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 Computer executives: Assistant Lecturer Dr. Muhammad Nahidh Linguistic referee: Prof. Dr. Hussain Faisal Al-Huwaizi Administrative secretary: Hadeel Abdul Wahab. For consultation, please contact: Website: www.baghdentistry.com E-mail: [email protected] Telephone: (+9641)4169375 Fax: (+9641)4140738 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: 1) Font size 18 and Bold for the title of the manuscript. 2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES. 3) Font size 12 Bold and italic for the names and addresses of the authors ex. Ahmed G. Husam 4) Font size 11 for the legends of the tables and figures. 5) Font size 10.5 for the text in the manuscript. 6) Font size 10 for the text inside the tables. 7) Font size 9 for the references at the end of the manuscript. Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand corner. Title of the manuscript: The title should be written with a capital letter for the first word as (Effect of the retention and stability….etc). Abstract and key words. The abstract should contain no more than 250 words. The abstract should be divided to the following categories: Background: (It contains a brief explanation about the problem for which the research was done as well as the aim of the study), Materials and methods:, Results:, and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article. The abstract should be written by the font Century Gothic size 8. Text. The body of the manuscript should be divided into sections preceded by the appropriate major headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES) which are written in bold and capital. Minor headings should be typed in bold and subheadings should be not bold but underlined. 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. Table 1). The tables should be done with a width of no more than 8 cm. Figures and illustrations. All figures must have a title placed below the figure. Identify figures with Arabic numbers (e.g. Figure 1). The figures should be done with a width of no more than 8 cm. 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. Restorative Dentistry 1 J Bagh College Dentistry 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: Restorative Dentistry The influence of different 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 2 J Bagh College Dentistry 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 Restorative Dentistry The influence of different 3 J Bagh College Dentistry 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. Restorative Dentistry The influence of different 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- 4 J Bagh College Dentistry Vol. 22(1), 2010 9. Asmussen E. Factors affecting the quantity of remaining double bonds in resin polymers. Scand J Dent Res 1982; 90:490-6. 10. Yearn JA. Factors affecting cure visible light activated composites. Int Dent J 1985; 35:218-25. 11. Peutzfeldt A, Sahari A, Asmussen E. Charecterization of resin composites polymerized with plasma arc curing unites. Dent Mat 2000; 16:330-6. 12. Vandewalle KS, Roberts HW, Tiba A, Charlton DG. Thermal emission and curing efficiency of LED and halogen curing lights. Oper Dent J 2005; 30(2):257-64. 13. Briso AL, Fedel TM, Pereira SM, Mauro SJ, Sundfeld RH, Sundefeld MLM. Influence of light curing source on microhardnes of composite resins of different shades. J App Oral Sci 2006; 14(1):10-5. 14. Yazici AR, Kugel G, Gül G. The Knoop Hardness of a Composite Resin Polymerized with Different Curing Lights and Different Modes. J Contemp Dent Pract 2007; (8)2: 52-9. 15. Hubbezoglu I, Bolayir G, Orhan Murat Dogan O. M,Arife Dogan , Özer A and Bek B. Microhardness Evaluation of Resin Composites Polymerized by Three Different Light Sources. Dent Mater J 2007; 26(6):845-53. 16. Hegde MN, Hegde P, Malhan B. Evaluation of depth of cure and knoop hardness in a dental composite, photoactivated using different methods. J Conserv Dent 2008; 11:76-81. 17. Cebllos L, Fuentes MV, Tafalla H, Flores J, Martinez A, Rodrigues J. Curing Effectiveness of resin composites at different exposure times using LED and halogen units. Med Oral Patol Oral Cir Bucal 2009; Jan: 14(1):51-6. 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. Restorative Dentistry The influence of different 5 J Bagh College Dentistry Vol. 22(1), 2010 The influence of different 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 Restorative Dentistry 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 J Bagh College Dentistry 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. Restorative Dentistry 7 J Bagh College Dentistry 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. Effectiveness of cure 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). Restorative Dentistry 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 J Bagh College Dentistry 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 Restorative Dentistry Effectiveness of cure 9 J Bagh College Dentistry 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 Restorative Dentistry 11- 121314- 1516- 17- 18- 10 Effectiveness of cure 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. J Bagh College Dentistry 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. Restorative Dentistry 11 J Bagh College Dentistry 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 Restorative Dentistry 12 J Bagh College Dentistry 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. Restorative Dentistry 13 Ear lobes as facial J Bagh College Dentistry 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). MATERIALS AND METHODS 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. Restorative Dentistry 14 J Bagh College Dentistry 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. Restorative Dentistry An evaluation of three 15 J Bagh College Dentistry Vol. 22(1), 2010 An evaluation of three 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. Restorative Dentistry 16 J Bagh College Dentistry 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. Restorative Dentistry An evaluation of three 17 J Bagh College Dentistry 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). MATERIALS AND METHODS 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. Restorative Dentistry 18 J Bagh College Dentistry 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 Restorative Dentistry Prevalence of dental attrition 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 J Bagh College Dentistry 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. Restorative Dentistry Prevalence of dental attrition 20 J Bagh College Dentistry 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 J Bagh College Dentistry 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). MATERIALS AND METHODS 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 Lactate dehydrogenase 22 J Bagh College Dentistry Vol. 22(1), 2010 Lactate dehydrogenase 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 (IHD) patients compared to healthy controls 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] (IHD) patients compared to healthy controls 0.672 0.021 0.87[NS] Age in years -272.91 -0.375 0.001 Male gender (compared to female) 102.887 0.211 0.05[NS] Body mass index (BMI)-categories 204.378 0.434 <0.001 Clinical Periodontal Sum Score (CPSS )- (tertiles) P (Model) = <0.001 R2 = 27.5% Backward elimination model 119.938 (Constant) -266.6 -0.367 0.001 Male gender (compared to female) 94.909 0.195 0.06[NS] Body mass index (BMI)-categories 205.306 0.436 <0.001 Clinical Periodontal Sum Score (CPSS )- (tertiles) 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 J Bagh College Dentistry 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 Lactate dehydrogenase 24 J Bagh College Dentistry 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) . MATERIALS AND METHODS 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 Oral and dental problems 32 J Bagh College Dentistry 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 Oral and dental problems 33 J Bagh College Dentistry 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 Oral and dental problems 34 J Bagh College Dentistry 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 dentistry, university of Baghdad. (2) Professor, department of oral diagnosis, college of dentistry, university of Baghdad. Oral Diagnosis 35 J Bagh College Dentistry 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 Control of recurrent 36 J Bagh College Dentistry 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. Control of recurrent 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 J Bagh College Dentistry 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), Control of recurrent 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 J Bagh College Dentistry Vol. 22(1), 2010 Control of recurrent 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 J Bagh College Dentistry 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 Control of recurrent 40 J Bagh College Dentistry 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 Control of recurrent J Bagh College Dentistry 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 J Bagh College Dentistry 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 Prevalence of severity 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 J Bagh College Dentistry 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. Table 3: Frequency and relative distribution of the signs of the TMDs according to sex Clinical signs of the TMDs Table 2: Frequency and relative distribution 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 Prevalence of severity 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 J Bagh College Dentistry Vol. 22(1), 2010 Prevalence of severity 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 J Bagh College Dentistry 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 Prevalence of severity 47 J Bagh College Dentistry 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 Prevalence of severity 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 often- discussed 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). 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J Orofac Pain 2001; 5:228-34. 10. Abdulla BA, Hussein SM. temporomandibular disorders among a sample of Mosul University Students. Thesis for degree of Master of Science in oral medicine .College of dentistry .University of Baghdad 1992. 11. Magnusson T, Egermark I, Carlsson GE. Treatment received treatment demand, and treatment need for temporomandibular disorders in 35-year-old subjects. Cranio 2002; 20:11-7. 12. Hiltunen K. temporomandibular disorders in the elderly, A 5-year follows up of signs and symptoms of TMD. [Thesis] the University of Helsinki, Institute of Dentistry, Mannerheimintie 172, Helsinki 2004. 13. De Kanter RJ, Truin GJ, Burgersdijk RC, Van´t Hof MA, Battistuzzi PG, Kalsbeek H, Käyser AF. Prevalence in the Dutch population and a metaanalysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993; 72:1509-18. 14. McNeill C. Management of temporomandibular disorders: concept and controversies. J Prosthet Dent 1997; 77: 510-22. 15.Nomura K, Vitti M, Oliveira AS, Chaves TC, Semprini M, Siéssere S, Hallak JE, Regalo SC. Use of the Fonseca's questionnaire to assess the prevalence and severity of temporomandibular disorders in braziliandental undergraduates. Braz Dent J 2007; 18(2):163-7. 16.Marklund S, Wänman A. Incidence and prevalence of myofascial pain in the jaw-face region, A one-year prospective study on dental students. Acta Odontol Scand 2008; 66(2):113-21. 17. Elfving L, Helkimo M Magnusson T. Prevalence of different temporomandibular joint sounds, with emphasis on disc-displacement, in patients with Oral Diagnosis Prevalence of severity temporomandibular disorders and controls. Swede Dent J 2002; 26: 9-19. 18. Al-Jundi MA, John MT, Setz JM, Szentpétery A, Kuss O. Meta-analysis of treatment need for temporomandibular disorders in adult nonpatients. J Orofac Pain 2008; 22 (2):97-107. 19. Glaros AG, Baharloo L, Glass EG. Effect of par functional clenching and estrogen on temporomandibular disorder pain. J Craniomand Pract 1998; 16: 78-83. 20. Egermark I, Carlsson GE, Magnusson T. A 20-year longitudinal study of subjective symptoms of TMD from childhood to adulthood. Acta Odontol Scand 2001; 59: 40-8. 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 J Bagh College Dentistry 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 J Bagh College Dentistry 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 Relationship between interlukine- 1 51 J Bagh College Dentistry 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 Relationship between interlukine- 1 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 J Bagh College Dentistry Vol. 22(1), 2010 Relationship between interlukine- 1 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). REFERENCES 1. Silverman SJr. Demographics and occurrence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. J Am Dent Assoc 2001; 132: 75-115. 2. Neville BW, Damm DD, Allen CM.,et al. Oral and Maxillofacial Pathology. 2nd ed. Phila., PA: Saunders 2002; 337-369. 3. Williams K. Interactions of polyamines with ion channels. Biochem J 1997; 325(pt2): 289-97. 4. Young MR, Wright MA, Lozano Y, Prechel MM and Petruzzelli GJ. Increased recurrence and metastasis in patients whose primary head and neck squamous cell carcinomas secreted granulocyte-macrophage colonystimulating factor and contained CD34 + natural suppressor cells. Int J Cancer 1997; 20: 74(1): 69-74. 5. Gleich LL, Biddinger PW, Duperier FD.and Gluckman JL. Tumor angiogenesis as a prognostic indicator in T2-T4 oral cavity squamous cell carcinoma: a clinical- pathological correlation. Head Neck 1997; 19: 276-80. 6. Chen Z, Malhotra PS, Thomas GR, et al. Expression of Proinflammatory and Proangiogenic Cytokines in Patients with Head and Neck Cancer. Clinical Cancer Research 1999; 5: 1369-79. 53 J Bagh College Dentistry Vol. 22(1), 2010 7. John MAR, Yang Li, Zhou X,Denny P,Ho CM., et al. Interleukin 6 and Interleukin 8 as potential biomakers for oral cavity and oropharyngeal squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 2004; 130: 929-35. 8. Schiper RG, Penning LC and Verhofstad AA. Involvement of polyamines in apoptosis-facts and controversies. Effectors or protectors? Semin Cancer Biol 2000; 10(1): 55-68. 9. Wang Y, Devereux W, Woster PM, Stewart TM, Hacker A, Casero RA. Cloning and Characterization of a Human Polyamine Oxidose that is Inducible by Polyamine Analogue Exposure. Cancer Research 2001; 61: 5370-3. 10. Wang W and Higuchi CM. Dietary Soy protein is associated with reduced intestinal mucosal polyamine. J Nutrition 2000; 130: 1815-20. 11. Wallace HM, Duthie J, Evans DM, Lamond S, Nicoll KM, Heys SD. Alterations in Polyamine Catabolic Enzymes in Human Breast Cancer Tissue. Clinical Cancer Res 2000; 6: 3657-61. 12. Fu S, Zou Y, Wang X and Liu X. Determination of polyamines in human prostate by high-performance liquid chromatography with fluorescence detect. J Chromatogr B Biomed Sci Appl 1998; 29:709(2): 297-300. 13. Venza M, Visalli M, Cicciu D and Teti D. Determination of polyamines in human saliva by highperformance liquid chromatography with fluorescence detection. J Chromatogr B Biomed Sci 2001; 5:757(1): 111-7. 14. Suh JW, Lee SH, Chung BC and Park J. urinary polyamine evaluation for effective diagnosis of various cancers. J. Chromatogr B. Biomed. Appl 1997; 688: 179-86. 15. Lee SH, Kim SO, Lee H and Chung BC. Estrogens and polyamines in breast cancer: their profiles and values in disease staging. Cancer Lett 1998; 133: 47-56. 16. Fabian, CJ, Kimler BF, Brady DA, Mayo MS et al. a phase П breast cancer chemoprevention trial of oral {alpha}-difluoromethyl ornithine: breast tissue, Oral Diagnosis Relationship between interlukine- 1 imaging, and serum and urine biomarkers. Clin Cancer Res 2002; 8: 3105-17. 17. Al-Hamad AKJ. Biochemical Evaluation of Polyamines as Tumor-Markers for Diagnosis of Various Types of Carcinoma. PhD thesis in clinical Biochemistry. College of Science Al-Mustansiriya University, Baghdad, Iraq 2003. 18. Kadhier AF. Spermidine, Spermine and Trace Elements Levels in Serum of Breast Cancer. MSC Thesis in Biochemistry. College of Science Al-Nahrain University Baghdad, Iraq 2004. 19. CañiZares F, Salinas J, Heras M.,Diaz J, Tovar I and Peñafiel R. Prognostic Value of Ornithine Decarboxylase and Polyamines in Human Breast Cancer: Correlation with Clinicopathologic Parameters Clinical Cancer Res 1999; 5: 2035-41. 20. Wang W, Liu LQ, Higuchi CM. Mucosal polyamine measurements and colorectal cancer risk. J Cell Biochem 1996; 63: 252-7. 21. Meyskens Jr, Gerner EW, Emerson S, Pelot D and Lagerberg W. Effect of alphadifluoromethylornithine or reactal mucosal levels of polyamines in a randomized, double-blinded trial for colon cancer prevention. J National Cancer Institute 1998; 90: 1212-8. 22. Porciani S, Lanini A, Balzi M, Faraoni P and Becciolini A. Polyamines as biochemical indicators of radiation injury. Physica Medicab 2001; 152:(1). 23. Graaf M, Schipper RG, Oosterhof GO, Schalken JA and Verhofstad AA. proton MR spectros copy of prostatic tissue focused on the detection of spermine, a possible biomarker of malignant behavior in prostate cancer MAGMA 2000; 10(3): 153-9. 24. Langkamp-Henken B, Johan LR, Viar MJ, Geller AM, Kotb M. Differential effect on polyamine metabolism in mitogen and superantigen-activated human T-cell. Biochim Biophys Acta 1998; 23: 1425(2): 337-47. 25. Chamaillard L, Catros-Quemener V, Delcros JG, Bansard JY and Havouis R. Polyamine deprivation prevents the development of tumor-induced immunesuppression. Br J Cancer 1997; 76(3): 365-70. 54 J Bagh College Dentistry 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. MATERIALS AND METHODS 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). J Bagh College Dentistry 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 The effect of a mouth rinse 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 Oral and Maxillofacial Surgery and Periodontology56 J Bagh College Dentistry 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. Oral and Maxillofacial Surgery and Periodontology57 The effect of a mouth rinse 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. J Bagh College Dentistry 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, Oral and Maxillofacial Surgery and Periodontology58 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 J Bagh College Dentistry 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 Oral and Maxillofacial Surgery and Periodontology59 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 J Bagh College Dentistry 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%, Oral and Maxillofacial Surgery and Periodontology60 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 J Bagh College Dentistry 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. 5. Horch HH. Iatrogen NervIasionen bei der zahnarztl Miitt 1984; 7: 708-715. Cited by. Int J Oral Maxillofac Surg 2001; 30: 333-8. 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 2001; 30: 333-8. 7. APPIAH-ANANE S, APPIAH ANANE MG. Protection of the lingual nerve during operations on the mandibular third molar: a simple method. Br J Oral Maxillofac Surg 1997; 35: 170-2. 8. 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. 11. 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 Path Oral Radiol Endod. 2004; 97: 438-446. Cited by. Jerjes W, EL-Maaytah M, Swinson B, Hopper C. experience versus complication rate in third molar surgery: Head face Med 2006; 2:14. 12. Berge TI, Boe OE. Predictor evaluation of postoperative morbidity after surgical removal of mandibular third molars. Act Odontol Scand. 1994; 52: 162-9. Cited by Jerjes W, El-Maaytah M, Swinson B, Hopper C. experience versus complication rate in third molar surgery: Head face Med 2006: 2:14. 13. 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. Saunders Company; 1993. P. 160. 15. Malamed S. Handbook of local anaesthesia. 3rd ed. Mosby St Louis; 1990. p. 153. Howe G L, Poyton H G. Prevention of damage to inferior alveolar nerve during the extraction of mandibular third molars. Br Dent J 1960; 109: 353-63. 16. Azaz B, Shteyer A, Piamenta M. Radiographic and clinical examination of the impacted mandibular third molar. Inter J Oral Surgery 1976; 5: 153. Oral and Maxillofacial Surgery and Periodontology61 17. 18. 19. 20. 21. 22. 23. 24. 25. Incidence of injury Andersen JO, Petersen JK, Laskin DM. Textbook & color atlas of tooth impactions. 1st ed. Mosby St. Louis Baltimore Boston London; 1997. P.473. Chiapasco M, De Cicco L, Marronr G. Side effects and complications associated with third molar surgery. Oral Surg Oral Med Oral Pathol 1993; 76: 412-20. Middlehurst RJ, Barker GR, Rood JP. Postoperative morbidity with mandibular third Molar surgery: a comparison of two techniques. J Oral Maxillofac Surg 1988; 46: 474-6. Bataineh AB. Sensory nerve impairment following mandibular third molar surgery. J Oral Maxillofac Surg 2001; 59: 1012-7. Sisk AL, Hammer WB, Shelton DW, Joy ED. Complications following removal of impacted third molars; the role of the experience of the surgeon. J Oral Maxillofac Surg 1986; 44: 855-9. Blackburn CW. A method of assessment in case of lingual nerve injury. Br J Oral Maxillofac Surg 1990; 28: 238-45. Root JP. permanent damage to inferior alveolar and lingual nerves during the removal of impacted mandibular third molars. Comparison of two methods of bone removal. Br Dent J 1992; 172: 108-10. Blackburn CW, Bramley PA. Lingual nerve damage associated with the removal of lower third molars. Br Dent J 1989; 167: 103-7. McGurk M, Haskell R. Wisdom tooth removal and lingual nerve damage. Br J Oral Maxillofac Surg 1998; 37: 253-54. J Bagh College Dentistry 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,* Oral and Maxillofacial Surgery and Periodontology62 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 J Bagh College Dentistry 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). Oral and Maxillofacial Surgery and Periodontology The prevalence of root 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 J Bagh College Dentistry 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. Oral and Maxillofacial Surgery and Periodontology The prevalence of root 64 J Bagh College Dentistry 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. Oral and Maxillofacial Surgery and Periodontology65 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 J Bagh College Dentistry Vol. 22(1), 2010 samples of patients with chronic periodontitis and normal healthy gingiva persons. MATERIALS AND METHODS 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 Oral and Maxillofacial Surgery and Periodontology66 Evaluation of salivary enzymes 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 J Bagh College Dentistry 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. REFERENCES 1. 2. 3. 4. 5. 6. Haffajee AD, Secransky SS, Goodson JM. Clinical parameters of predictors of destructive periodontal disease activity. J clinperiodontal 1983; 10: 257-65. Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic targets. Periodontol 2002; 28: 12-55. Armitage GC. Diagnosis of periodontal diseases [published erratum appears in J Periodontol 2004; 75:779]. J Periodontol 2003; 74(8):1237-47. Malamud D. Saliva as a diagnostic fluid. Br Med J 1992; 305:207-18. Kaufman E, Lamster IB. Analysis of saliva for periodontal diagnosis. J Clin Periodontol 2000; 27:453-65. Nagler RM, Lischinsky S, Diamond E, Klein I, Reznick AZ. New insights into salivary lactate dehydrogenase of human subjects. J Lab Clin Med 2001; 137: 363-9. Oral and Maxillofacial Surgery and Periodontology67 20. 21. 22. 23. Evaluation of salivary enzymes lonso de la Pena V, Diz Dios P, Lojo Rocamonde S, Tojo Siera R, Rodriguez-Segade S. A standardized protocol for the quantification of lactate dehydrogenase activity in saliva. Arch Oral Biol 2004; 49: 23-7. Pederson ED, Stanke SR, Whiener S J, Sebastiani PT, Lamberts BL, Turner DW. Salivary levels of α2macroglobulin, α1 antitrypsin, C-reactive protein, cathepsin G and elastase in humans with or without destructive periodontal disease. Arch Oral Biol 1995; 40: 1151-63. Markus R, Aaron Z. A manual for biochemistry protocols. Vol.3. World Scientific Publishing Co. Pte. Ltd. Singapore; 2007. P: 82. Ozmeric N. Advances in periodontal disease markers. Clin Chim Acta 2004; 343:1-16. Lang NP, Bartold PM, Cullinam M et al. International Classification Workshop. Consensus report: Chronic periodontitis. Annals of periodontology 1999; 4: 53. Todorovic T, Dozic I, Vicente-Barrero M, Ljuskovic B, Pejovic J, Marjanovic M, Knezevic M. Salivary enzymes and periodontal disease. Med Oral Patol Oral Cir BucaI 2006; 11: 115-9. Wendy A, Jean B. Clinical Chemistry. F. A. Davis Company. Philadelphia; 2007. P. 245-9. Nakamura M, Slots J Salivary enzymes. Origin and relationship to periodontal disease. J Periodontol Res 1983; 18:559-69. King GJ, Keeling SD, Wronski, TJ. Histomorphometric study of alveolar bone turnover in orthodontic tooth movement. Bone 1991; 12: 401– 9. Keeling S, King G, Valdez M. Serum and alveolar bone phosphatase changes reflect remodeling during orthodontic tooth movement. American J Orthodontics and Dentofacial Orthopedics 1992; 103: 320–6. Yamaguchi M, Shimizu N, Shibata Y, Abico Y. Effects of different magnitudes of tension-force on alkaline phosphatase activity in periodontal ligament cells. Journal of Dental Research 1996; 75: 889–94. Numabe Y, Hisano A, Kamoi K, Yoshie H, Ito K, Kurihara H. Analysis of saliva for periodontal diagnosis and monitoring. J Periodontology 2004; 40:115-9. Gaze DC. The role of existing and novel cardiac biomarkers for cardioprotection. Curr Opin Invest Drug 2007; 8 (9): 711–7. Awapara J, Seale B. Distribution of transaminases in rat organs. J Biol Chem 1952; 194:497-02. Emílio BS, Sérgio LS, José CF, Rosemary AC. Use of aspartate aminotransferase in diagnosing periodontal disease: a comparative study of clinical and microbiological parameters. J Oral Science 2003; 45(1) 33-8. Mc Culloch MW. Host enzymes in gingival crevical fluid as diagnostics indicators of periodontitis. J Clin Periodontol 1994; 21:497-506. Nakashima K, Gannoupolou C, Andersen E, Roehrich N, Brochut P, Dubrez B et al. A longitudinal study of various crevical fluid components as markers of periodontal disease activity. J Clin Periodontol 1996; 23:832-8. J Bagh College Dentistry 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). MATERIALS AND METHODS 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, University of Baghdad. 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 J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry 69 The effect of food simulants 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 J Bagh College Dentistry 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 The effect of food simulants 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 Orthodontics, Pedodontics and Preventive Dentistry 70 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. J Bagh College Dentistry 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 effect of food simulants 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 different studied group's Media 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. Orthodontics, Pedodontics and Preventive Dentistry 71 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). J Bagh College Dentistry Vol. 22(1), 2010 The effect of food simulants 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 Orthodontics, Pedodontics and Preventive Dentistry 72 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 J Bagh College Dentistry Vol. 22(1), 2010 The effect of food simulants 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 Orthodontics, Pedodontics and Preventive Dentistry 73 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 J Bagh College Dentistry Vol. 22(1), 2010 The effect of food simulants 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 different studied group's Media 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 Orthodontics, Pedodontics and Preventive Dentistry 74 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 J Bagh College Dentistry Vol. 22(1), 2010 REFERENCES 1. Gürsoy S, Güngör A, Şeşen Ç. Comparison of metal release from new and recycled bracket-archwire combinations. Angle Orthod 2005; 75(1): 92-4. 2. Kuhta M, Palvin D, Slaj M, Varga S, Varga ML, Slaj M. Type of archwire and level of acidity: Effects on the release of metal ions from orthodontic appliances. Angle Orthod 2009; 79(1): 102-10. 3. Sfondrini MF, Cacciafesta V, Maffia E, Massironi S, Scribante A, Alberti G, Biesuz R, Klersy C. Chromium release from new stainless steel, recycled and nickel-free orthodontic brackets. Angle Orthod 2009; 79(2): 361-7. 4. Staffolani N, Damiani F, Lilli C, Guerra M, Staffolani NJ, Belcastro S, Locci P. Ion release from orthodontic appliances. J Dent 1999; 27(6): 449-54. 5. Huang TH, Yen CC, Kao CT. Comparison of ion release from new and recycled orthodontic brackets. Am J Orthod Dentofacial Orthop 2001; 120(1): 68-75. 6. Huang TH, Ding SJ, Min Y, Kao CT. Metal ion release from new and recycled stainless steel brackets. Eurp J Orthod 2004; 26(2): 171-7. 7. Al-Joboury HM. The corrosion behavior and the biological effect of fixed orthodontic appliance in artificial saliva solution. A master thesis, Orthodontic 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 steel wires. Eur J Orthod 2005; 27(6): 533-40. 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 of orthodontic appliances. Part I. Biodegradation of nickel and chromium in vitro. Am J Orthod Dentofac Orthop 1993; 103(1): 8-14. 12. Duffó GS, Quezada CE. Development of an artificial saliva solution for studying the corrosion behavior of dental alloys. Corrosion 2004; 60(6): 595-9. 13. Ferriter JP, Meyers CE, Lorton L. The effect of hydrogen ion concentration on the force degradation rate of orthodontics polyurethane chain elastic. Am J Orthod Dent Orthop 1990; 98(5): 404-10. 14. Reed R, Holmes D, Weyers J, Jones A. Practical Skills in Biomolecular Sciences, 2nd ed, Pearson/Prentice Hall, 2003; p. 65. 15. Fontana MG and Greene ND. Corrosion engineering .2nd edition, Japan: Mc Graw-Hill Book Company.1982. 16. Lopez MF, Gutierrez A, Jimenez JA. The in vitro corrosion behavior of titanium alloys without vanadium. Electrochimica Acta 2002; 47(9): 1359-64. 17. Juraga I, Śimunović V, Śpanićek. Contribution to the study of effects of surface state of welded joints in stainless steel upon resistance towards pitting corrosion. Metalurgija 2007; 46 (3): 185- 9. 18. Hassoon AA. Ions release from new and recycled brackets and archwires. A master thesis. Orthodontic Orthodontics, Pedodontics and Preventive Dentistry 75 The effect of food simulants department, College of Dentistry, University of Baghdad, 2008. 19. Elshahawy W, Watanabe I, Koike M. Elemental ion release from four different fixed prosthodontic materials. Dent Mater 2009; 25(8): 976-81. 20. Vahed A, Lachman N, Knutsen RD. Failure investigation of soldered stainless steel orthodontic appliances exposed to artificial saliva. Dental material 2007; 23(7): 855-61. 21. Okazaki Y and Gotoh E. Metal release from stainless steel, Co-Cr-Mo-Ni-Fe alloys in vascular implants. Corrosion science 2008; 50(12): 3429-38. 22. Duffó GS, Farina SB. Corrosion behavior of a dental alloy in some beverages and drinks. Material chemistry and physics 2009; 115(1): 235-8. 23. Eliezer A, Medlinsky O, Haddad J, Ben-Hamu G. Corrosion fatigue behavior of magnesium alloys under oil environment. Material science and engineering 2008; 477(1-2): 129-36. 24. Al-Juhni AA, Newby BZ. Incorporation of benzoic acid and sodium benzoate into silicone coating and subsequent leaching of the compound from the incorporated coating, Progress Org coat 2006; 56(2-3): 135-45. 25. Rosliza R, Wan nik WB. Improvement of corrosion resistance of AA6061 alloy by tapioca starch in seawater. Current applied physics 2010; 10(1): 221-9. 26. Lin MC, Lin SC, Lee TH, Huang HH. Surface analysis and corrosion resistance of different stainless steel orthodontic brackets in artificial saliva. Angle Orthod 2006; 76(2): 322-9. 27. Kim H, Johnson JW. Corrosion of stainless steel, nickel-titanium, coated nickel-titanium, and titanium orthodontic wires. Angle Orthod 1999; 69(1): 39-44. 28. Luft S, Keilig L, Jäger A, Bourauel C. In-vitro evaluation of the corrosion behavior of orthodontic brackets. Orthod Craniofac Res 2009; 12(1): 43–51. J Bagh College Dentistry 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 Dentistry, University of Baghdad. (2) Professor, Department of preventive dentistry, College of Dentistry, University of Baghdad. 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). MATERIALS AND METHODS 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 J Bagh College Dentistry Vol. 22(1), 2010 Effect of in-dental clinic 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, Orthodontics, Pedodontics and Preventive Dentistry77 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 ). J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry78 Effect of in-dental clinic 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. J Bagh College Dentistry 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, University of Baghdad. (2) Professor, Orthodontic Department, College of Dentistry, University of Baghdad. Orthodontics, Pedodontics and Preventive Dentistry 79 J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry The effect of glucocorticosteroid 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 J Bagh College Dentistry Vol. 22(1), 2010 The effect of glucocorticosteroid 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 Orthodontics, Pedodontics and Preventive Dentistry 81 J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry 82 The effect of glucocorticosteroid 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. J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry83 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. J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry84 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 J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry85 J Bagh College Dentistry 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 20% water derum extract 3.157 0.034 30% water derum extract 10% methanol derum extract 0.945 0.372 20% methanol derum extract 6.113 0.007 30% methanol derum extract 3.933 0.017 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 20% water derum extract -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 REFERENCES 1. 2. 3. 4. 5. Khoory T. The use of chewing sticks in preventive oral hygiene. Clin Rev Dent 1983; 11-4. Wu CD, Darout IA, Skang N. Chewing sticks: timeless natural tooth brushes for oral cleaning. J Periodontal Res 2001; 36: 275-84. Pulger B, Gonuz A. Antimicrobial activity of certain plant used in Turkish traditional medicine. Asian J Plant 2004; 3: 104-7. Brchord R, Donald L, Kendral S, Fulcher R, Bey R. Antimicrobial activity of nature and naturalize plant of Minnesota and wisconsim. J Medicinal Plant Res 2008; 2(5): 98-110. Osman NA, Gafar SM, Salah el-Din M, Wassel GM, Ammar NM. Hazardous effect of topical cosmetic application of deirum (juglan regia plant) on oral tissue. Egypt Dent J 1987: Jan: 33(1): 31-5. Color Effects on acidogenicity Orange Weak effects Orange Orange Weak effects Weak effects Orange Orange Yellow Yellow Weak effects Weak effects No effects No effects Color of effective agent in Purple inhibition of acid formation 6. AlKhwaja AM. Studies in antimicrobial activity of juglan regia. Am J Chin Med 1997; 25(2): 175-80. 7. Dermani H, Nusayr T, Al-Hiyasut A. Effects of extract of miswak and derum on proliferation of Balb/c 3T3 fibroblasts and viability of cariogenic bacteria. Intern J Dent Hygiene 2006; 4(2): 62-6. 8. Johansson I, Birkhed D. Diet and the caries process. In: Thylstrup A, Fejerskov O. Text book of clinical cariology. 2nd ed. Munksgaard, Copenhagen; 1994. 9. Al-Ubaidi A. The prevalence of streptococcus mutans biotypes among preschool children. Master thesis, submitted to the college of Dentistry, University of Baghdad, 1993. 10. Al-Mizrakchi A. Adherence of mutans streptococci on the teeth surfaces: Microbiological and biochemical studies. Ph.D Thesis. College of Medicine, University of Al-Mustansiriyah, 1998. Orthodontics, Pedodontics and Preventive Dentistry86 J Bagh College Dentistry 11. Sulaiman A. Quantitative Measurement of urea content in saliva, acquired pellicle and dental plaque in relation to dental caries susceptibility in human adults. Ph. D. Thesis, College of Dentistry, University of Baghdad, 2000. 12. Baron E, Peteson L, Fingold S. Methods for Testing Antimicrobial Effectiveness. In: Bailey and Scotts diagnostic Microbiology. 9th ed. C.V. Mosby Co., St. Louis, USA; 1994. 13. El-Samarrai S. Major and trace elements contents of permanent teeth and saliva, among a group of adolescents, in relation to dental caries, gingivitis and mutans streptococci (in vitro and in vivo study). Ph.D Thesis, College of Dentistry, Baghdad University, 2001. 14. Clark AM, Jurgens TM, Hufford CD. Antimicrobial activity of juglon. Phytotherapy Research 1 990; 4(1): 1114. 15. Poyla GM. Biochemical targets of plant bioactive compounds. First ed. CRC/Press; 2003. p 384. 16. Jagtap AG, Karkera SG. Extracts of juglandaceae regia inhibits growth in vitro adherence, acid production and aggregation of streptococcus mutans. J Pharmacol 2000; 52: 235-42. Vol. 22(1), 2010 Effect of derum 17. Geissman TA. Flavonoid compounds, tannis, lignins and related compounds. In: Florkin M and Stotz EH (ed.). Pyrol pigments, isoprenoid compounds and phenolic plant constituents. Elsevier, New York, N.Y. (cited) 1963; 9: 265. 18. Urs N VRR, Dunleavy JM. Enhancement of the bacteriocidal activity of a peroxidase system by phenolic compounds (Xanthomonas phaseoli var. sojensis, soybeans). Phytopathology 1975; 65: 686-90. 19. Scalbert A. Antimicrobial properties of tannins. Phytochemically 1991; 30: 3875-83. 20. Manson TL, Wasserman BP. Inactivation of red beet beta-glucan synthase by native and oxidized phenolic compounds. Phytochemistry 1987; 26: 2197-202. 21. Nakahara K, Kawabata S, Ono H, Ogura K, Tanaka T, Ooshima T, Hamada S. Inhibitory effect of Oolong tea polyphenols on glucosyltransferase of mutans streptococci. Appl Environ Microbiol 1993; 59: 968-73. Orthodontics, Pedodontics and Preventive Dentistry87 J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry88 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). MATERIALS AND METHODS 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). J Bagh College Dentistry 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. Salivary insulin hormone 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 Orthodontics, Pedodontics and Preventive Dentistry89 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. J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry90 6. Salivary insulin hormone 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. J Bagh College Dentistry 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 Dentistry, University of Baghdad. (2) Professor, Department of Orthodontics, College of Dentistry, University of Baghdad. Orthodontics, Pedodontics and Preventive Dentistry91 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. MATERIALS AND METHODS 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. J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry92 Evaluation of buccal corridor 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. J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry93 Evaluation of buccal corridor 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 J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry94 Evaluation of buccal corridor 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 J Bagh College Dentistry 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). REFERENCES 1. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. 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Ackerman MB, Brensinger C, Landis JR. An evaluation of dynamic lip-tooth characteristics during speech and smile in adolescents. Angle Orthod 2004; 74(1): 43-50. 9. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod 2002; 36(4): 221-36. 10. Ghafari JG. Emerging paradigms in orthodontics—an essay. Am J Orthod Dentofac Orthop 1997; 111(5): 573–80. 11. Snyder RJ. Class II malocclusion correction: an American board of orthodontics case. Am J Orthod Dentofac Orthop 1999; 116(4): 424–9. 12. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofac Orthop 2000; 117(5): 567–70. 13. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992; 62(2): 91-100. 14. Swierernga D, Oeserle LJ, Messersmith ML. Cephalometric values for adults Mexican. Am J Orthod Dentofac Orthop 1994; 106 (2): 146-55. 15. British Standard Institution. Glossary of Dental Term (BS4492). London: BSI, 1983, [cited by: Jones ML, Oliver RG. W&H Orthodontic Notes. 6th ed. Oxford: Wright; 2000. p.62]. 16. Angle EH. Classification of malocclusion. Dent Cosmos 1899; 41(4): 248-64. 17. Foster TD. A text book of orthodontics. 2nd ed. Oxford: Blackwell Scientific Publication; 1985. 18. Ramadan OZ. Relation between photographic facial measurements and lower dental arch measurement in adult Jordanian males with class I normal occlusion: clinical and photographical study. A master thesis, Department of Pedodontics, Orthodontics, Pedodontics and Preventive Dentistry95 Evaluation of buccal corridor Orthodontics, and Preventive Dentistry, College of Dentistry, University of Mosul, 2000. 19. Ferrario VF, Sforza C, Schmitz JS, Miani A, Serrao G. A three-dimensional computerized mesh diagram analysis and its application in soft tissue facial morphometry. Am J Orthod Dentofac Orthop 1998; 114(4): 404 –13. 20. Al-Zubaydi FS. Evaluation of the gingival smile line in class I pattern in Iraqi sample aged 18-25: a comparative clinical and cephalometric study. A master thesis, Department of Orthodontics, College of Dentistry, University of Baghdad, 2005. 21. Kim JY, Lee SJ, Kim TW, Nahm DS, Chang Y. Classification of the skeletal variation in normal occlusion. Angle Orthod 2005; 75(3): 303-11. 22. Meneghini F. Clinical facial analysis. 1st ed. Springer-Verlag Berlin Heidelberg; 2005. p.16-7. 23. Ritter DE, Gandini JR, Santos Pinto ADS, Locks A. Esthetic influence of negative space in the buccal corridor during smiling. Angle Orthod 2006; 76(2): 198–203. 24. Jacobson A. Radiographic cephalometry from basics to videoimaging. 1st ed. Chicago: Quintessence publishing Co; 1995. 25. Zachrisson BU. Esthetic factors involved in anterior tooth display and the smile: vertical dimension. J Clin Orthod 1998; 32(7): 432-45. 26. Gosman SD. Anthropometric method of facial analysis in orthodontics. Am J Orthod 1950; 36(10): 749-62. 27. Ricketts RM. The biologic significance of the divine proportion and Fibonacci series. Am J Orthod 1982; 81(5): 351-70. 28. Ferrario VF, Sforza CH, Poggio CE, and Serrao G. Facial three-dimensional morphometry. Am J Orthod Dentofac Orthop 1996; 109(1): 86-93. 29. Moore T, Southard KA, Casko JS, Qian F, Southard TE. Buccal corridors and smile esthetics. Am J Orthod Dentofac Orthop 2005; 127(2): 208-13. 30. Woods GA. Changes in width dimensions between certain teeth and facial points during human growth. Am J Orthod Dentofac Orthop 1950; 35(9): 676-700. 31. Nasir DJ. Facial proportions and harmony of young adults sample: a clinical direct measurement study. A master thesis, Department of Pedodontics, Orthodontics, and Preventive Dentistry, University of Baghdad, 1996. 32. Blitz N. Criteria for success in creating beautiful smiles. Oral Health 1997; 87(4): 38-42. 33. Lundstrom A. Some asymmetries of the dental arches, jaws and skull, and their etiological significance. Am J Orthod 1961; 47(2): 81-106. 34. Ferrario VF, Sforza C, Serrao G, Colombo A, Ciusa V. Soft tissue facial growth and development computerized mesh diagram analysis. Am J Orthod Dentofac Orthop 1999; 116(2): 215-26. 35. Ackerman MB. Digital video as a clinical tool in orthodontics: dynamic smile design in diagnosis and treatment planning. Monograph: 29th Annual Moyers Symposium. Vol 40. Ann Arbor, MI: University of Michigan Department of Orthodontics, 2003. 36. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: part 2. Smile analysis of treatment strategies. Am J Orthod Dentofac Orthop 2003; 124(2): 116-27. J Bagh College Dentistry Vol. 22(1), 2010 Evaluation of buccal corridor 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 Orthodontics, Pedodontics and Preventive Dentistry96 J Bagh College Dentistry Vol. 22(1), 2010 Evaluation of buccal corridor 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) Mean S.D. S.E Mean S.D. S.E t-test 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) Mean S.D. S.E Mean S.D. S.E t-test 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 Orthodontics, Pedodontics and Preventive Dentistry97 J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry98 carbon dioxide from the tissue had a role as an initiating step in the formation of hard tissue barrier(7), (8). MATERIALS AND METHODS 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 J Bagh College Dentistry 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 Orthodontics, Pedodontics and Preventive Dentistry99 0.2 0 Group1 Group2 Figure 2: The difference in the means of apical calcified barrier thickness J Bagh College Dentistry 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). REFERENCES 1. Pinkham JR. Pediatric Dentistry. 3rd ed.Philadelphia. Saunders Company. 1999; Ch.12, P: 161. 2. Ghose LJ, Baghdady VS, Hikmat BYM. Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide. J Endod 1987; 13(6):285-90. Orthodontics, Pedodontics and Preventive Dentistry 100 Comparison of the 3. Al-Dahan ZAA. Apexification of immature apices of pulpless permanent anterior teeth without catalyst paste. J of College of Dentistry 1998; 3:75-90. 4. Cohen S, Burns RC. Pathway of the Pulp. 8th ed. St. Louis, Mosby Year Book, Inc., 2002; Ch.11, P: 415. 5. Torabinejad M, Chivian N. Clinical application of mineral trioxide aggregate. J Endod 1999; 25(3):197-205. 6. Ham K, Witherspoon D, Gutmann J, Ravindranath S. Preliminary evaluation of BMP-2 expression and histological characteristics during apexification with calcium hydroxide and MTA. J Endod 2005; 31(40):275279. 7. Tziafas D, Economides N. Formation of crystals on the surface of calcium hydroxide-containing materials in vitro. J Endod 1999; 25 (8) 539-42. 8. Holland R, Souza V, Nery MJ, Otoboni Filho JA, Bernabe PFE, Dezan FJ. Reaction of rat connective tissue to implanted dentin tubes filled with MTA or calcium hydroxide. J Endod 1999; 25(3):161-6. 9. Calt S, Serper A, Ozealik B, Dalat MD. PH changes and calcium ions diffusion from calcium hydroxide dressing materials through root dentin. J Endod 1999; 25(5):329-31. 10. Gaikwad B, Banga KS, Thakore AJ. Effect of calcium hydroxide as an intracanal dressing on apical seal: An in vitro study. J Endod 2000; 12: 7-12. 11. Goodell GG, Mork TO, Hutter JW, Nicoll BK. Linear dye penetration of a calcium phosphate cement apical barrier. J Endod 1997; 23(3):174-7. 12. Al-Atar AI. Evaluation of calcium and hydroxyl ions release from MTA mixed with four different vehicles: in vitro study. M.Sc. thesis, Department of Preventive and Pediatric Dentistry, College of Dentistry, University of Baghdad, 2003. 13. Al-Dahan ZAA. Apexification of immature apices of pulpless permanent anterior teeth without catalyst paste. J of College of Dentistry 1998; 3:75-90. 14. Sarkar NK, Caicedo R, Moiseyeva R, Kawashima I. Physiochemical basis of the biologic properties of MTA. J Endod 2005; 31(2): 97-100. 15. Welch S, William AP, Caicedo R, Moiseyeva R, Sarkar NK. Interaction between pulpal dentin surfaces and calcium-containing endodontic materials. J Dent Res 2005. 16. Arch G, Ritwick P, Caicedo R, Moseyeva R, Sarkar NK. Effects of water and a synthetic tissue fluid on selected properties of MTA. J Dent Res 2003. 17. West NM, Lieb RJ. Biological root end closure on a traumatized and surgically resected maxillary central 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 J Bagh College Dentistry calcified Vol. 22(1), 2010 Orthodontics, Pedodontics and Preventive Dentistry 101 Comparison of the J Bagh College Dentistry 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 Dentistry, Dental Collage, University of Baghdad. Orthodontics, Pedodontics and Preventive Dentistry 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. 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 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). J Bagh College Dentistry 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. Effect of ultrasonic cinnamon 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 Orthodontics, Pedodontics and Preventive Dentistry 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 J Bagh College Dentistry Vol. 22(1), 2010 root-dentin samples with the selected agents, there was an elevation in the microhardness value. MD (a) Effect of ultrasonic cinnamon 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 Orthodontics, Pedodontics and Preventive Dentistry 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. J Bagh College Dentistry 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. Orthodontics, Pedodontics and Preventive Dentistry 104 Effect of ultrasonic cinnamon J Bagh College Dentistry 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 Dentistry, Dental Collage, University of Baghdad. (2) Professro, Department of Pedodontic and Preventive Dentistry, Dental Collage, University of Baghdad. Orthodontics, Pedodontics and Preventive Dentistry 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 J Bagh College Dentistry 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). Orthodontics, Pedodontics and Preventive Dentistry 106 Oral health status and 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. J Bagh College Dentistry 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 REFERENCES 1. 2. 3. 4. 5. Orthodontics, Pedodontics and Preventive Dentistry 107 Oral health status and Strieder TG, Prummel MF, Tijssen JG, Endert E, Wiersing WM. Risk factors for and prevalence of thyroid disorder in a cross sectional study among healthy female relatives of patients with autoimmune thyroid disease. Clin Endocrinol Oxf 2003; 59(3): 396-401. Christopher, Edwards RW, Ian, Bouchire AD. Davidson’s principles and practice of medicine. 16th ed. Churchill Livingstone; 1991. Poumpros E, Loberg E, Engstrom C. Thyroid function and root resorption. Angle Orthod 1994; 64: 389-94. Pinto A, Glick M. Management of patient with thyroid disease. Am J Dent Assoc 2002; 133(7): 84958. Feitosa Ds, Marques MR, Casati MZ, Sallum EA, Nociti FH, De Toledo S. The influence of thyroid J Bagh College Dentistry Vol. 22(1), 2010 hormones on periodontitis-related bone loss and tooth supporting alveolar bone: A histological study in rats. J Periodontal Res 2008; October: 22. 6. Ayna B, Tumen D, Celenk S, Bolgul. Dental treatment way of congenital hypothyroidism. Case Report 2008; 1:1: 34-6. 7. Dixit PS, Ghezzi EM, Larger LA, Ship JA. The influence of hypothyroidism and thyroid replacement therapy on stimulated parotid flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endol 1999; 87(1): 55-60. 8. Rozmus A, Korczala K, Nowicka J, Ilewicz L, Parka D, Mlynarczy KB. Evaluations of salivary gland function in women with autoimmune thyroid disease. Wiladlek 2003; 56(9-10): 412-8. 9. Silness J, loe H. periodontal disease in pregnancy correlation between oral hygiene and periodontal condition. Acta Odont Scand 1964; 22: 121-35. 10. Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Perio 1959; 30: 51-9. 11. Loe H, silness J. 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Part 3, Saunders Elsevier: China; 1996. p.84-103. Jaafer N. Oral health status in relation to nutritional analysis and salivary constituents among a group of children with Down's syndrome in comparison to normal children. Ph.D. Thesis. College of Dentistry, University of Baghdad, 2009.