Scientific Journal Published by the College of Dentistry, University of Baghdad ISSN ISSN 1680-0087 I A quarterly peer reviewed and published scientific journal of the college of dentistry, university of baghdad.
Scientific Journal Published by the College of Dentistry, University of Baghdad ISSN ISSN 1680-0087 I A quarterly peer reviewed and published scientific journal of the college of dentistry, university of baghdad.
Scientific Journal Published by the College of Dentistry, University of Baghdad ISSN ISSN 1680-0087 I A quarterly peer reviewed and published scientific journal of the college of dentistry, university of baghdad.
College of Dentistry University of Baghdad ISSN ISSN 1680-0087
i
A quarterly peer reviewed and published scientific journal of the College of Dentistry, University of Baghdad. Editor in chief: Prof. Dr. Nazar G. Al-Talabani PhD Vice Editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi MSc, PhD
Editorial Board: Prof. Dr. Khalid Mirza FDSRCS Prof. Dr. Wael Al-Alousi MSc Prof. Dr. Mohammed K. Bazirgan MSc Prof. Dr. Maan R. Zakaria MSc Prof. Dr. Sulafa K. El-Samarai MSc,PhD Assist. Prof. Dr. Anwar Al-Saeed MSc Assist. Prof. Dr. Balkees Taha Garib MSc,PhD Assist. Prof. Dr. Natheer Al-Rawi MSc,PhD Assistant professor Dr. Abbas Faisal Al-Huwaizi MSc,PhD
Board of editorial consultants: 1- Prof. Dr. Haitham Al-Azzawi MSc 2- Prof.Dr. Salem El-Samarai PhD 3- Prof. Dr. Waleed Al-Hashemi MSc 4- Prof. Dr. Ausama Al-Mulla PhD 5- Prof. Dr. Ahlam Hamed MSc 6- Prof. Dr. Khalid Kezer FDSRCS 7- Prof. Dr. Zainab Al-Dahan MSc, PhD 8- Assist. Prof. Dr. Latifa Al-Mendalawi, MSc. 9- Assist. Prof. Dr. Lamia Al-Azzawi MSc, PhD 10-Assist.Prof.Akram F. Al-Huwaizi MSc, PhD 11- Assist. Prof. Dr. Bashar Hamed MSc, PhD 12- Assist. Prof. Dr. Lekka Mahmood MSc 13- Assist. Prof. Dr. Asma Tahsin MSc
Computer executives: Dr. Isaac Alber Dr. Abdul Baset Ahmad Administrative secretary: Hadeel Abdul Wahab. For consultation, please contact: Website: www.baghdentistry.com E-mail: dentalcoll@yahoo.com, info@baghdentistry.com Telephone: (+9641)4169375, Fax: (+9641)4140738
ii Contents i Editor and Editorial Board ii Contents iv Instructions for the Authors v Pioneers Restorative Dentistry The effect of prepared denture cleansers on some physical properties of stained acrylic resin denture base material cured by two different techniques. Salem A.L. Salem, Aseel M.A. Al-Khafaji. 1
A comparison of inferior alveolar nerve block and periodontal ligament injections during endodontic treatment of human mandibular first premolars. Majida K. Al-Hashimi, Waleed I. Ali. 9 An evaluation of the effects of different polishing agents on the surface roughness of porcelain. Maan R. Zakaria. Rawaa H. Al-Hadithy.
15 Percentage of undercut areas in edentulous patients. Ghayda'a H. Al-Izzi, Sabah S. Al-Habib 22 An assessment of the effect of using different post systems on the fracture resistance of endodontically treated teeth. Lamis A. Al-Taie, Aladin Al-Rubayi 25 Evaluation of interfacial bond strength of repaired composite resins. Ali M. Abdul Kareem 32
Oral Pathology,Oral Medicine, and Dental Radiology The prevalence of oral developmental disturbances and dental alignment anomalies in females of secondary schools in Thamar city (14-21years). Balkees T. Garib 35 Orthopantomographic assessment of mandibular asymmetry as an aid in diagnosis of tempromandibular problems. Asmaa T. Uthman, Natheer H. Al-Rawi. 40 Detection of acid fast bacilli in the saliva of patients having pulmonary tuberculosis. Gassan Yassen, Jamal Noori. 43 Burning mouth syndrome: an analysis of 130 patients. Shanaz M. Gaphor. 47
iii
Oral and Maxillofacial Surgery and Periodontology
Gutta-percha as retrograde filling in endodontic surgery without apicectomy (A clinical and radiographical study with new technique). Anwar A. Al-Saeed. 52
Comparison of conventional periodontal therapy versus scaling and root planing with subgingival minocycline gel 2%. Kholood A. Al Safi 57
The effect of aspirin on the periodontal parameter bleeding on probing. Maha Abdul Aziz 63
Blood groups and hypertension. Nasreen A.R. Wafi 68
Relations between dental plaque, gingivitis & dental caries among 21-50 years dental patients. Vian M. Al-Jaf 71
Drainage of submandibular abscess by using local anesthetic block technique of transverse cervical cutaneous nerve of the neck. Anwar A. Al-Saeed
75
Orthodontics, Pedodontic, and Preventive Dentistry
Treatment of clinically evident skeletal mandibular asymmetry. Nidhal H. Ghaib, Ali F. Al-Zubaidee, Zina Z. Al-Azawi. 83
Salivary calcium, potassium and oral health status among smokers and non-smokers (a comparative study). Wesal A. Al-Obaidi. 89
Prevalence, severity and pattern of dental fluorosis among a group of children in Dahmar Yemen. Wesal A. Al-Obaidi 92
Local anesthetic quality in pedodontic department, College of Dentistry/ University of Baghdad. Abeer M.Zwain. 96
Some societies of dental specialities
iv
Instruction for the Authors
The quarterly published J ournal of the College of Dentistry accepts manuscripts that address all topics related to dentistry. Manuscripts should be prepared in the following manner: Typescript. Type the manuscript on A4 white paper, with margins of 25 mm. Type the manuscript with English language font (Times New Roman) and the sizes are as follows: 1) Font size 18 and Bold for the title of the manuscript. 2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION,.etc. 3) Font size 12 and Bold for the names and addresses of the authors. 4) Font size 11 for the text of all the article, tables and legends of the figures. Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand corner. Title of the paper: The title should be written with a capital letter for every word as (Effect of the retention and stability.etc). The name of each author with her/his academic degrees should follow the title. The address, phone, fax, and e-mail of author responsible for correspondence about the manuscript should be typed. Abstract and key words. The abstract should contain no more than 250 words. The abstract should be divided to the following categories: Background: (It contains a brief explanation about the problem for which the research was done as well as the aim of the study), Materials and methods:, Results:, and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article. Text. The body of the manuscript should be divided into sections preceded by appropriate headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS, DISCUSSION) which are written in bold and capital. Major headings should be typed in bold and the first letter should be capital at the left hand margin; subheadings should be not bold and appear at the left hand margin with only the first letter of each word capitalized. References. References are placed in the text using the Vancouver system (Numbering system). Number references consecutively in the order in which they are first mentioned in the text. Identify references in the text, tables, and figures by Arabic numerals, and place them in parentheses within the sentence as superscription ex. (2) . Use the style of the examples given below in listing the references: Book 1. Hickey J C, Zarb GA, Bolender CL. Bouchers prosthodontic treatment for edentulous patients. 9 th ed. St. Louis: CV Mosby; 1985. p.312-23. Journal article 4. J ones ER, Smith IM, Doe J Q. Occlusion. J Prosthet Dent 1985; 53:120-9. Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g. Table 1). Cite each table in the text in the order in which it is to appear. Figures and illustrations. All figures must have a title placed below the figure. Identify figures with Arabic numbers (e.g. Figure 1). They must be placed on a separate page and numbered to correspond with the figures. If the article contains illustrations submit three clear unmounted glossy photographs and write the authors name and the figures number at the back of each illustration. The article should not exceed 10 pages. The author should submit three copies of the article (one original and two copies) and a (CD) containing the article.
v
Pioneers
In Memory of Prof. Suad Al-Ani
It is with sorrow that the college of dentistry, university of Baghdad lost one of its pioneers. She is Professor Suad Al-Ani. She was specialized in oral pathology since 1965. She was a supervisor of many postgraduate students in the department of oral diagnosis and a co-supervisor in other departments.
Date of Birth: 1/7/1937 Bachelor in Dentistry: 30/6/1961 Master degree in oral pathology: In Boston, USA, 12/7/1965 Assistant lecturer: 7/10/1965 Lecturer: 9/7/1970 Assistant professor: 15/8/1973 Head of the department of oral diagnosis: 1/9/1980 Professor: 10/12/1994
J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared The effect of prepared denture cleansers on some physical properties of stained acrylic resin denture base material cured by two different techniques
Salem A.L. Salem, B.D.S., Ph.D. (1)
Aseel M.A. Al-Khafaji, B.D.S., M.Sc. (1)
ABSTRACT Background: The debris in the denture cause many problem to the patient and the use of the denture cleanser is the solution for this problem but this denture cleanser may affect the properties of the denture. The aim of our study was to observe the effect of prepared denture cleansers on some physical properties (water sorption, water solubility and color stability) of the acrylic resin after their immersion in the tea solution and also to compare the effect of those denture cleansers on heat and microwave cure acrylic resin. Materials and methods: Heat curing and Microwave acrylic denture was prepared and immersed in four types of denture Cleansers after their staining with tea then the water sorption, water solubility and color stability of acrylic resin was measured . Results: There were no changes in the stained acrylic properties when the samples were immersed in the prepared denture cleansers and in the alkaline peroxide cleanser compared to that immersed in the distilled water. Furthermore no significant differences were observed between microwave and water bath cured specimens in respect to color stability, sorption and solubility of the testing groups. Conclusions: The prepared denture cleanser solutions are good and satisfactory cleanser materials for the acrylic resin denture base cured by two different techniques. Key words: Acrylic, denture cleanser, water sorption, water solubility. (J Bagh Coll Dentistry 2006; 18(2) 1-8)
INTRODUCTION 1
Acrylic plastic has been the most widely used and accepted among all denture base materials and it was estimated that they represent 95% of the plastics in prosthodontics (1, 2) . The unclear denture may have undesirable effect on patient's health and ability to successful wear of the denture (3) . If a patient's denture becomes unsanitary, the consequences may be bad breath, poor esthetic, denture stomatitis and angular cheilitis (4) . The efficient cleansing of the fitting surface of the denture is a key factor in the maintenance of healthy oral mucosa and important for the long term success of removable prosthodontics treatment (5,6) . Denture cleansers are a popular method used by denture wearers for cleaning (7) . There are wide varieties of denture cleansers used to remove soft food and hard deposits of calculus and stains on denture base and teeth; the most common of them used immersion technique and marketed as powder, tablets or liquid. In spite of the large variety of these cleansers and their different mode of action each had its advantages and disadvantages.
(1) Professor, Department of Prosthodontics, College of Dentistry, University of Baghdad. (2) Assistant lecturer, Department of Prosthodontics, College of Dentistry, University of Baghdad.
Cleansers and cleaning methods used may have harmful effect on the plastic or metal component of the denture (8) . Knowledge of constituents of denture cleansers, their efficiency, adverse effect and safety would aid in dispensing appropriate information to the patient (9) , so the dentist must be able to recommend a denture cleanser that is effective, non deleterious to denture material and safe for patient use (10,11,3) . This study evaluated the effects of prepared denture cleanser solution (4% Oxalic acid, 4%tartaric acid and 4%citric acid) in addition to alkaline peroxide solution on the water sorption ,water solubility and color stability of stained acrylic resin material that cured by two curing method.
MATERIALS AND METHODS A disc of (501 mm in diameter and 0.50.1mm in thickens) were constructed from Heat cured acrylic resin (major base 2\italy) and Microwave acrylic denture base resin (AcronTM MCGC 2AB) to measure water sorption , water solubility and color stability ;the preparation of the acrylic samples was conducted according to the ADA specification. Sample grouping The specimen grouping was classified as follows: Restorative Dentistry 1 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared Group 1: Specimens immersed in 4% citric acid denture cleanser solution. Group 2: Specimens immersed in 4% tartaric acid denture cleanser solution. Group 3: Specimens immersed in 4% oxalic acid denture cleanser solution. Group 4: Specimens immersed in alkaline peroxide denture cleanser solution. Group 5: Specimen immersed in distilled water (control group). Preparation of the solutions 1. Tea solution: 4 grams of dry tea boiled in 500 ml of distilled water for 4 minutes, and allowed to cool at room temperature, and then the solution was decanted from tea leaves (12) . 2. Alkaline peroxide solution: It's prepared according to the manufacturers instructions {1 tablet of alkaline peroxide added to 150 ml of warm distilled water (500C)}. 3. The experimental denture cleanser solutions: a fresh denture cleanser solutions was prepared by dissolving each of the oxalic acid, tartaric acid and citric acid in the isopropyl alcohol (the isopropyl alcohol was chosen as solvent to the acid powder due to its antiseptic effect) (13) as followed: 4 gm of acid powder +100 ml. alcohol 4% W/V of acid isopropyl denture cleanser solution Then, prior to the use each prepared denture cleanser solutions were diluted with an equivalent volume of distilled water as follow:- 50 ml. of + 50 ml. of prepared 100 ml. of distilled water. denture cleanser solutions. fresh diluted denture cleanser solutions.
Water sorption and water solubility test The specimens' preparation and testing procedure were done according to the ADA specification No.12 for denture base resin (9) . The no. of the specimens used in this study were 50 specimens for the two curing methods (25 specimens from the water bath curing method and 25 from the microwave energy)) (5 samples for each group). The specimens were dried in a desiccator containing freshly dried silica gel. The desiccator was stored in an incubator at a 37 0 C 2 0 C for 24 hours. After 24 hour, the specimens were removed to a similar desiccator at room temperature for one hour then weighed with a digital balance on a precision of 0.1mg. This cycle was repeated until a constant mass "conditioned mass" was reached (The weight loss at each disc was not more than 0.5mg in 24 hours period). Then the discs of group (1,2,3,4) were immersed in fresh tea solution for 24 hours. Afterwards, they were immersed in the denture cleansing solution for another 24 hours, while the discs of group 5 were immersed in distilled water at 370C20C for 48 hours. For all groups after which time the discs were removed from the solutions with tweezers wiped by a clean dry hand towel until free from moisture, waved in the air for 15 seconds and weighed one minute after removal from the solutions this mass was consider as mass after immersion . After that to obtain the value of solubility test, the discs were reconditioned to a constant mass in the desiccator at 370C 20C as done previously for sorption test and considered as the reconditioned mass. The values for sorption were calculated for each disc from the following equation and the final value should be rounded to the nearest 0.1 mg/cm2: Sorption (mg/cm2) =mass after immersion (mg)-condition mass (mg)/ Surface area (cm2) The soluble matter lost during immersion was determined to the nearest 0.01 mg/cm2 for each disk as follows: Solubility (mg/cm2) =condition mass (mg) - reconditioned mass (mg)/ Surface area (cm2)
Color stability test: The number of the specimens used in this study was 50 specimens for the two curing methods (25 specimens from the water bath curing method and 25 from the microwave energy)) (5 samples for each group). The color stability test was measured by two methods a. Objective method (Spectroscopic study). b. Subjective method (visual examination). We used a spectrophotometer device to measure the light absorption of each specimen at two wavelengths at 400 and 500.For all groups the light absorption for each disc was measured before immersion of the discs in the solutions. The discs of groups 1,2,3,4 were immersed first in the fresh tea solution then they were immersed in the denture cleansing solution while for the control group (group 5) the discs were immersed just in the distilled water. After the completion of immersion of the discs of all the groups the light absorption of the discs were measured as done before the immersion Restorative Dentistry 2 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared The ANOVA test of solubility demonstrated no significant difference between the investigating material (F =2.229, P =0.102, for water bath) and (F =0.177, P =0.948, for microwave). The results of the (t-test) show that there is no significant difference found between the microwave and water bath curing method for all tested groups as shown in Table and Figure 2. procedure by using a spectrophotometer at the same two wave length and the difference between the two readings were calculated. The visual examination of staining removal was assessed by ten independent observers (dentist). Each observer read the samples after their removal from the solutions. The samples were evaluated visually for staining removal by comparing the tested samples with the control group by placing the specimens on a white background and they were graded for the amount of staining on a scale of (No, slight, mild, moderate, sever). For the color stability test the mean and standard deviation of the amount of absorption difference before and after immersion in the denture cleanser solution as well as in distilled water are presented in Table and Figure 3. In the statistical analysis we used Descriptive statistics (Arithmetic mean, Standard deviation, Statistical tables) and Inferential statistics (ttest, one way analysis of variance test (ANOVA) and Multiple comparison tests utilizing the least significant differences (LSD) }. The ANOVA test revealed a highly significant difference between groups that cured by the microwave curing method for both wavelength 400 nm (F =9.572, P =0.000) and at 500nm (F =21.739, p =0.00) while for the samples that cured by the water bath method there is no significant difference between the groups at 500nm (F =2.803, P =0.054) but at 400nm there is a significant difference between the groups (F = 3.352, P = 0.030). Table 4 represent the results of the LSD test of the color stability.
RESULTS The mean and the standard deviation of sorption test for the experimental and the control groups that cured by the conventional water bath and microwave are listed in Table and Figure 1. There is no significant difference for all groups at the two wave length when compared between the two curing methods except the tartaric acid which showed a highly significant difference (P<0.01) at 400nm and a significant difference (P<0.05) at (500nm) by applying t test (Table 4, and Figure 3). The sorption value for all the groups are nearly similar in both curing method they were all within the ADA specification limit. No.12 for denture base polymers (the uptake should not be more than 0.8mg/cm 2 ). One way analysis of variance test (ANOVA) demonstrated a no significant difference in the sorption between the 5 groups in both curing method (F =0.117, P =0.975 for water bath) and (F = 0.077, P = 0.988 for microwave) (P >0.05). The result of visual examination of staining removal of all groups for both curing methods show no difference in the color when compared with the control group as shown in Table 5.
The (t-test) show there is no significant difference between the microwave and water bath method for each group as shown in Table and Figure 1.
Similar methods of statistical analysis used for sorption test were applied to the results of solubility test. The mean and standard deviation of solubility for both curing method are presented in Table and Figure 2.
The solubility value for both curing methods was complied with the ADA specification limit (The loss in weight should not be more than 0.04 mg/cm2).
Figure 1: Histogram of sorption test
Restorative Dentistry 3 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared
Table 1:Descriptive statistics and t-test of sorption test (mg/cm 2 ) Water bath Microwave Materials Mean S.D. Mean S.D. P value Sig. Citric acid 0.8 0.069 0.8 0.068 0.993 N.S. Tartaric acid 0.8 0.053 0.8 0.063 0.845 N.S. Oxalic acid 0.8 0.086 0.8 0.075 0.803 N.S. Alkaline peroxide 0.8 0.029 0.8 0.041 0.961 N.S. Distilled water 0.8 0.010 0.8 0.031 0.909 N.S.
Table 2:Descriptive statistics and t-test of solubility test (mg/cm 2 ) Water bath Microwave Materials Mean S.D. Mean S.D. P value Sig. Citric acid 0.004 0.004 0.046 0.04 0.140 N.S. Tartaric acid 0.005 0.002 0.044 0.01 0.052 N.S. Oxalic acid 0.006 0.006 0.044 0.02 0.285 N.S. Alkaline peroxide 0.013 0.006 0.024 0.01 0.108 N.S. Distilled water 0.010 0.005 0.044 0.03 0.298 N.S.
Figure 2: Histogram of solubility test
Table 3: Descriptive statistics and t-test of color stability test(nm) 400 nm 500 nm Water bath Microwave Water bath Microwave Materials Mean S.D. Mean S.D. Pvalue Sig. Mean S.D. Mean S.D. P value Sig Citric acid - 0.262 0.32 - 0.486 0.24 0.275 N.S. - 0.261 0.32 0565 0.05 0.10 N.S Tartaric acid - 0.191 0.13 - 0.420 0.12 0.006 H.S. - 0.195 0.15 0.406 0.14 0.01 S. Oxalic acid - 0.113 0.16 - 0.332 0.10 0.076 N.S. - 0.126 0.17 0.330 0.10 0.11 N.S Alkaline peroxide 0.178 0.29 - 0.024 0.15 0.161 N.S. 0.145 0.30 .018 0.18 0.32 N.S Distilled water 0.081 0.14 - 0.065 0.02 0.060 N.S. 0.067 0.14 0.056 0.03 0.08 N.S
Restorative Dentistry 4 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared Table 4: Mutiple comparison test (LSD) of color stability test (Spectroscopic studies) 400 nm 500 nm Water bath Microwave Water bath Microwave Materials Mean D.F. P value Sig. Mean D.F. P value Sig. Mean D.F. P value Sig. Mean D.F. P value Sig. Distilled Water + citric acid 0.344 0.02 S. 0.421 0.00 H.S 0.329 0.036 S. 0.509 0.00 H.S. Distilled Water + tartaric acid 0.273 0.07 N.S. 0.355 0.00 H.S 0.262 0.089 N.S. 0.350 0.00 H.S. Distilled Water + oxalic acid 0.195 0.18 N.S. 0.267 0.01 S 0.193 0.202 N.S. 0.274 0.001 H.S. Distilled Water + alkaline peroxide - 0.096 0.50 N.S. - 0.040 0.67 N.S - 0.077 0.602 N.S. - 0.074 0.327 N.S. Citric acid + Tartaric acid - 0.071 0.62 N.S. - 0.066 0.49 N.S - 0.066 0.654 N.S. - 0.159 0.044 S. Citric acid + oxalic acid - 0.148 0.31 N.S. - 0.153 0.12 N.S. - 0.135 0.366 N.S. - 0.235 0.005 H.S. Citric acid + alkaline peroxide - 0.441 0.00 H.S. - 0.461 0.00 H.S - 0.407* 0.012 S. - 0.584 0.00 H.S. tartaric acid + oxalic acid - 0.077 0.59 N.S. - 0.087 0.37 N.S - 0.068 0.644 N.S. - 0.076 0.316 N.S. tartaric acid + alkaline peroxide - 0.369 0.01 S. - 0.395 0.00 H.S - 0.340 0.031 S. - 0.424 0.00 H.S. Oxalic acid + alkaline peroxide - 0.292 0.05 N.S. - 0.308 0.00 H.S - 0.271 0.079 N.S. - 0.348 0.0 H.S.
Figure 3: Histogram of color stability (Spectroscopic studies)
Restorative Dentistry 5 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared
HOOC COOH
A HOOC CH COOH CH
OH OH HOOC CH 2 COOH C
CH 2 COOH C B OH
Figure 4: The chemical formula of the denture cleanser solutions powder {A. The oxalic acid. The Tartaric acid C. The citric acid} (38)
DISCUSSION Sorption of the material represents the amount of water absorption on the surface and into the body of the material, the sorption of poly methyl methacrylate (PMMA) is facilitated by its polarity and the mechanism primary responsible for ingress of water is diffusion (14) ; whereas solubility represents the mass of the soluble materials from polymer. The only soluble materials present in the denture base resins are initiator, plasticizers and free monomer (1,15,16) . The rate at which the materials absorbed water or lost soluble components varied considerably with the type of material, the amount of the plasticizer or filler content and the solution in which they were immersed (17) . In the present study the sorption and solubility were measured according to ADA specification no.12 (9) . The result of immersion of acrylic resin in the denture cleanser as well as in the distilled water complied with ADA requirement; the results of sorption and solubility tests showed that there was no statistically difference between the two curing methods (water bath and microwave energy). Similar conclusion was reported by others authors (18-21) while Al Doori and al Haydary disagreed with them where they found that the microwave group samples showed a lower sorption than the water bath group samples. (22, 23) The water molecules has affinity more than that of the chemical solution molecules to enter and get out from the acrylic resin (the water molecules has simple and small structure compared to the complex structure of the denture cleanser solutions), this might be the cause of the low solubility value of the water bath acrylic resin samples was lower when immersed in chemical solutions than when immersed in distilled water. A change in appearance indicates reduction of the long term quality of a denture (24) ; several denture base resins have been introduced that provide easier and faster processing, although these materials have adequate mechanical properties the color stability also of interest. For both curing methods there was no color change observed visually after immersion of the acrylic samples in the denture cleanser solutions and in the distilled water this may be due to that human eyes are not sensitive like the apparatus used in our study. The result of the spectrophotometer study showed that for all tested groups except the samples that immersed in tartaric acid there was no significant difference among the tested groups between the two curing methods this result agree with those done by an earlier studies (18, 25-27) who found that acrylic resin whether cured by microwave or by water bath methods showed adequate color stability when acrylic resin processed according to the manufacturers instructions, while May et al. found that there was a significant color difference between the two curing method. (28)
The tartaric acid had greater effect on the color of the acrylic resin this might be due to that the tartaric acid have 4 active groups in their structure that are available to molecular interacted with the acrylic polymer by formation of hydrogen bonds while the citric acid have 3 active groups ; the oxalic acid have 2 active groups and water molecules have only one active group in their structure; this could be used to explain the reason of that the microwave and water bath acrylic resin when immersed in the prepared cleanser solutions have significant color differences compared with that immersed in the distilled water (Figure 4). Restorative Dentistry 6 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared The statistical analysis for both curing method show a significant differences among the tested groups regarding the color stability test; the presence of the residual monomer could be one of the possible reason that may be used to explain the color changes (25, 28, 29) , while Gross and Moser showed that the surface porosity resulting from a dissolution of slight soluble component of the material which cause the color changes (30) . On the other hand other authors saw that the high immersed temperature might be sufficient to cause decomposition of the resin leading to discoloration; or the oxidation of the un reacted c=c double bonds produced colored peroxide product (30- 33)
Although the spectrophotometer study showed a statically significant difference among the tested groups for both curing methods but the color difference was often clinically insignificant because many reporters demonstrated that when the value of color difference was less than (1) it mean that the color difference was clinically insignificant .(34- 37) .
REFERENCES 1. Craig RG, Powers J M. Restorative dental materials.11 th edition. St. louis:mosby. 2002. 2. Craig RG, O'Brien WJ , Powers J M. Dental materials, properties and manipulation. 6th ed. St. Louis. The C.V. Mosby Co. 1996; 242-62. 3. Polyzois GL, Zissis AJ , Yannikakis SA. The effect of glutaraidehyde and microwave disinfection on some properties of acrylic denture resin. Int J Prosthodont 1995; 8 (2):150-4. 4. Suzuki T, Mizumi M, Furuya J , Okamoto Y, Rosenthal SF. Influence of ozone on oxidation of dental alloys. Int J Prosthodont 1999; 12(2): 179-83. 5. Budtz J rgensen EB. Materials and method for cleaning dentures. J Prosthet Dent 1979; 42(6): 619- 23. 6. Sindel DW, Billy EJ , Richards MW, Rains TC, Shan- Hua LI. Dissolution of cost aluminum in different cleansers. Int J Prosthodont 1994; 7(3): 280-4. 7. Sheen SR, Harrison A. Assessment of plaque prevention an dentures using an experimental cleanser. J Prosthet Dent 2000; 84(6): 594-601. 8. Dills SS, Olshan AM, Goldner S., Brogdon C. Comparison on the microbial capability of an abrasive paste and chemical soak denture cleansers. J Prosthet Dent 1988; 60:467. 9. ADA. American national standers institute/American dental association specification No. 12 for denture base polymer". Chicago: council on dental material and devices. 1999. 10. Neill DJ . A study of materials and methods employed in cleaning dentures. Br Dent J 1968; 124(3):107-15. 11. Backenstose WM, Wells J G. Side effects of immersion. Type cleaners on the metal components of dentures. J Prosthet Dent 1977; 37(6):615-21. 12. Scotti R, Mascellani SC, Foruiti F. The in vitro color stability of acrylic resins for provisional restorations. Int J Prosthodont 1997; 10(2):164-8. 13. Hatim NA, Salem AS, Khayat IK. Evaluating the effect of new denture cleansers on the surface roughness of acrylic resin denture base material (An in vitro study). Al-Rafidain Dent J 2003; 3 (1):31-8. 14. Anusavice KJ . Philips science of dental materials "10th ed. Philadelphia, WB Saunders Co. 1996. 15. Phillips RW. Skinners Science of dental materials" 7th ed. Saunders Company, Philadelphia. 1973. 16. Miettinen VM, Vallitlu PK. Water sorption and solubility of glass fiber-reinforced denture polymethylmethacrylate resin. J Prosthet Dent 1997; 76:531-4. 17. Kazanji MNM, Walkinson AC. Soft lining maerials:their absorption of, and solubility in artificial saliva. Br Dent J 1988; 165:91-4. 18. Reitz PV, Sanders J L, Levin B. The curing of denture acrylic resins by microwave energy, physical properties. Quintessence Int 1985; 8: 547-51. 19. Truong VT, Thomasz FGV. Comparison of denture acrylic resins cured by boiling water and microwave energy. Aust Dent J 1988; 33(31): 201-4. 20. Ilbay SG, Guvener S, Al-Kumru HN. Processing dentures using a microwave technique. J Oral Rehabil 1994; 21:103-9. 21. Hafidh MMJ . A study on the effect of the chemical disinfectants on acrylic resin cured by two different techniques". M.Sc. Thesis, University of Baghdad, collage of dentistry. 1995. 22. Al-Doori DJ I. Polymerization of poly methyl methacrylate denture base materials by microwave energy" M.Sc.D. Thesis University of Wales College of Medicine. 1987. 23. Al-Haydary ASA. The use of microwave energy in polymerization of radio opaque denture base polymer". M.Sc. Thesis, University of Baghdad, collage of dentistry. 1992. 24. Sazb G, Valderhaug J , Ruyter IE. Some properties of a denture acrylic coating. Acta Odontol Scand 1985; 43:249-56. 25. Austen AM, Basker RM. Residual monomer in denture bases the effect of varying short curing cycles. Br Dent J 1982; 153:424. 26. May KB, Razzoog ME, Koran A, Robinson E. Denture base resins: Comparison study of color stability. J Prosthet Dent 1992; 68:78-82. 27. Subhi MD. The effect of disinfectant solutions on some properties of acrylic dental base material". M.Sc. Thesis, University of Baghdad, college of dentistry. 1999. 28. May KB, Shotweell J R, Koran A. Color stability: Denture base resin processed with the microwave method. J Prosthet Dent 1996; 76:581-9. 29. Keng SB, Cruickshanks-Boys DW, Davies EH. Processing factors affecting the clarity of a rapid curing clear acrylic resin". J Oral Rehabil 1979; 6:327-35. 30. Gross MD, Moser J B. A colorimetric study of coffee and tea staining of four composite resins. J Oral Rehabil 1977; 4:311-22. 31. Brown RL, Argentor H. Diminishing discoloration in methacrylate accelerator systems. J Am Dent Assoc 1967; 75:918. 32. Lee HT, Orlowski J , Kobashigawa A. Handbook of dental composites, Lee pharmaceuticals, south EI Monte, Cal, 1973. Restorative Dentistry 7 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared Restorative Dentistry 8 33. Ferracane J L, Moser J B, Greener EH. Ultraviolet light-induced yellowing of dental restorative resins. J Prosthet Dent 1985; 54:483-7. 34. Kuehni RG, Marcus RT. An experimental in visual scaling of small color differences". Color Res Appl 1979; 4:83-91. 35. Ma TS, J ohnson GH, Gordon GE. Effects of chemical disinfectants on the surface characteristic and color or denture resin. J Prosthet Dent 1997; 77(2): 197-204. 36. Douglas RD, Brewer J D. Acceptability of shade differences in metal ceramic crowns. J Prosthet Dent 1998; 79:254-60. 37. Buchalla W, Attin T, Hilgers RD, Hellwing E. The effect of water storage and light exposure on the color and translucency of a hybrid and a microfilled composite. J Prosthet Dent 2002; 87:264-70. 38. Poylan PJ . Elements of Chemistry, Allyn and Bacon, united states of American.1965
J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior A comparison of inferior alveolar nerve block and periodontal ligament injections during endodontic treatment of human mandibular first premolars
Majida K. Al-Hashimi, B.D.S., M.S. (1)
Waleed I. Ali, B.D.S., M.Sc. (2)
ABSTRACT Background: Profound pulpal anesthesia for root canal treatment is difficult to achieve in mandibular posterior teeth. Several authors emphasized on the effects of periodontal ligament injection as a primary or supplementary technique. The aim of this study was to compare the efficacy of periodontal ligament injection and inferior alveolar nerve block injection in providing profound pulpal anesthesia for endodontic treatment of human mandibular first premolars; and to compare the discomfort associated with each injection in regard to initial needle insertion and injection of solution. Materials and Methods: Periodontal ligament injection was used as a primary injection technique to anesthetize 30 sound, healthy mandibular first premolars and it was compared to the pulpal anesthesia of the other 30 mandibular first premolars on the other side of the same patient, which were anesthetized using the inferior alveolar nerve block injection. Results: The results showed no statistically significant differences between the two injection techniques. Conclusion: The periodontal ligament injection can be used effectively to anesthetize mandibular first premolars, as a primary technique, during root canal therapy procedure. Pain associated with insertion of needle and injection of solution for both injection techniques was acceptable. Key words: Periodontal ligament, inferior alveolar, anesthesia. (J Bagh Coll Dentistry 2006; 18(2) 9-14)
INTRODUCTION 1
Local anesthesia is the primary method used in dentistry to control pain. However, even in the presence of an adequate soft tissue anesthesia after the standard injection by block or infiltration, there may be incomplete pulpal anesthesia. (1)
One of the techniques that have been used with success is the periodontal ligament injection (PDL). (2) The intercellular fluid of the gingival apparatus and the hydrostatic pressure of the ligmaject syringe the syringe for periodontal ligament injection, allows for a safer, more efficient means of local anesthesia. (3)
PDL injection is an effective technique for anesthetizing mandibular first premolars. (4) It was found that the success rate of profound pulpal anesthesia to be highest in molars and premolars and lowest in mandibular lateral incisors. (5) It has been reported that the PDL injection is an effective primary technique in anesthetizing mandibular first premolars using 2% lidocaine with 1:100,000 epinephrine. (6)
Edwards and Head (7) showed that PDL injection with lidocaine was effective in providing
(1) Professor, Department of Conservative Dentistry, College of Dentistry, University of Baghdad. (2) Assistant lecturer, Department of Conservative Dentistry, College of Dentistry, University of Baghdad.
adequate anesthesia, which was statistically more effective than were epinephrine or saline solutions. Zakaria (8) stated that PDL injection showed a success rate of 73.33% which was lower than that scored by the IAN block technique but no statistically significant differences were detected between them. Selection of an injection technique should be based on some factors that include the ability to determine the technique respective anatomical landmarks, the presence of accessory innervations, or trismus. (9) Al-Doori and Al- Hashimi (10) reported that 2% lidocaine with 1:80,000 epinephrine produces significantly higher rates of successful pulpal anesthesia than saline, especially in lower first molars.
MATERIALS AND METHODS All patients selected for this study (17 females and 13 males), aged between 18-25 years and were healthy with no allergic reaction to the used dental local anesthetic. They had bilateral lower first premolars that were clinically free of caries, filling, and periodontal disease, and were indicated for extraction for orthodontic reasons. Sixty lower first premolars from thirty subjects were used. In group A, 30 teeth on the right side received the PDL injections, and in group B, 30 teeth on the left side received the IAN block. All teeth in the two groups were Restorative Dentistry 9 J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior electrically pulp tested before the administration of the local anesthesia to measure the response threshold. In addition, all the teeth were electrically pulp tested after the administration of the local anesthesia to verify the success of anesthesia. Then access cavity was prepared and the pulp was extirpated on each tooth in both groups. Two parameters were used to define success of local anesthesia: The first was no subject response to the maximum output of the electrical pulp tester. The second was a rating scale as that designed by Eriksen et al (11) , which measures pain during pulpectomy procedures and was divided into score zero (adequate)pulpectomy could be performed without pain, score one (partial) pulpectomy could be performed with tolerable discomfort, score two (unacceptable) pulpectomy could not be performed due to intolerable pain. Pain rating of initial needle penetration and injection of solution were compared for each technique, using the scale designed by White et al(5) being score zero (no pain), score one (mild pain), score two (moderate pain), score three (severe pain). Electrical pulp tester technique. A small quantity of toothpaste was applied at the tip of the EPT (Analytic Technology Corp., U.S.A.) probe and the probe tip was placed on the middle third of the buccal surface of the experimental tooth and the mesial, and distal teeth to it. Two consecutive readings were obtained as base line vitality readings, similar to that used by Dreven et al. (12)
Periodontal ligament injection technique Periodontal ligament injections were given using Ligmaject syringe (Ligmaject, Germany) with 30-gauge ultrashort needles (length 12 mm, Morita, J apan). The needle was inserted through the mesial gingival sulcus to a point of maximum penetration. The bevel of the needle was directed away from the tooth surface and toward the crestal bone surface, at approximately 30-degree angle to the long axis of the tooth. The trigger of the syringe was pulled firmly until backpressure was achieved and this pressure was sustained for approximately 20 seconds. This procedure delivered 0.2 ml of the anesthetic solution (2% lidocaine with 1:100,000 epinephrine local anesthesia cartridges of 1.7 ml (3M ESPE, Germany)) for each injection. If no backpressure was achieved, the needle was repositioned and the injection was repeated. The injection was then repeated on the distal surface of the tooth. This technique was identical to that described by Schleder et al. (6)
lnferior alveolar nerve block technique The technique used to block the inferior alveolar nerve is the direct approach described by J astac et al (13) , in which the needle was advanced along a straight line to a point where the tip lies just over the mandibular foramen. The posterior ramus was grasped by the non- dominant hand of the operator with the thumb placed in the mouth to retract the cheek and the underlying loose connective tissue and fat pad laterally. Properly positioned, the thumb was parallel to the mandibular occlusal plane and in the greatest concavity of the coronoid notch. After drying the area with gauze, a 27- gauge long disposable dental needles (length 30 mm, Morita, J apan) was inserted at a height approximating an imaginary line running through the bisected thumbnail, and the needle was at least 1 cm. above the mandibular occlusal plane. With the syringe (Asculap, England) and needle axis oriented from the opposing lower premolars, the needle was advanced gently through the mucosa and the underlying soft tissues within the pterygomandibular space till it contacted the bone at a depth of 2 to 2.5 cm. Then the needle was withdrawn slightly, aspiration was performed and if negative, 1.7 ml of anesthetic solution was injected at a rate of 2 ml/mm using a stop watch. Technique of pulpectomy Access cavities were prepared on 60 premolars using carbide round bur no. 4 (Komet, Germany) in a contra-angle hand piece (W&H, Austria). Entrance was gained through the middle of the central groove of mandibular first premolars and the bur was kept parallel to the long axis of the buccolingual extension. Finishing of the cavity walls was completed with round-end tapered fissure bur (Komet, Germany). (14) A barbed broach (Komet, Germany) was passed to a point just short of the apex and rotated clockwise to engage the fibrous tissue of the pulp, then was slowly withdrawn. The data was analyzed using the Chi-square test and Student t-test.
RESULTS Pain rating during initial needle penetration The summary of numbers and percentages of needle penetration pain rating are presented Restorative Dentistry 10 J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior in Table I and Figure 1. Two of the 30 (6.66%) periodontal ligament injection caused no pain, and 2 of the 30 (6.66%) PDL injection caused severe pain, while 18 of 30 (60%) PDL injection caused mild pain and 8 of 30 PDL injections (26.66%) caused moderate pain. For the IAN block, 2 of 30 (6.66%) injection caused severe pain and 6 of 30 injection (20%) caused no pain and 18 of 30(60%) caused mild pain and 4 of 30 (13.33%) caused moderate pain. Statistical analysis using the chi-square test showed no significant difference between the two injections regarding pain of initial needle penetration.
Table 1: Pain rating during initial needle penetration. Score 0 Score 1 Score 2 Score 3 P value PDL 2/30 (6.66%) 18/30(60%) 8/30(26.66%) 2/30(6.66%) IANB 6/30(20%) 18/30(60%) 4/30(13.33%) 2/30(6.66%) P > 0.05 NS Chi-square = 5.3332, NS: Not significant.
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% Score 0 Scor e 1 Scor e 2 Scor e 3 PDL IANB
Figure 1: Pain rating percentages during initial needle penetration.
Pain rating during injection of solution Table II and Figure 2 show the summary of numbers and percentages of pain rating during injection of solution for both techniques. Ten of 30 (33.33%) PDL injections showed no pain during injection of solution, while 17 of 30 (56.66%) PDL injection caused mild pain and only 3 of 30 (10%) injections caused moderate pain, with no severe pain. For the IAN block, 15 of 30 (50%) showed no pain during injection of solution and 13 of 30 (43 .33%) caused mild pain and only 2 of 30 (6.66%) caused moderate pain, with no severe pain. No statistical significant differences were revealed between the two injections regarding pain during injection of solution. Table 2: Pain ratings during injection of solution.
Score 0 Score 1 Score 2 Score 3 P value PDL 10(33.33%) 17 (56.66%) 3 (10%) 0 (0%) IANB 15 (50%) 13 (43.33%) 2 (6.66%) 0 (0%) P > 0.05 NS Chi-square = 1.7333, NS: Not significant.
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% Scor e 0 Score 1 Scor e 2 Score 3 PDL IANB
Figure 2: Pain rating percentages during injection of anesthetic solution. Restorative Dentistry 11 J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior Pain rating during pulpectomy procedure Table III and Figure 3 show the summary of numbers and percentages of pain rating during pulpectomy procedure. Twenty-five of 30 (83.33%) PDL injection showed no pain during pulpectomy, and 3 of 30 (10%) injections showed partial response during pulpectomy and only 2 of the 30 (6.66%) PDL injection caused severe pain during pulpectomy. For the IAN block, 23 of the 30 (76.66%) injection caused no pain during the pulpectomy, while 4 of 30 (13.33%) injections caused partial response and only 3 of the 30 (10%) injection caused severe response during pulpectomy. Also no significant differences existed between the two injection techniques regarding pain during pulpectomy procedure.
Table 3: Pain ratings during pulpectomy procedure. Score 0 Score 1 Score 2 P value PDL 25/30(83.33%) 3/30(10%) 2/30(6.66%) IANB 23/30(76.66%) 4/30(13.33%) 3/30(10%) P >0.05 NS Chi-square = 0.7666, NS : Not significant.
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% Scor e 0 Scor e 1 Scor e 2 PDL IANB
Figure 3: Pain rating percentages during pulpectomy procedure.
The success rates for both injections was defined as no response to the maximum output of EPT and no patients response at pulpectomy and accordingly the success rate for PDL injection was 80.33%, and the success rate for IAN block was 76.66%. If the partial response (score two) at pulpectomy was regarded acceptable and was included in the success rates for both injections, then the success rate for PDL injection was 90.33%, and for IAN block was 90%. Statistical analysis using Student t- test showed no significant difference between the two injection techniques regarding success rates (P >0.05), (Tables IV and V).
Table 4: The mean and standard deviation (SD) of EPT readings for both groups before and after the administration of local anesthesia.
Before PDL After PDL Before IANB After IANB Mean 32.6667 76.1034 32.6333 74.6897 SD 4.2535 8.9815 4.0214 9.8093
Table 5: Student t-test results of EPT readings.
t-test df P PDL 0.189 28 0.851 (NS) IANB 1.013 28 0.320 (NS) df: degree of freedom, P : Probability values, NS : Not significant. Restorative Dentistry 12 J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior DISCUSSION It has been found that for healthy teeth an 80/80 EPT reading with no patients response was an indicator of profound pulpal anesthesia. A lower reading than the maximum output but higher than the baseline indicated unsuccessful pulpal anesthesia for pulp extirpation. This agrees with Dreven et al. (12)
The results of the present study showed that pain rating of initial needle penetration for the PDL injection was 86.66% of mild to moderate type with more mild (60%) and the pain of injection of solution was 90% of no pain to mild pain with more mild pain. These findings agree with White et al (5) and Schleder et al. (6)
On the other hand, for the IAN block, the pain rating of initial needle penetration was 80% of no pain to mild pain with more mild pain (60%) and the pain of injection of solution was 93.33% of no pain to mild pain, which agree with Whal et al. (15) Malamed (2) found that 70% of the patients preferred the PDL injection to the standard injection. Montagnese et al (16) reported that 40% of the patients found the standard injection painful (moderate to severe). Also Vreeland et al (17) reported that 33-40% of the subjects had moderate to severe discomfort during deposition of solution. Several factors may explain the results of this study regarding the above criteria. First, no topical anesthetic was used. Second, pain perception can be modified by psychological, social, and situational factors. Fear and anxiety may lower the pain threshold. Fear of the IAN block may be due to the injection site or the long needle penetration and fear of the PDL injection may be due to the gun-like appearance of the syringe. Third, pain on injection of the anesthetic solution could be due to the low pH of the solution, which may cause burning sensation. Fourth, pain threshold and tolerance of each patient may vary and the results should be considered as subjective evaluation of local anesthesia techniques. (11)
The success rate for the PDL injection was 83 .33%, which was lower than the success rate achieved by Malamed (88.52%) (2) and Schleder et al (86.7%) (6) and higher than the success rate achieved by Moore et al (78.9%) (4) and White et al (63.2%). (5) It seems that the most important factor in the success of the PDL injection is injection of the local anesthetic under strong backpressure. Smith and Walton (18) explained that, when the PDL injection was given under strong backpressure, there was spread of the injected material throughout the periodontal ligament, periapical tissues, medullary bone, and pulps of injected and adjacent teeth. Conversely, they found that when the PDL injection was given under little pressure, there was no spread or penetration of the injected material apically into the previously mentioned tissues. The success rate for IAN block achieved in the present study was 76.66% which was higher than the success rate achieved by Vreeland et al (63.3%) (17) and Kennedy et al (50%) (19) , but lower than that achieved by Malamed (82.05%). (2) Although Vreeland et al used sound teeth in their study, their lower success rate, when compared to the present study, may be due to their usage of different teeth (mandibular molars and incisors) and different concentrations of local anesthetic agents and vasoconstrictors. On the other hand the higher success rate achieved by Malamed may be because of that the majority of patients had simple procedures that actually did not cause pain. Inflammation plays a major role, which may be the cause of the lower success rate achieved in Kennedy et al study, (19) but was excluded from the present study as healthy mandibular premolars were used. Anatomical variation and accessory innervations were also found to play a role in the failure of block injection. The mylohyoid nerve has been shown to enter the mandible through a foramen between the premolars on the lingual aspect supplying the molars and premolars. The auriculotemporal nerve penetrates the retromolar region, the condyler area or near the insertions of the muscles of mastication. These nerves could ramify through the cancellous bone and eventually establish one or more obvious junctions with the main trunk of the inferior alveolar nerve. (20) Based on the results of this study it was concluded that the periodontal ligament injection can be used effectively to anesthetize mandibular first premolars, as a primary technique, during root canal therapy procedure. Pain associated with insertion of needle and injection of solution for both injection techniques was acceptable.
REFERENCES 1. Cohen HP, Spangberg LS. Endodontic anesthesia in mandibular molars: a clinical study. J Endod 1993; 19: 370-3. 2. Malamed SF. The periodontal ligament injection: an alternative to inferior a1aveolar nerve block. Oral Restorative Dentistry 13 J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior surg Oral path Oral med 1982; 53: 117-121. 3. Khedari AJ . Alternative to mandibular block injection through intraligamental anesthesia. Quintess Int 1982; 2: 231-7. 4. Moore KD, Reader A, Meyers MJ . Beck M, Weaver J . A comparison of the periodontal ligament injection using 2% lidocaine with 1:100,000 epinephrine and saline in human mandibular premolars. Anesth Prog 1987; 34: 181-6. 5. White J J , Reader A, Beck M, Meyers J . The periodontal ligament injection: a comparison of the efficacy in human maxillary and mandibular teeth. J Endod 1988; 14: 508-14. 6. Schleder J R, Reader A, Beck M, Meyers J . The periodontal ligament injection: a comparison of 2% lidocaine, 3% mepivacaine, and 1:100,000 epinephrine to 2% lidocaine with 1:100,000 epinephrine in human mandibular premolars. J Endod 1988; 14: 397-404. 7. Edwards RW, Head TW. A clinical trial of intraligamentary anesthesia. J Dent Res 1989; 68: 1210-4. 8. Zakaria MR. A Clinical evaluation of the periodontal ligament injection as a primary technique in preparing mandibular molar abutment teeth for crowns and bridges among Iraqi patients. J of College of Dent 1998; 2: 171-83 9. J acobs S, Haas DA, Meechan JG, May S. Injection pain: comparison of three mandibular block techniques and modulation by nitrous oxide: oxygen. J Amer Dent Assoc 2003; 134: 86976. 10. Al-Doori RS, Al-Hashimi MK. A clinical comparison between maxillary and mandibular posterior teeth using local anesthesia and normal saline by periodontal ligament injection. Master thesis. College of Dentistry. University of Baghdad. 2005.
11. Eriksen HM, Aamdal H, Kerekes K. Periodontal ligament anesthesia. A clinical evaluation. Endod Dent Traumatol 1986; 2: 267-269. 12. Dreven LJ , Reader A, Beck M, Meyers J , Weavers J . An evaluation of an electrical pulp tester as a measure of anesthesia in human vital teeth. J Endod 1987; 13: 233-8. 13. J astak J G, Yagiela J A, Donaldson D. Local anesthesia of the oral cavity, 1st ed. 1995, Philadelphia, W.B.Saunders, p. 23, 61, 87. 14. Ingle J I, Bakland LK. Endodontics, 4th ed. 1994, Philadelphia, Lea and Febiger; p. 215. 15. Wahl MJ , Overton D, Howell J , Siegel E, Schmitt MM, Muldoon M. Pain on injection of prilocaine plain vs. lidocaine with epinephrine: a prospective double-blind study. J Amer Dent Assoc 2001; 132: 1396-401. 16. Montagnese LA, Reader A, Melfi R. A comparative study of the Gow-Gates technique and a standard technique for mandibular anesthesia. J Endod 1984; 10: 158-63. 17. Vreeland DL, Reader A, Beck M, Meyers J , Weavers J . An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod 1989; 15: 6-12. 18. Smith NG, Walton RE. Periodontal ligament injection: distribution of the injected solution. Oral Surg 1983; 55: 232-7. 19. Kennedy S, Reader A, Nusstein, J , Beck M, Weaver J . The significance of needle deflection in success of the inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2003; 29: 630-3. 20. Chapnick L. Nerve supply to the mandibular dentition a review. J Can Dent Assoc 1980; 7: 446-8.
Restorative Dentistry 14 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
An evaluation of the effects of different polishing agents on the surface roughness of porcelain
Maan R. Zakaria B.D.S., M.Sc. (1)
Rawaa H. Al-Hadithy B.D.S., M.Sc. (2)
ABSTRACT Background: Rough porcelain surface due to faulty glazing technique or occlusal adjustment can cause grinding of opposing structure and tissue irritation. The aim of this study was to evaluate the effects of different polishing agents on the surface roughness of adjusted porcelain in comparison to applied glaze. Methods and Materials: Thirty five porcelain specimens resembling flat-back facing (metal porcelain buttons) were fabricated according to the manufacturers instructions. The specimens were randomly divided into five groups according to the type of surface treatment tested. Each group consisted of seven specimens and the groups were distributed as follows: Group I: Applied glazed; Group II: Polished porcelain using dental pumice; Group III: Polished porcelain using Dentalloy polishing paste; Group IV: Polished porcelain using Dentaurum universal polishing paste and Group V: Polished porcelain using Al203 paste. The surface roughness evaluation of the specimens was carried out by a surface roughness analyzer device (profilometer). Results: Statistical analysis showed no significance between porcelain samples polished by Dentaurum universal polishing paste and those subjected to applied glaze. Both techniques provided better smoothness than the rest polishing procedures. Conclusion: Final polishing of rough porcelain surface by Dentaurum universal polishing paste can be considered as an alternative to reglazing adjusted surfaces of porcelain restorations regarding the technique sensitivity and time consuming related to the latter procedure. Key words: Polishing agents, porcelain, surface roughness. (J Bagh Coll Dentistry 2006; 18(2) 15-21)
INTRODUCTION Porcelain has been available as a restorative material for over 150 years. Its an ideal material for replacement of lost tooth tissue because of its esthetic quality, low thermal and electrical conductivity, and its resistance to degradation in the oral environment (1) . Dental porcelain combines esthetic with excellent biocompatibility and remains an important restorative material (2) . Prevention of severe tissue irritation and plaque accumulation around unglazed porcelain seems to require that porcelain restorations be highly glazed before placement in the mouth (3) . Faulty technique during the laboratory procedure or some other manipulation in the dental office after fabrication of porcelain can result in a porcelain surface which might well cause irritation and unfavorable tissue reaction. Therefore, porcelain used as a restorative material should be well glazed (4) .
(1) Professor, Advanced fixed prosthodontics, Department of Conservative Dentistry, College of Dentistry, University of Baghdad. (2) Assistant lecturer, Department of Conservative Dentistry, College of Dentistry, Al-Mustansiriya University.
For many years, standard clinical and laboratory techniques indicated that adjusted porcelain surface should be reglazed to restore the surface finish; however, reglazing is not always convenient or possible. Many agents for polishing porcelain have been evaluated (5,6) . The surface finishing of polished and glazed porcelain have been compared (7,8) . Investigations have shown that there are advantages to polishing the porcelain surface after adjustment as opposed to glazing (9,10) . Different researches have been conducted concentrating on different methods of polishing porcelain using variable polishing agents (11,12) . Many of those works have shown that polishing adjusted porcelain surface gave better surface topography when compared to autoglazed surfaces. Polishing of adjusted porcelain with a polishing paste was reported to produce surface smoothness better than auto glaze (13) .
MATERIALS AND METHOD Thirty five porcelain specimens resembling flat-back facing of Vita ceramic were fabricated according to the manufactures instructions as follows: A sheet of modeling base plate wax (2 mm in thickness) was punched with copper ring (10 Restorative Dentistry 15 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
mm in diameter). Then five points were measured for uniform thickness of 2mm using wax caliper device (Aesculpa, Germany). Each seven samples were sprued together in one casting ring no. 9 (Dentaurum, Germany). The sprue former (wax wire) was 1.7 mm in diameter attached to running bar of 3.2 mm so that the samples could be located at approximately 4 mm from the open end of the ring which was lined with a single layer of asbestos-free ring liner after wetting it with water and adapting it to the inner surface of the ring. Surface tension reducing agent (Lubrofil, Dentaurum, Germany) was applied carefully to the pattern and left to dry for 5 minutes. Then the phosphate-bonded investment (Rema Exact, Dentaurum, Germany) was mixed according to the manufacturers instructions using vacuum auto mixing machine (Bego, Germany) to minimize the chance for air bubbles which could be attached to the pattern and compromise the result (14) . A brush was used to apply the investment material gently to the wax patterns, and then the remaining investment was poured into the ring carefully using an electrical vibrator (Degussa, Germany). Following the wax burn-out, the casting procedure was performed in a manual- driver broken arm centrifugal casting machine (Degussa, Germany) with the same casting pressure which was achieved by turning the casting arm for four turns before locking it in position with its pin (15) . The type of alloy used in the casting was nickel chromium alloy (Heraenium NA, Heraeus Kulzer, Germany), which was melted using a gas-oxygen torch (Perko D-7140, Germany). The mold was not removed from the burn out furnace until the alloy was melted and ready to cast. After completion of casting, each ring was immersed in water as soon as the red glow of the button disappeared (16) . The castings were divested and any residual surface investment was removed by sandblasting (Krupp, Germany) using (250 m) aluminum oxide abrasive. The sprues were cut using red cut off wheels (Moores Co. Inc, USA) mounted on straight hand piece. Metal finishing was done by using stone bur (Major, Italy) and carborandom discs (USA). The castings were then cleaned with ultrasonic cleaning device (Quayel Dental, England) using distilled water for five minutes and the thickness of each metal button was standardized using the metal caliper device (Aesculap, Germany) and rechecked by a micrometer at five points of each surface to be (2 mm). Oxidizing the castings was performed at 950 o C for 5 min according to the manufacturer instructions in a computerized porcelain furnace (Programat P10, Ivoclar, Vivadent, England). Sandblasting was performed according to the manufactures instructions to decrease the amount of the oxide layer using A1 2 O 3 powder (250 um) for 5 seconds under pressure of 5 bars. The distance between the button and nozzle was standardized at five cm (17) . Opaque porcelain (Vita 95, VitaZahnfabrik, Germany) was applied according to the manufacturers instructions by using a bristle dental brush. All metal buttons were coated with two layers of opaque porcelain. The first opaque layer was dried and fired at 940C, the holding time was one minute, at reduced pressure (760 mm. Hg). The second opaque layer (creamy layer) was condensed on the sample by vibrating the locking tweezers with the serrated portion of a porcelain carving instrument. Excess moisture was removed by blotting with a clean dry tissue paper, then was fired at 930C, with a holding time of one minute at reduced pressure (760 mmHg). After the opaque layers were completed, dentin and enamel layers were applied by using bristle dental brush and baked together at 920C with a holding time for one minute (760 mm Hg) in the porcelain furnace (under vacuum). After complete porcelain build up, the surface of porcelain was brought to a fine finish prior to glazing or polishing by using diamond finishing disc (18) . The final thickness of each specimen (porcelain +metal) was (4.0 mm 0.5) and was standardized using a micrometer at 5 point readings for each sample as in Figure 1.
Restorative Dentistry 16 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
Figure 1: Standardization of porcelain thickness using micrometer.
Profilometric readings were carried to standardize the surface topography of all samples before surface glazing and polishing. Group I samples were subjected to applied glaze (Universal Glasur Glaze, Ivoclar, Vivadent, England) by bristle dental brush technique and then subjected to a temperature of 900C at a holding time of one minute without vacuum. The samples were randomly divided into five groups according to the type of finishing and polishing. Each group consisted of seven specimens. The groups were as follows: Group I: Samples subjected to applied glaze. Group II: Samples polished with sand paper disc, porcelain rubber wheel, rubber cup, dental pumice. Group III: Samples polished with sand paper disc, porcelain rubber wheel, rubber cup, Dentalloy polishing paste. Group IV: Samples polished with sand paper disc, porcelain rubber wheel, rubber cup, Dentaurum Universal paste. Group V: Samples polished with sand paper disc, porcelain rubber wheel, rubber cup, Aluminum Oxide paste (Al 2 O 3 ). In order to construct a base for each metal- porcelain disc to be fixed to the lower member of the surveyor, an acrylic block was constructed for each disc as follows: A square-shaped sheet of wax 3x3 cm with 2 mm in thickness was placed on a cement glass slab with a circular punch at the middle made with a copper ring of 10 mm in diameter. Each metal-porcelain disc in the five groups was placed in the perforation in such a way that the porcelain surface was directed toward the cement glass slab. A plastic ring (20 mm in diameter, 25 mm in height), opened from both ends was lubricated with a separating medium and centered over the square shaped sheet of wax and a cold-cure acrylic resin was mixed in a mixing jar with powder to liquid ratio of (1.3:1) and poured in the plastic ring to embed the disc in it leaving the porcelain part of the disc outside the acrylic. Standardization of porcelain polishing was controlled using a straight hand piece (W&H, Austria) mounted on a surveyor (Cendrex Metauxy SA250, Bienne, Swiss) carrying sand paper disc (J elenko Mfg Co., USA), rubber wheels (Fine cut, Dedeco, USA) and rubber cups (Shoefu dental Mfg Co., J apan) at 90 angle to the porcelain surface. Each sample was attached by its acrylic base to the lower member of the surveyor to prevent sample movement. The arm of the surveyor was moved in estimated continuous circular movement (7 cycles per 10 seconds) to polish each sample. The hand piece was fixed in position just touching the sample and the speed was fixed at 35,000 r.p.m by the use of control switch for manual operation as in Figure 2. The time was also fixed to 10 seconds using a stop watch (Orient, J apan) (13) . The use of the hand piece permitted good control for finishing and polishing small samples. A lathe was not used for polishing to avoid problems if the specimen was accidentally caught in the polishing wheel and spunn off (14) . Each type of smoothing and polishing bur (sand paper disc, rubber wheel, rubber cup) was used for seven samples then discarded.
Figure 2: Polishing porcelain using rubber wheel.
Final polishing of group II samples was done using slurry of flour of pumice (20 m, Iraq) and distilled water. The ratio of powder to liquid mixing was 1.5:1. Group III samples were polished using Dentalloy polishing paste (Iraq-Factory for Dental Materials & appliances, Baghdad, Iraq), Figure 3.
Restorative Dentistry 17 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
Figure 3: Materials used for polishing group (III), sand paper discs, rubber wheels, rubber cups, Dentalloy polishing paste.
Group IV samples were finally polished using universal polishing paste (Tiger Starshine, Dentaurum, Germany), Figure 4.
Figure 4: Materials used for polishing group (IV) sand paper discs, rubber wheels, rubber cups, Dentaurum universal polishing paste. Group V samples were finally polished using slurry of A1 2 O 3 (30 um) (Batch no. 31166, Germany) and distilled water (1.5:1 ratio). The samples, after polishing, were cleaned with distilled water for 5 minutes then dried before profilometric testing. A surface roughness analyzer device (Hommel, Germany) was used to verify the surface topography of the glazed and polished samples. Profilometric parameter (Ra) was selected for this study, Figure 5.
Figure 5: Surface roughness testing of polished porcelain.
For each specimen, three readings were recorded, the first reading in a vertical line, the second in a horizontal line and the third in a radial line (slope line), and the mean value was calculated. The results were recorded and analyzed statistically using a one-way Analysis of Variance (ANOVA), Least Significant Difference (LSD) and Student t-test.
RESULTS The roughness mean values (Ra) of applied glazed, dental pumice, Dentalloy polishing paste, Dentaurum universal polishing paste and aluminum oxide before and after surface treatment (S.T.) are shown in Table I and Figure 6.
Table 1: Roughness mean values (Ra) in m of the tested groups, before and after (S.T.).
Applied glazed Group I Dental pumice Group II Dentalloy paste Group III Dentaurum paste Group IV Aluminum oxide Group V Before S.T. 0.93143 0.92857 0.920 0.91571 0.92286 After S.T. 0.71571 0.79286 0.74286 0.72571 0.840 0 0.2 0.4 0.6 0.8 1 Mean Ra (m) Group I Group III Group V Before After Figure 6: Histogram showing the means of differences in (Ra) values of the five groups (before and after S.T.).
In general, the highest mean score of Ra values after polishing were recorded in group V (Aluminum oxide) which represented the roughest surface followed by group II (dental pumice) then group III (Dentalloy polishing paste) then group IV (Dentaurum universal polishing paste). Group I (applied glaze) showed the lowest mean score of Ra values and thus the smoothest surface of porcelain Statistical analysis of the data using one- way Analysis of variance (ANOVA) revealed non significant statistical difference at level (P >0.05) between the five groups before S.T. as Restorative Dentistry 18 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
shown in Table 4. On the other hand, (ANOVA) test revealed very high statistical significant difference at level (P < 0.001) between the five groups after surface treatment, Table 5. Least significant difference test (LSD) of the data of the groups (after S.T.) revealed non-significant differences between group I and group IV while the rest of groups showed different significant levels as shown in Table 6. In addition, very high significant differences were present between the treated and untreated samples of each group using the Student t-test.
DISCUSSION In this study, surface roughness evaluation of polished porcelain using different agents was carried out to verify the best polishing system locally available as a substitute for the applied glaze technique. The glazed samples of group I scored smoothness of very high significant values than groups II, III and V; a finding that concurred with Campbell (15) and Patterson et al (16) results. On the other hand, no significance occurred between the glazed group and the polished porcelain using Dentaurum paste (group IV); a finding that disagreed with the results of Scurria and Powers (17) who reported that feldspathic porcelain could be polished smoother than glazed and also disagreed with Ward et al (18)
and Kawai et al (19) results.
Table 4: One-way (ANOVA) test of the five groups (before S.T.). ANOVA Sum of squares d.f Mean of squares F value Sig. Between Groups 0.001131 4 0.000283 Within Groups 0.0 13286 30 0.000443 Total 0.014417 34 0.64N.S 0.639 d.f.: degree of freedom N.S.: Non Significant
Table 5: One-way (ANOVA) test of the five groups (after S.T.). ANOVA Sum of squares d.f Mean of squares F value Sig. Between Groups 0.07596 4 0.01899 Within Groups 0.005029 30 0.000168 Total 0.080989 34 113.29 V.H.S. 0.001 d.f.: degree of freedom V.H.S.: Very High Significant difference
Table 6: L.S.D test. Comparison groups Difference between groups L.S.D 0.05 L.S.D 0.01 L.S.D 0.001 Sig. Group I vs. Group II 0.07715 *** Group I vs. Group III 0.02715 *** Group I vs. Group IV 0.010 N.S. Group I vs. Group V 0.12429 *** Group II vs. Group III 0.05 *** Group II vs. Group IV 0.13285 *** Group II vs. Group V 0.04714 *** Group III vs. Group IV 0.01715 * Group III vs. Group V 0.09714 *** Group IV vs. Group V 0.11429 0.014
0.019
0.025
*** * = Significant difference, ** = High Significant difference, ***Very High Significant difference N.S : Non Significant Natural glaze (autoglaze) was not tested in the present study since it has been shown to cause generalized pitted porcelain surface that was attributed to incomplete flow and coalescence of the superficial layer which would impact a desired stain texture to the porcelain surface (20) . As a result, natural glazing would be recommended for porcelain restorations that do not require additional stains otherwise applied glaze is preferred. The glazed retention was found to be far from guaranteed and once an interruption of the glaze occurs, deleterious effects of abrasion would start (21) . It has also Restorative Dentistry 19 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
been found that the glaze could be lost after a relatively short period of intraoral function corresponding to two days after final cementation of the porcelain restoration (22) . Polishing porcelain using dental pumice caused significantly very high levels of decreased smoothness in comparison to the applied glaze group, a finding that disagreed with Grieve et al (23) results. Also pumice significantly caused inferior smoothness than polishing with Dentalloy and Dentaurum pastes respectively. The Iraqi-made Dentalloy polishing paste, which was introduced to the market in 2002, produced significantly less smooth porcelain texture than both applied glaze and Dentaurum paste. On the other side, Dentaurum polishing paste resulted in non-significant porcelain surface characteristics compared to the applied glaze samples. This good polishing performance could be related to the fine particle size of the abrasive content which could fill the tiny scratches present in the adjusted porcelain surface thus providing a smooth surface rather than cutting grooves especially when a high speed polishing pattern was required by the solidity of the porcelain surface. Polishing surface with Al 2 O 3 -water paste produced the roughest surfaces among the treated samples of the other groups, which was not consistent with Klausner et al (24) results who showed no significant difference between using levigated alumina and glazing. Scurria and Powers (17) also concluded that Al 2 O 3
pastes were equivalent to polishing pastes and gels. Still it was evident in the present study, that polished samples of all groups exhibited very high significant difference in smoothness than the unpolished ones, which stresses the importance of glazing or polishing adjusted porcelain surfaces than keeping them rough. The disparity present in researches findings concerning porcelain texture following either glazing or polishing might be attributed to the different polishing agents and the different porcelain systems tested. While dental porcelains have been modified to a state of near perfection, they still acquire a number of decided flaws due to the inhomogeneous distribution of crystals in the glassy matrix (25) . Opinions vary as which method would provide the smoothest surface while maintaining the structural requirements of ceramic restorations, and it seems that the optimal ceramic finish will remain as an unsolved equation for dental ceramists for the time being and the nearest future.
REFERENCES 1. Leopold H, Charles B, Gerald T. Polish versus auto glazed porcelain surface. J Prosthet Dent 1982; 47 (2): 157-62. 2. Oram DA, Davies EH, Boyd CH. Fracture of ceramic and metalloceramic cylinders. J Prosthet Dent 1984; 52(2): 221-30. 3. Podshadley AG, Harrison JD. Rat connective tissue response to pontic materials. J Prosthet Dent 1966; 16: 110-8. 4. Clayton J A, Green E. Roughness of pontic materials and dental plaque. J Prosthet Dent 1970; 23 (2): 407- 11. 5. Newitter DA, Schlissel ER, Wolff MS. An evaluation of adjustment and post adjustment finishing techniques on the surface of porcelain-bonded-to-metal crowns. J Prosthet Dent 1982; 48: 388-95. 6. Goldstein GR, Barnnard BR, Penugonda B. Profilometer, SEM, and visual assessment of porcelain polishing methods. J Prosthet Dent 1991; 65: 627-34. 7. Sulik WD, Plekavitch EJ . Surface finishing of dental porcelain. J Prosthet Dent 1981; 46: 217-21. 8. Raimondo RL, Richardson JT, Weidner B. Polished versus autoglazed dental porcelain. J Prosthet Dent 1990; 64: 553-7. 9. Brewer J D, Garlapo DA, Chipps EA, Tedesco LA. Clinical discrimination between autoglazed and polished porcelain surfaces. J Prosthet Dent 1990; 64: 631-4. 10. J acobi R, Shillingburg HT, Dancanson M. A comparison of the abrasiveness of six ceramic surfaces and gold. J Prosthet Dent 1991; 66: 303-9. 11. Barghi N, King CJ , Draughn RA. A study of porcelain surfaces as utilized in fixed prosthodontics. J Prosthet Dent 1975; 34: 314-9. 12. Kiyoshi A, Dhuru V, Cariapa V, Ziebert G. Effect of various polishing agents on dental porcelain surfaces. J Dent Res 1995; 74: 425, Abstract No. 194. 13. Zakaria MR, Al-Naami MM. Profilometric study of the surface characteristics of porcelain using different glazing and polishing techniques. J College of Dent 2002; 11: 163-6. 14. Lombardas P, Carbunaru A, McAlarney ME, Toothaker RW. Dimensional accuracy of castings produced with ringless and metal ring investment systems. J Prosthet Dent 2000; 84: 27-31. 15. Campbell SD. A comparative strength study of metal ceramic and all-porcelain esthetic materials. Modulus of rupture. J Prosthet Dent 1989; 62: 476-9. 16. Patterson CJ W, McLundie AC, Stirrups DR, Taylor WG. Polishing of porcelain by using a refinishing kit. J Prosthet Dent 1991; 65: 383-8. 17. Scurria MS, Powers J M. Surface roughness of two polished ceramic materials. J Prosthet Dent 1994; 71: 174-7. 18. Ward MT, Tale WH , Powers J M. Surface roughness of opalescent porcelains after polishing. Oper Dent 1995; 20: 106-10. 19. Kawai K, Urano M, Ebisu S. Effect of surface roughness of porcelain on adhesion of bacteria and their synthesizing glucans. J Prosthet Dent 2000; 83: 664-7. Restorative Dentistry 20 J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the
20. Cook PA, Griswold WH, Post AC. The effect of superficial colorant and glaze on the surface texture of vacuum-fired porcelain. J Prosthet Dent 1984; 51: 476- 84. 21. Leinfelder KF. Will ceramic restorations be challenged in the future? J Am Dent Assoc 2001; 132: 46-7. 22. J agger DC, Harrison A. An in vitro investigation into the wear effects of unglazed, glazed and polished porcelain on human enamel. J Prosthet Dent 1994; 72: 320-3.
23. Grieve AR, J effert IW, Sharma SJ . An evaluation of three methods of polishing porcelain by comparison of surface topography with the original glaze. Restorative Dent 1991; 7: 34-6. 24. Klausner LH, Cartwright CB, Charbeneau GT: Polished versus autoglazed porcelain surfaces. J Prosthet Dent 1982; 47: 157-62. 25. Oh WS, Delong R, Anusavice, KJ . Factors affecting enamel and ceramic wear: A literature review. J Prosthet Dent 2002; 87: 451-9.
Restorative Dentistry 21 J Bagh Coll Dentistry Vol. 18(2), 2006 Percentage of undercut Percentage of undercut areas in edentulous patients
Ghayda'a H. Al-Izzi B.D.S, M.Sc. (1)
Sabah S. Al-Habib B.D.S, M.Sc. (2)
ABSTRACT Background: Bony undercuts are usually present in both maxillary and mandibular jaws (anteriorly and posteriorly) unilateral or bilateral. Their location is affected by bone resorption and aging process. Materials and methods: This study was conducted on a sixty male and female patients attending the fifth class clinic in college of dentistry / Baghdad University. Their ages ranged from 30 -80 years with no systemic diseases. Results: In the maxillary jaw the percentage of undercut in male anteriorly was 57%, while posteriorly was21%. In the mandibular jaw anteriorly was 24%; posteriorly was 43%. In the female subject the percentage of undercut was in maxillary jaw anteriorly 23%; posteriorly was 6%, in mandibular jaw anteriorly was 4%, posteriorly was 15%. Conclusion: There was a highly significant difference in the prevalence of undercuts between males and females, in the maxillary posterior region and mandibular anterior areas. A significant difference was also found between males and females in the maxillary anterior region and mandibular poster area. Key words: Maxillary undercut, mandibular undercut. (J Bagh Coll Dentistry 2006; 18(2) 22-24)
INTRODUCTION 1
One can not speak about complete or partial dentures and maxillofacial prosthesis without mentioning to the basal seat underneath which provides supports and retention for these prosthesis. The most important part of the basal seat is the undercut, which can be defined as the portion of the surface of an object that is below the height of contour in relationship to the path of placement. (11)
Undercut effect function and health of underling tissues. Many systemic and local factors may affect the presence and amount of these undercut. There location varies, they could be seen anteriorly, posteriorly, unit or bilaterally in single or both jaws. J aw bones are the mandible which looks like horse shoe and the maxilla form the maxillary jaw (8) . J aw bone is a living tissue with a collagenous protein matrix that has been impregrated with mineral salt, especially phosphates and calcium, also it is cellular and well vascularized (12) . The residual alveolar bone is that bone of the alveolar process which remains after teeth are lost and full with new bone later on. This alveolar process becomes the residual ridge which is the foundation of the denture. (4)
Results from some studies said that approximately 50% of the population become edentulous by the age of 60 years (3) , so the alveolar bone become under different forces which lead to remodeling of the bone and this continue until the forces are balanced and
(1) Assistant lecturer, Department of Prosthodontics, College of Dentistry, Baghdad University. (2) Assistant lecturer, Technical College, Baghdad University. equilibrium returns (9) . This remodeling determined by the timing and sequence of tooth loss, prosthesis wear and facial morphology (7) . The differential pattern of remodeling and resorption between maxilla and mandible lead to pseudo-class III relationship (7) . There are different factors act on ridge resorption observed on different patients like anatomic, metabolic, functional and prosthetic (1) . Investigators agree that individual difference in the rate of resorption of the ridge very great underling metabolic, hormonal and nutritional causes account for these differences (2) . Residual alveolar ridge undercuts are rarely excised as a routine part of improving a patient's denture foundation. Dentists utilized the undercut for extra stability (5, 6) . The aim of this study was to find the percentage of those undercuts in both jaws and find the relation between their location in male and female by intra oral examination, visual and palpation examination.
MATERIALS AND METHOD A sample was selected of 60 patients male and female from the clinic of dentistry college, Baghdad University. All patients have no systemic diseases and never received any surgical correction on both jaws and the age range between 3080 years old. Each patient was examined for presence of undercut areas by visual examination first by using dental mirror, second by palpation (Index Finger). The order of examination was maxillary anterior, maxillary bilateral posterior, mandibular anterior then mandibular bilateral posterior areas. The examinations were confirmed by examination of the final cast of 22 Restorative Dentistry J Bagh Coll Dentistry Vol. 18(2), 2006 Percentage of undercut each patient. Data were collected on a data sheet (Figure 3). Statistical analysis was done by using Chisquare and presented as histograms.
RESULTS Figure 1 shows the total number of females having anterior and posterior (mandibular and maxillary) undercut areas. Figure 2 represents the total number of males having anterior and posterior (mandibular and maxillary) undercut areas. Table 1 shows the percentage and number of males having undercut areas in maxillary and mandibular jaw posteriorly and anteriorly. Table 2 gives us an idea about the percentage and number of females having undercut areas in maxillary and mandibular jaw posteriorly and anteriorly. Table 3 explains a comparison between males and females having undercuts in mandibular and maxillary jaws both posteriorly and anteriorly.
Table 1: No. and percentage of males (maxillary and mandibular) Maxillary Mandibular Male Ant. N % Post. No % Ant. No % Post. No % 30-39 1 1.7 1 4.76 2 8.33 0 0 40-49 7 12.3 1 4.76 3 12.5 4 9.3 50-59 11 19.3 6 28.57 8 33.3 13 30.2 60-69 20 35.1 3 14.28 5 20.8 13 30.2 70-80 18 31.6 10 47.61 6 25 13 30.2 Total 57 21 100 24 100 43 100
Table 2: Number and percentage of females (maxillary and mandibular) Maxillary Mandibular Male Ant. No. % Post. No. % Ant. No. % Post. No. % 30-39 0 0 0 0 0 0 0 0 40-49 0 0 0 0 0 0 0 0 50-59 9 39.13 2 3.33 2 50 3 20 60-69 10 43.48 2 33.33 0 0 8 53.33 70-80 4 17.39 2 33.33 2 50 4 26.67 Total 23 100 6 100 4 100 15 100
Table 3: Chi- square between male and female Maxillary Chi square P value Sig. Mandibular Chi-Square P-value Sig. Anterior 3.071 0.042 S 4.265 0 HS Posterior 4.922 0 HS 3.282 0.012 Sig
Figure 1: Total female of anterior and posterior areas (Maxillary & Mandibular)
Figure 2: Total male of anterior and posterior areas (maxillary & mandibular)
DISCUSSION It was evident that there was high percentage of undercuts in the maxillary anterior and mandibular posterior areas (Table 1). This might be due to the pattern of resorption occurring as a normal process of aging and also due to the extraction of teeth. The same finding appeared in females that the highest percentage was in the maxillary anterior area. This is might be due to the same reason above, but the big difference in the percentage might be due to the anatomical variation between male and female in size of jaws and consequently in the amount of resorption. Also the high percentage of males in the presence of anterior undercuts might be due to ignorance of males to esthetic and oral hygiene steps (brushing, flossing, periodic checkup) which leads to early loss of teeth and subsequent bone resorption. The highly significant difference between males and females found in table 3 between posterior maxillary and anterior mandibular areas, and significant difference between anterior mandibular and posterior maxillary areas might be explained on the basis of hormonal factors affecting the resorption amount in females and also to the anatomical differences between both genders regarding to the size of jaws and to the force of muscles of mastication which may lead to more resorption in males when edentulous jaws used for mastication of food.
REFERENCES 1. Atwood DA. Some clinical factors related to rate of resorption of residual ridges. J Prosthet Dent 1962; 12: 441-50. 2. Ellaworth K. Changes caused by mandibular removable partial denture apposing a maxillary complete denture. J Prosthet Dent 1972; 27: 140-50. 3. Enlow DH. Alveolar bone: Review of literature. In lang BR, Kelsey CC (eds): International prosthodontic workshop. Ann Arbor M. The university of Michigan school of Dentistry; 1973. 4. Hickey J C, Zarb GA, Bolender CL. Boucher's. prosthodontic treatment for edentulous patients. 8th ed. St. louis:CV Mosby; 1980.P.3. 5. Hickey J C, Zarb GA, Bolender CL. Boucher's. prosthodontic treatment for edentulous patients. 8th ed. St. louis:CV Mosby; 1980. P.24. 6. Hickey J C, Zarb GA, Bolender CL. Boucher's. prosthodontic treatment for edentulous patients. 8th ed. St.louis:CV Mosby; 1980. P. 105. 7. Mercier P, Lafontant R. Residual alveolar ridge atrophy, classification and influence of facial morphology. J Prosthet Dent 1979; 41: 90-100. 8. Richard S, Snell. Clinical anatomy. 5th ed. 1995. P 687-8. 9. Scott RF. Oral and maxillofacial trauma in geriatric patient. In Fonseca RJ , Walker RV (eds): oral and maxillofacial trauma, vol 2. Philadelphia, WB Saunders; 1991. pp 754-80. 10. Tallagren A. The effect of denture wearing on facial morphology: A seven year longitudinal study. Acta Odont Scand 1967; 25: 563. 11. The Glossary of prosthodontic terms. J Prosthetic Dent 7th ed. 1999; 81: 105. 12. Ganong W F. Review of medical physiology.10th edition. Los Altos: California; 1981; P.309.
24 Restorative Dentistry J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the An assessment of the effect of using different post systems on the fracture resistance of endodontically treated teeth.
Lamis A. Al-Taie, B.D.S, M.Sc. (1)
Aladin Al-Rubayi, B.D.S, Ph.D (2)
ABSTRCT Backgroud: Different post systems are available in the market but the prognosis of teeth by which they are restored has been questioned. This in vitro study evaluated and compared the fracture resistance of endodontically treated teeth restored with four post systems. Materials and Methods: Forty intact human mandibular second premolars were selected for this study. These samples were endodontically treated, and randomly divided into 5 groups of eight each. Group I: the control group (without posts), group II: restored with prefabricated carbon fiber posts (C-post), group III: restored with prefabricated parallel- sided titanium posts (Radix-anker posts), group IV: restored with cast post and cores, and group V: restored with glass fiber posts (Postec), then the samples were tested to failure with an obliquely applied compressive load at 45 o C, using a Zwick testing machine with a crosshead speed of 5 mm/ min. until failure. Results: Failure load results were obtained for all test specimens. The means and standard deviations for each group were as follows: group 1 (control group): 113.875 4.19Kg; group 2: 89.875 4.16 Kg; group 3: 84 4.28 Kg; group 4: 82 5.58 Kg; and group 5: 80 5.21 Kg. Conclusions: The specimens restored with carbon fiber posts and composite cores showed significantly greater resistance to root fracture than those restored with the other three systems tested. There was a little difference in the fracture mode between the different treatment modalities, and teeth without post and core foundations tested significantly stronger than the other comparison groups. Key words: Fracture resistance, metal posts, fiber reinforced posts. (J Bagh Coll Dentistry 2006; 18(2)25-31)
INTRODUCTION Endodontically treated teeth with defective coronal aspects very often need to be restored with a post and core as foundation for the final restoration. (1) In the last decades, cast posts were most commonly used because of their favorable physical properties and biocompatibility. Unfortunately, several disadvantages associated with conventional cast post and core were found such as loss of retention of the post, potential for post and root fractures and risk of corrosion. (2) The difference between modulus of elasticity of dentin and post material is a source of stress for the root structure. (3) Until recently, all available prefabricated posts consisted of metal alloys that cause a final heterogeneous combination with the dentin, the metallic post, cement (usually zinc phosphate), and the core material.The major disadvantage of these techniques is that the stresses can be concentrated in uncontrolled areas that are sometimes very vital to the root.
(1) Assistant lecturer, Department of conservative Dentistry, College of Dentistry, University of Baghdad (2) Professor, retired. Furthermore, there is no adhesion between the zinc phosphate cement and the root structure or any of the restorative materials with which it is used. (4) Technology has produced rigid non-metallic composite posts that are strengthened by various kinds of fibers (carbon fiber, carbon-quartz, quartz, glass, and silicon) and can be formed in various configurations to make maximum use of its properties. Experimental studies done by King and Setchel (5) , and Isidor et al. (6) confirmed the value of such material and adhesive techniques to obtain a tooth-post-core monoblock instead of an assemblage of heterogeneous materials, which provides the most predictable post- endodontic treatment modality. The aim of this study was to evaluate the fracture resistance and mode of failure of the endodontically treated teeth restored with different post systems.
MATERIALS AND METHODS Forty sound recently extracted lower second premolars of comparable sizes and shapes, were selected for experimentation. All teeth were cleaned from soft tissue debris and stored in physiologic saline solution at room temperature from the time of extraction to the time of testing. The samples were randomly divided into 5 groups of 8 teeth each: Restorative Dentistry 25 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the Group I (control group): consisted of endodontically treated teeth without posts. Group II: consisted of endodontically treated teeth restored using carbon fiber posts (composi posts). Group III: consisted of endodontically treated teeth restored using parallel-sided titanium threaded posts (Radix anker posts). Group IV: consisted of endodontically treated teeth restored using nonprecious cast post- cores. Group V: consisted of endodontically treated teeth restored using glass fiber posts (postec). These samples were endodontically obturated with gutta- percha root canal filling material (DiaDent, Korea), and then the coronal portions of teeth in Group II, III, IV, and V were removed at a level 1mm coronal to the cemento-enamel junction with a diamond disk (Komet, Germany) and full water spray coolant. The coronal portions of teeth in group I (control group), were removed in the same way ending with (19 mm) tooth portion lengths. The gutta-percha was removed from the root canals of teeth in group II, III, IV, and V with peeso drills (Dentsply, Switzerland), to a depth of 10 mm measured from the coronal end of the root. Then the post spaces were prepared in all groups with the special preparation drills of each system. The carbon fiber posts (Composipost -No.2 0610122-, RTD, France) were used in group II, post no.2 was selected. The special drill of the system was used to prepare the post spaces under full water irrigation. Radix-Anker Standard posts (titanium parallel sided threaded posts) (Dentsply, Switzerland) were used in group III. Post no.3 was selected. The seating for the Radix-Anker Standard head was drilled with the root facer No.3. Precision drilling was performed manually with the spiral bur No.3 and mandrel. Glass fiber posts (Postec FRC -No.2 0123-, Ivoclar-Vivadent, Liechtenstein) were placed in group V, post No.2 was selected (the system was designed to have a tapered form; the degree of taper gradually decreased to 1.00 mm diameter at the apical end). The special drill of the system was used to prepare the post spaces under full water irrigation, while custom cast post and cores were made for group IV, in this group post space preparation was done using pesso drill No.2 (Preci-Line, Post set) under full water irrigation. The wax patterns were invested with a phosphate bonded investment material (Speedy, Italy). Then the casting was performed using a lost wax technique and nickel-chromium alloy (CB Blando 72, Hatakeyama dental Mfg. Co., J apan).(figure 1c). For group I (control group), the coronal gutta-percha was removed to a depth of 5 mm then filled with composite resin.After that,all teeth were embedded in individual blocks of acrylic resin. All posts were first tried inside the canals without cement to the full prepared length, then cemented using Panavia F dual cure adhesive resin cement (Kurary Co. LTD, Osaka, J apan).(Figure 1 a,b,d). Following the manufacturers directions, one drop of alloy primer bottle was applied homogenously on the surface of posts in group III and IV, and allowed to set for 60 seconds. One drop of each ED Primer (A and B) was dispended on a mixing dish, then applied homogeneously on dentin in the post space as well as on the surface of the posts (in group II and V) and allowed to set for 60 seconds, then carefully dried with a faint air jet. According to manufacturers instructions equal parts of Panavia F paste A and B were dispended on a paper mixing pad and were gently mixed using a plastic spatula for about 20 seconds until a creamy consistency with a uniform color mix was obtained. The mixed cement was inserted into the prepared canal with a lentulo spiral (Produits Dentaires S.A., Vevey, Switzerland), and the post was uniformly coated with cement and fully seated into the canal to the prepared length.Oxyguard II was applied homogeneously at the margin (which is an oxygen inhibition gel), it initiates curing mechanism of the Panavia F resin cement. In group II, III, and V composite cores were constructed using Tetric composite resin (Vivadent, Ets/ Liechtenstein).(Figure 1)a,b,d). Then, for all samples, crown preparations were done with a diamond chamfer bur (medium grain size particles, Meisinger, Germany) to standardized dimensions (6 mm height, 5.5 mm bucco-lingually, and 4 mm mesio-distally) and total axial taper of 5 degrees with a 1 mm gingival chamfer finishing line on a sound tooth structure. Restorative Dentistry 26 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the Wax patterns were constructed directly on the core samples using type II blue inlay wax after the application of the separating agent on the samples, then the wax patterns were invested with the phosphate bonded investment material , then casting was performed using a lost wax technique and nickle-chromium alloy (CB Blando 72, Hatakeyama dental Mfg. Co., J apan). Cementation procedure of the cast crowns was done using Panavia F dual cure adhesive resin cement, then the samples were subjected to 100 thermal cycles between 5 o C and 55 o C, keeping the samples for 30 seconds at each temperature bath. The samples were placed in a fixture attached to a universal testing machine (Zwick testing machine, Germany). A continuously increasing compressive force was applied to the facial cusp in the axio-occlusal line angle at 45 degrees to the long axis of the tooth at a crosshead speed of 5 mm/min. until failure (Figure 2). The fracture loads were determined, and the mode of fracture was recorded and classified as favorable (restorable), or catastrophic (non-restorable). One-way ANOVA test was used to determine the significance of failure loads among the tested groups.
a b c d Figure 2: Specimen positioned at 45 o in the mounting apparatus fixed in the universal testing machine. Figure 1: Specimens after cementation: a. C-post, b. Radix Anker post, c. Cast post, d. Glass fiber post.
RESULTS The data of the load failure of all tested specimens is shown in Table 1. Statistical analysis of data by using the analysis of variance ANOVA revealed that there was a statistically highly significant difference (P<0.000) between the mean forces among the five groups as shown in Table 2. Further investigation using LSD (Least Significant Difference) test showed that there was a statistically highly significant difference between group I (control group), and the other experimental groups, also between group II (carbon fiber post) and group V (glass fiber post). There was no significant difference in the mean failure load between groups III, IV, and V (Table 3). The mode of failure in all teeth tested were oblique and horizontal radicular fractures, the majority of fractures involved the buccal crown margin and extended to the cervical third of the lingual root surfaces. There was no significant difference in the fracture mode between groups, catastrophic fractures were observed in titanium parallel sided posts (Radix anker post) (Table 4 and Diagram 1).
Restorative Dentistry 27 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the Table 1: The data of failure loads (in Kg) for all test specimens with the mean and standard deviation of each group.
Table 2: Analysis of variance (ANOVA) test for the five groups.
Sum of squares Degree of freedom Mean square F
valu e Sig. P value Between groups 6098.150 4 1524.538 HS 0.000 Within groups 779.750 35 22.279 Total 6877.900 39 68.431
Table 3: Least significant difference LSD test to compare the mean failure loads between groups. Control Carbon fiber post (C-post) Radix anker post Cast post Glass fiber post
Table 4: The number of restorable and catastrophic fracture patterns for the five groups. Restorable Fractures Catastrophic Fractures Group I (Control) 6 2 Group II (Carbon fiber posts) 5 3 Group III (Radix Anker posts) 4 4 Group IV (Cast post and cores) 6 2 Group V (Glass fiber posts) 5 3
Group I Group II Group III Group IV Group V Sample No. Control Carbon fiber post (C- post) Radix anker post Cast post Glass fiber post 1 120 97 90 90 90 2 118 95 90 88 84 3 115 90 86 85 82 4 115 90 84 85 80 5 115 88 82 82 78 6 110 87 80 80 76 7 110 87 80 75 75 8 108 85 80 75 75 Mean 113.875 89.875 84 82.5 80 S.D 4.19 4.16 4.28 5.58 5.21 0.000 HS 0.000 HS
0.000 HS
HS
0.000
0.018 S 0.004
0.000
S
HS 0.529
0.099 NS
NS NS
0.297 HS: highly significant, S: significant, NS: non significant Restorative Dentistry 28 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the
Figure 3: Bar chart shows the mean failure loads (in Kg) for the five groups.
.
Diagram 1: Failure modes and distribution
DISCUSSION Under the conditions of this study, the results showed that the endodontically treated teeth without posts (Group I) recorded the highest mean failure load than the other groups (endodontically treated teeth with post and core).This indicates that the bulk of the remaining tooth structure, rather than the post, provides the strength and resistance to fracture for the endodontically treated tooth. This finding is in agreement with that obtained by Lovdahl and Nicholls (7) ; Sidoli et al. (8) ; and Dean et al. (9) . The results of this study demonstrated the higher mean failure load of Group II (carbon fiber posts) compared with Group III (Radix anker posts), Group IV (cast post and cores), and Group V (glass fiber posts).There are four possible explanations for the observed differences in the fracture resistance between teeth in Group II and the other groups; -Their module of elasticity, which at 21 Gpa resembles that of natural dentin, seems to have a positive effect on their biomechanical characteristics and eliminates the stresses that are often formed at the interfaces of different materials such as (dentin and fiber post). -The carbon fibers can actually reduce the stress by changing their orientation inside the post to correspond to that of the applied force, and it appeared able to distribute the applied forces evenly along the length of the post, as it was previously explained by King and Setchel (5) ; and Assif et al.. (10)
-The transfer of forces from the post to the tooth undoubtedly depends on whether the post is bonded or not. The resin bonding of the fiber posts seems to distribute the applied forces more or less equally over the entire bonded interface, as well as increasing the strength of the restored tooth. This was previously proved by Mendoza et al. (11) and Asmussen et al.. (12)
- The design of the C-post that was used in this study has particular advantages: 1. Beveling of the edges and the apex to reduce concentration of stresses in these areas. 113.88 0 20 40 60 80 100 120 F a i l u r e
l o a d s
i n
K g 89.88 84 82.5 80 Control Carbon fiber post (C-post) Radix anker post Cast post Glass fiber post Restorative Dentistry 29 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the 2. Relatively narrow diameter of the lower portion of the post to reduce the amount of tooth structure that must be removed. Cast and metallic posts transfer more stress to the root, predisposing to root fracture when compared to carbon fiber/ epoxy post (8,9,13) . The statistically significant difference in fracture resistance of teeth in Group II over that of Group III, is in agreement with the finding of Isidor et al. (6) and Isidor and Brondum (14) , but disagrees with the result of Dean et al. (9) who found that there was no statistically significant differences in fracture resistance of teeth restored with C-post, and those restored with prefabricated parallel sided posts. The statistically significant difference in fracture resistance of teeth in Group II over that of Group IV, is consistent with the finding of Isidor et al. (6) and Isidor and Brondum (14) , but inconsistent with the result of Martinez-Insua et al. (13) who found a statistically higher fracture thresholds which were recorded for the cast post and core group in comparison to carbon fiber post group. In their study the post-hole for the cast post was prepared to the same shape as prefabricated carbon fiber post using the same peeso drill of the Composipost system which may explain the disagreement. Although the new double taper system of the glass fiber posts was designed for the purpose of close canal adaptation with minimal tooth structure removal, the obvious problem that associated the use of tapered post design was the wedge- like action which was responsible for the increased stress concentration at the apical end resulting in root fracture. This post design may have accounted for the significant difference in fracture resistance of teeth in Group II over that of Group V. In the present study, the results showed that although the mean failure load of Group III was higher than that of Group IV, it was statistically not significant. The different post geometries were responsible for the observed difference. Tapered cast posts have been blamed for a wedging effect and lower failure loads (8) .This finding is in agreement with that of Sidoli et al. (8) ; Assif et al. (10) ; and Akkayan &Caniklioglu (15) , but disagrees with the finding of Tjan and Whang (16) and Assif et al.. (17) All of them observed that the threaded parallel-sided posts exhibited higher failure rate as a result of root fracture. Although roots in Group III exhibited higher mean failure load than Group V, it was also statistically not significant. This finding disagrees with the finding of Akkayan and Gulmez (18) who found that teeth restored with titanium posts exhibited lower mean resistance to fracture than those restored with glass fiber posts. The possible explanation for this finding is that the titanium posts used in their study had a tapered design while the glass fiber post used had parallel-sided and serrated designs, which in fact agrees with the results of this study. The pattern and location of root fractures were studied and there was a little difference in the fracture mode between groups.The descriptive evaluation of teeth in these groups revealed that the majority of fractures were extended obliquely from the buccal crown margins to the cervical third of the lingual root surfaces.The possible explanation of such finding is that when the force applied obliquely, the greatest compressive and tensile stresses were predicted to occur at the lingual (compression) or facial (tension) root surface on the coronal third of the root. This is consistent with the finding of Assif et al. (17) ; Hunter et al. (19) and Holmes et al.. (20)
The greatest number of catastrophic fractures was recorded in Group III (teeth restored with prefabricated parallel-sided titanium posts). This is due to the fact that one potential disadvantage of parallel-sided post system is the weakening of the apical part of the root during post space preparation accompanied with the high Young's modulus of titanium posts which makes the system stiff and unable to absorb stresses. This would imply that the overall strength of the system is related to the ability of remaining tooth structure to resist fracture.
REFERENCES 1. Gutman J L. The dentin-root complex: Anatomic and biologic considerations in restoring endodontically treated teeth. J Prosthet Dent 1992; 67:458-67. 2. Trabert KC, Cooney J P. The endodontically treated tooth. Restorative concepts and techniques. Dent Clin North Am 1984; 28: 923-51. 3. Lin LM, Langeland K. Vertical root fracture. J Endod 1982; 8: 558-621. 4. Fredriksson M, Astback J , Pamenius M, Arvidson K. A retrospective study of 236 patients with teeth restored by carbon fiber reinforced epoxy resin posts. J Prosthet Dent 1998; 80: 151-7. 5. King PA, Setchell DI. An in vitro evaluation of a prototype CFRC prefabricated post developed for the restoration of pulpless teeth. J Oral Rehabil 1990; 17: 599-609. 6. Isidor F, Odman P, Brondum K. Intermittent loading Restorative Dentistry 30 J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the of teeth restored using prefabricated carbon fiber posts. Int J Prosthodont 1996; 9: 131-6. 7. Lovdahl PE, Nicholls J I. Pin-retained amalgam cores versus cast gold dowel cores. J Prosthet Dent 1977; 38: 507-14. 8. Sidoli GE, King PA, Setchell DJ . An in vitro evaluation of a carbon fiber-based post and core system. J Prosthet Dent 1997; 78: 5-9. 9. Dean J P, J eansonne BG, Sarkar NK. In vitro evaluation of a carbon fiber post. J Endod 1998; 24: 807-10. 10. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993; 69: 36-40. 11. Mendoza DB, Eakle WS, Kahl EA, Ho R. Root reinforcement with a resin-bonded preformed post. J Prosthet Dent 1997; 78: 10-15. 12. Asmussen E, Peutzfeldt A, Heitmann I. Stiffness, elastic limit, and strength of newer types of endodontic posts. J Dent 1999; 27: 275-8. 13. Martinez-Insua A, Silva LD, Rilo B, Santana U. Comparison of the fracture resistances of pulpless teeth restored with a cast post and core or carbon- fiber post with a composite core. J Prosthet Dent 1998; 80: 527-32.
14. Isidor F, Brondum K. Intermittent loading of teeth with tapered, individually cast or prefabricated, parallel-sided posts. Int J Prosthodont 1992; 5:257- 61. 15. Akkayan B, Caniklioglu B. Resistance to fracture of crowned teeth restored with different post systems. Eur J Prosthodont Restor Dent 1998; 6: 13-8. 16. Tjan AHL, Whang SB. Resistance to root fracture of dowel channels with various thicknesses of buccal dentin walls. J Prosthet Dent 1985; 53: 496-500. 17. Assif D, Oren E, Marshak BL, Aviv I. Photo-elastic analysis of stress transfer by endodontically treated teeth to the supporting structures using different restorative techniques. J Prosthet Dent 1989; 61: 535-43. 18. Akkayan B, Glmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Prosthet Dent 2002; 87: 431-7. 19. Hunter AJ , Feiglin B, Williams J F. Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989; 62: 166-72. 20. Holmes DC, Diaz-Arnold AM, Leary J M. Influence of post dimension on stress distribution in dentin. J Prosthet Dent 1996; 75: 140-7. Restorative Dentistry 31 J Bagh Coll Dentistry Vol. 18(2), 2006 Evaluation of interfacial
Evaluation of interfacial bond strength of repaired composite resins
Ali M. Abdul Kareem B.D.S, Ph.D. (1)
ABSTRACT Background: Repair of composite restorationsis a choice if absence of caries is guaranteed. The purpose of this study was to evaluate the interfacial shear bond strength of the immediately repaired composite specimens. Materials and methods: Sixty specimens from 2 types of composite were made in a special mold and polymerized with light. Three methods of surface treatment of the initial layer were done prior to the application of the repair layer including the use of matrix strip or not and abrasion. The specimens were subjected to shear force from the testing machine and mean for each group was calculated. Results: The nonair inhibited specimens showed the highest values of shear bond strength (mean =13.1 Mpa) which was significantly different from the bur abraded specimens (p<0.05), but insignificant from the air inhibited specimens (p>0.05) for both types of composite. Conclusion: The absence of air inhibited layer by using matrix strip increase the interfacial bond strength of the immediately repaired composite with inferior interfacial bonding for the bur abrasion method. Keywords: Composite, bond strength, repair. (J Bagh Coll Dentistry 2006; 18(2) 32-34)
INTRODUCTION A freshly placed composite restoration is considered sometime unacceptable, because of color difference, incorrect contour and over finishing (1) . Therefore, there are two solutions, either to repair or replace the filling. Repair option is preferred to reduce pulp injury and cost. (2)
The most important thing in the repair procedure is the development of good bond strength in the interface between the old and new layers (3) . It has been found that the interfacial bond strength of the repaired restoration for various composite resins is affected by age of the initial layer, the condition of surface in the initial layer, the curing medium, contamination of the surface of the initial layer by saliva, the use of bonding agent (4,5) and similarity of the two composites (6,7) . The aim of this study was to measure the interfacial bond strengths of immediately repaired composite resins after different surface treatments of the initial layer.
MATERIALS AND METHODS Two types of commercially available composite resins were used in this study: Degufill mineral (Degussa Dental; Germany, hybrid composite) and Helioprogress (Vivadent; Liechtenstein, microfilled composite).
(1) Lecturer, Department of Conservative Dentistry, College of Dentistry, University of Baghdad. Sixty specimens were made by creating special mold (6mm in diameter and 8mm length). Then the materials were polymerized by light curing device (Coltolux 50 ColtenFrance) for 40 seconds. The samples were divided into 3 groups for each type of composite and treated as follows: Group I: Air-inhibited specimens. The composite material was placed in 6 mm diameter, 8 mm high gelatin capsules and placed on the top of the initial layer and cured for 80 seconds. Group II: Non-air inhibited specimens; 0.05mm thick matrix strip is used to cover the surface of the cured layer prior to the placement of the capsule and its polymerization. Group III: Abraded specimens; in this group, no strip was used. The surface of the cured layer was abraded with carbide bur prior to the placement of capsule and light curing. In all the three groups, the capsules were dissolved after polymerization and all excess material was removed carefully from the bonded site. All specimens were stored in normal saline for 4 weeks at 37 o C. The samples were subjected to shear loading until failure using shear punch test (8) with Zwick (Model 1454, Germany) testing machine (Figure 1). After fixation of specimens on special plate, a stainless steel chisel-shaped rod is directed toward the interface between the two layers, allowing the repair layer to be sheared from the initial layer in a displacement speed of 5mm/min. The shear bond strength was calculated by dividing the force by the surface area, and expressed in Mega Pascal (Mpa). Restorative Dentistry 32 J Bagh Coll Dentistry Vol. 18(2), 2006 Evaluation of interfacial
RESULTS After calculating the shear bond strength, the mean and standard deviation for each group were recorded (Table 1). The result data showed that the specimens showed different resistance to failure under loading as shown in figure 2. ANOVA test was done, and showed that there is a high significant difference between the three methods of treatment (P=0.000), while there is no significant difference (P>0.05) between the 2 types of composite used. In Group II in which there is no air-inhibited layer on the initial layer because of the placement of strip, the means of shear bond strength for both types of composite were higher than those in the group I, but the difference is statistically insignificant (p>0.05) according to T-test. Figure 1: The Zwick testing machine. In Group III in which the initial layer was abraded prior to the placement of repair layer, the specimens had the lowest mean of bond strength in both types (7.8, 6.7 Mpa) which were significantly different from the mean values for the Group I and II (P<0.05) by t tests.
Table 1: Mean and standard deviation values of the interfacial shear bond strength for the immediately repaired composite specimens (Mpa) Composite type Helio progress Degufill mineral Group Group I Group II Group III Group I Group II GroupIII Mean 11.2 13.1 6.7 11.4 12.3 7.8 SD 3.3 4.2 2.1 2.9 3.2 1.6
Figure 2: Bar chart showing the difference between the groups Restorative Dentistry 33 J Bagh Coll Dentistry Vol. 18(2), 2006 Evaluation of interfacial
DISCUSSION The immediate repair of composite resin restoration for minor correction is more preferable to replacement, to reduce pulp damage, cost of the replacement material and time. For immediate repair, several methods can be used like: direct application of the repair layer, application of acid etch and bonding agent on the initial layer and abrasion of the initial layer (9) . In this study, the effects of air-inhibited layer formation and abrasion of the surface layer were investigated. The result data showed that, the interfacial shear bond strengths for the non air and air-inhibited surface state of the initial layer were significantly indifferent, while these values were significantly different from the values of the Group III in which the surfaces were abraded. For specimen made of either types of composite, the absence of air- inhibited layer on the surface of initial layer led to increase in the interfacial shear bond strength and this agreed with (Croll 1990 (10) , Armstrong et al 2001 (11) and disagreed with (Li and others 1995 (12) and Eliades et al 1989 (13) who suggested that the formations of a thin viscous layer comprising unreacted methaycrylate groups on the cured layer during polymerization (because of inhibition by oxygen) will enhance the bonding between the initial and repair layer through the formation of covalent bond, secondary bonds and mechanical interlocking (14) . The present results supported the results of (Puckett et al 1991) (15) , who found that the oxygen inhibited film between adjacent composite layers reduced interfacial bond strength. This was argued to in adequate bonding, which is related to topical reduction of the initiator concentration arising form co- polymerization of the inhibited film with the repair composite. In group III, abrasion of the initial layer prior to the placement of the repair layer produced weaker bonds. The abraded surface consisted of exposed inorganic filler particles and exposed prepolymerized resin particles. Bonding to either of these particles is less favourable compared to a resin rich layer (un- abraded surface) because of the decreased ability for primary bonding to methacrylate groups (16) .
REFERENCES 1. Deligeory V, Major I, Wilson NA. An overview of reasons for the placement and replacement of restorations. Prime Dent Care 2001; 8: 5-11. 2. Bruke FJ , Wilson NH, Cheung SW. Influence of patient factors on age of restoration at failure and reasons for their replacement. J Dent 2001; 29: 317-29. 3. Pounder B, Greogery WA. Bond strengths of repaired composite resins Oper Dent 1987; 12: 127 31. 4. Hickel R, Manhart J . Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent 2001; 3: 45 64. 5. Swift EJ , Close BC, Boyer DB. Effect of Silane coupling agent on composite repair strengths. Am J Dent 1994; 7: 200 2. 6. Kao EC, Pryor HG, J ohnston WM. Strengths of composites repaired by Laminating with dissimilar composites .J Prosth Dent 1988; 60:328-33. 7. Miranda FJ , Dun Canson MG, Dilts WE. Interfacial bonding strength of repaired composite systems. J Prosthet Dent 1984; 51:29-32. 8. Nomoto R, Carrick TE, McCabe J . Suitability of shear punch test for dental restorative materials. J Dent Mater 2001; 17: 412 21. 9. Opdam NJ . Repair and replacement of composite. Ned Taandh eelkd 2001; 108: 90 3. 10. Croll TP. Repair of Class I composite resin restorations. Quint Int 1990; 21: 6958. 11. Armstrong S, Keller J C, Boyer DB. Mode of failure in the resin bonded joint as determined by strengthbased and fracture based mechanical testing. Dent Mater 2001; 17: 20110. 12. Li J , Liu Y, Sundostromf WM. Oxygen layer and bonding in dental composite. J Dent Research 1995; 74:493. 13. Eliades GC, Capto AA. The strength of layering technique in visible light cured composite. J Prosthet Dent 1989; 61: 318. 14. Vankerckhoven H, Lam Brechts P, Vanherle G. Un reacted methacrylate groups on the surfaces of composite resins; J Dent Res 1982; 61; 7915. 15. Puckett AD, Holder R, OHara J W. Strength of posterior composite repairs using different composite bonding agent combinations. Oper Dent 1991; 19:13640. 16. Boyer DB, Chan KC, Tormey DL. Build up and repair of light cured composites: bond strength J Prosthet Dent 1984; 43:1241 4.
Restorative Dentistry 34 J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral
The prevalence of oral developmental disturbances and dental alignment anomalies in females of secondary schools in Thamar city (14-21years) Balkees T. Garib Ph.D. (1)
ABSTRACT Background: Abnormalities of the oral and dental tissue are detected frequently during routine dental examination. and the prevalence of these anomalies is varying among different population. Materials and methods: A thousand young aged females (14-21 years) were collected randomly from secondary school in Thamar city- Yamen. Full oral examination was carried for the prevalence of any oral-dental anomalies. Results: Flourosis enamel hypoplasia is the predominant dental anomaly 10.2%. The second problem was the retained deciduous teeth 4.1% and the non erupted permanent dentition 3.9%, while malposed alignment accounts 12.8%. Soft tissue showed fissure and geographical tongue in n2.6% and 2% respectively. Other anomalies present in minimal percentages. Discussion: Esthetic problem are predominant in young females of Thamar city including both changes in enamel tooth structure (Flourosis) and mal alignment (crowding, spacing and malposed tooth). An obvious disturbance in shedding is present (4%) which may relate for further dental mal alignment. Key words: Developmental anomalies, flourosis, dental mal alignment. (J Bagh Coll Dentistry 2006; 18(2) 35-39)
INTRODUCTION The development of oral tissues may be subjected to several genetic and environmental factors resulting in certain anomalies. Some dental anomalies manifest themselves more frequently in deciduous teeth; however, they generally are more frequent in the permanent dentition (1) . Literature review indicates that different prevalence of various oral anomalies is reported in different populations (2-6) .Thamar, is one of the mountainous cities in Yemen. The majority of the inhabitants are depending in their nutrition on the local cultural plants which are irrigated from fountains that contain a high concentration of different minerals. In this study we selected young aged females to study the most common oral-dental anomalies at permanent dentition. Females were selected between ages 14-21 years to exclude the mixed dentition and to avoid the effect of Khat chewing, since females are not allowed to chew Khat before marriage.
MATERIALS AND METHODS This study was conducted in Thamar city in Yemen after getting the approval from the administration of the Al-Wihda secondary school for girls. It includes 1000 randomly selected females with age range between 14-21 years who represent most of the families resident in this city.
(1) Assistant Professor, Department Oral Diagnosis, College of Dentistry, Baghdad University Oral examination for dentition and soft tissue was carried out in the school using plane mouth mirror and sharp probe under the sun light. Any anomaly was recorded carefully by the author. No further investigation was done. Personal information including the age, habitation, habits, medical history..etc were as well recorded for each female. Any Yemeni females who were not born and living in Thamar city were excluded.
RESULTS Oro-dental anomalies represent 402 cases (incidence 40%) out of 1000 young females. There were 346 cases related to the teeth (218 teeth development, 128 teeth alignment) and 56 cases observed in oral soft tissue. Teeth anomalies Disturbances in structures: Enamel anomalies represent 115 (11.5%) cases out of the total 1000. The incidence of flourosis constitute was 10.2%. They range from sever to mild conditions that involve several or whole dentition. Local enamel hypoplasia was seen in 2 cases (involve the mandibular right 2nd premolar and central). Enamel hypocalcification was reported in 8 cases; 4 of them were generalized and 3 limited to the anterior teeth. Hutchinson's teeth enamel hypoplasia was seen in one case. Lastly amelogenesis imperfecta was seen in 2 cases only (Table 1, 2). Disturbances in size Macrodontia (large teeth) were recorded in 2 cases (involve the lateral incisors and 1st premolar both in mandibular right side). On the Oral Pathology, Oral Medicine, Dental Radiology 35 J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral
other hand, microdontia (small teeth) were more common, they included 18 (1.8%) cases, predominantly seen in maxillary lateral incisors 14 cases (4 cases were bilaterally, 8 cases on left side and 2 were on right side). However 4 cases were observed in mandibular arch (2 anterior lateral incisors bilaterally and 2 involve the 1st and 2nd left premolars) (Table 2). Disturbances in shape Talon cusp involving the mandibular left central incisor was observed in one case (0.1%). Disturbances in number This is either increase or decrease in the number of existing permanent teeth. It collectively accounts to 41 cases (4.1%). A supernumerary tooth was seen in 2 cases (0.2%) at the left maxillary lateral incisor area, while decrease number of teeth due to unerupted or missing permanent teeth with loss of primary teeth was seen in 6 cases maxillary permanent canines on both sides simultaneously and one case in mandibular left 2nd premolar. On the other hand, clinically missing permanent teeth with lost primary teeth was seen predominantly of lateral incisors in maxillary jaw (29 cases), and only 3 cases occurred in mandibular incisors teeth (Table 3). Disturbances in eruption This condition also accounts to 41 cases. Retained deciduous teeth were seen predominantly in maxillary deciduous canines (21 cases), and frequently at both sides simultaneously 11 cases (one case was associated with microdontia). The retention of most deciduous dentition was seen in 2 cases at age of 15-16 years. Few other teeth was recorded in other sites see table 4. Other cases (11) had both the successors and precursors at the same time and again predominantly in maxillary canines (10). On the other hand, only one case was seen in the left maxillary lateral incisor which was malposed. Disturbances in teeth alignment; spacing, crowding, and single malposed tooth. Spacing of anterior teeth was only seen in maxillary jaw (9 cases) beside 3 cases showed diastema while crowding of anterior teeth occurred frequently in mandibular arch (31 vs 7). Nevertheless, other cases showed crowding in both maxillary and mandibular anterior regions simultaneously or even in the whole arches (9 and 11 cases respectively) (Table 5). Single malposed tooth alignment was seen predominantly in canines (26 females, 45 teeth). Only in one case all the 4 canines were malposed, while in 7 females it simultaneously occurs in one arch bilaterally (2 maxillary and 5 mandibular). In general there was no difference between left and right sides and most of the maxillary canines located labially. On the other hand, in the mandibular jaw they either located labialy or rotated. Other malposed single teeth include lingual positioned premolar and rotated laterals (4 maxillary and 2 mandibular). There were 2 cases cross bite lateral and central incisors left side (Table 6). Oral soft tissue disturbances It constitutes of 56 cases (incidence 5.6%).The most common developmental anomaly was geographical tongue (20 cases); 4 of them were associated with symptoms. There were 26 cases of fissured tongue which was considered as age changes and large tongue was seen in 4 cases only. Other minority soft tissue developmental anomalies are illustrated in table 1. Table 1: The incidence of oral anomalies in 1000 young females (14-21y) in Thamar Types of oral tissue disturbances No. % Structure 115 11.5 Size 20 2 Shape 1 0.1 Number 41 4.1 Eruption 41 4.1 Teeth Alignment 128 12.8 Large 4 0.4 Fissured 26 2.6 Tongue Geographical 20 2 Lip (Pit commesures) 3 0.3 Palate (Torus) 2 0.2 Soft tissue Gingival hyperplasia 1 0.1 Total 402 40.2 Oral Pathology, Oral Medicine, Dental Radiology 36 J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral
Table 2: Teeth anomalies reported in 1000 secondary school females
Development disturbances in teeth No. % Structure Flourosis 102 10.2 E hypoplasia 2 0.2 E hypocalcification 8 0.8 Amelogenesis imperfecta 2 0.2 Hutchinson teeth 1 0.1 Size Small 18 1.8 Large 2 0.2 Shape Talon casp 1 0.1 Number Supernumerary tooth 2 0.2 Non erupted permanent teeth 39 3.9 Retained deciduous teeth 41 4.1 Alignment Malposed 52 5.2 Spacing 25 2.5 Crowding 51 5.1
Table 3: Non erupted permanent teeth
Tooth No. % 3I3
6 15.4 I5 1 2.56 2I2
10 25.6 2I2 2 5.13 I2
3 7.69 2I
16 41 1I 1 2.56 Total 39 100
Table 4: Retained deciduous teeth with or without permanent successors
without permanent successors with permanent successors tooth No. % tooth No. % c I c
11 36.7 3cIc3
4 36.4 cI 4 13.3 3cI
4 36.4 Ic 6 20 Ic3 2 18.2 Ib 2 6.67 Ib2 1 9 cI 1 3.33 Icde 3 10 Ie 1 3.33 Most of the teeth 2 6.67 Total 30 100 Total 11 100
Oral Pathology, Oral Medicine, Dental Radiology 37 J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral
Table 5: The disturbances in dental alignment; crowding and spacing
Table 6: The disturbances in dental alignment; Malposed teeth
DISCUSSION It is well accepted that the study of developmental anomalies of tooth number, size and morphology should be studied as a group rather than as an isolate. This study covers a broad range of developmental anomalies and morphologic variants that may occur in the oral cavity of females living in Thamar. One of the visible developmental enamel defects that is related to environmental alteration during secretion or maturation of enamel matrix is enamel hypoplasia. In Thamar city enamel hypoplasia is a predominant defect (11.5%) and mainly related to fluoride intake (flourosis) (10.2%) due to the high concentration of minerals in drinking water from fountains. This is unlike findings reported from countries with low fluoridation as Iraq (7,8)
and seems to be better than other fountain cities like Taiz, Yemen. The situation considered as a true esthetic problem for females. The trend of using purified mineral waters in sealed bottles is growing nowadays in several families. The second frequent developmental anomaly was the disturbances in the time sequence of deciduous teeth shedding (retained) and delayed permanent teeth eruption (8%). Retained deciduous teeth beyond their usual shedding schedule are usually out of function and had been reported to occur frequently in the maxillary lateral incisors (9) . Nevertheless, young females in Thamar showed that deciduous canines were the most frequent retained teeth, whether they were alone or associated with their permanent precursors (32 cases out of 41). On the other hand, delayed permanent teeth eruption may be attributed mainly to systemic factors including; nutritional, genetic and endocrinal deficiencies rather than local factors ( since there was no clinical evidence of blockage of eruption pathway, no radiographical images were taken). We reported 29 missing maxillary lateral incisors (partial hypodontia) and only 5 mandibular lateral incisors. The prevalence in the permanent mandibular central and lateral incisor region is low, ranging from 0.23%- 0.08% respectively. This is compared with an overall incidence of hypodontia of 3.49%. However, significant racial variation occurs (6,10) . The small percentage of local microdontia of maxillary lateral incisors is similar to that crowding spacing Regions No. % No. % Maxillary ant. 0 0 9 36 Mandibular ant. 31 60.8 7 28 U &L ant. 9 17.6 3 12 Both arches 11 21.6 2 8 Post region 54I 0 0 1 4 Diastema 3 12 Total 51 100 25 100 Maxillary Mandibular Teeth Position No. No. Labial 11 11 Left Palatal 2 0 Labial 9 9 Right Palatal 3 0 Canines Total 25 20 Cross bite 2 0 Incisors Rotated 2 2 Premolar Lingual 0 1 Oral Pathology, Oral Medicine, Dental Radiology 38 J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral
reported in Al-Radwanyia Iraqi village (8) . The smaxillary nummarary tooth is considered as a minor dental anomaly in this study. Talon casp that occur on central incisor is associated with clinical problems including unsight dental appearance indicated that central tubercle is more frequent and occlusal interference. Ooshim et al in permanent dentition (5) we reported only one case out of 1000 young females. There was no case of dens invaginatus reported here, which is unlike other report (11)
Malalignment of teeth (predominantly malposed canine 45% and anterior teeth spacing %)occur nearly equal in maxillary and mandibular jaws, while crowding of teeth (51%) predominantly seen in anterior mandibular teeth. This indicates to identify the predisposing factors for such disturbances and plan to prevent consequent complication related to the situation. The only obvious soft tissue anomaly was seen in the tongue and it represents 5% of all oral-dental conditions. It predominates with fissure and geographical tongue. The geographical tongue is of unknown etiology that may relate to fissure tongue. Its prevalence is approximately 1% of the population. This condition occurs over a wide age range. In this study it accounts 2% of young females while the females express fissured tongue in 2.6% with 4 cases complain from symptoms. Most studies have shown that the prevalence of fissured tongue range from 2-5% of the over all population (12) , and consider it as relatively common condition that attributed to aging, local environmental factors beside hereditary.
REFERENCES 1. Soams J V, Southan J C. Disorders of development of the teeth, In: Oral pathology, 3rd ed. Oxford 1998,p 33-7. 2. Friend GW, Harris EF, Mincer HH, et al. Oral anomalies in the neonate by race and gender in an urban setting. Pediatr Dent 1990; 12, 157-61. 3. Al-Nori AH. Developmental anomalies of teeth and oral soft tissue among 143-15 yrs old school children in Baghdad city. Thesis, College of Dentistry, University of Baghdad 1990. 4. Sedano HO, Garza MLG, Franco CMG et al. Clinical orodental abnormalities in Mexican children. Oral Surg 1989; 68, 300-11. 5. Ooshima T, IshidaR, Mishima et al. The prevalence of developmental anomalies of teeth and their association with tooth size in primary and permanent dentition of 1650 J apanese children. Int J Paediatr Dent 1996; 6, 87-94. 6. Kirzioglu Z, Koseler Sentut T, Ozay Erturk MS, Karayilmaz H. Clinical features of hypodontia and associated dental anomalies, a retrospective study. Oral disease 2005; 11, 399. 7. Al-Alousi W, Kadhim AM. Fluoride content of drinking water in Iraq. Iraqi Dent J 1983; 10, 8-14. 8. Sarkis SA. Dental anomalies in Al-Radwaniya Iraqi village. Iraqi Dent J 2003; 33, 83-90. 9. Bhashar SN, Orban's oral histology and emberyology. 12th ed Mosby Co. 1999. 10. Cameron J , Sampson WJ . Hypodontia of the permanent dentition. Aust Dent J 1996; 41, 1-5. 11. KannanSK, Bharadwaj TP, Urraj G. Dens in dente (dens invaginatus). Report of two unilateral and one bilateral case. Indian J Dent Res 2003; 14, 125-9. 12. Neville BW, Damm DD, Allen CM, Bouquot J E. Oral and maxillofacial pathology. 2nd ed. Sannders Co. 2002.
Oral Pathology, Oral Medicine, Dental Radiology 39 J Bagh Coll Dentistry Vol. 18(2), 2006 Orthopantomographi c assessment Orthopantomographic assessment of mandibular asymmetry as an aid in diagnosis of tempromandibular problems
Asmaa T. Uthman B.D.S., M.Sc. (1)
Natheer H. Al-Rawi B.D.S., M.Sc., Ph.D (1)
ABSTRACT Background: Dental rotational panoramic radiographs can be used to diagnose vertical asymmetries between the right (R) and left (L) mandibular condyle and/ or ramus. The aim of this study was to study the effect of dentition on condylar asymmetry which is the early risk of developing tempromandibular problems. Materials & Methods: A total sample of 70 Iraqi patients (30 dentate & 40 edentulous) were selected in this study. All were exposed with a Siemens OPG-5. The outline of the condyle & the ascending ramus of both sides were traced using acetate paper. The difference in vertical height between the two sides is expressed by an asymmetry index which is calculated with the formula (R-L)/ (R+L) X 100%. Results: A statistically significant difference was found between dentate & edentulous patients regarding condylar height symmetry. Conclusion: More than 6% differences measured on OPG-5 indicated condylar asymmetry. Keywords: condylar asymmetry, TMJ , OPG (J Bagh Coll Dentistry 2006; 18(2) 40-42)
INTRODUCTION 1
The increased clinical detection of the high prevalence of craniomandibular disorders has increased the demand for early tempromandibular joint diagnosis (1) . The procedure should include bilateral examination of the stomatognathic system. As the orthopantomaogram (OPG) provides such information, it may be justified as a routine tool for screening. The reliability of the vertical dimension images of the two condyles and their rami in the OPG has been described by Habets,et.al in 1987 (2) . The lateral parts of the condylar outline in the image are the medial areas of the condyle. Two hypotheses have been generated to explain mandibular asymmetries; the first one is that observed asymmetries are due to fluctuating morphological asymmetry (3) . The second is a functional and mechanical one. The chewing forces from the mandible to the cranium during mastication suggest the magnitude of joint loading overtime to be related to condylar size (4) . Stressing on the second hypothesis, two groups of patients were selected in this study: Dentate & edentulous group, to examine the effect of dentition on condylar asymmetry.
MATERIALS AND METHODS Two groups of Iraqi patients of both genders attended Dental College / Baghdad University were selected. Dentate group
(1) Assistant Professor, Department of Oral Diagnosis, College of Dentistry, University of Baghdad. consisted of 30 dentate patients (15 men & 15 women). The Edentulous group consisted of 40 edentulous patients (20 men & 20 women). The mean age of both groups is between 40-70 years. All were exposed with a Siemens OPG- 5
(Siemens Corporation, Dental Division,
Iselin, New J ersy). The outline of the condyle and the ascending ramus of both sides were traced on acetate paper. On the tracing paper a line was drawn between the most lateral point (C) of the condylar image and the ascending ramus image (R) (figure 1). To this line"the ramus tangent (I)" a perpendicular line (P) was drawn from the most superior point of the condylar image. The vertical distance from this line on the ramus tangent" to the most lateral point of the condyle (C) projected on the ramus tangent was measured. This distance was called the condylar height (CH). The distance between (C&R) was called the ramus height (RH) and measured.
Figure 1: Diagrammatic presentation of the lines & points Oral Pathology, Oral Medicine, Dental Radiology 40 J Bagh Coll Dentistry Vol. 18(2), 2006 Orthopantomographi c assessment To express the symmetry between the condyles and the rami on the OPG image the following formula [(R-L)/(R+L)X 100% was used. This calculation allows individual difference in size and provides a value for (a) asymmetry of each individual. The result of this ratio- formula gives a range from 0% (complete symmetry) to 100% (asymmetry). According to the study by Habits, et.al (2) a 6% difference between condylar vertical size in an OPG is acceptable with respect to a 1 centimeter change in head position. Differences between groups (Dentate & Edentulous) and subgroups (condyle, ramus, men & women) regarding symmetry {(R-L)/(R+L) X100%} were calculated with a student's t-test as level of significance P<0.05 was chosen.
RESULTS The measured mean differences between the two sides expressed in millimeter for dentate and edentulous groups are summarized in table 1. These differences were bigger in edentulous males than in dentate males regarding the condylar height. The only statistically significant differences were found for the condylar height between dentate and edentulous group of both genders, also there was a statistically significant gender difference among edentulous group only regarding condylar height expressed as a mean differences between the two sides (table 1). A statistical gender difference between dentate and edentulous group was seen regarding condylar height symmetry [(R- L)/(R+L) X100%. Non statistical difference between genders or between the two groups regarding the mean difference and symmetry for ramus height was seen (table1). Table 2 shows all calculations made after dividing the material into subgroups: (<3 asymmetry, 3-6% asymmetry and> 6% asymmetry). Generally, for ramus height, dentate group tend to be more symmetrical than edentulous group. Non statistical difference between two groups regarding condylar height symmetries, while a statistical gender difference for dentate group at 3-6% asymmetry and a statistical gender difference for edentulous group at both 3-6% and >6% asymmetries.
DISCUSSION The dentate group with an age ranging from 40-70 years are considered in this study, since skeletal growth rate has been completed & has no influence (4) . In the edentulous group, the subjects were selected so that they had a complete edentulous ridge for at least 5-11 months. The subjects selected having no history of any lower complete denture wearing, since condylar angle may be influenced by wearing dentures (5) . According to the results of Uthman in 1996 (6) , she concluded a good validity for the reference points used. The head position did not contribute to the variation in the measurements, but the type of panoramic machine has some influence.
Table 1: The measured mean differences between the two sides expressed in mm.(S.D) for dentate & edentulous group
* Significant at 0.05 level ** significant at 0.01 level
Oral Pathology, Oral Medicine, Dental Radiology 41 J Bagh Coll Dentistry Vol. 18(2), 2006 Orthopantomographi c assessment Table 2: The calculated symmetry of the ramus & condylar heights expressed in percentages according to the formula [(Right-Left) / (Right + Left) X100%] Sig. dentate vs. edentulous t-value No. Edentulous Sig males vs females No. Dentate Condylar Height Males 1 0 <3% N.S 0.44 4 5.330.14 S *
The values in table 1 indicate that the used methods are suitable in the discrimination of panoramic radiographically projected mandibular asymmetries. The differences between the two groups of patients regarding condylar height asymmetry are remarkable and seem to be of clinical use in the radiographic diagnosis. The border value of 3% asymmetry between the right and left sides was based purely upon the maximum 6% difference between the two sides which is due to technical errors (1) . A difference between the left and the right condyle of more than 6% difference measured on the OPG indicated condylar asymmetry which is higher in edentulous than dentate group which could provide a basis for the first distinction of the risk of developing cranio- mandibular disorders.
REFERENCES 1. Hansson LG, Hansson T, Petersson A. A comparison between clinical & radiologic findings 2. in 259 tempromandibular patients. J Prosthet Dent 1983, 50; 89. 3. Habets LMH, Bezuur J N, Hasson TL. The
4. orthopantomogram, an aid in diagnosis of TMJ problem 1. The factor of vertical magnitude. J Oral Rehab 1987; 14; 475-80. 5. Costa RL. Asymmetry of the mandibular condyle in Haida Indians. Am J Physical Anthropology 1986; 70; 119. 6. Mongini FG, Preti G, Calderale PM & Barberi G. Experimental strain analysis on the mandibular condyle under various conditions. Acta Orthopedica Belgica 1981;46,601. 7. Sato K, Mitani H. Relationship between late adolescent growth of mandible and maturity indicators mandibular third molar, hand bones, body height in J apanese boys (abstract).Nippon- Kyosei-Shika-Gakkai-Zasssh 1990;49(2):140-146. 8. Uthman AT. Registration of gonial angle, ramus height & mandibular body length among different age groups of Iraqi sample. A cross sectional panoramic radiographic study. M.Sc. Thesis, University of Baghdad, College of Dentistry,1996.
Oral Pathology, Oral Medicine, Dental Radiology 42 J Bagh Coll Dentistry Vol. 18(2), 2006 Detection of acid Detection of acid fast bacilli in the saliva of patients having pulmonary tuberculosis
Gassan Yassen B.D.S., M.Sc (1)
Jamal Noori B.D.S., M.Sc. (2)
ABSTRACT Background: Tuberculosis is a serious disease caused by bacteria called Mycobacterium tuberculosis. The disease is readily detected by demonstration of the bacteria in a clinical specimen. The purpose of this study was to determine the density of acid fast bacilli in the mixed and parotid saliva samples and to compare them with the sputum, in addition, to find out the efficacy of the saliva samples in the diagnosis of pulmonary tuberculosis. Subject and Methods: A sample of 25 patients of both sexes, Age ranged from 17-70 participated in this study, Unstimulated mixed saliva and the parotid saliva was collected for direct .smear of acid fast bacilli by Ziehl-Nelson acid fast stain. Five samples were inoculated on Lowenstein J ensen media and storen brink media to determine the presence of the bacilli in the samples. Results: Concerning the mycobacterium tuberculosis, about 60% of unstimulated mixed saliva revealed positive acid fast bacilli, while all samples of parotid saliva showed negative acid fast bacilli. There was no significant relationship between the duration of signs and symptoms of disease and the detection of mycobacterium tuberculosis in the collected specimens. The density of mycobacterium tuberculosis in the mixed saliva mainly was scanty which mean it was not more than 2-9 bacilli in at least 100 fields. This confirms the fact that the body fluids commonly contain only small number of mycobacterium tuberculosis. The five samples of saliva which were inoculated on Lowenstein J ensen media and stonebrink media showed positive cultures. Conclusion: Mixed saliva was less efficient than sputum by direct smear of sputum. Keywords: Mycobacterium tuberculosis, saliva. (J Bagh Coll Dentistry 2006; 18(2) 43-46)
INTRODUCTION Tuberculosis is a serious disease caused by bacteria called Mvcobacterium tuberculosis. The disease usually affects the lungs but other organs may also be affected. (1)
The variable nature of its manifestation, as well as its ability to involve almost every organ system, either singly or multiply, makes it essential that the possibility of extra pulmonary tuberculosis be included in the differential diagnosis of any infectious process in the body. (2,3)
The disease is considered a worldwide problem. Almost one-third of the world's population is infected with TB, although a healthy immune system can prevent active disease. (4)
The disease is readily detected by skin test, chest x-ray, or by demonstration of M. tuberculosis bacteria in a clinical specimen. There are two distinct stages of TB: 1. TB infected individuals are those who are tuberculin test positive, but do not have the
(1) Private practice. (2) Assistant professor, department of Oral Diagnosis, College of Dentistry, University of Baghdad.
bacteria in their saliva and are without clinical symptoms. 1
2. TB diseased persons have M. tuberculosis bacteria in their saliva and are symptomatic for the disease. (5)
Since the disease is infectious in nature, the clinical signs and symptoms of tuberculosis are common to many other diseases which are: . Loss of weight. . Loss of energy. . Poor appetite. . Fever and wet cough. TB is transmitted through the air from exposure to germs in the saliva of infected person from their lungs. (1,6) There are two kinds of active TB : Primary TB: Occurs soon after a person is first exposed to TB. Reactivation TB: occurs in people who were previously exposed to TB if their immune system is weakened, TB can breakout of the tubercles and cause active disease. Most of the cases of TB in people with HIV disease are due to reactivation of a previous TB infection. (7, 8)
TB may be of concern to the dentist from at least three standpoints:
Oral Pathology, Oral Medicine, Dental Radiology 43 J Bagh Coll Dentistry Vol. 18(2), 2006 Detection of acid First: It is an infectious disease and as such is communicable in its active state. The dentist is in a high-risk population and may contract the disease from a patient or patients may contract the disease from the dentist who might have an active case. Second: On rare occasions tuberculosis lesion may be found in the oral cavity; thus the dentist must be alert to include tuberculosis in the differential diagnosis of oral lesions. Third: The dentist may be the first person to discover that a patient has Tuberculosis. (1)
The treatment usually consists of combination of drugs. Generally, TB drugs are taken daily for 5 to 12 months. It is important that the exact Medication plan should be decided by qualified health care providers. If left untreated, an individual with TB disease can become severely ill and also transmit the disease to others. Untreated, TB disease can be fatal. (9)
The purpose of this study was finding out the density of acid fast bacilli in the mixed and parotid saliva samples and to compare them with the sputum, in addition, to determine the efficacy of the saliva samples in the diagnosis of pulmonary tuberculosis.
SUBJECTS AND METHODS A total of 25 subjects who were diagnosed as having pulmonary tuberculosis participated in this study. Their age ranged between 17-65 years. The subjects were not having systemic disease other than tuberculosis. Those patients were collected from Chest and Respiratory Disease Institute, TB Lab Reference. The patients were having duration of the disease between 2-12 months. The samples of the saliva were collected from the patients under standardized condition (between 10-12 a.m., at least 2hrs after eating and oral hygiene procedure). The mixed saliva samples were taken from the floor of the mouth, while parotid saliva was taken after localization of the orifice of the parotid salivary gland duct. The area was dried with a piece of cotton, and then the gland milked gently with the finger. The milked saliva was collected with blunt instrument and distributed on a glass slide for a direct smear. The slides were then processed and stained with Ziehl Nelson acid fast stain and examined under oil immersion (1000x) for the presence of acid fast bacilli. Culture of mycobacterium was done by digestion-decontamination method to confirm the presence of the micro-organism. Statistical analysis was done with the assessment of the values at the P>0.05 levels.
RESULTS The results of mixed saliva showed microorganisms in 15 patients. However, 10 patients showed negative results (absence of microorganisms) in the samples collected. The microorganisms could not be isolated from the parotid saliva of the total number (25 patients with pulmonary tuberculosis) so the results considered negative. However the microorganisms were isolated from the sputum of the whole number of the patients, as shown in table 1.
Table 1: The presence of mycobacterium tuberculosis in different specimens.
In the specimens examined, the presence of 2-9 bacilli in 100 fields was considered scanty positive) which were observed in saliva samples, while in the sputum, samples the microorganisms were scanty to sever; as shown in figure 1.
Figure 1: Scanty Mycobacterium TB in a specimen.
The duration of signs and symptoms of the total TB patients ranged between 1-12 months. In order to, compare the duration of signs and symptoms with the results of direct smear of saliva we divided the duration into four groups. Oral Pathology, Oral Medicine, Dental Radiology 44 J Bagh Coll Dentistry Vol. 18(2), 2006 Detection of acid The highest percentage of positive acid fast bacilli found in patients with 1-3 months duration of the disease, while the lowest percentage was found in 7-9 months. There was no significant relationship between the duration of signs and symptoms of the disease and the presence of microorganisms (Table 2).
Table 2: The duration of the disease and presence of microorganisms in the stimulated mixed saliva. Duration positive negative Total 1-3 12 5 17 4-6 2 2 4 7-9 0 1 1 10-12 1 2 3
DISCUSSION In this part of study about 25 patients having pulmonary tuberculosis were diagnosed by direct smear of sputum for acid fast bacilli. By using mixed saliva from those patients with pulmonary tuberculosis, about 15 (60%) revealed the presence of mycobacterium tuberculosis in the saliva. This confirms the fact of presence of mycobacterium tuberculosis in the saliva of patient having pulmonary tuberculosis. (10)
We did not identify mycobacterium tuberculosis in the parotid saliva because the microorganism which was identified in the mixed saliva was not present in the saliva primarily but it results from contact of the oral tissue with infected sputum. Up to our knowledge we did not find any study performed on the saliva as a sample for diagnosis pulmonary tuberculosis to compare our finding with these studies, so we did our comparison between the sensitivity of saliva and the sensitivity of sputum. In our study the sensitivity of direct smear of saliva for acid fast bacilli is equal to 60% of the sensitivity of sputum. The sensitivity of direct smear of sputum for the microorganism ranged from 22-80%. (11, 12)
The density of mycobacterium tuberculosis in the mixed saliva mainly is scanty which mean it was not more than bacilli in at least 100 fields (2-9) . This confirms the fact that the body fluid commonly contains only small number of mycobacterium tuberculosis. (10) Therefore, the mixed saliva was less efficient than sputum because by direct smear of sputum the quantity of the bacilli observed on the smear could be provided which serve in the demonstration of the severity of disease. To overcome this shortage, we had to concentrate the sample of saliva by using, cytocentrifugation, or sequential layering of several drops of uncenterfuged fluid, on-slide, or polycarbonate membrane. (10,13)
Cultivation To explain the ability of using saliva as sample for culture, five samples of mixed saliva selected randomly to be inoculated on the Lowenstein J ensen media and stone brink media. All samples revealed positive culture. This means that the mycobacterium tuberculosis which was recovered well by Lowenstein J ensen media and mycobacterium bovis which was recovered by stone brink media were present in the saliva. (14) So we can conclude that the sample of saliva can be inoculated on different media and we can use it if the sputum is unavailable. Therefore, we can summarize the difference between sample of saliva and sputum as shown in Table3.
Table 3: Comparison between the saliva and sputum Saliva Sputum Always available Sometimes not available Less efficient than sputum because is like other body fluids commonly contain only small numbers of mycobacteria More efficient than the body fluid Can be concentrated to maximize the yield of mycobacterium before inoculation on media and direct smear Also can be concentrated to maximize the yield of mycobacterium before inoculation on media and direct smear Can be inoculated to liquid and solid media Can be inoculated to liquid and solid media The sample which revealed positive is always scanty so we cannot graduate the severity of disease The sample which revealed positive may be scanty or moderate or severe so we can measure the severity of disease
Oral Pathology, Oral Medicine, Dental Radiology 45 J Bagh Coll Dentistry Vol. 18(2), 2006 Detection of acid RFERENCES 1. J ames W, Little D, Falace A. Pulmonary disease in: Dermal management of Medically Compromise Patients. Mosby Company. 5 th ed., 1997; 251-9. 2. Valdaso lP, Perez A, Albarracin A. Tuberculosis arthritis, Report of a case with multiple joint involvement and periarticular involvement and periarticular tuberculosis abscess. J Rheumatol 1990; 17; 399-401. 3. Mathew R, George F. Extrapulmonary tuberculosis experience of a community hospital and review of literature. American J Medicine 1985; 79: 467-77. 4. Mehta J B, Burt A, Harvill L, Mathews K. Epidemiology of extra-pulmonary tuberculosis. Chest 1991; 99:1134-8. 5. Lvfalcolm A, Lynch. Diseases of the respiratory system in;Burket's of oral .Medicine diagnosis and treatment. 4 th ed., J B Lippincot Company, Philadelphia, 1994; 435-48. 6. Lucas SB. Histopathology of tuberculosis in; Clinical tuberculosis, 2nd ed. Chapmann and Hall medical, 1998; 113-27. 7. Hang M, Gong J H, Lyer DV, J ones BE, Modlin RL, Barnes PF. T cell cytokineresponses in persons with tuberculosis and HW infection. J Clin Investig 1994; 94: 2435-42. 8. J eanne M, Wallace MD, Andrew L, Deutch MD, J ames H, Harrell MD, Kenneth M, Moser MD. Bronchoscopy and transbronchial biopsy in evaluation of patient with suspected active tuberculosis. Am J Medicine 1981; 70:1189-94. 9. Sharba J A. Tuberculosis in 1990s: Therapeutic challenge. Chest 1995; 108:585-625. 10. Beverly G, Metchock F, Ritchard J R. Mycobacterium In: Manual of clinical microbiology, 7 th ed ASM press Washington DC 1998; 399-437. 11. Lipsky BJ , Gats FC, Tenover J J . Factors affecting the clinical value of microscopy for acid fast bacilli. Rev Infect Dis 1984; 6:214-22. 12. Murray PR, Elmore K., The acid fast stain A specific and predictive test for mycobactrium disease. Ann Inter Med 1980; 92:512-13. 13. Saceanu C N, Pfeiffer, Miclean T. Evaluation of sputum smear concentrated by cytocentrifugation for detection of acid fast bacilli, J Clin J Micro 1993; 31:2371-3. 14. Zaher F, Mark J. Methods and medium for culture of tubercle bacilli. Tubercle 1997; 58: 143-5.
Burning mouth syndrome: an analysis of 130 patients Shanaz M. Gaphor B.D.S., M.Sc, Ph.D. (1)
ABSTRACT Background: Burning mouth syndrome (BMS) of the oral mucosa is relatively common complaints of dental patients. The aim of this study was to determine the possible causes of (BMS). Materials and methods: A sample of 130 patients (91 women and 39 men) was thoroughly studied. Results: Females were more commonly affected than males and particularly those aged over 50 years. The tongue and palate were the most frequently affected sites. Psychogenesis was found to be the most frequent cause, followed by geographic tongue and candidiasis. Conclusion: Burning mouth syndrome is a multifactorial condition generally affecting women much more than men. Keywords: BMS, local and systemic causes. (J Bagh Coll Dentistry 2006; 18(2) 47-51)
INTRODUCTION Burning mouth syndrome (BMS) is a multifactorial condition that generally affects women much more than men. The age group affected is usually over 50 years of age, and clinical examination reveals no mucosal abnormality (1,2) . A patient with a burning mouth often presents a diagnostic and therapeutic problem. Clinicians frequently consider the burning symptom to be psychologically induced (3,4) . Many precipitation factors are recognized and most patients with BMS respond to treatment (5, 6) . These include hematological disorders (7,1) , vitamin B complex deficiencies (8) , candidal infection (2, 3) , reduced salivary gland function (9) , climacteric and undiagnosed diabetes (7,10) , erosive lichen planus and geographic tongue. (3,6) Additional factors such as depression, anxiety, cancerphobia were also evaluated (11,12) . The purposes of the investigation are (1) to demonstrate any one or more specific diseases that may lead to stomatopyrosis, (2) to determine, if possible, the relative frequency of each disease as the cause of oral burning, (3) to demonstrate that the burning mouth is frequently caused by multiple etiologic factors, and (4) to describe a diagnostic protocol which will assure, in most cases, identification of the cause or causes of oral burning.
MATERIAL AND METHODS A total of 130 patients (91 women and 39 men, mean age was 48 years) with BMS was seen in the Oral Diagnosis (Oral Medicine) Department, College of Dentistry, University of
(1) Assistant Professor, Department of Oral Diagnosis, College of Dentistry, University of Baghdad. Baghdad from October 2000 to J une 2001. Each patient in this study had (1) a thorough clinical examination, (2) a complete review of past medical history, including drug history, and (3) a detailed history of duration of the condition burning symptom, site affected, and pattern of burning. The relation of the condition to wearing dentures and orthodontic appliance was established. Patients were asked directly about cancerphobia, depression and anxiety. Appropriate, laboratory procedures were performed; these included culturing for fungi, complete blood count, fasting blood glucose determination, and biopsy and neurologic and psychiatric examinations were performed. The clinical examination, medical history, history of symptoms, and laboratory results were assembled for each patient. The appropriate diagnosis was made from data gathered by the above methods.
RESULTS Table 1 shows the number of patients in each age group. All age groups were found to be affected with a peak from 41-60 years of age (50.7%). Table 2 shows the distribution among examined patients. Female (70%) were more commonly affected than males (30%). Figure 1 shows the site of the oral mucosa affected by the burning sensation. Tongue (69.2%) seems to represent the most common site of involvement followed by palate (30.7%). Table 3 shows the causes of burning mouth sensation among examined patients. Psychogenesis (28.4%) was found to be the most frequent cause followed by geographic tongue (21.5) and oral candidiasis (15.3%).
Local Causes Geographic Tongue There were 28 patients (21.5%) 20 females and 8 males whose burning was restricted to the tongue, where the typical patterns of geographic tongue were located. Their ages ranged from 8 to 60, with an average of 32.25 years. Ten patients described themselves as being nervous, stressful person. Cultures for fungi obtained from 8 patients were negative.
Site of burning sensation Figure 1: Histogram showing the site of burning as reported by patients. Erosive lichen planus Ten patients (7.6%) 6 females and 4 males who were complaining from burning mouth. Clinically, oral lesions appear as lacy white configurations (wickhams striae) with erosions and ulceration. Six of 10 patients complained of a burning buccal mucosa, 3 had a burning tongue and 2 had a burning gingiva. The diagnosis was confirmed by biopsies for 5 cases. Their ages ranged from 33-65, with average of 49 years. Oral Candidiasis Candidiasis is a group of burning mouths consisted of 20 patients (15.3%) 14 females and 6 males. The oral lesions were of the typical red and /or white monilial types. Their ages ranged from 23-75 years with an average age of 57.2 years. All had positive candida albicans cultures, 8 responded dramatically to topical antifungus therapy. Precipitating factors included complete maxillary denture (14), angular chelitis (3), steroid therapy (2) and general debilitation (1). Trauma There were 8 patients (6.1%) 5 females and 3 males; the burning mouth was diagnosed as being traumatic in origin. These patients ranged in age from 21-65 years, with an average age of (48) years. Three of the 8 patients complained of burning cheeks, 3 had a burning tongue, 2 had a burning of lips and one each had a burning maxillary, mandibular area and gingiva. Three of the 8 patients had traumatic Oral Pathology, Oral Medicine, Dental Radiology 48 J Bagh Coll Dentistry Vol. 18(2), 2006 Burning mouth syndrome
ulcers due to chronic irritation by orthodontic appliance and five of the 8 patients had denture irritation (ill fitted denture). All laboratory studies were negative. The blood glucose and blood count were normal.
Systemic causes Iron deficiency anemia There were 9 patients with burning mouth who had iron deficiency anemia (6.9%) seven females and 2 males. Six of (9) patients were with distinct atrophy of the dorsal portion of tongue. These patients ranged in age from 33- 65, with an average age of 47.2 years. There complete blood count, hemoglobin and serum iron concentration were decreased and serum iron binding capacity was increased. The blood glucose was normal and fungal cultures were negative. With appropriate antianemia therapy, the patient shows dramatic improvement of burning mouth. Hyperglycemia There were 8 patients (6.1%) 5 females and 3 males who were complaining from burning mouth and found accompanying fasting blood glucose concentrations. Four of these had an abnormal glucose tolerance test result. These patients ranged in age from 28-56, with an average of 46.3 years. Five of 8 patients had a burning tongue, 3 had a burning lips and buccal mucosa. Adequate control of diabetes was achieved and contributed to complete resolution of oral symptoms. The complete blood count was normal and fungal cultures were negative.
Idiopathic Psychogenesis In 37 patients (28.4%) 28 females and 9 males, the burning mouth was diagnosed as being psychogenic in origin. These patients ranged in age from 25 to 75 years, with an average of 52.2 years. Clinical oral examination showed no abnormality. Twenty five of the 37 patients complained of a burning tongue, 6 had a burning palate, 6 had a burning (lip)s, and one had a burning oral mucosa, alveolar ridge, and mouth. Medical history revealed that 4 had hypertension, 3 had had peptic ulcers, 1 had esophageal reflux, 5 patients suffered from family problems, 2 had dry mouth and 4 were heavy smokers. Cancerphobia was an important factor in 20 patients; reassurance alone was often successful in alleviating the burning sensation.
Multiple causes Ten patients had multiple coexistent causes (7.6%). Four of these (2 of each gender, with an average age of 29 years) had psychogenesis and geographic tongue as the multiple causes of their stomatopyrosis. They had a completely negative laboratory work-up. They had extremely adverse social circumstances. Many areas burned intraorally, including a solitary patch of geographic tongue located on the dorsum. Four of these (3 females- one male with an average age of 60.2 years) had psychogenesis and candidiasis as a cause. They were treated with antidepressant medication and demonstrable xerostomia which was most likely induced by the medications. All had positive candida albicans cultures and showed marked rapid improvement with topical antifungal therapy. Two patients (52 years old woman and 57 years old man) had geographic tongue, angular chelitis, inflamed gingiva and palate. A complete blood count and blood glucose determination were normal, but fungal cultures were positive.
DISCUSSION This study illustrates the multifactorial origins of the burning mouth syndrome and the results support findings of preponderance in women, particularly those aged over 50. It is imperative, however, to establish that patients are truly suffering from the syndrome, particularly that they have a normal mucosa on examination. Careful and thorough clinical and laboratory investigations are necessary if one is to identify the etiologic factors and administer appropriate therapy. In considering the etiological factors; errosive lichen planus and multiple causes each accounted for 7.6% of the cases, hyperglycemia and trauma each accounted for 6.1% of the cases, iron deficiency anemia 6.9%, oral candidiasis 15.3%, geographic tongue 21.5% and psychogenic factors 28.4%. The findings indicate that geographic tongue was found to be the sole cause in 28 patients (21.5%) and played a contributory role in 6 others (4.6%). Several patients complained of sensitivity to hot and /or spicy foods at the affected sites. As in the psychogenic group, females were more often affected than males. Oral Pathology, Oral Medicine, Dental Radiology 49 J Bagh Coll Dentistry Vol. 18(2), 2006 Burning mouth syndrome
Other clinicians mentioned the association of geographic tongue with stress, tension and worry characteristics noted in this group of patients (13,14) . Erosive lichen planus was the cause of oral burning in 10 patients (7.6%). Other clinicians mentioned the association of erosive lichen planus with burning sensation (14) . The findings also indicate that candidiasis was the sole cause of burning in 20 patients (15.3%) and a contributing cause in 6 patients (4.6%) thus; candidial infections played an etiologic role in 19.9% of the burning mouths. Problems with dentures are important in the syndrome; its clinically helpful if patients find that removal of the denture alleviates their symptoms. Oral candida infections are opportunistic and the underlying cause was easy to determine in each patient (15) . Candidial diagnosis was further corroborated in 8 patients by rapid improvement with topical antifungus therapy. Trauma was the cause of oral burning in 8 patients (6.1%). Trauma includes dental or denture irritation. Other clinicians mentioned the association of trauma with burning sensation (16,17) . Dental or denture irritation diagnosed easily and successfully treated of many such cases by the primary-care clinician without the need for referral to a specialist. It is generally accepted that undiagnosed iron- deficiency anemia and diabetes mellitus may cause burning mouth. In this study only 9 of the 130 patients (6.9%) the burning was explained by the presence of iron-deficiency anemia, and 8 of the 130 patients (6.1) in which diabetes was found to be the cause. Various reasons are put forward to support the suggestion that diabetes is a likely cause of a burning sensation in the mouth (18) . First, insulin increases the rates of glycogen, lipid and protein synthesis and it maintains a balance between anabolic and catabolic processes. It would see possible that lack of insulin would encourage the catabolic process within the oral mucosa, making the tissue less resistance to normal wear and tear. Secondly, xerostomia is a common symptom of diabetes. Thirdly, candidal infections are relatively common in diabetic patients. Psychogenic factors are often implicated as being etiologic in the burning mouth (19-21) and, indeed it constituted the most frequent cause of burning in 37 patients (28.4%) and a contributing cause in 8 additional cases (6.1%) so it was the major factor in oral burning. It is important to note that diagnosis of a psychogenically induced disease was established in all cases after all other local and systemic disease possibilities had been excluded by a negative clinical picture, negative laboratory findings, and positive historical data regarding emotional factors. In clinical practice three main factors are important: anxiety, depression and cancerphobia. For the patients who are cancerophobic the presence of unremitting oral symptoms leads them to believe either that they already have cancer or that they are about to develop it. Repeated reassurance and direct questioning of their fears are important, and occasionally we have restored to antidepressant treatment to break the vicious cycle. Some anxious patients readily become depressed, particularly if there is some additional adverse social circumstance such as bereavement. Other patients had histories of diseases often related to/or associated with stress, peptic ulcer and esophageal reflux which causing an irritation of the oral mucosa with consequent development of a burning sensation. It is of diagnostic interest that most psychologically induced burning occurred in women in the post menopausal age group. In this study, 28 of 37 (75.6%) patients were female and 20 of 28 (71.4%) were more than 50 years old. These features have been recognized by other authors whom symptoms of oestrogen deficiency occur (14,17) . The tongue is the most frequent sites of oral burning. The pain could often be aggravated with hot and/or spicy foods. The pathogenesis of those burning mouth patients in whom multiple etiologic factors were established was of considerable interest. This was particularly true for those 4 in the psychogenic-candidial group. It was especially notable that all 4 had histories of a psychiatric disorder (depression) followed by antidepressant medication and that each subsequently developed xerostomia which was soon followed by candidiasis. The following diagnostic protocol is suggested when a patient presents with a complaint of burning mouth. It should include but is not limited to the following. 1. Complete mouth examination: A thorough clinical examination is performed as is done for every new patient, but with special emphasis on detecting lesions of the oral soft Oral Pathology, Oral Medicine, Dental Radiology 50 J Bagh Coll Dentistry Vol. 18(2), 2006 Burning mouth syndrome
tissues which might be associated with the anemias, diabetes, candidiasis, geographic tongue, malnutrition, errosive lichen planus, local irritation and trauma. 2. History: A thorough history should be taken with particular emphasis on psychiatric disorders, systemic diseases (unassociated with or associated with psychogenic factors, such as peptic ulcer and esophageal reflux), and administration of medications, trauma events, and personal or social problems which might cause anxiety, worry, fear, stress and depression. 3. Laboratory investigations: Laboratory studies are mandatory for all patients with burning mouth. Routine tests should include a complete blood count, blood glucose defermenation, cultures for candida albicans and biopsy should be performed.
REFERENCES 1- Main DMG, Basker RM. Patients complaining of burning mouth. Br Dent J 1983; 154: 206-11. 2- Lamey PJ , Lamd AB. Lip component of burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1994; 78: 590-3. 3- Zegarelli DJ . Burning mouth: an analysis of 57 patients. Oral Surg Oral Med Oral Pathol 1984; 58: 34-8. 4- Rojo L, Silvestre FJ , Bagan J V, Vicente TD, Valencia MD. Prevalence of psychopathology in burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1994; 78: 312-6. 5- Domb GH, Chole RA. The burning mouth and tongue. Ear Nose Throat J 1981; 60: 310-4. 6- Lamey PJ , Lamb AB. Prospective study of etiological factors in burning mouth syndrome. Br Med J 1988; 296: 1243-6. 7- Basker RM, Sturdee DW, Davenport J C. Patients with burning mouths. Br Dent J 1978; 145: 9-16. 8- Lamey PJ , Hammond A, Allam BF, McIntosh WB. Vitamin status of patients with burning mouth syndrome and the response to replacement therapy. Br Dent J 1986; 160: 81-4. 9- Glick D, Ben-Aryeh H, Gutman D, Szargel R. Relation between idiopathic glossodynia and salivary flow rate and content. Int J Oral Surg 1976; 5: 161-5. 10- Ferguson MM, Carter J , Boyle P, Hart DMck, Lindsay R. Oral complaints related to climateric symptoms in Oophorectomized women. J R Soc Med 1981; 74: 492-8. 11- Browning S, Hislop S, Scully C, Shirlaw P. The association between burning mouth syndrome and psychosocial disorders. Oral Surg Oral Med Oral Pathol 1987; 64: 171-4. 12- Rojo L, Silvestre FJ , Bagan J V, De Vicente T. Psychiatric morbidity in burning mouth syndrome: Psychiatric interview versus depression and anxiety scales. Oral Surg Oral Med Oral Pathol 1992; 75: 308- 11. 13- Banoczy J , Szabol, Csiba A. Migratory glossitis. Oral Surg 1975; 39: 113-21. 14- Lynch MA, Brightman VJ , Greenberg MS. Burket's Oral Medicine. Diagnosis and Treatment.9 th ed. J .B. Lippincott Company Philadelphia; 1994.p 258-9. 15- Holmberg K. Oral mycoses and antifungal agents. Swed Dent J 1980; 4: 53-61. 16- Ali A, Bates J F, Reynolds AJ et al. The burning mouth sensation related to the wearing of acrylic denture. An investigation. Br Dent J 1986; 161: 444. 17- Grushka M. Clinical features of burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1987; 63: 30. 18- Hatch CL. Glossodynia as an oral manifestation of diabetes mellitus. Ear Nose Throat J 1989; 68: 782. 19- Koblenzer CS. Psychosomatic concepts in dermatology. Arch Dermatol 1983; 119: 501-12. 20- Hughes AM, Hunter S, Still D, et al. Psychatric disorders in dental clinic. Br Dent J 1989; 166; 16. 21- Mott AE, Grushka M, Sessle BJ . Diagnosis and management of taste disorders and burning mouth syndrome. In:D'Ambrosio J A, Fotos PG.Topics in oral diagnosis II. Dent Clin North Am 1993; 33: 37.
Gutta-percha as retrograde filling in endodontic surgery without apicectomy (A clinical and radiographical study with new technique)
Anwar A. Al-Saeed, B.D.S., M.Sc. (1)
ABSTRACT Background: Many materials are being used as retrograde filling materials. This study was to evaluate the effect of Gutta-percha as retrograde filling in endodontic surgery by using ultrasonic device in comparison to the use of Zinc free Amalgam. Patients and Methods: Fifty-seven patients of average age ranging from 18-34 years of old, 32 were males, while 25 were females of different socioeconomic status. All the cases had chronic periapical lesions that were exposed to endodontic surgery with the use of Gutta-percha as retrograde filling by the use of ultrasonic device. Clinical and radiographic evaluation was used as criteria for detection of the state of healing process for 1 year follow-up. Results: All the cases 57 (100%) showed a complete healing without any recurrence of periapical lesions. The current study shows that 42 (73%) of cases had faster and much better healing process in maxillary anterior region than that of the mandibular anterior region 15 (26.3%). Healing process was significantly and clearly better than in those patients with short duration of the pathological lesions, in comparison to the long duration lesions. The study registered that healing process was significantly better in males than in females. No rejections were detected from the use of Gutta-percha as retrograde filling materials in comparison retrospectively to the use of Zinc free Amalgam. Conclusion: No allergic reactions or rejections were reported from the use of Gutta-percha as reported from the use of amalgam. There was absence of contraction or microleakage of microorganisms in case of Gutta-percha while this has been reported in the use of amalgam and other materials. No remnant particles have been observed clinically or even radiographically in the use of Gutta-percha while these commonly occur and clearly observed in case of amalgam. Key words: Endodontic surgery, gutta-percha, ultrasonic technique. (J Bagh Coll Dentistry 2006;18(2) 52-56)
INTRODUCTION Retrograde filling of the root canal during endodontic surgery is a successful method that when orthograde filling to the root canal can not approach coronally, in addition to that this technique has been done to close and seal the apical foramen, and to arrest the spread of microorganisms or their toxins from/and to the surrounding tissues (1-3) . There are certain factors that play an important rule in the successful results of this procedure and these factors are the followings: 1. The experience and skills of the dental surgeon (4) . 2. The material that has been used as retrograde filling (5) . 3. The method of the approach to the apical area (6,7) . 4. The severity of the condition (duration, stage, the presence of internal and external root resorption).
(1) Assistant professor, Department of Oral and Maxillo- Facial Surgery, College of Dentistry, University of Baghdad. 5. The age, gender, and the oral hygiene of the patient. 6. The site of the operation. Usually, most of the dental surgeons suggest to use amalgam as retrograde filling in the past and till now (8,9) , but most of failures from the use of amalgam in this procedure are the followings: - 1. Contraction defects between the dentin wall and the amalgam filling (5) . 2. Microleakage occurs because of initial contraction and even the non gamma II amalgam shows such microleakage (10) . 3. Allergic or toxic reaction to mercury (oral galvanism) (10) . The need for retrograde filling materials other than amalgam seems to be obvious, so many processing and materials have been tried such as; Tin posts (11) , Methyl-2-cyano-acrylate (12), and Cavit (13) . On the other hand, in 1969, a glass-ionomer cement was used (14-16) , but many authors found that the glass-ionomer cement has a slight cytotoxic effect on cell cultures (17,18) , while Kloetzer and Langeland (19) , reported that mild to severe changes of pulp tissue in connection with application of glass-ionomer cement (19) .
Oral and Maxillofacial Surgery and Periodontology 52 J Bagh Coll Dentistry Vol. 18(2), 2006 Gutta-percha
MATERIALS AND METHODS Fifty seven patients were selected for this study. All the cases were indicated for endodontic surgery with retrograde filling and not for orthograde procedure. The average age of the patients used ranged from 18-34 years of old, 32 were a males, while 25 were females of different socio-economic status (Table 1). All the patients were healthy, without any history of any systemic diseases. Only the anterior teeth and premolars were used in the current study of both jaws.
All the cases were exposed to endodontic surgery with the use of Gutta-percha as retrograde filling and with the use of sealer, for the adherence of the Gutta-percha against the walls of the canal. Intra-canal instrumentation was done directly from the apical foramen of all cases by using ultrasonic device, as shown in Figure 1. Irrigation of the canal was performed by the use of normal saline associated with the device, and the paper points dried the canals (20) . The application of Gutta-percha was done according to the size that fitted to the root canal and apical area just closed the apical 1/3, which was enough to seal the apical foramen with good condensation by heated plugger. Follow-up examination from the time of operation up to 1 year by clinical and radiographic examination (21- 24) . Figure 1;A. Ultrasonic device B. Ultrasonic probe for retrograde preparation
C. Preparation for retrograde filling by ultrasonic probe device
eported that all the cases that we the healing process of ora of the mandibular anterior region as presented in rly much better in those pat
RESULTS This study r re exposed to endodontic surgery with the use of Gutta-percha as retrograde filling showed complete healing without any recurrence of the periapical lesions, as seen in Table 2, and Figure 2. Table 2 shows that l tissues and particularly the alveolar bone were observed clearly from the 3 rd week post- operative and completed at the period of 1-2 months. In addition to that 42 (73.7%) of cases showed better and faster healing process in maxillary anterior region than 15(26.3%) cases Table 3. On the other hand, the study does not report any rejection or complication from the use of Gutta-percha as retrograde filling like toxicity or allergic reaction. Table 4 shows that the healing process was significant and clea ients with short duration of the pathological lesions in comparison with those patients who had long duration lesions. The current study also reported that the healing process appear to be significantly much better in males than females, as recorded in Table 5. Oral and Maxillofacial Surgery and Periodontology 53 J Bagh Coll Dentistry Vol. 18(2), 2006 Gutta-percha
Table 1: The number, age gender, and duration of pathological lesions. Gender No Fem les s . of patients Average age years Duration of pathological lesion ales Ma 57 18-34 25 32 6months-5 years
Table 2: The healing process and the duration of follow-up Follow-up post-operation No. o 1M-2M 2M- during 1 year f patients 3M 3M-6M Recurrence 57 (100%) 3 1 6 (63%) 9 (33.3%) 2 (3.6%)
Table 3: The healing process according to the site of the jaws. No. of patients Healing process Maxillary anterior lar anterior region region Mandibu 42 (73.7%) 15 (26.3%) Fem %) Fem ) ale 12 (21.1 ale 13 (22.8% 57 (100%) Male 30 (52.6%) Male 2 (3.5%)
Table 4: Healing process according to the gender of the patient. No. of patients Duration of pathological lesion Duration of healing 57(100%) rs 30(5 ths
6Months-1year 1-2 years 2-3 years 3-5 1/5 yea 2.6%) within 1-2Mon 6(10.5%)within 1-2Months 19(33.3%)within 2-3Months 2(3.6%)within3-6Months
Table 5: Healing process according to the gender of the patient. No. of patients Healing process post-operation 1-2 Month onths s 2-3 Months 3-6 M 57 (100%) Fe ) Fem ) Fe ) male 4 (7%) Male 32(56.1% ale 19 (33.3% Male 0 (0%) male 2 (3.6% Male 0 (0%)
Figure 2-A: Immediately after operation B-Complete healing process of Gutta- of Gutta-percha as retrograde filling -Percha as retrograde within 2 month Oral and Maxillofacial Surgery and Periodontology 54 J Bagh Coll Dentistry Vol. 18(2), 2006 Gutta-percha
Figure 3: Periapical radiograph shows a clear remnant particles of Amalgam in the surrounding alveolar bone when used as retrograde filling. DISCUSSION Gutta-percha is an efficient and safe material to be used as a retrograde filling when compared with other materials, particularly the amalgam for the following reasons: - 1. It is biocompatible and it is used for many years as a conventional root canal filling without any rejection observed from the patient, particularly when it is used in a correct manner (1,21,22) . 2. Gutta-percha is the only material that can be used in every tooth in maxillary and mandibular jaw without any complications and difficulties (4) . 3. It is the only flexiblematerial that can be used for the straight and curved root canal (25,26) . 4. Gutta-percha does not precipitate remnant particles in the surgical field as seen with the use of amalgam (4) . 5. Sealing of the apical area by the use of Gutta-percha gives a better barrier to prevent a microleakage from microorganisms rather than amalgam, and other materials (8,10) . 6. It is easy to manipulate and apply. 7. It is non toxic as other materials (5,10) . In addition to the previous points the skills and the experience of the dental surgeon for approaching the apical foramen and accessing the instrumentation of the canal, stay a very important factor for giving the successful results beside the advantages of the material.
(6,7,27,28)
Some dental surgeons believed that the use of Gutta-percha sometimes shows complications when it is used as a conventional root canal filling particularly when there is over extension. On the other hand, the use of Gutta-percha as a retrograde filling, the filling seal the root canal and the apex so no excess of the material will leave outside the root canal, and this procedure is different from over extension of the Gutta- percha, because here it act as foreign body that cause a cellular reaction and aggregation of inflammatory cells (antigen-antibody reaction) around the apical surface which lead to recurrent infection and failure of the procedure, so there is no relationship between the two conditions. In the comparison between the results from the use of Gutta-percha as retrograde filling with amalgam, the study found according to the follow-up of both cases and from other literatures that most of amalgam cases failed and the patient came with recurrent lesion, which is not due to the lesion itself but from the use of amalgam material which may end with the tooth lost (5,8-10) . Radiographic findings of previous literatures shows clearly remnant of amalgam particles inside and around the surgical field and alveolar bone, which can not be observed during the operation, even when there is a dry field and with the use of isolated material (like bone wax). Even with the use of small curved amalgam carrier, the particles of amalgam are very fine and heavy weight which can not be removed by irrigation particularly when it settles down inside the cancellous of alveolar bone, and most of dental surgeons leave these particles inside the bone, because it is very difficult to localize and remove. These small particles act as antigen or foreign body inside the surgical region, which lead to toxicity reaction (Figure 3). Therefore, trying to remove of these particles after operation, needs another surgical interference and more alveolar bone removal randomly to involve these particles, because these particles can not be localized correctly even by the use of radiographs. Therefore, the procedure will change from the conservative manner to destructive manner. On the other hand, the comparison of these problems with the use of Gutta-percha according to the results from the current study found that no remnant of Gutta-percha particles are Oral and Maxillofacial Surgery and Periodontology 55 J Bagh Coll Dentistry Vol. 18(2), 2006 Gutta-percha
detected outside in the surgical field (4) and the entire pathological lesion would disappear. Perhaps, there is small piece of Gutta-percha outside the root canal such as in case of over- extension. Trying to remove is much easier for detection of the excess and approach surgically with conservative manner and give better prognosis rather than in case of excess of amalgam which may end with bad prognosis. From the previous literatures, other disadvantages from the use of amalgam as retrograde filling, and these are: - 1. Contraction defects between the dentin wall and amalgam filling (5) . 2. Micro-leakage of microorganisms commonly occurs (5,8,10) . 3. Allergic reaction to mercury (oral galvanism) (5,10) . 4. Cytotoxic reaction on cell cultures similar to the reaction observes in the use of glass- ionomer cement (14,15,19,24) . Histologically, Zetterquist in 1987 found that the use of both amalgam and glass- ionomer cement as retrograde filling caused vascular granulation tissues containing lymphocyte, plasma cells, and polymorph nucleated leukocytes observed around these materials. Phagocytizing polynuclear giant cells were focally sited in the granulation tissue that seen (5,21) . In this study, the healing process of all cases was successful without any signs or symptoms of complications or recurrent lesions were reported during the follow-up of all cases.
REFERENCES 1. Dahlen G, Beergen G. Endotoxic activity in teeth with necrotic pulps. J Dent Res 1980; 59: 1033-40. 2. Malooley J J R, Patterson. Response of periapical pathosis to endodontic treatment in monkeys. Oral Surg 1979; 47: 545-54. 3. Moller AJ R, Hyden G. Influence on periapical tissues of indogenous oral bacteria and necrotic tissue in monkeys. Scand J Dent Res 1981; 89: 475-84. 4. Robert K, Flath DDS. Retrograde instrumentation and the abturation with new Devices. J Endod 1987; 13: (11): 546-9. 5. ZetterQuist G, Anneroth, Nordenram. Glass-ionomer cement as retrograde filling material. Int J Oral Maxillofac Surg 1987; 16: 459-64. 6. Langeland K, Liaokek. Work-Saving devices in endodontics. Efficacy of sonic and ultrasonic techniques. J Endod 1985; 11: 499-510. 7. Marlin J , Krakow. Clinical use of injections molded thermoplaticized Gutta-percha for obturation of the root canal system: a preliminary report. J Endod 1981; 7: 277-81. 8. Feldman G, Nyborg H. Tissue reactions to root canal filling materials. Odontal Revy 1962; 13: 1-14. (Cited by ZetterQuist in Int J Oral Maxillofac Surg 1987; 16: 459-64). 9. Feldman G, Nyborg H. Tissue reactions to root canal filling materials. Odontal Revy 1964; 15: 33-40 (Cited by Zetterquist in Int J Oral Maxillofac 1987; 16: 459- 64). 10. Boyer DB, Torney DL. Microleakage of higher copper amalgams. J Dent Res 1979; 58A: 394 (abstract. No. 1213). 11. Vees A. Ergebinsse der chirugischen Wur- Zellbehandlung DasDtsch Z. 1966; 20: 35-8 (Cited by Zetterquist in Int J Oral Maxillofac 1987; 16: 459-64). 12. Nordenram A. Biobond for retrograde root filling in apicectomy. Scand J Res 1970; 78: 251-5. 13. Finne K, NorD PG, Person G. Retrograde filling with amalgam and cavit. Oral Surg 1977; 43: 621-7. 14. Hank CT, Anderson M, Craig RG. Toxicity tests with cultured cells of live dental cements. J Dent Res 1980; 59: 376. 15. Kawahara H, Imanishi Y, Oshima H. Biological evaluation on glass-ionomer cement. J Dent Res 1979; 58: 1080-6. 16. Kent BE, Wilson AD. The properties of the glass- ionomer cement. BDJ 1973; 135: 322-6. 17. Mealcan J W, Wilson AD. The clinical development of the glass-ionomer cement. Aust Dent J 1977; 2: 31-36, 120-7, 190-5. 18. Wilson AD, Kent RE. A new translucent cement for dentistry. The glass-ionomer cement for dentistry. BDJ 1972; 132: 133-5. 19. Kent BE, Langeland K. Tierexperimeutelle prulug von materialien und Metoden der Krnoenund Brunckenprosthetic. Scch Weiz-Msehri Zahnheilk 1973; 83: 163-244. (Cited by ZetteroQuist in Int J Oral Maxillofac Surg 1987; 16: 459-64). 20. Rud J , Andereasen J O, Moller. Radiographic criteria for the assessment of healing after endodontic surgery. Int Oral Surg Int J Oral 1972; 1: 195-214. 21. Andreasen J O, Rud J . Correlation between histology and radiograph in the assessment of healing after endodontic surgery. Int J Oral Surg 1972; 161-73. 22. Olav Molven et al. Observer strategy and the radiographic classification of healing after endodontic Surgery. Int J Oral Mazxillofac Surg 1987; 16: 432-9. 23. Rud J , Andreasen J O, Moller. A follow-up study of 1000 cases treated by endodontic surg. Int J Oral Surg 1972; 1: 215-28. 24. Mener O, DominQuez VF. Tissue response to a glass- ionomer used as endodontic cement. A preliminary study in dogs. Oral Surg 1983; 56: 198-205. 25. Chenail BL, Teplistsky BE. Endodontics in curved root canals. J Endod 1985; 11: 369-74. 26. Schneider SW. A comparison of canal preparations in straight and curved roots canals. Oral Surg 1971; 82: 271-5. 27. Eldeeb ME. The sealing ability of injection-modeled thermoplasticized Gutta-percha. J Endod 1980;11: 84-6. 28. Harrison J W, Todd MJ . The effect of root resection on the scaling property of root canal obstructions. Oral Surg 1980; 50: 204-72.
Oral and Maxillofacial Surgery and Periodontology 56 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional Comparison of conventional periodontal therapy versus scaling and root planing with subgingival minocycline gel 2% Kholood A. Al Safi B.D.S., M.Sc. (1) ABSTRACT Background: Alternative regimens using subgingival minocycline plus scaling and root planing (SRP/ M) significantly improved clinical attachment (CAL) and reduced probing depth (PD) compared with SRP alone. The purpose of this study was to evaluate clinical and radiographic outcomes in 2 periodontitis cohorts, one receiving conventional periodontal therapy and the other receiving scaling and root planing with multiple doses of subgingival minocycline Materials and Method: Moderate to advanced chronic periodontitis patients were concurrently treated with either:(1) scaling and root planing with 4 subgingival doses of minocycline in all 5mm pockets over a 6 month period (SRP/M) n = 25 patients or (2) conventional therapy 6 month period (SRP n = 25 patients). Clinical and radiographic measurements including (PD), CAL, BOP and interproximal bone height (BH), were analyzed at baseline and 1 year. Results: Baseline clinical and radiographic data were similar between SRP/M and SRP patients. PD showed greater mean improvement in SRP/M (1.1 0.1 versus 0.5 0.1 mm P=0.02) with 25% of subject of SRP/ M gaining 2mm compared to 4.2% in SRP. The mean loss in bone height and percent subjects losing bone height were less in SRP/M (2.9 0.6 mm) than SRP (3.7 0.7mm) while cross sectional SRP/M data between CAL and BH or PD and CAL were highly correlated, changes over 1 year were not correlated among any of these parameters. Conclusion: Scaling and root planing and subgingival minocycline in experimental sites resulted in more PD reduction and less frequent bone height loss than conventional periodontal treatment alone. Keywords: Root planing, minocycline. (J Bagh Coll Dentistry 2006; 18(2) 57-62)
INTRODUCTION The management of periodontal disease includes many treatment modalities such as conventional therapies consisting of surgery and/or non surgical methods. In any case, the purpose of periodontal treatment is to arrest progressive tissue destruction and to prevent further attachment loss. Undoubtedly to successfully treat periodontitis we have to find more effective technique surgical as well as non surgical (1-3) . Antimicrobial therapy has become an accepted part in periodontal treatment (4) . Use of subgingival antimicrobial medications including tetracycline, has been shown to improve probing depths (PD) and clinical attachments levels (CAL). (5,6). This is presumably due to decreases in gingival inflammation by modulating the inflammatory response and suppressing the pathogenic microbiota. The use of these medications may improve the clinical outcome of therapy. (7). The fact that periodontal tissues can be infected by specific anaerobes and that these bacteria are present in some sites with recurrent or persistent disease even after mechanical treatment methods so that it requires a special treatment concept, a combination of mechanical treatment modalities with antibiotics therapy had been suggested (8-10).
(1) Assist professor, Department of Periodontology, College of Dentistry, University of Baghdad. Clinical studies have demonstrated that minocycline has a beneficial effect on various parameters of chronic and acute inflammatory periodontal disease Due to the antibacterial and anticollagenolytic properties of tetracyclines, use of minocycline in conjunction with scaling and root planing (SRP +M) may further slow the rate of bone loss (10,11). In a randomized, double blind comparative study subgingival administrated minocycline in patients with adult periodontitis revealed that it was a safe and efficient adjunct to scaling and root planing (13) . It also led to significant adjunctive improvement after subgingival instrumentation in both clinical and microbiological variables over a 3 to 15 months period (12,13) . In vitro studies have also suggested that minocycline may be more effective than the other tetracycline on various microbiological components of dental plaque (14,15). In recent years, numerous studies have demonstrated improvement in clinical periodontal parameters after additional treatment with metronidazole and tetracycline in cases of sever periodontitis (7,16,17). It has become clear that scaling and root planing are essential in initial periodontal therapy to reduce inflammation via the removal of plaque, calculus and endotoxins from the root surfaces of all teeth. Therefore, the purpose of this study was to assess the comparison of conventional periodontal treatment versus scaling and root Oral and Maxillofacial Surgery and Periodontology 57 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional planing (SRP) with subgingival minocycline gel.
MATERIALS AND METHODS Patients selection and assignment to treatment groups Subjects presenting to the department of Periodontology College of Dentistry, University of Baghdad were selected after a periodontal screening examination by a periodontist. The selected patients were given an oral explanation of the clinical trial. A total of 50 patients with moderate to advanced chronic periodontitis were selected for these studies (28 females and 22 males, 35-65 years of age) met the following criteria: 1. At least 2 molar or premolar teeth with 5mm interproximal pockets, 2. Did not have specific systemic diseases. 3. Had not recently taken medication. 4. No scaling and root planing within the past 6 months. 5. Not pregnant or lactating. Once subjects were selected for participation, they were assigned to their respective treatment groups. The subjects were randomly divided into 2 groups. The test group, n=25; in those patients, all 5 pockets were scaled and root planed (SRP) using ultrasonic and hand curettes, then a dose of minocycline gel 2% is injected subgingivally. After baseline, no additional instrumentation was performed for 1 year. Control group, n=25, those patients received concurrent conventional therapy consisting of scaling, plaque debridement and root planing without minocycline application. Both groups received oral hygiene instructions as necessary. Delivery of minocycline After baseline clinical measurements, scaling and root planing, the minocycline gel 2% was delivered into each 5 pockets in every study subjected. Prior to delivering the minocycline gel into pocket, the site was dried and cleansed of blood, debris and saliva then application of a subgingivally-administrated gel formulation containing 2% minocycline hydrochloride delivered with a specially designed disposable applicator versus a vehicle control immediately after root planing, and after 1 month, 3 months and 6 months according to study protocol. After baseline appointment and over the course of 1 years investigation, study subject included in the data analysis did not receive any prophylaxis, root planing or drug therapy which could affect the plaque microorganisms. Clinical and radiographic measurements The clinical parameters that were recorded at baseline and 1 year including probing pocket depth (PPD), bleeding on probing (BOP) and clinical attachment level, (CAL). In addition four posterior vertical bitewing radiographs were taken at baseline and 1- year following up measurement were made by a masked evaluator from CEJ to alveolar bone height (BH). Statistical Analysis Data obtained in the present study were presented as a mean value and standard error. The comparison of clinical outcomes between control group and test group was done by the MannWhitney Utest, changes in PPD and BH within groups were evaluated using paired t test and between groups changes were tested using analysis of variance and chi-square analysis. Correlation coefficients were calculated among clinical and radiographic changes. The statistical computation was performed using a statistical soft ware program.
RESULTS The baseline clinical data indicated that test group SRP/M and control group SRP were similar according to interproximal probing depths of experimental sites (Table 1), as expected with the matching strategy in the study design. SRP/M had 12 premolar/38 molar sites and SRP had 10 premolars/40 molars. Bleeding upon probing was reduced over the period of investigation, both protocols reduced percent of patients bleeding on probing, but no statistical differences were found after 1 year (SRP/M =81%; SRP=72%). Changes in PD and BH over 1 year are summarized in Table 2. During one year, an improved PD and CAL were noticeable. The mean PD was reduced from 5.0 0.5 mm to 4.5 0.4mm in control group, and from 5.0 0.5 mm to 3.9 0.4mm in the test group. Probing depths were improved more than 1 mm on average for SRP/M which was significantly different than the SRP group. Both groups showed a significant reduction in PD between baseline and one year visits (P<0.0001 for both groups). Twenty five percent (25%) of SRP/M patients had an experimental site which was improved by 2.0mm compared to only 4.2% for SRP. In fact 8.3% of SRP patients had a site Oral and Maxillofacial Surgery and Periodontology 58 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional which lost 2.0mm probing depths, while SRP/M patients had no such sites. During the period of study, the mean CAL was reduced from 7.7 0.6mm to 5.7 0.2 mm in the control group, and from 7.70.6mm to 4.70.2mm in the test group. Both groups showed a significant CAL gain between the baseline and one year visits (P=0.01 for the control group and p =0.001 for the test group). The mean gain of CAL was 2.0 0.3mm in control group and 3.0 0.3mm in the test one, and this difference was statistically significant (P=0.03 and P<0.05) according to the Mann Whitney Utest. Average bone height losses appeared to parallel probing gain in that SRP/M had about twice the PD gain and almost about one of the BH losses of the SRP group over the 1 year period (Table 2). There was a statistical significant difference between groups for BH. Baseline PD versus CAL and BH versus CAL, as well as 1 year PD versus CAL and BH versus CAL, were significantly correlated in the SRP/M, with r values >0.61. Baseline BH also was correlated with 1 year CAL (r=0.72, P=0.001), and baseline CAL was correlated with 1 year BH (r=0.81, P=0.0001) in the SRP/M. PD was not significantly correlated to BH at any time in either group. Although there is cross sectional connections, no significant correlations could be found in either group when changes across the 1 year period were compared (Table 3). The highest correlation coefficient occurred between clinical attachment level and bone height changes measured in SRP/M group (r=0.45; P=0.09).
DISCUSSION It is widely recognized that scaling /root planing constitutes the basis of periodontal therapy. Clinical research has documented however, that conventional mechanical therapy often leaves behind significant numbers of pathogenic periodontal bacteria. Scaling and root planing may fail to eliminate these bacteria because of their location within the gingival tissue or because their location in tooth structures makes them inaccessible to periodontal instruments. This investigation demonstrated that local delivery of a minocycline periodontal formulation directly into the gingival crevice following root planing results in a greater reduction of periodontal pocket depth than root planing alone. Other investigators have also examined the effect of the antibiotics delivered into the gingival crevice on the subgingival plaque microbial flora. Our results are consistent with the findings of Goodson et al in 1985, Addy et al in 1988, Deasy et al in 1989, and Minabe et al in 1989 (18-21) , in that all of these investigators demonstrated the antibacterial effectiveness of local delivery antimicrobial agents including tetracycline and metronidazole as well as minocycline. All clinical and radiographic outcomes were numerically better in test group if compared with control group (Table 2). The SRP/M group in our study had a mean decrease in PD of 1.1mm while the SRP was 0.5mm for 5mm pockets (Tables 1 and 2).Other studies have shown PD reduction with SRP and subgingival chemotherapeutics but most of these studies were less 12 months in length (15,22- 24) . The SRP/M data was comparable to the study of Garrett et al in 2000 (15) who did scaling and root planing combined with subgingival medication in which SRP/M participated showed a mean 1.31mm reduction in PD for all pockets (5 to 9 mm) while our results demonstrated an overall 1.10mm PD reduction. The SRP group outcome was comparable to the study of Drisko et al in 1995 (26) , who reported a 0.36 mm PD decrease with prophylaxis alone while in our study PD reduction in this group was 0.50 Other studies of SRP alone during initial therapy of moderate pockets have shown PD reduction around 1mm after 1 year (26-30). The mean difference in PD changed between the 2 groups in this study was statistically significant (Table 2). The amount may appear to be less than clinically significant. However, no further instrumentation after baseline was performed in the SRP/M group and no chemotherapeutic treatment was given after the 6 months appointment. In addition, none of the patients had sites which increased in PD in the SRP/M group over 1 year study, (8.3% of SRP subjects had sites which increased, while 25% of subjects had at least one site which improved in PD 2mm (P=0.02). In the present investigation the local subgingival delivery of minocycline antimicrobial agent aids in the reduction of periodontal pocket depth and therefore, can help the clinician to achieve a more favorable therapeutic result when used as an adjunct to a Oral and Maxillofacial Surgery and Periodontology 59 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional root planing when compared to that observed with root planing alone, this is agreed with many studies. (4,5,16,31). Little information is available radiographically comparing changes in bone height for various local chemotherapeutics. J effcoat et al. showed no bone loss with the chlorhexidine chip in combination with SRP, while 25% of the sites showed some gain in the 9 months study (24) .No thresholds to determine real change were described, but mean changes in bone height were within =0.1mm .Our study had a predetermined threshold of 0.5mm based on three standard deviations of replicate measurements to provide 99% confidence of real change. The test group (SRP/M) and control group (SRP) in this study showed a minimal incidence of subjects with bone gain 0.5mm (4%) and no statistically significant difference between groups. Bone loss of 0.5mm occurred in more of the SRP subjects (17.0% SRP, 11.9% SRP/M) but differences were not significant. A comparable 15% of participants receiving SRP alone lost bone in the J effcoat study (24) . It is thought that chemotherapeutics work by modulating the inflammatory response and/or by suppressing or eradicating the pathogenic microbiota which should result in maintenance of bone height (32) . Even if additional bone height was not gained, a treatment which reduces the progression of bone loss is a step toward effective periodontal maintenance (33). The mean clinical attachment gain of the test group receiving the non surgical SRP and local minocycline therapy improved significantly over that of the control group receiving only conventional therapy SRP (Table 2). On the other hand Zucchelli (34) , administrated a slow releasing dental gel containing metronidazole benzoate (25%) and they found no statistically significant difference between test group receiving the local antimicrobial therapy and control group given systemic antibiotics. Although some studies concerning the local delivery of antimicrobial therapy, they had no effect of clinical significance on bone regeneration or on soft tissue attachment (3,35,36). Cross-sectional correlations were found between PD versus CAL and BH versus CAL in the SRP.M group but not between PD versus BH in either group. In additions, BH at baseline was correlated with CAL at 1 year and vice versa. These findings suggest that CAL and BH may parallel each other, but especially BH is not related to the common clinical measurement of PD. Changes in PD and CAL are subject to changes of inflammation where an increase in soft tissue integrity due to decreased inflammation may decrease probe penetration (37,38). Bone height measurements would not be expected to be affected by such inflammatory changes and appear to be an efficient measure to compliment PD and CAL in long-term analysis of subgingival antimicrobials (10). In general, it seems reasonable to conclude that minocycline delivered subgingival as an adjunct to scaling and root planing resulted in more PD reduction and slower BH loss than conventional therapy alone. The data from local-delivery controlled release antimicrobial studies in general, and this study in particular, suggest that further understanding is needed relative to the effects observed in no treatment groups and the impact of supragingival plaque control on the long term outcomes of this type of therapy.
Table 1: Base line clinical and radiographic data Group Age Gender PD CAL Interproximal bone height BOP Test (SRP/M) 53.5 0.5 M=11 F=14 5.0 0.5 7.70.6 4.5 0.4 56.20.5 Control (SRP) 55.12.5 M=12 F=13 5.0 0.5 7.70.6 4.0 0.4 57.50.5 P value 0.23 NS 0.72 NS 0.50 NS 0.11 NS
Oral and Maxillofacial Surgery and Periodontology 60 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional
Table 2: Change in clinical and radiographic data over 1 year Groups PD reduction % subjects with sites changing 2.0mm PD CAL gain Interproximal bone height % subject with sites changing 0.5mm BH BOP Test (SRP/M) 1.1 0.1 + 25.0 * 0.0 3.0 0.3 2.9 0.6 +4.5 -11.9 32.40.5 Control (SRP) 0.5 0.1 +4.2 -3.3 2.0 0.3 3.70.7 +4.1. - 17.0 33.00.5 P value 0.07 S
0.035 S 0.08 S
0.13 NS
Higher incidence of subject with PD improvement in SRP/M (P=0.020)
Table 3: Correlations among clinical and radiographic changes Comparison SRP/M SPR PD vs CAL -0.18, P=0.61 0.08, P=0.92 PD vs BH -0.12, P=0.72 0.03, p=0.81 CAL vs BH 0.40, P=0.11 0.10, P=0.64
REFERENCES 1- Saxen L, Asikaninen S, Kanervo A, Kari K, J ousimiesh. The long term efficacy of systemic Doxycycline medication in the treatment of localized juvenile periodontitis. Arch Oral Bio 1990; 35: 227- 9. 2- Killoy WJ . The use of locally delivered chlorhexidine in the treatment of periodontitis. Clinical results. J Clin Periodontal 1998; 25: 953- 8. 3- Van Steenberrghe D, Bercy P, Kohl J . Subgingival monocycline hydrochloride ointment in moderate to sever chronic adult periodontitis a randomized, double blind vehicle controlled, multicenter study. J Clin Periodontal 1993; 64: 637- 44. 4- Meinberg A, Barnes M, Dumming G, Reingardt A. Comparison of conventional periodontal maintenance versus scaling and root planing with subgingival minocycline. J Clin Periodontal 2002; 73: 163- 72. 5- Van Steenberrghe D, Rosling B, Soder P. A 15 month evaluation of the effect of repeated subgingival minocycline in chronic adult periodontitis. J Clin Periodontal 1999; 70: 657- 67. 6- J anson H, Brathall G, Saderhalm G. Clinical outcome observed in subjects with recurrent periodontal disease following local treatment with 25% Metronidazole. J Clin Periodontal 2003; 74: 372- 7. 7- Greenstein C. The role of Metronidazole in the treatment of periodontal disease. J Periodontal 1993; 64: 1- 15. 8- Gusberti FA, Syed SA, Lang NP. Combined antibiotic (Metronidazole) and mechanical treatments effect on the Subgingival bacteria flora of sites with recurrent periodontal disease. J Clin Periodontal 1998; 15: 353- 9. 9- Mangnusson I, Marks PG, Clark WB. Clinical microbiological & immunological characteristics of subjects with refractory periodontal disease. J Clin Periodontal 1991; 18: 291- 9. 10- Khattab Razan. Clinical response of early onset periodontitis to periodontal therapy supported by adjunct tetracycline and Metronidazole. Long term follow up. J ournal of the Arab Board of Medical Specializations (J ABMS) 2001; 3: 80- 90. 11- Ti- Sun K, Burklin T, Schacher B, Kruger P, Malthijs T, Renbbli H, Fiehn W, Frckholz P. Pharmacokinetic profile of a locally administrated Doxycycline gel in crevicular fluids, blood, and saliva. J Periodontal 2002; 73: 313- 9. 12- Ciancio SG, Slots J , Reynolds HS, Zambon J J , Mckenna J D. The effect of short term administration of minocycline HCL on gingival inflammation and Subgingival microflora. J Periodontal 1982; 53: 557- 61. 13- Omori N, Kobayashi H, Tsutsui T. Quantitative comparison of cytocidal effects of tetracyclines and fluoroquinolones on human periodontal ligament fibroblasts. J Periodontal Res 1999; 34: 290- 5. 14- Novak MJ , Stamatelakys C, Adair SM. Resolution of early lesions of juvenile periodontitis with tetracycline therapy alone. Long- term observations of 4 cases. J Clin Periodontal 1991; 62: 628- 33. 15- Garrett S, Adams S, Bagle G. The effect of locally delivered controlled release Doxycycline or scaling and root planing on periodontal maintenance patients over 9 months. J Clin Periodontal 2000; 71: 22- 30. 16- Okuda K, Wolf L, Oliver R, Osborn J , Stolitenberg J , Berenuter L, Anderson P, Foster N, Haridie D, Hara K. Minocycline slow release formulation effect on Subgingival bacteria. J Clin Periodontal 1992; 63: 73- 9. 17- Eickholz P, Kim TS, Burklin T. Non surgical periodontal therapy with adjunctive topical Doxycycline. A double blind randomized controlled Oral and Maxillofacial Surgery and Periodontology 61 J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional multicenter study. J Clin Periodontal 2002; 29: 108- 17. 18- Goodson J M, Offenbacher S, Farr DH, Hogan PE. Periodontal disease treatment by local drug delivery. J Clin Periodontal 1985; 56: 262- 72. 19- Addy M, Hassan H, Moran J , Wade W, New combe R. Use of antimicrobial containing acrylic strips in the treatment of chronic periodontal disease. A three month follows up study. J Periodontal 1988; 59: 557- 64. 20- Deasy PB, Collins AE, MacCarthy DJ , Russell RJ . Use of strips containing tetracycline hydrochloride or Metronidazole for the treatment of advanced periodontal disease. J Pharm Pharmacol 1989; 41: 694- 9. 21- Minabe M, Takeucgi K, Tamura T, Hori T, Umemoto T. Sibgingival administration of tetracycline on a collagen film. J Periodontal 1989; 60: 552- 6. 22- Newmann MG, Korman KS, Doherty FM. A six months multi- center evaluation of adjunctive tetracycline fiber therapy used in conjunction with scaling and root planing in maintenance patients. Clinical results. J Periodontal 1994; 65: 685- 91. 23- Caton J , Ciancio S, Bileden T. Treatment with subantimicrobial dose Doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis. J Clin Periodontal 2002; 71: 521- 32. 24- J effcoat MK, Palcains KG, Weather TW, Reese M, Gerus NC, Flashner M. Use of a biodegradable chlorhexidine chip in the treatment of adult periodontitis. Clinical and radiographic findings. J Clin Periodontal 2000; 71: 256- 62. 25- Kinane D, Radvar M. A six month comparison of three periodontal local antimicrobial therapies in persistent periodontal pockets. J Clin Periodontal 1999; 70: 1- 7. 26- Drisko C, Cobb C, Killey J . Evaluation of periodontal treatment using controlled release tetracycline fibers. Clinical response. J Clin Periodontal 1995; 66: 692- 9. 27- Claffy N, Loos B, Gantes B, Martin M, Heins P, Egelberg J . The relative effects of therapy and periodontal disease on loss of probing attachment after root debridement. J Clin Periodontal 1988; 15: 163- 9. 28- Kaldhal WB, Kalkwarf KL, Patil KD. A review of longitudinal studies that compared periodontal therapies. J Periodontal 1993; 64: 243-53.
29- Kaldhal WB, Kalkwarf KL, Patil KD, Movar MP, Dyer J K. Long term evaluation of periodontal therapy incidence of sites breaking down. J Periodontal 1996; 67: 93- 102. 30- Meinberg T, Canarsky A, McClenahan A, Poulsen D, Marx D, Reinhardt R. Outcomes associated with supporative periodontal therapy in smokers and non smokers. J Dent Hygiene 2001; 75: 15- 24. 31- Minabe M, Takeuchi K, Kumada H, Umemoto. The effect of root conditioning with minocycline HCL in removing endotoxin from the roots of periodontally involved teeth. J Clin Periodontal 1994; 81: 387- 92. 32- Yoshinari N, Tohya T, Kawase H, Matsuoka M, Nakane M, Kawachi M, Mitani A, Koide M, Inagaki K, Fukuda M, Noguch T. Effect of repeated local minocycline administration on periodontal healing following guided tissue regeneration. J Clin Periodontal 2001; 72: 284- 95. 33- J ames J , Brayton, Oing Yang, Robin J , Nakkula, J ohn D, Walters. An in vitro model ciprofloxacin and minocycline transparent by oral epithelial cell. J Clin Periodontal 2002; 73: 1- 1. 34- Zucchelli G, Sforza NM, Clauser C, Cesari C, Sonetis M. Topical and systemic antimicrobial therapy in guided tissue regeneration. J Clin Periodontal 1999; 70: 239- 47. 35- Goulding MJ , Sandhal KO, Nowadly CA, Zambon J J , Chrislersson LA. Release of minocycline after Subgingival deposition by use of a resorbable polymer. J Periodontal 1991; 62: 84- 5. 36- Williams RC, Paquette DW, Offenbacher S. Treatment of periodontitis by local administration on minocycline microspheres. A controlled trial. J Clin Periodontal 2001; 72: 1535- 44. 37- Fowler C, Garrett S, Criggar M, Egelberg S. Histologic probe position in treated and untreated human periodontal tissue. J Clin Periodontal 1982; 9: 373- 85. 38- Kaldhal WB, Kalkwarf KL, Patil KD, Movar MP. Responses of four teeth and site groupings to periodontal therapy. J Clin Periodontal 1990; 61: 173- 9.
Oral and Maxillofacial Surgery and Periodontology 62 J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of aspirin on the The effect of aspirin on the periodontal parameter bleeding on probing
Maha Abdul Aziz B.D.S., M.Sc. (1)
ABSTRACT Background: The absence or presence of bleeding on probing (BOP) is a sign of periodontal health or disease, but the presence of BOP is not an accurate predictor of disease progression. Aspirin is increasingly used in the prevention of cerebrovascular and cardiovascular diseases and is a non-disease factor that may modify bleeding indices given its antithrombolytic activity. The objective of this double-blind placebo-controlled randomized clinical trial was to study the effect of short-term daily aspirin ingestion on the clinical parameter BOP. Materials and methods: A total of 60 subjects were randomly assigned to oral administration to one of three arms: placebo (group 1), 100mg aspirin (group 2) , 300mg aspirin (group 3). Before (visit 1 V1) and after 7 days (visit 2 V2) exposure to the respective regimens, clinical parameters were measured on all teeth, included plaque index (PLI), probing depth (PD) and BOP. Results: The primary measure of interest was BOP so, the results of this study indicate that the group treated with 300mg aspirin demonstrated a statistically significant increase from base line in percent of BOP compared to the placebo group and 100mg aspirin group. Conclusion: Failure to consider the effects of aspirin on BOP could impair proper diagnosis and treatment planning for clinicians and introduce a significant confounding variable in research situations. Key words: Aspirin, bleeding on probing, clinical trial. (J Bagh Coll Dentistry 2006; 18(2) 63-67)
INTRODUCTION 1
Aspirin has been recommended by the American Heart Association as a therapeutic agent for cardiovascular disease (1) . In addition, it is commonly used to treat inflammatory joint diseases (2) . Aspirin is a non-steroidal anti-inflammatory drug (NSAID) (3) . It is absorbed from the duodenum and metabolically, it binds irreversibly with cyclooxygenase and inhibits the release of thromboxanes, which is responsible for platelet aggregation for a period of 7 to 10 days (4-6) . This change could increase the chances of bleeding and bleeding on probing for that period of time (2) . Bleeding indices are used to measure disease prevalence and treatment effectiveness in clinical trials and monitor disease progression
(7) . Thus failure to consider aspirin intake during a routine clinical dental examination could produce various false positive readings, which could result in an inaccurate patient diagnosis (2) . While several studies have examined the anti-inflammatory effects of (NSAIDs) on gingivitis and periodontitis (8-11) , some have attempted to specifically examine the effect of aspirin on BOP in patients with a clinically healthy periodontium. Their results demonstrated that aspirin intake of 325 mg daily for 7 days moderately and significantly increased the appearance of BOP (12) .
(1) Lecturer, Department of Periodontology, College of Dentistry, University of Baghdad. In another study done by Royzman et al. 2004 (2) reported that 7 days aspirin use in doses of 81mg and 325mg will significantly increase the percentage of BOP sites in a population with gingivitis.
MATERIALS AND METHODS The sample consisted of 60 subjects (30 males & 30 females), age range of 25-30 years. At the beginning, all the participants signed informed consent forms prior to entering the study then they were screened through evaluation of medical and dental histories. Exclusion criteria were any known contraindication to aspirin intake, compromising systemic medical conditions, any form of ongoing tobacco use, pregnancy or lactation, any condition requiring antibiotic premedication for the prevention of sub acute bacterial endocarditis, a history of systemic or topical use of any type of (NSAIDs) within 2 weeks prior to study entry, or requiring the use of any type of (NSAIDs) during the study period. Finally, any one found to have single or more PPD of 4mm , those with a previous diagnosis of chronic periodontitis and received periodontal treatment other than a routine prophylaxis within 12 months prior to entering the study. At day zero, baseline measurements (V1) of clinical parameters were recorded on all teeth except third molars, then subjects were randomized to one of the regimens (placebo, 100mg aspirin or 300mg aspirin) and were 63 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of aspirin on the provided with seven tablets with the instructions to consume one each day, for 7 consecutive days. Both the subjects and the investigator were blinded to the content of the tablets. After 7 days from exposure to placebo or aspirin regimens subjects were re-examined for outcome measurements (V2) of clinical parameters. The clinical examinations were conducted using graduated Williams periodontal probes and mouth mirrors. Clinical Assessments: 1- PLI: Plaque index system in scale from (0- 3) (13)
2- PD: The distance from gingival margin to the most apical extent of the probe to the nearest millimeter was recorded. 3- BOP: Absence or presence of bleeding on probing. (12)
RESULTS In this study, the sample consisted of 60 subjects (30 males & 30 females) each group divided into 3 groups, 20 in each, according to the type of regimen they received (Table 1). It is clear from Table 2 that the means of PLI in V1 are nearly similar at each gender group and the highest means of PLI at males, females and totally found in group 2. The results were 1.98, 1.84 and 1.91 respectively. At V2 means of PLI were slightly decreased but non significant differences were observed by comparing each type of regimen at V1 with V2 at each gender group (Table 5). Again the highest means of PLI at males, females and totally registered in group 2, the results were 1.909, 1.79 and 1.849 respectively. Generally, females showed lower means of PLI than males at V1 and V2 (Table 2). It is obvious from Table 3 that means of PD at V1 are nearly similar at each gender group and the highest means of PD at males and totally found in group 2, while at females presented in group 3, the results were 2.43, 2.185 and 1.95 respectively. At V2 means of PD were slightly decreased, although, when each type of regimen at V1 was compared with V2 at each gender group and totally a non significant difference were recorded (Table 5). In V2 the highest means of PD at males, females and totally found in group 2, the results were 2.10, 1.90 and 2.0 respectively. However females demonstrated lower means of PD than males (Table 3). Results from Table 4 and Figure 1 revealed that the percentages of BOP in V1 are nearly similar in each gender group and the highest percentage of BOP in males was found in group 1, the result was 22.86%, but at females and totally recorded in group 3, the results were 21.60% and 21.96% respectively. Placebo group registered slight increase in percentages of BOP at V2 but non significant differences were noted by comparing V1 with V2 at each group. The same results were recorded in respect to group 2 (Table 5), however at V2 higher increase in percentages of BOP than that registered in placebo group were observed, at males, females and totally, the results were 24.11%, 22.143% and 23.13% respectively (Table 4). On the contrary, a significant difference was noted in group 3 by comparing V1 with V2 at each gender group (Table 5). Additionally, at V2 this group demonstrated the highest increase in percentages of BOP at males, females and totally, the results were 27.86%, 27.15% and 27.5% respectively. Finally, females recorded lower percentages of BOP than males at each visit (Table 4).
DISCUSSION By evaluating the effects of treatments on plaque, it is interesting to point out that the three groups experienced a non significant decrease in means of PLI from baseline visit. The explanation of this situation could be attributed to the fact that the subjects may be slightly practiced better oral hygiene measures when they were invited to participate in the study. The other secondary measure of interest was PD. All groups showed a non significant decrease in means of PD by comparing V1 with V2, this finding agree with Schroder et al in 2002 (12) , and it is not in accordance with Royzman et al in 2004 (2) in which they reported that treatment with both aspirin regimens significantly decrease means of PD. Reduction in means of PD could be attributed to the anti-inflammatory effects of aspirin (3,6,14)
and could also be due to the Hawthorne effects, were subjects altered their regular practices due to their participation in a study. Not surprisingly there is a positive relationship between PLI and BOP. This positive association at V1 is supported by an overwhelming amount of evidence, which suggests that microbial plaque near the cervical 64 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of aspirin on the region of teeth causes gingivitis (15,16) . In contrast to the above, at V2 reduction in means of PLI were registered, in spite of that the group treated with 300mg aspirin demonstrated a statistically significant increase in percentages of BOP. However, the subjects in group 1 and group 2 showed a non significant increase in percentages of sites exhibiting BOP. These findings tend to support the results of Schroder et al in 2002 (12) , while Royzman et al. (2) reported a significant increase in percentages of BOP at both aspirin regimens groups. Anti-thrombolytic effects of aspirin (17-19) could explain the increase in percentages of BOP among groups treated with aspirin. However, this dose-dependent effect was somewhat surprising in that several studies indicated that due to aspirin's irreversible acetylation of cyclooxygenase enzyme. The effect of low dose aspirin is cumulative and over time is expected to have anti-thrombolytic activity equivalent to higher doses (17,20) . More recent study indicated that 100mg aspirin significantly reduced platelet aggregation after 4 hours of drug intake and the thromboxane 2 level, was significantly reduced after 7 days of the initial drug uptake, however, this study registered that low doses of aspirin may not achieve an equivalent effect to higher doses within a 1 week period (21) . Generally, females showed lower PLI, PD and BOP than males at V1 and V2, and these results corroborate with previous (2,12,12)
studies (22) , who describes females as having better oral hygiene, less gingival bleeding and less subgingival calculus compared to males. These findings can be explained by the fact that females are more concerned about their appearance especially from esthetic point of view thus they practiced a better oral hygiene regimens than males. Finally, meaningful comparisons between studies are not easy since investigators do not use standard criteria, methodologies can be different and also the interpretation of the data, hence one has to be cautious in this respect, so, in the previously mentioned studies (2,12) they use 81mg and 325mg aspirin regimens and the clinical parameters assessed using an automated pressure-sensitive probe. In spite of these differences, the findings of this investigation tend to slightly confirm the results of these studies.
Table 1: Number and percentage of study population according to treatment regimen by gender.
Table 5: Comparison of clinical periodontal parameters between visit 1 & visit 2 according to treatment regimen by gender. Male Female Total PLI P-value Sig P-value Sig P-value Sig Placebo 0.682 NS 0.556 NS 0.722 NS 100 mg 0.744 NS 0.799 NS 0.683 NS 300 mg 0.788 NS 0.882 NS 0.703 NS PD P-value Sig P-value Sig P-value Sig Placebo 0.092 NS 0.752 NS 0.096 NS 100 mg 0.674 NS 0.922 NS 0.962 NS 300 mg 0.982 NS 0.481 NS 0.892 NS BOP P-value Sig P-value Sig P-value Sig Placebo 0.887 NS 0.825 NS 0.798 NS 100 mg 0.356 NS 0.373 NS 0.202 NS 300 mg 0.033 S 0.031 S 0.002 S *P<0.05 significant, **P>0.05 Non significant 66 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of aspirin on the 78.39 21.61 79.11 20.89 78.04 21.96 77.95 22.05 76.88 23.13 72.5 27.5 0 10 20 30 40 50 60 70 80 % Visit1 Visit 2 Placebo 0 Placebo 1 100 mg 0 100 mg 1 300 mg 0 300 mg 1
Figure 1: Percentage of total bleeding on probing (visit 1 and visit 2).
The findings of this study lend credence to the notion that BOP may be related to an inadequate function of platelets in patients taking aspirin. Thus aspirin intake is an important factor to consider in clinical trials as an inclusion / exclusion criterion, in addition, failure of clinicians to take into account aspirin use in patients undergoing periodontal treatment could lead to false-positive results, which would lead to an improper diagnosis, treatment choice, and assessment of disease activity and progression because aspirin could significantly alter the sensitivity and specificity if one outcome being measured is BOP.
REFERENCES 1- Hennekens CH, Dykan ML, Fuster V. Aspirin as a therapeutic agent in cardiovascular disease; a statement for health care professionals from the American Heart Association. Circulation 1997; 96: 2751-3. 2- Royzman D, Recio L, Rachel LB, Joseph F, Goodson M, Howell H, Nadeem K. The effect of aspirin intake on bleeding on probing in patients with gingivitis. J Periodontol 2004; 75: 679-84. 3- Laurence DR, Bennett PN. Inflammation and non- steroidal anti-inflammatory drugs: Arthritis. In: clinical pharmacology, sixthed. Churchill livingstone, Edinburgh, London & New York. 1987; 279-99. 4- Brown BA. Hematology: Principles and procedures, 6th ed. Lea & Febiger, Philadelphia, 1993, p.268. 5- Liesner RJ, Machin SJ. ABC of clinical haematology. Platelet disorders. Br Med J 1997; 314: 809-12. 6- Craig CR, Stitzel RE. Modern Pharmecology with Clinical Applications. Philadelphia: Lippincott, Williams & Wilkins; 1997; 456-61. 7- Newburn E. Indices to measure gingival bleeding. J Periodontol 1996; 67: 555-61. 8- Heasman PA, Seymour RA, Kelly PJ. The effect of systemically administered flurbiprofen as an adjunct to tooth brushing on the resolution of experimental gingivitis. J Clin Periodontol 1997; 21: 166-70. 9- Jeffcoat MK, Haigh S, Buchanan W, Doyle MJ, Meresdith MP, Nelson SL, Goodale MB, Wehmeyer KR. Comparison of topical ketorolac, systemic flurbiprofen, and placebo for the inhibition to bone loss in adult periodontitis. J Periodontol 1995; 66: 329-38. 10- Lawrence HP, Paquette DW, Smith PC, Maynor G, Wilder R, Mann GL, Binder T, Troullose E, Annett M, Friedman M, Offenbacher S. Pharmacokinetic and safety evaluation of ketoprofen gels in subjects with a dult periodontitis. J Dent Res 1998; 77(11): 1904-12. 11- Al-Waheed ZA. The periodontal status of patients under NSAIDs therapy. A clinical study. A thesis presented to the University of Baghdad for the degree of Master of Science in periodontics 1999. 12- Schrodi J, Recio L, Fiorellini J, Howell H, Goodson M, Karimbux N. The effect of aspirin on the periodontal parameter bleeding on probing. J Periodontol 2002; 73: 871-6. 13- Silness J, Loe H. Periodontal disease in pregnancy. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964; 22: 121-35. 14- Flemming TF, Rumetsch M, Laiber B. Efficacy of systemically administered acetylsalicylic acid plus scaling on periodontal health and elastase-alpha -1- proteinase inhibitor in gingival crevicular fluid. J Clin Periodontol 1996; 23: 153-9. 15- Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965; 36: 177-87. 16- Page R, Schroeder HE. Pathogenesis of inflammatory periodontal disease. A summary of current work. Lab Invest 1976; 33: 235-49. 17- Patrono C, Ciabatton G, Patrignan P et al. Clinical pharmacology of platelet cyclooxygenase inhibition. Circulation 1985; 72: 1177-84. 18- Mealey BL. Periodontal implications. Medically compromised patients. Ann Periodontol 1996; 1: 256. 19- Carranza FA, Newman MG, Takei HH. Clinical periodontology. 9th edition, Philadelphia, W.B. Saunders company 2002; 544. 20- Patrignani P, Filabozzi P, Patrono C. Selective cumulative inhibition of platelet thromboxane production by low-dose aspirin in healthy subjects. J Clin Invest 1982; 69: 1366-72. 21- Bode-Broger SM, Boger RH, Shubert M, Frolich JC. Effects of very low dose and enteric coated acetylsalicylic acid on prostacyclin and thromboxane formation on bleeding time in healthy subjects. Eur J Clin Pharm 1998; 54: 707-14. 22- Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988- 1994. J Periodontol 1999; 70: 30-43. 67 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 Blood groups
Blood groups and hypertension
Nasreen A.R. Wafi MB.ChB, MSc (1)
ABSTRACT Background: Essential hypertension is very common worldwide & it has many harmful effects. The aim of our study was to find whether any relation between blood groups and essential hypertension exists. Materials and methods: 439 hypertensive patients were chosen from the hypertensive clinic in Sulaimanyia , 288 females & 151 males. Their age ranging between 40- 76 years (mean 58). The blood group of these patients was determined. At the same time a control group of 439 non hypertensive persons were chosen in whom the blood groups were determined. Results: A close relation between blood group O and hypertension where 51.2% of hypertensive patients were group O, while 23.5% were group A, 19.8% were group B and 5.2% were group AB. This close relation between hypertension and blood group O was found almost equally in both female & in male patients. Conclusion: Group O people in Sulaimanyia are more prone to have essential hypertension than other blood groups. Keywords: Essential hypertension, Blood groups. (J Bagh Coll Dentistry 2006; 18(2) 68-70)
INTRODUCTION Since the discovery of the ABO blood groups by Landsteiner in 1900, scientists were interested in finding a relation between these groups and different pathologies. The first relation that was found was the relation between gastric cancer and blood group A (1) . The second relation was the relation between peptic ulcer and blood group O (2) . After that different studies were carried out to establish other relations as for example the relation of group A with pancreatic cancer (3) , breast cancer (4) , upper urinary tract cancer (5)
ovarian cancer (6) and bladder cancer (7) . The relation between blood groups and pulmonary function was studied (8) , that with asthma (9) . The relation between these groups and psychological disorders (10) , urinary tract infections (11) & cardiovascular diseases (12) are documented. Thus the ABO system may be considered a predisposing factor in some pathology especially if environmental & heredity factors were added.
MATERIALS AND METHODS Essential hypertensive patients were chosen from the hypertensive unit in Sulaimanyia. Blood group were determined by the slide method using the anti-A & anti-B sera (Sera clone, Biotest). Blood groups of 439 normal people were determined at the same time to see the normal distribution of blood groups in Sulaimanyia from the period 1/11/2003- 1/3/2004
(1) College of Medicine, University of Sulaimanyia
For statistical analysis, the Chi square was used to estimate the significance of the results.
RESULTS As shown in table 1, the percentage distribution of essential hypertension was highest in group O people. Group O is the most frequent blood group as mentioned in text books, but in Sulaimanyia the distribution of group A was as equal as that of group O. Normally there is no gender difference in the distribution of blood groups as they are genetically determined & are carried with the autosomal chromosomes. The distribution of blood groups in male & in female hypertensive were determined as shown in table (2) to see whether any difference exist.
DISCUSSION Essential hypertension is by far the most common form of hypertension. It is the subject of great concern because of its high prevalence among the population and because of the great risk it can cause to different systems in the body. It can be the cause of a heart attack or can lead to hypertensive encephalopathy, hypertensive nephropathy & hypertensive retinopathy. It affects both genders about equally (12) . The main incidence falls between the ages of forty and sixty. It accounts for about 20% of all deaths over the age of fifty. Like other forms of cardiovascular diseases it is a mixture of genetic and environmental influences. Heredity is important and the disease tends to run in families (12) .
68 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 Blood groups
Table 1: Distribution of blood groups in hypertensive & in controls (using the Chi square there was a highly significant difference between both groups . The P-value was less than 0.01)
Blood Group Hypertension % Control % A 103 23.5% 148 33.7% B 87 19.8% 99 22.5% AB 23 5.2% 36 8.2% O 226 51.5% 156 35.5% TOTAL 439 439
Table 2: Distribution of blood groups in female & in male hypertensives (Using the Chi square there was no significant difference between the two groups) % Female hypertensives % Male hypertensives Blood Group 23% 68 23.6% 35 A 17.8% 60 20.8% 27 B 5.2% 15 5.2% 8 AB 53.6% 145 50.3% 81 O 288 151 TOTAL
Studies have been carried out to show the relation between blood groups and cardiovascular pathologies. Most of these studies pointed to a possible relation between blood group A and cardiovascular diseases (13- 20) . Wincap studied the relation between blood groups and platelet function (21) , while Robinson studied the relation between blood groups and venous thromboembolism (22) . Wong studied the relation of blood groups and cholesterol level in Japanese people (23) . He pointed to the possible relation with blood group A, while Malatani (24)
did not find this relation. One study was done on hypertension (25) , but it concluded that no relation existed between blood groups & hypertension. Our study showed a significant relation between blood group O & essential hypertension as shown in table 1. Essential hypertension makes about 95% of total cases of hypertension (12) . Probably the relation of group A to cardiovascular diseases that was found in western & in Japanese communities (as mentioned in the previous references) is not found in our community.
REFERENCES 1- Aird L, Bentall H. Relationship between cancer of stomach & ABO blood groups. BMJ 1953; 1: 799-801. 2- Aird L, Bentall H, Mehigan JA. Blood groups in relation to peptic ulceration & carcinoma of colon, rectum, breast & bronchus. BMJ 1954; 2: 321-5. 3- Aird L, Bentall H. ABO Blood groups & cancer of oesophagus, cancer of pancreas & pituitary adenoma. BMJ 1960; 1: 1163-6. 4- Anderson DE, Haas C. Blood type A & familial breast cancer. Cancer 1984; 54: 1845-9. 5- Kvist E. Relationship between blood groups & tumors of the upper urinary tract. Scan J Urol Nephrol 1988; 22: 289-91. 6- Zhan G. Influence factors in etiology of epithelial ovarian cancer. Chunig Hua Fu Chan Ko Tsa Chih 1997; 31(6): 357-60. 7- Nakatas P. Epidemiologic studies of risk factors for bladder cancer. ACTA Urologica japonica 1995; 41(12): 969-77. 8- Kauffmann F, Frette C, Pham QT. Association of blood group-related antigens to FEVI, wheezing & asthma. Am J Respir Crit care Med 1996; 153(1): 76-82. 9- Mozalevskii AF, Polymorphic blood system in children with bronchial asthma. Tsitol Genet 1985; May-Jun; 19(3): 220-5. 10- Rinieris P, Rabavilas A, Lykouras E. Neurosis & ABO blood types. Neuropsychobiology 1983; 9(1): 16-8. 11- Voigtmann B, Burchardt U. ABO blood groups in patients with nephropathies. Z Gesamte Inn Med 1991; 46 (5): 156-9. 12- Davidsons text book of medicine ,18 th ed,Chap.3;216- 23. 13- Ismagilov MF, Petrova SE. ABO blood group system and vegetative-vascular orders in children. Zh nevropatol Psikhiatr 1981; 81(10):1487-8. 14- Meshalkin EN, Okuneva GN. ABO and Rh blood groups in cardiovascular pathology. Kardiologiia 1981; 21 (4): 46-50. 15- Erikssen J, Thaulow E. ABO blood groups and coronary heart disease (CHD). A study in subjects with severe & latent CHD. Thromb Hemostat 1980; 18; 43 (2): 137-140. 16- Galeazzi L, Gualandri V. ABO blood-group phenotypes & pathogenesis of cardiovascular diseases.Congenital,rheumatic & coronary heart disease & arterial hypertension. G Ital Cardiol 1975; 5(5): 744- 51. 69 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(2), 2006 Blood groups
17- Allan TM. ABO blood groups age & work in ischemic heart disease. Atherosclerosis 1975; 21(3): 459-61. 18- Whncup PH, Cook DG. ABO blood group & ischemic heart disease in British men. BMJ 1990; 30: 300(6741): 1679-82. 19- Rosenberg L, Miller DR. Myocardial infarction in women under 50 years of age. JAMA 1983; 25: 250(20): 2801-6. 20- Platt D, Muhlberg W, Kiehl L. ABO blood group system, age, gender, risk factors & cardiac function. Arch Gerontol Geriatr 1985; 4 (3): 241-9. 21- Sweeney JD, Labuzetta JW. Platelet function & ABO blood group. Am J Pathol 1989; 91(1): 79-81. 22- Robinson WM, Roisenberg I. Venous thromboembolism & ABO blood groups in a Brazilian population. Hum Genet 1980; 55(1): 129-131. 23- Wong FL, Kodama K, Sasaki H. Longitudinal study of the association between ABO phenotype & total serum cholesterol level in Japanese cohort. Genet Epidemiol 1992; 9(6): 405-18. 24- Malatani TS, Katowah RA. Gall bladder disease & ABO blood groups. Afr J Med Sci 1997; Sep-Dec; 26(3-4): 141-3. 25- Gillum RF. Pressure & Obesity in adolescent. J Nati Med Assoc 1991; 83 (8): 682-8.
70 Oral and Maxillofacial Surgery and Periodontology J Bagh Coll Dentistry Vol. 18(1), 2006 Relations between Relations between dental plaque, gingivitis & dental caries among 21-50 years dental patients
Vian M. Al-Jaf B.D.S., M.Sc. (1)
ABSTRACT Background: The reason for this study was to find the relation between dental plaque, gingivitis and dental caries. Materials and methods: The study was conducted among 52 patients attending department of periodontics, college of dentistry, Arbil, age (21-50) years grouped into 3 age groups. The plaque index (PI), gingival index (GI), calculus index simplified (Cal-SI) and dental caries from the DMFS were used. Results: Positive correlation between PI and GI (r =0.48) & weak positive correlation between PI and Cal-SI (r =0.33). But negative correlation was found between PI and DMFS (r =-0.059). No significant differences were found for each of plaque, calculus and gingival indices between different age groups (P >0.05). The study showed higher mean number of DMFS in the age group (31-40) years with no significant differences between age groups and gender. Conclusion: Gingivitis is plaque associated disease but dental caries is not. Key words: Plaque, gingivitis, dental caries. (J Bagh Coll Dentistry 2006; 18(1) 71-74)
INTRODUCTION1 Both gingivitis and dental caries are plaque related diseases; the presence of plaque has been established as being a precondition for gingivitis, with the presence of strong association between plaque, calculus and periodontal disease (1) . Carious lesions may be considered as local plaque retentive sites and may be regarded as etiologic factors in periodontal diseases. However, little is known about the relationship between the presence of such lesions and progression of periodontal diseases (2) . Numerous investigators have attempted to determine the relation between the occurrence of periodontal diseases and dental caries. Many controversies were published with no clear cut positive or negative relationships have been established; although a positive correlation between them claiming that both diseases are caused by the same dental plaque (1- 3) . Some authors suggested an inverse relation between gingivitis & dental caries (4,5) and on the other hand no correlation had been found by Skier and Mandel (6) . The present study was conducted to find the relation between plaque, gingivitis & dental caries.
MATERIALS AND METHODS Fifty two adult patients (24 females and 28 males) were examined with an age range between 21-50 years attending department of
(1) Assistant lecturer, Department of Periodontics, College of Dentistry, University Of Salahaddin, Erbil
periodontics, college of dentistry, Arbil, during February and March, 2005.The patients were divided into three age groups as follows: Group 1: 21-30 years, Group 2: 31-40 years, and Group 3: 41-50 years. Every patient was examined generally to exclude any systemic disease. A complete dental examination was performed and the following indices were recorded: Plaque index (7) , gingival index (8) , simplified calculus index (9) and dental caries from Decay, Missing, and Filling Surfaces (DMFS) (10) , clinical examination of surfaces was conducted using mirror &dental explorer. After a complete examination was performed, All patients then received complete treatment including scaling, polishing and root planning with instructions about the most scientific method of tooth brushing and the use of dental floss with brief explanation of its effectiveness in reducing of inter proximal plaque accumulation, to overcome any periodontal problems in the future.
RESULTS All results were subjected to statistical analysis using t-test and Pearson correlation. The distribution of patients examined according to their age and gender are represented in figure 1. The highest percentage was for group 1 and was decreased in the older age groups. Regarding the mean number of plaque, gingival and calculus indices are shown in table 1 and for the total sample, plaque and gingivitis were of moderate type while calculus of mild type only. No significant differences were found for each of plaque, calculus and gingival indices between different age groups and Oral and Maxillofacial Surgery and Periodontology 71 J Bagh Coll Dentistry Vol. 18(1), 2006 Relations between gender (P>0.05). Pearson correlation between plaque and gingival indices was positive (figure 2) since the correlation coefficient (r=0.48), while Pearson correlation between plaque and calculus was weak positive since the correlation coefficient (r=0.33) (figure 3). The mean number of DMFS is shown in table 2; for total male & female it was higher in age group 2 and lowest in younger age group (group 1), with no significant differences between age groups and gender. The correlation coefficient between PI and DMFS or caries experience (r= -0.059) means negative correlation between them. The correlation between PI and DMFS is represented graphically in figure 4. There are highly significant differences in relation to plaque and DMFS between the three age groups.
0 10 20 30 40 50 60 70 No. % No. % Female Male V a l u e s Age groups 21-30 Age groups 31-40 Age groups 41-50
Figure 1: Distribution of patients according to their age and gender.
Table 1: Mean and standard deviation of plaque, gingival, and calculus indices, by age groups and gender.
0 0.5 1 1.5 2 2.5 3 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Pati ents V a l u e s plI GI
Figure 2: Correlation between mean plaque and gingival indices.
Pl GI Cal-SI Age groups in Years Gender Mean SD Mean SD Mean SD M 1.31 0.57 1.24 0.61 0.86 0.55 F 1.11 0.44 1.52 0.41 0.91 0.46 G 1-21-30 T 1.23 0.52 1.36 0.55 0.88 0.51 M 1.21 0.30 1.40 0.36 0.70 0.49 F 1.27 0.24 1.47 0.49 1.23 0.82 G 2 -31-40 T 1.27 0.26 1.45 0.42 1.05 0.73 M 1.60 0.31 1.82 0.24 1.32 0.48 F 0.80 0.00 0.80 0.00 0.80 0.00 G 3-41-50 T 1.49 0.41 1.67 0.44 1.24 0.48 M 1.35 0.47 1.40 0.54 0.92 0.55 F 1.19 0.36 1.47 0.44 1.08 0.65 Total T 1.28 0.43 1.43 0.49 0.99 0.60 Oral and Maxillofacial Surgery and Periodontology 72 J Bagh Coll Dentistry Vol. 18(1), 2006 Relations between Table 2: Mean and deviation of DMFS by age groups and gender. DMFS Age groups in Years Gender Mean SD M 11.60 7.46 F 12.55 6.28 21-30 T 12.00 6.87 M 27.00 15.25 F 28.33 20.47 31-40 T 27.84 18.28 M 23.00 11.88 F 36.00 0.00 41-50 T 24.86 11.91 M 17.89 12.49 F 21.42 17.01 Total T 19.52 14.71 0 0.5 1 1.5 2 2.5 3 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Pati ents V a l u e s plI calI
Figure 3: Correlation between mean plaque and calculus indices. 0 10 20 30 40 50 60 70 80 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Pati ents V a l u e s plI DMFS
Figure 4: Correlation between mean plaque and DMFS.
DISCUSSION The results of the present study shows positive correlation between plaque and gingival indices and this agrees fairly well with El-Samarrai 1992 (11,12) . Others found high significant and strong positive correlation between plaque & gingivitis (13-15) . Plaque accumulation results in gingivitis because plaque is composed mainly of bacteria, in the presence of bacterial challenge, numerous acquired and innate risk factors may influence the initiation and progression of periodontal disease (16) . The plaque index in this study measured the severity in or near the gingival sulcus only, but recent data indicate that periodontal pathogens reside in other sites intraorally such as tongue , mucosa, saliva and tonsils other than gingival sulcus and periodontal pockets and translocations might occur between these ecologic niches as well as between individuals (17, 18) . The effect of plaque is pointed out that the bacterial masses which accumulate at or in the gingival sulcus possess an array of antigens and possibly polyclonal activators capable of triggering sequences of host-mediated events that have been postulated as mechanisms of tissue destruction (19) . The moderate type of plaque results usually in moderate gingival inflammation that is to say a direct correlation between the amount of bacterial plaque and the severity of gingival inflammation 20 ( ) . Calculus is of grade one only or of mild type because calculus formation is influenced Oral and Maxillofacial Surgery and Periodontology 73 J Bagh Coll Dentistry Vol. 18(1), 2006 Relations between by saliva content (21) . Low severity of calculus comes in accordance with Hugoson et al (22)
who indicate a low severity of calculus among younger age groups in Sweden. This study showed negative correlation between plaque and caries experience by tooth surfaces and this come in agreement with other studies (23, 24) that support the hypothesis that plaque and dental caries are negatively associated. Plaque composed mainly of microorganisms about 109 organisms are present in 10 mg of plaque and the initiation of caries lesions requires the presence of cariogenic microorganisms, fermentable carbohydrates and susceptible tooth, for a significant time and the most efficient cariogenic organisms are Streptococcus mutans (25) . Acid production is the major output of metabolic activity for a number of bacterial plaques and any interference with this process may restrict the growth of Streptococcus mutans, and zinc in saliva was proved to depress acid production from glucose by these organisms (26) . A negative association between dental caries and salivary concentration of zinc, potassium and magnesium was observed by Ibrahim (27) . Buffer capacity of saliva may result in this negative correlation in addition to the effect of some minerals (28) . It may be concluded that clinical data collected in the dental clinic and statistical analysis of the data confirm that positive correlation exists between plaque and gingival index measurements, weak positive correlation between plaque and calculus index measurements, negative correlation between plaque and caries experience distributed by tooth surfaces.
REFERENCES 1. Loe H, Theilade E, J ensen S. Experimental gingivitis in men. J Periodontol 1965; 36:177-87. 2. Axelsson P, Lindhe J . Effect of controlled oral hygiene procedures on caries & periodontal disease in adults. J Clin Periodontol 1987; 5: 133. 3. Fermin A, Carranza, Michael G, Newman. Clinical Periodontology. 8th edition. 1996; 79. 4. Greene J S. Periodontal disease in India: report of an epiodemiological study. J Dent Res 1960; 39: 302 5. Ramfjord SP. the periodontal status of boys 11-17 years old in Bomby, India. J Periodontol 1961; 32:237. 6. Skier J , Mandel ID. Comparative periodontal status of caries resistant versus susceptible adults. J Periodontol 1980; 51: 614. 7. Silness J , Loe H. Periodontal disease in pregnancy II. Acta Odontol Scand 1964; 24: 74759. 8. Loe H, Silness J. Periodontal disease in Pregnancy I. Acta Odontol Scand 1963; 21: 53351. 9. Green J C, Vermilion J . The simplified oral Hygiene Index. J ADA 1964; 68: 7-13. 10. World Health Organization. Oral Health surveys; Basic Methods. 3rd ed. Geneva, WHO. 1987 11. El-Samarrai S. Relations between Dental Plaque, gingivitis & dental caries among children attending clinic of prevention, college of dentistry. Iraqi Dental J 1992; 7. 12. March P. Microbial ecology of dental plaque & its significance in health & disease. Adv Dent Res 1995; 8(2): 263 -71. 13. Miklos M, Breuer, Roberta S, Cosgrove. The relation between gingivitis & plaque levels. J Periodontol 1989; April: 1725. 14. Al-Sayyab MA. Oral Health Status among fifteen years old school children in the central region of Iraq. M.Sc. Thesis. College of dentistry, University of Baghdad. 1989 15. El-Sammarrai S. Major & trace elements contents of perminant teeth & saliva, among a group of adolescent, in relation to dental caries , gingivitis, & mutans streotococci. Ph.D. thesis, college of Dentistry, University of Baghdad. 2001 16. Mcleod D. A practical approach to the diagnosis and treatment of periodontal disease. J ADA 2000; 131: 483. 17. Greenstein G, Lmster I. Bacterial transmission in periodontal disease: a critrical review. J Periodontol 1997; 68: 421-31. 18. Quirynen M, Desoete M, Dierickxk Van Steenbrghe. The intra oral translocation of periodontal pathogens jeopardizes the outcome of Pd therapy. A review of Literature. J Clin Periodontol 2001; 28: 499-507. 19. J an Lindhe. Clinical periodontology & Implant Dentistry. 3rd edition. Munksgard. 1998 20. Eley BM, Manson J D. Text book of Periodontics; 2004. 5th edition, P 39. 21. Norman J E, McGurk M. Color Atlas & Text of salivary glands. Mosby. Wolf London; 1995; 42-5. 22. Hugoson A, Koch G, Bergendal T. Oral Health of individual aged 3-80 years in J onkoping Sweden, in 1973 & 1983. Swed Dent J 1986; 10: 175. 23. Green J S. Periodontal disease in India : report of an epidemiological study . J Dent Res 1960; 39: 302. 24. Liisi A, Sewon, J uija H, Parvinen, Tauno VH Sinisalo, Markku A, Larmas, Pentti J ., Alanen. Dental status of adults with & without periodontitis. J Periodontol 1988; Sept: 595-98. 25. Soames J V, Southern J C. Textbook of oral pathology, 3rd edition. 1998; p.24. 26. Harrap GJ , Best J S, Sexton GA. Human Oral retention of Zinc from mouth washes containing zinc salts & its relevance to dental plaque control. Arch Oral Biol 1984; 29: 87-91. 27. Ibrahim R. Relation between saliva zinc concentration & dental caries experience in dental students. College of Dentistry, university of Baghdad. 1993 28. Ashley F, Wilson R, Woods A. An initial evaluation of two caries prediction kits. J Dent Res 1983; 2 :17
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Drainage of submandibular abscess by using local anesthetic block technique of transverse cervical cutaneous nerve of the neck
Anwar A.Al-Hussain Al-Saeed, B.D.S., M.Sc. (1)
ABSTRACT
Background: The purpose of the current study was to create a painless drainage of submandibular abscess by using local anesthetic block technique of transverse cervical cutaneous nerve of the neck. Patients and Methods: Ninety-seven patients attending College of Dentistry /University of Baghdad, and Private Clinic in the period between (J anuary 2002-October 2004) were selected. The average age of the patients was ranged between 14-63 years from different socioeconomic status. Sixty-one were females, and thirty-six were males. All the patients were complaining of submandibular abscesses with severe pain huge swelling of different duration, and of several odontogenic etiologies. Clinical and radiographic examination was evaluated depending mainly on orthopantomography due to the presence of severe trismus. The patients were divided into two groups. The control groups (48 patients) who were treated by ordinary technique, by using topical ethyl chloride, incision, drainage, insertion of corrugated drain with suturing, covered by heavy dose of antibiotics according to the sensitivities of the patients. While the study group (49 patients) who were treated by using local anesthetic block technique of transverse cervical cutaneous nerve at the lateral side of the neck at the level of thyroid cartilage (Adams` apple). Measurement records of pain severity were registered during incision, drainage, and insertion of corrugated drain with suturing. Also other measurements were recorded for the state of consciousness of the patients during their treatments. Results: The study reported that 46 (96%) cases of the control group had severe pain during incision of the skin and subcutaneous layer over submandibular abscess in comparison to 0 (0%) case of the study group which showed no pain. The control group showed 48 (100%) cases having severe pain during drainage of submandibular abscess in comparison to 31(63%) cases of the study group, which shows no pain. Also 47 (96%) cases of the study group shows no pain by using local anesthetic block technique of transverse cervical cutaneous nerve in comparison to 48 (100%) cases which have severe pain. The study reported that 17 (35.4%) cases of control group showed fainting during drainage of submandibular abscess in comparison to only 5(10.4%) cases of the study group. No signs and symptoms of hematoma, ecchymosis, or parasthesia was detected during the use of local anesthetic block technique of transverse cervical cutaneous nerve. Conclusions: Incision through skin, and subcutaneous layer over submandibular region to drain a chronic abscess can be done safely without significant pain or spread infections as well as no significant pain during insertion of corrugated drain with suturing unlike the ordinary technique. Key words: Submandibular abscess, Transverse Cervical Cutaneous Nerve. (J Bagh Coll Dentistry 2006;18(2) 75-82)
INTRODUCTION Odontogenic infections are usually mild and easily treated which may require the administration of an antibiotic. Odontogenic infections may be more complex and require an incision and drainage, or they may be more complicated, which require admistration the patient to the hospital. Some infections that occur in the oral cavity are preventable if the surgeon uses appropriate antibiotic prophylaxis. (1-5) These infections may range from low-grade, well-localized infections that require only minimal treatment to severe, life threatening fascial space infections. (6-8) Odontogenic infections are caused by bacteria, which act as a part of the normal oral flora.
(1) Assistant professor, Chairman of Department of Oral and Maxillo-Facial Surgery, College of Dentistry, University of Baghdad.
Those are primarily aerobic gram-positive cocci, anaerobic gram-positive cocci, and anaerobic gram-negative rods. When these bacteria gain access to deeper underlying tissues, through a necrotic dental pulp or through a deeper periodontal pocket they cause odontogenic infections. (9-11) Most odontogenic infections penetrate the bone in such a way that they become vestibular abscesses. On occasion they erode into fascial spaces directly, and causing fascial space infection (12,13) (Figure 1). Fascia Spaces: They are fascia-lined areas that can be eroded or distended by purulent exudate. These are potential spaces that do not exist in healthy people, but become filled during infections. (14) Although, most infections of the posterior mandibular teeth erodes into the submandibular spaces if the infections erodes through the medial aspect of the mandible just Oral and Maxillofacial Surgery and Periodontology 75 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
inferior to the mylohyoid line. The mandibular third molar is the most commonly involved then follow by the second, and first molar. (15) The submandibular space: It lies between the mylohyoid muscle and the overlying skin and superficial fascia. The posterior boundary of the submandibular space communicates with the secondary spaces of the jaw posteriorly. (16)
Infection of the inferior border of the mandible may extend medially to the digastric muscle, and posteriorly to the hyoid bone. When bilateral submandibular, sublingual, and submental spaces become involved with an infection it is known as Ludwigs angina. (17)
This infection is a rapidly spreading cellulitis that commonly spreads posteriorly to the secondary spaces of the mandible. Severe swelling is almost always seen with elevation and displacement of the tongue, with tense hard induration of the submandibular region superior to the hyoid bone. (18) The patients have trismus, drooling of saliva, and difficulty with swallowing and sometimes breathing. The patient often experiences severe anxiety concerning the inability to swallow and maintain an airway. This infection may progress with alarming speed and thus may produce upper airway obstruction that often leads to death. (19,20)
Cutaneous Nerves: Cervical Plexus: At the mid point of the posterior margin of the sternocleidomastoid muscle, the superficial branches from the cervical plexus diverge into (21) :- Figure(2) 1. Ascending branches. 2. Transverse branches. 3. Descending branches. 1. Ascending Branches: Include the followings: a. Lesser occipital nerve (C2, C3). b. Greater auricular nerve (C2, C3). Lesser occipital nerve: The smaller one, which ascends along the posterior margin of the sternocleidomastoid muscle to the mastoid process. It divides into auricular, mastoid, and occipital terminal branches. These are sensory branches, which supply the skin of the three areas indicated by their names. (20,21)
Greater auricular nerve: Crosses at a point superficial to the sternocleidomastoid muscle and passes toward the angle of the mandible, dividing into; mastoid, auricular, and facial terminal branches. 2. Descending Branches: Includes; medial, intermedial, and lateral supraclavicular nerves (C3, C4), these are sensory nerves, supplying the skin of the upper anterior chest wall, the upper, and lateral areads of the shoulder. The medial nerve sends fibers to the sternoclavicular joint, and the lateral nerve sends fibers to the acromioclavicular joint. (20,21) 3. Transverse Cervical Branches: (C2, C3); They pass transversely across the posterior boarder of sternocleidomastoid muscle, at the level of thyroid cartilage (Adams` apple), just distally and laterally to the external jugular vein, and divided into superior innervation of the skin and subcutaneous tissue of the fronto- lateral part of the neck. (22)
PATIENTS AND METHODS Patients: Ninety-seven patients were attending College of Dentistry, and Private Clinic in the period between (J anuary 2002-October 2004). The average age of those patients were ranged between 14-63 years of old of different socioeconomic status, sixty one were females with average age ranged from (14-47) years, and thirty six were males of average age ranged of 16-63 years (Table 1). The patients were complaining of submandibular abscesses of both sides of the lower jaw with severe pain, huge swelling according to the stage of the infections, different duration periods, and of odontogenic etiology (Figure 4). All the patients were sent for radiographic examination (Figure 5), mostly dependant on orthopantomography due the presence of severe trismus. Examination of the patients was done by clinical and radiographic examination to determine the etiology, stage of the swelling, extension of the swelling to the neck, consistency of the swelling, and lymphadenopathy (Table 3) Methods: The patients were divided into two groups: - 1.Control group: It consisted of 48 patients, 23 were females, and 25 were males. Those patients were complaining from chronic submandibular abscesses that originated from different infected teeth involving the lower jaw as shown in Table 2. The treatment of submandibular abscesses was done by ordinary technique through using topical ethyl chloride on the fluctuant region of the skin in submandibular region. The incision was done one finger below the inferior boarder of the mandible by using blade (No; 11) for about 4-5 mm in length, deep enough to involve the Oral and Maxillofacial Surgery and Periodontology 76 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
subcutaneous layer and fascia, then complete the opening sinus forceps were used passed deeply through the platysma muscle until reach the submandibular space, through anterior, posterior , and inferior direction to the inner surface of the mandible to create enough poring of pus discharge , then completed by insertion of a corrugated drain in the incised region. During the treatment we determine the degree of the pain, and associated factors that enhance the pain during incision, drainage, and insertion of the drain. 2.Study group: It consists of 49 patients, 28 were females and 21 were males. Those patients were suffered from submandibular abscesses of various infected teeth of their lower jaws, as shown in Table 2. The treatments of chronic submandibular abscesses were done by using local anesthetic block technique for transverse cervical cutaneous nerves far away from the infected region. At the level of thyroid cartilage (Adams` apple) in the midline of the neck, the transverse cervical cutaneous nerve pass from the posterior boarder of large sternocleidomastoid muscle in the lateral side of the neck. In this area the nerve seek curls around the posterior boarder of this muscle as a small trunk, to branch and fan out to innervate the skin of the neck (Figure 3). Before injection of local anesthesia the skin region were disinfected by using habitant (detergent agent) to prevent cross bacterial infections (Figure 6). The local anesthetic solution used with adrenaline concentration of 1:80.000, with the help of aspirating dental syringe to avoid penetration of anesthetic solution into the external jugular vein which passes over the sternocleidomastoid muscle just anteriorly, and laterally to the transverse cervical cutaneous nerve. After trunk location of this nerve the surgeon should be stand behind the patient, and handling the dental syringe horizontally at the same level of the nerve trunk to pierce the skin and subcutaneous region just to do a parallelism of the needle puncture with the same direction of the nerve transmission to avoid damage or tearing the nerve sheath that lead to parasthesia. A quarter quantity of local anesthetic solution will be enough to anesthetize the nerve (Figure 7, 8). After few minutes the skin and the subcutaneous region in the lateral side of submandibular region will be anesthetized, and can be checked by asking the patient about the numbness feeling around nerve distribution areas. An incision was done by (No; 11) blade just one finger below the inferior boarder of the mandible at the fluctuant region (Figure 9-11). Then explore the drainage opening by using sinus forceps in different direction, and inserted the corrugated drain with suturing. A heavy dose antibiotics according to the patients sensitivities were instructed like 500 mg IM twice daily for three days, and heavy dose of metronidazol (Flagyl) (500 mg orally) for anaerobic microorganisms with the help of analgesics. The following records should be registered: - Measurement Records of pain severity: 1. During incision. 2. During drainage. 3. During corrugated drain insertion and suturing. Measurement Records of the level of fainting (Vasovagal attack): 1. Fainting with consciousness. 2. Fainting with unconsciousness. 3. No Fainting.
RESULTS The study showed a highly significant difference between the two groups during the incision technique through the skin and subcutaneous layer in the submandibular region. It was reported that 46 (96%) cases showed severe pain in comparison to 0 (0%) case of the study group, while 47 (96%) cases of the study group showed no pain records by using local anesthetic block of transverse cervical cutaneous nerve technique, as shown in Table 5. Table 6 showed a highly significant difference between the two techniques during drainage of submandibular abscess. The control group shows 48 (100%) cases with severe pain in comparison to 16 (33%) cases that showed severe pain, while, 31 (63%) cases had no pain by the use of local anesthetic block of transverse cervical cutaneous nerve technique. A significant difference was found regarding pain between two techniques during suturing of the corrugated drain. 48 (100%) cases of the control group showed severe pain in comparison to 0 (0%) case of the study group that showed 47 (96%) cases have no pain by using of local anesthetic block of transverse cervical cutaneous nerve technique, as shown in Table 7. Oral and Maxillofacial Surgery and Periodontology 77 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
The study reported that 17 (35.4%) cases of the control group showed fainting of the patient during drainage of submandibular abscess, 5 (10.4%) cases from these develope loss of consciousness, in comparison to 0(0%) case of the study group that showed all patients were not vasovagal attack by the use of local anesthetic block of transverse cervical cutaneous nerve technique as shown in Table 8. No significant differences of complications were observed in both groups during their follow up. Also no signs, and symptoms of any parasthesia or numbness feeling were detected following the used of local anesthetic block technique of transverse cervical cutaneous nerve in those of study group. However, no hematoma or ecchymosis was detected over the skin of the lateral side of the neck. . Table 1: The number of the patients, gender, average age and location of submandibular abscess in the lower jaw Patient No. Gender Average Age (Years) Left side Mandible Right Mandible Male 25(42%) 18-63 Control group (48) Female 23(48%) 14-42 20(42%) 28(58%) Male 21(43%) 14-51 Study group (49) Female 28(57%) 17-47 27(55%) 22(45%) Total 97 14-63 47(48%) 50(52%) Chi-square = 1.947 p-value = 0.377 Non significant
Table 2 Submandibular abscess according to the teeth involvement Patient No. Left Mandible Right Mandible 1 st Molar 2 nd Molar 3 rd Molar 1 st Molar 2 nd Molar 3 rd
Table 4: Spread of infections to other fascial spaces Patient No. Sub massetric spaces Buccal spaces Ptrygomandibular spaces Control group (48) 2(4%) 1(2%) 7(14.6%) Study group (49) 1(2%) 0(0%) 3(6%) Chi-square = 3.528 p-value = 0.1715 Non significant
Table 5: The characteristic features of pain during incision of the submandibular abscess in both groups Severity of Pain Patient No. Slight Moderate Severe No pain Control group (48) 0(0%) 2(4%) 46(96%) 0(0%) Study group (49) 0(0%) 2(4%) 0(0%) 47(96%) Oral and Maxillofacial Surgery and Periodontology 78 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
Chi-square = 0.223 p-value = 0.987 Non significant
Table 6: The characteristic features of pain during drainage of the submandibular abscess in both groups Severity of Pain Patient No. Slight Moderate Severe No pain Control group (48) 0(0%) 0(0%) 48(100%) 0(0%) Study group (49) 0(0%) 2(4%) 16(33%) 31(63%) Chi-square = 1.967 p= 0.373 Non significant
Table 7: The characteristic features of pain during suturing of the corrugated drain within the skin Severity of Pain Patient No. Slight Moderate Severe No pain Control group (48) 0(0%) 0(0%) 48(100%) 0(0%) Study group (49) 0(0%) 2(4%) 0(0%) 47(96%) Chi-square = 0.936 p-value = 0.626 Non significant
Table 8: Incidence of vasovagal attack (fainting) occuring during the treatment of submandibular abscess in both groups Fainting Patient No. Conscious Unconscious No Fainting 12(25%) 5(10.4%) Control group (48) 17(35.4%) 31(64.6%) 0(0%) 0(0%) Study group (49) 0(0%) 49(100%) Chi-square = 3.498 p-value = 0.174 Non significant
DISCUSSION The use of the ordinary technique for drainage of submandibular abscesses may be more painful and more aggressive for the patients whom they tend to refuse the treatment and they prefer to use a heavy dose of antibiotics in spite of drainage of abscesses which may lead to Antibioma. Some of the inefficient surgeon may act as a main cause of this problem for the patient. The feeling of pain during incision technique in the skin and subcutaneous layer in the control group was due to non-anesthetized region in the submandibular area, also drainage by sinus forceps, and suturing of corrugated drain may develop pain, and these are due to contraindication to use local anesthesia in the skin of the developed abscesses which may cause flare up of infections to the more serious facial spaces particularly retropharyngeal spaces which may eventually lead to death, and these were in agreement with Peterson (11,19) , and David Wray (6) . The study reported a significant difference between the two techniques during drainage of submandibular abscesses, which showed 47 (96%) cases with no pain by the use of local anesthetic block of transverse cervical cutaneous nerve at the lateral side of the neck, which becomes more comfortable for the patient than the ordinary way. This was due to anesthetized skin and subcutaneous layer in the region of submandibular area and anterior part of the neck, which supply by terminal branches of the transverse cervical plexus that give the sensory innervations of the lateral side of the neck. This is in agreement with Hamilton (22) , and Roycel Montgomery (20) .
Oral and Maxillofacial Surgery and Periodontology 79 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
Figure 1A: Facial swelling in the B;Chronic Submandibular abscess Right side of 49 years adult female
Figure 4: Impacted lower 3 rd molar Figure 5: Digital panoramic is one of causes of submandibular radiographs shows lower second abscess molar with chronic abscess
Oral and Maxillofacial Surgery and Periodontology 80 J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of
Figure 6: Use habitant at the site of Figure 7: Site of block injection of T.C.C.N. injection T.C.C.N at level of thyroid cartilage
Figure 8: Site of injection from other Figure 9: Site of incision and side of view drainage of submandibular abscess
Figure 10: Site of drainage from other Figure 11: After one week from Side of view drainage & treatment
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The current study shows that no signs and symptoms of complications in the study group like parasthesia or hematoma of the skin, and these were due to correct localization of block technique injection of the anesthesia, no nerve damage will developed, and no damage to the external jugular vein were detected due to the use of aspirating dental syringe, and these were in agreement with Roycel Montgomery (20) . 6. David Wray, David Stenhouse, David Lee et al. textbook of General and Oral Surgery 2003; p: 263-70. 7. Field EA, Martin MV. Prophylactic antibiotics for patients with artificial joints undergoing oral and dental surgery: necessary or not. J Oral Maxillofacial Surg 1991; 29 B: 341. 8. Haug RH, Picard U, Indreasano AT. Diagnosis and treatment of the retropharyngeal abscess in adults. J Oral Maxillofacial Surgery 1990; 28B: 34. However, there were no signs and symptoms of spreading infections by the use of local anesthetic block technique of transverse cervical cutaneous nerve, and these were due to the fact that the injection site was too far from the infections site (abscess), and no flare-up were detected during the follow up, and these are in agreement with Field et al. (7) , Lewis (15) , and Petersson (11) . 9. Heimdahl A, Nord CE. Treatment of orofacial infections of odontogenic origin, second. J Infect Dis 1985; 46 (suppl): 101. 10. Killey and Kays. Outline of Oral Surgery, Part I. Second edition 1987; p: 121-174. 11. Peterson LJ . Contemporary management of deep infections of the neck. J Oral Maxillofac Surg 1993; 51: 226. 12. Maclan D, Preece PE. Lecture Notes on Clinical Medicine and Surgery for Dental Students. Third edition 1986; p: 9,284,292. The development of vasovagal attack were highly significant in the control group than the study group, with only 5 (10.4%) cases developed unconsciousness, and these were due to severe pain during incision, drainage by sinus forceps, and suturing of corrugated drain in the control group, but the majority cases 31 (64.6%) were not developed vasovagal attack, and these were due to anesthesia of the drainage areas of the skin and subcutaneous layer in the submandibular region, which is in agreement with Roycel Montgomery (20) . 13. Labrioia J D, Mascaro J , Alpert B. The microbiologic flora of orofacial abscesses. J Oral Maxillofacial Surgery 1983; 41: 711. 14. Peterson L, Ellis E, Hupp J R, Tucker MR. Contemporary Oral and Maxillofacial Surgery forth edition 2003; P: 344-367. 15. Lewis MAO et al. A randomized trial of co- amoxiclav (Augmentin) versus penicillin V in the treatment of acute dentoalveolar abscess. Br Dent J 1993; 175: 169. 16. Lewis MAO. Prevalence of penicillinresistant bacteria in acute suppurative oral infection. J Antimicrob Chemother 1995; 3513: 785. 17. Macrciani RD. Clinical consideration in head and neck infections in. Principles of oral and maxillofacial surgery 1992 Philadelphia, J B Lippincott. REFERENCES 18. Onderdonk AB. Use of an animal model system for assessing the efficiency of antibiotics in treating mixed infections, Infect Dis Clin Prac 1994; 3(suppl I): 528. 1. Barratt GE, Koopmann CF, Coulthand SW. Retropharyngeal abscess: a ten years experience. Laryngoscope 1984; 94: 455. 2. Beck HJ et al. Life threatening soft tissue infections of the neck, Laryngoscope 1984; 94: 354. 19. Peterson LJ . Antibiotic prophylaxis against wound infections in oral and maxillofacial surgery, J Oral Maxillofac Surg 1990; 48: 617. 3. Conover MA, Kaban LB, Mulliken J B. Antibiotic prophylaxis for major maxillocranial surgery. J Oral Maxillofacial Surg 1985; 48: 865. 20. Roycel Montgomery. Head and Neck Anatomy. 1981; P: 28-30,98-99. 21. Sclar DA, Tartaglione TA, Fine MJ . Overview of tissue related to medical compliance with implications for out 336 patients management of infectious diseases. Infect Agents Dis 1994; 3: 266. 4. Peterson LJ . Microbiology of head and neck infections, Atlas oral Maxillofac Surg Clin North Am 1991; 3: 247. 5. Quayle AA, Russell C, Hearn B. Isolated from severe odontogenic soft tissue infections; their sensitivities to cefotetan and seven other antibiotics and implications for therapy and prophylaxis. J Oral Maxillofac Surg 1987; 25B: 34. 22. Hamilton WJ . Textbox of Human Anatomy Second edition. 1987; p: 627-8
Oral and Maxillofacial Surgery and Periodontology 82 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically Treatment of clinically evident skeletal mandibular asymmetry
Nidhal H. Ghaib B.D.S., M.Sc. (1)
Ali F. Al-Zubaidee B.D.S., F.D.S.R.C.S., F.F.D.R.C.S. (2)
Zina Z. Al-Azawi B.D.S., M.Sc. (3)
ABSTRACT Background: Orthodontists are frequently called upon to treat conditions in which there is asymmetry, either dentally, skeletally, or dentoskeletally, between the patients' right and left sides. Such asymmetries exist in all degrees of severity. It is well known that correction of dental and functional asymmetries can be accomplished with orthodontic treatment only whereas skeletal asymmetries are considered to present difficult orthodontic treatment problems and require orthopedic treatment and/ or surgical intervention. The aim of this study was to assess the extent to which combined orthodontic and surgical treatment are applied to treat patients with mandibular asymmetry. Materials and methods: The sample of this study consisted of 33 patients with different skeletal clinically evident mandibular asymmetry conditions. Comprehensive examination protocol was established for each patient and the deformity of mandibular asymmetry had been classified according to Henderson (1985) and J ames (1990) into 6 different conditions. Then the treatment has been determined according to each individual case following the policy of each of the operators in the different hospitals from which the sample had been collected. Results: The treatment of mandibular asymmetry conditions was found to be mostly achieved by surgical intervention with or without orthodontic treatment. Conclusion: The importance of the teamwork for the treatment of the candidates for orthognathic surgery was found to be realized by the operators in the different hospitals from which the sample had been collected but it needs to be emphasized and reinforced to be a well-established policy for the treatment of such cases. Keywords: Mandible, asymmetry, orthognathic surgery. (J Bagh Coll Dentistry 2006;18(2)83-88)
INTRODUCTION 1
It is well known that correction of dental and functional asymmetries can be accomplished with orthodontic treatment only whereas skeletal asymmetries are considered to present difficult orthodontic treatment problems and require orthopedic treatment and/or surgical intervention (1- 4) . With the advent of orthognathic surgery, the orthodontists role in diagnosis and treatment planning of cases involving skeletal disharmony has expanded greatly. Since contemporary surgical procedures can alter the bones relationship of the craniofacial complex, it is important that the orthodontist accurately assess the degree to which skeletal disharmony contributes to a given malocclusion before he/she formulates treatment objectives. Thus, close cooperation between the orthodontist and the oral and maxillofacial surgeon is needed (5, 6) .
(1) Professor, Department of orthodontics, college of dentistry, university of Baghdad. (2) Professor, college of medicine, university of Nahrain. (3) Assistant lecturer, Department of orthodontics, college of dentistry, university of Baghdad.
MATERIALS & METHODS
From the information elicited from the patient's history and clinical examination aided by orthodontic and surgical records, the diagnosis has been established for each of the 33 patient with skeletal clinically evident mandibular asymmetry, and according to Henderson (1985) (7) and J ames (1990) (8) , the asymmetric mandibular condition for each patient had been classified. Then treatment has been determined according to each individual case following the policy of each of the operators in the different hospitals from which the sample had been collected as follows: 1. Orthodontic treatment. 2. Surgical treatment. 3. Combination treatment.
RESULTS Table 1 shows counts and percentages for each condition with the treatment method, for the treatment method with each condition, and for the total. As the table shows that 20 patients out of 33 have been operated upon and only one patient out of 33 had been followed up. Orthodontic treatment alone constitutes 4.8%, while surgical treatment alone constitutes Orthodontics, Pedodontics and Preventive Dentistry 83 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically 61.9%. Combination treatment on the other hand, had been performed for 19.1% of the patients: 4.8% with presurgical orthodontics and 14.3% with postsurgical orthodontics. For 9.5% of the operated upon patients with presurgical orthodontics, it was decided to perform surgical intervention after the completion of their orthodontic phase of treatment. In only 4.8%, the treatment was postponed and follow up was indicated. Table 2 shows the methods applied for treatment of mandibular asymmetry and it is quite obvious that the females 12 patients were more willing to seek treatment than the male 8 patients.
DISCUSSION In this study, 20 patients out of 33 with mandibular asymmetry have been operated upon. As table 1 shows orthodontic treatment alone had been performed for 4.8% of the cases. This case was a mild form of HME and orthodontic treatment alone in form of upper and lower fixed appliances were satisfactory for the patients needs. Presurgical orthodontic treatment as a preparatory phase prior to the surgical intervention had been performed for 9.5% of the patients. Those patients had severe constricted maxilla with complete crossbite and upper and lower dental crowding, so presurgical orthodontics in the form of upper and lower fixed appliances were indicated to expand the upper arch and to remove dental compensations and crowding before surgery, which will be performed for those patients after the completion of the orthodontic phase of treatment. Surgical intervention had been performed for 61.9% of the patients without presurgical orthodontic treatment but postsurgical orthodontics might be performed later on for those patients. The allowed research period precludes the follow up of the patients to the end of the treatment; however, this study found that some of the patients would be encouraged to continue their treatment with orthodontic appliances after performing the surgical intervention. In 19.1% of the cases, combination of orthodontic and surgical treatment had been performed: 4.8% with presurgical orthodontics and 14.3% with postsurgical orthodontics. It is clear that surgical intervention had been performed in approximately all the patients. It is well known that skeletal asymmetries are not corrected orthodontically but rather surgery is employed because orthodontic treatment may align the teeth, but it will not straighten the face. Furthermore, stability, periodontal health and facial balance are optimized when dental midlines shifts that result from skeletal deviation are treated with surgical, rather than orthodontic, tooth movement. Attempts to orthodontically correct the bite when the etiology is skeletal can produce buccal plate violation and gingival recession (2, 9, 10) . When table 2 is reviewed, it can be noticed that a variety of surgical techniques for the treatment of mandibular asymmetry had been performed. In some cases, the surgical procedure did not involve the mandible only, but bimaxillary surgical correction has been required. This was done in cases when the mandibular asymmetry was just one component of existing deformities that may present, or when the occlusal plane was significantly canted especially in cases with craniofacial microsomia and early ankylosis; nevertheless many patients were treated by mandibular surgery only and the net result had been a high degree of patient satisfaction. Treatment of mandibular asymmetry by a variety of surgical procedures have been documented and established extensively in the literature (11-17) . Nevertheless, to achieve the morphological and functional requirements of the treatment, mandibular asymmetry is best managed by a team: the dentist, the orthodontist, and the oral and maxillofacial surgeon. However, in this study it was found that the orthodontic treatment was to be implicated mostly in cases with severe malocclusion so presurgical orthodontics was indicated to remove the dental compensations and to align the teeth within each arch before surgery. In this study, 1 case out of 33 patients presented with a history of late onset of HME (the onset was after 20 years). Suspicion of persistent active growth of the condyle on the affected side made the treatment to be postponed and the case was indicated for follow up for 6 to 12 months to ensure ceasation of the abnormal growth before establishment of treatment; this was done in order to prevent relapse, the most problematic postoperative issue. The follow up is achieved by taking history and full records (panoramic radiograph, lateral and posteroanterior Orthodontics, Pedodontics and Preventive Dentistry 84 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically cephalometric, upper and lower study models, and photographs) for the patient, then after 6 months another history and records will be made and compared with the first one. In the literature (8, 16, 18-22) there is a profound emphasis on what is considered as a more definitive evaluation for the presence or absence of abnormal condylar growth, this is technetium 99 bones scanning. However this method is not applied in the diagnosis of the presence or absence of abnormal growth in cases with mandibular asymmetry in the hospitals from which the sample had been collected because it is considered invasive technique. There is a great deal of literature referring to condylectomy or high condylar shave for treatment of CH; it was frequently used by many authors (7,17,23-27) . Concerning this point, the surgeons in the hospitals from which the sample had been collected follow two treatment options; the first one is to postpone surgery until growth is complete, but the patient may suffer during this period from functional, esthetic and psychological problems. In this study, this was indicated only for 1 case out of 33 patients as previously mentioned. The second option is to perform condylectomy or high condylar shave for the abnormally active condyle combined with orthognathic surgery for correction of the secondary deformity, if present, at the same time as one-stage operation or later on as two-stage operation. In this study, this was not applied for any patient as all the cases (except the case that discussed above) were presented with the abnormal condylar growth had been already settled down. In this study, it is obvious that the treatment plan in applying orthodontics and surgical procedures for those patients with facial asymmetry due to a growth disturbance in the mandible depends to a great extent upon: First: the nature of the deformity. Second: the patient needs. Third: clinical judgment and the experience of the operator. In addition, it is clear that the cooperation between the orthodontist and the surgeon is present but not to the optimal level, especially in the hospitals that have not been provided with orthodontists and orthodontic facilities. Therefore, sometimes the surgeon was reluctant to refer the patient for the orthodontic consultation and treatment before and/or after surgery. On the other hand, it is important for the orthodontist also not to be reluctant to refer such cases for the surgical consultation and treatment for the reasons explained above. Treatment of mandibular asymmetry by a team needs not to be overemphasized and therefore, it is important to reinforce this cooperation and to provide each consultant clinic of oral and maxillofacial surgery with orthodontist to work hand by hand with the surgeon in planning for the treatment of the candidates for orthognathic surgery.
REFERENCES 1. Mulick J K. An investigation of craniofacial asymmetry using the serial twin-study method, Am J Orthod 1965; 51 (2): 112-29. 2. Cook J T. Asymmetry of the cranio-facial skeleton. Br J Orthod 1980; 7: 33-8. 3. Yaillen DM. Case report: Correction of mandibular asymmetric prognathism. Angle Orthod 1994; 2: 99- 104. 4. Sarver DM. Esthetic Orthodontics and Orthognathic Surgery, St. Louis, Mosby Company, 1998. 5. Ellis E, J ohnson DG, Hayward J R. Use of the orthognathic surgery simulating instrument in the presurgical evaluation of facial asymmetry. J Oral Maxillofac Surg 1984; 42: 805-11. 6. Forsberg CT, Burstone CJ , Hanley KJ . Diagnosis and treatment planning of skeletal asymmetry with the submental-vertical radiograph. Am J Orthod Dent of Orthop 1984; 224-37. 7. Henderson D, Poswillo D. A Color Atlas and Textbook of Orthognathic Surgery: The Surgery of Facial Skeletal Deformity, London, Wolfe Medical Publications Ltd, 1985. 8. J ames D. Growth Problems, In: Norman J E and Bramley SP (eds.), Textbook and Color Atlas of the Temporomandibular J ointDiseases-Disorders- Surgery, England, Year Book Medical Publishers, Inc., 1990. 9. Thompson J R. Asymmetry of the face. J Am Dent Assoc 1943; 30 (1): 1859-71. 10. Arnett GW, Bergman RT. Facial Keys to orthodontic diagnosis and treatment planning-Part II. Am J Orthod Dent of Orthop 1993; 103: 395-411. 11. Gottlieb MD, Faust RA. Mandible fractures in children, emedicine 2001. [Internet] 12. Hinds EC, Reid LC, Burch RJ . Classification and management of mandibular asymmetry. Am J Surg 1960; 100: 825-34. 13. Mercier P. Mandibular asymmetry: Proposed classification and an analysis of two cases. J Cand Dent Ass 1969; 35 (3): 146-53. [French] 14. Erickson GE, Waite DE. Mandibular asymmetry. J Am Dent Assoc 1974; 89: 1369-73. 15. Hall HD. Facial Asymmetry. In: Bell WH, Proffit WR and White RP (eds.), Surgical Correction of Dentofacial Deformities, Philadelphia, WB Saunders Company, 1985. 16. Chen Y, Bendor-Samuel RL, Huang C. Hemimandibular hyperplasia. Plast Recon Surg 1996; 97 (4): 730-7. 17. Secchi A, Vanarsdall R. Efficacy of high Orthodontics, Pedodontics and Preventive Dentistry 85 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically condylectomy for management of condylar hyperplasia. Am J Orthod Dent of Orthop 2002; 121: 136-51. [Abstract] 18. Rubenstein LK, Campbell RL. Aberrations of development-Acquired unilateral condylar hyperplasia and facial asymmetry: Report of case. J Dent Child 1985; 114-20. 19. Zide BM. The Temporomandibular J oint, In: McCarthy J G (ed.), Plastic Surgery, Vol. 2, The Face (Part 1), Philadelphia, W.B. Saunders Company, 1990. 20. McCormick SU. Facial Asymmetry-The Diagnostic Challenge, In: Assael LA (ed.): Atlas of the Oral and Maxillofacial Surgery Clinics of North America, Philadelphia, W.B. Saunders Company, 1996: 4 81). 21. Quinn PD. Color Atlas of Temporomandibular J oint Surgery, St. Louis, Mosby, 1998. 22. Vittayakitpong P, Pripatananont P. Bone scintigraphy in the diagnosis and treatment planning of condylar hyperplasia. J Dent Assoc Thailand 2000; 50 (5): 407-14. [Abstract] 23. Bruce RA, Hayward J R. Condylar hyperplasia and mandibular asymmetry: A review. J Oral Surg 1968; 26: 281-90. 24. Graziani M. Laterognathism, supraclusion, and facial asymmetry from condylar hyperplasia. J Oral Surg 1972; 33 (6): 884-7. 25. Norderud RW, Ragab RR. Unilateral condylar hyperplasia and the associated deformity of facial asymmetry-Case report. Scand J Plast Reconstr Surg 1977; 11: 91-6. 26. Norman J E, Painter DM. Hyperplasia of the mandibular condyle-A historical review of important early cases with a presentation and analysis of twelve patients. J Maxfac Surg 1980; 8: 161-75. 27. Carlson ER. Pathologic Facial Asymmetries, In: Assael LA (ed.): Atlas of the Oral and Maxillofacial Surgery Clinics of North America, Philadelphia, W.B. Saunders Company, 1996: 4 (1).
Table 1: Cross tabulation of the conditions with the methods of treatment (descriptive statistics). Methods of Treatment Ortho. / Surg. CONDITION Ortho. Presurg. Ortho. Presurg. Postsurg. Ortho. Ortho. Surg. Follow up Total
(1) [25.0%] {50.0%} ((4.8%))
(3) [75.0%] {23.1%} ((14.3%))
(4) [100.0%] {19.0%} ((19.0%)) Prognathism with Anterior Open Bite (AMP+) Prognathism without Anterior Open Bite (AMP-)
(2) [100.0%] {9.5%} ((9.5%)) Total (1) [4.8%] {100.0%} ((4.8%)) (2) [9.5%] {100.0%} ((9.5%)) (1) [4.8%] {100.0%} ((4.8%)) (3) [14.3%] {100.0%} ((14.3%)) (13) [61.9%] {100.0%} ((61.9%)) (1) [4.8%] {100.0%} ((4.8%)) (21) [100.0%] {100.0%} ((100.0%)) ( ) count [ ] % within condition { } % within methods of treatment (( )) % of total
Orthodontics, Pedodontics and Preventive Dentistry 86 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically Table 2: Methods of treatment.
Case No Condition Gen./Age Surgical Procedure Orthodontic Procedure 3 HME F / 21 None Upper and lower fixed appliances. 5 UTMJ A F / 20 a. Anterior subapical maxillary osteotomy with extraction of 4 4 (set-back & upward movement). b. Centralizing sliding genioplasty / Splint. None
M / 16 a. Resection of ankylotic segment. b. b. Ipsilateral coronoidotomy. c. c. Early mobilazation & physiotherapy.
None
12
AMP +
M / 22 a. Bilateral sagittal split osteotomy (set-back and rotation). b. Genioplasty (reduction & backward movement). c. Le fort 1 osteotomy (upward movement) with bone graft /IMF.
F / 19 a. Maxillary bilateral posterior segmental osteotomy with extraction of 4 4 (upward movement). b. Bilateral sagittal split osteotomy (set-back & rotation) / IMF.
None 16 AMP + M / 21 Kle procedure / Splint. None 18 HME F / 19 Body ostectomy with extraction of 4 / IMF. None 19 AMP - F / 20 Body ostectomy with extraction of 4 / Splint. None
22
UCFM
F / 28 a. Le fort 1 osteotomy to correct canting. b. Bilateral sagittal split osteotomy / IMF.
None
24
AMP +
M / 16
None Upper & lower fixed appliances with extraction of 4 4 & expansion for 4 4 upper arch.
26
AMP -
M / 17
None Upper & lower fixed appliances with extraction of 5 & expansion for the upper arch. 27 AMP + M / 25 Body ostectomy with extraction of 4 / Splint. None 29 HMH F / 22 Lower border surgury. None
30
UCFM
F / 22 a. Le fort 1 osteotomy (to correct canting). b. Unilateral sagittal split osteotomy (Rt side), inverted L osteotomy (Lt side) with bone graft / IMF.
None 31 HMH M / 27 Lower border resection. None
33
HME
M / 20 a. Le fort 1 osteotomy (upward movement) with extraction of 4 4 & anterior segmental maxillary osteotomy (set-back). b.Genioplasty( reduction & forward movement). c. Bilateral sagittal split osteotomy (set-back and rotation) / IMF.
None
Orthodontics, Pedodontics and Preventive Dentistry 87 J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically
0 10 20 30 40 50 60 70 ortho. presurg. ortho. combination surg. follow up Co n d i t i o n s
Figure 1: Percentage distribution of the methods of treatment through the mandibular asymmetry conditions.
E D C B A Figure 2: Condylar hyperplasia (Hemimandibular Elongation Rt side) (A & C): Preoperative (B & D): Correction by body ostectomy on Rt side (E): Postoperative orthodontic treatment.
Salivary calcium, potassium and oral health status among smokers and non-smokers (a comparative study).
Wesal A. Al-Obaidi, B.D.S., M.Sc. (1)
ABSTRACT Background: Smoked tobacco contains various toxic substances which are primarily responsible for oral diseases. The aim of this study was to estimate salivary electrolytes (calcium and potassium), salivary parameters (pH and flow rate) and oral health status among smokers. Materials and methods: A sample included 30 healthy subjects, 15 smokers and 15 non-smokers. Clinical examination of dental caries and gingivitis and stimulated whole saliva were obtained. Results: Dental caries experience and gingivitis were significantly higher among smokers than non-smokers. No significant differences were found in mean pH and flow rate between the two groups (P>0.05). The mean salivary calcium (2.51.4 mg/100ml) and potassium (24.14.4 mmol/L) recorded were higher among smokers than non-smokers. Statistically, the difference was significant regarding potassium only (P>0.05). Conclusion: Smoking affects some salivary electrolytes. Dentists have an important role to play in preventing the harmful effects of smoking in the mouth. Keywords: Saliva, calcium, potassium, dental caries, gingivitis smokers. (J Bagh Coll Dentistry 2006; 18(2)89-91)
INTRODUCTION Tobacco is derived from the species of the plant of genus Nicotiana. Cigarettes contain various toxic substances (1) which have been shown to be secreted in salivary and gingival crevicular fluids (2) . The role of tobacco in the etiology of oral diseases has been studied (3- 7) . Smoking appears to increase the susceptibility to periodontal disease. Whether this is due to differences in amount and quality of plaque or to changes in defense mechanisms is still a matter of debate (8) . Cigarette smoking is most certainly associated with an increased caries rate but that a cause and effect relationship is still not proven (2) . Iraqi investigations reported the effects of smoking on salivary Streptococcus Mutans (7)
and salivary Lactobacilli (6) with no information regarding its effect on the salivary elements. The aim of this study was to evaluate the effects of smoking on salivary composition (calcium and potassium), salivary parameters and oral health.
MATERIALS AND METHODS Stimulated saliva secretion was collected by chewing 0.5 gm paraffin wax for 4 minutes from 31 healthy subjects. The sample was subdivided into 15 smokers and 15 non-smokers matching in age and gender.
(1) Assistant professor, Department of Pedodontic and Preventive Dentistry, Dental College, University of Baghdad.
Immediately after collection, the salivary pH was estimated by pH meter. The salivary flow rate for each subject was calculated and expressed by ml/1min. The collected saliva was centrifuged at 3000 r.p.m. for 40 minutes. Then, supernatant saliva was frozen at -20 o C until analysis. Atomic absorption spectrophotometer was used for calcium analysis, and flame photometer was used for potassium analysis. Gingival inflammation was assessed using Gingival Index (9) for each six Ramfjord Index teeth. Dental caries was measured following WHO criteria (10) . The oral examination was done using dental explorer and mirrors. Student's t-test was applied for statistical analysis.
RESULTS Table 1 reveals mean ages, caries experience (DMFS) and Gingival Index in both groups. Statistically, significant differences were found in the mean DMFS and GI between the two groups (P<0.005). Although, salivary calcium was higher among smokers, but statistically, the difference was not significant (P>0.05). Salivary potassium was significantly higher in the mean value among smokers than non-smokers (Table 2). Table 3 demonstrates non-significant differences in the mean pH and flow rate between smokers and non-smokers (P>0.05).
Orthodontics, Pedodontics and Preventive Dentistry 89
Table 1: Mean ages, caries severity and gingival index among smokers and non- smokers No. Age MeanSD DMFS MeanSD GI MeanSD Smokers 15 32.6 12.3 23.3 13.5* 1.17 0.2** Non-smokers 15 32.8 11.3 14.7 10.2 0.98 0.3 * t = 1.98 P<0.05 d.f = 28 ** t = 1.97 P<0.05 d.f = 28
Table 2: Salivary calcium and potassium concentrations among smokers and non- smokers No. Ca (mg/100ml) Mean SD K (mmol/L) Mean SD Smokers 15 2.5 1.4 24.1 4.4* Non-smokers 15 2.2 0.9 21.3 2.8 * t = 2.08 P<0.05 d.f = 28
Table 3: Salivary pH and flow rate among smokers and non-smokers No. pH Mean SD Flow Rate Mean SD Smokers 15 7.19 0.2 1.84 0.8 Non-smokers 15 7.20 0.3 1.80 0.9
DISCUSSION A high caries severity was recorded in this study which may be attributed to the over estimation of missing component by the teeth extracted due to the cause rather than caries (1) . A significant difference was found between the two groups regarding the caries experience (DMFS). This result is in agreement with many studies (5-7) . Increasing in dental caries may be attributed to the change in the dietary habits among smokers, like chewing gum (11) , eating candies (7) and high sugar tea (6) . It was reported that, mean Streptococcus Mutans counts were higher among smokers than non-smokers (7) , as well as, Lactobacilli (6) . The present study revealed a significantly higher mean GI among smokers than non- smokers, which is in discordance with many studies (2, 12) and in accordance with other studies (7, 13) . This result could be due to the poorer state of oral hygiene (7) and/or the harmful effect of smoking on the gingiva as a result of direct heat, irritating effect of tar and other toxic materials (1) . Although salivary calcium was higher among smokers, statistically, no significant difference was observed between the two groups. This result is in disagreement with other researches (14,15) . They revealed a significant increase in salivary calcium among smokers. Also, it is in disagreement with Kiss et al results (16) . They noted a decrease in skeletal bone density, a known side-effect of smoking, may reflect an increased level of salivary calcium which could be one of the most important reasons for the worse periodontitis of smokers. No significant difference was observed in calcium concentration, which is somehow, similar to Laine et al study (17) . Their results showed that salivary calcium was not affected by smoking among the younger group (45) and significantly higher among the older group. In this study, about 90% of the smokers were under the age of 45 years. Besides, a normal serum calcium concentration was recorded in osteoporosis in which smoking is considered to be one of the risk factors (18) . Potassium significantly increased in the smoking group compared to the non-smoking one. The same result was reported by Dogon et al (14) . They revealed that the increase in salivary potassium could not be due to the increased potassium intake from cigarettes, but more likely due to the pharmacological action of the nicotine in the tobacco smoke. While, Laine et al (17) demonstrated that salivary potassium concentration varies according to the age of the smokers. The result revealed that salivary flow rate had no significant difference between the two groups, which is in accordance with other investigations (6, 7, 12) . Long-term use of tobacco does not adversely affect the taste receptors and hence, salivary secretion (12) . Also, the clinical impact of the degenerative changes among intense smokeless tobacco appears to be minimal and cigarette smoking typically causes a noticeable short-term increase in salivary flow rates (2) . Statistically, mean value of salivary pH was found to be not significant between the two groups. This result is in disagreement with Al- Ward (7) and in agreement with Al-Weheb (6) . This may be explained by the fact that there was no reduction in the salivary flow rate among smokers, leading to no increase in the salivary hydrogen concentration.
REFERENCES 1. Peter S. Essentials of preventive and community dentistry. 2 nd ed. Sudhir Kumar Arya, Arya (Medi) publishing house. New Delhi 2003; 127-240, 468-504. Orthodontics, Pedodontics and Preventive Dentistry 90
2. Bouquot J, Schroeder K. Oral effect of tobacco abuse. J Am Dent Inst Cont Educa 1992; 43: 3-17. 3. Sham A, Cheung L, Jin L, Corbet E. The effect of tobacco use on oral health. Hong Kong Med J 2003; Aug; 9(4): 271-7. 4. Calsina G, Ramon J, Echeverria J. Effect of smoking on periodontal disease. J Clin Periodontol 2002; Aug; 29(8): 771-6. 5. Reibel J. Tobacco and oral diseases. Med Princ Pract 2003; 12 supp 1: 22-32. 6. Al-Weheb A. Smoking and its relation to caries experience and salivary Lactobacilli count. J Coll Dentistry 2005; 17(1): 92-5. 7. Al-Ward F. Oral health status and salivary mutans streptococci in smokers and non-smokers. Master thesis submitted to the College of Dentistry, Baghdad University, 2004. 8. Koch G, Moder T, Poulsen S, Rasmussen P. PedodonticsA clinical approach, 1 st ed. Munksgaard, Copenhagen; 1994; 211-4. 9. Loe H, Silness J. Periodontal disease in pregnancy. I. Acta Odontol Scand 1989; 21: 533-51. 10. WHO. Oral health survey. Basic methods. 4 th ed. Geneva, 1997. 11. Hirsch J, Livian G, Edward S, Noren J. Tobacco habits among teenagers in the city of Goteborg, Sweden and possible association with dental caries. Swedish Dent J 1991; 15: 117-23.
12. Khan G, Mehmood R. Effects of long-term use of tobacco on taste receptors and salivary secretion. J Ayab Med Coll Abbottabad 2003; Oct-Dec; 15(4): 37-9. 13. Erdemir E, Duran I, Haliloglu S. Effects of smoking on clinical parameters and the gingival crevicular fluid levels of IL-6 and TNF-alpha in patients with chronic periodontitis. J Clin Periodontol. 2004; Feb; 31(2): 99-104. 14. Dogon I, Amdur B, Bell K. Observations on the diurnal variation of some inorganic constituents of human parotid saliva in smokers and non-smokers. Archs Oral Biol 1971; 16: 95-105. 15. Zuabi O, Machtei E, Ben-Aryah H, Ardekin L. The effect of smoking and periodontal treatment on salivary composition in patients with established periodontitis. J Periodontol 1999; Oct; 70(10): 1240-6. 16. Kiss E, Gorzo I, Sewon L. Salivary calcium in relation to oral health of tobacco smokers. J Dent Res 2004; March; 13: 10-3. 17. Laine M, Sewon L, Karjalainen S, Helenius H. Salivary variables in relation to tobacco smoking and female sex steroid hormone-use in 30 to 59-year-old women. Acta Odontologica Scand 2002; Aug; 60(4): 237-40. 18. Nizel A, Papas A. Nutrition in clinical Dentistry. 3 rd ed. W.B. Saunders Company. Philadelphia. London; 1989; 144-66. Orthodontics, Pedodontics and Preventive Dentistry 91
J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and Prevalence, severity and pattern of dental fluorosis among a group of children in DahmarYemen
Wesal A. Al-Obaidi, B.D.S., M.Sc. (1)
ABSTRACT Background: Dental fluorosis is an irreversible condition caused by excessive fluoride ingestion during the tooth formation. The aim of the study was to estimate the prevalence, severity and pattern of dental fluorosis of the primary and permanent dentitions. Materials and Methods: A random sample of one hundred eighty children aged 6-12 years were examined by using Deans Flourosis Index modified criteria. Results: The prevalence of dental fluorosis was 77.8%. Permanent teeth fluorosis was higher than primary teeth fluorosis which was relatively uncommon. Dental fluorosis was most frequently seen on the posterior teeth (particularly the molars). 42.9% of the children had a moderate type of fluorosis. Dental fluorosis was more prevalent among males than females. Both early and late forming teeth were affected by fluorosis. Upper teeth were more affected than the lower teeth. There was a high degree of bilateral symmetry. Conclusion: Dental fluorosis was prevalent in both primary and permanent dentitions; it was a moderate public health problem. The high prevalence and severity of fluorosis emphasized the need to study the risk factors determining dental fluorosis in Dahmar Village rather than water fluoridation. Keywords: Dental fluorosis, children, Yemen. J Bagh Coll Dentistry 2006; 18(2)92-96)
INTRODUCTION Dental fluorosis is a specific disturbance of tooth formation caused by excessive fluoride intake through a disorder of ameloblasts during the period of teeth calcification. It is a chronic effect of fluoride toxicity on enamel (1) . The extent of subsurface of enamel porosity depends on the concentration of fluoride at developmental time (2) . The parts of crowns of developing permanent teeth are expected to be affected by systemic disturbances, from birth to seven years (3) , while primary teeth are protected against systemic disturbances until birth except for the severe one (4) . A population which receives 1ppm of fluoride (3, 5, 6) in drinking water, or less (5, 7)
exhibits symptoms of mild dental fluorosis. Varying amount of fluoride are found in many food substances (1) . Once the crowns of the teeth are formed, no further fluorosis can be induced by additional intake of fluoride (1, 8) . About 60-80% of dental fluorosis was found to be an important problem because of its unfavorable effects on an individual's personality (9) . This study was conducted to estimate the prevalence, severity and pattern of dental fluorosis among a group of children in Dahmar Yemen.
(1) Assistant professor, Department of Pedodontic and Preventive Dentistry, College of Dentistry, University of Baghdad.
MATERIALS AND METHODS A random sample of one hundred eighty children aged 6-12 years, residing in Dahmar was examined. Prevalence and severity of dental fluorosis were assessed using Deans Flourosis Index modified criteria. (10) . Each tooth present in an individual's mouth was rated according to the fluorosis index. The score assigned to an individual is the one which corresponds to the two most severely affected teeth in the mouth. If the two teeth were not equally affected, the classification given was that of the less involved tooth. The severity of dental fluorosis as a public health problem was determined using Community Fluorosis Index by Dean, (CFI =No.of individuals *statistical weights) (10)
No. of individuals examined
RESULTS Table 1 shows the high prevalence of dental fluorosis (77.8%). Dental fluorosis among males was higher than that among females. Figure 1 demonstrates the severity of dental fluorosis. It was found that the moderate was the predominant type, while the questionable and very mild types were the lowest percent. According to Dean Index, it was found that Community Fluorosis Index (CFI) =1.97. The percentage of teeth affected by fluorosis was found to be 30.8% among the total sample. Dental fluorosis was highly prevalent among permanent (95.5%) than that among primary Orthodontics, Pedodontics and Preventive Dentistry 92 J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and dentition, besides, 54.8% of the total teeth affected was prevalent in upper jaw (Figure 2). Dental fluorosis in relation to types of teeth was illustrated in Figure 3. Permanent second molar was the predominant tooth that was affected by fluorosis (66.7%), while the permanent first premolar was the lowest type that was affected (20.7%). Although the primary second molar had the highest prevalence of fluorosis among primary teeth, it was still lower than that among permanent one. Figure 4 shows the pattern of dental fluorosis in relation to mouth quadrants, there was a high bilateral similarity with the exception of permanent first molars and canines.
Table 1: Prevalence of dental fluorosis by gender Gender No. Dental fluorosis No. % Males Females Both 150 30 180 120 80.0 20 66.7 140 77.8
0 5 10 15 20 25 30 35 40 45 50
1 2 3 4 5 % p e r s o n Questionable Very Mild Mild Moderate Severe
Figure 1: Severity of dental fluorosis
0 20 40 60 80 100 120 1 2 3 4 5 6 %
Affected Healthy Upper Lower Primary Permanent
Figure 2: Percentages of teeth affected
Orthodontics, Pedodontics and Preventive Dentistry 93 J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and
E D C B A 7 6 5 4 3 2 1 1 2 3 4 5 6 7 A B C D Orthodontics, Pedodontics and Preventive Dentistry 94 J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and DISCUSSION The results showed high prevalence of dental fluorosis which was in accordance with many studies (7, 11-13) and in disagreement with others (14-16) . The moderate form of dental fluorosis was found to be the highest percent among the other types. This result was in agreement with other studies (6, 13) and in contrast with many studies (11, 14, 16, 17) . The controversy existing in the prevalence and severity of dental fluorosis may be attributed to the changing of the fluoride level in drinking water. Analysis of drinking water by national water and sanitation authority reported the fluoride level in Dahmar was ranged (0.1-1.9 ppm) (18) . This wide range may be due to that the most water resources came from wells. In addition to water fluoridation, dietary habits (tea and fish) which are the richest sources of fluoride (19) may be behind the increased prevalence of dental fluorosis (20) . Females had a lower prevalence of dental fluorosis than males. This result was in agreement with previous studies (7, 21) and may be due to the earlier tooth formation among females about half a year than males (3) . The second molars had the highest prevalence of fluorosis among the permanent teeth which was in agreement with previous investigations (22, 23) , while primary second molars were most commonly affected among primary teeth, this finding was in accordance with other researches (14,24) . These teeth have the longest mineralization period (3) , so that the latest the tooth was formed, the highest was the prevalence of dental fluorosis. Although the permanent lower incisors are of a short mineralization time, they were also affected by fluorosis which was almost of a mild type. This result was somehow in disagreement with Larsen et al studies (22) and in agreement with Larsen et al studies (23) . It is known that mineralization of primary crowns starts at 3.5 months in utero and become fully formed during the first year of life, while for the permanent crowns, it starts from birth till 7 years of age (3) . This fact may explain the higher prevalence of dental fluorosis among permanent than that among primary teeth, and the latter had a very low prevalence which was in accordance with other studies (14,24) . Moreover, primary teeth are protected parentally, because of the slow diffusion of fluoride through the placenta (4) , so it is mostly a postnatal phenomenon (14) . Besides, fluoride in the breast milk is less than half of that in plasma (1) which is the main child food during the first year of life. In general, upper teeth were more affected by fluorosis than the lower teeth, because that the mandibular teeth develop earlier than the maxillary teeth (3) . The dental fluorosis prevalence showed a high degree of bilateral symmetry which was in accordance with Manji et al study (12) , with the exception of permanent first molars and canines which may be attributed to variation in eruption time and/or missing teeth due to caries. All children with primary teeth fluorosis had permanent teeth fluorosis, and this result is in agreement with Warren's study (24) who concluded that "primary tooth fluorosis may be related to the occurrence of fluorosis in the permanent dentition". The occurrence of fluorosis was more in the posterior than anterior teeth, and this result was in accordance with Kumar et al research. (25) They noted that the longer maturation process of the posterior teeth and the thicker enamel appear to be the explanation for the higher occurrence in posterior teeth. The Fluoride Community Index was equal to 1.97; it meant that it was a medium public health problem (10) , which was in accordance with Ibrahim study (7) .
REFERENCES 1. Peter S. Essentials of preventive and community dentistry. 2 nd ed. Sudhir Kumar Arya, Arya (Medi) publishing house. New Delhi 2003; 279-371. 2. Harris NO, Clark DC. Water fluoridation, In: Harris NO and Christen AG, eds. Primary preventive dentistry, 4 th ed. Appleton and Lange, Stamford, Connecticut 1995; 157-91. 3. Koch G, Moder T, Poulsen S, Rasmussen P. PedodonticsA clinical approach, 1 st ed. Munksgaard, Copenhagen 1994; 42-64. 4. Andlaw RJ , Rock WP. A manual of pediatric dentistry, 4 th ed. Churchill, Livingstone. New York 1996; 141-8. 5. J ackson RD, Kelly SA, Katz BP, Hull J R, Stookey GK. Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water. J Public Health Dent 1995; spring; 55(2): 79-84. 6. McDonagh MS, Whiting PF, Wilson PM, Sutton AJ , Chestnutt I. Systemic review of water fluoridation. BMJ 2000; 321: 855-59. 7. Ibrahim YE, Affan AA, Bjorvatn K. Prevalence of dental fluorosis in Sudanese children from two villages with 0.25 and 2,56 ppm fluoride in the drinking water. Int J Paediatr Dent 1995; Dec; 5(4): 223-9. Orthodontics, Pedodontics and Preventive Dentistry 95 J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and 8. Horowitz HS. Indices for measuring dental fluorosis. J Public Health Dentistry 1986; 46(4): 179-83. 9. Welbury RR, Shaw L. A sample technique for removal of mottling, opacities and pigmentation. Dental Update 1990; 17: 161-3. 10. Dean HT, Arnold FA, Elvove E. Domestic water and dental caries. Public Health Repo 1942; 57(32): 1155-79. Cited in: Nizel A, Papas A. Nutrition in clinical dentistry, 3 rd ed. W.B. Saunders company, Philadelphia, London; 1989. 11. Skotowski MC, Hunt RJ , Levy SM. Risk factors for dental fluorosis in pediatric dental patients. J Public Health Dent 1995; 55(3): 154-9. 12. Manji F, Baelum V, Fejerslow O. Dental fluorosis in an area of Kenya with 2ppm fluoride in drinking water. J Dent Res 1986; May; 65(5): 659-62. 13. Irigoyen ME, Molina N, Luengas I. Prevalence and severity of dental fluorosis in a Mexican community with above-optimal fluoride concentration in drinking water. Community Dent Oral Epidemiol 1995; 8; 23(4): 243-5. 14. Warren J J , Levy SM, Kanellis MJ . Prevalence of dental fluorosis in the primary dentition. J Public Health Dent 2001; spring; 61(2): 87-91. 15. Leverett D. Prevalence of dental fluorosis in fluoridated and non-fluoridated communities a preliminary investigation. J Public Health Dent 1986; fall; 46(4): 184-7. 16. U.S. Department of health and human services, Public health service. Review of fluoride: benefits and risks. Report of the Ad Hoc subcommittee on fluoride. Washington DC; February 1991.
17. Levy SM, Guha-Chowdhury N. Total fluoride intake and implications for dietary fluoride supplementation. J Public Health Dent 1999; 59: 211-23. 18. National water and sanitation authority. Analysis of drinking water in Dahmar. 1990-2000. 19. Nizel A, Papas A. Nutrition in clinical dentistry, 3 rd
ed. W.B. Saunders company, Philadelphia, London; 1989: 167-95. 20. Lewis DW, Banting DW. Water fluoridation: current effectiveness and dental fluorosis. Community Dent Oral Epidemiol 1994; J un; 22(3): 153-8. 21. Al-J uboury HA. Prevalence of dental fluorosis in Yemen (accepted for publication in Al-Mustansiria Dent J 2005). 22. Larsen MJ , Kirkegaard E, Poulsen S. Patterns of dental fluorosis in European country in relation to the fluoride concentration of drinking water. J Dent Res 1987; J an; 66(1): 10-2. 23. Larsen MJ , Senderovitz F, Kirkegaard E, Poulsen S, Fejerskov O. Dental fluorosis in the primary and permanent dentition in fluoridated areas with consumption of either powdered milk or natural cows milk. J Dent Res 1988; May; 67(5): 822-5. 24. Warren J J , Kanellis MJ , Levy SM. Fluorosis of the primary dentition: what does it mean for permanent teeth? J Am Dent Assoc 1999; Mar; 130(3): 347-56. 25. Kumar J , Swango P, Haley V, Green E. Intrs-oral distribution of dental fluorosis in Newbunrgh and Kingston, New York. J Dent Res 2000; J ul; 79(7): 1508-13.
Orthodontics, Pedodontics and Preventive Dentistry 96 J Bagh Coll Dentistry Vol. 18(2), 2006 Local anesthetic quality Local anesthetic quality in pedodontic department, College of Dentistry/ University of Baghdad
Abeer M.Zwain B.D.S., M.Sc. (1)
ABSTRACT Background: Discomfort and pain usually is associated with dental work especially for young patients. Pain control can be achieved by using local anesthesia. This study is designed to estimate the frequency of ineffective pain control during treatment provided for children in pedodontic department in college of dentistry, university of Baghdad. Subjects and methods: 166 children, 82 males and 84 females 4.5-12 years old participated in this study. The level of child anxiety was measured before giving the injection, quadrant treated and type of treatment also recorded. The effectiveness of pain control had been rated by SEM (sound, eye, motor) scale during providing the dental treatment. Results: The local anesthesia was ineffective in 26.5% of the studied sample, while the others 73.5% undergone treatment with no signs of pain. Anxious children showed more signs of pain experience during treatment than the non anxious. Treatment in the mandibular jaw was associated with anesthetic failure more than that of the maxillary jaw. Conclusions: Ineffective pain control is relatively frequent in pedodontic department in College of Dentistry, University of Baghdad and there is a need for using more methods for reducing anxiety like nitrous oxide sedation (NO2) and computer controlled local anesthesia because of the close relation between anxiety and pain control. Key words: Local anesthesia pain. (J Bagh Coll Dentistry 2006; 18(2)96-99)
INTRODUCTION 1
The most critical subject in the pedodontic patient management during dental treatment is controlling the pain. Painful dental treatment will results in anxious person (1) that avoid seeking dental treatment in the future and were more likely to defer, cancel or not turn up for dental appointments (2, 3) . Local anesthesia is usually indicated when operative as well as surgical work is to be performed for adult as well as young children patients (4) . Little is known about the frequency of ineffective local anesthesia in pedodontic patients and its possible reasons, for the adult it's suggested that the failure of the anesthesia is common and its possible causes include anatomical variation, inflammation, anxiety and injection technique (5-7) . For pediatric dentistry, a child age, gender (8) , anxiety (9) , initial dose of anesthetic administration (10,11) , arch treated (8) , the operative procedures performed (12) , and the use of nitrous oxide (13,14) and oral premedication (15) all have been suggested to influence the effectiveness of local anesthesia. This study was carried out to add some information on the effectiveness of pain control in pedodontic department in college of dentistry, university of Baghdad by testing the
(1) Assistant lecturer, Department of Pedodontic and Preventive Dentistry, College of Dentistry, University of Baghdad
hypothesis that effective pain control could be related to some factors like anxiety, type of treatment, quadrant treated, and administration technique.
SUBJECTS AND METHODS One hundred and sixty child patients 82 males, 84 females. 4.5-12 years old in age were participated in the present study; any patient give history or clinical signs of infection or swelling were excluded from the study. The following information were recorded in a simple check list for each patients: age in years, sex, quadrants anesthetized, injection techniques, initial dose (to the nearest quarter of cartilage) of 2% lidocaine with 1:100,000 epinephrine, use of topical anesthesia in combination of local anesthesia and type of operative or surgical procedure performed. Child's anxiety has been rated before the initial injection into four categories according to Frankle scale: "definitely positive", "positive", "negative", "definitely negative", children rated into the negative categories were considered to be anxious (16) . The anesthetic injection had been given by the student under a supervision of senior instructor and each patient treated by the treatment demand while this the effectiveness of pain control had been rated by SEM (sound, eye, motor) scale (12) which consists of four levels ranging from comfort to painful takes into account sound, eyes and motor ( table 1). Orthodontics, Pedodontics and Preventive Dentistry 96 J Bagh Coll Dentistry Vol. 18(2), 2006 Local anesthetic quality RESULTS The studied sample included 166 children 82 males, 84 females 4.5-12 years old in age. Table 2 shows the effectiveness of local anesthesia in different age groups of the studied sample. No statistical differences was found between different age groups when compared to the total number of the sample (p=0.1245). 135 children were rated as not anxious while 31 children rated as anxious children from dental treatment. In 71 patients the treatment was provided for the maxillary jaw while 95 patients received treatment for the mandibular jaw. Ninety nine patients received restorative treatment, extraction or pulpotomies were performed for 67 patients (table3). Topical anesthesia in combination with local anesthesia was given for 63 patients, no significant relation was found between effectiveness of local anesthesia and the use of topical anesthesia. Figure 1 show the effectiveness of local anesthesia among the studied sample. Thirteen females and 31 males were reported that the local anesthesia was ineffective while 69 females and 53 males undergone the treatment with no signs of pain, ineffective local anesthesia was 26.5% of the total sample. Associated variables that affect successfulness of local anesthesia are seen in table 3 and 4. A significant relation was found between the level of child anxiety and effectiveness of local anesthesia according to SEM scale (P=0.034). The results show that anxious children show more signs of pain experience during dental treatment. Although no significant relation was found between pain experience and type of treatment (P=0.093), but the percentage of ineffective local anesthesia while the patients undergoing restorative treatment is relatively low (9.04%) when compared with that when the patient undergone more aggressive treatment like extraction or pulpotomy (17.5%). On the other hand, a significant relation between effectiveness of local anesthesia and quadrant treated was found (P=0.023) so that treatment in the mandibular jaw associated with pain experience more than that in the maxillary jaws. Table 4 shows the effectiveness of local anesthesia compared with administration technique. A significant relation was found between the two (P=0.0238), the more successful technique was buccal infiltration anesthesia for restorative treatment in the maxillary and mandibular anterior teeth, while inferior dental nerve block for operative treatment and inferior dental nerve block and long buccal nerve anesthesia for extraction in the mandibular jaw associated with high percentage of ineffective pain control, no significant difference was found between infiltration local anesthesia in the mandibular anterior teeth and that in the maxillary jaw .
DISCUSSION This study is the first study that deals with amount of pain associated with dental treatment provided for children attending pedodontic department in the College of Dentistry, University of Baghdad. 26.5% of the studied sample undergone the treatment suffered from pain. This percentage varies from study to study, it is ranged from 11.6 to 35 (12,17,18) . Females tend to be more suffering from pain than the males. This may be due to the physical and social nature of females that make them more apprehensive. Pain is a complex experience and it's highly related to the experience of anxiety (9) , so that anxious children before injection tends to show more pain experience than non anxious children, (P=0.034) as shown in table 3. This result was confirmed with NAKAI and his colleagues (12) . Although inhalation sedation with nitrous oxide can provide effects of good quality antianxiety sedation, amnesia in dental treatment (13,14) . In addition, a recent method for administration of local anesthesia is a computer controlled local anesthesia in which the flow rate of anesthetic solution is controlled by a microprocessor instead of the pressure of traditional syringe, so that the dentist can give a painless injection that decrease stress and anxiety of the patient (19) , but there are no facilities provided in the pedodontic department in the College of Dentistry, University of Baghdad for these methods. Type of treatment is considered to be one of the variables that effect amount of pain control during dental treatment (12) . No statistical significance was found between amount of pain associated with restorative treatment when compared with that associated with extraction or pulpotomy which is not confirmed with other studies (12,20) . The present study shows that anesthesia in the mandibular jaw which is inferior dental nerve block associated with high percentage of Orthodontics, Pedodontics and Preventive Dentistry 97 J Bagh Coll Dentistry Vol. 18(2), 2006 Local anesthetic quality failure as compared with infiltration technique. Complex administration technique which needs more experience and skill is the cause of this finding so that the students must have more knowledge about inferior dental nerve block anesthetic technique.
REFERENCES 1. Locker D, Shapiro D, Liddell A. Negative experience and their relationship to dental anxiety. Community Dental Health 1996; 13:86-92. 2. Bedi R, Sutcliffe P, Donnan P, Barrett N, McConnachie J . Dental caries experience and prevalence of children afraid of dental treatment. Community Dent Oral Epidemiol 1992; 20:368-71. 3. Poulton R, Thomson W, Brown R, Silva P. Dental fear with and without blood injection fear: implication for dental health and clinical practice. Behavior Research and Therapy 1998; 36:591-7. 4. McDonald RE, Avery DR, Dean J A. Dentistry for the child and adolescent 8th ed. Mosby-Yearbook; 2004:272. 5. Weinstein P, Milgram P, Kaufman E, Fiset L, Ramsay D. Patient perceptions of failure to achieve optimal local anesthesia. Gen Dent 1985; 33:218-20. 6. Brown RD. The failure of local anaesthesia in acute inflammation. Br Dent J 1981; 151:47-51. 7. Rood J P, Patromichelakis S. Local anaesthetic failures due to an increase in sensory nerve impulses from inflammatory sensitization. J Dent 1992; 10: 201-6. 8. Liddle A, Locker D. Gender and age differences in attitudes to dental pain and dental control. Community Dent Oral Epidemiol 1997; 25: 314-8. 9. Litt MD. A model of pain and anxiety associated with acute stressors: distress in dental procedures. Behave Res Ther 1996; 34:459-76. 10. Vreeland DL, Reader A, Beck M, Meyers W, Weaver J . An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod 1989; 15: 6-12. 11. Aberg G, Sydnes G. Studies on the duration of local anesthesia: effects of volume and concentration of local anesthetic solution on the duration of dental infiltration anesthesia. Int J Oral Surg 1978; 7:141-7. 12. Nakai Y, Milgrom P, Coldwell S, Ramsay D. Effectiveness of local anesthesia in pediatric dental practice. J ADA 2000; 131:1699-705. 13. Rodrigo MR. Use of inhalational and intravenous sedation in dentistry. Int Dent J 1997; 47(1):32-8. 14. Sun Y. Inhalation sedation with nitrous oxide in dental extraction. Zhonghua Kou-Qiaug-Yi-Xue 1998; 33(1): 24-6 (M.L.). 15. Henderson BN. Anxiolytic therapy: Oral and intravenous sedation. Dental Clinics of North America 1994; 38(4): 603-17. 16. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? J Dent Child 1962; 29:150-63. 17. Kaufman E, Holan G, Goodman E, Eidelman E. Evaluation of student's performance in obtaining local anesthesia in children. Int J Paediatr Den 1991; Dec; 1(3):147-50. 18. Kuster CG, Rakes G. Frequency of inadequate local anesthesia in child patients. J Paediatr Dent 1987; 3:7-9. 19. Loomer PM, Perry DA. Computer-controlled delivery versus syringe delivery of local anesthetic injection. J ADA 2004; 135(3), 358-65. 20. Wilson TG, Primoshc RE, Melamed B, Courts FJ . Clinical effectiveness of 1 and 2 percent lidocain in young pediatric dental patients. Pediatr Dent 1990; 12:353-9 (M.L.).
Table 1: Ratings of a child's pain according to the SEM scale. Comfort or pain level Observations of possible indications of pain 1-comfort 2-mild discomfort 3-moderately painful 4- painful Sound No sounds indicating pain Nonspecific sounds; possible indication of pain Specific verbal complaints (such as "OW"), raises voice Verbal complaint indicate intense pain (such as screaming sobbing) Eye No eye signs of discomfort Eyes wide, show of concern, no tears Watery eyes, eyes flinching Crying tears running down face Motor Hands relaxed; no apparent body tension Hands showing some distress or tension; grasping of chair owing to discomfort, muscular tension Random movement of arms or body without aggressive intention of physical contact, grimacing, twitching Movement of hands to make aggressive physical contact (such as puching, pulling head away)
Orthodontics, Pedodontics and Preventive Dentistry 98 J Bagh Coll Dentistry Vol. 18(2), 2006 Local anesthetic quality Table 2: Effectiveness of local anesthesia in different age groups of the studied sample. Ineffective L.A Effective L.A Total No. % No. % No. Age groups/years 13 3 5 4.8 8 4-5 27 7.8 13 8.4 14 6-7 55 6 10 27.1 45 8-9 50 7.2 12 22.9 38 10-11 21 2.4 4 10.24 17 12 166 26.5 44 73.4 122 Total P- Value = 0.1245
Table 3: Associated variables that affect successfulness of local anesthesia. Effective L.A
Ineffective L.A
P- value Sig
No. % No. % Total No.
Anxious 7 4.22 24 14.5 31 Child anxiety Frankle scale) Not anxious 115 69.3 20 12 135 0.034 S Operative treatment 84 50.6 15 9.04 99 Type of Treatment Extraction or pulpotomy 38 22.9 29 17.5 67 0.093 NS Maxillary 59 35.5 12 7.23 71 Quadrant treated Mandibular 64 38.6 31 18.7 95 0.023 S
Table 4: Effectiveness of local anesthesia compared with administration technique. Effective Ineffective
Administration Technique No. % No. % Total No. Buccal infiltration anesthesia for restorative treatment 35 20.48 0 0 35 Buccal & palatal infiltration anesthesia for extraction 24 14.46 13 7.63 37 Inferior dental nerve block anesthesia only for restorative treatment in the mandibular jaw 46 28.32 15 9.04 61 Inferior dental nerve block &long buccal nerve anesthesia for extraction in the mandibular jaw 18 10.85 15 9.04 33 P- Value =0.0238
Effective 73.5 Orthodontics, Pedodontics and Preventive Dentistry 99
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Some societies of dental specialities
Societies of Endodontics 1-American Association of Endodontists (AAE) http://www.aae.org/ 2-American Board of Endodontics (ABE) http://www.aae.org/ABE1.html 3-American Endodontic Society (AES) http://www.aesoc.com/ 4-Australian Society of Endodontology (ASE) http://www.ada.org.au/Societies/ASE/ 5-British Endodontic Society (BES) http://www.britishendodonticsociety.org/ 6-Canadian Academy of Endodontics (CAE) http://www.caendo.ca/ 7-European Society of Endodontology (ESE) http://www.e-s-e.org/ 8-Hong Kong Endodontic Society (HKES) http://www.hkes.org.hk/ 9-Malaysian Endodontic Society (MES) http://www.mda.org.my/mes/index.htm 10-Turkish Endodontics Society http://www.turkishendodontics.org/
Societies of Forensic Odontology 1-British Association for Forensic Odontology (BAFO) http://www.bafo.org.uk/
Societies of General Dentistry 1-Academy of General Dentistry (AGD) http://www.agd.org/
Societies of Oral and Maxillofacial Surgery 1-Academy of Oral Surgery - Chalmers J . Lyons http://www.cjlyons.org/ 2-American Association of Oral and Maxillofacial Surgeons (AAOMS) http://www.aaoms.org/ 3-American Board of Oral and Maxillofacial Surgery (ABOMS) http://www.aboms.org/ 4-American College of Oral and Maxillofacial Surgeons (ACOMS) http://www.acoms.org/ 5-Association of Oral & Maxillofacial Surgeons of India (AOMSI) http://www.aomsi.com/ 6-Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS) http://www.anzaoms.org/ 7-British Association of Oral and Maxillofacial Surgeons (BAOMS) http://www.baoms.org.uk/ 8-Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) http://www.caoms.com/
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9-Hellenic Association for Oral and Maxillofacial Surgery (HAOMS) http://www.haoms.org/ 10-International Association of Oral and Maxillofacial Surgeons (IAOMS) http://www.iaoms.org/ 11-Oral and Maxillofacial Surgery Foundation (OMSF) http://www.omsfoundation.org/
Societies of Oral Diagnosis 1-American Academy of Oral and Maxillofacial Pathology (AAOMP) http://www.aaomp.org/ 2-American Academy of Oral and Maxillofacial Radiology (AAOMR) http://www.aaomr.org/ 3-American Academy of Oral Medicine (AAOM) http://www.aaom.com/ 4-American Board of Oral and Maxillofacial Pathology (ABOMP) http://www.abomp.org/ 5-American Board of Oral and Maxillofacial Radiology (ABOMR) http://www.aaomr.org/ 6-Australasian Society of Oral Medicine And Toxicology (ASOMAT) http://www.asomat.org/ 7-British Society for Oral Medicine (BSOM) http://www.bsom.org.uk/ 8-European Association for Oral Medicine (EAOM) http://www.eastman.ucl.ac.uk/~eaom/ 9-European Society for Oral Laser Applications (ESOLA) http://www.esola.at/ 10-Indian Academy of Oral Medicine and Radiology (IAOMR) http://www.iaomr.tripod.com/index.htm 11-Organization for Teachers of Oral Diagnosis (OTOD) http://www.otod.org/
Societies of Orthodontics 1- Academy of GP Orthodontics (AGpO) http://www.academygportho.com/ 2-Academy of Interdisciplinary Dentofacial Therapy (IDT) http://www.dental-idt.com/ 3-American Association of Orthodontists (AAO) http://www.aaortho.org/ 4-American Board of Orthodontics (ABO) http://www.americanboardortho.com/ 5-American Lingual Orthodontics Association (ALOA) http://www.ormco.com/lingual/ 6-American Orthodontic Society (AOS) http://www.orthodontics.com/ 7-Asian-Pacific Orthodontic Society (APOS) http://www.ap-os.org/ 8-Australian Orthodontic Institute (AOI) http://www.austorthinst.org.au/ 9-Australian Society of Orthodontists (ASO) http://www.aso.org.au/ 10-Association of Orthodontists - Singapore http://www.aos.org.sg/
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11-Association of Philippine Orthodontists (APO) http://www.apo.com.ph/ 12-British Lingual Orthodontic Society (BLOS) http://www.blos.co.uk/ 13-British Orthodontic Society (BOS) http://www.bos.org.uk/ 14-Canadian Association of Orthodontists (CAO) http://www.cao-aco.org/ 15-Charles H. Tweed International Foundation http://www.tweedortho.com/ 16-College of Diplomates of the American Board of Orthodontists (CDABO) http://www.cdabo.org/ 17-Egyptian Orthodontic Society (EOS) http://www.egortho.org/ 18-European Federation of Orthodontic Specialists Associations (EFOSA) http://www.efosa.org/ 19-European Federation of Orthodontics (FEO) http://www.feo-online.org/ 20-European Orthodontic Society (EOS) http://www.eoseurope.org/ 21-European Society for Lingual Orthodontics (ESLO) http://www.eslo.de/ 22-Greek Orthodontic Society http://www.grortho.gr/ 23-New Zealand Association of Orthodontists (NZAO) http://www.orthodontists.org.nz/ 24-Orthodontic National Group, The http://www.orthodontic-ong.co.uk/ 25-Orthodontic Society of Ireland (OSI) http://www.orthodontics.ie/ 26-South African Society of Orthodontists (SASO) http://www.saso.co.za/ 27-World Federation of Orthodontists (WFO) http://www.wfo.org/
Societies of Osseointegration 1-European Association for Osseointegration (EAO) http://www.eao.org/
Societies of Pediatric Dentistry 1-American Academy of Pediatric Dentistry (AAPD) http://www.aapd.org/ 2-American Board of Pediatric Dentistry (ABPD) http://www.abpd.org/ 3-Korean Academy of Pediatric Dentistry (KAPD) http://www.kapd.org/
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