Vol 22 No. 1

Transcription

Vol 22 No. 1

Scientific Journal Published by the
College of Dentistry – University of Baghdad
Vol. 22 No.1 2010
ISSN
ISSN
1680-0087
A quarterly peer reviewed published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Ali Hussain AlKhafaji B.D.S., M.Sc. D (UK)
Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
Editorial Board:
National Members
International Members
Prof. Dr. Khalid Mirza
Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. Fakhri Al-Fatlawi MSc
Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Athraa Yahiai MSc, PhD
Prof. Dr. Adel Farhan Ibraheem M.Sc.
Prof. Dr. Khulood Al-Safi M.Sc. Ph.D.
Prof. Dr. Wasan Hamdi M.Sc. Ph.D.
Prof. Dr. Widad Al-Nakash M.Sc.
Assist. Prof. Dr. Sabah Nema Ph.D.
Assist. Prof. Dr. Wesal Al-Obaidi MSc
Dr. Jamal Abid MSc
Dr. Aeda Zaki MSc
Board of editorial consultants:
1- Prof. Dr. Wael Al-Aloosi MSc
9- Prof. Dr. Waleed Al-Hashemi MSc
2- Prof. Sulafa Al-Samaria MSc, PhD
10- Prof. Abdullatif Al-Jubory PhD
3- Prof. Dr. Ausama Al-Mulla PhD
11- Prof. Dr. Ahlam Hameed MSc
4- Prof. Dr. Raad Muhi AlDeen Helmi MSc
12- Assist. Prof. Akram Faisal Al-Huwaizi MSc, PhD
5- Prof. Nidhal Hussein MSc
13- Assist. Prof. Jamal Aziz MSc
6- Prof. Nabeel Abdulfatah MSc
14- Assist. Prof. Dr. Bashar Hamed MSc, PhD
7- Prof. Dr. Zainab Al-Dahan
15- Assist. Prof. Kadim Al-Soudani MSc
8- Prof. Riyad Al-Qaisi MSc, PhD
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Linguistic referee: Prof. Dr. Hussain Faisal Al-Huwaizi
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i
Contents
i
Editor and Editorial Board
ii
Contents
iv
Instructions for the Authors
Restorative Dentistry
1
The influence of different light curing systems with different curing depth on the microhardness of packable
composites. Ala`a J. Kadum, Ali H. Al – Khafaji.
7
Effectiveness of cure evaluation of four light-activated composites using different curing modes. Ali A. R. AlShekhli
11
14
18
Ear lobes as facial landmarks for determining the occlusal plane. Bayan S. Khalaf
An evaluation of three lubricants in reducing human enamel wear (In vitro study). Lamis AL-Taie
Prevalence of dental attrition among 5-11 years old children in Sulaimaniya city. Raad S. Al-Doory, Soolav F.
Al-Hadithy
Oral Diagnosis
21
Lactate dehydrogenase in serum and saliva of ischemic heart disease patients. Alaa M. Shaheed, Taghreed F.
Zaidan, Rehab A. Mahmood
25
Possible effects of chemical weapons used in Halabja martyr city at 16th march 1988 on developing oral and
dental tissues. Mohammed A. Mahmood, Balkees T. Garib, Saeed A. Abdulkareem
31
Oral and dental problems among thalassaemic patients in Diyala governorate. Dawood S. Hameed, Ghanim H.
Atia, Salwa S. Abdul- Wahid.
35
Control of recurrent oro-labial herpes simplex lesions by in vivo enhancement of salivary peroxidase system.
Ihsan A. Kameel, Rajaa Al-Joubori
42
Prevalence of severity and sex distribution of tempromandibular disorders and other related factors among a
sample of Sulaimani university students. Shanaz M. Gaphor, Soran M. Hameed.
ii
50
Relationship between interlukine- 1 alpha and polyamines levels in serum and saliva as potential
biomarkers in the diagnosis of oral squamous cell carcinoma. Shanaz M. Gaphor, Nazar G. Al-Talabani AbdulW. R. Hamad
Oral and Maxillofacial Surgery and Periodontology
55
The effect of a mouth rinse containing chlorhexidine & fluoride on plaque & gingival bleeding. Abdul Majeed
H. Al Ani
58
Incidence of injury to lingual nerve during surgical removal of lower third molar teeth. Akeel S. Abd Alsada
62
The prevalence of root exposure and its relation to mechanical tooth cleaning procedures. Fakhri A. Alkaisi
65
Evaluation of salivary enzymes activities among patients with chronic periodontitis. Mustafa J. Abdul-Hadi,
Khulood A. Alsafi
Orthodontics, Pedodontic, and Preventive Dentistry
68
The effect of food simulants on corrosion of simulated fixed orthodontic appliance. Afaf H. Hussien,Ausama
Al-Mulla
76
Effect of in-dental clinic bleaching agents on the releases of mineral ions from the enamel surfaces in
relation to their times intervals. Afnan AL-Shimmer, Mohammad Al-Casey.
79
The effect of glucocorticosteroid medication on orthodontically induced root resorption. (An experimental
study on rats). Haraa S. AL-Shaibany, Nidhal H. Ghaib
83
88
Effect of derum (Juglan Regia L. Bark) extracts on Mutans Streptococci in comparison to chlorhexidine
gluconate (in vitro study). Maythaa' S. Kadum.
Athraa' M. Al-Waheb
Salivary insulin hormone in relation to caries – experience among insulin-dependent diabetic children. Nadia
Al-Rawi, Sulafa El-Samarrai
91
Evaluation of buccal corridor in posed smile for Iraqi adults sample with Class I normal occlusion. Sajid C.A.
Al-Ramahi, Ausama A. Al-Mulla
98
Comparison of the calcified barrier formed by calcium hydroxide paste and MTA during apexification
procedure. Sarah T. AbdulQader
101
Effect of ultrasonic cinnamon extract on the microhardness and microscopic features of artificial root caries,
compared to fluoridated agent. Shaimaa T. Al-Baldawy, Wesal A. Al-Obaidi
105
Oral health status and dental treatment needs in relation to salivary constituents and parameters among a
group of patients with thyroid dysfunction. Yamama A. Al-Rubbaey, Sulafa k. El-Samarrai
iii
Instruction for the Authors
The Journal 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 page setup of 2.5 cm margins. Type the
manuscript with English language font Times New Roman and the sizes are as follows:
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MATERIALS AND METHODS, RESULTS and REFERENCES.
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right hand corner.
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The title should be written with a capital letter for the first word as (Effect of the retention and
stability….etc).
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headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES)
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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 at the end of the manuscript :
Book
1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9th
ed. St. Louis: CV Mosby; 1985. p.312-23.
Journal article
4. Jones ER, Smith IM, Doe JQ. 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.
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The article should not exceed 7 pages. The author should submit three copies of the article (one
original and two copies) and a (CD) containing the article.
iv
J Bagh College Dentistry
Vol. 22(1), 2010
The influence of different
The influence of different light curing systems with
different curing depth on the microhardness of packable
composites.
Ala`a J. Kadum,B.D.S. (1)
Ali H. Al – Khafaji, B.D.S., M.Sc. D. (U.K). (2)
ABSTRACT
Background: Adequate polymerization of resin composite is considered to be very important factor. The aim of this
study was to evaluate and compare the influence of different light curing system (conventional QTH, LED and PAC
units) with different polymerization depth (0-1,1-2, 2-3, 3-4 and 4-5 mm) on microhardness of two types of packable
composite (Filtek p60 & Surefil).
Materials and Methods: Two types of packable composites (Filtek p60 and Surefil) were tested. Thirty hemi cylindrical
specimens (5mm diameter x 6mm height) were made for each material. Photo-activation was performed using
conventional QTH, light emitting diodes (LED) or plasma arc (PAC).Exposure times were 40 seconds for QTH and LED
lights, and 12 seconds for the PAC light. After one day of storage, the microhardness test was measured at 5mm
depth intervals (0-1, 1-2, 2-3, 3-4 and 4-5 mm).
Results: The microhardness of packable composite resins (Filtek p60) showed a significantly higher microhardness
than packable composite (Surefil) in all light activation systems and in all depth intervals. The LED light curing system
produced superior mean microhardness value followed by conventional QTH and PAC light curing systems
respectively. And all of the tested composite resins groups with the three different types of light activation systems
showed a significant decrease in the microhardness with the increase of depth.
Conclusion: The microhardness of packable composite is affected by the type of materials, light curing systems and
curing depths.
Key words: microhardness, packable composite, light curing systems, curing depths. J Bagh Coll Dentistry 2010;
22(1):1-6
INTRODUCTION
Previous studies had been shown that many
factors affecting polymerization that include filler
type (size and loading), the effectiveness of the
light transmission, thickness and shade of
restorative material, exposure time, distance of the
light source from the restorative material and light
intensity (2)
Several types of available curing units have
different light intensities and light sources. Lightcuring units use halogen-based; light-emitting
diode, or LED; plasma-arc; or laser technology.
The energy levels range from 300 to more than
1,000 mill watts per square centimeter (4).
Because surface hardness measurement is an
effective way to evaluate the depth of cure, so the
aim of this study was to evaluate and compare the
influence of different light curing system
(conventional QTH, soft start LED and PAC
units)on micro hardness of two types of packable
composite (Filtek p60&Surefil ) at 5mm interval.
Packable composites have been introduced in
the market with high expectations as an amalgam
alternative. Compared with hybrid composites,
they are characterized by a higher filler load, an
improved filler technology, and modifications in
the organic matrices and improved handling
properties .Their ability to be bulk-cured results in
a more cost-effective treatment by reducing the
time needed to place a restoration (1).
Adequate polymerization is a crucial factor in
obtaining optimal physical performance to
improve the clinical performance of resin
composite materials. However, it is common
sense that incomplete polymerization of
composite restorations is one of the major clinical
problems to be overcome because since
inadequate resin activation compromises the
restoration both mechanically and biologically.
The non-polymerized components may influence
the material's chemical stability, increasing its
susceptibility to degradation and leading to
release of by products, such as formaldehyde and
acid methacrylates, which increases the possibility
of pulped adverse reactions and decreases the
wear resistance and color stability (2, 3) .
MATERIALS AND METHODS:
Two different groups of visible light activated
packable composite resin were used in this study
(table1). The first was Filtek p60 A3, and the
second was Surefil High Density Posterior
Restorative Composite A.
Specimens were prepared using a rectangular
split mold composed of three parts joined together
by two transversely aliened screws. It contains
two holes (one for each type of composite resin
(1)
MSc student, dep. of conservative dentistry, college of
dentistry, university of Baghdad.
(2)
Professor, Dean of the college of dentistry, university
of Baghdad.
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Vol. 22(1), 2010
materials tested) bisected by the middle part of the
mold that result in a hemi-cylindrical shape cavity
(5mm in diameter and 6 mm in height) allowing
the evaluation of the microhardness up to 5 mm of
depth.
the composite resin specimens were cured with
LED (LATTE, china) which is battery chargeable
.LATTE was fully charged every time it was used;
the curing of composite was by steeped energy
output, the light intensity began at 700 mWlcm2
for 4 seconds, increasing to 1000 mWlcm2 with
the total exposure time of 40 seconds (7). Curing
with the Plasma arc PAC was performed using a
curing unite Flipo (Lokki ,France) which achieved
an intensity of 1370 mWlcm2. The light exposure
was 12 seconds which achieve similar material
properties compared to 40seconds curing with
QTH lamps (8). The light intensity of the curing
unites was measured with a radiometer (model
100, Opteiox radiometer, USA) and it was
checked before irradiation to each sample groups.
Immediately after curing of composite resin
specimen, the celluloid strip was removed, thus
providing a hemi-cylinder with the same
dimension of the bisected hole, then stored for 24
hours in a light proof container with distilled
water at 37˚c to complete polymerization and
inhibit any further polymerization from transient
light (5).
After one day of storage in distilled water in a
light proof container at 37˚C, the specimens were
positioned within their mold and divided in 5 mm
depth intervals with a razor blade: 0-1, 1-2, 2-3, 34 and 4-5 mm (Figure 1).The Knoop hardness test
was performed with a Vickers microhardness
tester (micromet, U.S.A.) which was calibrated
with a load of 200 g load for 40 seconds (1).
Three indentations on the same line (equally
spaced over a circle and not closer than 1 mm to
adjacent indentation or margin of specimen) were
made in each millimeter interval and the
arithmetic means were calculated for each interval
of the specimen.
Table1: Manufactures Scientifics
documentation for the composite restorative
materials used in this study
SureFil High
Density Posterior
Restorative
3M Dental
Dentsply/Caulk
Manufacture
products(USA)
(USA)
Composite
Packable
Packable
Type
Method of
Visible Light
Visible Light
activation
cure
cure
Bis- GMA,
BisResin
UDMA,
GMA,UDMA,
Components
Bis-EMA.
TEGDMA
Barium fluoro
alumino
Zirconia/
borosilicate
Filler Type
Silica
glasses and blend
of fumed silica.
0.19-3.5µm
Average filler
0.04-10 µm
(average: 0.6
Particle size
(average: 0.8 µm)
µm)
Filler
Loading
83%wt/ 61%vol 82% wt /66% vol
(wt/vol)
Product
Filtek P60
A polyester strip was positioned between the
lateral and central parts of the molds to guarantee
the lateral smoothness of composite for the
microhardness evaluation (5). Then the mould
cavity was filled with the packable composite
resin in bulk increment and condenses with plastic
plugger manually to completely over fill the
cavity. Then the composite resin was covered
with a transparent celluloid strip and then thick
glass slide, which gently pressed under a load of
200 g for 1 minute (3). The glass slide was
removed & the composite resin was irradiated
from the top through the celluloid strip in away
that the distal end of the light curing machine tip
was held in contact to the celluloid strip & the
center was coincident with the Specimen’s long
axis (6). Photo-activation was performed with a)
Conventional QTH, b) light emitted diode LED,
or 3) Plasma arc PAC.
Ten specimens were prepared for each photoactivation method.
For the Conventional QTH
light activation method, the composite resin
specimens were cured using YDL light curing
unite (china) for 40 seconds with an intensity of
500 mWlcm2 (7).For the light emitted diode LED:
5
4
6
m
3
2
1
5m
Figure 1: division of the specimen for 5mm
for the hardness test
The data were submitted to the analysis of
variance (ANOVA) test for comparison of
significance among different groups. When a
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Vol. 22(1), 2010
significant difference was found, LSD test to find
where the significance occurs. Also paired t-test
was used for comparison of significant differences
between two mean values.
suggested that the hardness gradient should not
exceed 10% to 20% (hardness ratio greater than
0.8) to adequately photo-activate composite resins
(9, 10)
.
According to the effect of the light curing
system on the microhardness, results obtained
from this study showed that the mean hardness of
the composite restorations cured with LED light
curing system was the highest compared with
those of composite restorations cured with
conventional QTH and PAC light curing systems,
while the PAC showing the least mean hardness.
These results can be explained through the
analysis of the total amount of energy released by
each light curing unit during polymerization.
.According to Peutzfeldt et al. (11), when curing
light units are studied; an important parameter is
the amount of light energy of appropriate
wavelength emitted during irradiation. This
energy is calculated as the product of the output of
the curing light unit and the time of irradiation
and may be termed as energy density. So the total
energy released from the conventional QTH was
20 J/cm2 (0.500 x 40 sec). While for LED was
38.8 J/cm2 (0.70W/cm2 x4 sec for the initial
curing followed by 1.000 W/cm2 x 36sec for the
final curing). The PAC emits less energy in 12
sec than do the conventional and soft start LED
curing light units, the total energy released from
the PAC was 16.44 J/cm2 (1.370x12sec). This
could explain the lower depth of cure obtained
with this method when compared to the other
methods. These results agree with those of
Vandewalle et al (12), Briso et al (13),who found
that LED appliance emitting greater light intensity
provided the highest hardness values allowing the
best curing.
However, the results of this study disagree with
those of Yazici et al (14), who found that the mean
hardness values of the composite resin specimens
cured with QTH light curing unit was higher than
that of the specimens cured with a PAC & LED
systems at which LED demonstrated the lowest
values. The difference in the result can be
attributed to the difference in intensity of light
curing system in his study which was
400mW/cm2 for LED and 550 m W/cm2 for QTH.
Our results agree with those of Hubbezoğlu et
al (15), who compared the microhardness of
different composite resins cured with the
traditional halogen light source, light emitting
diode and plasma arc lamp. They reported that the
plasma arc lamp yielded lower hardness values for
both top and bottom surfaces.
Based on the decreased hardness values that
we and others obtained with PAC units, it would
appear the higher intensities of this curing light
RESULTS
Means, standard deviation and ratio of VHN of
two different lights activated composites and for
all groups are listed in table 2 and represented in
figure 2a and 2b. The result showed that the
microhardness of packable composite resins at
different depth for each type of composite is
affected by the type of light activation; the LED
light curing system produced superior mean
microhardness value followed by conventional
QTH and PAC light curing systems respectively.
However there was a highly significant difference
(P<0.001) among the groups that cured with
different curing unites at the different depth for
each type of composite.
Packable composite (Filtek p60) showed a
higher VHN value than packable composite
(Surefil) in all light curing unites and for all
depths and there is significant difference
(P>0.005) between Filtek P60 and Surefil
composite resins.
There was a decrease in the mean VHN value
with increased depth of filling for both composite
types and there was a highly significant difference
in the mean VHN among the subgroups (0-1,12,2-3,3-4 and 4-5) for each light Curing system
for both Filtek p60 and Surefil composite.
DISCUSSION
The development of new technologies for
photo-activation of restorative composite resins
has caused great interest among researchers
.However, the real advantages of these techniques
are not totally known. Before these methods can
be clinically applied, the final properties of the
photo-activated composite must be evaluated
(7)
.Adequate polymerization is required for
clinically successful restorations. Therefore, the
influence of different kinds of light curing units
with varying intensities on the hardness of
packable composite resin at different depth was
evaluated in the present study.
Measuring the material's hardness at specific
depths is one of the most used methods for
assessing in vitro depth of polymerization. As a
rule, high hardness means indicate an adequate
polymerization. If polymerization was effective
(i.e. maximum cure of the specimens were
achieved), an ideal 1:1 ratio should be reached
and top surface hardness would be similar to that
of the other depths. Nevertheless, it has been
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Vol. 22(1), 2010
cannot compensate for the reduced exposure time.
While these new high energy light-curing units
may require shorter polymerization times, this
finding may be due to the reality much of the light
emitted from a PAC unit lies outside the effective
polymerization region of 450–490 nm for
composite resin materials (14).
According to the effect of the depth on the
microhardness, there was a high significant
decrease in the microhardness mean values of the
composite specimens with increasing depth of
cure despite the curing system used and the
composite type. This may probably be attributed
to the fact that light intensity was greatly reduced
while passing the bulk of the composite resin due
to light scattering and absorptions, decreasing
polymerization effectiveness. This may be
accounted for the difference in the microhardness
at every depth of each material cured with
different light sources.
From table 2, it can be seen that, for depth of 2
mm, VHN for both materials was more than 0.8
for all groups .This result demonstrates that
despite the particular characteristics of each
method, the light intensity and the exposure time
were enough to adequately polymerize this
thickness of composite.
At a depth of 3 mm, the LED demonstrated the
highest hardness value, while the continuous QTH
method revealed an intermediate value with a high
statistical difference from the other methods. At
this depth the VHN was more than 0.8 for Filtek
p60 with the continuous QTH and the LED but
less than 0.8 with PAC method, while for Surefil,
the VHN was more than 0.8 with the LED only,
and less than 0.8 with the continuous QTH
method and PAC. This result can be related to the
low exposure time with the PAC, as the light is
absorbed and/or scattered when the thickness
increases, consequently decreasing the amount of
energy for photo-activation. This fact may explain
the lower hardness observed at 3 mm depth when
PAC was used. Despite this scattering and
absorbance of light, all other methods supplied
higher amounts of energy to the composite and,
thus, provided higher hardness values at 3 mm
depth. And the difference between (Filtek
p60/surefil) with the continuous QTH method can
be related to the difference in the materials'
composition.
For depths beyond 3mm, the mean hardness was
less than 0.8 for all groups despite the light curing
system used and composite types (but the VHN of
Filtek p60 was more than Surefil). We notice that
at depth beyond 4mm, Surefil irradiated with PAC
not cured and can scraped easily with razer blade.
An important finding of this study was that
each of the tested materials (Surefil, Filtek p60)
were not adequately polymerized beyond 3mm
depth, this fact compromise the success of the
restorative treatment with packable composite
when used as bulk technique because the
existence of unpolymerized resin in the bulk of
the restoration my have deleterious effects,
increasing the risk of secondary caries underneath
the material, hypersensitivity, discoloration or
even fracture of the restoration.
This result agree with Nogueira et al (3);Obici et
al (7); Hegde et al (16);Ceballos et al (17), who found
that the microhardness means decreased
significantly with increase depth and this drop
was more accentuated for depth beyond 2 mm.
According to the effect of the material on the
microhardness, Filtek p60 comes in three shades
only (A3, B2, C2), while Surefil comes in shade
(A, B, C), so difficulty in standardization of the
shade may lead to the difference in the result.
In this study, Filtek p60 (in all subgroups)
exhibited a statistical higher VHN than Surefil.
This may possibly be ascribed to the optical
properties of resins (optical transmission
coefficient), which vary with the material
composition (particle type, contents, morphology
and size) (18, 19). So regarding the particle type the
zirconium is harder than heavy-metal glass and
the crystalline form (zirconium silica) is harder
than non crystalline (glass) and it diffuse light as
it penetrate (20). As regards the particle contents, a
positive relationship between hardness and
inorganic particle contents has been observed, as
an increase in filler content results in higher
hardness means (3). Increasing in the hardness of
composite is exponentially related to the
increasing in the density of filler particles, size of
filler particle and type of filler particles itself
(21)
.while as regards the particle morphology it
was found that the filler shape was spherical for
Filtek p60 which allow for increased filler loading
in composite, as well as enhanced fracture
strength since mechanical stresses tend to
accumulate on angles and protuberances (22).
Microhardness depends on the depth of cure
which is related to the size of the incorporated
fillers. The filler particles in the resin-based
composites scatter light. This scattering effect is
increased as the particle size of the fillers in the
composite approaches the wavelength of the
activating light and will reduce the amount of
light that is transmitted through the composite (1).
Material with the smallest filler particle size
(0.19-3.3 µm) showed the highest values of
overall light transmittance for all filler contents,
whereas those with the larger-sized fillers (0.04-
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Vol. 22(1), 2010
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remaining double bonds in resin polymers. Scand J Dent
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10. Yearn JA. Factors affecting cure visible light
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E.
Charecterization of resin composites polymerized with
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18. Kawaguchi M, Fukshima T, Miyazaki K. The
relationship between cure depth and transmission
coefficient of visible activated resin composite. Dent Res
1994; 73: 516-21.
19. Kim KH, Ong JL, Okuno O. The effect of filler
loading and morphology on the mechanical properties of
contemporary composites. J Prosthet Dent 2002; 87:642-9.
20. Albers HF. Tooth – colored restoratives. 9th ed.
London: BC Decker Inc Hamilton, 2002; Ch 6: P82 –93,
Ch 7: 111 – 123.
21. Craig R, O'Brien W, Power J: Dental Materials:
properties and manipulation 6th ed. Mosby-year
Book1996; Ch2:p15; Ch4:p55-58.
22. Beun S, Glorieux T, Devaux J, Vreven J, Leloup G.
Characterization of nanofilled compared to universal and
microfilled composites. Dent Mater 2007; 23:51-9
23. Arikawa H, Kanie T, Fujii K, Takahashi H, Ban S.
Effect of Filler Properties in Composite Resins on Light
Transmittance Characteristics and Color. Dental Materials
J 2007; 26(1): 38-44.
24. 24. Quance SC, Shortall AC, Harrington E, Lumley
PJ. Effect of exposure intensity and post-cure temperature
storage on hardness of contemporary photo-activated
composites. J Dent 2001; 29:553-60.
25. Filho JDN, Poskus LT, Guimaraes JG, Barcellos
AAL, Silva EM. Degree of conversion and plasticization
of dimethacrylate-based polymeric matrices:influence of
light-curing mode. J Oral Sci 2008; 50(3) 315-21.
10) µm showed lower light transmittance for all
filler contents (23).On the other hand, materials
with smaller filler particle size showed sharper
angular distribution of diffuse light, indicating
that less light was scattered within the material.
As light scattering is expected to increase with
increasing filler particle diameter, the larger
scattering caused by larger fillers thus resulted in
higher transmittance loss in comparison with
materials containing smaller filler particles (23).
In addition, other characteristics of the material
may have contributed to the these results, among
which the organic matrix composition, as the
polymerization level varies according to the
amount of the monomers and oligomonomers
present in the composite resins, in Filtek p60 the
majority of the TEGDMA has been replaced with
UDMA which is an aliphatic high-molecular
weight monomer that gives the polymer chain
great mobility and the crosslink density of the
polymeric matrix ,therefore , microhardness (24,25).
These results are in agreement with the finding
of Nogueira et al 2007 (3) who study the
microhardness of different packable composite
resins and his results show that the VHN values of
Filtek p60 was more than Surefil.
REFERENCE
1. Manhart J, Chen HY, Hickel R. The suitability of
packable resin-based composites for posterior restorations.
J Am Dent Assoc 2001; 132 (5): 639-45.
2. Knezevic A, Tarle Z, Meniga A, Sutalo J, Pichler G,
Ristic M. Degree of conversion and temperature rise
during polymerization of composite resin samples with
blue diodes. J Oral Rehabil 2001; 28: 586–91.
3. Nogueira JCC, Borsatto MC, Wanessa Christine de
Souza-Zaroni WC, Ramos RP, Palma-Dibb RG.
Microhardness of composite resins at different depths
varying the post-irradiation time. J Appl Oral Sci 2007;
15(4): 1678-1757.
4. Davidson CL, DeGee AJ. Light- curing units,
polymerization and clinical implications. J Adhesive Dent
2000; 2(3): 167-73.
5. Araujo CS, Schein MT, Zanchi CH, Rodrigues SA,
Demarco FF. Composite Resin Microhardness: The
Influence of Light Curing Method, Composite Shade, and
Depth of Cure. J Contemp Dent Pract 2008; 9(4): 1-6.
6. Hackman ST, Pohjola RM, Rueggeberg FA. Depth of
cure and effect of shade using pulse delay and continuous
exposure photo-curing techniques. Oper Dent 2002;
27:593-9.
7. Obici AC, Sinhoreti MA, Sobrinho LC ,Goes MF,
Consani S. Evaluation of Depth of Cure and Knoop
Hardness in a Dental Composite Photo-activated Using
Different Methods. Braz Dent J 2004; 15(3): 199-203.
8. Kanaan SM. The influence of Different Photoactivation Methods on the Shear Bond Strength of
Composite Resin to Dentin. Master thesis submitted to the
college of Dentistry, University of Baghdad, Department
of conservative Dentistry, 2005.
5
Vol. 22(1), 2010
Table 2: Mean (M), Standard Deviation (SD) and ratio of the VHN for all groups
Plasma Arc
Conventional QTH Soft start LED
Filtek p60 Surefil Filtek p60 Surefil Filtek p60 Surefil
Depth M (SD)
M (SD) M (SD) M (SD) M (SD) M (SD)
{ratio} {ratio}
{ratio} {ratio}
{ratio}
{ratio}
89.06
70.9
94.95
86.09
80.18
62.09
0-1
(2.024) (5.015) (3.014) (3.841) ( 6.9925) (9.019)
83.89
58. 96
88.5
76.09
70.82
48.54
(2.322) (6.265) (3.334) (6.204) (2.300) (6.932)
1-2
{0.94} {0.83} {0.93} {0.88} {0.88} {0.78}
75.3
46.79
80.27
70.02
50.27
41
(2.539) (3.738) (4.482) (5.8032) (7.793) (4.2345)
2-3
{0.85} {0.65} {0.84} {0.81} {0.62} {0.66}
67.3
35.07
69.99
48.49
43.09
28.64
(2.129) (2.355) (2.152) (4.459) (4.239) (5.383)
3-4
{0.75} {0.49} {0.73} {0.56} {0.53} {0.46}
61.08
28.16
64.93
30.87
30. 76
6.06
(2.793) (2.548) (3.324) (3.269) (1.744) (0.400)
4-5
{0.68} {0.39} {0.68} {0.35}
0.38
{0.09}
100
100
90
90
80
80
70
70
mean
50
m ean
LED
QTH
PAC
60
40
60
LED
50
QTH
40
PAC
30
30
20
20
10
10
0
0
0-1
1-2
2-3
3-4
4-5
0-1
Figure 2a: Bar chart shows the means of the
VHN values for all groups of Filtek p60
1-2
2-3
3-4
4-5
depth in mm
depth in mm
Figure 2b: Bar chart shows the means of the
VHN values for all groups of Surefil
6
Vol. 22(1), 2010
Effectiveness of cure
Effectiveness of cure evaluation of four light-activated
composites using different curing modes
Ali A. R. Al- Shekhli B.D.S., M.Sc., Ph.D (1)
ABSTRACT
Background: The degree of polymerization of resin composites generally decreases from the surface of the
restoration inwardly. Ideally, the degree of polymerization of the composite should be the same throughout its depth
and the hardness ratio should be very close or equal to one and can be considered a good indicator for optimal
composite polymerization. This study investigated the influence of different new curing modes on the effectiveness of
cure of conventional light- activated composites to examine their efficacy in satisfying composite adequate
polymerization (hardness ratio ≥ 0.8).
Materials and methods: This study investigated the hardness of the top/bottom surfaces and hardness ratio of two
mm thick composite specimens after exposure to different curing modes. Parameters included six conventional
curing modes: Control (C), Pulse Delay I (PDI), Pulse Delay II (PDII), Soft-start (SS), Pulse Cure I (PCI), and Pulse Cure II
(PCII) plus three experimental curing modes of higher energy density: Prolonged low-intensity pulse cure mode
(PLPC), Prolonged moderate-intensity pulse cure mode (PMPC) and Rapid high-intensity continues cure mode
(RHCC) for each of the four different light-activated composites being tested (Tetric Ceram, Heliomolar, Herculite
XRV and Degufill Mineral).
Results: Results revealed that, there was a statistically significant difference for all the hardness ratios with the curing
modes except the hardness ratio of Heliomolar composite where, there was an insignificant difference because, the
mean hardness ratio of Heliomolar composite with the first six curing modes (control, PDI, PDII, SS, PCI, PCII) was not
calculated because of poor polymerization of Heliomolar bottom surfaces with these six curing modes.
Conclusion: This study concluded that, conventional curing modes had failed to cure Heliomolar and Degufill Mineral
composites adequately while the experimental curing modes of high energy density (PLPL, PMPC and RHCC) had
satisfied effectiveness of composite cure for all the composites being tested.
Key words: resin composite, light curing modes, microhardness test. J Bagh Coll Dentistry 2010; 22(1):7-10
INTRODUCTION
Light-activated resin composites, introduced
in the 1970s, revolutionized clinical dentistry by
maximizing working time and minimizing setting
time. Over the last few years, composite
restoratives and adhesive techniques have become
the foundation of modern dentistry.
The hardening of dental composite resulted from a
chemical reaction between dimethacrylate resin
monomers that produces a rigid and heavily crosslinked polymer network surrounding the inert
filler particles (1). The extent of this reaction often
referred to as the degree or effectiveness of cure,
is very important in that it dictates many physical
and mechanical properties of the composite
restoration (2). Inadequate polymerization has been
associated with inferior physical properties, higher
solubility, retention failures and adverse pulpal
responses due to un polymerized monomers (3).
The effectiveness of composite cure may be
assessed directly or indirectly.
Direct methods that assess degree of conversion,
such as infrared spectroscopy and laser Raman
spectroscopy, have not been accepted for routine
use because these methods are complex,
expensive, and time -consuming (4).
Indirect methods have included visual,
scrapping and hardness testing. Incremental
surface hardness has been shown to be an
indicator of the degree of conversion (5).High
intensity lights may provide higher values for
degree of conversion, but they also produce higher
contraction
strains
during
composite
polymerization (6). A slower curing process that
permits composite flow may allow for stress
relaxation to take place during photopolymerization (7). As the polymerization process
is dependent on total light energy rather than light
intensity alone (8), a slower curing process with an
equivalent degree of conversion can be obtained
by applying a lower intensity light for a longer
time or using variable intensities over a given time
period. Examples of the latter include soft-start
polymerization and pulse- delay cure. The softstart polymerization technique involves a stepwise modulation of light energy from low-to-high
intensities, while the pulse-delay cure consists of
an initial low-energy dose, a waiting period where
surface finishing is done, followed by curing at a
high intensity. The aim of this study is to
(1) Assistant Professor, Department of Conservative Dentistry,
Faculty of Dentistry, Ajman University of science and
technology network, UAE.
7
Vol. 22(1), 2010
investigate the influence of different curing modes
plus three experimental curing modes of high
energy density on the effectiveness of cure of four
different light-activated composites.
Mean and standard deviation were calculated
for each specific hardness ratio. The results were
analyzed with one-way ANOVA and least
significant difference (LSD)-test at 0.05 level of
significance.
MATERIALS AND METHODS
Four different light-activated resin composite
materials of A2 Vita shade were selected for this
study: Tetric Ceram (Ivoclar, Vivadent AG FL9494
Schaan/Liechtenstein.Lot:
E58102),
Heliomolar (Ivoclar, Vivadent AG FL-9494
Schaan/Liechtenstein.Lot: C37535), Herculite
XRV (sds Kerr, 1717 West Collins Orange, CA
92867, U.S.A.Lot: 205466.Item No.: 22860) and
Degufill Mineral (Degussa-Hüls AG, Degussa
Dental GmbH & Co. KG, Postfach 1364. D-63403
Hanau, Germany.Lot: 0885).
A stainless steel cylindrical mold of 2-mm
high and 4-mm in diameter (Iraqi construction)
was used to prepare the composite specimens, the
mold was placed on a clear glass slide (Blue star
glass industries, Delhi, India) with a transparent
celluloid strip (Hawe-Neos Dental, CH-6925
Gentilino, Switzerland) in between. Then, another
transparent celluloid strip was placed on the top
surface of the mold over which, a cover slide (0.3
mm in thickness) was then placed and excess
material was extruded by finger pressure
application to ensure that the exposed surface of
the composite was flat and parallel to the surface
of the mold. The composite was then photocured
from the top surface with nine different curing
modes (6 conventional and 3 experimental) (9)
using variable intensity polymerizer light curing
unit (VIP Light, Bisco Inc., Schaumburg, Ill.;
Spectrum
800,
Dentsply/Caulk,
Milford,
Del.).One hour after light polymerization, the
specimens were subjected for microhardness
testing with Micromet Vickers micro-hardness
tester (Adolph I. Buehler Inc. Optical and
Metallurgical instruments 2120 Greenwood
st/Evanston ILL USA 60204) (Figure 1) to
calculate Vickers hardness number (VHN) of the
top and bottom surfaces. A 500-gram load was
applied through the indenter with a dwell time of
45 seconds. The VHN corresponding to each
indentation was computed by measuring the
dimensions of the two diagonals of each
indentation and averaged to get the corresponding
VHN. Ten specimens were assigned for each of
the different curing modes and each type of
composite materials. Hardness ratio was
calculated using the following formula:
Hardness ratio=VHN of bottom surface/VHN of
top surface That means if the value exceeded 0.8,
the specimen was considered adequately
polymerized (10).
Figure 1: Micromet Vickers micro-hardness
testing devise
RESULTS
Mean VHN and standard deviation at the top,
bottom and mean hardness ratio of the four lightactivated composites cured with the nine-different
curing modes are listed in Table 1.
Table 1: Mean hardness ratio of the four
light-activated composites cured with the
nine-different curing modes.
Tetric
Heliomolar
Ceram
Curing
Mode
HR
HR
HercDeguf-ill
ulite
Mineral
XRV
HR
HR
0.71
0.8
0.63
?
(0.05)
(0.09)
(0.04)
0.77
0.87
?
0.6 (0.04)
PDI
(0.1)
(0.03)
0.81
0.88
0.56
?
PDII
(0.09)
(0.05)
(0.02)
0.78
0.87
0.68
?
SS
(0.04)
(0.01)
(0.05)
0.8
0.85
0.59
?
PCI
(0.04)
(0.03)
(0/03)
0.78
0.85
0.57
?
PCII
(0.02)
(0.03)
(0.02)
0.86
0.88
0.81 (0.04)
0.8 (0.02)
PLPC
(0.04)
(0.02)
0.9
0.87
0.81
0.8 (0.08)
PMPC
(0.07)
(0.04)
(0.09)
0.94
0.98
0.82
0.81 (0.05)
RHCC
(0.05)
(0.05)
(0.03)
Standard deviation in parentheses.
? : The hardness ratio is not calculated, because
of the poor polymerization of the bottom surface.
Control
8
Vol. 22(1), 2010
of Heliomolar bottom surfaces with the
conventional curing modes (Table 1). LSD-test of
the hardness ratio according to curing mode is
summarized in Table 2.
Table 2: LSD-test of the hardness ratio
according to curing mode.
Tetric Herculite Degufill
*
**
NS
Control PDI
***
**
Control PDII ***
**
**
*
Control SS
*
NS
Control PCI ***
*
*
**
Control PCII
***
***
Control PLPC ***
**
***
Control PMPC ***
***
***
Control RHCC ***
NS
NS
PDI
PDII NS
NS
NS
***
PDI
SS
NS
NS
NS
PDI
PCI
NS
NS
PDI
PCII NS
NS
***
PDI PLPC ***
NS
***
PDI PMPC ***
***
***
PDI RHCC ***
NS
NS
***
PDII
SS
NS
NS
NS
PDII
PCI
NS
NS
PDII PCII NS
NS
***
PDII PLPC NS
NS
***
PDII PMPC ***
***
***
PDII RHCC ***
NS
NS
***
SS
PCI
NS
***
SS
PCII NS
NS
***
SS
PLPC **
NS
***
SS PMPC ***
***
***
SS RHCC ***
NS
NS
PCI
PCII NS
NS
***
PCI PLPC *
NS
***
PCI PMPC ***
***
***
PCI RHCC ***
NS
***
PCII PLPC **
NS
***
PCII PMPC ***
***
***
PCII RHCC ***
NS
NS
PLPC PMPC NS
***
NS
PLPC RHCC **
***
NS
PMPC RHCC NS
NS : Insignificant difference
* : Significant difference
** : Highly significant difference
*** : Very highly significant difference
DISCUSSION
The relative importance of a microhardness
test lies in the fact that it throws a light on the
mechanical properties of a material (12). The
higher the degree of conversion, the better the
mechanical properties, hardness, biocompatibility,
water sorption, color stability and wear resistance
of the resin composites (13).
In this study, the top surface was not as
susceptible to the effects of light intensities as the
bottom surface. This finding agrees with Hansen
& Asmussen (14), who stated that, inferior curing
units (low energy density) polymerize the top
surface just as effectively as good light sources
(high energy density).
Rueggeberg et al. (15) have concluded that at
the top surface, only irradiation time is a
significant factor that contributes to monomer
conversion. The composite type and curing mode
were significantly affected the effectiveness of
composite cure (hardness ratio). It is believed that
microfills exhibit this reduced depth of cure
because their small filler particles cause light
scattering, which decreases the effectiveness of
the curing light (16). Composites that contained
prepolymerized filler particles (Heliomolar)
exhibited significantly lower physical properties
than composites that contained round, irregularshaped filler particles (Herculite XRV), or a
mixture of prepolymerized and irregular-shaped
particles. The results of this study were, in
agreement with the findings of Kim et al. (17), who
found that the filler loading also affected the
physical properties including microhardness of the
composites evaluated. The results of this study
indicated that, the Vickers hardness numbers of
the tested materials is directly proportional to the
amount of filler loading (by weight). This is due
to the fact that, Herculite XRV composite contains
79% by weight filler loading and in other
references (18) 87.1% by weight filler loading and
this increased filler loading or the type of its filler
loading could be the main cause for its highest
VHN followed by Degufill Mineral (80% filler
loading by weight), Tetric Ceram (79% filler
loading by weight) and finally Heliomolar (66.7%
filler loading by weight).
Statistical analysis of the data by using the
one-way analysis of variance revealed that, there
was statistically very highly significant difference
(***) (p<0.001) for all the hardness ratios with the
curing modes except the hardness ratio of
Heliomolar composite where, there was an
insignificant difference (NS) (p>0.05) because,
the comparison was made between the last three
experimental curing modes only (PLPC, PMPC
and RHCC). The mean hardness ratio of
Heliomolar composite with the first six curing
modes (control, PDI, PDII, SS, PCI, PCII) was
not calculated because of the poor polymerization
9
Vol. 22(1), 2010
REFERENCES
1-
Ferracane JL.Current trends in dental composites.
Critical Reviews in Oral Biology and Medicine1995;
6(4): 302-18.
2- Asmussen E. Restorative resins. Hardness and
strength vs quantity of remaining double bonds.
Scand J Dent Res 1982 a; 90(6): 484-9.
3- Blankenau RJ, Kelsey WP, Powell GL, Shearer GO,
Barkmeier WW, Cavel WT. Degree of composite
resin polymerization with visible light and argon
laser. Am J Dent 1991; 4(1): 40-2.
4- Rueggeberg FA, Craig R. Correlation of parameters
used to estimate monomer conversion in a light-cured
composite. J Dent Res 1988; 67(6): 932-7.
5- Asmussen E. Factors affecting the quantity of
remaining double bonds in restorative resin polymers.
Scand J Dent Res 1982 b; 90(6): 490-6.
6- Sakaguchi RL, Berge HX. Effect of light intensity on
polymerization contraction of posterior composites
(abstract 481). J Dent Res 1997; 76:74.
7- Sakaguchi RL, Berge HX. Reduced light energy
density decreases post-gel contraction while
maintaining the degree of conversion in composites. J
Dent 1998; 26(8): 695-700.
8- Miyazaki M, Oshida Y, Moore BK, Onose H. Effect
of light exposure on fracture toughness and flexural
strength of light-cured composites. Dent Mater 1996;
12:328-32.
9- Al-Shekhli AA. Depth of cure evaluation of four
different light-activated composites using different
curing modes. J Bagh Coll Dentistry 2009; 21(1):5-8.
10- Manga RK, Charlton DG, Wakefield CW. In-vitro
evaluation of a curing radiometer as a predictor of
11-
121314-
1516-
17-
18-
10
polymerization depth. General Dentistry 1995; 43 (3):
241-3.
Yap AUJ, Soh MS, Siow KS. Effectiveness of
composite cure with pulse activation and soft-start
polymerization. Oper Dent 2002; 27:44-9.
Braem M, Finger W, Van Doren VE, Lambrechts P,
Vanherle G. Mechanical properties and filler fraction
of dental composites. Dent Mater 1989; 5(5): 346-8.
Hinoura K, Akiyama Y, Miyazaki M, Kuroda T,
Onose H. Influence of irradiation sequence on dentin
bond of resin inlays. Oper Dent 1995; 20(1):30-3.
Hansen EK, Asmussen E. Visible-light curing units:
correlation between depth of cure and distance
between exit window and resin surface. Acta Odontol
Scand 1997; 55: 162-6.
Rueggeberg FA, Caughman W, Curtis JW. Effect of
light intensity and exposure duration on cure of resin
composite. Oper Dent 1994; 19: 26-32.
Kawaguchi M, Fukushima T, Miyazaki K. The
relationship between cure depth and transmission
coefficient of visible light-activated resin composites.
J Dent Res 1994; 73:516-21.
Kim KH, Ong JL, Okuno O. The effect of filler
loading and morphology on the mechanical properties
of contemporary composites. J Prosthet Dent 2002;
87: 642-9.
Hofmann N, Hugo B, Schubert K, Klaiber B.
Comparison between a plasma arc light source and
conventional halogen curin units regarding flexural
strength, modulus, and hardness of photoactivated
resin composites. Clin Oral Invest 2000; 4(3): 140-7.
Vol. 22(1), 2010
Ear lobes as facial
Ear lobes as facial landmarks for determining the occlusal
plane
Bayan S. Khalaf B.D.S. M.Sc. (1)
ABSTRACT
Background: Difficulties arise when attempting to imagine the interpupillary line and comparing it with the Fox plane
guide and not more difficult than holding any instrument over the movable pupils just to demonstrate the
interpupillary line. The aim of this study was to introduce ear lobes as alternative landmarks for the interpupillary line
during orientation of the occlusal plane. Also, the other aim was to compare the ear lobes with the pupils of the eyes
to verify that they were indifferent as anatomical landmarks.
Materials & methods: The alternative landmarks, ear lobes, were presented and the method for orienting the occlusal
plane with these landmarks was introduced. Digital pictures of 30 subjects, who participated in the study, were
analyzed to compare the parallelism of the interpupillary line with the ear lobes.
Results: The results of this study showed that the interpupillary line was parallel with the line drawn between both ear
lobes for the same subject.
Conclusion: The ear lobes were reliable and dependable alternative landmarks for the orientation of the occlusal
plane and could be used with less effort than that of the conventional method utilizing the interpupillary line.
Key words: earlobe, landmark, occlusal plane. J Bagh Coll Dentistry 2010; 22(1):11-13.
INTRODUCTION
Husseinovitch & Chidiac(6) used a modified
occlusal plane indicator which is a fox plane
guide with two rulers fixed with three long
screws. The rulers were used for illustrating the
interpupillary and camper’s lines. Nayer(7)
pressed a piece of string, immersed in talcum
powder or plaster of Paris, against the patient's
cheeks to mark the Camper’s line.
Some authors suggested other facial
landmarks like Zepa and Huggare(8) who
introduced the supra-orbital line in posterioanterior cephalograms as a substitute for the
interpupillary line.
In this article the ear lobes were presented as
alternative landmarks for orienting the occlusal
plane instead of the pupils of the eyes,
interpupillary line. Also, the ear lobes were
compared with the pupils to verify that they were
indifferent from the pupils as anatomical
landmarks.
The occlusal plane can be defined as "the
average plane established by the incisal and
occlusal surfaces of the teeth".(1) The orientation
of the occlusal plane is one of the steps needed in
determining the maxillo-mandibular relationship
and, eventually in the arrangement of the
artificial teeth during complete denture
construction. This could be achieved by
contouring the maxillary occlusal rim to achieve
an occlusal plane which lies parallel with facial
guides, interpupillary and Camper’s (ala-tragus)
lines. An occlusal plane indicator such as a Fox
plane guide could be used to achieve this
goal.(2,3)
There were several authors who used
different methods or designed instruments to
help in obtaining the occlusal plane. One of those
authors was Pound (4) who favored placing the
patient's head in a perfectly erect position and
made the occlusal plane parallel to the floor
regardless of the eyes or any other facial features.
Kazanoglu & Unger(5) determined the occlusal
plane with a Camper’s plane indicator which
consisted of two parallel metal plates. The lower
plate was inserted in the mouth and pressed
against the upper occlusal rim while the upper
plate was used to compare with the interpupillary
and camper’s lines.
MATERIALS & METHODS
The ear lobes can be used during maxillomandibular relationship registration. This is
commenced by comparing the Fox plane guide
with the ear lobes on both sides simultaneously,
as in figure 1. The distance between the inferior
border of the ear lobe and the Fox plane guide
should be equal on both sides and this is
estimated with the practitioner’s eyes. Any
discrepancies can be adjusted by adding or
removing from the occlusal rim.
(1) Assistant lecturer, Department of Prosthodontics, College of
Dentistry, Baghdad University.
11
Vol. 22(1), 2010
Ear lobes as facial
statistically insignificant. This demonstrated that
the two corresponding angles for each subject
were to a great degree equal to each other and the
slight difference was statistically insignificant.
Table 1: Paired-Sample T Test and the
measuring unit is radian (SI unit).
Mean Std. Dev. t df P value
PT-ET .000233 .004461 .286 29 .777
Figure 1
P>.05 (insignificant), P<.05 (significant), and P<.01
(highly significant)
In this research 30 subjects participated with
an age range of 22-40 years.
A digital picture was taken from the frontal
view of each subject with the head in an upright
position. Each picture was than analyzed in a
computer with the Dimaxis 2.3.3 software by
Planmeca. Two lines were drawn; the first (P)
passing through the center of the pupil and the
second (E) passing through the inferior border of
both ear lobes of each subject, as seen in figure
2. A third line (T) (transversal line) was drawn
crossing the previous two lines, thus creating two
corresponding angles. The angle between lines
(P) and (T) was named (PT) and the angle
between lines (E) and (T) was named (ET).
The angles were than measured with the
same software, Dimaxis 2.3.3 software. The unit
in which the angles were measured was in degree
(˚) which was converted to the Système
International d’Unités (SI unit) which was in
radian (rad).
The two angles, (PT) and (ET), were
compared with each other and statistically
analyzed for any significant difference with the
Statistical Package for Social Sciences (SPSS)
version 15.0 for Windows. The Paired-Sample T
Test was used for analysis of the data.
DISCUSSION
Determining the Occlusal plane during
interarch relationship registration in completely
edentulous subjects is quite confusing, especially
for less experienced practitioners who are
attempting to align the occlusal plane with the
interpupillary line. This difficulty arises from the
fact that trying to imagine the interpupillary line
and comparing it with the Fox plane guide is
quite difficult and not more difficult than holding
any instrument over the movable pupils just to
demonstrate the interpupillary line. Also, it’s
more difficult for the practitioner to compare
between the fox plane guide and an instrument
that represents the interpupillary line with a
distance of several centimeters apart. A
comparison of a centimeter, more or less, for the
distance between the ear lobes and the fox plane
guide is much easier.
This alternative method is very simple and
needs no extra effort as compared to the
conventional technique which depends on the
pupils to orient the occlusal plane. This method
is also easier and less confusing to the dental
practitioner. The practitioner would not need to
imagine or try to present the interpupillary line
with any instrument. The Fox plane guide would
just be compared with the inferior border of ear
lobes on both sides simultaneously with the
practitioner's eye while standing in front of the
patient (figure 1).
The ear lobes are stable landmarks unlike the
moving pupils of the patient. It's difficult to fix
or stabilize the pupils because the patient doesn't
understand the importance of stabilizing the
pupils, nor does he/she know in which correct
position to stabilize the pupils.
In elderly subjects who receive the majority
of the complete dentures the muscle coordination
is poor.(3) The method suggested in this study
was, thus, favorable because no effort was need
from the patient.
The human face is not perfectly symmetrical
and what implies on the ear lobes also implies on
the pupils of the same face. Furthermore, a range
T
90.5˚
90.5˚
P
E
Figure 2
RESULTS
The (PT) and (ET) angles displayed a mean
difference of 0.000233 rad (0.013˚) (table 1).
This difference between the angles was
12
Vol. 22(1), 2010
of facial asymmetries that can influence the
choice of occlusal plane during prosthodontic
treatment exists. Thus, an occlusal plane parallel
to the ala tragus and interpupillary lines, as often
supported by prosthodontists, may result in less
than ideal esthetics in the final restoration.(9)
It was obvious from the results, as seen in
table 1 that the corresponding angles (PT) and
(ET) were insignificantly different and this
meant that lines (P) and (E) were parallel. This is
true because when a transversal line cuts two
lines, if the corresponding angles are equal in
size, then the two lines are parallel.(10)
The ear lobes are, thus, reliable and
dependable alternative landmarks for the
orientation of the occlusal plane and can be used
with less effort than that of the conventional
method utilizing the interpupillary line.
REFERENCES
1. The glossary of prosthodontic terms. 7th ed. J Prosthet
Dent 1999; 81: 39-110.
2. Fox FA. The principles involved in full upper and
lower denture construction. Dental Cosmos 1924; 66:
151-7.
3. Zarb GA, Bolender CL, Eckert SE, Fenton AH, Jacob
RF, Mericske-Stern R. Prosthodontic Treatment for
Edentulous Patients: Complete Dentures and ImplantSupported Prosthesis. 12th ed. St. Louis(MO): CV
Mosby; 2004. p.27-8,262-3.
4. Pound E. Aesthetic dentures and their phonetic values.
J Prosthet Dent 1951; 1: 98.
5. Kazanoglu A, Unger JW. Determining the occlusal
plane with the Camper’s plane indicator. J Prosthet
Dent 1992; 67: 499-501.
6. Husseinovitch I, Chidiac JJ. A modified occlusal
plane device. J Prosthet Dent 2002; 87: 240.
7. Nayar S. A simple technique for marking the alatragal line. J Prosthet Dent 2005; 94: 304.
8. Zepa I, Huggare J. Reference structures for
assessment of frontal head posture. European Journal
of Orthodontics 1998; 20: 694-9.
9. Namano S, Behrend DA, Harcourt JK, Wilson PR.
Angular asymmetries of the human face. Int J
Prosthodont 2000; 13(1): 41-6.
10. Thomas GB, Finney RL. Calculus and Analytic
Geometry.7th ed. USA: Addison Weslay; 1988, p.8.
13
Ear lobes as facial
Vol. 22(1), 2010
An evaluation of three
An evaluation of three lubricants in reducing human
enamel wear (In vitro study)
Lamis AL-Taie B.D.S, M.Sc (1)
ABSTRACT
Background: Management of tooth wear from grinding presents a significant clinical challenge .Acrylic night guards
are often used to protect the teeth. The long term objective is to find a simple approach to control tooth wear as an
alternative to the use of night guards. This in vitro study aimed to assess the effectiveness of three lubricants in
reducing enamel wear.
Materials and Methods: Thirty two extracted human third molar were selected, randomly assigned in to four groups of
eight teeth each ,teeth were sectioned longitudinally in to two halves (buccal and lingual ),the sectioned specimens
were apposed each other in an electro mechanical wear machine under a load of 3 Kgs. The machine simulated
tooth grinding for (20000) wear cycles. The experiment was repeated for another (20000)wear cycles under four
different conditions: Group I: without using lubricants. Group II: The use of dry lubricant (Calcium Fluoride Ca F
powder). Group III: The use of Olive -Oil. Group IV: The use of combination of Calcium Fluoride /Olive-Oil slurry. Wear
rates of enamel were quantified by weighing the specimens before and after the use of lubricants. Analysis of
variance ANOVA test was performed between experimental groups to test the differences of wear rates among the
four groups.
Results: All three lubricants reduced enamel wear significantly when compared with wearing specimens with out
adding lubricants. Wear rates were significantly less for Olive-Oil, and Ca F /Olive- Oil slurry compared with Ca F
alone, while there was no significant difference between the use of olive oil alone and the use of Ca F/Olive- Oil
slurry.
Conclusion: It was confirmed that each of the three lubricants reduced the wear rates of enamel substantially during
tooth grinding when compared with wear rates of enamel without lubricant. This study also confirmed that Olive-Oil is
very effective lubricant.
Key words: Enamel wear, lubricant, Olive oil, Calcium Fluoride (Ca F). J Bagh Coll Dentistry 2010; 22(1):14-17.
INTRODUCTION
Clinicians are commonly used acrylic night
guards of different designs to protect the teeth
from tooth grinding. Furthermore, no one knows
the effect of long term use of night guards. It
seems that the patient still grind on these
appliances and that they serve mainly as physical
barriers to protect tooth structure (4).Recent in
vitro studies indicated that wear rates of enamel
follow two phases: an initial fast "primary phase"
and the slower consistent "secondary phase".
Wear rates of enamel are determined by a number
of extrinsic variables including: load, PH of the
oral environment, and the nature and the type of
lubricants (5, 6).Lubricants in nature, whether they
are liquids or in solid state (dry) acting as a
separating medium between opposing surfaces. In
this investigation three different lubricants were
used in the experiment. The first was the dry
lubricant (Calcium Fluoride Ca F powder) which
is recognized by tribologists to be one of the best
found in nature. The second was Olive-Oil, while
the third was a combination of Ca F/Olive-oil
slurry.
With the changing age profiles, a greater
number of older individuals in most countries
with improving dental health presented an
extensive tooth wear. This can result in
discomfort when areas of dentin become exposed,
and lead to un acceptable aesthetic changes
associated with reduced crown height and in some
cases, compromised function (1).There are several
mechanisms that contribute to tooth wear, these
include: abrasion resulting from the friction of
exogenous material forced over tooth surfaces;
erosion resulting from the chemical dissolution of
tooth surfaces; and attrition from tooth to tooth
contact (night grinding).This in vitro study
focused on attrition of enamel resulting from
tooth grinding , the etiology of this condition
range from sleep disorders, stress, occlusal
discrepancies, and the physiological function (2).
Because the successful management of extensive
tooth wear can be complex and expensive, it is in
the patient's best interest that potential problems
are identified as early as possible and appropriate
preventive measures instituted to reduce the rate
of loss of tooth substances (3).
Thirty two extracted human third molar were
selected, the teeth were cleaned with water,
sectioned longitudinally, and dried in air for two
days in constant environment so that each
specimen consisted of a buccal or lingual half
(1) Lecturer, Department of Conservative Dentistry, College of
Dentistry, University of Baghdad.
14
Vol. 22(1), 2010
crown with a root portion. Each half crown was
attached to a specimen holder that fitted on to the
wear machine (an electro-mechanical wear
machine specially designed, constructed and
tested to wear natural teeth under controlled
conditions) (Figure 1), so that the buccal and
lingual surfaces of the same tooth were apposed
(Figure 2).Variables were controlled included the
load imparted upon opposing surfaces (3Kg) (6),
the relative direction of movement, the duration of
contact between opposing surfaces, the number of
cycles, the relative speed of each cycle, as well as
the quality and quantity, and the flow rate of
various lubricants. Quantification of wear
involved weighing specimens using an electronic
analytic balance (Balance/Sartorius/BP 30 15,
Germany). After sectioning, all specimens were
weighed at the same time under the same
conditions. Each pair of specimen was worn for
20000 cycles to ensure that the facets were
produced well for the secondary phase of wear.
The teeth were covered with nail varnish to
prevent the ingress and the egress of water,
leaving only facets exposed After weighing the
specimens lubricants were included and the wear
continued for another 20000 cycles. The samples
were divided in to four groups of eight teeth each:
Group I: without using lubricants (control).
Group II: The use of dry lubricant Calcium
Fluoride Ca F powder (Cacl2.2H2OM 247, 02
PH5.20C ARLOERBA. Italy).
Group III: The use of Olive-Oil (AL-Shemma,
Syria).
Group IV: The use of combination of Calcium
Fluoride /Olive-Oil slurry. (1: 1 by volume).
Then the teeth were cleaned from the lubricant
using water, dried, and re weighed. Wear rates
were quantified by comparing the initial and the
final weights of the specimens (before and after
the use of lubricants).Analysis of variance
(ANOVA) test was performed among the
experimental groups to determine whether there
was any statistically significantly difference under
various conditions.
Figure 1: An electro mechanical wear machine
Figure 2: The buccal and lingual surfaces of
the same tooth were opposed in the wear
machine.
Further investigation using LSD (Least
significant Difference) test showed that there was
a statistically significant difference (P<0.05)
between group I (control group), and group II
(with Ca F lubricant). A statistically highly
significant difference (P<0.001) has been found
between group I (control group), and both group
III (with Olive –Oil lubricant), and group IV(with
Ca F/Olive-Oil lubricant). Group II also showed a
highly significant difference with group III, and
group IV. There was no significant difference
(P>0.05) in the wear rates between groups III, IV
Table (3).
DISCUSSION
The tribiological aspects of human teeth are
very complicated subject. A wide range of
environmental conditions are possible for the
numerous functions of the tooth.
Furthermore the properties of a typical human
tooth vary very much with personal hygiene, diet,
physical activity level, and the numerous habits of
the individual. Although there are many variables
that must taken in an account for the applicability
of experimental and clinical studies as a general
rule for all teeth, so for better understanding on
methods of comparing and preventing wear in
modern dentistry. (9)
RESULTS
The data of wear rates of the all tested
specimens with the means and standard deviations
are presented 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 wear
rates among the four groups as shown in Table 2.
15
Vol. 22(1), 2010
Table 1: The data of wear rates (in g) for all test specimens with the mean and
standard deviation of each group .
Group I
Group IV Group III Group II
CaF/Olive oil Olive Oil Ca F
Control
Sample No.
Lubricant Lubricant lubricant Without lubricant
0.0311
0.0221
0.0463
0.0834
1
0.0296
0.0330
0.0397
0.0604
2
0.0325
0.0352
0.0577
0.0573
3
0.0283
0.0400
0.0491
0.0910
4
0.0291
0.0378
0.0662
0.0753
5
0.0321
0.0270
0.0535
0.0820
6
0.0299
0.0309
0.0551
0.0677
7
0.0347
0.0268
0.0477
0.0831
8
0.03091
0.03160 0.05191
0.07503
Mean
0.00211
0.00608 0.00808
0.01208
S.D
Table 2: Analysis of variance (ANOVA) test for the four groups.
Mean
Sum of squares
Significance
Degree of freedom
F value
square
P value
0.0034799
3
0.0104398 Between groups
HS
Within
55.12 0.0000631
28
0.0017676
0.000
groups
31
0.0122074
Total
Table 3: Least significant difference LSD test to compare the mean wear rates between groups.
Control CaF
Olive oil CaF/Olive oil
Lubricant Lubricant Lubricant
S
0.0007
0.0000
HS
0.0000
HS
HS: highly significant
S: significant
NS: non significant
Figure 3: Bar chart shows the mean wear rates (in g) for the four groups.
16
Vol. 22(1), 2010
4-Dao TT, Townsend GC. Oral splints: the crutches for
tempromandibular disorders and bruxism. Crit Rev Oral
Biol Med (1998); 9:345-61.
5-Burak N, Kaidonis JA, Richards LC,Townsend GC.
Experimental studies of human dentin wear. Arch Oral
Biol 1999; 44: 885-7.
6-Kaidonis JA, Richards LC, Townsend GC, Tansley GD.
Wear of human enamel a quantitative in vitro
assessment. J Dent Res 1998; 77: 1983-990.
7-Teo C, Young WG, Daley TJ, Sauer H. Prior
fluoridation in childhood affects dental caries and tooth
wear in south east Queensland population. Aust Dent J
1997; 42: 92-102.
8- Kaidonis JA, Gratiaen J, Bhatia N, Richards LC,
Townsend GC. Teeth wear prevention: a quantitative
and qualitative in vitro study. Aust Dent J 2003;
48(1):15-9.
9-Balooch G, Marshall SJ, Warren OL, Asif SA, Balooch
M. Evaluation of a new modulus mapping technique to
investigate micro structural feature of human teeth.
Dent Mat 2004; 20(4): 322-9.
10-Li H, Zhou ZR. Wear behavior of human teeth in dry
and artificial saliva conditions. Wear 2002; 249: 980-4.
11-Khan F, Young WG, Daley TJ. Dental erosion and
bruxism. A tooth wear analysis from south east
Queensland. Aust Dent J 1998; 43:117-27.
This study had shown that enamel wear can be
reduced significantly by using various lubricants
between opposing teeth that are worn together
under controlled condition. The addition of a
lubricant not only reduces the coefficient of
friction, but adds necessary cooling to better
mimic conditions in human mouth. This agrees
with he findings of Li and Zhou (10), and kaidonis
et al (6). It is well established that Calcium and
Fluoride concentrations with in the oral
environment prevent demineralization, promote
remineralization, and protect against caries and
erosion, so that a fluoridated tooth is more
resistant to attrition. The findings of the present
study indicate that the physical effects of a dry
powder such as CaF can reduce can reduce
significantly tooth wear, purely in a mechanical
manner, provided the powder can be applied and
maintained on occluding tooth surfaces. The
anisotropic characteristics of enamel prisms, even
in the form of a powder between surfaces, may
tend to produce more wear when compared with
Ca F powder. The result of this study agrees with
that of Teo et al (7) and Khan et al (11). The use of
Olive-oil and Ca F/Olive-oil slurry were
significantly more effective than Ca F alone. It
was anticipated that if a powder lubricant was
applied to the teeth in vivo, it would need to be
maintained on the buccal surface to have any
effect. As a result, Olive-Oil was selected to form
slurry, acting as a neutral (non reactive) carrier for
the calcium fluoride. The combination of Ca F
/Olive –Oil slurry showed a positive effect and
confirmed that the Ca F powder could be
incorporated effectively in to the oil to form
slurry. The fact that the wear rate of enamel with
this combination was not significantly different
from Olive-Oil alone implies that Olive-Oil is the
predominant agent in reducing enamel wear. The
finding of this study was in agreement with that of
Kaidonis et al (8), who found that the use of
lubricants significantly reduces enamel wear.
Finally, the enamel undergoes substantial
breakdown almost at a catastrophic rate. This
threshold varies among lubricants, and may
explain the results obtained in this study. Further
research is required to clarify their possible
clinical application.
REFERENCES
1- Richards LC, Kaidonis JA, Townsend GC. A Model for
the prediction of tooth wear in individuals. Aust Dent J
2003; 48(4):259-62.
2-Rugh JD, Ohrbach R. Occlusal Para function. In: Mohl
ND,Zarb GA,Carlson GE. Text book of occlusion.
Chicago Quintessence 1998: 249-61.
3-Young WG. The oral medicine of tooth wear. Aust Dent
J 2001; 46: 236-50.
17
Vol. 22(1), 2010
Prevalence of dental attrition
Prevalence of dental attrition among 5-11 years old
children in Sulaimaniya city
Raad S. Al-Doory, B.D.S. M.Sc. (1)
Soolav F. Al-Hadithy, B.D.S. M.Sc. (2)
ABSTRACT
Background: Dental attrition is one of the problems affecting the tooth structure. The aim of this study was to
determine the prevalence of dental attrition in Sulaimaniya Kurdish children.
Materials and methods: A sample of 132 children aged 5-11 years in Sulaimaniya city was examined according to
Hansson and Nilner classification.
Results: The results showed that girls had higher attrition scores than boys and most of the diagnosed dental wear
was of a grade I and mostly in the canine regions. Dental wear of primary teeth was found mostly in the canines
while dental wear of permanent teeth was found mostly in the incisors.
Conclusion: Dental attrition was found to be higher in primary teeth than in permanent teeth.
Keywords: Dental attrition, prevalence, children. J Bagh Coll Dentistry 2010; 22(1):18-20.
There are many factors found to cause incisal
and occlusal break down including masticatory
(4,5)
habit and parafunctions
. The most visible sign
of functional wear and possibly bruxism is dental
(6)
(7)
attrition . The composition of saliva , dietary
(8)
variable , digestive disturbance and industrial
(9)
environmental factors , were found to influence
the dental wear.
Several studies have been done in other parts
of the world on dental attrition and wide age
(6,10-12)
ranges of population examined
. In Iraq,
although few studies have been carried out to
investigate tooth attrition and mainly a study was
carried out on 1500 Iraqi children of 5-14 years
(13)
old to investigate bruxism and related factors
,
(14)
and Al-Obaidi and Rassim
investigated the
prevalence of dental attrition in relation to
tempromandibular joint problem among 166 Iraqi
population aged 12-30 years and Al-Obaidi and
(15)
Shanaz
investigated the prevalence of dental
attrition among 98 children aged 5-11 years old
in Albu-Etha village in Baghdad but there is still a
lack in the knowledge concerning the dental wear
in children. Therefore it was decided to conduct a
cross- sectional study in Sulaimania city to
investigate the prevalence and severity of incisal
and occlusal tooth wear among Iraqi children, in
order to evaluate the changes in the oral health
and provide a baseline data aids for future
comparison with other studies.
INTRODUCTION
The loss of tooth tissues can occur due to
carious and non-carious phenomena. Tooth wear
describes the non-carious loss of tooth tissue as a
result from the interaction of three processes
which may occur in isolation or in combination;
(1-3)
attrition, erosion and abrasion
. Attrition is the
loss of tooth structure by mechanical forces from
opposing teeth. Attrition initially affects the
enamel and, if unchecked, may proceed to the
underlying dentin. Once past the enamel, attrition
quickly destroys the softer dentin.
The most common cause of attrition is
bruxism. Functional habits are those such as
chewing and swallowing, which usually puts very
little force on opposing teeth. Parafunctional
habits, such as clenching and clicking the teeth
together nervously, place greater amounts of
forces on opposing teeth and begin to wear the
teeth. As expected, wear usually begins on the
incisal or occlusal surfaces.
Characteristic Features: Development of a
facet (flat surface with circumscribed and well
defined border). Opposing tooth facets will match
perfectly in occlusion, while erosion is the
progressive loss of hard dental tissues by
chemical processes not involving bacterial action.
On the other hand abrasion is the pathological loss
of tooth substance caused by abnormal and
repetitive mechanical wears other than tooth to
tooth contact (1).
This study involved 132 randomly selected 511 years-old Kurdish children from three primary
school and two kindergartens in Sulaimania city
these included 68 boys and 74 girls Clinical oral
examination of study samples was done in the
school premise using a sun light, ordinary chair,
(1) Assistant lecturer, Department of Conservative Dentistry,
College of Dentistry, Sulaimaniya University.
(2) Assistant lecturer, Department of Orthodontic, College of
Dentistry, Sulaimaniya University.
18
Vol. 22(1), 2010
disposable mouth mirrors, and dental probes to
remove food debris. The examined child was
seated on the chair, with the operator seated
behind and the recorder in front of the child. To
enhance vision in the mouth, the teeth were dried
using cotton wool rolls. The severity of attrition
was determined according to Hansson and Nilner
(16)
(17)
and Nilner and Lassing
classification:
0 = No wear
1 = wear of enamel only
2 = one or more teeth worn into dentine
3 = one or more teeth worn up to 1/3 of the crown
4 = extensive wear of one or more teeth more than
1/3 of the crown.
The children with heavily caries teeth were
excluded from the sample. Chi-square test was
applied for statistical analysis of the data.
Differences were accepted at a level of
significance of 0.05.
dentition The association between types of teeth and
dental attrition according to segment was found to be
significant (p<0.05).
Table 1: Prevalence of attrition according to
sex
Without attrition With attrition
No.
% No.
%
18.7 46
67.6
M 68 12
22.9 57
77.1
F 74 17
21.9 103
78.1
total 132 29
Sex No.
Table 2a: The frequency distribution of
attrition scores according to the segment in
deciduous teeth.
Sum of
scores
370
M
378
F
Total 748
Sex
RESULTS
This cross-sectional study involved 132
children of primary schools and kindergartens.
Table 1 showed the prevalence of attrition
according to sex. The total sample consists of 132
children, 68 boys and 74 girls, 103 (78%) children
from 132 with dental attrition, 46 boys (67.6%)
and 57 girls (77.1%). Table 2 showed the
frequency distribution of attrition scores
according to the segment, girls had higher attrition
scores than boys. There is no association between
sex and the dental wear according to the segment.
In deciduous teeth the canines region showed
higher attrition scores of both sexes (38.6%) and
less in molar (35.5%) and then (25.9%) for incisors.
In permanent teeth the incisors region showed
higher attrition scores of both sexes (70.5%) and
less in molar (16.1%) then (10.2%) for canine and
then (2.9%) for premolar.
Table 3 showed the distribution of dental wear
scores according to severity. Dental wear scores of
both sexes were found to be commonly of grade I
(57.1%).
Table 4 showed distribution of traumatic
children according to the severity of attrition. From
46 boys found 33 (71.7%) had grade I and less in
grade II then IV and III while from 57 girls found 45
(78.9%) had grade I and less in grade II, grade III and
then IV. Table 5 showed frequency distribution of
attrition scores according to primary and permanent
teeth. For primary teeth, the canines showed to be the
most commonly involved, while incisors were the
least affected. For permanent dentition the incisors
were found to be the most commonly affected.
While, the premolars the least affected. For the
total number, it was found that primary dentition
more affected by dental wear than permanent
Incisors Canine Molars
No.
% No. % No. %
106 28.6 141 38.1 123 33.2
87 23.1 148 39.1 143 37.8
193 25.9 289 38.6 266 35.5
Table 2b: The frequency distribution of
attrition scores according to the segment in
permanent teeth.
Molars
Sum Incisors Canine
Premolars
No.
No.
No.
of
No. %
%
%
%
scores
14
2
3
20
1
5
M
70
10
15
34
5
8
48
1
5
F
70.8
10.4
16.6
48
7
2
11
Total 68
70.5
10.2
2.9
16.1
Sex
Table 3: Frequency distribution scores
according to the severity of attrition.
Sex
Sum
of
scores
M
390
F
426
Total 816
I
No.
%
209
53.5
257
60.4
466
57.1
II
No.
%
108
27.6
115
26.9
223
27.3
III
No.
%
47
12.0
33
7.7
80
9.8
IV
No.
%
26
6.6
21
4.9
47
5.7
Table 4: Distribution of the traumatic
children according to the severity of attrition
I
II
III
IV
No. % No. % No. % No. %
M 46 33 71.7 19 41.3 6 13.0 7 15.2
F 57 45 78.9 20 35.0 10 17.5 3 5.2
Total 103 78 75.7 39 37.8 16 15.5 10 9.7
Sex No
19
Vol. 22(1), 2010
8- LinKosalo E, MarKKanen H. Dental erosion in relation to
lactovegetarian diet. Scand J Dent Res 1985; 93: 436-41.
9- Enoborn E, Magnusson T, Wall G. Occlusal wear in
miners. Swed Dent J 1986; 10: 165-70.
10- Hugoson A, Bergendal T, Ekfeldt A, Helkimo M.
Prevalence and severity of incisal and occlusal tooth
wear in an adult Swedish population. Acta Odontol
Scand 1988; 46: 255-65.
11- Egermark- Eriksson I, Carlsson GE, Magnusson T. A
long-term epidemiologic study of the relationship between
occlusal factors and mandibular dysfunction in children and
adolescents. J Dent Res 1987; 66: 67-71.
12- Kiadonis JA, Richards LC, Townsend GC. Nature and
frequency of dental wear facets in an Australian aboriginal
population. J Rehab 1993; 20 (3): 333-40.
13- Saeed WK. Bruxism and related factors among 5-14
year olds in Baghdad city. Master Thesis, College of
Dentistry, University of Baghdad. 1998.
14- Al-Obaidi WA, Rassim WF. Dental attrition in
relation to tempromandibular joint problem. Iraqi Dent J
2002; 30, 231-8.
15- Al-Obaidi WA, Shanaz MG. Prevalence of dental
attrition among 5-11 year-old children in Albu-Etha
village (Baghdad). J College Dentistry 2005; 17 (1):
105-7.
16- Hansson Nilner. A study of the occurrence of
symptoms of diseases of TMJ, masticator masculator
and related structure. J Oral Rehabil 1975; 2: 313-20.
17- Nilner Lassing. Prevalence of functional disturbances
and diseases of stomatognathic system in (7-14) years
old. Swed J 1981; 5(5-6): 173-87.
18- Bernal M, Tsamtsouris A. Signs and symptoms of
temporomandibular joint dysfunction in 3-5 year old
children. J Pedod 1986; 10(2): 127-40.
19- Birgit T, Guillermo R, Lucia P, Clara DM. Prevalence
of tempromandibular dysfunction and its association
with malocclusion in children and adolescents: An
epidemiologic study related to specified stages of dental
development. Angle Orthodontist, 2002; 72: 2.
20- Ni l n e r M. Prevalence of functional disturbances and
diseases of the stomatognathic system in 15-18 year
old. Swcd Dent J 1981; 5(5-6): 189-97.
21- Magnusson T, Carlsson GE, Egermark-Erikssonl.
Changes in clinical signs of craniomandibular disorders
from the age of 15 to 25 years. J Orofac Pain 1994; 8(2):
207-15.
22- Al-Huwaizi AF. Temporomandibular disorders in
pretreatment orthodontic patients as related to
malocclusion. Master Thesis. College of Dentistry,
University of Baghdad. 1996.
23- Ahmed R. Bruxim in children. J Pedod 1986; 10 (2):
105-26.
Table 5: Frequency distribution of attrition
scores according to primary and permanent
teeth
2
2
Total
Canine
289
7
296
Molars
Incisors
193
48
241
Premolars
Teeth
Primary
Permanent
Total
266
11
277
748
68
816
P<0.05 Significant
DISCUSSION
In this study, most of the diagnosed dental
attrition was of grade I This finding is
agree
with other studies (18,19), and disagree with others
(14,15,20)
. Dental wear of primary teeth was found
mostly in the canines. This finding agrees with (15)
and disagrees with (18), who reported that dental
attrition of primary teeth mostly in the incisors.
The frequency of wear recorded at the canines for
primary teeth may be attributed to delay
exfoliation of these teeth (about 11-12 years), so
they exposed to dental factors more than the other
teeth. On the other hand, dental wear of
permanent teeth was found mostly in the incisors
and this was consistent with many studies
(13,15,21,22)
. The high frequency of wear recorded at
the incisors may be attributed to earlier eruption
of these teeth (about 6 years) so they exposed to
dental factors earlier; in addition, certain oral
habit like object and nail biting which are
commonly seen in children may be contributed
with dental wear of incisors. Dental attrition was
fount to be higher in primary teeth than in
permanent one, this finding was in agreement
with (23) and disagree with (15).
REFERENCES
1- Langlais RP, Miller CS. Acquired defect of teeth: Noncarious loss of tooth structure. Color Atlas of common
Oral Diseases, Second Edition, 1998; p.237-9.
2- Murray JJ. The Prevention of oral disease, Third
Edition. Oxford: Oxford University Press 1996.
3- Ibbetson R, Eder A. Tooth surface loss: Editors’
introduction. Br Dent J 1999; 186(2): 60.
4- Russell MD. The masticatory cycle in relation to
occlusal wear and its treatment. J Dent 1982; 10: 6977.
5- Jemt T. Masticatory mandibular movements. Swed Dent
J 1984; 23(suppl):36.
6- Seligman DA, Pullinger AC, Solberg WK. The
prevalence of dental association and its association with
factors of age. gender, occlusion TM.J symptomatology.
J Dent Res 1988; 67 (10): 1323-33.
7- Carlsson GE, Johansson A, Lundqvist S. Occlusal wear.
A follow-up study of 18 subjects with extensively worn
dentitions. Acta Odontol Scand 1985; 43: 83-90.
20
Vol. 22(1), 2010
Lactate dehydrogenase
Lactate dehydrogenase in serum and saliva of ischemic
heart disease patients.
Alaa M. Shaheed B.D.S., M.Sc. (1)
Taghreed F. Zaidan B.D.S., M.Sc., Ph.D. (2)
Rehab A. Mahmood M.B.Ch.B., A.B.C.M. (3)
ABSTRACT
Background: Lactate dehydrogenase (LDH) is an enzyme detectable in cytoplasm in almost every cell of the
human body, which becomes extracellular upon cell death. Therefore, its extracellular presence is always related
to cell necrosis and tissue breakdown. The aim of this study was to assess LDH in ischemic heart diseased patients
and chronic periodontitis patients and to assess the role of saliva as a diagnostic tool for this biochemical analysis.
Materials and Methods: One hundred and forty individuals were enrolled in this study; forty of them were patients
having ischemic heart diseases (IHD); sixty patients were age and sex matched risk groups (thirty patients with
hypertension and thirty with diabetes mellitus type 2); the last group was age and sex matched apparently
healthy control individuals. Serum and saliva samples have been taken from each subject for LDH analysis.
Periodontal status have been determined using the clinical periodontal sum score (CPSS).
Results: the mean activity of serum LDH was significantly higher in IHD patients compared to healthy controls & risk
groups, while salivary LDH was highest in relation to highest score of chronic periodontitis (CPSS).
Conclusions: Serum LDH is highly significant in predicting IHD patients, while salivary LDH increases with chronic
periodontitis progression.
Key words: Ischemic heart diseases, chronic periodontitis, and Lactate dehydrogenase (LDH). J Bagh Coll
Dentistry 2010; 22(1):21-24.
INTRODUCTION
The isoenzymes are composed of two
different types of subunits, called M and H that
are combined randomly with each other in a
tetrameric structure. The five major isoenzymes
have the compositions M4, M3H, M2H2, MH3,
and H4, with M subunits predominant in skeletal
muscle and the liver and H subunits predominant
in the heart (2).
Nagler et al.(3) investigated the source of the
salivary LDH by examining its activity in the
specific parotid-secreted and submandibular/
sublingual-secreted saliva and found that these
glands contributed about 8.2% and 14.7%,
respectively, of the total activity of whole saliva
in the oral cavity. It was concluded that
approximately 75% of the LDH in whole saliva
does not originate from the major salivary
glands. Stimulating the major salivary glands,
and consequently increasing their secretions and
their relative volumetric part in whole saliva,
resulted in a profound diluting effect of the
whole salivary LDH, with a 76% reduction of
total activity and this adds credence to the
conclusion that the major source for wholesaliva LDH is non glandular. For this reason, it
has been suggested that the main source of LDH
in whole saliva was the oral epithelium, and not
rather than the salivary glands the main source
of LDH in whole saliva. LDH, whose molecular
weight is 140 kd, is composed of five
isoenzymes that are distributed differentially in
various organs. The prevalence of isoenzymes
Within the cell, glucose is used principally
for the production of pyruvate in the glycolysis
pathway. Under aerobic conditions, pyruvate
enters the mitochondrial matrix, where it is
oxidized by the action of pyruvate
dehydrogenase, being transformed into acetylCoA which, still under aerobic conditions,
subsequently enters the citric acid cycle. In an
anaerobic medium, pyruvate is reduced to lactate
in a reversible reaction catalysed by lactate
dehydrogenase (LDH), which uses nicotinamide
adenine dinucleotide as a coenzyme as shown in
figure 1 (1). LDH is an enzyme detectable in
cytoplasm in almost every cell of the human
body, which becomes extracellular upon cell
death. Therefore, its extracellular presence is
always related to cell necrosis and tissue
breakdown. Its serum activity non-specifically
increases in many pathological conditions such
as myocardial infarction, liver disease (being
particularly high in toxic hepatitis with
jaundice), megaloblastic anaemias, renal disease
(especially in patients with tubular necrosis or
pyelonephritis), malignant disease (Hodgkin’s
disease, cancer of the abdomen
(1) Specialist in ministry of health
(2) Assistant Professor, Oral Diagnosis, College of Dentistry,
Baghdad University
(3) Specialist in internal medicine/ ministry of health
and lung, teratoma, liver metastases or leukaemia), progressive
muscular dystrophy and pulmonary embolism (1).
Oral Diagnosis
21
Vol. 22(1), 2010
LDH-1 and LDH-2, which originate from the
heart, predominate in plasma, while LDH-4 and
LDH-5 were found to predominate in saliva,
with specific activities 9.3-fold and 7.9-fold
higher, respectively, than in plasma. LDH-1 and
LDH-2, which predominate in plasma, could be
detected to only a limited extent in saliva
secreted at resting conditions, whereas LDH-1 in
saliva could barely be detected under stimulated
conditions (3). Other sources of LDH in saliva
could include serum or bacteria (4). Salivary
LDH was found to be the most useful enzyme
for the screening of periodontitis. LDH is a
ubiquitous enzyme that plays a significant role in
the clinical diagnosis of pathologic processes (5).
(p< 0.001) than that of HT patients (188.01
U/L), DM (199.68 U/L) and that of healthy
controls (183.53 U/L) (Table 1-1) and. The
mean activity of salivary LDH in healthy
controls (532.28 U/L) was lower than that of
IHD group (591.01 U/L), HT group (618.07
U/L), and DM group (689.54 U/L), but it did not
reach a significant level by Bonferroni t-test so
no significant differences were found between
all the study groups (Table 1).
Unstandardized Beta helps in ranking the
explanatory (independent) variables according to
their importance in effect on response variables.
Group membership (IHD vs healthy controls)
was the most important explanatory factor. The
magnitude of effect for group membership and
CPSS categories was shown after controlling for
a set of important confounding (other
explanatory) variables including age, BMI, and
gender. Being an IHD case is expected to
increase serum activity of LDH by a mean of
203.44 U/L compared to healthy controls (after
controlling for other independent variables
included in the model). The model was
statistically significant and able to explain 30.3%
of variation in the dependant variables. The
backward elimination model showed that group
membership was the sufficient factor that affects
serum LDH. CPSS was the most important
explanatory factor that affects salivary LDH
followed by gender and BMI categories.
Increase in the CPSS tertiles was expected to
increase salivary LDH by 204.38 U/L, Being a
male is expected to decrease salivary LDH by a
mean of 272.9 U/L compared to females, and
increase in the BMI categories was expected to
increase salivary LDH by 102.89 U/L The
backward elimination model showed that CPSS,
gender, and BMI were the three sufficient
factors that affect salivary LDH (Table 2).
Subjects with lowest salivary LDH (473.05 U/L)
have a lowest CPSS tertile and subjects with
highest salivary LDH (613.98 U/L) have a
highest tertile; the observed trend was
statistically non significant (Table 3).
One hundred and forty individuals were
enrolled in this study divided as follow:1. Ischemic heart disease patients (IHD)
group:- forty patients were diagnosed as
ischemic heart disease (Angina Pectoris and
Myocardial Infarction), their ages ranged
between 42-80 years, 20 males and 20
females.
2. Risk patients groups:- sixty patients were
age and sex matched risk groups (thirty
patients with hypertension and thirty with
diabetes mellitus type 2)
3. Healthy control group: - forty individuals
were age and sex matched healthy looking
volunteers with no signs and symptoms of
any systemic disease, including 20 males and
20 females.
Patients were selected from the cardiac care
unit and the internal medicine department in ALYarmuk Teaching Hospital. For each individual
a questionnaire case sheet was filled out. Blood
and saliva were collected for each subject at the
same time at 8-10 AM. About 2-3 mls of
unstimulated (resting) whole saliva was
collected after an individual was asked to rinse
his mouth thoroughly with water to allow
removal of debris. LDH activity has been
estimated for all the samples and Periodontal
status have been determined using the clinical
periodontal sum score (CPSS) which is the sum
of the number of sites with probing pocket
depths of 4mm or greater, the number of
gingival sites with bleeding after probing, the
visible suppuration, and the number of furcation
lesions exceeding grade 1 (6).
DISCUSSION
In this study the mean activity of serum
LDH was significantly higher in IHD group
compared to healthy controls and risk groups,
being an IHD case was expected to increase
serum LDH by a mean of 204.36 U/L compared
to healthy controls. This was in agreement with
Abraham et al.(7).
RESULTS
The mean activity of serum LDH in IHD
patients (386.88 U/L) was significantly higher
Oral Diagnosis
22
Vol. 22(1), 2010
Table 1: The distribution of LDH activity according to study samples.
healthy controls
(IHD)
Risk groups
(HT)
(DM)
P
<0.001
Serum LDH activity (U/L)
(81- 259)
(145.7 - 1165.7) (100.7 - 299.5) (48.6 - 388.6)
Range
183.53
386.88
188.01
199.68
Mean
45.74
221.71
57.54
69.92
SD
P (Bonferroni t-test) for difference in mean between:
Cases (IHD) x healthy controls <0.001
Cases (IHD) x (Hypertension) <0.001
Cases (IHD) x (DM) <0.001
0.44[NS]
Salivary LDH activity (U/L)
(40.5 - 919)
(72.9 - 2112.8) (56.7 - 1185.6) (32.4 - 2039.9)
Range
532.28
591.01
618.07
689.54
Mean
290.79
423.09
321.08
549.9
SD
Table 2: The effect of the independent variables on serum and salivary LDH activity in IHD
patients compared to healthy controls by using Unstandarized Beta test.
Serum LDH activity
Unstandardized B Standardized B P
All independent (explanatory) variables included
115.334
(Constant)
203.439
0.533
<0.001
(IHD) patients compared to healthy controls
0.211
0.012
0.92[NS]
Age in years
35.513
0.093
0.39[NS]
Male gender (compared to female)
11.095
0.043
0.68[NS]
Body mass index (BMI)-categories
9.293
0.038
0.71[NS]
Clinical Periodontal Sum Score (CPSS )- (tertiles)
P (Model) = <0.001
R2 = 30.3%
Backward elimination model
182.518
(Constant)
204.362
0.536
<0.001
P (Model) = <0.001
R2 = 28.7%
Unstandardized B Standardized B
P
Salivary LDH activity
47.166
(Constant)
51.235
0.07
0.57[NS]
0.672
0.021
0.87[NS]
Age in years
-272.91
-0.375
0.001
102.887
0.211
0.05[NS]
204.378
0.434
<0.001
P (Model) = <0.001
R2 = 27.5%
Backward elimination model
119.938
(Constant)
-266.6
-0.367
0.001
94.909
0.195
0.06[NS]
205.306
0.436
<0.001
P (Model) = <0.001
R2 = 26.8%
Table 3: Distribution of salivary LDH activity according to clinical periodontal sum score
tertiles.
Clinical Periodontal Sum Score (CPSS )
Lowest tertile (<4) Middle tertile (4-8) Highest tertile (>8)
Salivary LDH activity
(56.7 - 868.5)
Range
473.05
Mean
331.22
SD
Oral Diagnosis
0.32[NS]
(89.1 - 884.4)
552.07
255.53
23
(40.5 - 919)
613.98
347.43
Vol. 22(1), 2010
in saliva of healthy and periodontitis sick juveniles.
Stomatologiia (Sofiia) 1988; 70:1–4.
11.
Barer GM, Pankova SN, Volozhin AI.
Characteristics of the course of periodontitis in kidney
pathology. Stomatologiia (Mosk) 1989; 68: 34–7.
12.
De La Pena VA, Diz Dios P, Sierra RT.
Relationship between lactate dehydrogenase activity
in saliva and oral health status. Arch Oral Biology
2007; 52: 911-5.
13.
Tietz NW, Wekstein DR, Shuey DF, Brauer
GA. A two-year longitudinal reference range study
for selected serum enzymes in a population more than
60 years of age. J Am Geria Soc 1984; 32: 563–70.
14.
Smith QT, Au GS, Freese PL, Osborn JB,
Stoltenberg JL. Five parameters of gingival crevicular
fluid from eight surfaces in periodontal health and
disease. J Periodontal Res 1992; 27: 466-75.
15.
Atici K, Yamalik N, Eratalay K, Etikan I.
Analysis of gingival crevicular fluid intracytoplasmic
enzyme activity in patients with adult periodontitis
and rapidly progressive periodontitis. A longitudinal
study model with periodontal treatment. J Periodontol
1998; 69: 1155-63.
The mean activity of salivary LDH runs
parallel to the CPSS tertile, it was highest among
subjects in the highest tertile and lowest among
subjects in the lowest tertile, which means that
tissue breakdown caused by gingivitis and
periodontitis leads to increase in salivary LDH.
This is in agreement with Popova et al.(8), Sornin
et al.(9), Vassileva et al.(10), Barer et al.(11),
Nomura et al.(5) and De La Pena et al.(12).
According to Unstandarized Beta, the backward
elimination model showed that salivary LDH
was significantly affected by gender and CPSS
tertiles. Being a male was expected to reduce
salivary LDH by 272.9 U/L; this agrees with the
results of Tietz et al.(13) and De La Pena et al.(12)
who showed that LDH activity in whole saliva
was slightly higher in females than males. Every
increase in CPSS tertiles, increased salivary
LDH by 204.378 U/L which is agreed with the
results of Smith et al.(14) who found that LDH
activity is higher in subjects with increased
probing depth (PD) than in individuals with
healthy PD.
The progression of periodontal disease may
be associated with the level of LDH in gingival
crevicular fluid (15).
REFERENCES
1. Moss DW, Henderson AR. Clinical enzymology. In:
Burtis Ca., Ashwood Er., editors. Tietz textbook of
clinical chemistry. 3rd edition. Philadelphia:
Saunders, 1999; 617–721.
2. Beitner R. Regulation of carbohydrate metabolism
(vol 1 and 2). Boca Raton, FL: CRC Press 1985.
3. Nagler RM, Lischinsky S, Diamond E, Klien I,
Reznick AZ. New insights into salivary lactate
dehydrogenase of human subjects. J Lab Clin Med
2001; 137: 363-9.
4. Chen A, Hillman JD, Duncan M. L-(+)-lactate
dehydrogenase deficiency is lethal in streptococcus
mutans. J Bactriol 1994; 176: 1542-5.
5. Nomura Y, Tamaki U, Tanaka T, Arakawa H,
Tsurumoto A. Screening of periodontitis with salivary
enzyme tests. J Oral Science 2006; 48 (4):177-83.
6. Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H,
Valtonen VV, Nieminen M. Age, dental infections,
and coronary heart disease. J Dental Res 2000; 79:
756–60.
7. Abraham N, Carty R, Du Four D, Pincus M. Clinical
enzymology. In: Mc Pherson, Pincus M, eds. Henry's
Clinical diagnosis and management by laboratory
methods 21st ed. Philadelphia, Pa: Saunders Elsevier,
chap 20: 2006.
8. Popova S, Ivanova Z, Bozoukova T, Vulchev D.
Changes in the activity of lactate dehydrogenase,
malatdehydrogenase, alkaline and acid phosphatase in
the saliva of anesthesiological personnel. Folia Med
1986; 28:40–4.
9. Sornin C, Bousquet C, David P. Lactic acid formation
in the oral cavity. Chir Dent Fr 1986; 56: 63–7.
10.
Vassileva S, Zaprjanov M, Targova S.
Comparative studies on lactate, proteins and enzymes
Oral Diagnosis
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Vol. 22(1), 2010
Possible effects of
Possible effects of chemical weapons used in Halabja
martyr city at 16th march 1988 on developing oral and
dental tissues
Mohammed A. Mahmood, , M.Sc.(1)
Balkees T. Garib, , Ph.D. (2)
Saeed A. Abdulkareem, M.Sc. (3)
ABSTRACT
Background: The development of oral and dental tissue is a complex process regulated by genes that are very
sensitive to disturbances in the environment. Although many studies were conducted in different parts of Iraq,
Halabja city is different; it had been subjected to chemical weapons in 1988, that if not produce death, it is
expected to produce developmental anomalies.
Methods and methods: A total of 457 persons were selected and divided to include 3 age groups, those born before
1971 (control group), those who were in utero during 1988 (group2), and those born in 1993 in Halabja city (group3).
Full extra-oral and intra-oral examination was carried out to diagnose any existing anomalies.
Results: Oro-dental anomalies were associated with history of parents’ exposure to chemical weapons (r = 0.3); no
sex difference was detected. Clinically missing teeth and retained deciduous teeth were the predominant
anomalies(11%) and correlated with history of parents’ exposure to chemical weapons predominantly in group2
(r=0.24). Enamel hypoplasia and local enamel opacities observed in 9.85%; macroglossia, fissured tongue, and
ankyloglossia were seen in 6.13%.
Conclusion: History of the exposure to chemical weapons effects teeth number, structure, and tongue anomalies.
Clinically missing teeth and retained deciduous teeth were the predominant anomalies.
Key words: Halabja city, chemical weapons, developmental anomalies. J Bagh Coll Dentistry 2010; 22(1):25-30.
INTRODUCTION
The aim of the study was to identify the types
and percentage of oral and dental tissue anomalies
in Halabja in relation to the events of chemical
weapons used in 1988.
Dental anomalies are caused by complex
interactions between genetic, epigenetic and
environmental factors during the long process of
dental development. This process is multifactorial,
multilevel, multidimensional and progressive over
time (1). Nevertheless, teeth anomalies are
uncommon (2). Several studies were performed to
register their prevalence in various Iraqi cities (3-5),
Halabja is a distinguished city in the north of Iraq.
It had been subjected to multiple chemical agents
(mustard gas, nerve agent; sarin, tabun and VX)
during the war between Iran and Iraq in 1988 that
expected to produce anomalies (6). These gases are
potent chemical vesicant warfare agents that
remain significant military and civilian threat,
their effect is dose dependent, and causes either
airway inflammation and pulmonary damage or a
life threatening cholinergic crisis (7). Prolonged
exposure to small amounts of mustard gas was
reported to cause a slight chromosomal change
(8,9)
.
A total of 457 persons from Halabja martyr
city were randomly selected to fit into 3 age
groups, according to their birthday; before, during
and after 1988 as follow: The first age group (58
person, 37 males and 21 females) included all
possible persons examined in the schools and
institutes born in Halabja before 1971 (i:e in 1988
they were 18 years old, so the teeth and soft
tissues had full developed and considered as a
control group to compare the effect of chemical
weapon). The second selected group (154 person;
67 males and 87 females) including all possible
existing person in Halabja, who born between
16/3/1988 to 25/12/1988 (they were in-utero
during chemical bombardment). The third group
(245 persons; 70 males, and 175 females)
included those born in Halabja in 1993, to
represent the possible late effect of the chemical
weapon, as the people return to their city in 1992
at the end of the war.
An official permission from the Halabja’s
General Directorate of Education and Institutions
in the city was obtained to perform examination in
(1) Lecturer, University of Sulaimani, College of Dentistry,
Sulaimani, Iraq.
(2) Assistant professor, University of Sulaimani, College of
Dentistry, Sulaimani, Iraq.
(3) Lecturer, University of Sulaimani, College of Dentistry,
Sulaimani, Iraq.
Oral Diagnosis
25
Vol. 22(1), 2010
the schools and institutions. Personal information
and a thorough history of their mothers’ exposure
to the chemical weapons (MECW) were reported.
Teeth were examined (use the Modified
Developmental Defect of Enamel Index)10, after
wrapping them with cotton to remove debris and
dental plaque, using sterilized dental probe and
mirror, under strong artificial light and any
existing soft tissue anomalies were all recorded in
a case sheet.
The calculated data was tabulated regarding
the age group, sex, MECW. Chi-square test and
Spearman’s correlation were applied to test
differences and correlations among the
parameters.
Talon cusp represents 0.87% of the total
sample. No such anomaly was reported in the 1st
group and all the cases affected the canine.
Considering the anomalies in tooth size,
microdontia was reported in 1.75% with no
differences among studied groups (table 2). The
upper lateral incisors was more affected and
predominantly in females (87.5%). Microdontia
seems to be associated with other dental
anomalies.
Anomalies in teeth structure (enamel
hypoplasia and hypocalcification) represent
9.85%of the total sample with weak correlation
with history of MECW. The 3rd age group was the
most affected one and predominantly in females.
Enamel hypoplasia alone comprised 3.06% of
total sample (figure 2). The largest percentage
was reported in the 3rd group with female
predilection and most of them (70%) had family
exposed to the chemical weapons. On the other
hand, enamel opacities represent 6.78% of the
total sample (figure 2) also with predominant
female involvement and 91% of the cases had
history of MECW. It presents in all age groups
(table 2).
Soft tissue & other anomalies
Tongue anomalies in general represent
6.13%, it had a weak correlation with history of
MECW, r = 0.11, p = 0.02. Macroglossia alone
comprised 0.66%of the total sample. It was seen
only in 2nd age group (1.95%), most of them had a
history of MECW (table 2). While fissured tongue
represents 1.31% of the total sample (figure 2).
Most of them in 2nd group 2.6%. No case was
seen in the1st group. On the other hand,
ankyloglossia accounts 4.16% of the total sample
(3.45%, 3.25% and 4.9% in the 1st ,2nd and 3rd
groups respectively). All cases reported in 2nd and
most of the 3rd group had history of MECW (table
2). Commissural lip pits and cleft lip and palate
both observed in 0.22% for each, in females.
RESULTS
Out of the 457 examined persons (i:e,
affected and non affected persons) 36.54% had a
history MECW (13.35% males and 23% females)
with no sex variation. Oro-dental developmental
anomalies were reported in 129 persons (28.22%)
(9.85% male and 18.1% female) with significant
high percentage of them 59.68% had history of
MECW, p<0.001, r = 0.3, (Figure 1 and table 1).
The reported anomalies were 10.3% , 24.7% and
34.7% in the 1st , 2nd and 3rd groups respectively
with a prominent female involvement in 1st group
and no sex variation in the remaining other
groups. The presence of a history of mother
exposure to chemical weapons was 86.8% and
51.8% in 2nd and 3rd groups respectively (table 1).
Tooth anomalies:
Anomalies in teeth number and eruption
comprised 11% of the sample, they include 3.28%
clinically missing permanent teeth and 7.66%
retained deciduous teeth, the latter was
predominantly in females. They were significantly
correlated with the history of MECW (r = 0.24; p
= 0.01) (Figure 2 and Table 2). The largest
frequency of this anomaly was reported in the 2rd
group (5.84%) with (100%) history of MECW
(table 2). The upper lateral incisor was the most
affected tooth (44%) equally distributed between
males and females, followed by maxillary canine
(37%). Interestedly, we see 66.7% of the cases
with symmetrical bilateral clinically missing teeth
with history of MECW.
Retention of deciduous teeth was seen only in
the 3rd age group. It comprised 14.3% with no sex
variation, 54.3% of them had parents exposed to
chemical weapons (table 2). Females had multiple
retained deciduous teeth. The primary lower
second molar (38.4%), followed by deciduous
upper canine (24.7%) were the more frequently
retained teeth.
Oral Diagnosis
Possible effects of
DISCUSSION
This study remarks that developmental orodental anomalies in Halabja martyr city may be
associated with exposure to chemical weapons
with no sex variation. These anomalies were
evident in 28.22% and more predominantly in
those born during 1993 inside the Halabja city
(35.1%) thus the effect of chemical weapons
seems to increase the incidence of these anomalies
nearly twice to three times than that before the
time of bombardment (10.3% to 24.7% to 34.7%).
Although the percentage of affected persons
with history of parent’s exposed were reduced in
the last group (0% to 87% to 52%). This may
attributed to the persisting effects of toxic gases in
26
Vol. 22(1), 2010
the environment in similar manner to the sublethal effects of organophosphates insecticides
(poison gases: Sarin and tuban types) which
persist for longer time than the offending
chemical (9). Yet, not every exposed parent had
affected offspring and vice versa, this pursues the
avenues of gene-environment interactions, which
are incompletely understood (1,2).
Tooth anomalies:
The existence of clinically missing teeth may
indicate failure of teeth to develop or erupt. Thus
possibly involve early stages of tooth genesis or
later stages of root formation. Yet this anomaly in
Halabja was less than that found in Sulaimani city
(5)
and no case was reported in Baghdad city (3).
On the other hand Japanese children living in area
exposed to chemical and nuclear weapons had
reported to have less missing teeth (2.38%) than
our study, but they indicated tendency of
increasing its incidence (11,12). On the other hand,
clinically missing teeth in Halabja city was
significantly correlated with the exposure to the
chemicals. Thus one may suggest that failure of
teeth to develop or erupt could be related to the
effect of chemical weapons on the early stages of
tooth genesis and later stages of root formation.
Nevertheless more specified study with
radiographical investigation may declare this
point.
The most missing tooth was the maxillary
lateral incisor followed by maxillary canine. This
is in line to what is published previously after
excluding the third molars (1,5), although other
population showed the maxillary canine to be in
the top of the list (13).
As the permanent precursors develop and
begin to erupt, they influence the pattern of
resorption of the deciduous teeth and their
exfoliation. In human this process starts at 7.4
years in sequential order that last for 11.9 years
when the last tooth (lower second molar in males)
shed and it is earlier in females than males. If
deciduous teeth are retained beyond time of
exfoliation, they cause delay in eruption of
permanent teeth (14). Interestingly, only citizen
born in 1993 in Halabja had retention of their
deciduous teeth. The absence of radiograph may
produce limitations in considering these cases as
anomaly. Nevertheless missing or impaction of
the permanent may be the cause, but at time of our
examination, the pupils were14 years old which is
beyond the age of eruption of permanent teeth by
approximately 2 years, so this may consider as an
abnormal process rather than a normal
physiological delay. No case was reported in
Baghdad (3) or in Sulaimani (5) cities. Primary
lower second molar was the most affected tooth
Oral Diagnosis
Possible effects of
found in this series unlike previous study in which
the primary upper canine was the offended tooth
(13)
.
On the other hand, Talon cusp is an
asymptomatic and incidental dental finding during
routine dental examination, its frequency in the
population ranges from less than 1%- 8% (14). The
incidence of Talon cusp in Halabja city is nearly
equal to that reported in Sulaimani city (5), and
greater than that found in Baghdad (3), Mosul
cities (4) and other countries (11,13) but it was less
than that observed in other studies (15,16). Since this
anomaly was not found in people born before
1971, and in the second age group (1988) is
associated with history of parents’ chemical
exposure, this also may remark to the early effect
of chemical weapons on morpho-differentiation. .
The prevalence of isolated microdontia is not
uncommon (14). Its occurrence in Halabja city is
similar to that reported in Turkish population (17),
but it was more frequently in females. There was
no case reported in Sulaimani (5) and Baghdad (3)
cities.
Lastly, anomalies in enamel structure reflect
disturbances in ameloblasts’ secretions that
influenced by many environment and systemic
disturbances (18). Such enamel defects represent
the 2nd most common anomalies that observed
predominantly in females in Halabja city. It
correlated significantly with history of MECW.
However, the percentage was lower than that
reported in primary schools children of Sulaimani
(28.9%) (5), Baghdad city (42.7%) (3) and Iranian
junior high school children (32.7%) (19). This may
be attributed on one hand, to the nature of water
supply in Halabja city, which comes from lakes
and fountains from the surrounding mountains
which are rich in minerals (5) and on the other
hand, variation in sampling techniques, and
difference in diagnostic criteria. However, the
results of this study preliminary reflect that
chemical weapons seems to related with the
increase of the frequency of this anomaly in those
born in 1993, and it needs further investigations
to declare this point.
Soft tissue and other anomalies
The frequency of tongue anomalies was more
frequently seen in Halabja’s population than in
Sulaimani (5) and Ankara (20) and less than that
observed in Baghdad city (3).
Macroglossia was only seen in the those born
in 1988 and no case was reported in Baghdad or
Sulaimani cities (3,5). It was more than that
reported in Turkish population (1.24%) (21). Two
third of the reported cases had history of MECW;
this could be attributed in part to the late effect of
chemical. On the other hand, the frequency of
27
Vol. 22(1), 2010
12.
Endo T, Ozeo R, Kubota M, Akiyama M, and
Shimooka S. A survey of hypodontia in Japanese
orthodontic patients. American J of Orthod and
Dentofac Orthop 2006; 129: 29-35.
13.
Garib BT. The prevalence of oral developmental
disturbances and dental alignment anomalies in female
of secondary school in Thamar city (14-21 years). J of
College of Baghdad Denti2stry 2006; 18: 35-9.
14.
Neville BW, Damm DD, Allen CM, Bouquot JE.
Developmental defects of the oral and maxillofacial
region Ch1 and abnormalities of teeth Ch2. In: Oral and
maxillofacial pathology,2nd ed. Pennsylvania, Saunders,
2002.
15.
Saini TS, Kharat Du, Mokeem S. Prevalence of
shovel shaped incisor in Saudi Arabian dental patient.
Oral Surgery Oral Medicine Oral Pathology 1990; 70:
540-4.
16.
Dankner E, Harari D, Rotstein I. Dens evaginatus
of anterior teeth. Literature review and radiographic
survey of 15,000 teeth. Oral Surgery Oral Medicine
Oral Pathology Oral Radiology Endodontics 1996; 12:
472-5.
17.
Altug-Atac AT, Erdem D. Prevalence and
distribution of dental anomalies in orthodontic patients.
Amer J Orthod and Dentofac Orthop 2007; 131: 510-4.
18.
Nanci, Antonio. Ten Cate’s Oral Histology,
Development, Structure, and Function. 6th ed. Mosby,
2003.
19.
Daneshkazemi AR, Davari A. Assessment of
DMFT and Enamel Hypoplasia Among Junior High
School Children in Iran. J of Contemp Dental Practice
2005;6: 085-092.
20.
Ugar-Cankal D, Denizci S, Hocaoglu T.
Prevalence of tongue lesions among Turkish
schoolchildren. Saudi Medical J 2005; 26: 1962-7.
21.
Avcu N, Kanli A. The prevalence of tongue
lesions in 5150 Turkish dental outpatients. Oral
Diseases 2003; 9: 188–95.
22.
Salem G, Holm SA, Fattah K, Basset S, Nasser
C. Developmental oral anomalies among school
children in Gizan region. Saudi Arabian Community
and Dental Oral Epidemiology 1987;15: 150-1.
23.
Jiang R, Bush JO, Lidral AC. Development of the
upper lip: Morphogenetic and molecular mechanisms.
Developmental Dynamics 2006; 235:1152-66.
fissured tongue in Halaba’s population is nearly
similar to the findings of Saudi Arabia (22) but
lesser than the results of Baghdad (3), Mosul (4),
and Sulaimani (5). Although the condition reported
to be increase with age (14), nevertheless, in our
study it was seen in adolescents and young.
The result of ankyloglossia frequency in
Halabja is high and disagrees with published
reports of other Iraqi governorates (3-5), but it is
located within the maximum normal limit (14). This
can be attributed to the immediate and late effects
of the exposure to chemical weapons. On the
contrary commissural lip was lesser than the
results of above studies (3-5).
Cleft lip with or without cleft palate in
general has an occurrence of 1 in 500 to 2,500
live births worldwide which mean (0.2%- 0.04%) of
live births (23) which is in line with our results. The
mother of affected person in 2nd group had
subjected severely to the chemical weapons and
she is still suffering now from skin and respiratory
problems, and
all of her family members
especially those who born after her are suffering
from cleft lip and palate and other systemic
problems.
REFERENCES
1.
Shashi S, Hart TC. Environmental Etiologies of
Orofacial Clefting and Craniosynostosis. In :
Understanding Craniofacial Anomalies. Editors: Mark
P. Mooney, Michael I. Siegel. 2002 , Wiley-Liss, Inc.
2.
Soames JV, Southam JC. Disorders of
development of teeth. In: Oral Pathology, Oxford, 2005.
3.
Al- Nori AH, Al- Talabani NG. Developmental
anomalies of teeth and oral soft tissues among (14-15)
years old school children in Bagdad city. Jordan Dental
J 1993;8: 5-15.
4.
Hag-Kasim. Developmental Anomalies of Teeth
and Oral Soft Tissues among (14 -15) years old school
children in Mosul City. Master Thesis, University of
Baghdad, 1995.
5.
Mohammed DN. Developmental Anomalies of
Teeth and Oral Mucosa in (6-12) years old school
children in Sulaimani city. Master thesis, University of
Sulaimani, 2006.
6.
http://en.wikipedia.org/wiki/Mustard_gas
.
Accessed September 2009
7.
Newmark J. Nerve Agents: Pathophysiology and
Treatment of Poisoning. Seminars in Neurology 2004;
24:185-96.
8.
Ramos MJ. Mutilating Breaths. ENGG
1111;2002: Section 3.
9.
Volans GN, Karalliedde L. Long-term effects of
chemical weapons. The Lancet Supplemen 2002; 360:
35-6.
10.
Clarkson J, O'Mullane' D. A modified DDE index
for use in epidemiological studies of enamel defects. J
of Dental Res 1989; 68: 445-50.
11.
Yonezu T, Hayashi Y, Sasaki J, Machida Y.
Prevalence of congenital dental anomalies of the
deciduous dentition in Japanese children. Bulletin
Tokyo Dental College 1997; 38: 27-32.
Oral Diagnosis
Possible effects of
Table 1: The percentage distribution of the
persons with history of parent exposed to
chemical weapons, persons having
developmental anomalies and persons with
both conditions, in different age groups.
Group1Group2 Group3 Total
persons with
history of parent
exposed to
chemical weapons
persons with
developmental
anomalies
persons with
developmental
anomalies and
exposed parents
28
0
53.6
34.7
36.54
10.3
24.7
34.7
28.22
0
86.8
51.8
59.68
Vol. 22(1), 2010
Possible effects of
Table 2: The percentage distribution of different oral and dental developmental anomalies
in examined groups in relation to history of exposure of parents to chemical weapons
Type of anomalies
Number &
eruption
11%
Clinically missing permanent
teeth
Retention of deciduous teeth
Shape
0.87%
Talon cusp
Size
1.75%
Microdontia
Enamel hypoplasia
Enamel structure
9.85%
Enamel opacity
Macroglosia
Tongue
6.13%
Fissure tongue
Ankyloglossia
Lip pit
Lip
0.44%
cleft
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Affected persons
With exposed
parents
Group1 Group2
Group3
No. % No. % No. %
1 1.72 9 5.84 5
2.04
0
0
9 100 3
2
1.3
35
14.3
19
54.3
2
0.82
2 100 0
1 1.72 3 1.95 4
0
0
3 100 0
1 1.72 3 1.95 10
0
0
60
0
1.63
0
4.08
2 66.7 7
70
1 1.72 11 7.14 19
4.9
0
75
0
10 91 10
3 1.95
2 66.7
4
2.6
2
0.82
2
50
1
50
2 3.45 5 3.25 12
4.9
0
75
0
5 100 9
1
0.41
0
0
1 0.65
1 100
Figure 1: The frequency distribution of developmental anomalies in relation to sex and the
history of parent exposed to chemical weapons.
Oral Diagnosis
29
Vol. 22(1), 2010
Possible effects of
Figure 2: The percentage distribution of different types of oral and dental
developmental anomalies reported in Halabja
Oral Diagnosis
30
Vol. 22(1), 2010
Oral and dental problems
Oral and dental problems among thalassaemic patients in
Diyala governorate
Dawood S. Hameed M.B.Ch.H, D.C.H, C.A.B.P. (1)
Ghanim H. Atia B.D.S (2)
Salwa S. Abdul- Wahid M.B.Ch.B. B.M Sc. PH.D
(3)
ABSTRACT
Background: Thalassaemia is a genetic disorder leading to anemia, the disease is originally wide spread in the
Mediterranean Basin. This study was carried out to identify some sociodemographic factors, oral and dental
problems among thalassemic patients, in Diyala governorate.
Subjects and Methods: The study sample included 110 patients 65 of them males and 45 females, from the
thalassemic clinic in AL –Battool hospital in Diyala governorate 68 patients from the original sample; aged 6-20 years
were examined for oral and dental problems.
Results: It was seen that 11.8% of the males, 16.2% of the females had class 11 occlusal defect, 17.6% of the males,
11.7% females had gingivitis and 10.3%, 22% of the male and female respectively had bad oral hygiene.
Conclusions: Thalassemic patients had oral and dental problems, and recommend promotion of oral and dental
cares services in this clinic.
Key word: Thalassemia , oral and dental problems. J Bagh Coll Dentistry 2010; 22(1):31-34.
INTRODUCTION
These patients are well at birth but developed
anemia which must be corrected by blood
transfusion which result in iron overload .Unless
the iron is removed with chelation therapy these
patients die of hemosiderosis(2).
Age of onset: 1st year of life (thalassemia major )
2-4 years (thalassemia intermedia)
Types of beta thalassemia are:
Hetrozygous states Thallassemia Minima –silent
beta –chain defect
Thalassemia Minor one normal beta –globin chain
gene and one beta-thalassemia gene.
Homozygous states Thalassemia Intermedia 2beta-thalassemia genes (later onset) Thalassemia
Major-2 beta-thalass.genes (early onset)
Complications of thalassemia:
1. Craniofacial features; represents medullary
hemopoiesis, mandibular prominences, maxillary
overbite eminences, depressed nasal bridge and
frontal bossing.
2. Extramedullary Hematopoiesis; hepatomegaly
and splenomegaly
3. Iron overload (Hemosiderosis); hepatic fibrosis,
sideroblastic
cardiomyopathy
and
endocrinopathies (Diabetes and hypothyrodism)
4. Others: recurrent infections, septicemia, failure
to thrive (4) .
Thalassemia is a disease which was originally
widely spread in the Mediterranean Basin, SouthEast Asia and various countries in the equatorial
Africa. However, following its persistent
migration over plane it is today verifiable in
almost all region of the globe.
The term Thalassemia implies a genetic
disorder of an extremely heterogeneous group
which is characterized by a reduced or erroneous
production of hemoglobin , the respiratory
pigment contained in the red cells .The probability
of a child being born affected by Thalassemia
Major the most serious form of this genetic
disorder also known as beta –thalassemia or
cooleys disease is a 25% chance if the parents are
carriers , that is to say if both possess one of the
two genes for erroneously coded hemoglobin in
their chromosomeic make-up , it is estimated that
in Italy only , the number of affected by
Thalassemia Major fluctuates between 5,000 and
8,000 individuals.
The genetic defect which characterizes
thalassemia major is intrinsic to the hemopoeitics
cells which are present in bone marrow .If up until
now correct transfusion therapy the only available
treatment , it is today possible to cure the disease
by performing Bone Marrow transplant using a
compatible donor by replacing diseased cells with
healthy one(1).
SUBJECTS AND METHODS
Subjects:
The sample of the study consisted of 110
patients with thalassemia-major (B-thalassemia)
who were attending the thalassemic clinic in
ALBattool Hospital in Diyala
governorate
(1) Pediatric Department Diyala Medical College
(2) Instructor Institute of Medical Technology Baghdad
(3) Community Medicine Diyala Medical College
Oral Diagnosis
31
Vol. 22(1), 2010
among them 68 patients were regularly examined
for dental and oral problems age ranging from 620years, mean age (13 years)
Exclusion Criteria:
1. Thalassemic patients with irregular visits to this
clinic.
2. Patients with blood diseases other than B thalassemia major.
3. Thalassemic patients from other governorate.
Methods
1) Special data sheet was designed for collection
of information for each patient enrolled in this
study, these information including personal (e.g.
income, home condition, number of persons living
at same home, availability of health services
nearby) and sociodemographic variables about the
patients and his family .The data sheet filled by
interviews with the patient and the family during
their visit to the thalassemic clinic.
2) Oral examination was performed by the second
author at Baquba primary health center (dental
clinic)
The instruments used for the examination were
standard plane mouth mirrors and sickle shaped
clinical explorer. Recording of dental caries was
carried out according to the criteria suggested by
the WHO in its publication Oral health surveys.
Basics methods. Codes given for individual tooth
status are; O sound 1 decayed 1 filled 1 missing.
The caries status was based on the examination of
the teeth which may be decayed (D) missing (M)
and filled (F) (7). The examination for gingivitis
was depending on clinical criteria of redness,
swelling and bleeding on probing and whether
there are ulcers or not. The examination for oral
hygiene was depending on plague index whether
it is good or bad i.e. the presence of plague,
calculus and carries.
table shows the distribution of the sample
according to sector (area) location , parent relation
and number of affected siblings , that more than
one thalassemic patient in the family that 1.8% of
families have 4 thalassemic children while 53.6%
of the families have one thalassemic child.
Table 3 shows the frequency of occlusal
relationship among thalassaemic patients in
Diyala governorate the data shows that 11.8% ,
16.2 of the males and females respectively had
class II occlusion defect and 1.5% , 2.9% of them
had class III occlusional defect .
Table 4 reveals the distribution of oral
hygiene among the study sample, 10.3% of the
males and 22% of the females had bad oral
hygiene i.e. the presence of plague, calculus and
multiple carious teeth.
Table 5 shows the frequency of gingivitis
among the study samples, 17.6 % of the males
and 11.7% of the females respectively had
gingivitis.
Table 1: Distribution of thalassaemic
patients according to sex in relation to age ,
splenectomy , blood group and birth order.
Male Female
Total p. value
No. % No %
16 14.5 16 14.5 32 29
1-4
2.5 22.7 15 13.6 40 36.3
5-9
9 8.1 9 8.1 18 16.3 p.<0.05
10-14
6 5.4 4 3.6 10 9
15-19
20 & more 9 8.1 1 0.9 10 9
65 59 45 41 110 100
Total
Splenectomy
27 24 16 14.5 43 39.1
Yes
p.<0.05
38 35 29 26.3 67 60.9
No
65 59 45 41 110 100
Total
B . g.ABO
20 38.8 14 31.11 34 30.9
A +v e
4 6.2 2 4.4 6 5.4
A –v e
15 23.1 12 26.7 27 24.5
B +v e
- 2 4.4 2 1.8
B –v e
1 1.5 2 4.4 3 2.7 p.>0.05
AB +v e
- AB –v e
25 38.5 13 28.9 38 34.5
O +v e
- O –v e
65 59 45 41 110 100
Total
Birth .
24 21.8 8 7.8 32 29.1
order 1st
18 16.4 10 9 28 25.4
2nd
6 5.4 6 5.4 12 10.9
3rd
6 5.4 8 7.3 14 12.7 p.<0.05
4th
11 10 13 11.8 24 21.8
>5th
65 59 45 41 110 100
Total
Age
RESULTS
Table 1 present the description of
thalassaemic patients according to sex in relation
to individual factors depending in our study.
There is a statistical association found
between thalassaemia and splenectomy (p<0.05).
This table also reveals the distribution of
thalassaemic patients according to blood groups ,
the table reveals that 83.5% of the males were of
blood group O +ve while 31.1% of the female
were of group A+ v e , no association was found
between thalassaemia and blood group (p>0.05).
The same table shows the birth order of
thalassemic patients the highest percentage 21.8%
for males of 1st birth order, while 9% for the
female of 2nd birth order (p<0.05) .
Table 2 presents some sociodemographic
factors of thassaemic patients under study , the
Oral Diagnosis
32
Vol. 22(1), 2010
Lastly table 6 shows the distribution of
decayed, missing, filled teeth according to the
type of teeth.
The data reveals that the highest prevalence
of decayed among thalassemic patient was 64.7
for first molar , 22.0% for first premolar , 17.6%
for second molar , and 4.4% for second premolar .
Table 5: Distribution of gingivitis among
thalassemic patient according to sex
Male Female Total
No. % No. % No. %
12 17.6 8 11.7
Yes
*grade(1) 8 11.73 6 8.8 20 29.5
*grade(2) 4 5.87 2 2.9
No
23 33.8 25 36.7 48 70.5
gingivitis
35 51.5 33 48.5 68 100
Total
Gingivitis
Table 2: Distribution of thalassaemic
patients according to sociodemographic
factors
*redness .swelling and bleeding on probing . **with
ulcer
Characteristics
No %
Sector
53 48.7
Sector I (Baquba)
13 11.8
Sector II (AL-Khalis)
Sector III (AL-Muqdadia) 22 20
14 12.7
Sector IV (Baladroz)
8 7.2
Sector V (Khanaqin)
Location
72 65.5
Rural
38 34.5
Urban
Parent relation
1st degree mother relation
32 29.1
1st degree father relation
38 34.5
nd
2 degree father relation
12 10.9
No relation
28 28.5
No. of affected sibling
1sibling
2sibling
3sibling
4sibling
56
38
8
2
Table 6: Distribution of decayed, missing,
filled teeth according to type of teeth
Dental
finding
1st
2nd
1st
2nd
premolar premolar
molar molar
No. % No. % No. % No. %
Decayed 44 64.7 12 15 22 22 3 4.4
0
0
Missing 4 5.8 - - 0
0 - - 0
0
0
Filled
DISCUSSION
Failure to synthesize beta chains (Bthalassemia) is the commonest type. Hetrozygotes
thalassemia minor usually is characterized with
mild anemia and little or no disability.
Homozygotes thalassemia major is unable to
synthesis hemoglobin A, and after neonatal period
have profound hypochromic anemia associated
with evidence of red cell dysplasia and increased
destruction [3].
In the present study the highest percentage of
thalassemia 22.7 %were of age group 5-9 among
males while it is equal percentage 14.5% for
males and females for age group (<1-4) years .
An increased blood requirement due to
hypersplenism accelerates iron loading, increases
the risk of transfusion –mediated infection and
imposes an additional psychosocial burden on the
patient and family.
The majority of patients with homozygous
thalassemia require splenectomy at some stage,
but high transfusion retards or prevents
hypersplenism and splenectomy is now less
frequent than in the past [ 2] .
It is an interesting point that all the study
sample was of Rh +ve except 6.2%, 4.4% of the
males and females were of blood group A-ve.
Regarding sociodemographic variable the highest
percentage was of Baquba district 48.7% followed
by AL-Moqdadia, Beldroz, AL Khalis and
Kanakin. We noticed that 65.5% of thalassaemic
patient were of rural area this can be explained on
the basis of consanguineous marriages.
53.6
34.5
7.2
1.8
Table 3: Distribution of occlusal relationship
among thalassaemic patient according to sex
Occlusal
Male Female Total
relationship No. % No. % No. %
26 38.2 20 29.4 46 76.7
Class I
8 11.8 11 16.2 19 27.9
Class II
1 1.5 2 2.9 3 4.4
Class III
35
51.5 33 48.5 68 100
Total
Table 4: Distribution of oral hygiene
according to sex among thalassemic patient
Oral
Male Female Total
hygiene
No. % No. % No. %
6 10.3 15 22.0 22 32.4
Bad*
Good 27 39.7 19 27.9 46 67.6
Total 35 51.5 33 48.5 68 100
* plague ,calculus and multiple carious teeth
Oral Diagnosis
33
Vol. 22(1), 2010
[6] World Health Organisation. Oral health surveys, basic
methods .3rd Ed. 1987.
[7] Gohn Macleod. Davidson's Principles and practice of
Medicine, Beta Thalassemia 2000; 205.
[8] Antonoio Cao, Vilma Gabutti, Renzo Galanello.
Genetic counseling. Dental caries, management
protocol for the treatment of thalassemia 7th Ed.2006; 4:
25: 29.
[9] Behrman Kliegman Jenson. Nelson Text Book Of
Pediatrics, NewYork , Judith Fletcher. 2004; 1064.
[10] Raham TF, Abdul Wahid SSh. Prevalence of
Hepatitis B and C in Diyala governorate. The first
scientific
conference
on
thalassemia
and
hemoglobinopathies (Abstract) M.O.H. Jan 2002; 18-9.
[11] Robert M Kliegmin, Karen J Marcdante, Hal B
Jenson. Nelson Essentials of Pediatrics, 5th Ed,
Philadelphia 2006; 619.
As the same table shows that 34.5 % and
29.1% had first degree relation between the father
and the mother. The parents need genetic
counseling and the availability of prenatal
diagnosis is too helpful.
In our study we found the presence of one
thalassemic child in the family 53.6%, with 2
children in one family in 7.2% while 1.8% for
family with 4 affected children. The parents
should be informed that their other children have
a 50 % risk of also being a carrier, screening
should be offered for the relatives of both parents,
and the carriers identified should be provided with
genetic counseling. A family tree should be kept
in the patients notes [9] .
Some problems which face thalassemic
patients are dental and oral complications. These
problems result from the changes and the sequel
of B- thalassemia major , massive expansion of
bone marrow of the skull produce characteristic
faces, severe maxillary hyperplasia and
malocclusion may occur and hyperplasia of the
gum also may be present [3,8] (table 3).
Oral hygiene was bad in 10.3% of the males
and 22% of the females (table 4). 17.6% & 11.7%
of the males and females respectively had
gingivitis (table 5). These finding reflect an
unawareness of the importance of the teeth or a
negative attitude of the parents towards dental
treatments in addition to psychological upset of
the family about their child 's disease, poor health
education about dental care and poor follow up as
most of the families were from rural area (table 2)
and there is difficulties to reach health services in
general .Decayed teeth present in 64.7% in first
molar missing teeth in 5.8% as (table 6) shows
and there is no filled teeth among the study
sample this indicate poor dental care .
However in the past many thalassaemic
children had malformations of the facial bones
and sever dental carries. Since the malformations
are due to marrow expansion, they are seen much
less than before.
REFERENCES
[1] Rino Vullo, Evgenia Georganda.What Is Talassemia,
Nicosia. Thalassemia Intern Feder (TIF) 2000; 26-8.
[2] Nica Cappellini, Androulla Eleftheriou. Guidelines
for the Clinical Management of Thalassemia. NicosiaCyprus, (TIF), 2006; 86.
[3] Sonis ST. Dental Secrets, 2nd Ed.George Watt.
2000:170.
[4] Hong GR. Hemoglobin disorder in Richard E.
Beharman, Nelson Text book of Pediatrics 6thEd. 2000;
1484-5.
[5] Bunn FH. Disorders of hemoglobin structure and
function and synthesis in Harrisons '17th Ed.2007; 188496.
Oral Diagnosis
34
Vol. 22(1), 2010
Control of recurrent
Control of recurrent oro-labial herpes simplex lesions by
in vivo enhancement of salivary peroxidase system
Ihsan A. Kameel
B.D.S M.Sc (1)
Rajaa Al-Joubori B.D.S M.Sc Ph.D (2)
ABSTRACT
Background: Many studies have been conducted to enhance the salivary innate defense factors against bacteria;
this study was conducted to enhance the salivary natural peroxidase system in vivo to prevent recurrent herpes
simplex type 1 infection.
Subjects and methods: This study had been carried out on 40 healthy subjects (mean age 22), who were suffering
from recurrent oro-labial lesions. A mouth rinse was made to stimulate the salivary peroxidase system to produce
hypothiocyanite (OSCN-) at an antimicrobial level; the rinse was tried on 30 subjects for 100 days, while the rest were
the control.
Results: It had been shown that the use of the rinse led to generation of OSCN- ≥ 100 µM which was highly efficient in
reducing recurrent oro-labial herpes simplex lesions in study group.
Conclusion: The properties of a mouth rinse that increases the in vivo generation of salivary OSCN- are: H2O2 3 mM,
KSCN 1 mM in PBS pH 5.5, the rinse volume is 5 ml and the time of rinsing is 2 minutes.
Key words: recurrent oro-labial herpes simplex lesion – peroxidase system. J Bagh Coll Dentistry 2010; 22(1):35-41.
INTRODUCTION
Previous study done by the researcher showed
that asymptomatic seropositive subjects have high
concentrations of salivary hypothiocynite (≥ 90
µM), while symptomatic seropositive subjects
have lower concentrations (30-70 µM).
This significant relation between OSCNconcentrations and recurrent herpes infection led
us to think that the level of salivary
hypothiocyanite may play a major role in
controlling recurrent herpes simplex-1 infection,
and to confirm this hypothesis, a development of
mouth rinse that enhances the salivary peroxidase
system to increase in vivo generation of salivary
hypothioctanite was favorable.
Techniques which enhance natural defense
factors offer clear advantages over alternative
therapies for the prevention of oral disease. The
salivary peroxidase system, one of the nonimmunoglobulin defense factors, has the potential
for such an enhancement. The enzyme, salivary
peroxidase (SP) catalyzes the oxidation of
thiocyanate ion (SCN-) by hydrogen peroxide
(H2O2) to form products with antimicrobial
properties.(1)
The principal product at neutral pH is the
hypothiocyanite anion, OSCN-. (2)
All the components of the SP-system, as well
as OSCN-, are present in human saliva. (3) The
concentration of OSCN-, however, is just below
the level required for microbial inhibition. (4) It
had been reported that it is possible to increase the
concentrations of OSCN- in saliva both in vitro
and in vivo by supplementing saliva with SCNand H202 (5). They also reported that H202 and, in
some cases, SCN- are limiting for OSCNgeneration, furthermore, it was recently shown
that pH is a significant determinant of the yield of
OSCN-obtained when H202 and SCN are added to
saliva (6).
Since H202 concentration has been shown to
be a limiting factor for OSCN- generation,
practical attempts have been made to activate the
salivary peroxidase system through a peroxidegenerating toothpaste. The results from clinical
trials and animal studies are somewhat
conflicting.
Positive results were reported in humans and
rats (7), on the other hand, reported no effect on
dental caries development in rats (1).
The objectives of the present study were to
determine the optimum composition and volume
for a mouth rinse which would consistently
generate an in vivo OSCN- concentration of 100
µM or more and to be tested whether it is efficient
in reducing recurrent oro-labial herpes lesions.
(1)
PhD student, department of oral diagnosis, college of
(2)
Professor, department of oral diagnosis, college of
Oral Diagnosis
35
Vol. 22(1), 2010
in vitro only when it falls significantly below 1
mM (12, 13), therefore, the choice was KSCN at a
concentration of 1 mM.
Step 3: Selection of H2O2 concentration:
A solution containing a concentration of
H2O2more than 6 mM may interfere with
peroxidase system (12), so varying H202
concentrations (1,2,3, 4 and 5 mM) in phosphatebuffered saline pH 7.1 (without any other
additive) were tried on 10 subjects from group A
who have the lowest salivary OSCNconcentration at five successive days, each
concentration was tried on subjects at one day and
average concentration of OSCN- was measured
(the same previous procedure) each time after
expectoration of the rinse.
Step 4: Selection of mouth rinse volume:
The best result of H202 concentration determined
in Step 2 was selected and used in three different
volumes of rinse 2.5, 5, and 7.5 ml, and the three
trials had been carried on for the same subjects at
different days, after each, and saliva was tested
for OSCN- concentration and the average
concentration was recorded.
Step 5: Selection of rinse pH:
Although the pH optimum for generation of
OSCN- in vitro in saliva is 6.5-7.1, the
antimicrobial properties of OSCN- are greater at a
lower pH 6,14, therefore, we tested a rinse with
the same composition as that determined in Step
3, but at different pH 5.5 and 6.5, both types of
the rinse were tried on 10 subjects from group A
with the lowest OSCN- concentration (30 µM) at
different days, after expectoration, saliva was
tested for OSCN- concentration and the mean
OSCN- concentration was recorded for each PH.
Experimental trials
After selection of the best formula for the
rinse (pH, volume, time and ingredients
concentrations) that leads to generation of
maximum
concentration
of
salivary
hypothiocyanite, subjects were divided into 2
subgroups, 30 as study group and the rest 10
subjects as control.
Each one of study group was given 500 ml of
the final formula of the rinse, while each subject
in control group was given 500 ml of PBS only
(they were not aware). All were instructed to rinse
with 5 ml once a day for 2 minutes at bed time which is the ideal time for reactivation of virus
(15)- for 100 days.
It was known from those subjects that each
one of them experienced nearly 2-3 recurrent
labial lesions during the 100 days preceded the
trial, so comparing the use of rinse with control as
well as pretreatment group (no=40) along this
period will give good evaluation of the rinse and
SUBJECTS AND METHODS
Sample collection: Forty dental students were
enrolled in this study with informed contest, they
were suffering from recurrent oro-labial herpes
simplex lesions with annual recurrence of about
8-10 time.
All chemical and biochemical procedures had
been carried out in biochemistry laboratory of
Dentistry College / Mustansirya University under
supervision of specialist chemist.
Measurement of salivary hypothiocyanite:
Hypothiocyanite was assayed by reducing 5,5'
dithiobis-2 nitrobenzoic acid (DTNB) with 2mercaptoethanol (2-ME) to produce the yellow
colored anion 5-thio-2-nitrobenzoic acid (TNB)
(8), then by mixing equal sizes of saliva and
mixture, the hypothiocyanite present in saliva will
reoxidize TNB to the colorless DTNB again (2).
peroxidase
SCN- +H2O2
OSCN- + H2O.
The OSCN- ion is relatively stable and can be
quantified by the oxidation of two sulfhydryl
compounds, 5-thio-2-nitrobenzoic acid, to one
disulfide compound (DTNB) (9).
OSCN- + 2R-SH
SCN- + R-SS-R + H2O.
Each mol of DTNB upon complete reduction
(cleavage of the disulfide bond) will yield 2 mols
of TNB (10), and each 2 mol of TNB are
reoxidized to the colorless DTNB again by 1 mol
of hypothiocyanite (11).
All measurements of salivary hypothiocyanite
were carefully recorded.
Experimental steps: The goal of the study was to
find the optimum conditions for elevating the in
vivo concentration of OSCN- with a mouth rinse.
The concentration of OSCN- developed during
rinsing is determined by many variables, the most
significant of which are time of rinsing, volume of
the rinse, composition of the rinse (SCN- and
H2O2 concentrations), as well as pH 12. These
variable factors interact in a complex way to
influence the concentration of OSCN- generated,
and to find the optimum conditions. It had been
decided on the following step-wise approach,
which was practical, although somewhat arbitrary.
Step 1: Selection of rinsing time:
This selection represents a compromise between
the ideal length of time required for optimum
rinse activity from one side and the length of time
which is within the normal bounds of human
patience on the other side, so two minutes rinsing
time was selected because that is the time period
used in fluoride rinses.
Step 2: Selection of SCN- concentration:
The concentration of SCN- in human saliva
becomes a limiting factor for OSCN- generation
Oral Diagnosis
36
Vol. 22(1), 2010
salivary
hypothiocyanite
in
controlling
reactivation of the latent herpes virus.
Subjects were followed every 3-4 days and
examined for any recurrent labial herpes lesion
along the trial period of 100 days, and all results
were recorded.
Persistence of hypothiocyanite after rinsing:
In order to determine how long the
hypothiocyanite levels remained elevated, four
subjects from group A (OSCN- concentration 30
µM), rinsed with the solution described in Step 5.
After two minutes of rinsing, the subjects
expectorated as much of the liquid in their mouths
as possible into a beaker and then allowed saliva
to accumulate in their mouths. They subsequently
expectorated 0.5 ml saliva into test tubes at oneminute intervals for five successive minutes and
hypothiocyanite
assays
were
performed
immediately on all samples.
Figure 1: Line graph showing the median
(with its inter-quartile range) OSCNconcentration after 5 different H2O2 conc.
Results showed that a concentration of 1 mM
yielded a mean of 50 µM, 2 mM caused a mean
generation of less than 70 µM hypothiocyanite,
while a concentration of 3 mM or 4 mM was
required to obtain consistently a concentration of
OSCN exceeding 100 µM OSCN- in the
expectorate. Rinse concentrations of H2O2 of 3
mM and 4 mM gave approximately the same
RESULTS
mean OSCN- concentratil6ns (140 µM by 3 mM
Results of experimental steps
and 130 µM by using 4 mM H2O2), while 5 mM
1- Selection of H202 concentration:
concentration of H202 resulted in significant drop
of OSCN- concentration (70 µM) as shown in
figure. So 3 mM H2O2 had been chosen because
the concentration is high enough to give the
desired level of OSCN-, but low enough to avoid
salivary peroxidase activation and to be safe for
routine use
H202
Table 1: The median OSCN- after 3 different rinse volumes.
Rinse volume
OSCN conc
Baseline (before)
2.5 ml
5 ml
7.5 ml
(90 to (120 to (60 to
(30 to 30)
Range
120)
160)
80)
30
100
140
80
Median
(90 to (130 to (70 to
(30 to 30)
Interquartile range
110)
150)
80)
10
10
10
10
No
P (repeated measure ANOVA) for the median difference in OSCN
<0.001 <0.002 <0.003
concentration between each rinse volume and the previous one
2 - Selection of rinse volume:
(with its inter-quartile range) OSCNconcentration after 3 different rinse volumes.
Results showed that 2.5 and 5 ml rinse volume
generated concentrations of hypothiocyanite 100
µM and 140 µM respectively, while the
concentration generated by 7.5 ml volume was 70
Figure 2: Line graph showing the median
Oral Diagnosis
37
Vol. 22(1), 2010
µM, and 5 ml volume was chosen because it led
to higher OSCN- concentration and was more
preferable for subjects.
3- Selection of rinse pH:
Results showed that the rinse of pH 6.5 generated
a mean hypothiocyanite concentration of 140 µM
(similar to that of rinse pH 7.1 in previous result),
Figure 3: Line graph showing the median (with
its inter-quartile range) OSCN concentration
while the concentration was 170 µM by using the
pH 5.5 rinse. after 3 different pH values
.
Table 2: The changes in OSCN- concentration after 3 different rinse volumes compared to
baseline (pretreatment).
OSCN conc
Range
Median
Interquartile range
No
P (repeated measure ANOVA) for the overall effect of changing
rinse volume on median OSCN concentration <0.001
P (repeated measure ANOVA) for the median difference in
OSCN between baseline and each rinse volume
Changes after different rinse volumes
compared to baseline
2.5 ml
5 ml
7.5 ml
(60 to 90)
(90 to 130)
(30 to 50)
70
110
50
(60 to 80)
(98 to 120)
(40 to 50)
10
10
10
<0.001
<0.002
<0.003
Table 3: The changes in OSCN- (µM) concentration after 3 different pH values compared to
baseline (pretreatment).
OSCN conc
Range
Median
Interquartile range
No
P
Changes after different PH values compared to baseline
pH 7.1
pH 6.5
pH 5.5
(90 to 130)
(90 to 130)
(120 to 160)
110
110
140
(100 to 120)
(98 to 120)
(128 to 150)
10
10
10
<0.001
<0.001
The above results showed that there was not
any difference in concentration of hypothiocyanite
generated by using rinse pH 7.1 or 6.5, but there
was significant rise in this concentration when pH
became more acidic 5.5.
According to results in steps of the rinse, it
was clear that the best composition of a mouth
rinse which enhances the salivary peroxidase
system is 3 mM in hydrogen peroxide and I mM
in potassium thiocyanate at pH 5.5, the best
rinsing volume is 5 ml for 2 minutes.
The volume of the rinse, the H2O2
concentrations, and the pH were shown to be
determinants of the concentration of OSCNgenerated by the rinse.
Results of experimental rinse
The mouth rinse prepared above was given to
(30) subjects (study group) who have the lowest
Oral Diagnosis
<0.001
hypothiocyanite concentration in their saliva (30 60 µM) and annual recurrent oral lesions of 10
times which almost means once a month, the rest
10 subjects were the control.
Survival analysis
The mean survival (recurrence free) period
was significantly longer in active treatment group
compared to both placebo and untreated group.
While no important or statistically significant
difference was observed between placebo and
untreated groups (table 4 and figure 4).
Table 4: The mean survival (recurrence free)
period in days in 3 treatment groups
Mean SE 95% CI
Placebo
32 9 (13.3 - 50.3)
Active Treatment
89 4 (81 - 97.8)
Pretreatment (untreated) 43 1 (40.7 - 44.4)
38
Vol. 22(1), 2010
1.0
0.9
Cum survival
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
100 90
80 70 60 50 40 30 20
100 days before using the rinse
Active treatment group
10
0
Placebo
10
20
30 40 50 60 70 80
100 days using the rinse
90
100
Pretreatment group
Figure (3-7) The difference in cumulative survival (recurrence free) rate
µM above base line) and back to base line level
30 µM after 4 minutes (as shown in figure 5 and
6), so the effective antimicrobial concentration of
salivary hypothiocyanite remains for 2 minutes
after expectorating the rinse.
Results of persistence of hypothiocyanite after
rinsing
Results showed that after one minute, the
mean level of hypothiocyanite was 160 µM(130
µM above base line) , 100 µM after 2 minutes (70
µM above base line), 70 µM after 3 minutes (40
4
Medians (error bars: 25-75 percentiles)
150
140
130
120
110
100
90
80
70
60
50
4
40
30
20
10
0
Changes in OSCN conc (uM) after 1 minute of rinsing compared to baseline
1 min
2 min
3 min
4 min
Figure 5
Figure 6
Changes in OSCN concentration within 5 minutes following rinsing
DISCUSSION
limiting factor for production of hypothiocyanite,
but to a certain range above which, a decline in
the product concentration will occur, so at 4 mM
of H202, OSCN- concentration decreases to 130
µM, and when 5 mM H202 is added, sharp
decrease in OSCN- concentration occurred (70
µM ). This is because of reduction in activity of
peroxidase enzyme which will be inactivated by
the high concentration of H202 (3).
Experimental steps
1- Selection of H202 concentration:
Hydrogen peroxide is essential for oxidation
of thiocyanite (by salivary peroxidase) to
hypothiocyanite, as results showed, 1 mM H202
generated 50 µM, 2 mM generated 70 µM, and
when the concentration of H202 was increased to 3
mM, oxidation of SCN- also increased to yield
140 µM, this means that H202 concentration is a
Oral Diagnosis
39
Vol. 22(1), 2010
infectious virion (20) and hence the significant
control and prevention of recurrent labial lesions
along the mentioned period, and for the two
females, they showed reduction in recurrence
times of the lesion.
5.2. D–Persistence of hypothiocyanite after
rinsing
The production of hypothiocyanite depends
on the concentration of H2O2, thiocyanite and the
activity of peroxidase enzyme (6), so at the first
minute after rinsing, the highest OSCNconcentration was detected due to the high
productive concentrations of peroxidase system
components, after two minutes it reduced to 100
µM because of reduction in concentrations of
reactants and lowering of enzyme activity (3),
decline of product concentration continues at the
third minute after rinsing, and when reactants
depleted, the concentration of hypothiocyanite
returns back to previous level.
2- Selection of rinse volume:
Concentration of hypothiocyanite varied with
different rinse volumes, the amount of reactants
(especially 3 mM H2O2) in 2.5 ml was sufficient
to produce 100 µM of hypothiocyanite, and when
this amount was doubled to 5 ml, better result
was obtained (140 µM) because oxidation of
SCN- increased without affecting the activity of
peroxidase enzyme, but when the volume of rinse
was increased to 7.5 ml, the quantity of H2O2
became high enough to affect the activity of
peroxidase enzyme which led to subsequent
reduction in OSCN- production (3).
3- Selection of rinse pH:
The activity of peroxidase enzyme is reduced
after catalyzing the oxidation of thiocyanite in
neutral pH, while the acidic pH stimulates
peroxidase enzyme and largely increases its
activity (12). Rinse of pH 7.1 and 6.5 did not
show
difference
in
concentration
of
hypothiocyanite because the first is neutral and
the second is slightly acidic so results were
similar, but the rinse of pH 5.5 succeeded in
stimulating peroxidase enzyme and hence the
higher concentration of hypothiocyanite.
Experimental rinse
Peroxidase catalyzes the oxidation of SCNby H2O2 to yield the antimicrobial oxidizing
agent hypothiocyanite ion (OSCN-) (2, 16)
H2O2+ SCN
H20 + OSCNThe OSCN- anion is the major product at neutral
pH 6, but at low pH (pH of rinse is 5.5) the major
product is hypothiocyanous acid (HOSCN), which
is in acid-base equilibrium with OSCN- (17)
H+ OSCNHOSCN
REFERENCES
1- Stiles, Loesche, O'Brien. The Inhibitory Action of the
Lactoperoxidase System on Streptococcus mutans and
Other Microorganisms in: Proceedings, Microbial Aspects
of Dental Caries; Sp Supp Microbiology Abstracts. Eds,
1986; 353-7.
2Tenovuo,
Anttonen.
Peroxidase-catalyzed
Hypothiocyanite Production in Human Salivary Sediment
in Relation to Oral Health. Caries Res 1998; 14:269-75.
3- Aune, Thomas. Accumulation of Hypothiocyanite Ion
During Peroxidase-catalyzed Oxidation of Thiocyanate
Ion. Eur J Biochem 2004; 80: 209-14.
4-Carr Berg, Winterbourn. Thiocyanation of cholesterol in
cell membranes by hypothiocyanous acid. Arch Biochem
Biophys 1996; 332: 63-9.
5- Pruitt Adamson, Arnold. Lactoperoxidase system:
Inhibition of HSV Binding to cellular membrane. Infect
Immun 2002; 25: 304-9.
6- Thomas Bates, Jefferson. Peroxidase Antimicrobial
System of Human Saliva: Requirements for Accumulation
of Hypothiocyanite. J Dent Res 2001; 60: 780-96.
7- Hoogendoorn Piessense, Scholtes, Stoddard.
Hypothiocyanite Ion; The Inhibitor Formed by the System
Lactoperoxidase-Thiocyanate-Hydrogen Peroxide. Caries
Res 2000; 11: 77-84.
8- Bjorck Claesson. Correlation Between Concentration of
Hypothiocyanite and Antimicrobial effect of the
Lactoperoxidase System Against Escherichia coli. J Dairy
Sci 1998; 63: 919-22.
9- Wood. Organic Reactions. 1996; 3: 240-66.
10- Bacon Irwin. Limiting factors in redox reactions. J
Chem SOC 1998; 778-90.
11- Wood. Biochemistry. In: Chemistry and Biochemistry
of Thiocyanic Acid and Its Derivatives; Newman, Ed.,
New York: Academic Press, 1997, pp. 156-221.
12- Pruitt Tenovuo, Fleming Adamson. Limiting Factors
for the Generation of Hypothiocyanite Ion, an
Antimicrobial Agent, in Human Saliva. Caries Res 1998;
16: 315-23.
13- Tenovuo Makinen. Concentration of Thiocyanate and
Ionizable Iodide in Saliva. J Dent Res 1996; 55: 661-3.
Due to its uncharged nature, HOSCN may
penetrate viral envelopes more readily than does
OSCN- (8). This occurs by breaking bonds of the
lipid bilayer envelope of the virus.
Hypthiocyanous acid reacts with unsaturated
bonds in lipids, but not saturated bonds (18), and
the OSCN- ion does not participate in this
reaction. This reaction occurs by hydrolysis of
lipids with addition of thiocyanite to one of the
carbons and a hydroxyl to the other, the resulting
compound is a thiocyanodrin (19) which disrupts
lipid bilayers and could increase permeability (4).
Disruption could occur if enough thiocyanodrin.is
formed (19,18). That is why; the peroxidase system
is more effective at low pH.
Symptomatic seropositive subjects rinsed
once daily along 100 days, the pH of rinse was 5.5
which increased the effect of peroxidase enzyme
and caused the production of hypothiocyanous
acid which has more antiviral effect through
destruction of the viral envelope resulting in non-
Oral Diagnosis
40
Vol. 22(1), 2010
14- Pruitt Mansson-Rahemtullah, Tenovuo. Detection of
the Hypothiocyanite (OSCN-) Ion in Human Parotid
Saliva and the Effect of pH on OSCN- Generation in the
Salivary Peroxidase Antimicrobial System. Arch Oral Biol
1993; 28: 517-25.
15- Douglas Couch. A prospective study of chronic herpes
simplex virus infection and recurrent herpes labialis in
humans. J Immunol 1990; 104: 289–95.
16- Hogg Jago. The Antibacterial action of
Lactoperoxidase. The nature of the Bacterial Inhibitor.
Biochem J 1997; 117: 779-90.
17- Domigan Vissers, Winterbourn. Modification of oral
microbes by hypothiocyanous acid and hypothiocyanite.
Redox Rep 1997; 3: 263-71.
18Hazen
Hsu,
Duffin
einicke.
Molecular
hypothiocyanous acid generated by the myeloperoxidasehydrogen peroxide-thiocyanite system of phagocytes
converts low density lipoprotein cholesterol into a family
of thiocynated sterols. J Biol Chem 1996; 271: 23080-8.
19- Winterbourne Berg, Roitman Kuypers. Thiocyanodrin
formation from unsaturated fatty acids reacted with
hypothiocyanous acid. Arch Biochem Biophys 1992; 296:
547-55.
20- Nermut Steven (eds). Animal Virus Structure. Elsevier
1987.
Oral Diagnosis
41
Vol. 22(1), 2010
Prevalence of severity
Prevalence of severity and sex distribution of
tempromandibular disorders and other related factors
among a sample of Sulaimani university students
Shanaz M. Gaphor B.D.S, M.Sc., PhD
Soran M. Hameed B.D.S, H.D.D (2)
(1)
ABSTRACT
Back ground: Temporomandibular disorders (TMDs) have been recognized as a common orofacial pain condition.
The term (TMDs) refers to a group of disorders characterized by pain in the temporomandibular joint (TMJ), the
periauricular area, or the muscles of mastication, TMJ noises (sounds) during mandibular function and deviations, or
restriction in mandibular range of motion.the aim of this study was designed to evaluate the prevalence, severity and
sex distribution of signs and symptoms of (TMDs) among the young adults. And to evaluate their relation to oral
parafunction habits, recurrent headache, history of past events and occlusion.
Patients and Methods: A total of 500 university students (250 females, 250 males), ages ranged between 18-26 years,
were interviewed and examined for evaluating the symptoms and signs of TMDs. Anamnestic dysfunction (Ai) of
Helkimo (1974) was used to determine the severity of the subjective symptoms. Clinical dysfunction (Di) of Helkimo
(1974) was used to estimate the severity of the signs of TMDs.
Results: results showed that prevalence of one or more symptoms of TMDs was 27%, while the prevalence of one or
more signs of the TMDs was 63.8% which was generally mild in severity. Mild anamnestic symptoms (Ai0) were found
in 18.8%, severe symptoms (AiI) were found in 8.4%, while mild clinical signs DiI, moderate clinical signs DiII and severe
clinical signs (DiIII) were found in (47.4%, 14%, 2.4%) respectively.
Conclusion: Signs and symptoms of the TMDs were relatively high in the university students. An etiology of the TMDs
remains unclear but mostly appears to be multifactorail.
Keywords: TMDs, prevelance, Helkimo index. J Bagh Coll Dentistry 2010; 22(1):42-48.
INTRODUCTION
At present, it is the opinion of most authors
that the causation of TMDs is multifactorail (3).
The aim of this study to determine the
prevalence and the degree of severity of the signs
and symptoms of TMDs among young age’s
adults of a sample of sulaimani university
students, to found out the possible underlying
causative factors and to study the relationships of
recurrent headache, oral parafunctions and
previous trauma with the severity of the
symptoms and signs of the TMDs.
Temporomandibular disorders (TMDs) are a
collective term embracing various clinical
problems
that
involve
the
masticatory
musculature and the temporomandibular joint.
TMDs are characterized by pain in the
masticatory muscles, the temporomandibular joint
and the associated hard and soft tissues, limitation
in jaw function and sounds in the TMJ(1).
It has been well established, by means of
epidemiological studies that signs and symptoms
of TMDs are common in adults of all ages (2).
There is some evidence to suggest that anxiety,
stress, and other emotional disturbances may
exacerbate TMDs, especially clinically in patients
who experience chronic pain (3). Nevertheless the
cause of the signs and symptoms of TMDs is not
clearly understood and various opinions on their
etiology have been offered (4).
TMDs are among the most common orofacial
pain conditions of non dental origin, and often
they are self limited in the adult populations and
the prevalence of these disorders differ between
studies, probably because of variations in
methodology and definitions of TMDs
(1)
(2)
MATERIAL AND METHODS
1 -The sample:
The sample consisted of 500 undergraduate
students from four different colleges of the
sulaimani University; 250 were males, while the
other 250 was females. The age ranged between
18-26 years with mean age of (21.4 years).
2- Interview:
The subjective symptoms were obtained by
asking the students the following questions with
adequate explanation as needed which history of
emotional
stress,
maxillofacial
surgery,
orthodontic treatment and history of trauma by
dental work. Then information about related
factors were obtained and recorded, which
included headache more than twice a week or
more, previous trauma to head and neck and oral
Assistant professor, college of dentistry, university of
Sulaimania.
Assistant lecturer, college of dentistry, university of
Sulaimania.
Oral Diagnosis
43
Vol. 22(1), 2010
parafunctions, the subjects was asked if s/he
frequently did one or more of the following oral
habits (grinding, clenching, nail-, object-, lipcheek biting, chewing gum, chewing on one side
and sleeping on their face).
Anamnestic dysfunction index of Helkimo
(1974) (5) was used to determine the severity of the
subjective symptoms.This index was classified
into three grades:
(Ai0) denotes complete absence of subjective
symptoms of dysfunctions of the masticatory
system. (AiI) denotes mild symptoms; one or
more of the following symptoms were reported in
anamnesis: joint sound, feeling of fatigue, feeling
of stiffness of the jaws on awaking. (AiII)
denotes severe symptoms of dysfunction; one or
more of the following symptoms were reported in
anamnesis: difficulty in opening the mouth
widely, locking, subluxation, pain on movement
of the mandible, facial and jaw pain, pain and
tiredness on chewing.
3-Clinical examination
The student was seated on a straight chair
with tall back on which the student head could
rest in order to be examined and the artificial light
was used when needed. Then masticatory system
was examined in the following systematic way
according to Helkimo (5).
Clinical examination include Measurements
of maximal opening capacity, overbite and over
jet, examination of occlusion, examination of
impaired TMJ function which include clicking,
crepitation,
deviation,
locking,
luxation,
examination of masticatory muscle pain or
tenderness.
The severity of the clinical signs was
determined according to clinical dysfunction
index by Helkimo. The severity of the clinical
signs according to the scores was classified into
four dysfunction groups; each group was given an
index value as follows:(Di0)=Dysfunction group 0=0 point =clinically
free. (DiI)=Dysfunction group 1=1-4 points =mild
(DiII)=Dysfunction group 2=5-9 points =
moderated. (DiIII)=Dysfunction group 3=10-25
points =sever dysfunction.
5.0%, then difficulty in the mouth opening which
represented 4.4%.The distribution of other
symptoms was relatively low; pain on movement
represented 2.4%, both subluxation and pain on
chewing represented 1.8%, locking, jaw and facial
pain both of them represented only 0.6% of the
total collected sample. There was significant
difference between males and females according
to one symptom or more, with males being
significantly higher than females P<0.05, while
insignificant differences were found between
males and females for the other symptoms as
shown in table1.
Table 1: Frequency and relative distribution
of symptoms of the TMDs according to sex.
Gender
Femal
Males
Symptoms
e
No
No
%
%
.
.
19 76. 18 72.
No
2 8 1 4
TMJ sound
23.
27.
Ye
58
69
2
6
s
No
Feeling
stiffness
of
23 95. 23 94.
8 2 7 8
Ye
12 4.8 13 5.2
s
No
Difficulty in
opening wide
Pain
movement
24 96. 23 94.
1 4 7 8
Ye
9
s
No
on
3.6 13 5.2
24 96. 24 98.
2 8 6 4
Ye
8
s
3.2 4
1.6
24 98. 24
98
No
Pain
or
6 4 5
tenderness
Ye
on chewing
4 1.6 5 2
s
No
One or more
Symptom
RESULTS
I- Prevalence, severity and sex distribution of
the symptoms of the TMDs:
Table 1 shows the distribution of the
symptoms of the TMDs among the investigated
students, 27% of the studied group had at least
one or more symptoms of the TMDs in the total
collected sample. The most common symptom
was TMJ sounds 25.4% of the total sample,
followed by feeling of stiffness which represented
Oral Diagnosis
19 76. 17 68.
2 8 2 8
23.
31.
Ye
58
78
2
2
s
Total
X2
No
%
.
37 74. X2=1.2
3 6 77
df=1
12 25.
p>0.05
7 4
*
47
X2=0.0
95
5
42
df=1
25 5.0 p>0.05
*
47 95. X2=0.7
8 5 61
df=1
22 4.4 p>0.05
*
48 97. X2=1.3
8 6 66
df=1
12 2.4 P>0.05
*
49 98. X2=0.1
1 2 13
df=1
9 1.8 P>0.05
*
36 72. X2=4.0
4 8 40
df=1
13 27.
P<0.05
6 2
**
*Not significant, **Significant.
Table 2 shows the distribution of the young
adults according to the anamnestic dysfunction
index (Ai), 72.8% were symptoms free (Ai0),
18.8% had mild symptoms (AiI), while 8.4%
complained of severe symptoms (AiII). Although
mild and severe symptoms were more frequent in
44
Vol. 22(1), 2010
males 21.6%, 9.6% respectively than in females
16%, 7.2% respectively, insignificant differences
were found between males and females in relation
to the anamnestic dysfunction index (Ai), as
shown in table 2.
of the signs of the TMDs according to sex
Clinical signs
of the TMDs
of the young adults according to sex and
symptoms codes (Ai).
Clicking
on
examinati
on
Deviation
on
examinati
on
TMJ pain
or
tendernes
s
Symptoms code (Ai)
Total
X2
Ai0 AiI AiII
40
18
250
No. 192
Female
16
7.2 100 2
% 76.8
X =4.041
54
24
250
No. 172
df=2
Male
% 68.8 21.6 9.6 100 P>0.05*
94
42
500
No. 364
Total
% 72.8 18.8 8.4 100
Gender
II- Prevalence, severity and sex distribution of
the signs of the TMDs
Table 3 shows the distribution of the signs of
TMDs that 63.8% of the examined students had
one sign or more. The most common sign was
clicking 43.2%, followed by TMJ pain or
tenderness 27%, deviation of the mandible 23.2%,
restricted mouth opening 18%, pain on movement
of the mandible 10.6%, then muscle pain and
tenderness 10%, while 10 subjects with
subluxation and 6 subjects with crepitation and 5
subjects with deflection were found in the entire
sample giving the percentage of 2%, 1.2% and 1%
respectively, however there was no locking on
examinations. There was significant difference
between males and females according to one sign
or more, in females it is significantly higher
68.4% than male’s 59.2%. For different signs,
restricted maximal opening capacity and
subluxation were significantly higher in females
25.6%, 3.6% than in males 10.4%, 0.4%
respectively.
p<0.05
while
insignificant
differences were found between males and
females for the other signs as shown in table 3.
Table 4 shows the distribution of the subjects
according to the clinical dysfunction index (Di),
36.2% of the individuals were free from the
clinical signs (Di0), the percentages of the
subjects decreased with increasing severity of the
clinical signs, 47.4% with mild signs (DiI), (14%)
with moderate signs (DiII), 2.4% with severe
signs (DiIII). There was no significant difference
between males and females according to clinical
dysfunction index (Di) as shown in table 4.
Oral Diagnosis
ye
s
No
Ye
s
No
Ye
s
No
Ye
Pain on
s
movemen
t
No
Gender
Femal
Male
e
No
No
%
%
.
.
10 43. 10 42.
9 6 7 8
14 56. 14 57.
1 4 3 2
23.
23.
58
58
2
2
19 76. 19 76.
2 8 2 8
28.
25.
71
64
4
6
17 71. 18 74.
9 6 6 4
10.
10.
27
26
8
4
22 89. 22 89.
3 2 4 6
25.
10.
64
26
6
4
Tot Tot
al al
No. %
X2
X2=0.33
d
f=1,p>0.0
284 56.8
5*
216 43.2
116 23.2 X2=0.000
df=1,
384 76.8 P>0.05
135 27 X2=3.030
df=1,
365 73 P>0.05*
53 10.6 X2=0.025
df=1,
447 89.4 P>0.05*
X2=20.24
Ye
90 18
Restricted s
9
mouth
df=1,
18 74. 22 89.
opening No
410 82 P<0.01**
6 4 4 6
*
Ye 17 68. 14 59.
2
319 63.8 X =4.581
1 4 8 2
One or
s
df=1,
more sign
31. 10 40.
181 36.2 P<0.05**
No 79
6 2 8
*Not significant, **Significant. ***Highly significant.
Table 4: Frequency and relative
distributions of the young adults according
to sex and (Di) signs codes.
Severity of the signs
Total
X2
Di0 DiI DiII DiIII
7
250 X2=5.117
No. 79 129 35
Female
df=3
% 31.6 51.6 14 2.8 100
P>0.05*
5
250
No. 102 108 35
Male
2
100
% 40.8 43.2 14
*Not
No. 181 237 70 12 500
significant.
Total
% 36.2 47.4 14 2.4 100
Gender
III- Relationship between signs and symptoms
of the TMDs.
The relationship between the anamnestic (Ai)
and clinical dysfunction index (Di) shows that in
young adults who were symptoms free (Ai0)
72.8% was found in those who had mild signs
(DiI) 47.2% and the highest percentage of the
young adults with mild and severe symptoms
18.8%, 8.4% respectively was also found in those
45
Vol. 22(1), 2010
who had mild signs 52.1%, 38% respectively as
shown in table 5.
Table 5: Relative distribution of (Ai) in
relation to (Di) among young adults.
Symptom
s
No.
Ai0
%
No.
AiI
%
No.
AiII
%
No.
Total
%
Severity of the
Total
X2
signs
DiII No
Di0 DiI DiII
%
I
.
36 72.8
153 172 39
0
4
%
42. 47. 10.7
10
0
0 2
9
0
18.8 X2=86.84
23 49 18
4 94
%
8
24. 52.
10
df=6
19.1 4.2
4 1
0
P<0.01*
5 16 13
8 42 8.4%
11. 38.
10
30.9 19.0
9 0
0
50
181 237 70 12
0
36. 47.
10
14 2.4
2 4
0
Figure 1: Relations between oral
parafunction , masticatory muscle pain and
headache.
•
•
Relation between oral parafunction and MMP:
X2=2.488, P<0.05, significant.
Relation between oral parafunction and headache
:X2 =6.425 ,P<0.05, significant
**Highly significant.
IV- Related factors:
The relationships between oral parafunction
and masticatory muscle pain and headache shows
that when one or more oral parafunctional habits
is present, masticatory muscle pain and headache
tend to increase, from 8.9% to 14% for
masticatory muscle pain, and 28% to 41.8% for
headache as shown in figure 1. Figure 2 shows
the relationships between masticatory muscle pain
and recurrent headaches. There is increasing in
percentages of recurrent headache from 30% to
38% when there is masticatory muscle pain or
tenderness in 1-3 palpation sides, and there was
significant increase in frequency of recurrent
headache when tenderness of muscle increases in
4 or more palpation sides. Relation between
masticatory muscle pain and recurrent headache
was found to be statistically significant,
X2=8.020, df=2, P<0.05.
The percentage of students with no history of
previous external trauma tends to decrease from
73.4% with no symptoms (Ai0) to 7.7% with
those who had severe symptoms (AiII) with the
increasing severity of the symptoms. The
percentage of the students with positive history of
external trauma tend to increase from 14.3% of
those who had mild symptoms (AiI) to 57.1% of
those who had severe symptoms and the
distribution was highly significant P<0.05.
Oral Diagnosis
Figure 2: Relationship between masticatory
muscle pain and recurrent headache.
In the other hand the highest percentage of
those who had no trauma was found in group with
mild signs 47.8%, while the highest percentage of
those who had previous external trauma was
found in group with moderated signs 57.1%. This
relationship was found to be statistically highly
significant P<0.01.In regard to various factors of
occlusion, highest percentage of subjects who had
cross bite was distributed in subjects with mild
clinical signs 61.7%, and the distribution was
statistically
significant<0.05.
The
highest
percentage of cross bite was symptom free 65.9%
with Ai0. In the present study high percentage of
mild symptoms and mild clinical signs were
present in canine guidance and high percentage of
severe symptoms and severe clinical signs were
present in subjects with posterior contact only.
V- Relationships between possible etiological
factors and signs and symptoms of the TMDs.
Figure 3 shows the distribution of etiological
factors and their significant relation to symptoms
of the TMDs, it reveals that high percentage of
symptoms present more in subjects with nonworking occlusal interference 90%, followed by
emotional stress 80%, then trauma 71.4%. The
remaining was present in low percentages; for
history of trauma by dental work 43.75%, oral
parafunctions 41.8%, history of orthodontic
46
Vol. 22(1), 2010
treatments 40.9%, and the last one history of
maxillofacial surgery 30.4%.These distributions
were significant in subjects with non-working
occlusal contact interference X2=14.02, df =2,
P<0.05, and highly significant in history of
emotional stress X2=4.366 and whiplash injury
X2=7.03, df =1, P<0.01. The most oftendiscussed peripheral etiological factors are socalled occlusal interferences While Figure 4
shows the severity of one or more clinical signs in
subjects with different etiological factors that may
affect TMJ function. High percentage of clinical
signs was found in subjects with previous trauma
(whiplash injury) 100%, followed by history of
emotional stress 90%, non-working occlusal
contacts which shows 88%, history of orthodontic
treatment 81.8%, history of trauma by dental
work 75%, oral parafunction 67.3% and the
lowest one was history of maxillofacial surgery
which was only 58.6%.Statistical significant
relationships were present only in subjects with
whiplash injury X2=4.02, df=1 and non-working
occlusal contacts X2=6.40, p<0.05 and clinical
signs.
technique is also more flexible than questionnaire
formula which is needed in this study, but the
influence of the interviewer should always be
considered. In this study the prevalence of one or
more symptoms was found to be 27.6%; in
comparison with other international studies, the
present finding lied within the ranges of (23%31%) (7) but higher than Gesech et al ( 2.7%)(8)
and lower than Pow et al.( 33%)(9).This variations
may have resulted from differences in the
questionnaire form, differences in wording,
meaning and number of questions used or due to
differences in the composition of the materials.
In this study there was significant sex
difference concerning one symptom or more,
males 31.2% being significantly higher than
females 23.2%, and female to male ratio were
1:1.3. These results disagree with others who
suggest the same frequency in females and males
(4,5,10,11).
Lower percentages in females comparing
to males may be due to embarrassment to answer
(Yes) comparing to males because of
environments in which the questions were asked
without privacy.
Concerning the distribution of young adults
according to the anamnestic index (Ai), mild
symptom AiI was found in percentage of 18.8%,
close to Hiltunen (17%)(12) ,at the same time our
result tend to be higher to Kalanzi et al ( 7.1%)(2)
who reported low frequency of mild symptoms
comparing to their severe symptoms.Our study
reveals that mild symptoms 18.8% were more
frequent than severe symptoms 8.4%, this finding
is consistent with that reported by Abdualla and
Hussein (10) (mild symptoms 30% versus severe
symptoms 8%); De Kanter et al (13) (mild
symptoms 16.6% versus severe symptoms 4.9%);
Otuyemi et al (7) (mild symptoms 26.3% versus
severe symptoms 2.9%) and disagree with
Kalanzi et al (2) ( mild symptoms 7.1% versus
severe symptoms 28.6%).
In this study there was no sex difference
concerning anamnestic dysfunction index Ai
(mild and severe symptoms). This result tends to
agree with (2,6,10). However De Kanter et al (13)
found a higher incidence in females; this may be
attributed to the finding that more females are
seeking treatment for the TMDs than males (14).
In this study the prevalence of one sign or more
was 63.8%, this percentage falls within the range
28%-92% which is reported by other
investigations among the young adults. This
finding is consistent with the finding reported by
other investigators (59%-67%) Kalanzi et al
(60%) (2). The sex distribution in this study
showed that one sign or more was significantly
higher in females, which agrees with (10,11,13,15,16).
Figure 3: Possible etiological factors and its
relation to one or more symptom of TMDs
Figure 4: Possible etiological factors and its
relation to one or more sign of the TMDs
DISCUSSION
In this investigation interview was used
because it is preferable to questionnaire as the
identity of the interviewed individuals can be
confirmed, it is also possible to find out whether
questions have been understood or not (6). This
Oral Diagnosis
47
Vol. 22(1), 2010
In this study the most common signs represent
clicking at very high percentage of 56.8% with no
sex difference. This tends to be close and in
agreement with Elfving et al 56% (17). The
distributions of young adults according to the
clinical dysfunction index (Di) found that mild
signs were more frequent than moderate, while
the severe signs were the least frequent. 36.2% of
the individuals were free from the clinical signs
(Di0), the percentage of the subjects decreased
with increasing severity of the clinical signs,
(47.4%) with mild signs (DiI), (14%)with
moderate signs (DiII), (2.4%) with severe signs
(DiIII). These results tend to be close to other
studies (5, 9, 11) but disagree with Otuyemi et al (7)
who showed that severe clinical signs DiIII are
much less than our results 0.3%. A highly
significant relationship between anamnestic and
clinical dysfunction index was found in this study.
The majority of subjects with symptoms free,
mild and severe symptoms had mild clinical signs
and these results are highly significant. The
present study also suggests that most people with
clinically detectable dysfunction are functioning
adequately without significant symptoms and are
not in need of treatment. As a result of this study,
the differences in the perceived need for treatment
related to anamnestic or clinical dysfunction
subgroups indicate the limited value of the
Helkimo dysfunction indices in the general adult
population and its substantial and varies according
to definition, criteria, and age (18). Our results
agree with De Kanter et al (13) and disagree with
Otuyemi et al (7). In the present study, there was a
significant relationship between masticatory
muscle pain and oral parafunctions. When
parafunctional habits were present, there was
increase in masticatory muscle pain or tenderness
which agrees with Glaros et al (19), in the other
hand there is significant increase in recurrent
headache which agrees with Glaros et al (19).
These results disagree with other studies (20, 21).
The differences are possibly due to the use of
dental attritions caused by clenching or other
habits as an excuse for oral parafunction habits
and then relating them to signs and symptoms of
TMDs. This result of our study could explain that
recurrent headache and masticatory muscle pain
that associated with TMDs may be related to the
oral parafunctions. These results clarify the
important role of parafunctions in TMDs. In this
study significant relationship between trauma and
one or more clinical signs tend to agree with
Friedman and Weisberg (22). There is significant
relationship between non-working occlusal
contact and clinical signs and this result tends to
agree with other studies (23) who reported that the
Oral Diagnosis
number of masticatory muscles tender to
palpation was related to reports of fatigue in the
jaw, TMJ tenderness, and mediotrusion
interferences. In regard to the relation of
etiological factors to TMDs symptoms, the most
oftendiscussed peripheral etiological factors are
so-called occlusal interferences, which some
authors consider extremely important Dawson (24),
while others disregard them almost totally Greene
and Marbach (25). Other reviews indicate that
occlusal factors are in general not of major
importance, but between the calm and nervous
subjects. Whiplash trauma found to be the third
etiological factor that the question is still
controversial Greene (26). Our research shows
significant association between emotional stress
and symptoms of the TMDs but not to clinical
signs and this will support many theories of
relating this to psychological cause (27) however
this concept disagree with Farsi (28) who showed
statistically significant differences in the
prevalence of TMJ tenderness affects reporting
symptoms and is statistically significant and this
agrees with Kamisaka et al (29).
Central factors shown to be of possible
etiological importance are psychological states
and psycho physiological responses, but they
should nevertheless be included in a multifactorial
concept.
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Oral Diagnosis
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21.Pergamalian A, Rudy T, Zaki H, Greco CM. The
association between wear facets, bruxism, and
severity of facial pain in patients with
temporomandibular disorders. J Prosthet Dent 2003;
90(2):194-200.
22. Friedman MH, Weisberg PT. The craniocervical
connection: a retrospective analysis of 300 whiplash
patients with cervical and temporomandibular
disorders. J Craniomand Pract 2000; 18: 163-7.
23. Marzooq AA, Yatabe M, Ai M. What types of occlusal
factors play a role in temporomandibular disorders...?
A literature review. J Med Dent Sci 1999; 46:111-6.
24. Dawson PE. Evaluation, Diagnosis and Treatment of
Occlusal Problems, St. Louis: C. V. Mosby 1974.
25. Greene CS, Marbach JJ. Epidemiologic Studies of
Mandibular Dysfunction: A Critical Review. J
Prosthet Dent 1982; 48:184-90.
26. Greene CS. Temporomandibular Joint Disorders. In
Clinical Dentistry, J.W. Clark, Ed., and Philadelphia:
Harper & Row Publishers 1984; 2: Chapter 37.
27. Molin C. From bite to mind: TMD--a personal and
literature review. Int J Prosthodont 1999; 12(3):27988.
28. Farsi N. Temporomandibular dysfunction and
emotional status of 6–14 years old Saudi female
children. Saudi Dent J 1999; 11:114-9.
29.Kamisaka M, Yatani H, Kuboki T, Matsuka Y &
Minakuchi H. Four-year longitudinal course of TMD
symptoms in an adult populat ion and the estimation
of risk factors in relation to symptoms. J Orofac Pain
2000; 14: 224-32.
49
Vol. 22(1), 2010
Relationship between interlukine- 1
Relationship between interlukine- 1 alpha and
polyamines levels in serum and saliva as potential
biomarkers in the diagnosis of oral squamous cell
carcinoma
Shanaz M. Gaphor B.D.S., M.Sc, Ph.D. (1)
Nazar G. Al-Talabani BDS,Ph.D.(2)
Abdul-W. R. Hamad BSc., MSc., Ph.D.(3)
ABSTRACT
Back ground: Oral cancer is one of the prevalent cancers of the body and is one of the 10 most common
causes of death. Oral squamous cell carcinoma (OSCC) accounts for over 90% of these tumors. The aim of this
study was designed to detect biochemical markers in serum and saliva of oral squamous cell carcinoma
patients and to evaluate their validity in monitoring and diagnosis and to correlate relation ship between IL-1
alpha and polyamines. .
Patients and Methods: The level of polyamines in the serum and saliva of (30) patients with OSCC and (20)
healthy individuals as control group was measured. Level of proinflammatory cytokine Interleukin 1α (IL-1α) was
detected by enzyme linked immunosorbent assay (ELISA). Polyamines (spermidine and spermine) were
determined by high performance liquid chromatography (HPLC) in both serum and saliva of patients with OSCC
and control group.
Results and Discussion: Salivary IL-1 alpha was useful in the diagnosis of OSCC patients. The total serum and
salivary polyamines level of OSCC were significantly higher than the control group (P<0.001). Both salivary and
serum polyamines level were reliably accurate test in separating between OSCC patients and control group.
There was significant difference in salivary spermine level among OSCC patients in relation to lesion status.
Spermine levels were reduced in recurrent lesion especially with metastases. There were significant differences
in serum polyamines level among OSCC patients in relation to duration of the disease (P<0.05).
Conclusion: There was a significant weak correlation between salivary IL-1α and salivary spermine (r=0.377)
(p<0.05). From the results of the presents study, it can be concluded that detection of polyamines in serum and
saliva are useful and valuable diagnostic markers in diagnosis and early detection of OSCC.
Keywords: Oral cancer; polyamines; Interleukin 1α (IL-1α); OSCC. J Bagh Coll Dentistry 2010; 22(1):50-54.
INTRODUCTION
Intracellular concentrations of naturally occurring
polyamines, spermidine and spermine, have been
demonstrated to be important in normal and
neoplastic cell proliferation and differentiation (8,
9)
). Cellular levels of polyamines increase
significantly when cells are stimulated to
proliferate. Abnormal hyperproliferative cells
such as preneoplastic tissue exhibit high
requirement for polyamines to sustain cell growth
(10)
. Elevated polyamine levels have been found
within neoplastic tissues and many types of
cancer cells (11) and body fluids, such as urine,
serum and saliva (12, 13). The purpose of the
present the study is:
(1) to measure the level of IL-1 alpha and
polyamines in serum and saliva in patients with
oral squamous cell carcinoma and a healthy
control group.
(2) To investigate the validity of IL-1 alpha and
polyamines as informative and useful biomarkers
in the diagnosis of OSCC.
(3) To correlate relationship between IL-1 alpha
and polyamines.
Cancers of the oral cavity represent
approximately 2-3% of all malignancies.
Squamous cell carcinoma (SCC), which arises
from the oral epithelium, accounts for over 90%
of these tumors (1, 2). SCC of head and neck is the
sixth most common human malignancy (3).
Alterations in host immunity, inflammation,
angiogenesis, and metabolism have been noted to
be prominent clinical features in patients with
head and neck squamous cell carcinoma
(HNSCC) (4, 5). The local and systemic nature of
these responses suggests the hypothesis that
cytokines with proinflammatory, proangiogenic,
and immunoregulatory activity are produced by
SCC and could contribute in the pathogenesis of
HNSCC (6, 7).
(1) Assistant professor, department of oral diagnosis, college of
dentistry, university of Sulaimania.
(2) Professor, department of oral diagnosis, college of dentistry,
university of Sulaimania.
(3) Professor, college of medicine, university of Nahrain.
Oral Diagnosis
50
Vol. 22(1), 2010
Immunological Assay:
Determination of Serum and Salivary Interleukin
levels:
Enzyme
linked
immunosorbent
assay
(ELISA) kit for specific cytokine was used
(Immuntech, a beckman compant, Marseille,
France) according to the manufacturer's protocol.
Biochemical Analysis:
Determination of Serum and Salivary Polyamines
(Spermidine and Spermine) Level:
High performance liquid chromatograph
(HPLC) was used to analyze benzoylated
polyamines (Spermidine and Spermine) with a
10µl sample loop, UV absorption detector (254
nm), a shim-pack C18, 5 µm particles, (ODS)
Octadecyl Silinon column (250X 4.6mm I.D.).
The mobile phase was (60:40) methanol-water run
isocratically at a flow rate of lml/min.
Derivatization:
1. Stock solution (1 ml) of 2% benzoyl chloride in
methanol was added to 500 µl of sample (serum
or saliva) in 10.0 ml screw-capped vial.
2. One ml of 2 molari of sodium hydroxide was
added and the mixture vortexed for 30 seconds
and incubated at 37ºC for 18-20 min.
3. The reaction was terminated by addition of
2.0ml of a saturated aqueous sodium chloride
solution followed by 3.0ml of diethyl ether.
4. This solution was vortexed for about 1-2 min.
and then centrifuged at 3000 rpm for 10 min. to
separate the aqueous and organic solvent
phases.
5. The upper ether phase containing benzoylated
polyamines was transferred to another set of
screw-capped tubes and evaporated to dryness
to remove any traces of water.
6. Benzoylated polyamines were dissolved in 300
µl of methanol and vortexed. After 10 min., this
methanol solution was filtered through
Millipore HV filters (0.45 Mm) to remove
particles.
7. Benzoylated polyamines could be stored up to
three weeks at -20ºC.
Chromatographic Separation of Polyamine
Derivative:
Isocratic conditions using methanol/water
mixture as the mobile phase was used for the
separation of spermidine (spd) and spermine
(spm). Benzoylated polyamines were separated
within 15 min.
Statistical Analysis:
Data are calculated and interred into a
computerized data base structure. Statistical
analyses were done by using SPSS (Statistical
Package for Social Sciences). Frequency
distribution for selected variable was done first.
The non-normally distributed variables (IL-
PATIENTS AND METHODS
Patients:
Fifty individuals were employed in this study.
Thirty patients suffered from lesions that were
diagnosed clinically and histologically as oral
squamous cell carcinoma (OSCC). Their age
ranged between 22-84 years, (16 males and 14
females).Patients admitted to the Maxillofacial
Centers in Surgical Specialty Hospital in Baghdad
and Oral Surgery Department of the College of
Dentistry, University of Baghdad during the
period from February till September 2004.
Twenty three patients were newly diagnosed
untreated primary lesions, whereas 7 cases
represented recurrent lesions after previous
therapy. Twenty healthy persons were used as
control (10 males and 10 females); they didn’t
have medical history of any chronic or acute
diseases; their age ranged between 13-63 years.
Patients were evaluated by full medical history to
exclude any existing systemic diseases such as
diabetes or hypertension and periodentitis that
may affect the parameters to be examined.
Patients with such medical were excluded from
the study.
Fluids Collection and Preparation:
Blood Sample
Ten mls of venous blood were aspirated from
antecubital vein from each individual using plastic
syringe and 21 gauge stainless needles. The whole
blood was collected into plain polyethylene tube
until blood clot formation. The clots were
separated from the wall of the tube using a
wooden applicator stick. The serum was separated
by centrifugation at 3000 rpm for 10 minutes and
then transferred immediately into another tube
and divided into 5 equal parts and frozen at (20°C) for subsequent analysis.
Saliva
Five to six mls of unstimulated (resting)
whole saliva were collected two minutes after the
patients had rinsed his mouth several times with
tap water. The accumulated saliva in the floor of
the mouth was drawn by a plastic disposable
pipette and collected into a plastic polyethylene
tube of 10 ml capacity. Saliva sample collected
from OSCC patients as well as from the normal
individuals. The collection period was 20 minutes
and sampling time was always between 10 AM 1PM. The collected saliva was centrifuged at
3000 rpm for 10 minutes; this was done within
one hour after collection to eliminate debris and
cellular matter. The centrifuged supernatants were
divided into 5 equal parts. All samples were
stored frozen at (-20 ˚C) in polyethylene tubes
until assayed.
Oral Diagnosis
51
Vol. 22(1), 2010
1alpha) are described by median and interquartile
range instead of mean ±SD. The difference in
median between two groups was assessed by
Mann-Whitney tests. The difference in mean of
normally distributed variables (polyamines)
between two groups was assessed by independent
samples t-test
there was no statistically significant change in
salivary polyamine (spermidine) level of OSCC
patients in relation to lesion status, while there
was a statistically significant difference in
salivary polyamine (spermine) level of OSCC
patients in relation to lesion status (p<0.05). There
were statistically significant differences in the
mean of serum polyamines level in relation to
duration of the disease in months (p<0.05), while
There were no statistically significant differences
in salivary polyamines level in relation to duration
of the disease.
Correlation- Coefficient of Study Parameters:
This study showed a significant weak
correlation between salivary spermine and
salivary IL-1 alpha (r = 0.377). Interestingly, this
study showed significant correlation between
serum spermidine and serum spermine (r = 0.931)
(P<0.01) and significant correlation between
salivary spermidine and salivary spermine (r =
0.836) (P<0.01). As anticipated, the current study
revealed that serum spermidine showed a weak
significant correlation with salivary spermidine (r
= 0.450) and salivary spermine (r = 0.436), in the
other extreme serum spermine showed a
significant weak correlation with salivary
spermine (r =0.411) and salivary spermidine
(r=0.399).
RESULTS
Assessment of Interleukins Level:
There were no significant difference in serum
IL-1α between OSCC patients and control group
as shown in table 1. Table 1 demonstrates that
there were a highly significant difference
(p<0.001) in salivary IL-1 alpha level of OSCC
patients (median 968.8pg/ml) in comparison to
that of control group (225pg/ml).
Assessment of Polyamines Level:
Table 2 revealed a highly significant
elevation in serum spermidine and spermine
levels among OSCC patients (154.1 µ mol/ml,
175.7 µ mol/ml) respectively in comparison to
that of control group (40.3µ mol/ml, 48.2 µ
mol/ml ) respectively (p<0.001). As shown in
table 3 there was a highly significant difference in
salivary spermidine and spermine levels among
OSCC patients (14.7 µ mol/ml, 16.9 µ mol/ml)
respectively in comparison to that of control
group (3.9 µ mol/ml, 4.9 µ mol/ml) (p<0.001).
Table 1: Level of interleukin in serum and saliva among OSCC patients and control group using
Mann-Whitney test.
Interleukins
Controls (n=20) (Oral Cancer) (n=30) P
[NS]
Serum IL-1 alpha concentration
(0 - 5)
(0 - 137.5)
Range
1.3
3.8
Median
(0 - 5)
(0 - 12.5)
Interquartile range
<0.001
Salivary IL-1 alpha concentration
(187.5 - 675)
(175 - 1000)
Range
225
968.8
Median
(187.5 - 497.9)
(389.4 - 1000)
Interquartile range
Table 2: Mean Concentration of serum polyamines among OSCC patients and control group.
Polyamines
Control (n=20) (Oral Cancer) (n=30) P
<0.001
Serum SPD concentration
(20.1 – 64.7)
(100.3 – 220.5)
Range
40.3
154.1
Mean
14.3
29.9
±SD
3.19
5.46
±SE
<0.001
Serum SPM concentration
(27.5 – 74.3)
(110.7 – 265.3)
Range
48.2
175.7
Mean
14
38.8
±SD
3.12
7.09
±SE
Oral Diagnosis
52
Vol. 22(1), 2010
Table 3: Mean Concentration of salivary polyamines among OSCC patients and control group.
Polyamines
Control (n=20) (Oral Cancer) (n=30) P
<0.001
Salivary SPD concentration
(2.1 - 5.6)
(8.6 - 22.2)
Range
3.9
14.7
Mean
1.1
3.1
±SD
0.24
0.57
±SE
<0.001
Salivary SPM concentration
(2.9 - 6.7)
(11.5 - 24.6)
Range
4.9
16.9
Mean
1.2
3.6
±SD
0.27
0.65
±SE
DISCUSSION
A concentration of serum IL-1α was detected
at the limits of sensitivity of the assays, and no
significant differences was detected in serum of
patients with OSCC and control group. These
findings were similar to that reported by Chen, et
al. (6) who demonstrated that there was no
significant difference in serum IL-1alpha of
patients with HNSCC and control group.
Although IL-1α was not detected at significant
level in serum, this cytokine was detected at
higher concentrations in saliva of patients with
OSCC in comparison to that of control group.
Detection of IL-1alpha in saliva holds a potential
role for OSCC diagnosis and has been reported to
play an important role in the initiation of local
inflammation and activation of lymphocyte
responses as well as serve as useful biomarkers in
the diagnosis of OSCC than serum IL-1 alpha.
The present study demonstrated that
polyamine levels in serum and saliva from OSCC
patients were higher than those found in control
group. The results of this study are generally in
agreement with the findings of other studies in
which an increase in the concentrations of salivary
polyamines (13), serum and urinary polyamines in
the diagnosis of various cancers and several
pathological conditions (14-16). Al-Hamad and
coworkers (17) was reported that the concentration
of serum polyamines (spermidine and sperrmine)
increased in patients with breast cancer,
pancreatic cancer and lymphocytic leukemia.
Kadhier and coworkers (18) was found that serum
polyamines (spermidine and sperrmine) level in
patients with breast cancer were significantly
higher than the control grouped. Several studies
reported high intra cellular concentrations of
polyamines in many types of cancer cells,
including human breast cancer tissue (11, 19), colon
cancer (10, 20, 21) and prostate cancer (22, 23).
Polyamines play an important role in cell
proliferation, differentiation and transformation
that explain the rapid tumor growth which has
been associated with markedly altered polyamine
Oral Diagnosis
biosynthesis and accumulation (11, 19). High
concentrations of polyamines may be derived by
increased synthesis, by decreased degradation, by
increased uptake of polyamines, or by decreased
export of acetylpolyamines (11). All four
mechanisms could contribute to the over all
increased polyamine content of OSCC due to
increase requirement of natural polyamines in
cancer cell growth.
The level of polyamines in proliferating cells
was much higher than those of non – proliferate
cell to sustain cell growth and replication (10).
There was a significant weak correlation between
salivary IL-1α and salivary spmermine (r=0.377)
(p<0.05). This could be explained on the basis
that: the polyamines are important for regulation
of lymphocyte differentiation and proliferation (24)
and have direct effect on immune effecter cell
metabolism (25).
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Venza M, Visalli M, Cicciu D and Teti D.
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Suh JW, Lee SH, Chung BC and Park J. urinary
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Fabian, CJ, Kimler BF, Brady DA, Mayo MS et
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Oral Diagnosis
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54
Vol. 22(1), 2010
The effect of a mouth rinse
The effect of a mouth rinse containing chlorhexidine &
fluoride on plaque & gingival bleeding
Abdul Majeed H. Al Ani, BDS, MSc (1)
ABSTRACT
Background: The aim of this study was to test the effect of a rinse with 0.05% Sodium Fluoride and 0.05% chlorhexidine
(CHX) on plaque and gingival inflammation compared with a placebo without these agents.
Patients & methods: In a double – blind study, 39 adults with > 20 teeth and CPITN score > 1 but < 4, randomized into
test and control groups.
Results: After baseline assessments for plaque index, bleeding on probing, teeth were professionally cleaned.
Subjects were asked to rinse for 30 seconds with 10 ml of the respective test or placebo rinse after normal oral
hygiene for 8 weeks. There were no significant differences in the 2 groups at baseline with respect to either plaque
(PLI) or bleeding scores (BOP). After sealing and 8 weeks use of the test rinse, there was significant reduction (P<
0.001) in both (PLI) and (BOP). The control group showed no significant reduction in plaque scores after 8 weeks, but
a significant (P<0.05) reduction in (BOP).
Conclusion: This reduction was significantly greater (P< 0.001) in the test group than in the control. It is concluded
that, as an adjunct to normal oral hygiene, the chlorhexidine/fluoride rinse had an inhibitory effect on (PLI) and (BOP)
Key words: Plaque; gingival bleeding; chlorhexidine; fluoride. J Bagh Coll Dentistry 2010; 22(1):55-57.
: ‫اﻟﺨﻼﺻﺔ‬
‫ ﻣﻊ ﻣﻘﺎرﻧﺔ ﺑﺎﻟﻤﺤﺎﻟﻴﻞ‬، ‫آﻠﻮرهﻜﺴﺪﻳﻦ ﻋﻠﻰ اﻟﺼﻔﻴﺤﺔ اﻟﺠﺮﺛﻮﻣﻴﺔ واﻟﺘﻬﺎب اﻟﻠﺜﺔ‬٪٠٫٠٥ ‫ ﻓﻠﻮرﻳﺪ اﻟﺼﻮدﻳﻮم و‬٪٠٫٠٥ ‫اﻟﻐﺮض ﻣﻦ هﺬا اﻟﺒﺤﺚ هﻮ اﺧﺘﺒﺎر ﺗﺎﺛﻴﺮ اﺳﺘﻌﻤﺎل ﻏﺴﻮل اﻟﻔﻢ‬
‫ ﻣﺠﻤﻮﻋﺔ ﺗﺨﻀﻊ‬، ‫ وﻗﺴﻤﻮا ﻋﺸﻮاﺋﻴﺎ اﻟﻰ ﻣﺠﻤﻮﻋﺘﻴﻦ‬، ‫( ﺷﺨﺺ ﺑﺎﻟﻎ ﻓﻲ اﺧﺘﻴﺎر ﻋﺸﻮاﺋﻲ ﻣﺰدوج‬٣٩ ) ‫اﻟﺨﺎﻟﻴﺔ ﻣﻦ هﺬﻩ اﻟﻤﻮاد اﻟﻤﺬآﻮرة اﻋﻼﻩ ﺑﻌﺪ ﺗﻨﻈﻴﻒ اﻻﺳﻨﺎن اﻟﻴﻮﻣﻲ ﺑﺎﻟﻔﺮﺷﺎة ﻟﺪى‬
‫ ﻟﺘﺎﺛﻴﺮ اﺳﺘﻌﻤﺎل اﻟﻤﺤﻠﻮل اﻟﻤﺤﺘﻮي ﻋﻠﻰ اﻟﻤﺎدﺗﻴﻦ اﻟﻤﺬآﻮرة‬. ‫وﻣﺠﻤﻮﻋﺔ ﺗﺨﻀﻊ ﻻﺳﺘﻌﻤﺎل ﻣﺤﻠﻮل ﺧﺎﻟﻲ ﻣﻦ هﺬﻩ اﻟﻤﺎدﺗﻴﻦ‬
‫ﻓﻲ ﺑﺪاﻳﺔ اﻟﺒﺤﺚ ﺗﺆﺧﺬ اﻟﻘﻴﺎﺳﺎت اﻻوﻟﻴﺔ ﻟﻠﺼﻔﻴﺤﺔ اﻟﺠﺮﺛﻮﻣﻴﺔ واﻟﻨﺰف اﻟﻠﺜﻮي اوﻻ ﺛﻢ ﻳﻘﻮم اﻻﺷﺨﺎص اﻟﻤﺘﻄﻮﻋﻴﻦ اﻟﻰ ﺗﻨﻈﻴﻒ اﺳﻨﺎﻧﻬﻢ ﺑﺎﻟﻔﺮﺷﺎة ﻳﻮﻣﻴﺎ وﺑﻌﺪهﺎ ﻳﻘﻮم اﻻﺷﺨﺎص‬
‫( اﺳﺎﺑﻴﻊ ﻓﻲ ﺑﺪاﻳﺔ‬٨) ‫ وﻳﺘﻢ هﺬا ﻟﻤﺪة‬. (‫ﻣﻞ‬١٠)‫( ﺛﺎﻧﻴﺔ ﺑﻤﻘﺪار‬٣٠) ‫ﺑﺎﺳﺘﻌﻤﺎل ﻏﺴﻮل اﻟﻔﻢ اﻣﺎ ﺑﻤﺤﻠﻮل ﻳﺤﺘﻮي ﻋﻠﻰ اﻟﻤﺎدﺗﻴﻦ اﻟﻤﺬآﻮرﺗﻴﻦ اﻋﻼﻩ او ﺑﻤﺤﻠﻮل ﺧﺎﻟﻲ ﻣﻦ هﺎﺗﻴﻦ اﻟﻤﺎدﺗﻴﻦ وﻟﻤﺪة‬
. ‫اﻟﻔﺤﺺ اﻻﺳﺎﺳﻲ ﻟﻼﺷﺨﺎص ﺗﺒﻴﻦ اﻧﻪ ﻻ ﻳﻮﺟﺪ اي ﻓﺮق واﺿﺢ ﺑﺎﻟﻨﺘﺎﺋﺞ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﺠﻤﻮﻋﺘﻴﻦ ﻣﻦ ﻧﺎﺣﻴﺔ اﻟﺼﻔﻴﺤﺔ اﻟﺠﺮﺛﻮﻣﻴﺔ وﻧﺰف اﻟﻠﺜﺔ‬
‫( اﺳﺎﺑﻴﻊ ﺗﺒﻴﻦ ان هﻨﺎك‬٨) ‫وﻟﻜﻦ ﺑﻌﺪ اﻟﺘﻨﻈﻴﻒ ﻋﻨﺪ ﻃﺒﻴﺐ اﻻﺳﻨﺎن واﻟﺘﻨﻈﻴﻒ اﻟﻴﻮﻣﻲ ﻟﻼﺳﻨﺎن ﺑﺎﻟﻔﺮﺷﺎة واﺳﺘﻌﻤﺎل اﻟﻤﺤﻠﻮل اﻟﻤﺤﺘﻮي ﻋﻠﻰ اﻟﻤﺎدﺗﻴﻦ اﻟﻤﺬآﻮرﺗﻴﻦ اﻋﻼﻩ ﻟﻤﺪة‬
. ‫اﻧﺨﻔﺎض ﻓﻲ ﻣﺴﺘﻮى اﻟﺼﻔﻴﺤﺔ اﻟﺠﺮﺛﻮﻣﻴﺔ واﻟﻨﺰف اﻟﻠﺜﻮي اآﺜﺮ ﻣﻦ اﻟﻤﺠﻤﻮﻋﺔ اﻟﺜﺎﻧﻴﺔ اﻟﺘﻲ ﺗﺴﺘﻌﻤﻞ ﻏﺴﻮل اﻟﻔﻢ اﻟﺨﺎﻟﻲ ﻣﻦ هﺎﺗﻴﻦ اﻟﻤﺎدﺗﻴﻦ اﻟﻤﺬآﻮرﺗﻴﻦ‬
‫ﻧﺴﺘﻨﺘﺞ ﻣﻦ هﺬا اﻟﺒﺤﺚ ﺑﺎن اﺳﺘﻌﻤﺎل ﻏﺴﻮل اﻟﻔﻢ اﻟﻤﺤﺘﻮي ﻋﻠﻰ ﻣﺎدة اﻟﻜﻠﻮرهﻜﺴﺪﻳﻦ وﻓﻠﻮرﻳﺪ اﻟﺼﻮدﻳﻮم هﻮ آﻌﺎﻣﻞ اﺿﺎﻓﻲ وﻣﺴﺎﻋﺪ ﻟﻌﻤﻠﻴﺔ اﻟﺘﻨﻈﻴﻒ اﻟﻴﻮﻣﻲ ﺑﺎﻟﻔﺮﺷﺎة ﻓﻲ اﻇﻬﺎر اﻧﺨﻔﺎض‬
. ‫واﺿﺢ ﺟﺪا ﻟﻠﺼﻔﻴﺤﺔ اﻟﺠﺮﺛﻮﻣﻴﺔ واﻟﻨﺰف اﻟﻠﺜﻮي‬
INTRODUCTION
For medically compromised patients and for those
at risk of developing gingivitis, a mouth wash
combining the antiplaque action of chlorhexidine
with the inhibitory effect of fluoride would be of
considerable value (1-3).
The daily use of 0.05% Sodium Fluoride month
wash has been shown to be effective (4-6).
Chlorhexidine rinses at the recommended
concentration of 0-1-0.2% are successful in
inhibiting plaque, and there is a significant effect
when the two agents are used together.
The aim of the present study is to test the effect of
a 0.05% solution Fluoride and 0.05% (CHX) on
plaque and gingival bleeding in adults following
their usual oral hygiene practice.
1.
A double–blind controlled clinical trial
design was employed.
(1) College of Dentistry, Al- Anbar University, Head of
Periodontal department.
Oral and Maxillofacial Surgery and Periodontology55
2.
The test solution contained 0.05% CHX
and 0.05% Sodium Fluoride at a PH of 6. The
placebo Solution was of a similar co lour and
flavor but with no active components.
3.
Test and placebo solutions were supplied in
identical bottles which delivered 10 ml of solution
at a time. The bottles were randomly numbered,
so that neither examiners nor subjects were aware
of the distribution of test or placebo solutions.
Selection of subjects:
1. Thirty nine subjects will at least 20 teeth with
good medical history. All subjects had a CPITN
score greater than 1 but less than 4. This selection
showed signs of gingivitis but no pocket greater
than 4mm in depth present.
2. Criteria for exclusion from the trial were:
pregnancy, partial dentures, orthodontic banding,
mentally and physically handicapped patients.
Clinical assessments:
1.
Plaque was assessed according to the
plaque index (Silness and Loe) for all sites of all
teeth (7).
2.
Gingival (BOP) was assessed on the same
four surfaces around all teeth with the
modification that the periodontal probe was
inserted in to the periodontal pockets to a depth of
only 1-2mm and not to the base of the pocket (8).
Vol. 22(1), 2010
Trial design:
All subjects were asked to follow their routine
dental hygiene practice but to use 10ml of the
mouth wash for 30 seconds twice a day following
brushing with tooth paste and rinsing with water.
The schedule of visits for the subjects in the trial
is shown as follow:
1. In the first visit (week 0), after assessments, the
subjects were referred to scale and polish all teeth.
However, no oral hygiene instructions were
given. Each subject was supplied with a new
toothbrush, toothpaste, enough month wash for
4weeks and diary cards to record compliance.
They were instructed to rinse with 10ml of the
mouthwash for 30 seconds twice a day, as before.
2. In the second visit (often 4 weeks), the subjects
retimed to the examiner for checking the
compliance and issued more month wash and
troth paste.
3. In the third visit, (week 8): The subjects
returned for final assessments 4weeks later.
Scaling and polishing, as well as oral hygiene
instructions, were then carried out by the
examiners. An assessment of subject compliance
was made by calculating the volume of month
wash that had been returned and from the
completed diary cards previously issued.
RESULTS
Plaque and gingival bleeding:
1. Mean plaque and bleeding scores of baseline
of the 2groups revealed that there was no
significant difference in the composition of the
two groups at baseline with respect to either
plaque or bleeding scores.
2. After 8 weeks of rinsing with the test
mouthwash, there were highly significant
reductions (P<0.01) in both plaque and gingival
bleeding. In contrast, for the control group, there
was no significant difference (P<0.005) between
the plaque score at baseline and after 8week.
3. The bleeding scores for the control group
showed a significant (P<0.05) reduction after
8weeks, although this reduction was not as
marked as for the test group.
4. A comparison between test and control
groups for gingival bleeding after 8weeks showed
a significantly greater reduction in the test group.
1.2
1
0.8
0.6
Baseline
0.4
After study period
0.2
0
test
Control
Figure 1
0.8
0.6
Baseline
0.4
After study period
0.2
0
Test
Control
Figure 2
The figure shows the mean plaque score at
significant reduction in bleeding in both groups
baseline and at the end of the study period for test
but this reduction is significantly greater in the
and control groups. After scaling and polishing
test group. (P<0.05, P<0.001).
followed by 8weeks of rinsing, there was a
significant reduction in the test group but not in
DISCUSSION
the control group (P<0.001).
The result of this study shown that
The figure shows the mean bleeding score at
mouthwash containing low (0.05%) concentration
baseline and at the end of the study period for test
of CHX and fluoride used twice daily as an
and control groups. After scaling and polishing
adjunct to normal oral hygiene practices is
followed by 8weeks rinsing, there was a
Vol. 22(1), 2010
clinically useful in controlling both plaque and
gingival bleeding.
After rinsing for 8weeks with the placebo
solution, plaque levels returned to values not
dissimilar from those at baseline. In contrast, with
the same regime, a significant fall in the mean
plaque score was achieved in the test group. It
would therefore appear that participation in the
trial did not alter the subject’s usual practice of
oral hygiene and that the active ingredients in the
test mouth wash prevented the return in plaque
score to their original baseline values.
As a result of the initial scaling, both test and
control groups showed significant reduction in
gingival bleeding at the end of the trial. However,
this reduction was significantly greater in the test
group than in the control group, indicating that the
active mouthwash would add a useful component
to scaling in the control of gingival bleeding.
The present study demonstrates that a
mouthwash combining fluoride with CHX can
inhibit plaque. It showed that the addition of
fluoride to a CHX solution did not adversely
affect its antiplaque action (9).
In the present study plaque was not
completely inhibited, nor was gingival
inflammation completely prevented. Nevertheless,
significant and clinically useful reduction in
gingival inflammation was achieved when
combined with normal oral hygiene (10).
REFERENCES
1. Tinanoff N, Brady JM, Gross A. The effect of
Sodium Fluoride and SnF₂ mouth rinses on
bacterial colonization of the tooth enamel. TEM
and SEM studies 2001; 10: 415-6.
2. Gjermo P, Rölla G. The plaque inhibiting effect
of
chlorhexidine
containing
dentifrices.
Scandinavian J Dental Res 2000; 79:126-32.
3. Flötra L. Different modes of chlorhexidine
application and related local side effects. J
Periodontol Res and Supplement 2002; 12:41-4.
4. Weiss E, Gedalia I, Zilberman Y. The effect of
topical application with an organic and an
inorganic fluoride compound on the inhibition of
dental plaque in human. J Dental Res 2003;
56:1345-8.
5. Svatun B, Gjermo P, Erirsen HM, Rölla G. A
comparison of the plaque inhibiting effect of
Stannous Fluoride and chlorhexidine. Scand J
Dental Res 2003; 35:247-50.
6. Gjermo P, Baastad KL, Rölla G. The plaque
inhibiting
capacity
of
eleven
antibiotic
compounds. J Periodontol Res 1999; 5:102-9.
7. Gjermo P, Bonesvoll P, Rölla G. Relationship of
plaque inhibiting effect and relationship of
chlorhexidine in human oral cavity. Arch Oral
Biol 2000; 19:1031-41.
8. Senior N. Some observations on the formulation
and properties of chlorhexidine. J Soc Cosmetic
Chemistry 2001; 24:259-78.
9. Carlson HC, Porter CK. The inhibitory effect of
synthetic antimicrobial mouthwash (QR-711) on
dental plaque and gingivitis in young adults. J of
Periodontology 2001; 44:225-7.
10.Flötra L, Gjermo P, Rölla G, Waerhaug J. Side
effects of chlorhexidine mouthwashes. Scand J
Dental Res 2000; 79:119-25.
Vol. 22(1), 2010
Incidence of injury
Incidence of injury to lingual nerve during surgical
removal of lower third molar teeth
Akeel S. Abd Alsada B. D. S. M. Sc (1)
ABSTRACT
Background: The precise anatomic location of the lingual nerve in relation to the lingual cortex of the posterior
mandibular third molar is clinically significant because lingual nerve subjected to injury during varieties of oral and
maxillofacial surgery especially in the surgical removal of impacted lower third molar.
In this study we find the incidence of injury to lingual nerve as a complication of surgical removal of impacted third
molar. Fifty dental patients of 20-25 years old, male and female, 25 cases were done by me and other 25 cases were
done by my colleagues in the maxillofacial department in the college of dentistry-university Sulaimani, suffering from
impacted lower third molar tooth, subjected to surgical removal of these teeth, we study the incidence of injury to
lingual nerve in form tip of the tongue parasthesia for one month postsurgery. The aim of study is that to find the
incidence of injury to lingual nerve during surgical removal of fully impacted lower third molar tooth and factors
affecting this surgery.
Materials and methods:, 84 third molars surgery of mucoperiosteal marginal soft tissue flap of buccal approach were
carried out under local anaesthesia by using surgical set for tooth extraction, 4.0 black silk suture to close the wound.
Results:, The incidence of injury to the lingual nerve is 2.8% as a temporary sensory disturbance , while no patient 0%
of permanent of sensory disturbance.
Conclusion:, The incidence of injury to the lingual nerve can be reduced by careful clinical evaluation, proper
surgeon’s experience, and wide anatomical knowledgement during surgical removal of impacted lower third molar
tooth.
Key words: Lingual nerve. Impacted lower third molar. J Bagh Coll Dentistry 2010; 22(1):58-61..
INTRODUCTION
The anatomic proximity of the lingual nerve
to the mandibulr third molar region plays an
important role in planning and performing
surgical intervention in this area (1). The lingual
nerve pass foreword in the submandibular region
from infratemporal fossa by running beneath the
origin of the superior constructor muscle, which
attach to posterior border of mylohiod line on the
mandible, here it is closely related to the last
molar and is liable to be damage in case of
clumsy extraction of an impacted third molar (2).
Kisselbad and Chamberlai (3) demonstrate that the
lingual may be located at sometime superior to the
crest of bony ridge medial to the mandibular third
molar region and only 1 or 2 mm toward the
midline in the lingual soft tissue. In this location
the lingual nerve in rare occasions, will be
vulnerable to stress as flap is raised from an
impacted third molar and it will in risk during
other surgical maneuvers performed during the
removal of a mandibular third molar. Mozovy and
Middlecton (4) showed may variation of normal
anatomy exist including lingual nerve position.
(1) Department of Maxillofacial Surgery, College of dentistry,
University of Suliamani,
The risk of damaging the lingual nerve during
mandibular wisdom tooth surgery differs in the
literature. Horch (5) reports an injury incidence of
0.05% and Hoffmeister (6) 0.04% while AppiahAnane(7) gives an incidence of reversible
dysesthesia after mandibular wisdom tooth
surgery.
Most studies of lingual nerve damage have
shown an incidence ranging from about 1% to 6%
during surgical removal of lower third molars(8),
although a recent study found an incidence of
11% (9) of injury to lingual nerve.
In spit of the removal impacted third molar is
a common procedure, in some case it can be
difficult, it is hard to evaluate factors of the longvariation among patients, and difficult of using a
study design (10). The surgical removal of third
molars may result in a number of complication
including pain, swelling, bleeding, alveolar
ostieitis, and nerve dysfunction (11). The factors
that usually contribute to such problems are
numerous and include the patient-tooth related,
the surgeon's operative experiences (12). The first
classification system employs a description of the
angulations of the long axis of the impacted lower
third molar with respect of the long axis of the
second molar in form of mesioangular, horizontal,
vertical impaction, and distoangular (13); while
Pell & Gregory (14).
Classification that depend on the relationship
between the impacted tooth and anterior part of
the ramus, in the class 111 and class 11 there is
Vol. 22(1), 2010
possibility of postoperative lingual nerve
dysfunction.
A great deal of research has been undertaken
in relation to the incidence of nerve injury during
lower third molar surgery, but little is known
about the factors affecting the rate of damage.
This study dealing with some of these factors as
the long surgeon experience, wide anatomical
knowlegments about this area, type of surgical
flap for removal of impacted lower third molars
(surgical factor), and clinical evaluation of a case.
All these factors may contribute in the reduction
the incidences of the injury to the lingual nerve
during third molar surgery, also to determine if
the incidence of lingual nerve damage differs to
any signified extend from that reported elsewhere.
Incidence of injury
department of college of dentistry University of
Sulimani, other were carried in my private clinic.
All the procedures were done according to
standardized protocol with the patients, under
local anaesthesia in form of inferior alveolar nerve
block injection and long buccal nerve block
injection with buccal infiltration injection.
The fully impacted lower third molar was
removed in only one of these procedures. A
mucoperiosteal marginal soft tissue flap was used
with or without releasing incision, lingual tissues
were retracted during bone removal with howarthperiosteal elevator. The flap was reflected, the
contiguous bone was removed bucally and
sometimes distally according to the cases with a
round burr and a fissure burr in a high –speed
hand piece was used to section the teeth. Constant
irrigation with cold sterile physiological saline
solution was used with the burr. The flap was then
repositioned and by a 4-0 silk suture was used to
close the wound; no lingual flap was employed in
any of the cases.
METHOD: All the patients before the operation
subjected for clinical examination and the causes
for removal of impacted teeth was recorded as in
table (1), Type of angulations of teeth13 was
recorded as in table (2). Periapical X-ray view
preoperatively assessment for all patients. (16, 17).
Postoperatively, those patients who did proceed to
lower third molar surgery were reviewed one
week after operation when they asked about
altered sensation related to lingual nerve sensory
disturbance and anatomical distribution of lingual
nerve were assessed by testing with a probe or
cotton wool. The primary focus of this study was
overall nerve damage and not a degree of sensory
deficient present, these patients with evidence of
sensory disturbance were reviewed every week
for one month.
Table 1: Indication for removal of wisdom
tooth
Figure 1: lingual nerve origin and
distribution (15)
PATIENTS AND METHODS
Subject: Fifty out patients male and female, ratio
1: 1.6 the mean age 23 years (range 20-26 years),
68(%) were suffering from bilateral fully
impacted wisdom teeth while remaining 32 (%)
patients had only one side of fully impacted third
molars, that means 84 third molars surgery were
carried out, most of them were in maxillofacial
Indication for removal of wisdom Number of
tooth
teeth
31
Asymptomatic (prophylactic cause)
8
Chronic periodontitis
Crowding of anterior teeth
45
(orthodontic cause)
Table 2: Types of angulation of impacted
tooth
Types of angulation of
impacted tooth
Distoangular impaction
Horizontal impaction
Mesioangular impaction
Vertical impaction
Number of
impacted tooth
7
6
40
31
Vol. 22(1), 2010
Figure 2: Sensory distribution of lingual
nerve; the shadow area indicates a typical
area of sensory loss resulting from damage to
the ipsilateral lingual nerve (18).
RESULTS
Eighty four lower third molar surgery for 50
patients male & female mean age 23 years. All the
patients treated under local anaesthesia. The
surgical procedures were performed on buccal
approach avoiding lingual split technique. The
finding 2 patients 2.8% have temporary sensory
disturbance in form of parasthesia of side of the
tongue as incidence of injury to lingual verve.
While no patient 0% of permanent of sensory
disturbance.
While the incidences of injury to lingual
nerve in form of permanent disturbance no case
was recorded 0%.
These 2 patients belong to group of horizontal
angulations impaction, the incidence of injury to
lingual nerve in this type of impaction of lower
third molar is 28%.
Other finding in this study
•
Sectioning of crown of impacted tooth 53
teeth 63%.
•
Bone removal from buccal and
buccodistally 76 teeth 90%.
•
Soft tissue reflection but no need for bone
removal 8 teeth 9.6%.
DISCUSSION
Previous studies have shown the incidence of
damage to the lingual nerve following mandibular
third molar surgery varied from 0% (19) to 23%
(20)
. The incidence of temporary nerve parasthesia
and permanent nerve dysfunction in our study are
in keeping with these studies. The incidence of
permanent damage of lingual nerve during third
molar surgery were to be found lower than the
incidence reported by Bataineh (21). The result of
this study is quiet consistent with the result of
Sisk et al. (22), but the finding of this study is not
consistent with Horch (5) who reported an
incidence of injury of lingual nerve 0.5%,
Incidence of injury
HOFFMEISTER(6)
0.04% in the primary
disturbance of lingual nerve but the study
consistent with the result of permanent disorder of
lingual nerve injury. Also the finding of this study
is fewer incidences than that finding by APPIAHANAAE (7) who give 11.5% as incidence of
reversible dysesthesia after mandibular tooth
surgery. Similar to result of this study was
reported by Blackburn (23) who stated that " most
studies of lingual nerve damage have shown an
incidence ranging from about 1 to 6 per cent
during surgical removal of lower third molars,
although a recent study found an incidence of 11
per cent (9). Root (24) estimated the incidence of
permanent lingual sensory deficit to be in the
region of one per cent while Blackburn &
Bramley (9) report an incidence of half a per cent.
Surgical factor is very important factor to
reduce the lingual nerve damage as this study
ensures, this is consistent with a number of studies
pointed to elevation of lingual flap as the most
important factor causing lingual nerve damage
(9,25)
. As well as the incidence of lingual nerve
injury can be reduced by good skill surgeons this
finding of this study is consistent with the finding
of McGurk(26) and Haskell that attempted recently
to rationalize the argument surrounding the
relationship of surgical technique and of operator
to lingual nerve morbidity during wisdom tooth
removal.
Specialists with an optimal skill base should
be able to use either technique as long as audit
shows that their performance is better than
currently published standards (25).
Previous studies have shown that such an
incidence may relate to the surgeon's experience,
improper use of the forceps and proper instrument
handling 12, this study is consistent with this
opinion that we can reduce the incidence of
lingual nerve injury during third molars surgery
through surgeon's experience and proper use of
forceps with proper instrument handling
especially drilling instruments as burr and
handpiece at lingual plate of impacted lower third
molar.
From an international standpoint, removal of
impacted third molar under local anaesthesia and
the willingness of purchasers to pay for it that
reducing the incidence of lingual nerve injury as
possible as can by help these factors; surgeon's
experience, surgery factors, and proper evaluation
of case.
REFERENCES
1.
Holzle FW, Wolff KD. Anatomic position of the
lingual nerve in the mandibular third molar region
with special consideration of the atrophic mandibular
Vol. 22(1), 2010
crest, an anatomical study. Int J Oral Maxillofacial
Surg 2001; 30: 333-8.
2.
Richard S, Sneel SR. Clinical anatomy. 7th ed.
Lippincot: Wiliams & Wilkins; 2004. p. 788.
3.
Kisselbacch JE, Chamberlain GC. Clinical and
anatomical observation o the relationship of the
lingual to the mandibular third molar. J Oral Surg
1984; 42: 565.
4.
Mozovy PG, Middleton RA. Microsurgical
reconstruction of the lingual nerve. J Oral Surg 1984;
42: 415.
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Horch HH. Iatrogen NervIasionen bei der
zahnarztl Miitt 1984; 7: 708-715. Cited by. Int J Oral
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6.
Hoffmeister B. Vverletzung des Nervus
lingualis-Eine klinische und tierexperimentelle
studie. Habilitaionsschriften der Zahn, Mund-und
kieferheikunde, Quintessenz Verlags-GmbH, Berlin
1989: 81-82. Cited by Int J Oral Maxillofac Surg
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APPIAH-ANANE S, APPIAH ANANE MG.
Protection of the lingual nerve during operations on
the mandibular third molar: a simple method. Br J
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Blackburn CW. A method of assessment in
cases of lingual nerve. Br J Oral Maxillofac Surg
1990; 28: 238-45.
9.
Blackburn CW, Bramley PA. Lingual nerve
damage associated with removal of lower third
molars. Br Dent J 1989; 167: 103-7.
10.
Yuasa H, Kawai T, Sugiura M. Classification of
surgical
difficulty in
extraction
impacted
third molar. Br J Oral maxillofacial Surg 2002; 40:
26-31.
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Benediktsdottir IS, Wenzel A, Petersen JK,
Hintz H. Mandibular third molar removal risk
indicators for extended operation time, postoperative
pain, and complications. Oral Surg Oral Med Oral
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Berge TI, Boe OE. Predictor evaluation of
postoperative morbidity after surgical removal of
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Swinson B, Hopper C. experience versus
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Med 2006: 2:14.
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Peterson LJ, Ellis E, Hupp JR, Tucker MR.
Contemporary Oral Maxillofacial Surgery. Principle
of management of impacted teeth; 3 th ed. MosbyYear Book; 1998. p. 226.
14.
Pell GJ, Gregory GT. Impacted mandibular third
molar; classification& modified technique for
removal. Dent Dig 1933; 39: 330. Cited by. Alling C
C. Helfrick JF, Alling RD. Impacted teeth. 1 th ed.
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Malamed S. Handbook of local anaesthesia. 3rd
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Azaz B, Shteyer A, Piamenta M. Radiographic
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Incidence of injury
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Bataineh AB. Sensory nerve impairment
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and lingual nerve damage. Br J Oral Maxillofac Surg
1998; 37: 253-54.
Vol. 22(1), 2010
The prevalence of root
The prevalence of root exposure and its relation to
mechanical tooth cleaning procedures
Fakhri A. Alkaisi, B.D.S, MSc.(1)
ABSTRACT
Background: Tooth root Exposure is the denudation of the tooth root surface due to apical movement of the gingiva
&it is a common clinical finding in adults. Prevalence of tooth root exposure related to mechanical oral hygiene
procedures was recorded and correlated to tooth brushing.
Materials and methods: 550 patients were involved in this study. Their ages range from 20 to 59 years. Root exposure
measurements & Oral hygiene status were examined,
Results: 31.47% of the cases exhibited root exposure of 0.5 mm or greater .The occurrence of root exposure was
.found to vary from 20.39% of all subjects in the (20-29 years) age group to 40.6% of the subjects in the (50-59 age
group. Root exposure increased in both numerical occurrence and linear dimensions with age. Males showed
greater exposure than females of the same age group; also exposure occurred most often on facial surfaces of
maxillary cuspids and bicuspids. Individuals with good oral hygiene showed greater exposure than those with poor
oral hygiene
Conclusions: The possibility of developing such lesions in gingiva should not prevent dental professionals from
recommending the mechanical method of supragingival plaque control measures (tooth brushing & inter dental
cleaning aids) by the proper instruction of the right technique of brushing that may not induce or increase an existing
recession.
Key words: Gingival recession, prevalence. J Bagh Coll Dentistry 2010; 22(1):62-64.
__________________________________________________
INTRODUCTION
Exposure of tooth root is defined as the
denudation of the tooth root surface due to apical
movement of the gingiva(1). It is a common clinical
finding in adults .Gingival lesions possibly caused by
tooth brushing may be classified in terms of three
groups:
lacerations,
gingival
recession
and
hyperplasia.
Laceration or ulceration of the gingival tissues is
usually recognized as an acute mechanical trauma,
where as gingival recession and hyperplasia are
thought to be characterizations of chronic lesions (1) .
A classification of gingival recession according to the
depth and width of gingival sulcus has been suggested
by Sullivan & atkins (2).
Morphologically, the gingiva may shows a clefts
(Stillman s cleft), festoon–like thickening of the
marginal gingival (McCalls festoon), and simple
retraction exposing the root surfaces (3).
It has been suggested that tooth–brushing lesions
on the gingiva are usually restricted to the facial
aspects of the dental arch, and are more pronounced
on the left side of the mouth (4).
Furthermore, the lesions seem to develop more
rapidly in the areas of cuspids and the premolars, and
the gingival covering of buccally malaligned teeth
than that in a lingual position.
(1) Lecturer, Department of periodontics,College of Dentistry,Bagdad
University Lecturer,*
Gorman stated that, mal positioned teeth and tooth
brushing trauma were the frequent etiologic factors of
gingival recession.(5).
Sangues & Gjermo (6) have reported the frequency
of different types of traumatic lesions in gingival
tissues .Kitchen (7) described the prevalence for tooth
root exposure in different age groups.
Since mechanical oral hygiene is emphasized in
modern preventive dentistry, so new and
comprehensive epidemiological studies on these topics
are needed, and data of gingival traumatism caused by
oral hygiene procedures are limited (6).
The purpose of the present investigation was to
study the prevalence of tooth root exposure among
patients attending the Oral Diagnosis Clinic, College
of Dentistry, and Baghdad University.
MATERIALS & METHODS
Five hundred and fifty patients attending Periodontic
Dept. College of Dentistry, Baghdad University during
the years 2004, 2005, 2006 were involved in this
study. Their ages range from 20 to 59 years (Table 1).
At least 4 teeth in each quadrant should be present
Table 1:Distribution of the subject materials
according to age.
Age group Male Female
Total
(Yr.) (No.) (No.)
70
64
134
20-29
76
69
145
30-39
60
65
125
40-49
89
57
146
50-59
295 255 550
Total
Vol. 22(1), 2010
50-59:146 patients of a total of a 1505 teeth examined
in this age group, 642 teeth exhibited root exposure
with a prevalence of 42.6%, which means that the
highest prevalence of tooth root exposure was found in
this age group (Table 3). If we consider the average
percentage of teeth that are free from any exposure in
this group, we found that only 39.8%in males and
46.1% in females, which means that this group
showed similar sex differences but to a lesser degree
(Table 4).
The number of examined patients was 247 with
fair oral hygiene, 119 of poor oral hygiene and 158
with good oral hygiene. 6 patients were not classified.
The oral hygiene level was better in males than that in
females in general.
Root exposure measurements:
Visible root exposure measurements from the
cemento-enamel junction to the gingival margin for
tooth at midlabial or midbuccal aspects. The
measuring was done with a graduated perio.prope and
as follow :
A. free from exposure .
B. 0.5 mm exposure .
C. I mm exposure .
D.1.5 mm exposure.
E. 2mm exposure.
F. 2.5 mm exposure .
G. 3 mm exposure .
H. more than 3 mm exposure.
Recessions in areas with a history of previous
periodontal surgery were excluded. The clinical
recordings were performed by a well –trained
periodontist.
Oral hygiene
The subjects were graded on the oral hygienic
basis into three: Poor, fair and good oral hygiene,
depending on the amount of dental plaque, calculus
debris and the condition of the gingiva. The
information concerning each patient were gathered on
a mimeograph from which it includes: patient name,
age, sex, educational level, use of tooth brush,
frequency of tooth brushing per day, medical history
and the location of recession on the teeth .
Table 2: Distribution of subjects with root
exposure related to tooth brushing in both sexes
and in different age groups
Total
Age
No.
Males Females Total
Exposure Prevalence
Groups
of
teeth
RESULTS
Age groups: (Table 2)
20-29: 134 patients (64 females and 70 males) which
had a total of 2424 teeth present were examined. Only
499 teeth showed visible tooth root exposure, which
was found largely of 0.5 mm type with some instance
of I mm, but very little in excess of that figure. The
prevalence of the cervical exposure was 20.39%.
Clinically visible root exposure was found more
frequently on facial surfaces of maxillary cuspids and
bicuspids.
30-39: 145 patients with a total of 2766 teeth were
examined, the teeth that showed exposure were 768
and the prevalence was equal 27.5%.The most
pronounced increase of exposure sites was from the
20-29 to the 30-39 age groups and this was especially
true for males .Tooth root exposure was found more
frequently on the maxillary facial surfaces of the
cuspids and bicuspids (Table 3). Males in this age
group had a greater frequency and extend of exposure
than females (Table 4).
40-49: 125 patients, the prevalence of root exposure in
this age group was found to be equal to 35.3% (Table
2).Gingival retraction was found more frequently on
the maxillary cuspids and bicuspide on the facial tooth
surfaces (Table 3). Males showed greater frequency
and extent of exposure (Table 4).
20-29
30-39
40-49
50-59
70
76
60
89
64
69
65
57
134
145
125
146
2424
2766
2135
1505
499
768
754
642
20.39%
27.50%
35.30%
42.60%
Total
295
255
550 8830
2663
31.46%
Table 3: Distribution of root exposure.
Age
groups
20-29
30-30
40-49
50-59
Number of teeth With visible root exposure
Cuspids&
Maxilla Mandible Incisors
Molar Facial lingual
Bicuspids
1988
961
227
1577
645 2425
28
1462
905
335
1049
881 2766
0
1147
993
555
1133
497 1981 154
758
748
417
698
390 1357 148
Table 4: Average percentage of all teeth free
from any cervical exposure.
20-29 30-39 40-49 50-59
Male 81.4% 54.9% 47.7% 39.8%
Females 88.1% 75.2% 53.1% 46.1%
Both 84.7% 65.05% 50.4% 44.5%
DISCUSSION
From the total of 8830 teeth examined 2663 or
32% showed root exposure of 0.5 mm or greater. The
individuals of all age groups had varying degree of
root exposure, this involvement ranged form 20.39%
in the first age group (20-29yr.) to 42.6%in the 50-59
yr age group. These findings agree generally with the
results of Kitchen (7) and Gorman (3) .
63
Vol. 22(1), 2010
4. Watson PJC. Gingival recession. J Dentistry 1984; 12: 29-35.
5. Klickman s I. The periodontium,Sounders Co. Philadelphia
2003; pp114.
6. Sangues G, Gjermo P. Prevalence of oral soft and hard tissue
lesions related to mechanical tooth cleaning procedures.
Comm Dent Epidemiol 1979; 7: 57-64.
7. Kitchen P. The prevalence of tooth exposure and the relation
of the extent of such exposure to the degree of abrasion in
different age classes. J Dent Res 1941; 20: 565-81.
8. Olery T, Drake RB, Grump PR. The incidence in young
males. A further study. J Periodontol 1971; 43: 264.
Kitchen also reported that females showed less
exposure than males within the same age groups. We
found the same result except in 1 age group (40-49
years). Gorman showed that gingival recession
increased with almost arithmetical progression with
age and it was slightly greater in males.
The average of gingival recession increased from
0.97 mm in the 16-25 yr. age group to 1.4 mm in the
46-86 yr. age group. In females the average midline
recession increased from 0.8 mm in the youngest age
group. The corresponding average increases in the
males were from I mm to 1.5 mm.
Although, the effect of oral hygiene were not fully
assessed in this study, subjects with good oral hygiene
showed greater overall exposure than those with poor
oral hygiene
The recording of the oral hygiene as good did not
necessarily imply that tooth brushing technique were
sound (5). Number of times that the patient brushes his
/her teeth and the gingiva daily ,was considered less
important to oral cleaning than the manner (technique)
in which it was achieved .
Besides better oral hygiene was found in male
group and such a finding is in agreement with the
observation of Sangues & Gjermo (6) .Another finding
in this study showed that root exposure occurred most
often on the maxillary teeth (56%). cuspids and
bicuspids (56%) and facial tooth surfaces (97%)
.These findings were in agreement with those carried
by many authors, like Gorman (3) ,Olery et al. (8) and
Kitchen (7).
The majority of subjects with cervical root
exposure in this study were not aware of the condition,
and only few of them suffered from sensitivity ,this
indicates that traumatism related to tooth brushing
procedures constitute only minor clinical problems.
The possibility of developing such lesions in
gingiva should not prevent dental professionals from
recommending
the
mechanical
method
of
supragingival plaque control measures (tooth brushing
& inter dental cleaning aids ) on the other methods
(5)
.This can be best achieved by the proper instruction
on the right technique of brushing that may not induce
or increase an existing recession .
However, researches on the specific etiological
factors involved in the development of various lesions
on the gingiva are desirable in order to reduce their
frequency and to minimize its severity.
REFERENCES
1. Sangues G. Traumatization of teeth and gingival related to
habitual tooth cleaning procedures. J Clin periodonton
1976; 3: 94-103.
2. Sullvan HC, Atkins JH. Free autogenous gingival graft. 3
Utilization of graft in the treatment of gingival recession.
Periodontic 1968; 6: 152-60.
3. Gorman WJ. Prevalence and etiology of recession. J
Periodontal 1967; 38: 316.
64
Vol. 22(1), 2010
Evaluation of salivary enzymes
Evaluation of salivary enzymes activities among patients
with chronic periodontitis
Mustafa J. Abdul-Hadi B.D.S. (1)
Khulood A. Alsafi B.D.S., M.Sc., Ph.D (2)
ABSTRACT
Background: The cells of periodontium contain many intracellular enzymes like (alkaline phosphatase ALP, aspartate
aminotransferase AST and alanine aminotransferase ALT) that are released outside into the saliva and gingival
crevicular fluid GCF after destruction of periodontal tissue during periodontitis. The aim of this study is to determine
the activities of these enzymes in saliva and its relation to the clinical periodontal parameters during chronic
periodontitis.
Materials and methods: Measurements of plaque index (PLI), gingival index (GI), bleeding on probing (BOP), probing
pocket depth (PPD) and clinical attachment level (CAL) were taken from sixty subjects (thirty with chronic
periodontitis and thirty with healthy periodontium), only male were included and saliva was collected from them and
subjected to biochemical analysis of the enzymes alkaline phosphatase ALP, aspartate aminotransferase AST and
alanine aminotransferase ALT levels.
Results: Statistical analysis of the results revealed the presence of a highly significant difference in the enzymatic
activity between healthy and chronic periodontitis subjects with absence of any correlation between the activities of
these enzymes and the clinical periodontal parameters except between alanine aminotransferase ALT and PLI
(Pvalue :0.049) and between alkaline phosphatase ALP and BOP (P value: 0.041).
Conclusions: It can be concluded that these enzymes are good biochemical markers and helpful in early diagnosis
of chronic periodontitis.
Key words: Saliva, enzymes, chronic periodontitis. J Bagh Coll Dentistry 2010; 22(1):65-67.
INTRODUCTION
Periodontal disease is one of the common
inflammatory diseases within complex etiology
and multifactorial in origin. Diagnosis of
periodontal disease has been primarily based upon
clinical and radiographic measures of periodontal
tissue destruction. These parameters provide
measures of past destruction and are of limited
use in early diagnosis (1). However, advances in
molecular biology and genetics are leading to a
better knowledge of the pathways and
mechanisms through which bacteria maintain the
host immune/inflammatory response (2). New
auxiliary diagnostic tools based on body fluids,
such as saliva and gingival crevicular fluid (GCF),
as well as studies of subgingival microflora and
genetic susceptibility, are useful and should be
further developed (3).
Saliva has been discussed lately as an
important biological material that introduces new
diagnostic tests which may contribute in the
diagnosis and explaining the pathogenesis of
many diseases (4).
(1) MSc student, department of periodontics, College of
Dentistry, Baghdad University.
(2) Professor, department of periodontics, College of Dentistry,
Baghdad University.
It has been extensively studied in relation to
periodontal disease because it is easily collected
and allows analysis of several local and/or
systemic biological markers such as proteins,
enzymes, host cells, hormones, bacterial products,
volatile components and ions (5). Saliva also
contains many enzymes and some inflammatory
markers. These enzymes in serum have been
routinely examined for screening of systemic
disease. Therefore, no specific laboratory devices
are necessary, and this approach may be suitable
for public health use (6-8).
Enzymes are biological catalysts that carry
out tightly controlled biological reactions with
high specificity. Like a chemical catalyst, an
enzyme acts by lowering the activation energy of
a reaction, thereby inducing the formation of the
products from the substrates(9) Intracellular
enzymes such as aspartate aminotransferase
(AST), alanine aminotranferase (ALT), lactate
dehydrogenase (LDH), acidic and alkaline
phosphatase (ACP and ALP) etc. are increasingly
released from the damaged cells of periodontal
tissues into the saliva (5).
Such AST, ALT and ALP can help to monitor
the progression of the periodontal disease. These
enzymes appear to be useful to test the activity of
periodontal disease (10). Due to these detectable
issues, therefore we decide to study the clinical
periodontal parameters and the biochemical
analysis of ALP, AST and ALT enzymes in saliva
Vol. 22(1), 2010
samples of patients with chronic periodontitis and
normal healthy gingiva persons.
Human sample
Sample population consisted of sixty
individuals; only males with an age ranged
between 25 to 45 years old. All individuals had no
history of systemic disease. The exclusion criteria
were including a course of anti-inflammatory or
antimicrobial therapy within the previous three
months, a history of regular use of mouth washes,
use of any vitamin supplementation, smoking,
mucosal lesions, chemotherapy, radiation therapy
and Medications that cause xerostomia.
The sample was divided into two groups. The
study group consisted of thirty males who
attended the Department of Periodontology of the
College of Dentistry at the University of Baghdad.
All subjects had chronic periodontitis based on
clinical examination. Chronic periodontitis in
patients was defined as the presence of teeth with
probing pocket depth >4mm with clinical
attachment loss, this was made according to the
international classification system for periodontal
disease in 1999 (11). The control group consisted
of 30 male. All of them had healthy periodontium
depending on the absence of clinical signs of
inflammation and using the traditional clinical
periodontal parameters.
Saliva samples collection
The study and control subjects were
instructed not to eat or drink for at least 1 hour
before collection of the sample. After that, the
subject rinsed his mouth several times with
distilled water and then waiting for 3 minutes for
water clearance. Then, each one of the study and
control groups’ subjects was asked to spit his
saliva into a polyethylene tube until 3-4ml was
collected. After that, the sample was put in a
cooling box to stop the growth of bacteria before
storing at -20 ˚C in the freezer.
Clinical examination
Collected data included assessment of plaque
index PLI (Silness and Loe in 1964), gingival
index GI (Loe and Silness 1963), bleeding on
probing BOP (Ainamo and Bay, 1975), probing
pocket depth PPD (Saiko et al, 2005) and clinical
attachment level CAL (Lindhe et al, 1998).
Biochemical analysis
For enzymes analysis we use kits
manufactured by BIOLABO SA which were used
routinely to measure the activities of ALP, AST
and ALT in serum. The activity of ALP was
determined by measuring its absorbance at 510
nm by the spectrophotometer, while the activities
of AST and ALT were determined by measuring
the
absorbance
at
505nm
by
the
spectrophotometer.
Statistical analysis
Descriptive statistics in the form of mean,
standard deviation and standard error and
inferential statistics in the form of Student t-test,
p-value, Pearson and Spearman correlation were
used in this study.
RESULTS
The results of this study showed that the
activities of the enzymes ALP. AST and ALT in
saliva samples of patients with chronic
periodontitis were higher in relation to the control
group (table 1).
Statistical analysis using the student t-test
revealed the presence of a highly significant
difference in the activities of these enzymes
between the study and the control groups (pvalue< 0.001).
Table 1: The means of ALP, AST and ALT
activities in IU/L in the study and the control
groups
Enzyme Study group Control group
ALP 33.021±5.1716 4.6235±0.657
AST 30.462±5.3709 20.103±4.1311
ALT 23.276±4.9059 15.406±4.1633
Regarding the correlation between the
activities of these enzymes with the clinical
periodontal parameters (PLI, GI, BOP, PPD and
CAL), this study revealed the absence of any
correlation
except
between
alanine
aminotransferase ALT and PLI (Pvalue: 0.049)
and between alkaline phosphatase ALP and BOP
(P value: 0.041).
DISCUSSION
A response of an organism to the periodontal
infection includes production of several
intracellular enzyme families which are released
from stromal, epithelial, inflammatory or bacterial
cells such as ALP, AST and ALT (12).
Alkaline Phosphatases are a group of
enzymes found primarily in the liver (isoenzyme
ALP-1) and bone (isoenzyme ALP-2) (13).
Salivary and serum ALP mean concentration was
shown to be positively correlated with periodontal
disease activity and is higher in individuals with
periodontal diseases than periodontally healthy
subjects (14). Our findings revealed that the level of
Alkaline Phosphatase ALP in the study group was
significantly higher than the control group. The
explanation for this difference in the enzyme
activity between the two groups may be due to the
Vol. 22(1), 2010
fact that ALP is present at or near the cell
membrane of alveolar bone osteoblasts and
fibroblasts of the PDLs (15-17). During the active
stages of periodotitis, there will be destruction of
alveolar bone osteoblasts and fibroblasts and their
cell membrane will be ruptured releasing their
intracellular contents outside. So ALP will be
released into saliva and GCF and the level of ALP
will increase in saliva (5, 10, 18).
AST is present in the liver and cardiac cells
and is most useful as a marker of liver or cardiac
injury (19), while ALT is especially concentrated in
the liver; it leaks out of the liver cell and increases
in the serum with liver damage, as in hepatitis and
mononucleosis (20). According to Kaufman and
Lamster in 2000 both of these enzymes are
increasingly released from the damaged cells of
inflamed periodontal tissue. This study revealed
the presence of a highly significant difference in
the enzymatic activity of AST and ALT between
the two groups. A possible explanation of this
difference in the enzyme activity of AST and
ALT between the two groups may be due to the
fact that significant AST and ALT levels have
also been found in human gingival epithelial cells,
human gingival fibroblasts and human periodontal
ligament fibroblasts i.e. the cells of the soft tissue
(21)
. During peroidontitis or gingivitis, the cells of
the soft tissue of periodontium become damaged
due to edema or destruction of the cell membrane
releasing their enzymatic contents into saliva and
gingival crevicular fluid GCF. So the activity of
AST and ALT will increase in saliva (22, 23).
Concerning the correlation between the
activities of these enzymes with the clinical
periodontal parameters, our study did not show
any correlation except between ALT with PLI and
between ALP with BOP, while other previous
studies show different correlations.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
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Vol. 22(1), 2010
The effect of food simulants
The effect of food simulants on corrosion of simulated fixed
orthodontic appliance
Afaf H. Hussien, B.D.S., M.Sc. (1)
Ausama Al-Mulla, B.D.S., Dr.D.Sc. (2)
ABSTRACT
Background: Fixed orthodontic appliances were considered as a source of human exposure to different elements used in
manufacturing of these appliances. Physical and chemical properties of food and liquids can affect the corrosion of
these appliances. This study was designed to determine the effect of dietary simulating liquids and artificial saliva on the
corrosion rate of fixed orthodontic appliances.
Materials and Methods: a seventy set of fixed orthodontic appliances (Ortho Technology, USA) each one simulated half
maxillary arch was used. These were divided in to seven groups according to the immersion solution: artificial saliva,
distilled water, 10% ethanol, 50% ethanol, 3% acetic acid, corn oil, and 1% citric acid, the immersion done at 37° for 28
days. The measurement of the released ions was done by using the Atomic Absorption Spectrophotometer and
Spectrophotometer. The orthodontic sets was Weighed before and after each immersion period.
Results: The results revealed that the higher amounts of ions were released on the first 7 days, and the higher levels of ions
were released in acidic solutions, and the least amount of the ions were released in corn oil and distilled water solutions.
The results of weighing the orthodontic sets revealed that all the appliances has a higher weight at the end of the study.,
Conclusion: The corrosion rate of orthodontic appliances increases with decreasing the PH of the solutions, and the
presence of oil decreases the corrosion rate of these appliances.
Key words: corrosion, food, ion release, ph. (J Bagh Coll Dentistry 2010; 22(1):68-75).
INTRODUCTION
Fixed orthodontic appliances usually include
brackets, bands, and archwires. Most orthodontic
bands, brackets, and archwires are made of stainless
steel containing 8% to 12% nickel, 17% to 22%
chromium, and various proportions of manganese,
copper, titanium, and iron (1-–3). The marked increase
of orthodontic treatment has drawn attention to
potential undesired effects (4).
In the oral environment, orthodontic appliances
are exposed to potentially damaging physical and
chemical agents which may cause metallic
corrosion. Factors such as quantity and quality of
saliva, salivary PH, plaque, the amount of protein in
the saliva, physical and chemical properties of foods
and liquids, and general and oral health conditions
may influence corrosion in the oral cavity.
Corrosion will occur continuously in the mouth, due
the release of ions with abrasion by foods, liquids
and tooth brush (3, 5–6).
Preparation of the orthodontic samples used in
the study
This study used seventy orthodontic sets. Each
set represents half average fixed orthodontic
(1) Master’s graduated student / Ministry of Health
(2) Professor, Department of Orthodontics, College of Dentistry,
Orthodontics, Pedodontics and Preventive Dentistry 68
appliance for the maxillary arch. Each appliance
consisted of five brackets, from second premolar to
central incisor, a molar band with double tubes and
a hook buccally and cleats lingually, and an
archwire tied to the brackets and band with metal
ligature wires. All materials used were made by
Ortho Technology (USA).
The archwire length was determined basing on a
standard cast, and it was found that it was about
5.8cm. The measurement was done from the
midline point anteriorly and extended 1.5 mm distal
to the first molar band tube posteriorly, the end of
the wire was bent posteriorly to prevent slippage of
the appliance during the experiments (7).
Each piece of the appliance was cleaned
ultrasonically with ethanol and acetone, rinsed with
distilled water and then dried in hot air (8–9). After
that, the components of each sample were gathered
and held securely to the 0.017 by 0.025 inch
stainless steel archwire. The ligation was done by
using 0.001 inch stainless steel ligature wires (7)
Figure 1.
No attempt was made to cover either the inner
surface of the bands or the bonding surface of the
brackets. This was done to eliminate the
introduction of any possible extraneous sources of
ions. In a clinical situation, the inner surface of
bands would be coated with a cementing medium,
and the mesh or bracket bases would be covered
with a composite bonding material. Therefore it
could be assumed that the surfaces available for
Vol. 22(1), 2010
biodegradation and metal release are approximately
double what would be available clinically (7, 10–11).
Figure 1: Orthodontic sample used in the
study
Preparation of Testing Solutions
The artificial saliva was prepared according to
modified Carter’s solution which is a modification
to the old one used by Gerdet and Hero in 1963 (12).
The PH of the artificial saliva was adjusted to (7+
0.2) to simulate the oral environment (the range of
normal saliva and dental plaque) (13). The
preparation of 10%ethanol, 50% ethanol, 3% acetic
acid, 1% citric acid was done according to C1V1=
C2V2 formula (14), then the PH of each solution was
measured using PH meter and is found it 5.7 + 0.2
for 10% ethanol, 5.5 + 0.2 for 50% ethanol, 2.9 +
0.2 for 3% acetic acid, 2.7 + 0.2 for 1% citric acid.
Immersion Procedure
Each set was placed in a glass container contain
30ml of artificial saliva or the chosen food simulant,
and held at the end of the archwire distal to the first
molar tube using dental floss in such a way that the
sample was fully immersed in the testing solution
without touching the walls of the container, each
container was closed by parafilm to control
evaporation. The glass containers were placed in the
incubator at 37°C for 28 days (7).
Weighing the Orthodontic Samples
Each orthodontic set was weighed before the
immersion in the testing solution and at the end of
each time interval using analytic balance device.
Each sample was weighed after they dried in hot air.
Estimation of Ions Concentration
The samples were collected after 7, 14, 21, and
28 days and replaced with fresh solution to avoid
saturation with the released ions during the
incubation period. Precautions were taken to avoid
contamination during sample preparation or from
reagents. So 2 ml of each solution was aspirated
using a mechanical micro-pipette and new pipette
tip at each time of measurement of each ion, the
aspirated solution was put in a new plane tube to
avoid any contamination.
The solution was analyzed for chromium,
nickel, and copper concentration using atomic
absorption spectrophotometer (Buck scientific,
210VGP, USA), and analyzed for iron
concentration using spectrophotometer (Cecil ce
7200, Japan) following standardized procedure.
Statistical Analysis
Data were collected and analyzed using SPSS
(statistical package of social science) software
version 15 for windows XP Chicago, USA which
include: descriptive statistics (mean, SD, minimum,
maximum), and inferential statistics (ANOVA test
and LSD test).
RESULTS AND DISCUSSION
It is virtually impossible to design an in vitro
experimental model that mimics the real-life
situation. This is why we chose to assay ion release
in extreme conditions which were much more
favorable to the corrosion of the orthodontic
appliances than those normally found in the oral
cavity (4). By using chemical methods, we studied
the corrosion through 28 days at 37°C which
represent the normal temperature of the oral cavity.
The Amount of Ion Release
The Effect of Time
Time was a significant factor in this study, as
seen from Table 1; figure 2, 3, 4, and 5, there was a
significant difference in the release of chromium,
nickel, copper and iron ion between the successive
time intervals in all the studied groups. Our results
showed the greatest release of ions during the first
week of the study, and gradual decline thereafter.
Figure 2: Mean distributions of Chromium–
ion (Cr) levels (µg/ml) in the related periods
for different studied group's Media
This cannot be ascribed to saturation of the
solution with metal ions because the solution was
Vol. 22(1), 2010
changed for every time period. Such decrease of
ions release can be explained by natural ability of
stainless steel of passivation, by the formation of a
film of chromium oxides that prevents corrosion in
many environments, when this protective film is
formed, the corrosion rate will be reduced (16–17).
For the chromium and nickel ions, the greatest
ion release occur during the first week of this study,
then there is a gradual decrease in ion release. This
kinetics of ion release coincides with the result of
several studies (5, 10–11, 18). Staffolani et al (4) found
that the largest daily ion release was noticed after
the first day of exposure to the solution. Also, AlJoboury (7) and Kuhta et al (2) found that the actual
reduction in the release occur after the 7th day
reaching several fold smaller values at the end
point.
1% C.A.
C Oil
3%A.A.
50% E
10% E
Dw
A.S.
Media
Table 1 Difference in ions release between two successive time intervals at different storage periods
Io
ns
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
Cr
Ni
C
u
Fe
ANOVA(d.f.=39)
F
p
63.698
51.835
0.000
0.000
LSD (p level)
7/14 14/21 21/28
day
day
day
0.000 0.021 0.000
0.000 0.007 0.097
105.992
0.000
0.000
0.002
0.000
49.804
23.587
39.298
0.000
0.000
0.000
0.000
0.002
0.000
0.156
0.017
0.014
0.084
0.035
0.014
93.564
0.000
0.131
0.000
0.003
22.177
69.435
301.200
0.000
0.000
0.000
0.001
0.000
0.000
0.018
0.000
0.000
0.200
0.281
0.030
1007.335
0.000
0.000
0.009
0.074
255.971
59.664
92.967
0.000
0.000
0.000
0.000
0.000
0.002
0.004
0.076
0.000
0.733
0.018
0.000
22.806
0.000
0.015
0.014
0.010
466.063
195.286
300.137
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.060
0.000
0.000
0.154
0.615
1301.560
0.000
0.000
0.000
0.000
861.956
42.047
35.306
0.000
0.000
0.000
0.000
0.000
0.075
0.000
0.342
0.000
0.000
0.570
0.002
31.209
0.000
0.055
0.271
0.000
156.064
144.435
314.477
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.003
0.007
0.036
383.178
0.000
0.000
0.000
0.000
686.330
0.000
0.000
0.000
0.000
The result clearly showed that the iron ion was
released at the higher level within the first week of
this study, and then progressively diminished in all
the studied groups. This result was in consistent
with the finding of Hwang et al (5) and by Kuhta et
al(2), and in contrast to Hassoon (18), whose result
showed that the release of iron ions increased as the
immersion time progressed.
Vol. 22(1), 2010
The higher level of the release of iron ion
compared with chromium and nickel seems to
comply with the abundance of the elements in the
alloy composition. This can be explained as iron is
the major component of the stainless steel, iron
oxide (Fe2O3) is not adherent, and because of the
low amount of chromium comparing with the high
amount of iron, it may not enough to produce such
strongly adherent passivating layer of chromium
oxide on the surface to prevent corrosion of iron (19).
The result showed a significant difference between
studied groups in the amount of ions released, table
2, and figure 2-5. The higher levels of ions
Figure 4: Mean distributions of Copper–ion
(Cu) levels (µg/ml) in the related periods for
different studied group's Media
Table 2: Difference in ions release in different
storage media during each storage period
(ANOVA test, p– values)
Figure 3: Mean distributions of Nickel–ion
(Ni) levels (µg/ml) in the related periods for
The finding of this study showed that large amount
of copper ion was released for two weeks with the
higher level in the first 7 days period, and then there
was a decreased in the level of released ion. This
result comes in accordance with Kuhta et al (2) who
reported that the greatest release of ions occur
during the first 7 days and a gradual decline
thereafter.
Most metal brackets are not cast or fabricated in one
piece. Instead, the wing and the base portion of the
metal bracket are connected by solder, which is
primarily comprised of Cu (6). The presence of
soldered joints however, has exacerbated corrosion
susceptibility since they have a tendency to emit
electro galvanic currents with saliva and
consequently release metal ions (5, 20).
The Effect of Food Simulants
This study emphasizes the importance of the
immersed solution on the release of metal ions from
fixed orthodontic appliances. Although the
quantities of released metal ions measured in this
study and other similar studies cannot be directly
applied to in vivo conditions, but they are useful for
relative comparisons and for determination of the
effect of each individual solution on ions release
without the influence of external factors.
Days
7
14
21
28
Ions
Cr
Ni
Cu
Fe
Cr
Ni
Cu
Fe
Cr
Ni
Cu
Fe
Cr
Ni
Cu
Fe
ANOVA
F
p
94.122
0.000
298.397 0.000
1089.205 0.000
654.484 0.000
96.611
0.000
213.285 0.000
490.303 0.000
275.655 0.000
38.497
0.000
30.008
0.000
277.877 0.000
61.802
0.000
21.906
0.000
30.193
0.000
83.331
0.000
35.803
0.000
were released in 1% citric acid group (PH= 2.7 +
0.2) and in 3% acetic acid group (PH=2.9+ 0.2)
followed by 10% ethanol (PH= 5.5+ 0.2) and 50%
ethanol (PH=5.7 + 0.2) groups, and then the
artificial saliva group (PH=7+ 0.2). The least
amount of ions was released in distilled water
(PH=8+ 0.2) and corn oil groups.
In the first week of this study which represents
the higher level of ions release, the LSD test
showed that there was no significant difference
between 1% citric acid and 3% acetic acid groups,
and between 10% ethanol and 50% ethanol groups,
and between corn oil and distilled water groups for
most of the measured ions (Table 3).
Vol. 22(1), 2010
Table 3: Difference in chromium ion release in different storage media during each storage period
(LSD test, p– values)
Media
A.S.
A.S.
A.S.
A.S.
A.S
A.S.
DW
DW
DW
DW
DW
10% E
10% E
10% E
10% E
50% E
50% E
50% E
3%A.A.
3%A.A.
C Oil
DW
10% E
50% E
3%A.A.
C Oil
1%C.A.
10% E
50% E
3%A.A.
C Oil
1%C.A.
50% E
3%A.A.
C Oil
1%C.A.
3%A.A.
C Oil
1%C.A.
C Oil
1%C.A.
1%C.A.
Cr
7
0.110
0.000
0.000
0.000
0.001
0.000
0.000
0.000
0.000
0.093
0.000
0.865
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.932
0.000
14
0.504
0.001
0.000
0.145
0.000
0.000
0.000
0.000
0.036
0.000
0.000
0.738
0.036
0.000
0.000
0.016
0.000
0.000
0.000
0.000
0.000
21
0.099
0.579
0.000
0.579
0.000
0.000
0.029
0.000
0.029
0.000
0.000
0.000
1.000
0.000
0.000
0.000
0.000
0.023
0.000
0.000
0.000
28
0.549
0.007
0.000
0.113
0.004
0.000
0.001
0.000
0.031
0.022
0.000
0.004
0.249
0.000
0.002
0.000
0.000
0.764
0.000
0.000
0.000
Table 4: Difference in nickel ion release in different storage media during each storage period (LSD
test, p– values)
Media
A.S.
A.S.
A.S.
A.S.
A.S
A.S.
DW
DW
DW
DW
DW
10% E
10% E
10% E
10% E
50% E
50% E
50% E
3%A.A.
3%A.A.
C Oil
DW
10% E
50% E
3%A.A.
C Oil
1%C.A.
10% E
50% E
3%A.A.
C Oil
1%C.A.
50% E
3%A.A.
C Oil
1%C.A.
3%A.A.
C Oil
1%C.A.
C Oil
1%C.A.
1%C.A.
Ni
7
0.023
0.000
0.000
0.000
0.015
0.000
0.000
0.000
0.000
0.869
0.000
0.239
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
14
0.091
0.000
0.000
0.000
0.807
0.000
0.000
0.000
0.000
0.146
0.000
0.000
0.465
0.000
0.000
0.005
0.000
0.000
0.000
0.000
0.000
21
0.141
0.324
0.000
0.012
0.553
0.000
0.621
0.000
0.000
0.374
0.000
0.000
0.001
0.692
0.000
0.002
0.000
0.009
0.002
0.000
0.000
28
0.012
0.037
0.255
0.000
0.063
0.000
0.647
0.000
0.000
0.493
0.000
0.002
0.000
0.819
0.000
0.002
0.003
0.000
0.000
0.001
0.000
Vol. 22(1), 2010
Table 5: Difference in copper ion release in different storage media during each storage period
(LSD test, p– values)
Media
A.S.
A.S.
A.S.
A.S.
A.S
A.S.
DW
DW
DW
DW
DW
10% E
10% E
10% E
10% E
50% E
50% E
50% E
3%A.A.
3%A.A.
C Oil
DW
10% E
50% E
3%A.A.
C Oil
1%C.A.
10% E
50% E
3%A.A.
C Oil
1%C.A.
50% E
3%A.A.
C Oil
1%C.A.
3%A.A.
C Oil
1%C.A.
C Oil
1%C.A.
1%C.A.
Cu
7
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.724
0.000
0.276
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.460
0.000
14
0.000
0.008
0.000
0.000
0.000
0.000
0.119
0.000
0.000
0.767
0.000
0.000
0.000
0.065
0.000
0.000
0.000
0.000
0.000
0.000
0.000
21
0.000
0.000
0.000
0.000
0.000
0.000
0.051
0.000
0.000
0.872
0.000
0.000
0.000
0.035
0.000
0.002
0.000
0.000
0.000
0.000
0.000
28
0.001
0.089
0.000
0.001
0.000
0.000
0.077
0.000
0.000
0.846
0.000
0.000
0.000
0.051
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Table 6: Difference in Iron ion release in different storage media during each storage period (LSD
test, p– values)
Media
A.S.
A.S.
A.S.
A.S.
A.S
A.S.
DW
DW
DW
DW
DW
10% E
10% E
10% E
10% E
50% E
50% E
50% E
3%A.A.
3%A.A.
C Oil
DW
10% E
50% E
3%A.A.
C Oil
1%C.A.
10% E
50% E
3%A.A.
C Oil
1%C.A.
50% E
3%A.A.
C Oil
1%C.A.
3%A.A.
C Oil
1%C.A.
C Oil
1%C.A.
1%C.A.
Fe
7
0.000
0.000
0.000
0.000
0.376
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.272
0.000
14
0.000
0.020
0.003
0.000
0.658
0.000
0.000
0.000
0.000
0.000
0.000
0.488
0.000
0.006
0.000
0.000
0.001
0.000
0.000
0.000
0.000
21
0.000
0.312
0.826
0.000
0.121
0.000
0.000
0.000
0.000
0.000
0.000
0.427
0.000
0.012
0.000
0.000
0.078
0.000
0.000
0.173
0.000
28
0.000
0.000
0.002
0.000
0.027
0.002
0.000
0.002
0.000
0.000
0.001
0.000
0.203
0.000
0.000
0.000
0.299
0.912
0.000
0.000
0.353
Vol. 22(1), 2010
function by strong adsorption and decrease the
attack by creating a barrier between the metal and
their environment (24–25) .
Weighing the Orthodontic Appliances
The result of this study as seen table 7 and
figure 6, showed that the weight of orthodontic sets
in all groups was increased after immersion in
testing media; this may be explained by adsorption
of ions from immersed media during the process of
oxide layer formation.
Figure 5: Mean distributions of Iron–ion (Fe)
levels (µg/ml) in the related periods for
So the levels of released ions were gradually
increased with decreasing solution PH. These
results agree with the finding of Staffolani et al (4)
and Kuhta et al (2). Also this finding also coming
with the result of Huang et al (6), Okazaki and Gotoh
(21)
, Elshahawy et al (19).This occurred because the
acidic condition provide a reducing environment in
which the stainless steel oxide film required for
corrosion resistance is less stable (3).While our
finding disagree with the result of Duffó and Farina
(22)
who showed that the aggressiveness of the
different liquids is independent on the PH of the
solution.
In this study the least amount of chromium,
nickel, copper ion release was demonstrated in the
corn oil group. This could be explained by the
formation of a thin layer of an ‘oily phase’ on the
metal surface. The oil adsorption to the metal
surface can be a result of physical adsorption,
chemical adsorption, or chemical reaction (23), so
instead of reacting with or removing an active
corrosive species, the filming corrosion inhibitor
Figure 6: Mean distributions of weight factor
in the related periods for different studied
group's Media
The result of LSD test showed no significant
difference on the weight of orthodontic sets between
the successive time intervals in the studied groups
except for 10% ethanol group. The greater increase
in the weight of the appliances after 7 days can be
explained by formation of oxide layer, so the release
of ions as seen in table 3 was greatly reduced after 7
days especially for copper ion.
Table 7: Difference in the weight between two successive time interval at different storage periods
(ANOVA test, LSD test, p– values)
ANOVA (d.f.
= 49)
F
p
1.375 0.258
AS
0.699 0.597
DW
10%E 10.180 0.000
50%E 1.369 0.260
3%AA 1.870 0.132
C Oil 7.770 0.000
1%CA 1.638 0.181
LSD (P level)
Media
0-7
0.363
0.761
0.000
0.091
0.649
0.069
0.531
7-14
0.952
0.247
0.000
0.861
0.211
0.095
0.673
14-21
0.773
0.496
0.677
0.973
0.501
0.940
0.179
21-28
0.304
0.774
0.000
0.554
0.150
0.140
0.322
Vol. 22(1), 2010
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release from new and recycled bracket-archwire
combinations. Angle Orthod 2005; 75(1): 92-4.
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Orthod 2009; 79(1): 102-10.
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7. Al-Joboury HM. The corrosion behavior and the
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department, College of Dentistry, University of Baghdad,
2001.
8. Huang HH, Chiu YH, Lee HT, Wu SC, Yang WH, Su
KH, Hsu CC. Ion release from NiTi orthodontic wires in
artificial saliva with various acidities. Biomaterials 2003;
24(20): 3585- 92.
9. Oh KT, Kim KN. Ion release and cytotoxicity of stainless
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10.
Park HY, Shearer TR. In vitro release of nickel
and chromium from simulated orthodontic appliances .
Am J Orthod 1983; 84(2): 156-9.
11.
Barrett RD, Bishara SE, Quinn JK. Biodegradation
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and chromium in vitro. Am J Orthod Dentofac Orthop
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Duffó GS, Quezada CE. Development of an
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behavior of dental alloys. Corrosion 2004; 60(6): 595-9.
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Ferriter JP, Meyers CE, Lorton L. The effect of
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Reed R, Holmes D, Weyers J, Jones A. Practical
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Fontana MG and Greene ND. Corrosion
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Lopez MF, Gutierrez A, Jimenez JA. The in vitro
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Juraga I, Śimunović V, Śpanićek. Contribution to
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Hassoon AA. Ions release from new and recycled
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Elshahawy W, Watanabe I, Koike M. Elemental
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Vahed A, Lachman N, Knutsen RD. Failure
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Okazaki Y and Gotoh E. Metal release from
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Duffó GS, Farina SB. Corrosion behavior of a
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Vol. 22(1), 2010
Effect of in-dental clinic
Effect of in-dental clinic bleaching agents on the releases of
mineral ions from the enamel surfaces in relation to their
times intervals.
Afnan AL-Shimmer B.D.S (1)
Mohammad Al-Casey B.D.S, M.PH., Ms,PH .(2)
ABSTRACT
Background: Alterations of the enamel after topical application of bleaching agents, presenting as major
consequences are: ions release, increased superficial roughness, stronger bacterial attachment and hardness
alteration. The aims of the study: To evaluate the effects of two different types of bleaching agents for vital teeth by
using with light source on the release of ions ( Calcium and phosphate ions ) from the enamel surface.
Materials and methods: Fifty three sound enamel surface for calcium ions release and Fifty three sound enamel
surface for phosphate ions, were subject to treated with bleaching agents ( 35% hydrogen peroxide and carbamide
peroxide ) and then application of light and laser radiation to activate the bleaching agents. Spectrophotometer
and Buck scientific atomic absorption spectrophotometer, were used to measure the ions release from enamel
surface.
Results: highly significant increase in the release of ions ( calcium ions ), while significant increase in the release of ions
(phosphate ions ) in relation to the times intervals.
Conclusions: In this study showed that release of calcium ions from enamel surface after treated with both 35%
carbamide peroxide and 35% hydrogen peroxide increase with increase the time and compared with release of
phosphate ions release and control groups.
Key word: Enamel surface, Ions release, Bleaching agents. J Bagh Coll Dentistry 2010; 22(1):76-78.
INTRODUCTION
In recent years, with more and more people
interested in cosmetic enhancement, the demand
of tooth bleaching is increasing sharply. Not only
conventional bleaching of non-vital teeth, the
needs for bleaching of vital teeth is also increase
(1)
Tooth bleaching can be performed externally,
termed vital tooth bleaching (2) various methods
and bleaching chemicals have been used
extracoronally
on
teeth
with
vital
pulps(3)Bleaching systems that act by means of
strong oxidizers are mostly used for brightening
of teeth. Depending on the form of application,
the concentrations lie between 10-35% peroxide.
In particular, 35% concentrated hydrogen
peroxide or carbamide peroxide are used. The
action mechanism is based on oxidative
discoloration of incorporated colorants. However,
strong oxidizers also degrade structure-relevant in
the enamel (4). The most popular technique for the
in-office bleaching of vital teeth involves 35%
hydrogen peroxide, with phosphoric acid to
facilitate bleaching and etching the teeth either a
heating element or a light source to enhance the
action of the peroxide (5). The use of optical
radiation in the so called light assisted tooth
bleaching procedure has been suggested to
enhance effect of the bleaching agent (6) .
(1) MSc student, Department of preventive dentistry, College of
(2) Professor, Department of preventive dentistry, College of
Orthodontics, Pedodontics and Preventive Dentistry76
Many authors have demonstrated alterations
of the enamel after topical application of
bleaching
agents,
presenting
as
major
consequences are: ions release, increased
superficial
roughness,
stronger
bacterial
attachment, hardness alteration, color alteration,
and adhesion to resinous materials (7) . Research
in this area has showed penetration easily the
hydrogen peroxide, because of its low molecular
weight, passes through the enamel and dentin to
the pulp(8).
One hundred six non carious maxillary first
premolar teeth extracted for orthodontic purpose.
Teeth were fixed in temporary state in an auto
polymerizing resin base (cold cure resin) and
became ready for application. The bleaching
process was done according to manufacturers
instruction and this done by using a disposable
brush to paint the totally cover the surface of the
tooth and the time of application is 8 min and
each sample three times application of pola office
gel, each samples exposure to 40 second a curing
light machine and Laser unit used for this study is
continuous power (CW ) Nd-YAG laser for
exposure to the bleaching agent This step was
repeated for four times for each sample as
recommended by the manufacturers instructions
Then the samples were washed using a continuous
jet of syringe for one minute to dissolve the
bleaching agent on the tooth surface and dried
Vol. 22(1), 2010
with air syringe for 30 seconds. Then storages in
10ml of de-ionized water in sterilized glass
container and returned to incubator in 37Ċ until
the time of testing.
Essential elements release from sample in deionized water were analyzed at the poisoning
consultation centre /specialized surgeries hospital
by using Buck scientific atomic absorption
spectrophotometer
following
standardized
procedure.
demineralization (loss of mineral) result in
decreased the enamel microhardness.
This may be due to higher concentration of
peroxide and formed free radical is higher from
laser than from halogen light, so causes more
demineralization to the enamel (Loss of calcium
ions). This result agree with some study (10,11),
concluded that 35% HP with light may cause
significantly more loss of Ca+2 from the enamel
surfaces than lower concentration CP.
RESULTS
Table 1: Descriptive statistics of ions release
from enamel surface of all groups in ppm.
DISCUSSION
It is obvious from the results of this study the
enamel surface when treated with 35% hydrogen
peroxide gel and activated with the halogen light
resulted in marked increase in the means of
release of calcium ions at the 96hrs, in compared
to the control groups. While result found, when
treated with 35% hydrogen peroxide gel and
activated with the laser irradiation for the same
period of time (96hrs.), found the means is higher
than that of halogen light and also much higher in
compared to control.
This adverse effect of bleaching on the enamel
mineral (ions) was noted by many researches,
may be due to the concentration or type of the
bleaching agent used, this agree with the many
study (9), showed that after treatment bleaching
with high concentration of hydrogen peroxide,
Groups
Light
cure
Laser
radiation
Light
cure.
35%
35%CP 35%CP
H.P
Control
group
Laser
Radiation
35%
H.P
For statistical analysis was used in this study:
means and standard deviation values of ions
release from enamel surface that activated by two
different light sources and for all groups are listed
in table 1. The data revealed that there was
increase in ions release values for the sound
enamel surface over the time for all the groups
and after bleaching with both 35% carbamide
peroxide and 35% hydrogen peroxide. Statistical
analysis of data by using ANOVA test show in
table 2 revealed that there was a non- significant
difference (P>0.05) among the control groups,
while highly significant difference (P<0.0001)
among when use light source ( halogen light ) and
also highly significant difference (P<0.0001)
among the different groups when use light source
(laser light) at different period of times for the
release of calcium ions, while for the phosphate
ions show in the table 3 revealed that there was a
non-significant difference (P>0.05) among the
control groups, while highly significant difference
(P<0.001) among the different groups when
bleaching is done using light source (halogen
light) and also highly significant difference
(P<0.001) among the different groups when use
light source (laser light) at different period of
times.
Calcium ions
Times Mean SD
48hrs 0.248 0.029
72hrs 0.277 0.046
96hrs 0.335 0.0102
48hrs 0.462 0.157
72hrs 3.181 0.480
96hrs 4.937 0.520
48hrs 0.318 0.260
72hrs 2.303 0.322
96hrs 3.287 0.414
48hrs 2.462 0.343
72hrs 3.486 0.311
96hrs 4.328 0.285
48hrs 0.711 0.079
72hrs 2.641 0.312
96hrs 3.824 0.555
Phosphate
ions
Mean SD
0.248 0.0295
0.277 0.0466
0.335 0.0102
0.659 0.020
2.366 0.273
4.135 0.735
0.588 0.078
1.716 0.194
2.414 0.664
0.791 0.040
1.409 0.094
2.711 0.235
0.265 0.060
1.378 0.122
1.840 0.103
Table 2: ANOVA test for release of ions
(calcium ions) from enamel surface at
different period of time when activated with
laser light and halogen light .
Agents
df F-test P-values Sig
2 7.450 .012 NS
control
35%H.P
2 35.323 .000 HS**
Act. With laser
35%H.P
2 71.868 .000 HS*
Act. With light
Table 3: ANOVA test for release of ions (
phosphate ions ) from enamel surface at
different period of time when activated with
laser light and halogen light .
Agents
df F-test P-values
2 7.450
.012
control
35%H.P
2 174.887 .000
Act. With laser
35%H.P
2 269.106 .000
Act. With light
Sig
NS
HS**
HS*
HS = Highly significant different ( p< 0.0001).
NS = Non signifiant different ( p>0.005 ).
Vol. 22(1), 2010
The treatment with carbamide peroxide and
activated with laser and halogen light show in the
revealed highly significant different ( P< 0.001 )
for both light source this may be indicated
changes in the enamel crystal composition and
alter enamel structure the result agree with other
research (12-14), show that bleaching with hydrogen
peroxide or hydrogen peroxide releasing agents
may result in significant decrease of enamel
calcium and phosphate content and morphological
alteration in the most superficial enamel
crystallites. In this study show that carbamide
peroxide causes local microstructure and chemical
changes, such as loss phosphate ions, as show in
the ANOVA table, represent highly significant
different between the group at three period of time
for the two activation used (Halogen light and
laser radiation) This indication alteration in the
composition of enamel these result agree with
other result showed that in-office bleaching
caused deleterious alterations in the composition
and structure of enamel that significantly affected
the crystalline and mineralization of the tissue(15) .
In this study showed that the means of release the
calcium ions from sound enamel surface are
higher than the phosphate ions as showed in the
table 1. This is may be due to the concentration of
the calcium ions is higher than the phosphate ions
in the enamel surface of permanent teeth, this
result agree with many study(16, 17), Calcium ions
followed by phosphorus ion were the major
elements in enamel sample.
REFERENCES
1. Rodrigo A, Jose R, Hugo H, Luiz T, Rodrigo C. Effect
of hydrogen peroxide topical application on the enamel
and composite resin surfaces and interface Indian J
Dental Res 2009; 20(1): 65-70.
2. Watt A, Addy M. Tooth discoloration and staining a
review of literature. Br Dent J 2001; 190(6): 309-16.
3. Goldstein R, Garber D. Complete dental bleaching.
1sted Chicago Quintessence Publishing Co Iinc.1995.ch.
1,2.
4. Nakamura T, Saito O, Kong T, Maruyama T. The
effects of polishing and bleaching on the colour of
discolored teeth in vivo. J Oral Rehab 2002; 28: 1080-4.
5. Goldstein R, Haywood B. Bleaching teeth: new
materials-new role. J Am Dent Assoc. Quintessence Int,
1992; 23: 471-88.
6. Bruzell E, Johnsen B, Alerud T, Dahl J, Christensen T.
In vitro efficacy and risk for adverse effect of light
assisted tooth bleaching photochemical Photo biological
Sci. Dental Material 2009; 8(13): 377-85.
7. Rotstein I, Dankner E, Goldman A, Heling I, Stabholtz
A, Zalkind M. Histochemical analysis of dental hard
tissues following bleaching. J Endod 1996; 22: 23-5.
8. Oltu U, Gürgan S. Effects of three concentrations of
carbamide peroxide on the structure of enamel. J Oral
Rehabil 2000; 27: 332–40.
9. Pinto C, Oliveira D, Cavalla V, Giannini M. Peroxide
bleaching agents effects on enamel surface
micohardness, roughness and morphology. J Braz Oral
Res 2004; 18(4): 306-11.
10.
Hüseyin T, Ozlem S, Ferit O, Hande D, Ziya O.
Effect of bleaching agents on calcium loss from the
enamel surface. Quintessence Int 2007; 38 (4): 339-471.
11.
Bowles W, Ugwuneri Z. Pulp chamber
penetration by hydrogen peroxide following vital
bleaching procedures. J Endod 2001; 8: 375-7.
12.
Basting R, Rodrigues A, Serra M. The effect of
10% carbamide peroxide, carbopol and/or glycerin on
enamel and dentin microhardness. Oper Dent 2005;
30(5): 608-16.
13.
Lee K, Kim K, Kwon Y. Mineral loss from
bovine enamel by a 30% hydrogen peroxide solution. J
Oral Rehabil 2006; 33(3): 229-33.
14.
Fu B, Hoth-Hannig W, Hannig M. Effect of
dental bleaching on micro and macro-morphological
alteration of the enamel surface. Am J Dent 2007;
20(1): 35-40.
15.
Severcan F, Gokduman K, Dogan A, Bolay S,
Gokalp S. Effects of in-office and at home bleaching on
human enamel and dentin: an in vitro application of
fourier transform infrared study. Department of
Biology. Appl Spectro Sc 2008; 62(11): 1274-9.
16.
Haitham G. Concentration of major and trace
elements in permanent teeth and enamel among ( 11-14
) years old children in relation to dental caries. A thesis
submitted to the college of dentistry university of
Baghdad. 2005.
17.
Justino L, Tames D, Demarco F. In situ and in
vitro effect of bleaching with carbamide peroxide on
human enamel. J Oper Dent 2007; 29(2): 219-25.
Vol. 22(1), 2010
The effect of glucocorticosteroid
The effect of glucocorticosteroid medication on
orthodontically induced root resorption
(An experimental study on rats)
Haraa S. AL-Shaibany BDS, MSc (1)
Nidhal H. Ghaib BDS, MSc (2)
ABSTRACT
Background: Many patients use drugs on a daily basis, and all these drugs have therapeutic effects, as well as side effects
that may influence the cells targeted by orthodontic forces. The aim of this study was to investigate the effect of different
courses of glucocorticosteroid treatment on orthodontically induaced root resorption.
Materials and method: A 'Split- mouth design performing orthodontic tooth movement in 30 male Wistar albino rats divided
into three groups: control (n = 10), acute (n = 10) and chronic (n = 10). Acute and chronic groups received corticosteroid
treatment (5 mg/kg/day of methylprednisolone) for 3 and 7 weeks, respectively, while no pharmacological treatment was
performed in the control group. The upper right 1st molar was moved mesially for 21 days in all three groups with a closingcoil spring delivering 20 g of force to cause orthodontic tooth movement by means of fixed orthodontic appliance. A
histopathological based assessment method for the percentage of root resorption was performed at the coronal and apical
level on both compression and tension sites of the non-appliance and appliance sides.
Results: The results revealed that the acute group showed significantly more root resorption at the compession-coronal level
compared with the control and the chronic course group.
Conclusion: The percentage of root resorption is increased significantly in steroid treated groups compared to control group,
therefore; steroid administration will influence the occurrence of root resorption.
Key words: Glucocoricosteroid; orthodontics; rats; root resorption. J Bagh Coll Dentistry 2010; 22(1):79-82.
INTRODUCTION
that could possibly affect bone metabolism (6).
Corticosteroids are a class of steroid hormones,
produced in the adrenal cortex. They are involved in
many physiologic systems, such as stress response,
inflammatory and immune responses, carbohydrate
metabolism, protein catabolism, and blood electrolyte
levels. Corticosteroids are commonly used to treat
many different diseases because of their antiinflammatory effect. Allergy, asthma, dermatitis and
eczema are all diseases with high incidence and
rapidly increasing prevalence commonly treated with
corticosteroids (7).
This high prevalence and the increasing evidence
of systemic effects of most forms of steroid
treatment, stress the need for a better understanding
of the consequences in relation to orthodontic
treatment. In the present study the effect of shortterm and long-term administration of therapeutic
dosages of corticosteroid on orthodontically induced
root resorption was investigated experimentally on
rat model.
Root resorption is a physiologic or a pathologic
process resulting in the loss of cementum and dentin.
Root resorption is a common, but unavoidable,
adverse reaction to orthodontic tooth movement (1).
The exact etiology of root resorption is unknown, but
most likely it is a multifactorial problem involving
genetic predisposition, environmental factors related
to the morphology of the roots, and orthodontic
treatment-related issues (2). Numerous potential
factors, related to both the individual patient and to
treatment, have been suggested as risk factors for root
resorption, but direct causal factors have not been
identified(3). This lack of consistent findings has led
to the recent suggestion of a different approach to the
analysis of the problem, where the primary effect is
studied among patient factors rather than among
treatment variables. Among the patient-related
factors, recent investigations have examined the role
of genetics, the immune system and the patient’s
medical history (4).
It has been shown that
orthodontic tooth movement can be influenced by
general and local pharmacological modulation,
patients requiring orthodontic treatment can be
anticipated to present variations from normal bone
turnover due to metabolic disease or medication, e.g.
steroid treatment of allergies(5).
Orthodontic patients may be affected by systemic
diseases that need medical treatment with drugs
MATERIALS AND METHOD
Laboratory animals. Thirty adult male Wistar
albino rats, weighing (220-320g) aged 12 weeks were
used for this experiment. The rats were kept in the
animal department of (National Center for Drug
Control and Research/Baghdad-IRAQ) in separate
cages in a 12:12 hour light/dark environment at a
constant humidity and temperature of 23°C according
to the National Research Council’s guide for the care
and use of laboratory animals and accessed to
drinking water ad libitum and standard laboratory rat
(1) MSc student, Orthodontic Department, College of Dentistry,
(2) Professor, Orthodontic Department, College of Dentistry,
Orthodontics, Pedodontics and Preventive Dentistry
79
Vol. 22(1), 2010
pellets. According to the pharmacological treatment
(8)
, the rats were randomly divided into three groups:
Group І: a control group (n = 10) without any
pharmacological treatment but received orthodontic
treatment for 3 weeks (week 1–3).
Group ІІ: an acute group (n = 10) received
Methylprednisolone and orthodontic treatment
simultaneously for 3 weeks (week 1–3).
Group ІІІ: a chronic group (n = 10) received
Methylprednisolone For 7 weeks (week 1–7) and
orthodontic treatment for the last 3 weeks (week 5–
7), as shown in Figure 1.
The experimental groups received 5 mg/kg/day of
methylprednisolone
(Solu-medrol;
Pharmacia
NV/SA, Puurs-Belgium) intramuscularly every 24
hrs for the prescribed number of days (9).
closing-coil spring of fixed orthodontic appliance
was delivering a total orthodontic force of 20 g for
mesial traction of maxillary 1st molar was measured
by pressure-gauge (CORBLX, Dentarum, Germany).
As the closing-coil spring was being attached to the
ligature wire, the end of the ligature wire had been
carefully adapted toward the distal grooves by using
Adam's plier. In order to avoid any mechanical
trauma from the appliance to the surrounding oral
tissues and to ensure maximum stability of the
appliance, a light-cured filling composite material
was added to the maxillary incisors. The appliance
was checked weekly to ensure any loose or damage
to the appliance. Consequently a mesially directed
orthodontic force to the maxillary 1st molar with the
incisors were used as anchorage teeth resulted in
mesial traction of the 1st molar and space creation
between the 1st and 2nd molar teeth.
According to Ren et al (10) to limit the influence of
inter-animal variation in response to metabolic
stimuli, a split-mouth design was used as the right
side served as the appliance side and the left side
served as the non-appliance side, as shown in Figure
2. At the end of treatment for each group the rats
were sacrificed and the maxillae were excised.
Figure 1: Flow diagram illustration the
treatment of the rats in the experimental
groups.
Placement of orthodontic appliance. The appliance
was inserted under general anaesthesia, induced by
an intramuscular injection of a mixture of ketamine
(90 mg/kg body weight) and xylazine (10mg/kg body
weight). Orthodontic tooth movement was generated
by the insertion of a stainless steel ligature-wire with
a diameter of 0.009" and 4mm in length interdentally
between the 1st and 2nd maxillary molars, which
looped around the cervical part of the 1st molar. It
was ligated tightly to ensure maximum stabilization
of the wire to which a closing-coil spring (9 mm in
length, Dentaurum, Germany) was attached, and the
end of the wire was bent carefully toward the buccal
surface of the tooth by double ended-ligature tucker
to avoid any mechanical trauma to the surrounding
oral tissues and the slippage of the coil. To
compensate the conical shape of the rats' incisors and
subsequently prevent the slippage of the wire as well
as the appliance, a TEC-TORQUE, angled hand piece
(W&H-Austria) with an inverted-cone bur was used
to make grooves cervically on the disto-labial
surfaces of both maxillary incisors to which another
preformed stainless steel ligature wire, with a
diameter of 0.009" and 5 mm length, was looped. The
ligature wire ligated tightly to which the other end of
the closing-coil spring was attached, so that the
Figure 2: Orthodontic fixed appliance in situ.
Evaluating the percentage of root resorption. On the
eight H&E stained sections of each group, percentage
of root resorption were determined. On the magnified
(x120), areas for measurement in the non-appliance
side were the mesial and distal aspects of the mesial
root of maxillary 1st molars, corresponding to
compression and tension sites, respectively, in the
appliance side at both coronal and apical levels. A
transparent sheet with 10 x 10-mm grids was
superimposed and the numbers of grids with or
without resorption lacunae were counted separately.
Root resorption (percentage of resorption grids) was
determined by dividing the number of grids with
resorption lacunae by the total number of grids along
the root surface. Percentage of Root resorption =
(number of girds containing resorbed lacunae/total
number of grids) x100(11).
RESULTS
The percentage of root resorption was in general
larger on the appliance side than on the nonappliance side in all three groups, as shown in Table
1&2. Steroid administration influenced the
80
Vol. 22(1), 2010
occurrence of root resorption. The acute group
showed significantly more root resorption at the
compression-coronal level than that in the chronic
and the control groups (Figure 3).
Table 1: The difference in mean of percentage of root
resorption on the non-appliance side at different sites
and levels between 3 studied groups.
Coronal
Apical
Coronal
Apical
Tension
Compression
Site Level Variables
Range
Mean
SD
SE
N
Range
Mean
SD
SE
N
Range
Mean
SD
SE
N
Range
Mean
SD
SE
N
Studied Groups
ANOVA
Control Acute Chronic
1.3-2.1 2.7-3.6 1.6-2.9
1.67
3.1
2.41
0.29
0.32
0.44 < 0.001
0.1
0.11
0.16
8
8
8
0.7-1.4 1.9-2.7 1.5-2.4
1.06
2.28
1.81
< 0.001
0.3
0.3
0.3
0.09
0.11
0.11
8
8
8
0.4-1.4 1-2.2 0.8-1.7
0.98
1.57
1.43
= 0.009
0.4
0.3
0.4
0.14
0.1
0.14
8
8
8
0-0.3 0.9-1.7 0.9-1.2
0.14
1.35
1.12
< 0.001
0.1
0.1
0.2
0.03
0.04
0.09
8
8
8
Sig.
Figure 3: Microphotograph view for cross
section to 1st molar rat tooth in the acute group
(appliance side) showing highly obvious root
resorption in the Mesial root (MR) at
Compression site (C) compared to Tension site
(T), H & E ×100.
HS
DISCUSSION
HS
The percentage of root resorption on the nonappliance side is in general greater in the steroid
treated groups compared to the control group. This
increase is due to the fact that steroid treatments
affect on the mineralized tissues of the body in many
ways, they adversely affect on the bone remodeling
cycle (lack balance between bone formation and bone
resorption) that results in different bone turnover
rates between steroid treated groups.
Root resorption is a common, undesirable and the
least predictable sequelae of orthodontic treatment, in
this experimental study the results indicate that
orthodontic treatment cause an increase in the
percentage of root resorption in all three groups, and
the appliance side has significantly more root
resorption compared to non-appliance side in all
groups.
As in the non-appliance side, the higher
percentage of root resorption on the appliance side is
greater in the steroid treated groups compared to
control group. This increase indicates that the
pharmacological treatment adversely affecting the
occurrence of orthodontically induced root
resorption. This may be attributed to the fact that in
addition to the effect of steroid treatment on bone
metabolism as shown on the non-appliance side with
the presence of mechanical loading on the appliance
side that produce an adjunctive effect on the
percentage of root resorption in steroid treated groups
compared to control group.
The acute group showed significantly more root
resorption at the appliance side compared with the
chronic and the control group. While the chronic
group showed slight increase in the percentage of
root resorption compared to the control group. This
increase in the acute group is due to the effect of
steroid treatment on changing the effect of
orthodontic appliance on the percentage of root
resorption resulting from imbalance in bone
metabolism occurring in the initial phase of drug
administration (as shown in non-appliance side) with
higher hyalinization, which could aggravate the
HS
HS
Table 2: The difference in mean of percentage of
root resorption on the appliance side at different
sites and levels between 3 studied groups.
Site Level Variables
Coronal
Mean
SD
SE
N
Coronal
Apical
Range
Apical
Tension
Compression
Range
Mean
SD
SE
N
Range
Mean
SD
SE
N
Range
Mean
SD
SE
N
Studied Groups
ANOVA Sig.
Control Acute Chronic
16.66-7.6
7.1-9.6
20.5
6.96 18.48 8.55
< 0.001 HS
0.5
1.2
0.8
0.19
0.44
0.28
8
8
8
122.2-3.2
4.7-6.3
15.6
2.71
13.8
5.57
< 0.001 HS
0.3
1.2
0.5
0.12
0.43
0.18
8
8
8
2.2-3.4 5.8-7.2 2.3-3.8
2.55
6.49
3.11
< 0.001 HS
0.5
0.5
0.6
0.16
0.19
0.22
8
8
8
1-1.9 3.8-5
1-2
1.46
4.42
1.54
< 0.001 HS
0.3
0.4
0.4
0.11
0.15
0.12
8
8
8
81
Vol. 22(1), 2010
occurrence of orthodontically induced root resorption
compared to control group. This is consistent with the
finding of Verna et al (12) where a positive association
between imbalance in bone metabolism and root
resorption induced by orthodontic treatment was
found. It can thus be suggested that in clinical
situations where turnover of alveolar bone is
enhanced or unchanged due to drug administration,
root surfaces could already be affected by root
resorption as a baseline condition.
In the chronic group which showed less root
resorption compared to the acute group is due to
faster remodeling of bone (high bone turnover rate)
that have been reached during the first 4 weeks of
drug administration preceding the appliance insertion
with less hyalinization, the result is thus leading to
less remodeling of root tissues. Therefore, such a
state could slightly increase or unchanged the
occurrence of orthodontically induced root resorption
compared to control group. This is in accordance
with previous investigations of Midgett et al (13);
Goldie and King (14) that did not find increased
amounts of root resorption in animals with increased
bone turnover. The protective effect against root
resorption observed by Poumpros et al (15) was not
confirmed by the results of the present study, as the
rats with high bone turnover did not display less root
resorption than those with low bone turnover.
The percentage of root resorption at the coronal
level is higher than that in the apical level in the three
studied groups. The localization of root resorption at
the coronal level is consistent with studies performed
by King et al (16); Ballard et al (17) showing that the
coronal level is the area that undergoes the largest
changes after the application of a tipping force.
However, these findings are in controversy to a study
performed by Verna et al (6) showed no difference in
changes
between
compression-coronal
and
compression-apical sites after the application of
controlled-tipping force. The lack of a higher results
at the apex compared to coronal level could be
ascribed to a larger concentration of stress at the
coronal than at the apical level due to the type of
tooth movement achieved(18). Another possible
explanation could be the difference in root anatomy
at the apical and coronal level. At the apical level, the
root was smaller, more irregular and decreased in size
very rapidly close to the apex. In this situation, a
slight deviation of the cutting plane will have a larger
effect at the coronal level.
Clinical Consideration
Increased amount of root resorption can be
expected in patients using short-term corticosteroid.
As asthma and other allergic symptoms are in fact
often treated in an acute manner and for shorter
periods of time, therefore; the orthodontist need to be
particularly aware of the increased risk of root
resorption in this group of patients. The clinical
consequences could be to induce a passive treatment
phase during the periods where steroids are
administered. Increased frequency of radiographs to
control for root resorption may also be indicated,
especially in patients who for other reasons are prone
to root resorption.
REFERENCES
1.
Talic NF, Evans C, Zaki AM. Inhibition of
orthodontically induced root resorption with echistatin, an RGDcontaining peptide. Am J Orthod Dentofacial Orthop 2006; Feb:
129 (2): 252-60.
2.
Abass SK, Hartsfield J. Orthodontics and external
apical root resorption. Semin Orthod 2007; 13 (4): 246-56.
3.
Abuabara A. Biomechanical aspects of external root
resorption in orthodontic therapy. Med Oral Patol Oral Cir Bucal
2007; Dec: 12(8): E610-3.
4.
Lopatiene K, Dumbravaite A. Risk factors of root
resorption after orthodontic treatment. Stomatologija, Baltic
Dent Maxillofac J 2008; 10 (3): 89-95.
5.
Bartzela T, Türp JC, Motschall E, Maltha JC.
Medication effects on the rate of orthodontic tooth movement: A
systematic literature review. Am J Orthod Dentofacial Orthop
2009; Jan: 135 (1): 16-26.
6.
Verna C, Dalstra M, Melsen B. The rate and the type
of orthodontic tooth movement is influenced by bone turnover in
a rat model. Eur J Orthod 2000; Aug: 22 (4): 343-52.
7.
Angeli A, Dovio A, Sartori M, Masera RG, Ceoloni B,
Prolo P, Racca S, Chiappelli F. Interactions between
glucocorticoids and cytokines in the bone microenvironment.
Ann N Y Acad Sci 2002; Jun: 966: 97-107.
8.
Ørtoft G, Oxlund H. Reduced strength of rat cortical
bone after glucocorticoid treatment. Calcif Tissue Int 1988; Dec:
43(6): 376-82.
9.
Dekhuijzen PN, Gayan-Ramirez G, de Bock V, Dom
R, Decramer M. Triamcinolone and prednisolone affect
contractile properties and histopathology of rat diaphragm
differently. J Clin Invest 1993; Sep: 92(3): 1534-42.
10.
Ren Y, Maltha JC, Kuijpers-Jagtman AM. The rat as a
model for orthodontic tooth movement- a critical review and a
proposed solution. Eur J Orthod 2004; 26 (5): 483-90.
11.
Lu L, Lee K, Imoto S, Kyomen S, Tanne K.
Histological and histochemical quantification of root resorption
incident to the application of intrusive force to rat molars. Eur J
Orthod 1999; 21 (1): 57-63.
12.
Verna C, Dalstra M, Melsen B. Bone turnover rate
does not influence root resorption induced by orthodontic
treatment. Eur J Orthod 2003; Aug 25 (4): 359-63.
13.
Midgett RJ, Shaye R, Fruge JFJ. The effect of altered
bone metabolism on orthodontic tooth movement. Am J Orthod
Dentofacial Orthop 1981; 80: 256-62.
14.
Goldie RS, King GJ. Root resorption and tooth
movement in orthodontically treated, calcium-deficient, and
lactating rats. Am J Orthod Dentofacial Orthop 1984; 85: 42430.
15.
Poumpros E, Loberg E, Engström C. Thyroid function
and root resorption. Angle Orthod 1994; 64 (5): 389-93.
16.
King
GJ,
Keeling
SD,
Wronski
TJ.
Histomorphometric study of alveolar bone turnover in
orthodontic tooth movement. Bone 1991; 12 (6): 401-9.
17.
Ballard D, Jones A, Petocz P, Darendeliler A. Physical
properties of root cementum: Part 11. Continuous vs intermittent
controlled orthodontic forces on root resorption. A
microcomputed-tomography study. Am J Orthod Dentofacial
Orthop 2009; Jul: 136 (1):8.e1-8.e8.
18.
Nikolai RJ. On optimum orthodontic force theory as
applied to canine retraction. Am J Orthod Dentofacial Orthop
1975; Sep: 68 (3): 290-302.
Vol. 22(1), 2010
Effect of derum
Effect of derum (Juglan Regia L. Bark) extracts on
Mutans Streptococci in comparison to chlorhexidine
gluconate (in vitro study)
Maythaa' S. Kadum B.D.S, M.Sc. (1)
Athraa' M. Al-Waheb B.D.S, M.Sc.(2)
ABSRTACT
Background: Derum is one of the natural "chewing sticks" obtained from the bark of walnut tree (Juglan regia L.) and
used mainly by women in some countries as a tooth brush and as a dye for cosmetic purpose. This study was
conducted to test the effect of derum extracts on growth, adherence and acidogenicity of mutans streptococci in
comparison to chlorhexidine gluconate 0.2% as control positive and de-ionized water as control negative.
Materials and methods: Derum extracts were prepared by two methods (water and alcohol). Stimulated saliva were
collected from volunteers of dental students/University of Baghdad (21-23 years), from which Mutans Streptococci
were isolated, purified and diagnosis according to morphological characteristic and biochemical test. In vitro
experiments were done to evaluate the effect of different types of derum extracts on growth, adherence and
acidogenicity of mutans streptococci.
Results: Both types of derum extracts were effective in the inhibition growth of Mutans Streptococci and inhibition
increased with the increasing concentrations. Viability counts of mutans streptococci in comparison to control, at
concentrations (20% and 30%) both types of derum extracts there were statistically significant reduction in the counts
of Mutans Streptococci. Both types of derum extracts (water and methanol) at concentrations (10% and 20%) were
effective in prevent adherence and retardation of acid formation.
Conclusion: Both types of derum extracts (water and methanol) were succeeded to prevent growth, adherence
and acid production of Mutans Streptococci.
Key words: Walnut tree, juglan regia Linn, Mutans Streptococci, antimicrobial. J Bagh Coll Dentistry 2010; 22(1):83-87.
INTRODUCTION
For many centuries different populations and
cultures around world have been using various
tools, ranging from porcupine bones to chewing
sticks to clean their teeth and gum (1,2). The
relative accessibility and the popularity of
chewing sticks have made it a very effective
agents for plaque control in different
communities, although chewing sticks differ in
their sours, various components of chewing
sticks and other related plants have reported been
to have beneficial biological properties, including
significant antibacterial and antifungal activity
(3,4).
Derum is one of the natural "chewing sticks"
obtained from the bark of walnut tree (Juglan
regia L.) and used mainly by women in some
countries as tooth brush and as a dye for
cosmetic purpose(5), its extract showed broad
spectrum antimicrobial activity.
It inhibition microorganisms representing
Gram-positive bacteria like (Staphylococcus
aureus and Streptococcus mutans), Gramnegative bacteria like (Escherichia coli and
Pseudomonas aeruginosa) and pathogenic yeast
(Candida albicans); derum extract also increase
the pH of the saliva (6,7)
Dental caries may develop in an individual if
the
three
prerequisites:
cariogenic
microorganisms, fermentable carbohydrates, and
susceptible teeth, are present for a significant
time (8). Many epidemiological and experimental
studies showed a positive association between
mutans streptococci and initiation of a carious
lesion (9-11). This study was conducted to test the
effect of derum extracts on growth, adherence
and acidogenicity of mutans streptococci in
comparison to chlorhexidine gluconate 0.2% as
control positive and de-ionized water as control
negative.
MATRIAL AND METHODS
(1)M.Sc.Student, Department of Pedodontic and Preventive
Dentistry, Dental College, University of Baghdad.
(2)Professor, Department of Pedodontic and Preventive
Dentistry, Dental College, University of Baghdad.
The present study involved four in vitro
experiments, concerning the effects of derum
extracts on the viable counts, acidogenicity and
adherence of Mutans Streptococci. Derum
extracts were prepared by two methods (water
and alcoholic). It was conducted in the College
of Dentistry /University of Baghdad during 2009.
Vol. 22(1), 2010
Preparation of derum extracts: Derum sticks
were cut into small pieces and ground to powder
by using a mill. A Preparation of derum extracts:
Derum sticks was cut into small pieces and
ground to powder using a mill. Aqueous extracts
was prepared by mixing (150 g) of the powder of
derum sticks with (1 liter) of sterile de-ionized
water and left for (48h) at (4oC). The extracts
were sterilized using filters (No.1). The filtrate
extract was then left to dry at (40oC) in hot air
oven to allow the evaporation of water and to
obtain the powder of derum extract. The extract
was not stored but used immediately. Preparation
of derum powder from methanol was done by
(150g) of derum powder were soaked in one liter
of methanol 99.8% and shaken on an automatic
shaker for (72h). Then it was filtered using filter
paper (No. 1). The alcohol was evaporated at
40oC under reduce pressure to give crud
alcoholic extract, then the extract dissolved in
water to prepare different concentrations.
In vitro experimental: stimulated saliva was
collected
from
volunteers
of
dental
students/University of Baghdad (21-23years),
from which Mutans Streptococci were isolated,
purified
and
diagnosis
according
to
morphological characteristic and biochemical
test. Chlorhexidine gluconate use in this study as
a control positive, de-ionized water was used as a
control negative. Sensitivity of mutans
Streptococci to different concentration of derum
extracts (water and alcohol) were tested
according to Agar Well Technique. The viability
counts of Mutans Streptococci inoculated from
broth media, to which different concentrations of
derum extracts, CHX 0.2% and de-ionized water
were added have been estimated in comparison
to the control (broth and bacteria only), the
procedure was carried on 5 isolates of mutans
streptococci, the concentrations were 10%, 20%,
and 30% of water and water-methanol extracts of
derum(12). The adherence of Mutans Streptococci
to the teeth and stainless steel wire after the use
different concentrations of derum extracts,
chlorhexidine 0.2% and de-ionized water
compared to the control positive (broth and
bacteria without agent) and control negative
(broth and agent without bacteria)(13). Mutans
streptococci were allowed to grow in vitro, in
order to test the effects of different
concentrations of derum extracts on the ability of
acid production of the bacteria (13).
RESULTS
Sensitivities of Mutans Streptococci to
different concentrations of derum extracts (water
and alcohol) were tested according to Agar Well
Effect of derum
Technique. The result showed that, both types of
derum extracts were effective in the in derum
extracts were effective in the inhibition of
Mutans Streptococci and the inhibition increased
with the increasing concentrations start from
(5%) to (50%) which more effective (figure 1).
Mutans streptococci were more sensitive to
chlorhexidine compare to both types of derum
extracts excepted for high concentrations (table
1).
The effects of different concentrations of
derum extracts (10%, 20% and 30%) on the
viability counts of Mutans Streptococci in
comparison to control were studied, statistically
no significant reduction in the viability counts
was record when derum extracts (water and
methanol) at concentration 10%, at higher
concentrations of both types of derum extracts
(20% and 30%) showed statistically a significant
reduction in the counts of mutans streptococci
(P<0.05), chlorhexidine gluconate 0.2% showed
highly significant reduction in the counts of these
bacteria (P<0.001) (figure 2 and table 2). The
result showed that both types of derum extracts at
concentrations 10% and 20% and chlorhexidine
gluconate 0.2% were effective in prevent
adherence (table 3) and retardation of acid
formation (table 4).
DISCUSSION
A variety of chemotherapeutic agents have
been investigated for a possible ability to control
oral pathogens. Herbal materials are one of
groups which have been studied in such
investigations. The present study was designed to
obtain information on the microbial effect of
juglan regia bark on Mutans Streptococci and
findings have validated the presence of such
effect. At present study evidence support an
antibacterial effect of derum on Mutans
Streptococci. Polyphenol and derivatives are not
only antimicrobial compounds isolated from
juglan regia bark (5,7), but juglon and glycosides
are amongst strongest antimicrobials constituents
of juglan regia bark (14,15). The anti-microbial
effects of derum was observed on in grampositive, gram-negative and fungi (6,7). Inspite of,
very little information exist about antimicrobial
properties of derum spatially against Mutans
Streptococci some study report that aqueous and
alcoholic extracts of juglan regia inhibited in
vitro growth, adherence, acid production and
glucan induce adherence of Streptococci Mutans
(16)
and that coincidence with this study. The
antibacterial effect of derum against gram
positive cocci, like Mutans Streptococci may be
through the following mechanisms: The number
Vol. 22(1), 2010
of hydroxyl group (OH)- on the some
constituents of derum special for the polyphenol
thought to be related to their relative toxicity to
microorganisms, with evidence that increased
hydroxylation result in increased toxicity (17).
Furthermore, the more oxidized phenol, the more
inhibitory effect (18,19). In this situation the
oxidized phenols react with sulfhydyl group or
interact no specifically with proteins that will
Effect of derum
interact with bacterial growth and metabolism
enzymes and cell envelop transport protein (20).
Polyphenol in juglan regia bark exert antiMutans Streptococci activity via inhibiting the
bacterial glucosyltransferase enzyme which
responsible for adherence of bacteria (21). Juglon
one constituent of juglan regia bark may inhibit
some metabolic enzymes of bacteria.
Figure 1: Mean of inhibition zones of Mutans Streptococci to different agents (Agar well
diffusion technique)
Table 1: Student t-test between CHX with water- methanol and water extracts of derum (Agar
well diffusion method).
Conc.
5%
10%
15%
20%
25%
30%
40%
50%
Water-methanol extracts Water extracts
t-test
P-value
Sig t-test P-value Sig
15.667 0.000
HS 15.513 0.000 HS
15.470 0.000
HS 13.860 0.000 HS
11.880 0.000
HS 8.552 0.000 HS
7.560
0.000
HS 7.442 0.000 HS
5.333
0.001
S
6.014 0.000 HS
3.742
0.007
S
3.942 0.004 S
1.898
0.100
NS 2.372 0.537 S
0.697
0.508
NS 0.645 0.537 NS
Figure 2: Mean of viability count of Mutans Streptococci x 103 for Control, CHX, de-ionized
water, water derum extract and methanol derum extract, in vitr
Vol. 22(1), 2010
Effect of derum
Table 2: Student t-test between viability counts of control with all agents
Agents
t-test P-value
0.927 0.406
10% water derum extract
4.264 0.013
3.157 0.034
10% methanol derum extract 0.945 0.372
1.405 0.233
De- ionized water
10.46 0.000
CHX
Sig
NS
S
S
NS
S
S
NS
HS
Table 3: The effects of derum extracts, CHX and de-ionized water on adherence of mutans
streptococci in vitro.
Agents (2 minutes)
Adherence
-ve
10% water derum extrac
-ve
-ve
10% methanol derum extract
-ve
20% methanol derum extract
-ve
CHX
+ve
De-ionized water
+ve
Control positive
-ve
Control negative
Table 4: The effects of different agents on ability of mutans streptococci to produce acid.
Agents
10% water derum extracts
20% water derum extracts
10% methanol derum extracts
20% methanol derum extracts
CHX
De-ionized water
Control positive
Control negative
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Weak effects
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Vol. 22(1), 2010
Salivary insulin hormone
Salivary insulin hormone in relation to caries – experience
among insulin-dependent diabetic children
Nadia Al-Rawi M.Sc. (1)
Sulafa El-Samarrai M.Sc., PhD
(2)
ABSTRACT
Background: Diabetic children are a specific group who requires a proper dental care and a special preventive
program. This can be achieved not merely by studying the distribution and severity of oral diseases but also by the
understanding of their etiological factors. The objective of this study was conducted to investigate the severity of
dental caries among insulin dependent diabetic children in relation to salivary insulin hormone.
Materials and methods: The study group consisted of 60 diabetic children (30 with long duration) and (30 newly
diagnosed), in addition to 30 control healthy non diabetic children. Dental caries was recorded by lesion severity
through the application of decayed missing filled surfaces (1). Stimulated salivary samples were collected and salivary
samples were chemically analyzed, for detection of insulin hormone.
Results and conclusion: The mean value of salivary insulin hormone concentration was higher in the control group.
Difference was statistically highly significant. Statistically significant correlation was found in insulin hormone with (DS)
fraction in the long duration diabetic group.
Keywords: Diabetes mellitus, insulin hormone, dental diseases. J Bagh Coll Dentistry 2010; 22(1):88-90.
INTRODUCTION
Many definitions of diabetes mellitus were
found as that given by World Health Organization
(2)
and American Diabetes Association (3).
Diabetes mellitus (DM) is a chronic systemic
metabolic disorders characterized by increased
levels of glucose in the blood (hyperglycemia)
and abnormalities in the metabolism of lipid and
proteins. Hyperglycemia results from a defect in
insulin secretion, insulin action, or both. There is
a relative or absolute lack of insulin or an
inadequate function of insulin. Diabetes mellitus
is a state of chronic blood glucose elevation
(hyperglycemia) often accompanied by other
clinical and biochemical abnormalities. A raised
fasting blood glucose (more than 8 mmol/L) or a
postabsorption level in excess of 11 mmol/L is a
clear indication that the patient has diabetes
mellitus (4).
Dental caries continues to be a major oral
health problem affecting children, adolescents,
adults as well as elderly people. It is a
multifactorial disease involving interactions
among the diet, saliva, the plaque microflora, and
susceptible tooth surface in the presence of time
factor (5, 6). The disease is accumulative chronic
dynamic process which leads to a change in the
equilibrium between tooth substance and
surrounding environment and the net result is the
loss of tooth mineral, or demineralization (7).
(1) PhD student, Department of Prevention Dentistry, college of
dentistry, University of Baghdad.
(2) Professor, Department of Prevention Dentistry, college of
dentistry, University of Baghdad.
Insulin is a hormone composed of 32 amino
acids. It promotes glucose uptake in the liver and
inhibits production and release synthesis of fatty
acid in the adipose tissues increases body protein
store by increasing tissue amino acid uptake and
protein synthesis and decreasing protein
catabolism(8). As long as ß-cells can compensate
for the degree of insulin resistance, glucose
tolerance remains normal. The total amount of
insulin may be normal or even increased, but the
temporal insulin secretion is disturbed. This
concerns particularly the early phase of insulin
secretion resulting in postprandial hyperglycemia
(9).
A (30-40) % reduction in insulin mediated
glucose
disposal
leads
to
progressive
compensatory fasting hyperinsulinaemia until
fasting plasma glucose exceeds 7mml/L;
thereafter,
endogenous
insulin
secretion
progressively fails (10). Increased plasma levels of
proinsulin-like
molecules
indicate
B-cells
dysfunction; this is an early feature, being
demonstrable prior to the development of diabetes
in high risk group (11).
Determination of salivary and serum insulin
hormone
Principle of the method:
Salivary insulin hormone were measured by
Insulin-G which is a solid phase enzyme
immunoassay employing recombinant human
insulin for the quantitative detection of antibodies
against human insulin in human saliva, the assay
is a tool in the diagnosis of insulin dependent
diabetes mellitus (AIDA, Autoimmune diagnostic
assays) (12).
Vol. 22(1), 2010
Salivary samples diluted 1:10 are incubated in
the microplates coated with the specific antigen.
Patients antibodies, if present in the specimen,
bind to the antigen. The unbound fraction is
washed off in the following step. Afterwards antihuman immunoglobulin conjugated to horseradish
peroxidase (conjugate) is incubated and react with
the antigen-antibody complex of the samples in
the microplates. Unbound conjugate is washed off
in the following step. Addition of TMB-substrate
generates an enzymatic colorimetric (blue)
reaction, which is stopped by diluted acid (color
changes to yellow). The rate of color formation
from the chromogen is a function of the amount
of conjugate bound to the antigen-antibody
complex and this is proportional to the initial
concentration of the respective antibodies in the
patient sample.
three groups. A negative significant correlation
was observed between insulin hormone and (DS)
fraction in the long duration diabetic group (P
<0.05).
Long duration Newly diagnosed Control
NS
HS
HS
Figure 1: The least significance differences in
salivary insulin hormone between different
groups
Table 2: Correlations coefficients between
dmfs, ds, DMFS, DS scores with salivary
insulin hormone among study and control
groups
Salivary Insulin
r
p
0.224 0.316
dmfs
Long
0.119 0.597
ds
duration diabetics
DMFS -0.346 0.061
-0.364* 0.048
DS
0.163 0.505
dmfs
Newly diagnosed
0.196 0.422
ds
diabetics
DMFS -0.299 0.109
-0.286 0.126
DS
0.361 0.170
dmfs
0.411 0.114
ds
Control
DMFS -0.026 0.889
0.049 0.796
DS
Groups
RESULTS
The mean value of salivary insulin hormone
concentration was higher in the control group
compared with the two diabetic groups.
Difference was statistically highly significant
(Table 1). The LSD test revealed that difference
was statistically highly significant between the
control and the both diabetic groups, while
statistically no significant difference existed
between the two diabetic groups (Figure 1). In
regarding to gender, females exhibited more mean
values in the control and in the newly diagnosed
diabetic groups compared with males, differences
were statistically not significant (P >0.05).
Table 1: Salivary insulin hormone (mean
and standard deviation) among study and
control groups
Groups
Long
duration
diabetics
Newly
diagnosed
diabetics
Control
Salivary Insulin
Gender hormone U/ml
^^Mean ± SD
2.416±1.509
M
2.189±1.486
F
T
2.318±1.478
M
F
T
M
F
T
1.738±1.275
3.299±5.499
2.415±3.746
4.592±2.045
4.975±2.342
4.758±2.148
F = 8.250, df = 2, 87, P = 0.001 Highly Significant
Table 2 demonstrates the correlations
coefficients between salivary insulin hormone
level with dmfs, ds, DMFS, and (DS) among the
Variables
* Significant
DISCUSSION
Diabetes mellitus is a metabolic disorder of
multiple etiologies. Effects of the disease include
long-term damage, dysfunction and failure of
various organs in addition to oral complications.
Dental caries by lesion severity was explored by
the present investigation. Results showed that
diabetic children were affected by dental caries in
much more frequency and severity compared to
the control group. This finding was also reported
by other Iraqi previous studies (13-15).
Salivary insulin level has been evaluated in
the present study. Mean level of insulin hormone
concentration in saliva was higher in the control
group compared to the both diabetic groups and
the lowest value in the long duration diabetic
children, with highly significant differences
between control and both diabetic groups.
Unfortunately no previous studies were able to be
found regarding salivary insulin hormone in
relation to the type 1 diabetic children to compare
with.
Vol. 22(1), 2010
The present study showed that insulin
hormone in spite of its low level among diabetic
children, a negative correlation coefficient was
reported with caries- experience which was
significant in the long duration diabetic group. It
is not known if insulin hormone has any
protective effect against dental caries.
In addition to the evaluation of insulin
concentration among diabetic and non diabetic
children in the present investigation salivary and
serum insulin autoantibodies (IAA) were studied
by means of a solid-phase enzyme immunoassay,
among the newly diagnosed diabetics, and in
affected long duration of insulin-dependent
diabetics, in addition to the control non diabetic
children.
Results
showed
an
insulin
autoantibodies (IAA) in 17 of 30 (56.66%)
children among IDDM, and in 6 of 30 (20%)
children of newly diagnosed diabetic mellitus,
insulin antibodies were seldom found in control
group in the present study, in the present study,
insulin autoantibodies (IAA) did not detect in
salivary sample of all diabetic and healthy
children, while the detection was only in serum
samples.
It
is
suggested that insulin
autoantibodies (lAA) were not inevitably
associated with clinical diabetes because they
were found in newly diagnosed diabetic who are
not under insulin treatment. However, cannot
exclude the possibility that insulin autoantibodies
(IAA) are markers for islet-cell damage which has
not progressed to IDDM. While not all diabetics
and newly diagnosed diabetics had IAA in this
comparative study. It remains to be established
whether IAA are specific for islet-cell
autoimmunity or exert any functional effect on
circulating insulin.
REFERENCES
1.
Muhlemann HR. Oral epidemiology-caries. In:
Introduction to oral preventive medicine. Buch-und
Zeitschriftien-Verlag,
Die
Quintessenze
1976
(Translated in English).
2. World Health Organization. Definition, Diagnosis
and Classification of Diabetes Mellitus and Its
Complication. Part 1: World Health Organization,
Geneva 1999.
3. American Diabetes Association. Standards of medical
care in diabetes: Diabetes care 2006; 29 (suppl1): S18S19.
4. Tierney SJ, McPhee MA, Papadakis. Current medical
Diagnosis & Treatment. International edition. New
York: Lange Medical Books /McGraw-Hill 2002;
pp. 1203–1215.
5. Thylstup A, Fejerskov O. Clinical and pathological
features of dental caries In. Textbook of Clinical
Cariology 2nd ed. Munksgaard. Copenhagen 1996; 11158.
6.
Mitchel L, Mitchel D. Oxford handbook of clinical
dentistry. Oxford university press. 4th ed. Chapter five;
2005.
7. Kingman A, Selwitz R. Proposed methods for
improving the efficiency of the DMFS index in
assessing initiation and progression of dental caries.
Corn Dent Oral Epidemiol 1997; 25: 60-8.
8. Virtanen S, Knip M. "Nutritional risk predictors of
beta cell autoimmunity and type 1 diabetes at a young
age". Am J Clin Nutr 2003; 78 (6): 1053–67.
9. Zimmet PZ. The Pathogenesis and Prevention of
Diabetes in Children. Diabetes Care 1995; 18: 1050-69.
10. Isomaa B, Almgren P, Tuomi. Cardiovascular
Morbidity and Mortality Associated with Metabolic
syndrom. Diabetes Care 2001; 24: 683-9.
11. Krentz AJ. Churchill’s Pocket look of Diabetes. First
edition. London: Churchill’s Livingstone 2000; 1-30.
12. Witkin TJ. Insulin autoantibodies as markers for type
1 diabetes. Endocrine Reviews 1990; 11: 92-104.
13. El-Samarrai S, Sabri N, Makki Z. Dental caries
among young diabetic patients in Baghdad-Iraq. Iraqi
Dent J 1997; 20: 14-23.
14. Al-Hayali AM. Isolation and purification of
glucosyltransferase from Mutans Streptococci .A Ph.D
Thesis, College of Dentistry, University of Baghdad
2002.
15. Foad SA. Proinfiammatory cytokines inflammatory
markers in type I diabetes children and adolescents. A
Ph.D. Thesis. University of Baghdad 2005; pp 51-4.
Vol. 22(1), 2010
Evaluation of buccal corridor
Evaluation of buccal corridor in posed smile for Iraqi
adults sample with Class I normal occlusion
Sajid C.A. Al-Ramahi B.D.S., M.Sc. (1)
Ausama A. Al-Mulla B.D.S., Dr. D.Sc. (2)
ABSTRACT
Background: The purposes of this study were to determine the soft tissues parameters that affect the buccal corridor
widths, to determine the difference of buccal corridor widths between both sides in both genders and in normal and
gingival smile line groups, and to correlate the buccal corridors widths with face width and smile index for sample of
Iraqi adults with Class I normal occlusion.
Materials and Methods: The sample consisted of 60 Iraqi adults (30 males and 30 females) aged 18-25 years with
Class I pattern. It was classified into two groups; the first group (totaling 30 adults, 15 males and 15 females) had a
gingival smile line. The second group (totaling 30 adults, 15 males and 15 females) had a normal smile line. Clinical
examination and digital frontal photograph with posed smile were performed for each individual. Six linear soft tissue
parameters were measured for each photograph using AutoCAD program 2008. Descriptive statistics and
independent sample t-test were performed to evaluate the buccal corridor widths in both normal and smile line
groups quantitatively. Correlation analysis was obtained between buccal corridors and other soft tissue
measurements.
Results and Conclusions: The following results were obtained: the buccal corridor width was smaller in normal smile
than gingival smile line males and females. Buccal corridor width was larger in males than in females in normal smile
line group, and larger in females than males in gingival smile line group. There was significant difference between
right and left buccal corridor widths in normal smile line group and no significant difference in gingival smile line
group for both genders. There was direct correlation between buccal corridor widths and outer commissural width in
normal smile line group, and direct correlation between buccal corridor widths and face width, but statistically non
significant. There was no significant correlation between buccal corridor widths with smile index.
Key words: Buccal corridor, posed smile, normal occlusion. J Bagh Coll Dentistry 2010; 22(1):91-97.
INTRODUCTION
Buccal corridors (negative or black spaces)
were defined by Frush and Fisher (1) as the spaces
between the facial surfaces of posterior teeth and
the corners of lips when a person is smiling,
while Roden-Johnson et al. (2) defined buccal
corridor space as the distance between the lateral
junction of the upper and lower lips and the distal
points of the canines during smiling.
Krishnan et al. (3) noticed that there is a
difference of opinion among investigators about
the esthetic value of buccal corridors. RodenJohnson et al. (2) explained that some
investigators did not recognize any esthetic value
for buccal corridor; while others believe that
visible buccal corridors are unattractive. In
contrast to other opinions that consider the
buccal corridor is one of the evaluation points in
smile esthetics (4,5).
Generally, a smile includes not only the six
anterior teeth but also the first premolars.
Henceforth, posterior teeth should be included
when evaluating buccal corridor space (2).
(1) MSc student, Department of Orthodontics, College of
(2) Professor, Department of Orthodontics, College of Dentistry,
The anterior-posterior position of the maxilla
and the rotation of the upper molars could be
influencing factors on the buccal corridor (6-9).
The narrow maxillary arch and extraction in the
upper dentition were thought to be causes of the
buccal corridor (10-12).
Reviewing of the literature shows that there
are few studies about the buccal corridor which
comprehend all the causative factors and the
different clinical presentations of this condition.
The purposes of this study were to determine the
soft tissues parameters that affect the buccal
corridor widths, to determine the difference of
buccal corridor widths between both sides in
both genders and in normal and gingival smile
line groups, and to correlate the buccal corridors
widths with face width and smile index for
sample of Iraqi adults with Class I normal
occlusion.
The sample
Out of 161clinically examined students (98
males and 63 females) only 30 males and 30
females fit the criteria of sample selection. The
sample of the study composed of 60 Iraqi adult
students with an age ranged between 18-25 years.
They were selected from Colleges of Medicine
and Dentistry- University of Baghdad.
Vol. 22(1), 2010
The sample was classified into two groups
and as follows:
1. Thirty adult students (15 males and 15
females) with gingival smile line (gummy
smile) defined as 2 mm or more of maxillary
gingiva exposed above the left central incisor
on maximum smile (13).
2. Thirty adult students (15 males and 15
females) with normal smile line.
Criteria for Sample Selection
All subjects had the following criteria:
1.
Full permanent dentition excluding the
third molars (14).
2.
Class I incisor classification (15).
3.
Bilateral Class I molar and canine
relationships (16).
4.
Class I skeletal relationship, determined
clinically (17).
5.
No crown and bridge prosthesis or large
dental fillings.
6.
No anterior or posterior crossbite.
7.
No or minor crowding and spacing.
8.
Free of local factors that disturb the
integrity of the dental arches (congenital
missing teeth, supernumerary teeth and
fractured or traumatized anterior teeth) (18).
9.
Competent and normal function of lips
and absence of gross asymmetry of the face
and the jaws with acceptable facial esthetic (19).
10.
No history of bad oral habits like thumb
sucking, tongue thrust or mouth breathing (20).
11.
No previous orthodontic, orthopedic, or
facial surgical treatments (13).
12.
Overjet and overbite of 2-4 mm (21).
13.
No active periodontal diseases and
gingivitis, also no periodontal treatment except
for ordinary scaling and polishing (3).
Instruments and Equipments
The following equipments were used:
1.
A set of plane dental mouth mirrors and
kidney dish.
2.
Cotton and disinfectant agent for ear
rods sterilization (spirit 75%).
3.
Cotton.
4.
Sterilizer.
5.
Dental vernier and indelible pencil.
6.
Digital camera (Sony CyberShot H 50,
9.1 Mega pixels, 15 X optical zoom, Sony
Corporation, Nagoya, Japan).
7.
A height adjustable tripod, used for
fixing the camera in position.
8.
Two flash lights, with holders and two
umbrellas.
9.
A blue background panel, 0.95 m width
and 1.10 m length.
10.
A small rectangular reflecting aluminum
panel of 0.35 x 0.7 m.
11. Stool.
12. Cephalostat: the cephalostat provided
with the Planmeca X-ray machine
13. Ruler (6 cm in length) and measuring
tape.
14. Personal computer.
15. AutoCAD program (2008).
Methods
History
Each subject was seated on the dental chair
in an upright position and asked information
about name, age, medical and dental histories.
Clinical Examination
The subject was asked to sit upright in the
chair and look straight ahead. In this position, the
Frankfort plane should be approximately parallel
to the floor of the room, and the head in natural
(relaxed) position. The subject occluded in
centric relationship. The skeletal classification,
molar relation, incisor relation, canine relation,
overjet and overbite were evaluated.
Standardization of the Photographs
The camera was fixed in position and
adjusted in height to be at the level of subject’s
eyes with a height adjustable tripod. The distance
from the camera to the subject was fixed at a
distance of about 1.01m measured from the
tripod’s column to the ear rods. In order to
eliminate the problem of shadows on the
submental region and under the nasal base, the
subject held with his/her hands, a small
rectangular reflecting panel of 0.35 x 0.7 m. This
panel was positioned horizontally against the
chest, just under the collarbone. The blue
background, 0.95 m width and 1.10 m length was
made of a piece of cloth (22). Two flash lights,
with two umbrellas to diffuse and soften the
light, were used to obtain the best quality and
consistency of photographs. A ruler was placed
on the adjustable plastic nasal stopper part of the
cephalostat, to be used later for magnification
correction (3,23).
Photographical Technique
The subject was seated on a stool and his
head was fixed with the aid of the cephalostat.
The Frankfort horizontal plane was parallel to the
floor (24). The digital camera was set on manual
exposure shooting chosen from the model dial
that determined the desired function and from
wheel dial the camera was set on:
1. ISO
(International
Standardization
Organization) value of 80.
2. Shutter speed of 2.5.
3. Aperture value of 3.5.
4. Grid lines shown to aid in determining the
center of the subject’s face.
5. Flash on.
Vol. 22(1), 2010
The subject was asked to close in centric
occlusion, smile and say word “cheese” to obtain
an ideal lip-tooth presentation at smile (25) after
which, the photograph was captured.
Measuring Techniques
Firstly, the photographs were imported to
the AutoCAD program. Secondly magnification
correction was done in reference to the attached
ruler, so that the real measurements were
obtained. After that, landmarks were identified
during smiling, and measurements were
determined.
Measurement of Gingival Display
Additional measurements were made for
gingival smile subjects, as follows: A vertical
line was drawn along the facial midline. Two
lines were drawn perpendicular to it. The first
line was drawn tangent to the gingival margin of
the maxillary left central incisors, which
established the horizontal zero point. The second
one is the smile line, drawn tangent to the upper
lip border at maximum smile. The distance
between the zero-point line and the smile line
represented the amount of gingival display the
subject had (13).
Soft Tissue Landmarks
1. condylion (con): the most lateral point on the
surface of condyle of the mandible, this is can
be palpated when the jaw is opened, and when
the mandible is closed this point is usually just
anterior to the upper margin of the tragus of the
ear (26).
2. chilion (ch): a point located at each angle of
mouth and selected to be on same level with
stomion (27), but during smiling located with
the level of stomion superius.
3. stomion superius (stos): The lower most point
on the vermilion border of the upper lip (24).
4. stomion inferius (stoi): the upper most point
on the vermilion border of the lower lip (24).
Reference lines
1.
Inner commissural line (ICL): it is a line
passes through the mucosa overlying the
buccinators muscle where it inserts with
the orbicularis oris muscle fibers at the
modiolus (3,9).
2. Outer commissural line (OCL): it is a line
passes through chilion point parallel to inner
commissural line (3,9).
Linear Measurements
True vertical and horizontal lines were
drawn through the previously identified and
located points:
1. Bicondylar distance or Face width (FW): It
is the distance between two condylion points,
because condylion points can be palpated
whether mandibule opened or closed (26), so it
is the better distance represents the face width
during smile (28).
2. Buccal corridor width (BCW): It is the
distance between inner commissural line and
outer commissural line (3,9).
3. Outer commissural width (OCW): It is the
distance between right and left outer
commissural line (29).
4. Inner commissural width (ICW): It is the
distance between right and left inner
commissural line (29).
5. Inter-labial gap (ILG): It is the distance
between stomion superius point and stomion
inferius point (9).
6. Smile index (SI): It represents the smile zone,
obtained by dividing the outer commissural
width by the inter-labial gap (9).
Statistical Analyses
The data recorded in this study subjected
to computerized statistical analysis using the
statistical programs of social sciences, version
15.0 (SPSS 2006, Chicago, Illinois, USA). The
statistical analyses were:
1. Descriptive statistics- include: mean,
standard deviation, standard error, statistical
tables.
2. Inferential statistics- include:
a.
Paired samples t- test: to test for
statistical significance between right and left
buccal corridor widths in each group.
b.
Independent samples t-test: to test for
statistical significant differences between
genders in the same group, and between the
two groups for each gender.
c.
Pearson correlation coefficients: used
to test the relationships between the
measured variables in both groups.
In the statistical evaluation, the following
levels of significance were used
Non-significant
NS P > 0.05
Significant
*
0.05 ≥ P > 0.01
Highly significant
**
0.01 ≥ P > 0.001
Very highly significant *** P ≤ 0.001
RESULTS AND DISCUSSION
Gender variations of linear measurements
All the linear measurements of young adult
males were higher than that of young adult
females as shown in table 1 and 2. This comes in
line with Woods (30) and Nasir (31). One exception
was found in right and left buccal corridor widths
for gingival smile line group where the right and
left buccal corridor widths in females were
higher than the right and left buccal corridor
widths in males, this may be attributed to
Vol. 22(1), 2010
difference in tone of facial muscles between both
genders as mentioned by Blitz (32).
Genders difference in normal smile line group
(Table 1)
Independent sample t-test revealed nonsignificant difference in left buccal corridor
width and significant difference in right buccal
corridor width between both genders, this may be
caused by normal sample group was right handed
so use the left side of mouth make it more
functional leads to decrease in thickness of
buccal soft tissue in that side as described by
Lundstrom (33). Independent samples t-test
revealed very high significant difference in the
inner and outer commissural width in both
genders. This may follow the general rule that
the males are larger than the females in all
dimensions (34). Independent samples t-test
revealed high significant difference in face
width, this comes in agreement with Nasir (31).
Independent samples t-test revealed very high
significant difference between both genders in
interlabial gap. This may caused by the upper lip
moved to a more superior position in males as
compared with females which is a similar to the
findings of Al-Zubaydi (20). Independent samples
t-test showed significant difference between both
genders in smile index. This may attribute to
females produce wider smile than males; this
comes in agreement with Ackerman (35) and
Sarver and Ackerman (36) who used this ratio to
compare smiles among different patients or
across time in one patient, they found that this
ratio in females was larger than males.
Genders differences in gingival smile line
group (Table 2)
Independent
sample
t-test
shows
significant difference between both genders only
in the inter-labial gap, this may be attributed to
the upper lip moved to a more superior position
in males as compared with females which is a
similar to the findings of Al-Zubaydi (20).
Comparison between the left and right buccal
corridor widths in normal and gingival smile
line group for both genders (Table 3)
The results indicate that there is high
significant difference in normal females and
significant difference in normal males, this
difference may be attributed to the presence of
some degree of dental arch asymmetry or a
difference in tone of facial muscles; this
disagrees with results of Ritter et al. (23) and
Krishnan et al. (3). On the other hand the gingival
smile males and females show non-significant
difference between the right and left buccal
corridor widths.
Group differences between normal and
gingival smile line males groups (Table 4)
Independent sample t-test revealed very
highly significant difference for inter-labial gap,
this may be attributed to excessive smile curtain
that leads to much greater range of smile activity
and gingival exposure during smile than do
averages as described by Sarver and Ackerman
(36)
, and smile index that show very highly
significant difference. These results are due to
that the index is indirectly proportional to inter
labial gap as shown by Ackerman et al. (6), so
according to the finding of present study in
which the inter labial gap was larger in gingival
smile line group than normal smile line group,
this leads to normal smile line group has high
smile index as compared with gingival smile line
group.
Group differences between normal and
gingival smile line females groups (Table 5)
Independent sample t-test shows very
highly significant difference between both
groups in the following: right and left buccal
corridor widths; this may be due to difference in
thickness of lips commisures, inner and outer
commissural width; this may be either due to
difference in thickness of lips commisures or
difference in smile styles, inter-labial gap; this
may result from greater muscular capacity found
in gingival smile line group to riase lip and this
comes in agreement with Al-Zubaydi (20) and
smile index; this comes in agreement with
Ackerman et al. (6), Ackerman and Ackerman (9)
and Sarver and Ackerman (36).
Pearson correlation test
among the
measurements in normal smile line group
(Table 6)
In male group, there is direct very highly
significant correlation between right and left
buccal corridor widths with the outer
commissural width, this comes in agreement with
Moore et al. (29). In female group, there is
moderate direct highly significant correlation
between right buccal corridor width and outer
commissural width and weak direct significant
correlation between left buccal corridor width
and outer commissural width, this comes in
agreement with findings of Ritter et al. (23) and
Moore et al. (29).
Pearson correlation test
among the
measurements in gingival smile line group
(Table 7)
In male group, there is moderate indirect
significant correlation between the right and left
buccal corridor widths with the inner
commissural width, this comes in agreement with
Ritter et al. (23). In female group, there is
Vol. 22(1), 2010
moderate direct highly significant correlation
between right buccal corridor width and outer
commissural width; this comes in agreement with
findings of Ritter et al. (23) and Moore et al. (29).
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Vol. 22(1), 2010
Table 1: Descriptive statistics and genders difference for normal smile line male and female
group.
Variables
Gender
Normal male Normal female
group
difference
group
(N=15)
(d.f.=28)
(N=15)
Mean S.D. S.E. Mean S.D. S.E t-test p-value
0.04
Rt
5.29 1.46 0.37 4.25 1.25 0.32 2.10
*
BCW
0.07
Lt
4.96 1.39 0.35 4.05 1.26 0.32 1.87
(NS)
BCW
0.000
ICW 54.7 2.49 0.64 49.93 2.76 0.71 4.96
***
0.000
OCW 64.96 4.22 1.09 58.29 2.9 0.74 5.03
***
0.002
FW 135.68 3.32 0.85 130.15 5.53 1.42 3.32
**
0.000
ILG 10.67 1.55 0.40 8.23 1.41 0.36 4.49
***
0.011
SI
6.19
0.9 0.23 7.26 1.21 0.31 -2.73
*
Table 2: Descriptive statistics and genders difference for gingival smile male and female group.
Gingival smile
Gingival smile
Gender
Variables male group (N=15) female group (N=15) difference (d.f.=28)
Mean S.D. S.E Mean S.D. S.E t-test
p-value
Rt BCW 5.92 1.19 0.30 6.09 1.28 0.33 -0.38 0.70 (NS)
Lt BCW 5.81 1.21 0.31 6.06 1.31 0.33 -0.54 0.59 (NS)
54.62 3.5 0.90 52.64 2.59 0.66 1.75 0.09 (NS)
ICW
66.37 2.88 0.74 64.79 3.62 0.93 1.31 0.20 (NS)
OCW
135.38 7.12 1.83 130.48 6.84 1.76 1.92 0.06 (NS)
FW
15.32 1.92 0.49 13.94
1 0.25 2.45
0.02 *
ILG
4.39 0.58 0.14 4.66 0.39 0.10 -1.5 0.15 (NS)
SI
Table 3: Comparison between the left and right buccal corridor widths in normal and gingival
smile line groups for both genders
Sides differences of
Normal smile
Gingival smile
buccal corridor widths
Male Female
Male
Female
(d.f.=14)
0.332 0.195
0.108
0.338
Mean difference
2.79
3.6
1.58
0.420
t-test
0.014 * 0.003 ** 0.136 (NS) 0.681 (NS)
p-value
Vol. 22(1), 2010
Table 4: Descriptive statistics and groups difference for normal and gingival smile line male
groups.
Gingival smile
Group
Normal
Variables male group (N=15) male group (N=15) difference (d.f.=28)
p-value
Rt BCW 5.29 1.46 0.37 5.92 1.19 0.30 -1.28 0.21 (NS)
Lt BCW 4.96 1.39 0.35 5.81 1.21 0.31 -1.78 0.08 (NS)
54.7 2.49 0.64 54.62 3.5 0.90 0.07 0.93 (NS)
ICW
64.96 4.22 1.09 66.37 2.88 0.74 -1.06 0.29 (NS)
OCW
135.69 3.32 0.85 135.38 7.12 1.83 0.15 0.87 (NS)
FW
10.67 1.55 0.40 15.32 1.92 0.49 -7.28 0.000 ***
ILG
6.19 0.9 0.23 4.396 0.58 0.14 6.5
0.000 ***
SI
Table 5: Descriptive statistics and groups difference for normal and gingival smile line female
groups.
Normal
Gingival smile
Group
Variables female group (N=15) female group (N=15) difference (d.f.=28)
p-value
4.25
1.25
0.32
6.09
1.28
0.33
-3.99
0.000
***
Rt BCW
6.06
1.31 0.33 -4.28 0.000 ***
Lt BCW 4.05 1.26 0.32
49.94 2.76 0.71 52.64 2.59 0.66 -2.77 0.009 **
ICW
58.29 2.9 0.74 64.79 3.62 0.93 -5.42 0.000 ***
OCW
130.15 5.53 1.42 130.48 6.84 1.76 -0.14 0.88 (NS)
FW
8.23 1.41 0.36 13.94
1
0.25 -12.75 0.000 ***
ILG
7.26 1.21 0.31
4.66
0.39 0.10 7.87 0.000 ***
SI
Table 6: Pearson correlation analysis for the measured variables in normal smile line group.
Variables
r
p
r
OCW
p
r
FW
p
r
ILG
p
r
SI
p
ICW
Male
Female
Rt BCW Lt BCW
SI
ILG Rt BCW Lt BCW
SI
ILG
0.33
0.17
0.24
0.09 -0.09
-0.22
-0.08
0.32
0.22
0.53
0.38
0.72
0.7
0.35
0.75
0.18
0.86
0.76
0.12
0.28 0.59
0.47
-0.04
0.36
0.000 *** 0.000 *** 0.67
0.3 0.009 ** 0.04 *
0.87
0.13
0.11
0.065
0.12 -0.09 0.21
0.11
-0.45
0.54
0.69
0.81
0.66
0.73
0.4
0.66
0.06 0.01 **
0.33
0.33
-0.91
0.16
0.12
-0.93
0.22
0.21 0.000 ***
0.51
0.63 0.000***
-0.009
-0.06
0.02
0.03
0.973
0.83
0.94
0.89
Table 7: Pearson correlation analysis for the measured variables in gingival smile line group.
Variables
r
p
r
OCW
p
r
FW
p
r
ILG
p
r
SI
p
ICW
Male
Female
Rt BCW Lt BCW
SI
ILG Rt BCW Lt BCW
SI
ILG
-0.59
-0.55
0.18 0.05 0.001
-0.03
0.42
0.04
0.02 * 0.03 *
0.51 0.86 0.99
0.9
0.12
0.89
0.09
0.16
0.34 -0.03 0.7
0.67
0.52
0.16
0.73
0.57
0.21 0.92 0.004 ** 0.005 ** 0.05 * 0.57
0.19
0.18
0.31 -0.16 0.03
0.04
0.14 -0.09
0.47
0.53
0.26 0.56 0.93
0.89
0.62
0.74
-0.1
-0.11
-0.94
0.18
0.19
-0.76
0.72
0.69 0.000***
0.52
0.48 0.001 ***
0.14
0.15
0.32
0.28
0.62
0.59
0.25
0.3
Vol. 22(1), 2010
Comparison of the calcified
Comparison of the calcified barrier formed by calcium
hydroxide paste and MTA during apexification procedure
Sarah T. AbdulQader B.D.S., M.Sc. (1)
ABSTRACT
Background: Apexification had been found to be high effective in the management of immature necrotic
permanent teeth. It is the induction of an apical calcified barrier or the creation of an artificial barrier across an open
apex against which filling material can be packed. The aim of this study was to evaluate appearance, thickness,
and time needed for the apical calcified barrier formation by using calcium hydroxide paste and MTA.
Materials and Methods: Forty premolars with single root canals were prepared to simulate an open apex of 1mm
diameter. These roots were divided into 2 groups: group A consists of 20 roots filled with Ca(OH)2 paste and group B
consists of 20 roots filled with MTA. Each root was placed in a polyethylene vial containing synthetic tissue fluid. The
presence of apical calcified barrier of each root was checked at weeks 1, 2, 3, 4, 5, 6, 7, and 8. At the end of the test
period, each root was taken out and the thickness of the formed apical calcified barrier was measured by vernier.
Results: All samples have calcified barrier at the end of 8 weeks. This barrier formed in 55% of the roots filled with
Ca(OH)2 paste at the beginning of 3rd week and in 40% of the roots filled with MTA at the beginning of 5th week. The
calcified barrier that formed by Ca(OH)2 paste had a chalky and irregular surface while that formed by MTA had a
glassy and regular surface. There was a highly significant difference in the thickness of this barrier between these two
groups.
Conclusions: The apical calcified barrier can be formed without the involvement of Hertwig’s epithelial root sheath.
There was a difference in the appearance of the calcified barrier formed by Ca(OH)2 paste and MTA. The apical
calcified barrier formed earlier and faster and was thicker in the roots filled with Ca(OH)2 paste as compared with
those filled with MTA.
Keywords: Apexification, Calcium hydroxide past, MTA. J Bagh Coll Dentistry 2010; 22(1):98-100.
INTRODUCTION
When pulp death occurs in an open apex tooth,
it can be successfully treated by apexification(1).
Apexification procedure had been historically
used to establish apical closure.This procedure
requires the chemomechanical debridement of
the canal followed by placement of an intracanal
medicament to assist or stimulate apical healing
and formation of an apical barrier (2).
Several materials had been used as intracanal
dressing to stimulate hard tissue formations
during apexification procedure (3). The material
of choice used for apexification for many years
is calcium hydroxide (4).
Recently, a single appointment technique by
using mineral trioxide aggregate (MTA) as an
apical plug has been proposed as an alternative
to the multiappointment calcium hydroxide
apexification(5).
The mode of action of MTA is similar to that
of calcium hydroxide which is mainly
encouraging hard tissue formation (6).
Even MTA did not have calcium hydroxide
in its composition but it had calcium oxide that
could react with tissue fluid to form calcium
hydroxide. Both MTA and calcium hydroxide
led to the formation of crystals, these crystals
which were originating from reaction of calcium
ions from MTA and calcium hydroxide with
(1) Assistant lecturer, Department of paediatric and preventive
dentistry, College of Dentistry, University of Baghdad.
carbon dioxide from the tissue had a role as an
initiating step in the formation of hard tissue
barrier(7), (8).
Forty freshly extracted human premolars with
single straight root canals and closed apices were
used in this study. The crown portion of each
tooth was removed at the cementoenamel
junction (CEJ) of the buccal surface to permit
ideal access to the root canal (9).
The patency of each canal was checked by
passing No. 10 K-type file through the apical
foramen and the working length was determined
by subtracting 1mm from the length at which the
tip of the file just appeared at the apical foramen
and standardized to 12 mm length (10).
The root canals were prepared to simulate an
open apex by using conventional hand
instrumentation technique with circumferential
filing action. These root canals were
instrumented starting with size No. 10 K- type
file to the master apical file No. 100 until the tip
of the master apical file extended 1mm beyond
the apex to have 1 mm aperture size (11). Two
coats of clear nail polish were applied to the
entire external root surface except the apical
foramen, and allowed to dry at room temperature
(12)
.
On the base of filling materials, the roots
were divided into 2 groups as follow: Group A:
20 roots filled with Ca(OH)2 paste, Group B: 20
Vol. 22(1), 2010
roots filled with MTA. Ca(OH)2 paste filling was
carried out by placing the needle of the syringe
in the canal 2mm shorter than the working length
and slowly withdrawn while the paste was being
injected. A radiograph was taken immediately to
assess the quality of the obturation and the extent
of the filling material. Then, a pledged of cotton
was placed in the cervical cavity over the paste,
and the cervical access was sealed with amalgam
(13)
. MTA filling was carried out by mixing the
MTA powder with distilled water according to
the
manufacturer’s instructions in 3:1
(powder/liquid) ratio on a clean dry glass slab
into a putty consistency and carried to the canal
with the aid of an endodontic messing gun. The
nozzle of the messing gun was placed into the
canal 4 mm shorter than the working length to
create 4 mm plug then depressed with plunger.
Roots were radiographed to ensure that an
adequate apical obturation had been performed.
Then the blunt end of a large paper point was
moistened with distilled water and left in the
canal for 3-4 hours to promote setting. After that
the paper point was removed and an endodontic
plugger was introduced inside the canal and was
lightly tapped against the MTA plug to confirm a
hardened set. The rest of the canal was obturated
with gutta-percha and ZOE sealer using lateral
condensation technique(5). The roots were
radiographed to determine if the root canals were
properly filled then the cervical access of each
canal was sealed with amalgam. Each root was
placed in a polyethylene vial containing 25 ml of
synthetic tissue fluid (STF) and incubated at
37°C. STF has the following composition: 1.7
gm of potassium dihydrogen phosphate
(KH2PO4), 11.8 gm of disodium hydrogen
phosphate (Na2HPO4), 80.0 gm of sodium
chloride (NaCl), and 2.0 gm of potassium
chloride (KC1) in 10 litter of distilled water (14),
(15)
.
The presence of apical calcified barrier of
each root was checked at weeks 1, 2, 3, 4, 5, 6, 7,
8 of the test period. At the end of the test period,
each root was taken out the STF and the total
length of the root with the calcified barrier was
measured by vernier as shown in figure 1.
Thickness of the formed apical calcified barrier
was obtained by subtraction 12 mm from the
total length as follow:
Thickness of barrier = Total length-12 mm
Comparison of the
surface while that formed by MTA had a glassy
appearance and regular surface.
The calcified barrier formed in 55% (n=11)
of the roots filled with Ca(OH)2 paste at the
beginning of 3rd week and 100% (n=20) of these
roots had apical calcified barrier at the beginning
of 4th week while this barrier began to form in
40% (n=8) of the roots filled with MTA at the
beginning of 5th week and 100% (n=20) of these
roots had apical calcified barrier at the beginning
of 7th week.
At the end of the test period, the thickness of
this barrier of all samples was measured by
vernier. The mean value of the apical calcified
barrier thickness was 1.099±0.214 mm in the
roots filled with Ca(OH)2 paste and 0.490±0.223
mm in the roots filled with MTA.
Figure 1: Measurement of the apical
calcified barrier
The statistical analysis of these results
showed highly significant difference (p<0.01)
between these two groups as shown in table 1,
and figure 2.
Table 1: The difference in the apical calcified
barrier thickness in mm
Mean±SD
Group 1 1.099±0.214
Group2 0.490±0.223
8.81
t-test
0.000
p-value
HS
Sig.
*P<0.01 High significant
1.099
1.2
1
0.8
Mean
calcified
0.490
0.6
0.4
RESULTS
After experimentally induced apexification,
gross evaluation of this phenomenon indicated
that the calcified barrier that formed by Ca(OH)2
paste had a chalky appearance and irregular
0.2
0
Group1
Group2
Figure 2: The difference in the means of
apical calcified barrier thickness
calcified
Vol. 22(1), 2010
DISCUSSION
Synthetic tissue fluid (STF) was chosen to
simulate the in vivo conditions in which
Ca(OH)2 paste and MTA were used as reported
by Sarkar et al. (14). It was an appropriate storage
media for Ca(OH)2 paste and MTA specimens
for in vitro tests as mentioned by Tziafas and
Economides (7), and Arch et al. (16).
After 8 weeks, the calcified barrier has been
formed in all samples. This emphasizes that the
formation of the apical calcified barrier can be
performed by the osteogenic potential of the
filling material without the involvement of
Hertwig’s epithelial root sheath as demonstrated
by West and Lieb(17),and Ohara and
Torabinejad(18).
The calcified barrier formed in MTA
specimens was more regular and uniform than
that formed in Ca(OH)2 paste specimens. This
may be attributed to its sealing ability and to its
ability to induce regular hard tissue formation as
reported by Shabahang et al. (19).
The formation of the apical calcified barrier
in the roots filled with Ca(OH)2 paste was faster
than in the roots filled with MTA. This result can
be attributed to that the Ca(OH)2 paste
dissociates directly into calcium and hydroxyl
ions, whereas calcium oxide (CaO) which
present within the composition of MTA reacts
with tissue fluid and gives Ca(OH)2 which then
can dissociate into calcium and hydroxyl ions as
mentioned by Holland et al.(8), this reaction
between CaO and STF might delay the formation
of the calcified barrier in the roots filled with
MTA.
The apical calcified barrier was thicker in
the roots filled with Ca(OH)2 paste as compared
with those filled with MTA. This can be
explained by the faster reaction of Ca(OH)2 paste
with the surrounding STF. Also, Ca(OH)2 paste
undergoes disintegration over time that lead to
continuous deposition of heavy hard tissue as
mentioned by Weine (20) while MTA does not
undergo disintegration because it is mainly
composed of an insoluble matrix of silica that
maintains its integrity even in contact with
periradicular tissues and permits a limited
reaction between its outer surface and
surrounding fluid as reported by Bakland(21) and
Fridland and Rosada(22).
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incisor. Endod Dent Traumatol 1985; 1: 146-9
18. Ohara PK, Torabinejad M. Apical closure of an
immature root subsequent to apical curettage. Endod
Dent Traumatol 1992;8:134-7.
19. Shabahamg S, Torabinejad M, Boyne PP, Abedi H,
Mcmillan P. A comparative study of root-end induction
using osteogenic protein-1, calcium hydroxide, and
mineral trioxide aggregate in dogs. J Endod 1999;
25(1):1-5.
20. Wein FS. Endodontic Therapy. 6th ed. St. Louis,
Mosby Year Book, Inc., 2004; Ch.2, P: 46.
21.Bakland LK. Management of traumatically injured
pulps in immature teeth using MTA. J Calif Dent Assoc
2000; 28(11):855-8.
22. Fridland M, Rosada R. MTA solubility and porosity
with different water-to-powder ratios. J Endod 2003;
29(12):814-7
calcified
Vol. 22(1), 2010
101
Comparison of the
Vol. 22(1), 2010
Effect of ultrasonic cinnamon
Effect of ultrasonic cinnamon extract on the
microhardness and microscopic features of artificial root
caries, compared to fluoridated agent
Shaimaa T. Al-Baldawy B. D. S (1)
Wesal A. Al-Obaidi B. D. S., M. Sc. (2)
ABSTRACT
Background: Cinnamon has a long traditional in use as a popular mouthwash, breath freshener and food flavoring,
in addition to its medical benefits. The purpose of this study was to test the effect of ultrasonic extract of cinnamon
on the microhardness before and after artificially initiated carious lesion of the outer dentin-root surface compared
with sodium fluoride and de-ionized water.
Materials and Methods: Thirty teeth of upper first premolars extracted from 11-14 year old patients, referred from
Orthodontic Department, College of Dentistry, Baghdad University. They were randomly divided to four study groups
and one control group. After production of initial carious like lesion of outer dentin surface, the teeth were immersed,
for four minutes of selected agents which were ultrasonic cinnamon extract (0.5%, 1% and 5%), sodium fluoride 0.05%
and de-ionized water. Then each tooth was rinsed and storage with de-ionized water. This procedure was repeated
daily for one week. Teeth were subjected to Vicker’s microhardness and microscopic examination before and after
the pH cycle and following the treatment with the selected solutions.
Results: Ultrasonic cinnamon extract and sodium fluoride were successful in elevation of the microhardness values of
demineralized dentin surface, this was statistically highly significant for cinnamon extract at (0.5% and 1%), and
sodium fluoride 0.05%, but significant with 5% cinnamon extract concentration, while the microscopic examination of
dentin-root ground section under light microscope revealed that zone of remineralization in dentin was seen after
treatment with all concentrations (0.5%, 1% and 5%) of ultrasonic cinnamon extract, and sodium fluoride, but it
revealed more with 0.5% cinnamon extract concentration.
Conclusions: The three concentrations of ultrasonic cinnamon extract were effective in remineralization of the outer
dentin-root surface; which was reflected by increase in dentin microhardness values.
Key words: Cinnamon, Microhardness, Root caries. J Bagh Coll Dentistry 2010; 22(1):101-104.
INTRODUCTION
Root caries is the predominant disease of the
tooth tissues which produced by acid
demineralization in exposed root surfaces;
therefore it is widely spread in elderly population
with periodontal disease (1). It has been estimated
that there are 250.000 to 500.000 species of plants
on earth (2). Relatively small percentages (1-10%)
of these are used as food for human and animal
species (3). It is possible that even more are used
for medicinal purpose like cinnamon (2).
Cinnamon is the inner bark of a tropical evergreen
tree. Because of cinnamon’s health benefits, it has
been used in many purposes as a food
preservative, flavoring agent in food, dental and
pharmaceutical preparations, toothpastes and
mouthwashes (4, 5). It has an active role as
anticariogenic agent and in treatment of toothache
and fight bad breathe (6). There is only one
available Iraqi research study the effect of water
cinnamon extract on the teeth microhardness but
in enamel (7).
(1)M. Sc. Student, Department of Pedodontic and Preventive
Dentistry, Dental Collage, University of Baghdad.
(2)Assistant Professor, Department of Pedodontic and Preventive
101
Beside all that, and because there is no
previous Iraqi studies regarding the effect of
ultrasonic
cinnamon
extract
on
the
remineralization of dentin-root surface, this study
was designed.
Thirty teeth of upper first premolars extracted
from 11-14 year old patients, referred from
Orthodontic Department, College of Dentistry,
Baghdad University. They were extracted
atraumatically as much as possible, washed with
de-ionized water, and then each tooth was stored
in 20 ml of de-ionized water to which 0.1%
thymol was added to prevent microbial growth.
Then teeth were kept in refrigerator at 4oC until
use. Teeth were molded by cold cure acrylic in
special models separately. The buccal block
surface was grinded by grinding machine and
silicon carbide grit paper finishing disc, firstly
with size 120, the speed was 250 rpm and for 30
second. The polishing was performed by size
2400 grit paper and certain cloth piece with nonfluoridated pumice by using the same time and
speeds. The final preformed surface was very
smooth and shiny for microhardness testing (8).
Vol. 22(1), 2010
The root surfaces were divided buccaly into
three equal parts (cervical, middle and apical),
adhesive circular tape was cut by using punch
pliers, size 3 mm in diameter and burnished on the
buccal surface of the root at the line that separate
between cervical and middle third using
burnisher; after that, an acid resistant nail varnish
was used to paint the tooth and block surfaces; the
adhesive tape was removed leaving a window on
the buccal surface. The molded teeth were
randomly divided to four study groups and one
control group. After production of initial carious
like lesion of outer dentin surface, the teeth were
immersed, for four minutes, individually in 20ml
of estimated solution from selected agents which
were ultrasonic cinnamon extract (0.5%, 1% and
5%), sodium fluoride 0.05% and de-ionized water.
Then each tooth was rinsed with de-ionized water
for two minute and restored in the de-ionized
water at 37oC for the next day. This procedure
was repeated daily for one week. Teeth were
subjected to Vicker’s microhardness and
microscopic examination before and after the pH
cycle and following the treatment with the
selected solutions.
that sound dentin surface that demonstrated as
clear and intact dentin surface shows in Figure 2,
while in Figure 3 a considerable loss of minerals
is shown by clear area of demineralization in the
outermost layer, with four zones of dentin-root
caries. Zone of remineralization in dentin was
seen after treatment with all concentrations (0.5%,
1% and 5%) of ultrasonic cinnamon extract, and
sodium fluoride 0.05%, but it revealed more with
0.5% cinnamon extract concentration as in Figure
4.
DT
D
Figure 2: Normal Sound Root Dentin,
(Ground Section 20X). D: Dentin, DT:
Dentinal Tubules.
RESULTS
Figure 1 revealed that ultrasonic cinnamon
extract and sodium fluoride were successful in
elevation of the microhardness values of
demineralized dentin surface, this was statistically
highly significant for cinnamon extract at (0.5%
and 1%), and sodium fluoride 0.05%, but
significant
with
5%
cinnamon
extract
concentration. However, none of the mentioned
agents able to increase the microhardness to
approximate the original values of sound dentin.
SZ
BZ
DZ
TLZ
Figure 3: Demineralized Root Dentin,
(Ground Section 20X). TLZ: Translucent
Zone, DZ: Dark Zone, BZ: Body Zone, SZ:
Surface Zone.
DISCUSSION
Figure 1: Comparison Microhardness Mean
Values of the Sound Dentin, after
Demineralization and Following Treatment
with the Selected Agents.
The microscopic examination of dentin-root
ground section under light microscope revealed
102
Prevention of dental caries is directed to
increase the resistance of teeth to acid attack by
the multiple fluoride therapy; but the use of
natural herbs as an alternative to conventional
treatment in healing and treatment of various
diseases has been on the rise of the last few
decades, one of such plants was cinnamon (2, 9).
Dentin microhardness was measured for sound
root-dentin, after demineralization and following
treatment with the chosen solutions. Statistically,
a highly significant reduction was found in the
microhardness of dentin surface after pH cycling
as an indication of dentin demineralization and
initiation of carious lesion. After treatment of
Vol. 22(1), 2010
root-dentin samples with the selected agents, there
was an elevation in the microhardness value.
MD
(a)
may be an indication of incorporation of ions that
decrease porosity and increase the microhardness
of demineralized dentin; such an observation was
not seen for samples treated with de-ionized
water. This was also confirmed by the
microscopic examination, which showed a zone of
remineralization in dentin after treatment with all
concentrationsMD
(0.5%, 1% and 5%) of cinnamon
extract, and 0.05% sodium fluoride. The increase
of dentin microhardness after application of
sodium fluoride may be related to the reaction of
fluoride ion with dentin surface in the form of
calcium fluoride (CaF2). CaF2 is the major product
by the reaction of fluoride with the dental apatite,
which precipitates wherever the hard dental
tissues are exposed to high concentrations of ionic
fluoride (9, 10).
Ca10 (PO4)6 (OH)2 + 20F- + 11H+
3H2 PO4- + 3HPO4= + 2H2O
MD
(b)
MD
(c)
MD
(d)
All that may increase tooth structure
mineralization, which may explain the increase of
the microhardness values of artificially initiated
caries. The MD
increase in the microhardness of
demineralized dentin surface was also recorded
following application of cinnamon extract at
0.5%, 1% and 5%. These results may be attributed
to their content of calcium and phosphorus ions
which are the major components of apatite crystal.
It is assumed that these elements are incorporated
in the outer dentin surface explaining the increase
in the values of the microhardness (11). There are
many elements other than calcium like manganese
and iron in the cinnamon extract (12); they may
substitute calcium ion of hydroxyapatite crystals
lead to decrease in the Ca/P molar ratio and
forming other crystals that may decrease the
microhardness of tooth structure, that may explain
the incremental amount of dentin microhardness
value decreased with increase cinnamon extract
concentrations, and that also agreed with the
microscopic examination (11).
REFERENCES
1)
Figure 4: Remineralized Root Dentin, after
Treatment with (a) 0.5% Cinnamon Extract.
(b) 1% Cinnamon Extract. (c) 5% Cinnamon
Extract. (d) 0.05% NaF. (Ground Section
20X). MD: Mineralized Dentin.
This elevation was significant for 5%
concentration of cinnamon extract solution, and
highly
significant
for
other
cinnamon
concentrations and sodium fluoride 0.05%. This
103
10CaF2 +
2)
3)
4)
Peter S. Essential of preventive and community
dentistry. 3rd ed. Arya Puplishing House. Darya Ganj.
New Delhi 2008.
Borris R. Natural products research: perspectives
from a major pharmaceutical company. J
Ethnopharmacol 1996; 51: 29- 38.
Cowan M. Plant products as antimicrobial agents.
Clin Microbio Rev 1999; 12 (4): 564-82.
Fine D, Furgang D, Barnett M, Drew C, Steinberg L.
Effect of essential oil-containing antiseptic
mouthrinse on plaque and salivary Streptococcus
mutans levels. Clin Periodo J 2000; 27: 157–67.
Vol. 22(1), 2010
5)
Al-Zubaidi L. Inhibition activity of bark cinnamon
extracts against some microorganisms to use in
ground meat preservation. A master thesis. Genetic
Engineering and Biotechnology Institute, University
of Baghdad 2005.
6) Takarada K, Kimizuka R, Takahashi N. A
comparison of the antibacterial efficacies of essential
oils against oral pathogens. Oral Microbiol Immunol
2004; 19 (1): 61- 4.
7) Shaker N. Effect of water extracts of cinnamon on the
microhardness and microscopic features of initial
caries-like lesion of permanent teeth, compared to
fluoridated agent. A master thesis. Collage of
Dentistry, University of Baghdad 2008.
8) Elwakeel A, Adel M. In vitro evaluation of the
remineralizing capacity of fluoride releasing
restorative materials at the internal cavity wall and
external margin. Cairo Dent J 2007; 23: 239-47.
9) Thylsrup A, Fejerskov O. Texbook of clinical
cariology. 2nd ed. Copenhagen: Munksgaard 1996:
111-49.
10) Saxegaard E, Valderhaug J, Rolla G. Deposition of
fluoride on dentin and cementum after topical
application of 2 percent NaF. In: Thylstrup A. Leach
S. Dentin and dentinreactions in the oral cavity.
Oxford: IRL. Press 1987: 199- 206.
11) Einsphar H, Bugg C. Enamel appatite and caries. In
the biological bases of dental caries. Harper and Row
publ Hagerstown 1980, 191-207.
12) Ensminger A, Esminger M. Food for Health: A
Nutrition Encyclopedia. Clovis, California: Pegus
Press 1986.
104
Vol. 22(1), 2010
Oral health status and
Oral health status and dental treatment needs in relation
to salivary constituents and parameters among a group of
patients with thyroid dysfunction
Yamama A. Al-Rubbaey B.D.S, M.Sc.(1)
Sulafa k. El-Samarrai M.Sc., Ph.D.(2)
ABSRTACT
Background: Thyroid dysfunction is a common disorder especially in women; this study was conducted to investigate
the effect of salivary constituents' changes on the dental, gingival and periodontal disease among patients with
thyroid dysfunction.
Materials and methods: A sample composed of 60 females patients with thyroid dysfunction (30 with primary
hyperthyroidism and 30 with primary hypothyroidism) (study groups), their age range was 20-25 years, while control
group composed of (30 females) matching with age, all females were examined using the criteria of WHO1987, and
periodontal parameters which include plaque index (PlI), calculus index (CalI), gingival index(GI), and Ramfjod index
for the loss of periodontal attachment.
Results: The total mean values of caries experience were found to be highest in the study groups as compared to the
control group, the same results were found for the all periodontal parameters. Salivary pH and flow rate were
observed to be lower among study groups compared to control group. There were weak correlations between
salivary organic and inorganic constituents and caries experience for both study and control groups.
Conclusion: Patients with thyroid dysfunction showed highly significant differences in dental caries and periodontal
diseases compared to control group. Patients with thyroid dysfunction need special attention for their dental health.
Key words: Thyroid dysfunction, dental caries experience, salivary composition. J Bagh Coll Dentistry 2010; 22(1):105108.
INTRODUCTION
Thyroid dysfunction is a common disorder
especially in women; and both genetic and
environmental factors are involved in its
pathogenesis (1). The major manifestations of
thyroid
dysfunction
are
hyperthyroidism,
hypothyroidism and goiter (2). Hyperthyroidism; is
due to excessive thyroid hormone secretion
(excessive
thyroid
function).
While
Hypothyroidism; due to deficient thyroid
hormone secretion (low thyroid function) and
goiter which means enlargement of the thyroid
gland, there may not be abnormal hormone
secretion. Most investigations have found an
increase in the prevalence of dental caries and
severity of periodontal disease among patients
with thyroid dysfunction (3-5). Several causes were
proposed as, the impact of the disease process
itself, or as a result of the surgical treatment
(thyroidectomy), in addition to medication taken
affected certain factors (risk factors) leading to
increase in the severity of oral and dental
diseases(6). Studies showed conflicting results in
salivary changes among patients with thyroid
dysfunction.
(1)M.Sc. Student, Department of Pedodontic and Preventive
(2) Professro, Department of Pedodontic and Preventive
105
An increase, decrease or no difference in the
salivary pH, flow rate in addition to some salivary
organic and inorganic constituents was reported
(7,8)
. The aim of the study was to investigate the
effect of salivary constituents changes on the
dental, gingival and periodontal disease among
patients with thyroid dysfunction and to compare
results with healthy subjects and correlate
between clinical and biochemical parameters.
MATRIAL AND METHODS
The study groups consisted of 60 females
patients with confirmed diagnosis of the disease
(30 with primary hyperthyroidism and 30 with
primary hypothyroidism), their age range was 2025 years, recorded according to the last birthday
(WHO, 1997). All patients were examined in two
different centers and one hospital in Baghdad city
(Nuclear Medicine Center, AL-Kindy Center for
Endocrinology and Diabetes Mellitus, and
Educational Baghdad Hospital).Those patients
were under the treatement of (propanolol and
carbimazole tablets for hyperthyroidism and
thyroxine hormone tablet for hypothyroidism),
while patients under other types of medication
were excluded from this study, in addition any
patient with thyroid dysfunction and any other
systemic disease like diabetes, hypertension …
etc was excluded from the study. A control group
Vol. 22(1), 2010
of (30 females) matching with age was examined,
at the College of Dentistry, they were those
accompanied dental patients, healthy looking
without any general health problem.
Salivary Samples
For each patient sample of stimulated saliva
was collected between 9.00 am and 11 am, at least
one hour after breakfast. The collection of
stimulated salivary samples from subjects was.
Within 15 minutes the pH of saliva was measured
using a digital pH meter, salivary volume was
estimated by measuring cylinder and the rate of
secretion was expressed as milliliter per minute
(ml/min). Each salivary sample was centrifuged at
3000 r.p.m for 40 minutes. The supernatants
samples were stored and frozen at -20ºC for the
subsequent analysis which was carried out in a
maximum period of three week
Periodontal Health Assessments
Oral examination was carried out using plane
mouth mirror and dental explorer, in addition to
blunt probes used for the detection of gingival
inflammation. All permanent teeth were examined
for recording of dental plaque, gingival condition,
calculus and clinical pocket depth. The
examination started with the buccal surface of the
tooth and followed by the mesial, lingual and
distal surfaces. The periodontal parameters
included plaque index(9) (PlI), calculus index(10)
(CalI), gingival index(11) (GI), and Ramfjod index
for the loss of periodontal attachment.
RESULTS
Table 1 represents the rate of secretion of
stimulated saliva expressed in ml/min, in addition
to the salivary pH and flow rate for both study and
control groups. Results showed that the total
sample of the salivary pH and flow rate were
highest in the control group when compared to the
study groups and these differences were
statistically highly significant (F= 5.33, P= 0.007,
df=2, F= 11.526,P <0.01, df=2) respectively.
Clinical examination showed that all females
were affected by dental caries. Caries experience
(mean value and standard deviation) of DMFS for
the study and control groups are presented in
Table 2. It is clear that the values of the total
sample of DMFS were higher in the study groups
as compared to the control group and these
differences were found to be statistically highly
significant (F= 15.416, df=2, P >0.01). According
to age, for the study groups, there were no
statistically
significant
differences
among
different age groups (P >0.05). For the control
group, there were statistically significant
differences among different age groups (DMFS,
F=3.263, df=2, P <0.05).
106
Table 3 and 4 demonstrates the correlation
coefficient between inorganic and organic salivary
constituents and caries experience in the study
and control groups respectively. For the
hyperthyroid group, all correlations were weak
and not significant with all variables (P >0.05)
only the correlation with triglycerides and DMFS
was statistically significant (P <0.05), while for
the hypothyroid group, only the correlation with
salivary iron and DMFS was statistically highly
significant (P <0.01). In the control group, only
the correlations with cholesterol and low density
lipoprotein with DMFS was statistically
significant (P <0.05) for cholesterol and highly
significant for low density lipoprotein (P <0.01).
The mean values and standard deviation of
plaque, gingival, calculus indices, in addition to
the pocket depth and loss of attachment are shown
in table 5. For all, results showed the higher
values of the total samples were observed among
the study groups as compared to the control group
with highly significant differences (P <0.01).
According to age groups, for the study and control
groups, a moderate plaque scores were recorded
for all age groups. Gingivitis was found in all of
the subjects examined. For the study, groups,
gingivitis was found to be of moderate type, for
the control group, gingivitis was of mild type.
Calculus index was of mild type for both study
and control groups.
DISCUSSION
Saliva plays a significant role in relation to
dental caries through both flow rate and
constituents (12). This study revealed a reduction in
the flow rate of stimulated saliva in study groups
compared to the control group, and these
differences were found to be statistically highly
significant. The reduction in salivary flow rate
may be associated with disturbances in the
salivary secretion which depends on thyroid
hormone production. It was suggested that
significant involvement of salivary glands occurs
in cases of thyroid dysfunction which indicate that
common mechanisms may frequently be operative
in the development of thyroid and salivary gland
immune disease(13). In another word, the reduction
in salivary flow rate is associated with the
reduction in buffer capacity and salivary pH, also
affects oral sugar clearance negatively, may cause
the increase in the severity of dental caries among
those with thyroid dysfunction(14,15,16). The
reduction in salivary flow rate as reported by the
present study may give an explanation of the high
caries experience among those with thyroid
dysfunction as shown in table 2.
Vol. 22(1), 2010
In this study, a weak negative highly
significant correlation was recorded between
salivary iron and DMFS for hypothyroid and
weak positive non significant correlation for the
hyperthyroid group. This may indicate the
presence of other factors affecting caries
experience among the study groups. Weak
negative significant correlations were recorded
between salivary cholesterol, and highly
significant for low density lipoprotein and DMFS,
among control group, the same correlation was
recorded between salivary triglycerides and
DMFS among hyperthyroid group no explanation
was able to be given, may be examining a larger
age group and a larger sample size may give more
obvious picture concerning these variables and
caries experience among the study groups. The
moderate type of gingival inflammation was
found to be the most common among patients
with thyroid dysfunction compared to the control.
The higher value of gingival index may be related
to the higher value of plaque and calculus index.
Table 1: Salivary pH and flow rate (means
and standard deviation) of the study and
control group
PH
Flow rate
Mean ±SD Mean ±SD
Hyper. 7.19 0.32 0.82 0.32
Hypo. 7.17 0.44 0.75 0.37
Control 7.43 0.23 1.11 0.21
Age (year) Groups
Total
Table 2: Caries experience of permanent
teeth (DMFS) among study and control
groups
Age group
DMFS
Groups
(years)
Mean ±SD
Hyper. 25.45 17.70
Total
Hypo. 20.52 8.8
Control 8.89 5.92
Dental plaque is considered to be the main
etiological factor for the gingival inflammation.
Previous Iraqi studies recorded highly significant
association between plaque and gingival
indices(17). The cause of increased the progression
of periodontal disease in patient with thyroid
dysfunction is still unclear, it may be related to
the decrease of serum level of thyroid hormones
may enhance periodontal disease related bone
loss, due to increase number of resorbing cells,
where as the tooth supporting alveolar bone seem
to be less sensitive to alteration in hormones
levels(5).
Table 3: Correlation coefficient between
salivary inorganic constituents and caries
experience in the study and control groups
Variable
Ca
Po4
Fe
Hyperthyroid Hypothyroid Control
group
group
group
r
p
r
p
r
p
-0.091 0.63 0.058
0.76 -0.061 0.75
-0.35 0.06 0.177
0.35 -0.082 0.67
0.152 0.42 -0.461** 0.01 -0.043 0.082
Table 4: Correlation coefficient between
organic salivary constituents and caries
experience in the study and control groups
Hyperthyroid Hypothyroid Control
group
group
group
r
p
r
p
r
p
-0.021 0.91 -0.09 0.64 -0.104 0.58
TP
0.033
Choles -0.026 0.89 -0.117 0.54
0.391*
TG -0.417* 0.022 0.035 0.86 0.353 0.06
HDL -0.083 0.66 0.189 0.32 0.383 0.07
0.043 0.82 -0.089 0.64
0.015
LDL
0.44**
VLDL -0.335 0.07 0.035 0.86 0.353 0.06
0.011 0.96 -0.05 0.79
TSH
Variable
Table 5: Plaque, gingival and calculus
indices, pocket depth and loss of attachment
(means and standard deviation) of the study
and control groups
PlI
Grou
Mean±
ps
SD
Hype 1.62±0.
16
r.
1.73±0.
Hypo.
16
Contr 1.21±0.
09
ol
GI
Mean±
SD
1.52±0.
16
1.50±0.
11
0.98±0.
20
CalI
Mean±
SD
0.72±0.
14
0.81±0.
17
0.17±0.
05
Po.D
Mean±
SD
3.61±0.
25
3.68±0.
12
2.66±0.
17
L.A
Mean±
SD
2.17±0.
49
2.15±0.
28
0.67±0.
96
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