communication technology used in orthodontics [ 36]. Regarding initial orthodontic consultations, teledentistry can be particularly useful in evaluating treatment options and diagnosis plans, measuring calibration and orientation, and assessing functional appliances and removable appliances. Although teledentistry has not completely eradicated the need for in-person clinical care, most of the dentists and patients believe that online consultations or teledentistry are more convenient and cost-effective in orthodontic treatment [ 37, 38]. Minor orthodontic emergencies such as rubber ligature displacement, pain, and cheek irritation can be handled at home via teledentistry, reducing the need for in-person visits to the dental clinic [ 39]. Nevertheless, many procedures that need direct access to the oral cavity cannot be performed by teledentistry, despite having unique advantages. For instance, an orthodontist may carry out a preliminary examination such as gathering data, installing brackets and bands, bonding and removing them, occlusal correction, and changing the wires [ 38]. Teledentistry still has to address the issue regarding the conceptualization of data and information in order to maintain a level of quality equivalent to that of on-site orthodontic consultations [ 36].

3.4. In Restorative Dentistry and Endodontics

Endodontics is a highly sophisticated branch of dentistry that is handled by specialist dentists called endodontists. The provision of endodontic care to underprivileged patients is possible through the use of teledentistry. Teledentistry can be used to recognize root canal orifices from a distance, which tends to suggest that highly trained endodontists can help general dentists in the identification of root canal orifices by providing guidance and instruction over the telephone about the recognition of root canals [ 40]. Teledentistry, which utilizes the internet as a communication medium, has proven to be effective in the diagnosis of periapical lesions of the anterior teeth [ 41]. It has the dual benefit of lowering the costs associated with long-distance visits and increasing the accessibility of emergency assistance.

3.5. In Pediatric Dentistry

A child's overall health and well-being are significantly affected by their oral and dental health [ 42]. Pediatric dentists can be given the chance to use technological developments in the information and telecommunications field to serve their patients and encourage better oral hygiene habits [ 43, 44, 45]. For pediatric patients, preventive counseling can be given over the phone to initiate treatment regimens. Over the telephone or through email, dietary charts can be sent or provided in advance, and introducing patients to online dental hygiene resources is possible. A high-strength sodium fluoride toothpaste prescription might be administered by an online prescription system [ 46]. Some pediatric patients could be sent to a specialist pediatric dentist for delayed tooth eruption or tooth exfoliation. In this regard, an initial video call for an evaluation of the condition of the oral cavity could be helpful in determining whether or not the patient needs to undergo further professional consideration. In addition, pediatric dentists and orthodontic specialists who wait for the shedding of the deciduous teeth before performing final treatment may find that teledentistry is an advantageous alternative. Other developmental problems such as neonatal or natal teeth and eruption cysts might all be monitored by teledentistry [ 47]. One of the main benefits of teledentistry is that it eliminates the need for patients and parents to travel and leave their workplace or school in order to see a dentist in person [ 48]. Nevertheless, the high expense of having a smartphone or computer means that some patients may be unable to use teledentistry.

5. Dentist-Patient Relationships

In the dentist-patient relationship, mutual trust is required when the dentist asks the patient to provide the necessary information and when the patient agrees to the dentist's treatment policy. Therefore, it is necessary to implement this based on mutual agreement. The agreement should include specific rules for implementing online consultation. However, there is a difference in medical knowledge between dentists and patients. Dentists must provide sufficient information to patients about the advantages of online consultation and the disadvantages that may occur. Therefore, it is necessary to obtain the consent of the patient thoroughly, and then the dentist should make appropriate decisions, including the applicability of online dental care [ 15]. For this reason, online dental care is used only when there is already a direct relationship between the dentist and the patient. It is required that the same dentist should perform face-to-face online dental care in an appropriate combination ( Figure 2).

Figure 2.

A feasible and practical workflow of an online real-time consultation between patient and dentist.

10. Limitations during Online Consultations

Online consultations have limitations in diagnosing diseases and evaluating patient problems, especially in dentistry. Sometimes, clinicians may be the most significant impediment to implementation, being resistant to change due to various influencing factors, having concerns about the consistency of patient interactions, and being concerned about technological difficulties. The difficulty of assessing the dentition and soft tissue, especially in the posterior oral cavity, would be the utmost limitation of online consultations in this field. Image quality, internet accessibility, and patient considerations including the ability to connect to the software, provide real-time interactive video consultations, proper light arrangement, manual dexterity, and acquaintance with mobile/tablet devices should be taken into consideration. However, the ability to assess extraoral and intraoral swelling, grossly carious teeth, soft tissue lesions, mobile teeth, fractured prosthodontic work, and orthodontic emergencies is highly impractical through online consultation [ 52].

Furthermore, a combination of the store-and-forward approach with real-time video can minimize the limitation of poor image quality. Moreover, clinical examinations are not possible, and video conferencing cannot provide an adequate definition to facilitate oral examination. In addition, special investigations that require direct patient contact and would aid in an accurate diagnosis are difficult to obtain in an online teledentistry consultation [ 11].

13. Teledentistry during COVID-19

Teledentistry is an innovative approach to dentistry and access problems that does not require close contact with the dental professional. Dentistry has been slower than other healthcare areas in terms of communication and information technologies while providing dental care. The rapid adoption of teledentistry by the dental profession during the COVID-19 pandemic offers an excellent opportunity to investigate how teledentistry can be used in dental treatment in the long-term and short-term process, as well as providing a safe and secure environment in which to deliver high-quality care while minimizing the risk of infection. Dentists can use online teledentistry consultation to provide necessary advice, monitor a patient's condition more than once, and treat patients with emergency dental problems both during and after the COVID-19 pandemic. In the current situation, it will be essential for dental services to have access to a video consultation solution in order to provide a better triage service to those who need it more effectively. Using a video consultation service will aid in limiting patient contact during the COVID-19 outbreak's recovery and restoration phase, as well as in the future. This will allow practices to manage the backlog of patients currently unable to access dental care and prioritize those with acute therapy problems so that the return of routine dental care can be facilitated over time ( Figure 3) [ 6].

Figure 3.

Application of teledentistry during COVID-19 pandemic situation.

14. Acceptance of Teledentistry by Dentist and Patient

Most dentists worldwide may find teledentistry to be a complex system and struggle on many points to adopt these new skills [ 53, 54]. Not only do they find it a technologically challenging procedure, but they are also fearful of making an incorrect diagnosis.

In some cases, the expanded level of cause and expense is also a matter of concern for the dentists. Poor internet connection, a lack of suitable technological devices and support, and inadequate training facilities are the limitations in this field [ 55]. Furthermore, dentists are confronted by various challenges, such as scarce financial reimbursement, deficient guidelines, the inharmonious relationship between the organization of teledentistry with the healthcare service providers, a lack of coordination, lack of connection between the central and remote centers, and, lastly, the high costs of infrastructure [ 54]. A lack of ability to perform tooth percussion and pulp vitality tests is an additional constraint.

Accepting the expansion of teledentistry, it is necessary to address the challenges mentioned above. Therefore, dentists should receive sufficient training and develop their knowledge about the technology. Acknowledging the COVID-19 situation, dental healthcare providers should be trained regularly to face the obstacles of transmissible diseases and deal with any pandemic situation by implementing teledentistry. Nevertheless, adequate capitalization, research funds, and validation of teledentistry within the healthcare system should be necessary [ 55, 56].

Acceptance of teledentistry by the patient is fundamental to the success of this component. The patient may perceive that reduced communication with their dentists may occur due to a lack of face-to-face communication, which may lead them to feel anxious about the situation. With the broad expansion of telemedicine, teledentistry will gain more acceptance from patients day by day. Numerous studies have revealed that teledentistry is gradually becoming more recognized by both patients and dentists [ 56, 57].

15. Recommendations for Effective Online Teledentistry Consultation

An online consultation is the act of examining a patient between a dentist and a patient via an information and communication device and recommending a dental clinic/hospital to see a dentist in real time in teledentistry. Encouragement of consultation with the minimum necessary diagnosis according to the individual patient's condition, such as selecting the appropriate dental specialized department, is important. Diagnosing specific diseases (if the diagnosis is adequately made), informing patients of the diagnosis, instructing them on the specific use of over-the-counter drugs, prescribing, etc., are all examples of online medical treatment that can also be performed via online teledentistry consultation. In addition, there are cases where follow-up or non-examination instructions are given to persons with symptoms that are clearly not enough to see a dentist or undergo dental treatment according to the patient's individual condition. General consultation recommendations that do not involve any judgment can be provided as remote health and consultations.

16. Future Perspectives of Teledentistry

Although teledentistry has been around since the 1990s, its significance was only recently recognized in the pandemic situation that developed worldwide. Since the pandemic is still ongoing, teledentistry will likely be around for a very long time. Patients who are unable to go outside due to health issues and must remain inside their homes can now obtain dental consultations and treatments with the simple press of a phone button, thanks to the advent of teledentistry. At the same time, elderly patients and those with physical disabilities or who are incarcerated for various reasons can benefit from the emergence of teledentistry, which allows dental care to be delivered remotely. Similarly, for patients living in rural and inaccessible areas, for whom the time to travel to and from the dental clinic is a major setback, teledentistry represents a promising solution. Taking into account that it has such widespread use, as well as the significant number of drawbacks, both for patients and dental specialists, it will only be utilized to an increasing degree in the future. The major innovation in this field is the availability of high-quality software programs that are reasonably priced and simple to use by both patients and professionals. Although its benefits have been addressed, teledentistry cannot be regarded as a substitute for traditional dental care; instead, it can only be considered an addition to conventional dentistry. However, it is safe to state that the intersection of dental and telecommunications is now well established and is expected to progress on a constructive path. This convergence of dentistry and telecommunications is the future of dentistry.

17. Conclusions

Currently, advanced medical equipment and instruments have made teledentistry a more convenient way to reach patients on a large scale by providing teleconsultation support at any time and place through internet-based media platforms. Campaigning for public awareness about various health issues and promulgating valuable information can be achieved with an extensive group of targeted patients with the assistance of this media platform, particularly in an emergency. Teledentistry has no alternative to provide a safer patient consultation by lessening the burden of clinics at times of crisis. Hence, teledentistry plays a vital role in serving patients with a dynamic management strategy and fulfills the needs of the patient's treatment in the best possible way.

Author Contributions

Conceptualization, R.I. and M.R.R.I.; writing-original draft preparation, R.I., M.R.R.I. and S.F.; writing-review and editing, C.W., M.Y., M.K.A. and H.S.; supervision, H.S. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This research was funded by JST SPRING, Grant Number JPMJSP2119, and the APC was funded also by JST SPRING.

Footnotes

Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

16. Chang S.U., Plotkin D.R., Mulligan R., Polido J.C., Mah J.K., Meara J.G. Teledentistry in rural California: A USC initiative. J. Calif. Dent. Assoc. 2003;31:601-608. [PubMed] [Google Scholar]

19. Clark G.T. Teledentistry: What is it now, and what will it be tomorrow? J. Calif. Dent. Assoc. 2000;28:121-127. [PubMed] [Google Scholar]

20. Folke L.E. Teledentistry: An overview. Tex. Dent. J. 2001;118:10-18. [PubMed] [Google Scholar]

27. Arora P.C., Kaur J., Kaur J., Arora A. Teledentistry: An innovative tool for the underserved population. Digit. Med. 2019;5:6-12. doi: 10.4103/digm.digm_13_18. [DOI] [Google Scholar]

51. Bhargava A., Sabbarwal B., Jaggi A., Chand S., Tandon S. Teledentistry: A literature review of evolution and ethicolegal aspects. J. Glob. Oral. Health. 2019;2:128-133. doi: 10.25259/JGOH_68_2019. [DOI] [Google Scholar]

Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Not applicable.

Articles from Healthcare are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

# data[].attributes.attachment_link.title
Teledentistry as an Effective Tool for the Communication Improvement between Dentists and Patients: An Overview

# data[].attributes.attachment_link.description
Teledentistry is an online dental care service that allows patients and dentists to meet in real time, safely, without being at the same location. During the COVID-19 pandemic, real-time videoconferencing has gained popularity in the field of ...

# data[].attributes.body
Summary: It is important to understand that teledentistry doesn't take away the importance of getting hygiene care from a hygienist. This article talks about how teledentistry can be used with hygiene care to improve a patient's oral care. Using teledentistry can help show a patient what we as hygienists see in their mouths, certain pinpoint areas that they can improve either in bruhsing or flossing

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Role of teledentistry in enabling improved oral care outcomes - British Dental Journal

# data[].attributes.attachment_link.description
British Dental Journal - Role of teledentistry in enabling improved oral care outcomes

# data[].attributes.body
advantages:

improves pateints communication

improves patient education

increase accessibility for low-income communities

disadvantages:

lack of hands on care

diagnostic limitations

technoglie barriers

# data[].attributes.body
There are many different companies that do teledentistry, whether it's in-house or subscriptions for patients at home. One-time self-payments can range up to $50. Where some in-house care can range up to $200. Many bigger insurance companies cover teledentistry, while others don't.

# data[].attributes.body
Summary: This paper reports a randomized, split-mouth pilot study comparing nonsurgical periodontal therapy (NSPT) with and without the aid of a periodontal endoscope. The authors found that sites treated with endoscopic assistance showed reduced bleeding on probing (BOP), suggesting that visualization may help clinicians detect and remove more subgingival deposits. However, the study is limited by its small size and short follow-up, so the authors call for larger trials to better establish clinical benefits.

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Academic Editor: Sivakumar Nuvvula ✉Corresponding author.

# data[].attributes.attachment_link.title
Effects of Periodontal Endoscopy-Assisted Nonsurgical Treatment of Periodontitis: Four-Month Results of a Randomized Controlled Split-Mouth Pilot Study

# data[].attributes.attachment_link.description
Although the therapeutic effects of nonsurgical periodontal therapy (NSPT) are well established, the clinical benefits of the additional use of periodontal endoscopy (PE) remain controversial. Therefore, this randomized controlled split-mouth pilot…

# data[].attributes.headline
Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis (Systematic Review)

# data[].attributes.subject
Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis (Systematic Review)

# data[].attributes.body
Summary: This systematic review of randomized clinical trials (RCTs) evaluated use of periodontal endoscopy (PEND) as an adjunct to subgingival debridement. The authors found that PEND was associated with greater reductions in probing depth and improvements in CAL and bleeding on probing compared to conventional debridement in the included RCTs. The review concludes that PEND may enhance non-surgical therapy but notes that the number and size of high-quality trials remain limited.

# data[].attributes.attachment_link.title
Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis: A Systematic Review of Randomized Clinical Trials

# data[].attributes.attachment_link.description
This study aims to evaluate the clinical efficacy of periodontal endoscopy (PEND) during subgingival debridement to treat periodontitis. A systematic review of randomized clinical trials (RCTs) was performed. The search strategy included four databases: PubMed, Web of Sciences, Scopus, and Scielo. The initial online exploration generated 228 reports, and 3 RCTs met the selection criteria. These RCTs described a statistically significant decrease in probing depth (PD) in the PEND group compared to controls after 6 and 12 months of follow-up. The improvement in PD was 2.5 mm for PEND and 1.8 mm for the control groups, respectively (p < 0.05). It was also described that the PEND group presented a significantly inferior proportion of PD 7 to 9 mm at 12 months (0.5%) as compared to the control group (1.84%) (p = 0.03). All RCTs noted improvements in clinical attachment level (CAL). It was described as having significant differences in bleeding on probing (BOP) in favor of PEND, with an average reduction of 43% versus 21% in the control groups. Similarly, it was also presented that they were significant differences in plaque indices in favor of PEND. PEND during subgingival debridement to treat periodontitis demonstrated efficacy in reducing PD. Improvement was also observed in CAL and BOP.

# data[].attributes.headline
Periodontal Endoscopy for Mechanical Debridement in the Non-Surgical Management of Peri-Implantitis (Narrative Review)

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Periodontal Endoscopy for Mechanical Debridement in the Non-Surgical Management of Peri-Implantitis (Narrative Review)

# data[].attributes.body
Summery: This narrative review surveys the evidence on using periodontal endoscope (aka perioscopy) in non-surgical therapy of peri-implant diseases and periodontitis. It discusses how the enhanced visualization may help detect residual calculus and biofilm in deep or complex pockets, potentially reducing the need for surgical exposure. The review also cautions that clinical evidence is still heterogeneous and underscores the need for more robust trials to define indications and effectiveness.

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Periodontal Endoscopy for Mechanical Debridement in the Non-Surgical Management of Peri-Implantitis: A Narrative Review

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Background: The aim of the present narrative review is to synthesize the available scientific evidence on the effects of submarginal instrumentation with periodontal endoscopy and evaluate its’ potential efficacy in terms of the non-surgical therapy of peri-implantitis. Methods: The literature search was performed via electronic databases, including PubMed, Web of Science, Cochrane, and Scopus, and was supplemented by manual searching. A literature review was conducted addressing the following PICOS questions: (1) What is the efficacy of non-surgical submarginal instrumentation of the implant surface with the aid of a periodontal endoscope in patients with peri-implantitis? (2) What is the efficacy of non-surgical subgingival instrumentation performed with the aid of a periodontal endoscope compared with conventional subgingival instrumentation in patients with periodontitis, in terms of clinical parameters and patient-reported outcomes? Mechanical decontamination of the implant surface is crucial for resolving inflammation and arresting further bone loss. However, there is no consensus on the most effective treatment. Non-surgical therapy remains the initial intervention, focused on biofilm removal to control the disease, although with limited capability to achieve complete disease resolution as the presence of threads and the complex-structured implant surface hinder effective biofilm removal. This evokes the need for providing supporting technologies such as periodontal endoscopy, which enables direct visualization and precision, potentially enhancing the outcomes and reducing the necessity for surgical procedures and their associated risks. Within the limitations of this narrative review, periodontal endoscopy may offer a less tissue-invasive approach. Larger prospective studies and RCTs are needed to confirm these findings and guide clinicians in determining periodontal endoscopy’s suitability based on specific case characteristics.

# data[].attributes.body
Advantages:

Provides real-time subgingival visualization of calculus, root surface, and pocket anatomy.

Can improve detection and removal of residual calculus and biofilm.

May reduce the need for surgical access in some cases.

Enhances precision during nonsurgical periodontal therapy.

Useful in managing deep pockets and around implants (peri-implantitis).

Disadvantages:

Requires longer treatment time compared to conventional scaling.

High cost of equipment and training.

Learning curve for clinicians; requires specialized training.

Evidence shows limited additional clinical benefit (PD and CAL improvements may not be significantly better than conventional SRP).

Equipment can be fragile and needs careful maintenance.

# data[].attributes.attachment_link.title
Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis: A Systematic Review of Randomized Clinical Trials

# data[].attributes.attachment_link.description
This study aims to evaluate the clinical efficacy of periodontal endoscopy (PEND) during subgingival debridement to treat periodontitis. A systematic review of randomized clinical trials (RCTs) was performed. The search strategy included four…

# data[].attributes.body
The cost of periodontal endoscopy (perioscopy) is considered one of its main drawbacks. The equipment itself can be expensive, often ranging from $10,000–$15,000 or more for the complete system, in addition to maintenance and disposable sheath costs. Because of this investment, many dental practices charge patients an additional fee when perioscopy is used, sometimes comparable to or higher than surgical periodontal therapy. While some providers see it as a valuable alternative to surgery especially for patients who prefer minimally invasive treatment the high upfront cost, ongoing maintenance, and longer chair time make it less widely adopted in everyday practice.

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Summary: Within this article, CAT has a significant advancement in orthodontics, giving patients a comfortable alternative to braces. While CAT is highly effective for mild to moderate cases, it's not the best for all patients. It's important that patients wear their aligners daily to make sure there isn't any time of relapse.

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Clear Aligner Therapy: Up to date review article

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The advantages of Clear Aligners Therapy (CAT) include the braces being virtually invisible, comfortable to wear, and removable for eating and brushing; that way, CAT can be used to treat a wide range of orthodontic issues. In 1999, the company…

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Expert consensus on the clinical strategies for orthodontic clear aligner therapy 

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Expert consensus on the clinical strategies for orthodontic clear aligner therapy 

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This article provides expert recommendations for improving the use of clear aligners in orthodontic treatment. It highlights the importance of proper case selection, treatment planning, and understanding the biomechanics of aligners compared to traditional braces. The authors emphasize that while aligners are more comfortable and esthetic, their effectiveness depends on correct attachment placement, force control, and patient compliance. The consensus offers practical guidelines to enhance treatment outcomes and expand aligner use in more complex orthodontic cases.

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Expert consensus on the clinical strategies for orthodontic treatment with clear aligners - International Journal of Oral Science

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International Journal of Oral Science - Expert consensus on the clinical strategies for orthodontic treatment with clear aligners

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The effectiveness of orthodontic treatment with clear aligners in different thicknesses 

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The effectiveness of orthodontic treatment with clear aligners in different thicknesses 

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This study compared the performance of clear aligners with two thickness levels 0.5 mm and 0.75 mm in patients with mild crowding. Results showed that thicker aligners produced slightly greater tooth movement but also caused more pain, while thinner aligners provided higher comfort and satisfaction. The findings suggest that aligner thickness influences both treatment efficiency and patient experience, emphasizing the need for clinicians to balance force and comfort when choosing aligner materials.

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The effectiveness of orthodontic treatment with clear aligners in different thicknesses - Scientific Reports

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Scientific Reports - The effectiveness of orthodontic treatment with clear aligners in different thicknesses

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advantages:

comfort

convenient for patients

easier to maintain good hygiene

disadvantages:

costly

require the patient to wear them consistently for 20-22 hours every day

needs to be cleaned regularly

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In many cases, getting orthodontic aligners is more expensive than traditional braces, ranging from $2,000 to $5,000. Since aligners tend to be more patient-friendly, with patients able to not have any food restrictions and easy to maintain oral hygiene, many patients see the value in getting aligners instead of braces.