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CONTENTS
SCIENTIFIC ARTICLES
Periodontology
Effectiveness of nonsurgical periodontal therapy in conjunction with IL-1B polymorphisms
A. Mlachkova, Chr. Popova
3
Conservative Dentistry
A comparative study on the use of posts from dental practitioners and students
E. Boteva
9
Comparison of the root canal obturation methods in the preclinical endodontics
E. Boteva
13
Paediatric Dentistry
Children`s oral diseases in Rouse region – Epidemiological research, a part of the National Program of
Prophylaxis of oral diseases in children at the age of 0 – 18
M. Rashkova, L. Ribagin, Ts. Doganova, V.Alexieva
17
Parental role in relationship dentist - child
M. Georgieva, M. Peneva
29
Influence of the etching time on dentin bond strength of primary teeth – in vitro study
N. Gateva, R. Kabaktchieva
35
Prosthetic Dentistry
Chewing simulator“Sofia”– construction, working principle and possible application of the device. Part I
I. Ivanov, I. Chakalov
43
Construction of the chewing simulator“Sofia”– Basic modules, principle of functioning and possible
applications. part II.
I. Ivanov, I. Chakalov
Orthodontics
Epidemiological study of dental status and permanent canine erupt in children and adolescents aged 7 to 18
years
H. Arnautska, V. Krumova
48
52
Public Dental Health
Demographic processes and structure of the dental practices as prerequisites for market development of the
dental services in Bulgaria
K. Tzokov, L. Katrova
58
Review
Children with special healthe care needs and prevention of oral diseases in the population
L. Doichinova
63
Treatment of oral lesions in HIV and AIDS
A. Krasteva, Vl. Panov
74
3
Periodontology
Effectiveness of non-surgical periodontal treatment of chronic periodontitis in
conjunction with IL-1B gene polymorphism
Chr. Popova 1, A.Mlachkova2
Summary
Background: The accepted in last two decades paradigm for the pathogenesis of periodontal diseases
includes increased knowledge about effects of genetic factors in the initiation and progression of periodontitis.
It is suggested that IL-1B-single nucleotide gene polymorphism (different alleles of cytokine genes) influence on
susceptibility to periodontitis, on the progression of periodontal disease and on variations in clinical expression
and outcome to therapy.
Aim: The aim in this study was the identification of IL-1B genotype in patients with moderate
and severe chronic periodontitis and treatment evaluation in conjunction with IL-1B gene polymorphisms and
IL-1β expression.
Material and methods: The patients with chronic periodontitis were divided in two groups according to
treatment and were tested for IL-1B gene polymorphism in gingival tissue samples by single nucleotide
polymorphism (SNP) PCR. Analysis of the IL-1β gene expression deviations was performed in the same patients
by PCR.
Results: The results of this study show that patients having IL-1B C [3953 / 4] T and IL-1B T [-511] C
polymorphism demonstrate higher therapeutic efficiency with additional anti-inflammatory (Aulin®) compared
to conventional non-surgical treatment.
Conclusion: The presence of gene polymorphisms of IL-1B can determine susceptibility to periodontitis and
additional modulating therapy is more appropriate.
Key words: chronic periodontitis, IL-1B gene polymorphisms, single nucleotide polymorphisms, antiinflammatory therapy, IL-1β gene expression.
1
2
Assoc.Professor, PhD, Head of Dept of Periodontology, Medical University, Faculty of Dental Medicine, Sofia
Assist.Professor, Dept of Periodontology, Medical University, Faculty of Dental Medicine, Sofia
4
When discussing the clinical decisions in the
treatment plan for chronic periodontitis consideration
of the role of IL-1 genotype of the patient is not
recognized - for now there are no serious grounds to
believe that genotype-positive patients should be
treated differently from those who are genotypenegative for IL-1 gene polymorphism (8, 24, 25, 26,
27). The accepted concept for the influence of
genotype on periodontitis requires the establishment
of new therapeutic strategies that are focused on
controlling
genetic
factors
associated
with
mechanisms of bone destruction and loss of
attachment (11, 12, 18, 21, 22, 28, 30). The use of
additional
anti-inflammatory
agents
in
the
conventional antimicrobial therapy of chronic
periodontitis may modulate the response of the tissues
so as to reduce loss of bone and connective tissue
attachment in the presence of genetic susceptibility
associated with gene polymorphism (9, 10, 20, 23,
31). The development of an integrated approach to the
introduction of pharmacotherapy to target the body's
response is expected to lead to the establishment of
more effective and predictable periodontal therapy
and long term successful control of periodontitis.
Contemporary host modulation periodontal therapy
(Host modulatory therapy) is justified precisely by the
concept that it is possible to reduce tissue destruction
and to achieve periodontal stability by inhibition of
periodontal destructive aspects and / or stimulation of
protective and regenerative components of the host
response (13,14,15,17,23,28,30,33). There are clinical
studies showing effectiveness of the administration of
various non-steroidal anti-inflammatory drugs
(NSAIDs) in the treatment of inflammatory
periodontal disease (1,2,3,4,6,7,16,31,32), but no
definite answer in the literature regarding the
effectiveness of such adjunctive therapy in patients
with chronic periodontitis and predetermined
susceptibility to destructive response-related gene
polymorphisms and increased production of proinflammatory cytokines (IL-1).
Literature data suggests that additional antiinflammatory agents tend to show higher effectiveness
of treatment as measured by reduction in the levels of
pro-inflammatory cytokines and clinically by a greater
reduction in pocket depth and bleeding on probing,
and more gain of attachment (6,7,16,19,29,31).
More evidence is needed to demonstrate the
effectiveness of adjunctive therapy with NSAIDs in
the presence of genetic factors responsible for the
higher production of important pro-inflammatory
cytokines such as IL-1β, as the presence of a genetic
polymorphism of IL-1B.
Aim of this study is to evaluate the effectiveness of
the adjunctive therapy with NSAIDs in chronic
periodontitis compared to conventional non-surgical
therapy in the presence of IL-1β gene polymorphism
with clinical parameters and changes in the expression
of IL-1β in gingival tissues.
Material and methods
1. Selection of patients was made based on
clinical and radiographic diagnostic criteria. The study
included 30 patients with moderate (loss of
attachment from 2 to 4 mm) and severe periodontitis
(loss of attachment 4 to 6 mm, pocket’s depth 4-6mm,
alveolar bone loss 4-7 mm, measured on conventional
radiographs), without a periodontal therapy in the last
6 months, without systemic diseases and without
medication in the last 6 months, with a minimum of
20 teeth.
2. Clinical evaluation of periodontal status of
patients following clinical parameters measured:
Hygiene index - HI, Papillary bleeding index - PBI,
probing pocket depth in mm (Pocket depth - PD), loss
of clinical attachment in mm (Clinical attachment
level - CAL), width of attached gingiva in mm
(Attached gingiva width-AGW), gingival recession in
mm (Gingival recession - GR), furcation lesions in
horizontal probing
(Furcation involvement-F) classification of Hamp
1975 and teeth mobility qualification in grades 1 to 3.
3. Patients were grouped according to type of
treatment applied in the control group (cause-related
non-surgical - scaling and root planning (SRP), and an
experimental group (cause-related non-surgical
therapy and additional administration of NSAIDs
(Aulin - twice 100 mg daily for 14 days).
4. An analysis of gene expression alteration levels
of IL-1β in the gingiva of patients with chronic
periodontitis before and after the applied non-surgical
therapy was made. For this analysis was used one of
the most modern methods for testing the amount of
inflammatory mediators by gene expression changes
of IL-1β monitoring in gingival tissue of patients with
5
periodontitis by PCR (polymerase chain reaction) TagMan RT - PCR (5) .
5. A study of gene polymorphism of IL-1β in
material from gingival tissues of periodontitis patients
in both groups by the method of single nucleotide
polymorphism (SNP). PCR method for IL-1β gene
polymorphism detection was applied.
6. Statistical methods. Data were entered and
processed with statistical package IBM SPSS Statitics
19.0. Level of significance for rejecting the null
hypothesis was chosen as
p<0, 05.
The following methods were applied:
1. Descriptive analysis - in tabular form is the
frequency distribution of the signs at issue, by groups
of study.
2. Variance analysis - calculating estimates of
central tendency and dispersion.
3. χ2 test and Fisher accuracy test - to check the
hypothesis of a link between categorical variables.
4. Nonparametric test of Shapiro-Wilkie - to check
the type of distribution.
5. Nonparametric test of Mann-Whitney - for
hypothesis testing for difference between two
independent samples.
Control group
(without Aulin)
Index
ddCt (IL1β)
Results and discussion
Evaluation of the effectiveness of both kind of nonsurgical therapy administered in this study has been
made through changes in gene expression of IL-1β in
gingival tissues of patients with moderate and severe
chronic
periodontitis
and
established
gene
polymorphisms IL-1B C [3953/4]T ( rs_1143634) and
IL-1B
T[-511]C
(rs_16944).
Table 1 shows the change in gene expression
of IL-1β, depending on the applied therapy conventional or non-steroidal anti-inflammatory
complemented by an agent - Aulin .
The alteration (ddCt) in the expression of IL-1β in
the two groups of patients was compared. Patients
treated with additional Aulin, register suppression of
the expression of IL-1β. Comparative analysis of gene
expression in patients taking and not taking Aulin
showed that the administration of Aulin have
significantly higher average change in gene
expression compared to untreated with this drug
(table. 1) (p <0.05). Negative values ddCt in patients
in the control group reflect a lower degree of
inhibition of gene expression. Hence, in patients who
were not taking Aulin, the expression of IL-1β is
suppressed to a much lesser degree.
n
10
X
-
1,862
SD
1,461
Experimental group
(with Aulin)
n
SD
X
20
0,191
2,033
p
0,016
Table 1: Comparative analysis in the changes of gene expression of IL-1β in control and experimental
group.
6
Alleles
When comparing the gene expression of IL1β
according
to
presence of gene polymorphisms of IL-1B T [-511]
C with borderline significance
(p = 0.07) proved
the difference between the change in gene expression
in heterozygotes and homozygotes for the IL-1B [511] C. The average change is higher in
the relevant type of homozygotes genotype (Table
2).
n
16
Homozygotes
SD
X
0,32
2,34
n
14
Heterozygotes
SD
X
-1,39
1,78
p
0,568
Table 2: comparative analysis in the changes of
gene expression of IL-1 β according to genotype IL1B[-511] C
In a second study of genotype IL-1β C [3953 / 4] T
are not found statistically significant differences
between changes in gene expression of IL-1β in
comparison to patients with homozygotes and
heterozygotes in this genotype (p = 0.568) (table 3).
Homozygotes
N
18
X
-0,60
Heterozygotes
SD
2,35
n
12
X
-0.29
n
SD
X
a
2,26
C
13
0,84
T
3
-1,93
0,91
T/C
14
-1,39b
1,41
Table 4: Comparative analysis in the changes of
gene expression of IL-1β according to genotype IL-1B
T[-511] C
Table 4 shows that patients with C allele (genotype
of IL-1B T [-511] C) had significantly greater change
in gene expression of IL-1β than those with alleles T
and T/C (p<0,05). These data suggest a better healing
response to therapy and kave shown consistence with
relatively low risk of these patients to develop severe
periodontitis (data published in previous post).
Therefore, the result of this study indicate that
patients with C allele (genotype of IL-1B T [-511] C)
have moderate risk of developing severe chronic
periodontitits and showed good response to therapy by
the change in gene expression of IL-1 β.
According to genotype IL-1B C [3953 / 4] T the
difference between changes in gene expression of IL1β in patients with allele C, T and T / C have not
significant character (p>0.05) (Table 5).
p
SD
1,78
0,568
Table 3 Comparative analysis in the changes of
gene expression of IL-1β according to genotype IL1B C [3953/4] T
Alleles
C
T
T/C
n
15
3
12
X
a
-0,70
-0,07
-0,29a
SD
2,52
1,39
1,78
Table 5: Comparative analysis in the changes of
gene expression of IL-1β according to genotype IL-1B
C [3953/4] T
*- the same letters show missing of significant
differences
The investigation results show a higher efficiency
of additional anti-inflammatory agent therapy
(Aulin®) compared to conventional non-surgical
therapy indicated in patients with IL-1β gene
7
polymorphism C [3953 / 4] T and IL-1β gene
polymorphism T [-511] C.
Conclusions
1. It is established a higher efficiency of adjunctive
therapy with anti-inflammatory agent (Aulin®)
compared to conventional non-surgical therapy in
patients with chronic periodontitis and identified IL1B polymorphism C [3953 / 4] T and IL-1β
polymorphisms T [-511] C by demonstrating a high
degree of change in gene expression of IL-1β
(p<0.05).
2. It is established a better response to initial
periodontal therapy in patients with C allele (IL-1β
genotype T [-511] C) compared to those with alleles T
and T/C (p<0.05).
3. The results showed no statistically significant
difference between changes in gene expression of IL1β in response to therapy when comparing patients
with IL-1β C [3953/4] T homozygosis and
heterozygosis.
The findings from this study serve to supplement
the understanding of pathogenesis and treatment
approaches of periodontitis, greater clarity in the
individual planning and evaluation of the applied
therapy for chronic periodontitis. Genetic tests
determining the presence of gene polymorphisms of
IL-1β in clinical practice may be useful in predicting
the development of chronic periodontitis and response
to therapy and in the interpretation of the results to
therapy in individuals with chronic periodontitis.
Tests to identify the gene polymorphism of IL-1β can
be useful in planning and evaluating the effectiveness
of host modulations therapy for inhibition of the
production of IL-1β and to serve the planning of
future treatment and maintenance of periodontal
diseases.
Completed research project is under GRANT №
55, № 14/ 2010 contract funded by the Medical
University of Sofia, Council of Medical Science.
Reference
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Address for correspondence:
Assoc. Prof. Dr Chr. Popova
Faculty of Dental Medicine, MU-Sofia
1, St. G. Sofiiski Blvd, 1431 Sofia
Tel: 0888 75 90 49
Е-mail: [email protected]
9
Conservative dentistry
A comparative study on the use of posts from dental practitioners and students
E. Boteva 1
SUMMARY
Introduction: In the last decade there is a significant increasing in the post and core restorations after
endodontic treatments.
Aim: The aims of this study are to find the differences in the use of posts and pins from dental practitioners
and undergraduate students: the frequency of iatrogenic mistakes and their use in different types of teeth, what
types of post are most common.
Material and methods: 1860 x-rays of dental practitioners with 1291 endodontic treatments and 2116 root
canals were observed under magnification x5. 150 teeth with 156 posts were included in the study. The second
group of participants were patients of 124 students with the same number of teeth. The posts in this group were
314. The applied criteria was: type of the tooth, type of the post, length in the root canal, mesiodistal dimension
of each post and iatrogenic errors like – perforations, empty root canals and post bigger than 2/3 of the
mesiodistal root canal dimension.
Results: There is no evidence of the use of esthetic posts in this study. Most frequent is the use of posts in
incisors and premolar teeth in 81,3% from dentists and in 88% from students. The use in molars is respectively
18 and 11,5%. Students use posts and pins is equal, but dentists use more posts than pins. Casted posts and
cores are used more from students – 14,9%, than from dentists – 8,9%. These evidences suggest that in dental
practices the choice is based mainly on the lower price. Mistakes made from students are in 33,2% of the cases
and 45,5% from dental prctitioners.
Conclusions: Iatrogenic errors among students are 12,2 and among dentists 12,8%. For better treatment
outcomes will be very useful the choice of the posts, the fixation technique and radiographic conttrol to be
carefully revised for each patient.
Key words: endodontics, posts, posts and cores
1
Assoc.Professor , Department of Conservative Dentistry, Faculty of Dental Medicine, Sofia
10
Introduction
The use of posts for reconstruction of dental
crowns became a routine practice in the last two
decades, not only for incisors but for distal teeth too.
Different visions exist in the dental literature about
this problem. The traditional approach of replacement
of more than one wall or cusp with a post is more or
less based on the knowledge of preadhesive dentistry
era.
There is a long history of the use of posts. Back in
1839 and 1848 posts were already used for restorative
treatments of crowns ( Harris, Tomes ). Some authors
suggest that if the teeth are not quite destroyed, their
durability is longer without posts (Guzy, Trope,
Sidoly). Even without massive hard tissue loses,
MOD cavities are lowering tooth resistance up to 63%
( Reeh 1989 ). The fracture resistance is related to the
amount of remaining dentine, especially in buccolingual dimension and to the amount of preparated
root canal ( Stockton ).
On the other hand, in the last 15-20 years, prefabricated ready made posts are in use much more
often than casted post and cores. Their use is cheaper
and much faster (Torbjorner ).
In the dental literature eight are the retentive and
mechanical factors of posts (Hu.Y.H.): length,
diameter, type of post, type of cement and method of
cementation (Goss J.M.), dimension of the root canal,
its preparation and the place of the particular tooth in
the dentition (10-Stockton ).
The post and core method can result in iatrogenic
errors and complications leading to teeth extractions
or bone operative interventions.
In our dental literature this problem is published
recently only in one literature review and very few of
the main problems are looked at: length, diameter, and
length and diameter of the root canal and the type of
the post (1).
Problems like the frequency of use in different
groups of teeth (3,12) and the frequency of iatrogenic
errors in teaching practice are unknown (2,3).
Unknown is also the clinical application of the
teaching criteria of their use.
Aims
1. To register the differences in the technology of
the use of posts from GP,s and undergraduate dental
students.
2. To find out the frequency of complications.
3. To find the frequency of use of posts in
different groups of teeth.
4. To investigate what types of posts are in use
most and how they are used.
Participants in the first study group are patients of
the Dental Faculty in Sofia between 2008-2010. All
their previous posts and cores fixed not from students
were observed on x-rays, three per tooth, n=1860
total. All endodontically treated teeth were 1291 with
2116 root canals, from them 150 teeth were with 156
posts, two of them fixed on teeth with periapical
pathology.
Participants in the second group are patients of
124 dental students from 2008-2010, followed up with
x-rays. Total number of endodontically treated teeth is
1291 with 2116 root canals. Our follow up was on 319
teeth with 319 posts, plus 5 fixed on teeth with
periapical lesions. This makes 2.6 from the required 7
per student under the requirements of the clinical
course. Only 47 of these are casted, the rest more than
half were not followed up.
X-rays
X-RAYS of the treated teeth on Dick dental
radiographs are observed and registered for:
1. Type of the tooth with post : incisor, premolar,
molar.
2. Type of the post: screw post, cemented or
casted posts.
3. Length in the root canal:<1/2, up to ½, up to
2/3.
4. MD dimension of the root canal <1/3, up to 1/3
and up to 2/3.
5. Iatrogenic errors >2/3 and perforations.
6. Posts on large periapical lesions in 265 treated
lesions.
7. Posts in empty root canals
Exclusion criteria: x-rays with poor quality, and
teeth out of correct focus.
From 156 posts on 150 teeth 53 or 35.3% were
used for front teeth restorations. For restorations of
premolar teeth 69, 46.0% were used and only 23,
15.2% were fixed on distal teeth. Only few were the
posts fixed of third molars.
11
According to the type of fixation 94 were cemented
– 60.3% and 48, 30.8% were screw posts (endo pins).
Only 14, 9.0% were the casted post and cores.
Less than ½ of root canal length were 80, 51.3%,
up to ½ were 49, 31.4% and up to 2/3 were 17, 10.9%
of the posts. Less than 1/3 of the MD dimension were
37, 23.7%, up to 1/3 – 38, 24.4% and up to 2/3 were
50 or 32.05%. Over preparation of root canal dentine
Type of tooth
and sizes over 2/3 of MD dimension were found in 21
teeth or 13.5%, 4 perforations, 2.6% and in 11 cases –
7.0% were cemented in not filled root canals.
Type of post
MD dimension
Errors
Upto2/3 >2/3
30
125
I163
PM
119
М
37
Cem
132
Pins
135
Cast
47
<1/3
45
Upto1/3
125
<1/2
60
43
13
60
42
16
35
45
27
10
½
55
35
14
44
48
13
4
50
47
5
2/3
48
35
10
28
45
18
6
30
Table 1: X-ray valuation of posts of the GP,s, 3 Ro gr per one post (n=15)
51
15
Lenght
Lenght
Type of tooth
I
53
PM
69
М
23
МD dimention
Type of post
Cem.
94
Pins
48
Cast
14.
<1/3
37
Upto1/3
38
<1/2
29
41
8
53
25
2
35
18
½
21
20
11
30
12
7
2
16
2/3
3
8
4
9
5
3
4
Table. 2 X-ray valuation of the posts of the students, 3 Ro gr per post (n=319)
From all endodontically treated teeth 1291, 50%
were restored with posts and half were followed up 319, according to the protocols. From these 319, most
were used for incisors 163, 52.5% and premolars 119,
37.3% and less in distal teeth 37, 11.5%.
In relation to the method of fixation 132 were
cemented, 42%, 135, 42.9% were pins and only 47,
14.9% were casted.
Shorter than ½ of the root canal length were 116
posts, up to ½ were 104 and up to 2/3 - 93 posts. Less
than 1/3 of the MD dimension were 45 posts, up to 1/3
125 and up to 2/3 125 too. Over preparation of dentine
in the root canal and posts bigger than 2/3 were found
in 30 patients and only in one case a perforation.
Upto2/3
50
18
24
8
Errors
>2/3
21
8
9
4
In both groups in 457 posts esthetic posts are not
found.
Three figures with 13 x-rays of different posts are
available in the original paper in the magazine
Problems of dental medicine 2011,37,2, p.15-16
After treatment on present periapical lesions 2
posts were fixed from GP,s and 5 from the students.
This is understandable with the lack of time for follow
up of the cases. In the practice the mistakes
concerning fixation of posts in empty root canals were
more often (7% and 2,8%) due to the tutors control
among students and to so called “routine” among
practitioners. Another iatrogenic error was an over
preparation of the dentine walls in 13,5% in GP,s and
12
9,4% in the students. Perforations were 4 in the
practice and only 1 in the students group, although
students patients were twice more.
Summarizing the complications the GP mistakes
were 23,1% and 12,2% were they in the students
group. Non effective, short and thin posts were 22,4%
and twice less 11% among students. Only the short
posts, with length less than ½ of the root length were
80 – 51,3% fixed from GP,s and 116 – 36,4% fixed
from students. This makes all together poor quality of
the posts in the dental practice 45, 5%. Comparing
this data with the undergraduates – 33,2% suggests
that the final step of the endodontic treatment can
compromise the whole treatment.
The mistakes in the treatment of front teeth were
very often, nearly in half of the cases. In incisors the
access is not difficult the root canals are straight and
the visual inspection is easy. The errors show that the
accuracy in the choice anа technology is very poor.
Casted posts and cores were rare due to the time
consuming technology and higher price. The
advantages of prefabricated posts were published in
2010 on 112 teeth followed up for a period of 10 years
(3) and in 2007 (2) in 317 patients both in clinical
Reference
1. Ж.Миронова, Р.Василева. Съвременни
подходи в употребата на РЩ. Дентална медицина,
2, 2008, с.137-141
2. Bolla M. et all. Root canal posts for the
restoration of root filled teeth. Evid.Based Dent.
2007,8,2,pp.42
3. Gomes – Polo M.et al.A 10 year retrospective
study of the survival rate of teeth restored with metal
prefabricated posts versus cast metal posts and cores.
J Dent.2010,Aug.
4. Goss J.M. Radiographic appearance of
titanium alloy prefabricated posts cemented with
different luting materials. J of Prosthet.Dent.1992, 67,
5, 632
5. Guzy G.E. , Nicholls J.I. In vitro comparison
of
intact
endodontically
treated
teeth.
Endod.Dent.Traumat. 1985, 1,108-11
6. Harris.C.A.The Dental Art.,1839, Baltimore,
Armstrong and Berry, pp.305-347
7. Hu Y.H. et al Fracture resistance of
endodontically treated anterior teeth restored with four
studies. Most mistakes were made when screw posts
were fixed -6 cases.
Conclusions
1. Esthetic posts were not found in this study in
both groups.
2. Posts are use most in the treatment of incisors
and premolars and in molars only 18-11,5% of the
cases.
3. Students use equally screw posts and cemented
posts, GP,s use more cemented posts. Casted posts
were used more from the students- 14,9% to 8,9%.
4. The choice of the posts most often is related to
the lowest possible price.
5. Poor fixation is more often in GP,s 45,5%,
compared with 33,2% in students.
6. Useful recommendations for the practice are:
better attention of the the choice of the posts and their
combination with different materials, treatment
methods and techniques. A x-ray follow up can be
essential for a good treatment outcome.
post core systems. Quint.Int.2003. May,
34,5,pp.349 - 53
8. Mentink A., Meeuwissen R., Kayser A.,
Mulder J. Survival rate and failure characteristics of
the all metal post and core restoration. J Oral Rehabil,
1993, 20, 455-61
9. Reeh E.S., Messer H.H., Douglas W.H.
Reduction in tooth stiffness as a result of endodontic
and
restorative
procedures.
J
Endodontics
1989,15,512
10. Stockton L.W. Factors affecting retention of
post systems: A literature review, The journal of
prosthetic dentistry, 1999, 81, 4, 380-384
11. Trope M, Maltz D.O., Tronstad L. Resistance
to fracture of restored endodontically treated teeth.
Endod. Dent.Traumat.1985, 1, 108-11
12. Torbjorner A.,Karlsson S., Odmann P.A.
Survival rate and failure characteristics for two post
designs.J Prosthet .Dent.1995, 73, 4
Dr. Ekaterina Boteva
12
Conservative dentistry
Comparison of the root canal obturation methods in the preclinical endodontics
E. Boteva 1
SUMMARY
Introduction: The Step Back root canal preparation technique and cold condensation are methods taught
worldwide. Recently condensation is replacing the conventional root canal fillings, although they are not
universal by definition, indicators and contra-indicators.
Aim: The aim of the present study was to valuate the quality of root canal fillings with cold condensation
and conventional method and the produced microleakage.
Material and methods: 320 extracted, sound human molars, with 797 roots and 898 root canals were used
in the study. Cold condensation was used for distal canals of lower molars and lingual canals of upper molars.
Buccal and medial canals were filled with pasta and central Gutta cone. One to three years after treatment
teeth were treated for 24 hours in 2% methilene blue, rinsed up to 3 hours in running tab water and dried for 24
hours. All roots are cut twice, 1/3 from apex and 2/3 from apex.
Results were observed under magnification x5. Higher microleakage was found in the cold condensation
roots in their firs third (p<0.05). Under the conditions of thi study the conventional obturation method was
found to prduce lower microleakage.
Conclusions: The use of lower number of Gutta cones, but bigger as size is recommended.
Key words: root canals, obturation, endodontics.
1
Assoc.Professor , Department of Conservative Dentistry, Faculty of Dental Medicine, Sofia
14
Introduction
The Step Back root canal preparation technique
and cold condensation are methods taught worldwide.
They are present in 83% of the courses in the USA
and in all three faculties in Bulgaria (6). Recently
condensation is replacing the conventional root canal
fillings with similar use 89,6% and 100%, Although
they are not universal by definition, indications and
contraindications. According to the dental literature
the mean rates of success of endodontically treated
teeth is 7,5 years which is a very short duration.
Several studies are looking at the clinical qualities of
the endodontically treated teeth from 1987 to 2005
(7,5-13). In this mentioned studies the frequency rates
of failures are quite large from 21,7 to 63% and the
success rates even larger from 14% in Germany to
50% in Denmark in the year 2000. Most authors
accept 60-70% as successful scores (5-13). It is well
known that this rates decrease from incisors to molars.
The aim of the present study was to evaluate the
quality of root canal fillings with cold condensation
and central cone method during the endodontics
preclinical exam. To compare the microleakage
between dentine and root canal filling material and to
compare the efficiency of both methods.
TEETH: 320 extracted, sound human molars, with
797 roots and 898 root canals were used in the study.
Most teeth from the exam of four different tutors and
lecturers between 2004 and 2008 are included in the
study.
Techniques
Standard root canal treatment of sound matured
teeth was performed. Working length was detected
with x-ray method. Mechanical preparation was with
the Step Back method and all canals were medicated
with 3% sodium peroxide and with 0,5% NaOCl.
Obturation
Cold condensation was used for distal canals of
lower molars and lingual canals of upper molars.
Buccal and medial canals were filled with pasta and
central Gutta cone.
Microleakage
After keeping the teeth in the same conditions one
to three years after treatment they were treated for 24
hours in 2% methilene blue, rinsed up to 3 hours in
running tab water and dried for 24 hours. All roots are
cut twice, 1/3 from apex and 2/3 from apex. Results
were observed under magnification x5. 1554 cuts two
for each tooth were done with diamante blades and all
teeth were rinsed well under tab water. The results
were registered on the basis of presence or absence of
microleakage and if there is presence : 1/3 or 2/3 of
the space around of the filling.
Results
Significant differences in the groups of different
lecturers in the department were not found. This was
the main reason all teeth to be presented in the table 1.
It is well established from the table that the method
is standardized. Higher scores of microleakege
towards the crown are present in the cold
condensation group only up to 1/3 of the roots. A
possible explanation of this fact can be lower pressure
in the apical zone around the apical stop.
CCT with pasta and single cone is surprisingly
successful. This data is giving a better outcome of the
results than the x-ray controls after the treatment.
According to the x-rays our mean marks are 4.5-5.25.
Usually on this x-rays the examiners registers
deviations in the length of the root canal filling, air
bubbles or fractured instruments (1).
15
Method:
Penetratio
n of
methilene:
CC
1/3
Total n
Number
of root
canals
337
1/3
Up to 1/3
1/3
CC
CC
CCT
CCT
CCT
Mean in
group
%
94.8
16.6
56
16.6
Number
of root
canals
569
66
10.5
15.9
96
16
16.6
Up to 2/3
34
7.5
22.1*
125
20.8
16.6
1/3
Full
64
10.6
16.5
146
24.3
16.6
1/3
0
176
29.3
16.6
202
33.6
16.6
2/3
Total n
342
57
16.6
682
113.6
16.7
2/3
Up to 1/3
99
16.5
16.6
155
25.8
16.6
2/3
Up to 2/3
55
9.2
16.7
154
25.6
16.6
2/3
Full
47
7.8
16.6
133
22.2
16.7
2/3
0
141
23.5
16.6
175
29.2
16.7
Part of the
root canal
Mean
in group
%
Table 4 Microleakage in cold condensation (CC) and in central cone technique (CCT) ,*p<0.05
Discussion
It is well known from the literature that all
materials have microleakage at least up to one month
after root canal obturation (2). In the dental literature
higher microleakage has been observed between pasta
and gutta cones, than between pasta and dentine. Due
to this fact is the established in this study higher
microleakage in the CC group. For CC root canals are
enlarged more in the apical zone, where condensation
and pressure are more difficult. Aiming for a higher
number of cones in one root canal which was a
teaching dogma in the department is obviously not the
correct approach. Fillings with smaller number of
Gutta cones for CC can be much better for best apical
sealing results (12, 13 ).
Comparing our data with the one from Cardiff,
Wales, UK, from 157 teeth only 13% are acceptable
during the clinical course, likely due to gaps in the
preclinical teaching skills (9). The quality of
preclinical endodontics including a well balanced
clinical number of cases are a very important basis for
a successful clinical outcomes.
Success and failures in root canal treatment are
investigated from 306 published clinical trials from
1966 to 2004, Glickman (8). Unfortunately the quality
of teaching during the preclinical course is not
investigated in the literature.
Conclusions
1. Adhesion in root canals in both root canal
obturation techniques, teached in the department of
Conservative dentistry in Sofia is very good.
2. Under the conditions of this study CCT seems
to be better for students practicals method for root
canal obturation, when Step Back preparation
technique is applied.
3. The teaching of preclinical endodontics in Sofia
is very well standardized and very well practiced in all
lecture courses up to year 2008.
16
Reference
1. Ботева Е. Изследване на предклиничното
обучение по КЗ – ендодонтска част. Зъболекарски
преглед ,2011,2
2. Ботушанов П. Ендодонтия – теория и
практика 1998, Автоспектър, Пловдив, 401 – 418
3. Дачев Б. и кол. Ръководство за практически
упражнения по пропедевтика на терапевтичната
стоматология. 1990, Медицина и физкултура,
София 47-48
4. Ендодонтия 2002, под редакцията на
Б.Инджов, Медицинско издателство Шаров
5. de Chevigny C. et al. Treatment outcome in
endodontics : The Toronto study – phases 3 and 4.
JOE, 2008, 34,2,130-137
6. Cailleteau J.G., Mullaney T.P. Prevalence of
teaching apical patency and various instrumentation
and obturation techniques in US dental schools. J OE,
1997, 23, 394 – 6
7. Eleftheriadis G.I., Lambrianidis T.P. Technical
quality of root canal treatment and detection of
iatrogenic errerors in an undergraduate dental clinic.
Int.Endod J. 2005, 38, 725 – 34
8. Glickman G., A.Gluskin, W. Johnson,
L.Jarshen The crisis in endodontic education: current
perspectives and strategies for change. JOE 2005,
31,4,225 - 261
9. Hayes S.J., Gibson M., Hammond M., Brayant
S.T., Dummer P.M. An audit of root canal treatment
performed by undergraduate students. Int. Endod. J.
2001, 34, 501
–5
10. Qualtrough A.J., Whitworth J.M., Dummer
P.M.Preclinical endodontology: an international
comparison. Int. Endod.J. 1999, 32, 406 – 14
11. Schulte A., Pieper K., Charalabidou O., Stoll
R., Stachniss V. Prevalence and quality of root canal
fillings in a German adult population. A survey of
ortopantomograms taken in 1983 and 1992. Clin.Oral
Invest. 1998, 2, 67 - 72
12. Sonntag D. et al. Pre-clinical endodontics: a
survey amongst German dental schools. Int. Endod. J.
2008, 41, 863 – 868
13. Wu MK., Shemesh H., A.R. Wesselink.
Limitations of previously published systematic
reviews evaluating the outcome of endodontic
treatment. Int. Endod. J. 2009, 42, 8,656
Dr. Ekaterina Boteva
17
Paediatric dentistry
Oral status of children from Rousse district – Epidemiological research, part of
National program for prevention of oral diseases in children from 0 to 18 years in
Bulgaria
M.Rashkova 1, L.Ribagin1, Ts. Doganova2, V.Alexieva1
SUMMARY
Introduction. Epidemiological research in Rouse and Rouse region is a part of a National Prophylaxis
program of the children in Bulgaria.
Materials and methods. Epidemiological research of oral status of 723 children, using WHO method, was
held in Rouse and Rouse region. Children are at the age of 6, 12, and 18 years old, divided in groups of 60
children according their sex and place of living (town and village). Methods include evaluation of dental caries
(DMF), the results for diagnostic D3 was used. Oral hygiene (OHI), periodontal status of 18 years old children
(CPITN), existing orthodontic deformation and fluorosis were considered.
Results show that DMF- indexes of 6 years old children are 2,70±3,64, of 12 years old children –
3,80±2,67, and 18 years old - 4,9±3,36. Research shows that dental caries rises with the age. There are no
significant differences between boys and girls from town and village.
Oral hygiene index in 12 years old children is highest : OHI - 1,86±1,01, lower in 18 years old children 1,40±1,01 and is lowest in 6 years old children - 0,94±1,86.
Half of examined children have orthodontic deformation and 1, 9% of children have dental fluorosis. 45%
of 18 years old children are without periodontal diseases, but the rest of them have mostly localized gingival
diseases.
Conclusion: The oral status of the children in Rouse and Rouse region is with a complex pathology, as
caries progress with the age. Oral pathology and orthodontic deformity affect more than the half of the
children, included in the investigation. This refers a new preventive method in the treatment with the motivated
participation of both children and parents.
Key words: epidemiological research, National prophylactic program, dental caries, oral hygiene,
periodontal diseases, orthodontic deformity.
1
2
Faculty of Dental Medicine – Sofia, Department of Pediatric Dentistry
Dental center - Rouse
18
Introduction
Dental caries is the most common chronic disease
from the of age 5 to 18. (12.16). There has been a
decrease in dental caries in many countries of Western
Europe, North America and others at the end of the
last century. While in 1973, DMFT in 12 year group
was 4.8 , in England and Wales the index in the same
age group dropped to 1.2 in 1993. In Sweden, in 1964
DMFS (on surfaces) in 12 year old group was 40,
compared to 1994 when the same index was less than
1. In the Netherlands in 2008 DMFT a group of 12
year old children was registered with less than 1
,whereas in Canada the caries-free dentition was 41%
(12. – 19 years old) (8). In the U.S. in 2007. over 50%
of 5-9 year old children have at least one cavity or
filling (16).
Meanwhile, epidemiological studies show that
DMFT index in Eastern Europe is still high: in 1994.
in Latvia, DMFT, at 12 years was 7.0, in Poland - 5.1,
and in Hungary - 4.1 (8). In China (2007) have studied
2014 children aged 3-5, in the WHO criteria and
reported that 55% of the children had caries, 14% had
"rampant caries". In 5 year old children, 76% had
caries and DMF-T was 4.5 (10.19).
In 2003, WHO published the "World Report on
oral health - continuous improvement of oral health in
the 21st century - new goals" (15). In 2007 the 60th
World Health Organisation (WHO) adopted the
resolution "Oral health: action plan for promotion and
integrated disease prevention" (WHA60.17). These
are the documents that govern the programs and
activities to reduce tooth decay worldwide (20).
What is the status of the problem in Bulgaria?
Epidemiological study was conducted on children in
1982 regarding the WHO standards in 8 major
Bulgarian cities (N. Atanassov et al.). The results
showed: caries-free temporary teeth of children 6
years old - 12.77%; caries-free permanent teeth of
children 6 years old - 80.84%; DMFT 12 year olds 3.85; DMFT 18 year olds - 7.61; DMFT 35-44 year
olds - 16.53; DMFT 65 - 17.42, 18 year olds with at
least three healthy sextants by CPITN - 62.11% Data
are quoted on the first national meeting of the
Association of DDM, November 2011. Hisar (8).
Peneva,
Kukleva,
Kondeva
in
different
epidemiological studies discovered that tooth decay in
Bulgaria varies from 3 to 8 DMFT in children of
different age groups (1,2,3). In 2008. Peneva and
Rashkova made epidemiological research for
scientific purposes, which showed DMFT – 6 at 6
year old children in diagnostic threshold D3, which
rose to 10 when reversible carious lesions (diagnostic
threshold D1, D2) were includeed. 80% of children at
the age of 6 had caries. In the group of 12 year old
children, 80% had caries, and DMF-T was 4,3 in
diagnostic threshold D3, and rose up to 7 in the
diagnostic threshold D1. (4,5,6,7).
On 16th of April 2009 National program for
prevention of oral diseases in children 0-18 years was
adopted in Bulgaria with Protocol № 15 of the
Council of Ministers. (8). In 2010
national
epidemiological survey was conducted across the
country to record the oral health of children in
Bulgaria. Such large-scale epidemiological study has
not been performed in Bulgaria for over 20 years.
The aim of this article is to present an
epidemiological study of oral status of children in
Rousse District as part of the National program for
prevention of oral diseases in children 0-18 years in
Bulgaria.
The epidemiological study was conducted on 723
children 6, 12 and 18 years old. Age groups were
formed on the recommendation of WHO as target
matches for this type of study. Urban and rural
populations were examined. Formed groups are
represented in the following table 1:
city
sex
6y.
12y.
18y.
1♂
61
60
57
2♀
61
60
63
3♂
60
60
4♀
60
60
Table 1: Distribution of studied children.
village
59
60
For oral status registration, modified WHO card
was used for the needs of the study. Caries detection
with diagnostic threshold at D3 was registered
(clinically visible caries in dentin with cavity) (6).In
this study oral-hygiene status (OHI-S), periodontal
status by CPITN, presence of orthodontic anomalies
and dental fluorosis were also included.
19
From a statistical standpoint a SPSS-16 program
was used. The results are summarized in the following
chart 1.
4,9
3,8
2,7
DMF
Kids at 6y.
Kids at 12y
Kids at 18y.
Chart 1: Tooth decay in children examined by age group
The chart shows that DMF-T index rises with
aging. The differences between the age groups were
statistically significant (P <0,05). On average, three
teeth of 6 year olds were affected by caries, 4 teeth in
12 year olds and 5 teeth in 18 year olds. Number of
caries lesions had
fillings, others had tooth
extractions due tooth decay complications. The results
are divided by age groups. Tooth decay in children 6
years old. The results are presented on the chart 2 and
table 2, 3.
Chart 2: Tooth decay in 5-6 year olds-DMF (T + t)
Present DMF (T + t) at 5 to 6 year old children was
formed by the sum of carious lesions of temporary
and permanent teeth. No significant difference was
observed between boys and girls and between children
from urban and rural population (P> 0,05). There is a
20
slight tendency of lower tooth decay amongst girls.
The distribution of carious deciduous teeth and teeth
with fillings in children at the age of 6 is presented in
the following table 2.
Locations
sex
n
d
f
Df
mean ±SD
mean ±SD
city
1♂
61
2,05±2,64
0,43±1,11
2♀
61
2,36±3,16
0,23±0,74
village
3♂
60
2,55±3,00
0,47±1,18
4♀
60
2,12±2,86
0,25±0,81
t р
t1,2=0,59
t1,2=0,32
Р>0,05
t2,4=0,8
t3,4=1,16
t1,3=0,39
Table 2: dft of deciduous teeth in 6 years children
Legend: d- carious teeth, f- filled teeth, df-carious and filled deciduous teeth
Tooth decay presence in temporary teeth of
children at 6 years of age has no significant difference
between girls and boys, and between nonrural and
rural population (P> 0.05). The table shows an
interesting relationship between caries and restored
with fillings teeth: boys - 5 teeth with caries vs. only
Locations
sex
n
Dmean±SD
city
village
t p
one filling; girls - 8-10 carious teeth vs. one filling.
No difference was observed between the ratio of
carious teeth and restored teeth between children from
city and rural origin. The distribution of carious teeth
and restored teeth at 6 years old children are presented
in the following table 3.
DMF
M
F
mean±SD
1
♂
61
0,03±0,25
0
0
0,03±0,25
2
♀
61
0,11±0,52
0
0
0,20±0,81
3
♂
60
0,05±0,22
0
0
0,05±0,22
4
♀
60
0,03±0,25
0
0
0,03±0,25
t1,2=1,10
t3,4=0,38
Table 3: DMF-T of permanent teeth in 6 years old children
p>0,05
The results show no difference between girls and
boys, and between children from either the city or
country. It is noteworthy that in all age groups there is
no filling on permanent teeth. This is of particular
concern,because the age of 6 is the onset of the
occlusal caries in permanent molars. As shown it is
not reported neither by dentists, where an apparent
mean±SD
2,46±3,12
2,30±2,55
2,92±3,27
2,37±3,04
t1,2=0,32
t3,4=0,95
t1,2=1,5
t3,4=0,38
lack of a preventive approach is present, nor by the
parents of the children who probably are not aware
that their children already have tooth decay in
permanentmolars.
Tooth decay in 12 years children. Results are
presented on the next chart 3 and Table. 5.
21
DMF
4,07
3,92
3,77
3,46
♂
♀
♂
city
♀
vilage
Chart 3: Tooth decay in 12 year olds DMF (T + t)
Tooth decay in 12 year old chldren did not differ
between boys and girls and between from urban and
rural populations(P> 0,05). DMF index is between 3.5
and 4. Comparing our results obtained with the global
objectives for 2010 by WHO (20), which recommends
up to 3 DMF for 12 year olds may say that in the city
of Ruse and Ruse region overall, the average tooth
city
village
t Р
decay is relatively close to the recommended by
WHO. There is a part of children 12 years of age, still
having deciduous teeth, which decays are not a
significant part of total tooth decay. It is presented in
the following table 4.
sex
n
mean±SD
1♂
60
0,83±1,41
2♀
60
1,10±1,70
3♂
60
1,18±2,10
4♀
60
0,97±2,28
P> 0,05
t1,2=0,93
t3,4=0,54
Table 5: Tooth decay in deciduous teeth in 12 years children
The mean DMF-t index of 12 year old children,
includes primary teeth caries or restored with fillings
temporary teeth.
Tooth decay in permanent teeth of 12 year olds is
presented in the following table 5 including the
distribution of caries, fillings and extracted teeth due
of caries.
22
village
t Р
D
M
F
mean±SD
mean±SD
mean±SD
DMF
1
♂
60
2,03±1,86
0
0,93±1,22
Общо*
0,93±
2
♀
60
1,93±2,05
0,02±0,13
0,92±1,28
1,24
2,87±2,65
3
♂
♀
60
60
2,45±2,36
2,34±2,15
0
0
0,57±1,07
0,52±0,80
0,55±
2,83±2,4
2,87±2,22
sex
city
nn
4
t*=2,66
t1,2=1,10t3,4=0,38
0,95
р<0,05
mean±SD
2,93±2,20
t1,2=0,15t3,4=0,08
Table 5: Tooth decay in permanent teeth in 12 years. Children
restored with fillings teeth than the urban children.
This fact is supported with statistical confidence (p
<0,05).
Tooth decay in 18 year olds. The results are
shown in chart 4 and Table. 6.
The table shows that there is no significant
difference of DMF-T for 12 years old children of rural
and nonrural populations and between boys and girls.
In the whole group there is only one child with a tooth
extraction due to caries, which is in the group of girls
from the city itself. It is noteworthy that the ratio of
carious teeth and restored with fillings teeth is 2:1,
while the rural population at 12 years have twice less
DMF
5,29
4,97
4,6
♂
4,73
♀
city
♂
♀
village
Chart 4: Tooth decay at 18 year old children (DMF-T)
23
Locations
city
village
Т Р
sex
n
D
mean±SD
M
mean±SD
F
mean±SD
DMF
mean±SD
1
♂
57
2,40±2,37
0,04±0,18
2,18±2,52
4,6±3,21
2
♀
63
2,14±2,40
0,06±0,3
2,81±2,2
4,97±3,13
3
♂
59
2,17±2,45
0
2,46±2,38
4,73±4,22
4
♀
60
Р> 0,05
2,80±2,76
0,05±0,28
2,57±2,41
5,29±2,76
t1,2=0,63
t3,4=0,85
t1,2=0,59
t3,4=1,31
t1,2=0,61
t3,4=1,33
t1,2=1,47
t3,4=0,48
Table 6: Distribution of 18 years. children in Rousse Distric performance of the DMF-T index
are almost the most common teeth linked to tooth
There is a trend that correlates the increase in DMF decay. Unfortunately there are extractions due to
with age, for instance an increase in the number of caries and its complication. Nine children from 239
DMF to 5 in 18 years old children. Again, there si no registered in this group had an extracted tooth because
differences between boys and girls and children from of caries, which represents 3.76% of the children.
urban and country areas (P> 0.05).
Proportion of children without caries are grouped
There are no differences between the number of together in three age groups. The results are presented
teeth with tooth decay of children in urban and in Table 7.
country areas and between boys and girls. Filled teeth
5 -6 years.
city
village
total
city
37,7%
41,5%
39,6%
22,3 %
Table 7: Proportion of children without caries
12 years.
village
20,8%
total
21,6%
city
19,2%
18 years.
village
3,4%
than in the city (p <0.05). This trend is alarming,
especially since childhood is the most suitable period
for prevention and halting the development and
progression of tooth decay.
2. Oral - hygien status of children from Rousse
region. Summarized results are presented on chart 5.
It is noteworthy that children without caries
decreased rapidly with age. They are approximately
40% of 6 years old children, twice as less in 12 years
old children and only 11% of children around 18
years. Children without caries are less in the country
OHI
1,4
Kids at 18y.
1,86
Kids at 12y.
0,94
Kids at 6y.
0
Chart 5: OHI of children studied
0,5
total
11,3%
1
1,5
2
OHI
24
The chart shows that oral hygiene index (OHI) of 6
year old children on average is less than 1, which is
explained by lesser plaque retention in temporary
teeth, despite the insufficient oral hygiene linked to
these children. In the group of 12 year old children,
OHI is rising and close to 2. Neglect of oral hygiene
in this group of children is explained by puberty. In 18
year old children a drop in OHI is reported because of
an improved oral hygiene.
30%
3. Teeth and jaw deformities in children from
Rousse region. The results are shown in chart. 6 and
Table. 8.
45%
without DFD
light DFD
25%
severe DFD
Chart 6: Dento-facial deformities (DFD) in children studied
Children without teeth and jaw deformities are
approximately half of all examined children. The rest
are distributed amongst children with mild to severe
orthodontic and dentofacial deformities, the milder
ones are prevailent. This is a fact that requires special
attention, especially since a minor part of children
examined had an orthodontic treatment during the
examination. The distribution of teeth and jaw
deformities studied in children by age groups is shown
in table 8.
age groups
without GFD
1-st degree
2-nd degree
total
Kids at 6y.
number
164
%
67,5%
number
45
%
18,5%
number
34
%
14,0%
number
243
%
100%
Kids at 12y.
71
29,5%
58
24,0%
112
46,5%
241
100%
Kids at 18y.
92
38,5%
74
31,0%
73
30,5%
239
100%
Independent
t1,2=9,05
T-test
P<0,05
Table 8: GFD surveyed children ages
t1,2=1,50
P>0,05
t1,3=4,44
P<0,05
25
There are significant differences in the distribution
of orthodontic deformities and severity in all three age
groups (X2 = 96.15, P <0.05). Children without
orthodontic deformities are significantly more in the
group of 6 year old children (P <0,05). Mild
orthodontic deformities are distributed evenly in the
three age groups. Severe orthodontic deformities are
less at 6 year old children (P <0,05), affecting
approximately half of the 12 year old children and one
third of the 18 year old children.
4. Periodontal status of 18 year old children from
Rousse region. CPITN index was used to objectify
periodontal status for epidemiological studies adopted
by WHO. The results are presented on the next charts
7,8 and Table 9.
CPITN
34%
with code 0
45%
with code 1
21%
with code 2
Chart 7: Periodontal status in '18 children
45,20%
20,90%
11,70%
7,50%
with 6 sextants
5,90%
with 4 sextants
6,30%
2,50%
with 2 sextants
Chart 8: Healthy sextants by CPITN at 18 years old
with 0 sextants
26
group kids
Boys
Girls
total
Х2
code 0
numbar
%
46
39,7%
62
50,4%
108
45,2%
CPITN
code 1
numbar
%
30
25,9%
20
16,3%
50
20,9%
code 2
numbar
%
40
34,5%
41
33,3%
81
33,9%
Х2 = 4,181 Sig=0,124
total
numbar
116
123
239
%
100%
100%
100%
P>0,05
Table 9: CPITN at 18d. children, disaggregated by gender
45% of children at 18 years of age have a healthy
periodontium. In 34% code 2 was registered, which
means significant gingival inflammation and calculus
in at least one of the examined sextants, without
affecting the alveolar bone. In 21% of children mild
gingival inflammation is was noticed - code 1.
There are no reliable differences in periodontal
status between boys and girls (P>0,05). The
distribution of healthy sextants in 18 years old
children is presented to the chart 8.
Almost half (45.2%) of the children studied, were
with 6 healthy sextants. These are children with a
healthy periodontium. 34.3% of children had 5,4 or 3
healthy sextants. The share of children with 0, 1, 2
healthy sextants was 20.5%. These are children with
severe generalized gingival inflammation. It can be
concluded that children from 6 to 3 healthy sextants
were 79.5%.
5. Comparison of the results of an
epidemiological study of children from district of
Rousse with the global objectives of the WHO for
2010.
WHO - recommended for the following purposes oral
The District Rousse, in 2010. results of the WHO
health for 2010:
criteria are:
50% of children 5-6y., not be affected by caries;
36.6% of children 5-6y. are not affected by caries;
Children of 12 years with no more than 3 DMF;
Children of 12 years are with 3,8 DMF;
85% of 18 year olds do not have a tooth extracted;
96.24% of 18 year olds have no a tooth extracted;
90% of 18 years of age to have 3 healthy sextants by
79.5% of 18 years of age have three healthy sextants by
CPITN.
CPITN.
Table 6: Comparison of the results of an epidemiological study of children from district of Rousse with the
global objectives of the WHO for 2010
27
Comparative analysis of WHO criteria shows that
36.6% of 6 year old children are free of caries,
which is lower than recommended by WHO. In 12
year old group DMF index is close to the
benchmark. 18 year old children in our study had
teeth extracted 10% more than recommended.
Children with a healthy periodontium up to 3
sextants in our study were 10% fewer than
recommended. Although our indicators are close to
the recommended by WHO, the analysis of the oral
status of children in Rousse region shows a lack of
preventive approach in the treatment of tooth decay,
untreated orthodontic anomalies and in half of the
children - gingivitis of varying severity.
Conclusions
1. Children of Rousse District have an average of 3
tooth caries at 6 years of age, 4 at 12 years and 5 at
18. There are no differences between boys and girls
and between children from the city or country in the
area.
2. The proportion of children without tooth decay
sharply decrease with age to reach 11% at 18.
3. Oral hygiene deteriorated significantly in 12 year
olds and improved in 18 year olds.
4. Over 50% of children have orthodontic
deformities.
5. 45% of 18year old children had a healthy
periodontium, and the rest had mainly localized
gingival inflammation.
Reference
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В.,
М.Куклева,
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С.Рималовска. Оклузален и проксимален кариес
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7. Пенева М, Пътят за преминаване от
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World Health Organization (WHO), International
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Ogawa H. Oral health information systems –
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28
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Maya Rashkova, Associate professor, DM
Department of Children's dental medicine,
Faculty of Dental medicine, MU-Sofia
e-mail: [email protected]
29
Parental role in relationship dentist – child
M.Georgieva1, M.Peneva2
SUMMARY
Introduction:. Good communication between dentist, child and parent provides a basis for quality
treatment.Parental role in this triangle is less clear although it seems to give a great part of existing child
dental fear in last few years.Dentists face the challenge to treat children who have self-discipline problems and
could not cope with new difficult situation such as dental treatment.Parents have unreal expectations for his
child behaviour and great expectations for dentist who choose behaviour management strategy.The aim of this
study is to investigate parental role for child dental fear.For this purpose 30 children at the age between 3-4
years old from kindergarden in Sofia were examined.Each child completed drawing test and questionnaire in
order to determine their anxiety.Each parent completed a questionnaire for define their emotional intelligence
and anxiety.Children were examined in dental office at the end and information about their cooperation were
reported. For fearful parents who could not manage with anxiety and transfer it to a child is recommended to
find out another relative or adult to accompany child. The relationship between dental fear and uncooperative
behaviour of a child patient and his parents was confirmed and is the key to successful child behavior
management.
Key words: Behaviour, dental fear, parental anxiety
1
2
Assistant., Department of Pediatric Dental Medicine, FDM - MU Sofia
Professor, D.M., Department of Child Dental Medicine, FDM - MU Sofia
34
Introduction
Child oral health demands early visits in dental
office and getting used to treatment. At the same time
childhood is a period of emotional, personal and
cognitive maturation which leads to distinct fear and
anxiety (1,2,4,6). It is very easy to create a
uncooperative behavior to dental office which makes
difficult normal procedure (3,5,7 ,9 ,11). There are
previous researches for children’s behavior
determination in our country as well as different
behavior management methods. But still there are no
studies concerning direct mother influence over
children’s behavior. During early childhood and
preschool age the connection between mother and
child is extremely stronger and she is responsible for
his development and behavior to dental treatment (8,
10, 12).
The aim of this study was to examine the
relationship between mother’s behavior when
educates children and its contribution to children’s
dental fear.
The subjects were 42 children at the age between 4
and 5 years old in kindergarten in Sofia. According to
their behavior in dental office children were divided
into 4 groups using Frankl behavior rating scale –
definitely positive, positive, negative, definitely
negative. 1 definitely positive child and 3 definitely
negative children were examined from the group.
This is the reason for formation of only two groups
from positive and from negative children.
Mothers were asked to complete a questionnaire
which consists of 22 questions in order to determine
their education. 7 of these questions concern mother
emotional intelligence, 6 questions define mother
authority during educational process, 2 questions
determine mothers attitude towards children dental
health and the rest 7 questions concern surroundings,
family background, number of children in family,
person who raise the child and if the child is planned
or unwanted.
Children were asked 9 questions which are looking
for the result from mother behavior concerning
children’s behavior formation. Five of the questions
are in reply to mother’s authority and another four are
in response to mother’s love which child feels during
childhood.
Studying the results from questionnaire with
mothers and children includes definition of numbers
to each answer. Mothers who receive 22 points
occupy
favorable educational behavior, for
emotional intelligence – 7 points, for lack of authority
– 3 points. From the child’s inquiry for whole
favorable influence – 9 points, when child does not
fell his mother authority – 5 points.
Family drawing test of V. Huls and J.Dileo was
used in which interpersonal relationships are assessed
by having the child draw a family or some other
situation in which more than one person is present.
The test gives the opportunity to see the world
through child eyes, to find out his subjective opinion
about the family, his relationship with family
members and his place in the family. Results were
analyzed using five aspects - favourable family
surroundings, anxiety, family troubles, lack of selfesteem and hostility in family.
Personality technique where anxiety acts as
diagnosed component graphic technique "cactus"
M.Pamfilova. The test used to study the emotionalpersonal sphere of the child. When conducting
diagnostic examinee is given a sheet of paper of A4
format and a pencil. The child was given the
opportunity to draw a cactus the he had imaged it
without questions and additional explanations. The
child was given enough time for drawing picture.
In addition, take into account the specific
indicators that are specific to this method asking
questions:
1. Is the cactus wild or domestic? characterization
of the "image of a cactus (wild, domestic, feminine,
etc.)
2. Can you touch it? characterization of needles
(size, location, number)
3. Does the cactus like taking care of it: to water, to
fertilize?
4. Does the cactus live alone or with other plants?
If the cactus is not alone or with what kind of
neighbors it lives with?
5. When the cactus grows what will change in it?
When the results are taken into account the data
corresponding all graphical methods, namely: spatial
position, image size, characteristics of lines, the force
pressure on the pencil.
35
Results and discussion:
Results of mother’s characteristic that best
predicted children’s behaviour problems during
education are presented in table №1.
Average
All the
points
σ
answers
Т, р
children n
number
%+
+
positive 24
17,5
1,64 79,5%
4,78
negative 18
14,8
1,98 67,1% р<0,001
Table 7: Mother’s behavior during child education
It is clear from analyzing the whole mother’s
behavior during child education that mothers of
children with positive attitude towards dental
treatment have average 17,5 positive points, while
those with negative – 14,8. Difference between them
is statistically reliable which proofs definitely the
relationship between mother’s dental behavior and
children’s dental behavior. Mothers of children with
positive attitude to dental treatment positive answers
are close to 80% , those with negative – under 70%.
children
n
Average
points
number
+
σ
% + All
the
answers
children
n
Average
points
number +
σ
%+ All
the
answers
Т, р
positive
24
5,08
1,21
72,6%
2,27
negative 18
4,33
0,97
61,8%
р<0,05
Table 9: Mother’s emotional intelligence
Responses of mothers to 7 questions and their
answers were used to determine emotional
intelligence. Answers show the sincerity of mothers,
optimism, concern of child’s problems, spending time
with the child etc. The obtained results indicate that
mothers with higher emotional intelligence reply
positive children, while those with negative response
to the manipulation have mothers with lower
emotional intelligence. The difference is statistically
significant although not very clear.
children
n
Average
points
number +
σ
%+ All
the
answers
Т, р
positive
24
0,91
0,65
30,3%
2,9
negative 18
0,33
0,48
11%
р<0,05
Т, р
positive 24
6,66
1,34
74%
5,35
negative 18
5
0,68 55,5% р<0,001
Table 8: Mother’s behavior reflection on children
Complete effect from mother’s behavior influence
was found in the amount of all children’s answers.
Positive children have average about 7 answers, which
shows favorable mother’s influence from the whole 9
answers, while negative children have only 5 answers
and the differences between them is statistically
significant. Positive children have 74% positive
points, while negative have a bit over 50%. This
shows children’s dependence on mother’s behavior.
Table 10: Mother’s authority during education
According the authority in education results show
that more mothers use this kind of education.
Although there is a danger the survey questions to
refer mothers to the right answer even it is not
truthful, the ones which indicate imposing punishment
in case of not keeping mother's orders were formed in
pairs, so that the polite answer could be compared to
the particular action.Mothers who educated children
with strictness are very often irritated by disobedience
and impose a punishment. Positive children have
positive mother’s behavior only 30%, while negative only 11%. Here however there is a reliable difference
and mothers of positive child are less authoritarian.
36
children
n
Average
points
number +
σ
%+ All
the
answers
Т, р
positive
24
2,75
1,39
55 %
4,78
negative 18
1,22
0,64
24,4%
р<0,05
pressure on the pencil; family conflict expressed by
stumbling block and space between figures; sense of
inferiority expressed by author isolation from his
mother; hostility in the family – deformed figures.
Such an example is shown in the next figure №1.
Table 11: Authoritarian behavior and emotional
surroundings impact on children
Authoritarian behavior of mothers has a reflection
on children and this could be defined by their answers
about mother’s punishment, emotional dependence of
her, lack of self-dependence, maturity and tranquility.
Positive children have 55% positive answers, while
negative – only 24%. Difference is definite and
statistically significant, which indicates the great
importance of mother in forming independence and
willingness to cope with new situation such as dental
treatment.
children
n
Average
points
number +
σ
%+ All
the
answers
Т, р
positive
24
2
0
100%
7,12
0,22
0,42
11%
р<0,001
negative 18
Figure 1
In cooperative children with positive attitude to
dental treatment predominate optimum and friendly
surroundings, which could be founded in presenting of
all family members, picture begin with a drawing of
person, some family members absent, lines are well
done. Such an example is shown in the next figure
№2.
Table 12: Mother’s behavior towards child oral
health
The relationship between mothers’ attitude towards
child oral health and child behavior in a dental setting
is strongly demonstrative. Cooperative children have
parents who are anxious about their oral health in
100%. While only 11% of parents of uncooperative
children have positive attitude. Mothers’ responses
also showed contradiction and insincerity because
they mentioned that children visit dental office
regularly and have not behavior problems but
children have such problems objectively.
The influence of family environment and finding
his place in it was determined by using a drawing test
“My family”. Analysis shows that in negative children
predominate anxiety expressed by strokes, the force
Figure 2
Application of graphic technique "cactus”
confirmed the results. Positive children
show
sincerity - prominent needles, leadership - picture
with good proportions, filling the paper, optimism –
expression of „ happy cactus”, extroversion – other
cactus presence. Such an example is shown in the next
figure №3.
37
Conclusions
1. Mother’s emotional intelligence helps formation
of child positive behavior to dental treatment;
2. Authoritarian education in combination with
punishment forms negative children;
3. Mother’s concern for child oral health creates
cooperative behavior;
4. Solidarity and tenderness in the family create
positive child behavior;
5. Conflicts in the family form negative child
behavior.
Figure 3
In negative children predominate aggression – long
needles presence, reticence – zigzags drawing inside
the figure, introversion – presence of only one cactus
close to the end of the paper. An example is shown in
the next figure №4
Figure 4
The obtained proofs show clearly that mother has a
great influence on child behavior in dental office and
plays a significant role in helping children to cope
with dental treatment. Circumstances which form
children as well-balanced, independent and ready to
solve the problems or as closed, aggressive, uncertain
and worried about every new situation are family
surroundings, love in the family, mistakes intolerance,
imposing punishment, affection need. The results give
us confidence to continue and extend our study for
standardization of parent behavior models in child
raising and educating.
Reference
1. Панфилова – Игротерапияобщения. Тесты и
коррекционныеигры.Гном и д, 2008,
160.
2. American Academy of Pediatric Dentistry.
Guidelines for behavior management of
The
American Academy of Pediatric Dentistry. Va Dent J
1994,71,20-25.
3. Arnrup K, Berggren U, Broberg AG. Attitudes
to dental care among parents of uncooperative child
dental patients. Eur J Oral Sic 2002, 110, 75-82.
4. Cardoso CL, Loureiro SR, Nelson-Filho P.
Pediatric dental treatment: manifestation of stress in
patients, mothers and dental school students. Braz
Oral Res 2004, 18, 150-155.
5. Colares V, Richman L. Factors associated with
uncooperative behavior by Brazilian preschool
children in the dental office. ASDC J Dent Child
2002, 69, 87-91.
6. Dileo Joseph H. Interpreting children’s
drawings.New York, Psychology Press, 1983, 234.
7. Huber M, Freeman R, Humphris G et al.
Empirical evidence of the relationship between
parental and child dental fear: a structured review and
meta-analysis. Int J Pediatr Dent.2010, 20, 83-101.
8. Klingberg G, Berggren U, Carlsson SG, Noren
JG. Child dental fear: cause –related factors and
clinical effects. Eur J Oral Sci 1995, 103, 405-412.
9. Klingberg G, Lofqvist LV, Hwang CP. Validity
of the children's dental fear picture test (CDFP). Eur J
Oral Sci 1995, 103, 55-60.
10. Lara A, Grego A, Maroto M. Emotional
contagion of dental fear to children: fathers' mediating
role in parental transfer of fear. Int J PediatrDent
2011,10, 60-65.
38
11. Milgrom P, Mancl L, King B et al. Origins of
childhood dental fear. Behaviour Research and
Therapy 1995,33, 313-319.
12. Muris P, Steerneman P, Merckelbacw H. The
role of parental fearfulness and modeling in children's
fear.BehaviourResearch Therapy 1996, Vol. 34, No.
3, pp. 265-268.
13. Ten Berge M, Veerkamp JSJ, Hoogstraten J et
al. Parental beliefs on the origin of child dental fear in
the Netherlands. J Dent Child 2001, 68, 51-54.
14. Wigen TI, Skaret E, WangNJ. Dental
avoidance behaviour in parent and child as risk
indicators for caries in 5-year-old children.Int J
Paediatr Dent. 2009 Nov;19(6):431-7.
Address for correspondеnce:
Professor Milena Peneva, D.M.
Department of Pediatric Dental Medicine
35
The impact of the etching time upon the bond strength with the dentine in primary
teeth - in vitro study
N. Gateva1, R. Kabakchieva 2
SUMMARY
Objective: The aim of this study was to investigate the influence of the etching on the bond strength of
total etch adhesives used in primary tooth dentin.
Methods: Flat dentin surfaces from 48 primary molars were divided in 4 groups. Two different total
etch adhesive systems were used – one tree steps (OptiBond FL, Kerr) and one two steps (Exite, VivaDent). In
half of the specimens, the recommended etching time was used 15 s, in the other half the etching time was
reduced to 7 s. After applying the adhesive, resin composite build-ups were constructed by means of
conventional copper ring and stored in water for 72 h at room temperature. Specimens were tested for
macrotensile bond strength. Debonded surfaces were analyzed by SEM.
Conclusion: Reducing the dentin etching time to 7s in primary teeth and using total etch adhesives
improve macrotensile bond strength
Key words: primary teeth, etching, bond strength, adhesive system
1
2
Assistant professor, Department of Pediatric Dentistry, Faculty of Dental Medicine, Sofia
Assoc.Professor , Department of Pediatric Dentistry, Faculty of Dental Medicine, Sofia
36
Introduction
Instructions for application of all adhesive systems
still lack specific guidance for their application in the
primary dentition. Their use in the restoration of
deciduous teeth in everyday dental practice is
transmitted from the permanent dentition, without
taking into account the lack of recommendations by
the manufacturers for application of a treatment
protocol for primary teeth (5, 12, 16, 20, 27, 34, 38).
Between the two dentition there are certain
differences in terms of the structures that built them
(15, 17, 27, 36, 38). These differences have an impact
on the quality of adhesion, and their bond to the
aesthetic restorative materials and hence on the
durability of these restorations (17, 24, 25, 26, 32, 35,
38). The greater density of dentine tubules per unit
area and the thicker peritubular dentine in deciduous
teeth, reduce the amount of intertubular dentine,
which is available to perform the bonding procedures
(18, 22, 36). From a chemical point of view, the
dentine of the primary teeth is more reactive to the
effect of the acid conditioners, due to the lower degree
of mineralisation of the tooth structure of the primary
dentition (2, 14, 19, 24, 25, 32). SEM observations
indicate the formation of a thicker hybrid layer in
deciduous teeth compared to that in the permanent
teeth after the same etching time (5, 24, 25, 32, 33,
36). Studies made on samples of primary teeth
showed incomplete infiltration of the adhesive
monomer in the spaces between the collagen fibers at
the bottom of the demineralised area, leading to the
formation of a zone of exposed collagen fibers at the
bottom of the hybrid layer which compromises the
adhesive bond (10, 24, 25, 30, 31, 32). This
demineralised, non impregnated dentine at the bottom
of the hybrid layer has been described as the most
weak and vulnerable area at the dentin-adhesive
border (10, 24, 25, 32).
NN Etching time
Group
Group 1
37% phosph.etch gel – 15 s
10
Group 2
10
Group 3
10
Group 4
10
Table 1: Grouping of the experimental samples
Reducing the dentine etching time of primary teeth
is offered as an opportunity to achieve adequate bond
strength by forming a homogeneous hybrid layer (24,
25, 27, 33, 38). Due to the greater reactivity of the
dentine of primary teeth to etchants, they can be
applicated for a shorter time compared to that of
permanent teeth. Moreover, there is no positive
correlation described between hybrid layer thickness
and bond strength (10, 30, 33). To determine the
effectiveness of the adhesive systems, the most
commonly used methods are SEM observation and
bond strength tests (21, 27, 37).
The aim of this study was to evaluate the impact of
etching time on the primary teeth dentin bond strength
and total-etch adhesives.
- To achieve this aim the following tasks were
set for completion: To assess the impact of the
etching time - 7 and 15 s on the primary teeth dentine
bond strength and application of total-etch adhesives;
- To determine by SEM observation the type of
destruction after the application of macrotensile bond
strength test.
For the purposes of the study, 48 intact deciduous
molars were used. The teeth were collected from
healthy children, after an informed consent was signed
by their parents for its use in the experiment. The
teeth were extracted due to physiological changes or
orthodontic indications. They were cleaned from the
soft tissues, and the existing roots were removed. By
the time when the experiment started, the teeth were
stored in saline for no longer than three months.
Grouping of the experimental samples. The teeth
were randomly selected into 4 groups which are
presented in Table 1. From each group 2 teeth were
prepared for SEM observation of the dentine-adhesive
zone.
Adhesive system
OptiBond FL (Kerr) – 3 steps-total etch
Exite (Ivoclar,Vivadent) - 2 steps-total etch
OptiBond FL (Kerr) – 3 steps-total etch
Exite (Ivoclar,Vivadent) - 2 steps-total etch
37
Preparation of the dental surface. From the occlusal
crown surface of all samples the enamel and part of
the dentine were removed. Using round turbine burr
(ISO 806 314 001534 012 for primary teeth) and
water cooling, a medio-distal cut is made through the
central occlusal fissure.The depth of the cut is
compatible with the size of the burr. The depth of the
enamel and dentine to be removed from the occlusal
surface is marked in advance, which allows for
removal of relatively compatible layer of enamel and
dentine for each of the experimental samples. A cut
parallel to the occlusal surface is done with highspeed burr (ISO 806204108524835010) and under
water cooling. The cut is made up to the controlled
depth determined by the initial cut with the round
burr. The surface is smoothed with a polishing disc.
This leads to the formation of a smooth dentine
surface, which is at compatible distance from the
central fissure. Samples are observed with optic
microscope OLYMPUS VANOX-T under zoom 25x
to 100x to establish whether the enamel has been
completely removed from the occlusal surface.
Making of the restoration. A copper rings (№15)
with height 5 mm and diameter 5mm are used for the
manufacture of comparable and predictable surfaces
of the restoration. Factory-made standard copper rings
are cut with the help of two-side diamond disks, in
order to achieve the desired height.
The etching was performed for 15 s in specimens
from group 1 and 2 and for 7 s in those from group 3
and 4. The etching and application of the adhesive
system (according to the manufacturer's instructions)
was done centrally on the exposed dentine surface on
an area with a diameter comparable to the copper ring.
On the prepared dentine surface copper ring was
placed. Within this ring is placed one layer light cure
composite (Tetric EvoCeram, Ivoclar Vivadent, A3
shade) was placed with thickness up to 2 mm, which
is polymerized with UV light for 40 s from a UV lamp
(Coltolux 75, Curing Light, Coltène Whaledent). The
next step consists of setting a metal loop of
orthodontic wire (№0.8), perpendicular to the cut of
the occlusal surface with a length of about 10mm in
the center of the ring, and a fresh amount of
composite, which stretches the metal ring and clamps
the metal loop. Up next comes light polymerization
for 40 s. The two free ends of every metal loop, which
is placed in the copper ring and is covered with
composite, are finished with retainer loop.
From the side of the pulp chamber, on the level of
the cut roots, the preparations of the specimens
consists of etching of the entire pulp chamber for 15 s,
washing – 15 s, air-drying and application of 3-steps
adhesive system. A layer of composite is placed,
along with light polymerization for 40 s. After that a
second metal loop is being placed, aligned to the one,
which is already on top of the occlusal surface in the
metal ring. The final step is addition of composite
untill the whole pulp chamber is filled, along with
light
polymerization
for
40s.
The prepared specimens are stored in water at room
temperature for 72 hours, prior to the test.
Testing the bond strength.The measurement of the
achieved bond strength is conducted on stand for
physical-mechanical examination type INSTRON –
1185. Metal loops similar to the ones built in the
studied teeth are fixed rigidly in the standard grips of
the machine and at the other end - hinged to the metal
loops of the model. The loading bar is moving at a
steady speed of 1 mm/min. The maximum force of
resistance, causing debonding (in MPa) is
registered. The test is terminated after the final
destruction of the test specimen.
Determining the type of destruction. After the
macrotensile bond strength test specimens were
dehydrated in ascending concentrations of ethanol 75%, 95% and 100% for 1 h in each
concentration. After dehydration the samples were
placed on the filter paper and covered with a glass lid
for 24 h. Both halves of each specimen were observed
in the SEM under 18 x to 1500 x magnification to
determine the type of destruction. SEM observation
allows more precise determination of the place of
failure. The failure type for each sample is classified
into one of the following types:
Type 1: Adhesive failure mode – the fracture line is
located in the adhesive layer of the border zone
dentine – adhesive or composite – adhesive - this is a
failure in the adhesion.
Type 2: Cohesive failure mode - fracture line
passes only within the composite.
Type 3: Mixed failure mode - the specimens show
both types of fracture - the adhesive and cohesive
destruction - dentin-adhesive-composite.
38
Furthermore two teeth from each group, prepared
in the same way described were cut perpendicular to
the bonded surface to examine the morphology of the
borderline surface between the adhesive system and
dentine for the two different etching time - 7 and 15 s.
The prepared samples are placed on an aluminium
discs. They are then covered in vacuum with golden
powder in a media of argon-cathode atomization with
JEOL JFC – 1200 Fine coater. The research was
carried out with scanning electron microscope type
JEOL JSM – 5510 SEM with 750x zoom.
Our study evaluated the impact of etching time on
the dentine bond strength of deciduous teeth after
application of total etch adhesive systems. Table 2
presents the measured average bond strength after
recommended (15 s) and shortened etching time for 7
s with 37% phosphoric acid and application of total
etch adhesives.
N
Adhesive
Etching
Macrotensile bond strength (МРа)
Group
system
time
mean ± SD
Minimum
Maximum
group 1
10
OptiBond FL
15 s
12,68±0.52
9,72
14,87
group 2
10
Exite
15 s
10,24±0.31
8,87
12,02
group 3
10
OptiBond FL
7s
16,00±0.87
10,78
21,66
group 4
10
Exite
7s
15,48±0.87
11,60
18,97
Table 13: Bond strength in primary teeth and total etch adhesives
When comparing the mean of the bond strength in
specimens that were etched for 15 s (Table 2, groups 1
and 2) with the ones etched for 7 s (table 2, groups 3
and 4), the results show that the etching time
influences the registered mean values of the bond
strength in total etch adhesive systems.
The reduction of the etching time up to 7 s (group
3-16,00 MPa and group 4 – 15,48 MPa,table 2) leads
to increased mean values of the bond strength
compared to those in specimens etched for 15 s (group
1-12,68 MPa and group 2 – 10,24Mpa, table. 2).
These differences are statistically significant for both
adhesive systems considering the bigger bond strength
and the shorter etching time (tabl. 3). The relation
between the type of the adhesive system and the bond
strength is an object of another study performed by us.
Group
N
Group 1
Group 3
Group 2
Group 4
10
10
10
10
Bond
strength(МРа)
mean ±SE
12.68±0.52
16.00±0.87
10.24±0.31
15.48±0.87
Т
Р
3.26
<0.01*
5.65
<0.0001*
*The difference is statistically significant
Table 3: Bond strength in primary teeth etched for
7 and 15 s.
The results from the observations with SEM to
determine the type of the destruction are presented in
Table 4.
Adhesive
Cohesive
Mixed failure
failure mode
failure mode
mode
N
%
N
%
N
%
Total etch
Group 1
7
70.0
0
0.0
3
30.0
adhesives
Group 2
9
90.0
0
0.0
1
10.0
Mean
16
80.0
0
0.0
4
20.0
Group 3
3
30.0
1
10.0
6
60.0
Group 4
3
30.0
2
20.0
5
50.0
Mean
6
30.0
3
15.0
11
55.0
Table 4: Distrubution according to the failure mode in primary teeth specimens and total
systems for 15 s and 7 s.
Total
Group
N
%
10
100
10
100
20
100
10
100
10
100
20
100
etch adhesive
39
The reduction of the etching time (group 3 and 4)
leads to decreased adhesive failure mode in primary
teeth from 80 % to 30 % and increased cohesive and
mixed failure mode (table. 4)
We performed SEM observation of the border zone
dentine-adhesive system.
A
B
Figure 1: SEM of hybrid (between the arrows) and adhesive (AD) layer within the dentine borders in a
primary molar, etched with 37 % phosphoric acid for 15 s (fig.1A) and 7 s. (fig. 1 B) and adhesive system
OptiBond FL (three step system). Multiple adhesive resins (R) and microcracks (fig.1A-thumb) are visible
within the dentine (D); C=composite.
A
B
Figure 2: SEM of hybrid (between the arrows) and adhesive (AD) layer within the dentine borders in a
primary molar, etched with 37 % phosphoric acid for 15 s (fig.2A) and 7 s. (fig.2B) and adhesive system Exite
(two step system). Multiple adhesive resins (R) and microcracks (fig.2A-thumb) are visible within the dentine
(D); C=composite.
Fig. 1 and fig. 2 show the border zone dentineadhesive, after the application of the two generation
adhesive systems (optiBond and Exite) and different
etching time (15 s and 7 s). The etching time of 15 s
leads to formation of a thicker hybrid layer with both
adhesive systems. The comparison of the photos of
the specimens from group 1 with those from group 3
(fig. 1 A and B) and the specimens from group 2 and
4 (fig. 2 A and B) shows the formation of a thicker
hybrid layer with the presence of microcracks in the
specimens etched for 15 s (Fig. 1 A and fig. 2Athumb) at the border between the adhesive and hybrid
layers, as well as inside the hybrid layer.
To achieve effective bonding to the dentine, the
applied adhesive system should form a hybrid layer as
a result of the infiltration of the adhesive monomers
between the organic components – the collagen fibers
of the dentine (8, 23, 29). The quality of the hybrid
layer depends on the pH of the etching agent, the
40
ability of the resin monomers to infiltrate the
demineralized dentine and the specific properties of
the dentine substrate (3, 6, 7, 8, 20, 27, 33, 36). The
bonding is stable if the etching agent has been
infiltrated completely by the adhesive and the
different levels of incomplete impregnation have been
avoided (9, 31, 38). The bond strength with the
dentine depends significantly on the properties/
quality of the formed hybrid layer, but not on its
thickness, that means that thicker hybrid layer doesn’t
contribute to better adhesive bond strength (5, 9, 11,
24, 25, 28).
In our experiment, the reduction of the etching time
up to 7 s, showed higher values of the bond strength
compare to the groups in which the teeth were etched
for 15 s with the two types of adhesives (Tabl. 3).
These differences are statistically significant (p<0.05).
SEM analysis showed the formation of significantly
thicker hybrid layer after etching for 15 s (fig.1A and
fig.2A), compared to that formed after etching of the
specimens for 7 s (fig.1B and fig.2B). These results
correspond to the results reported from other
researchers and confirm that there is a lack of positive
correlation between the thickness of the hybrid layer
and the bond strength (10, 30, 32). Although, the
hybrid layer formed after 15 s etching is almost twice
thicker for both adhesive systems, the bond strength is
less compared to that in specimens etched for 7 s.
(Tabl. 3). The results from another research done by
us showed that etching for 7 s with 37 % phosphoric
acid leads to formation of the dentine surface clean
from the smear layer and precipitates (1). The primary
teeth dentine is less mineralized than that of the
permanent teeth (13, 14, 19). Therefore, it has reduced
buffer capacity towards acids used for etching (14, 19,
32). If the etching time is increased that leads to
deeper demineralization of intertubular dentine and
formation of thicker hybrid layer in primary teeth. The
possibility that deeply demineralized dentine to be
incompletely impregnated by the adhesive system
leads to the risk of formation of a zone not infiltrated
with adhesive between the hybrid layer and the intact
dentine structure. That zone remains less resistant at
the bottom of the hybrid layer and could be a
possible path for micro- and nanoleakages, enzymatic
and hydrolytic degradation, and in general a point for
a bond failure (10, 24, 25, 31, 32). The reason for this
is probably the microcracks observed by us in
specimens from groups 1 and 2, that have been etched
for 15 s. (Fig. 1A and 2 A thumb)
The SEM observation that we conducted to
determine the type of the failure after the macrotensile
test was performed showed that the redusing of the
etching time up to 7 s within the dentine with totaletch adhesive systems results in decreased percentage
of the adhesive failure mode and increased cohesive
and mixed failure mode in primary teeth (the adhesive
failure mode decreases from 80 % to 30 % - table 4).
These correspond to the results observed from the
macrotensile test (tabl. 3). In other words, if the values
of the bond strength are higher, it is more likely to
have cohesive or mixed failure mode. (4, 34).
This in vitro study showed that the reduction of the
etching time up to 7 s within the dentine in primary
teeth plays significant effect on the bond strength
when the total etch adhesives are applied. The reduced
etching time, results not only in higher bond strength
values, but is a prerequisite for formation of a hybrid
layer which is significantly more resistant to
destruction.
Conclusions
1. In primary teeth the reduction of the etching
time within the dentine up to 7 s results to increased
values of the registered bond strength compared to
that after 15s etching time and the application of total
etch adhesives.
2. In primary teeth the thickness of the formed
hybrid layer increases if the etching time is longer.
3. The thicker hybrid layer is not a guarantee for
a better mechanical bond strength.
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Evaluation of Tensile-Bond Strength, Fracture Mode
and Microleakage of Fifth, and Sixth Generation
Adhesive Systems in Primary Dentition. J Indian Soc
Pedod Prev Dent 2005; June: 83-88
36. Sumikava DA., еt al.: Microstructure of
Primary Tooth Dentin. Ped Dent 21, 1999; № 7: 439444
37. Toledano M. et al.: Microtensile bond strength
of several adhesive systems to different dentin depths.
Am J Dent 2003; 16: 292–298.
38. Torres CP., et al.: Tensile Bond Strength To
Primary Dentin After Different Etching Times J Dent
Child 2007; 74: 113-117
Adress for correspondence:
Gateva Natalia
43
Prosthetic dentistry
The “Sofia” Chewing Simulator – construction, working principle and possible
applications of the device – I part
I.Ivanov 1, I.Chakalov 2
SUMMARY
Objective: The main objective of the present work is the creation of a chewing simulator – a device
reproducing in a laboratory the main parameters of the chewing cycle.
Materials and methods: The chewing simulator was designed on a “Solid Works” software, allowing for
planning, visualization, and motion simulation of all the components of the device long before it was created.
The original construction principle of the chewing simulator, designed in order to obtain a dynamic force
curve of the chewing cycle, was the application of magnetic field generated by a permanent magnet and a
rotating laser-cut cam made of a ferromagnetic material. The variation in the distance between the cam and the
magnet added to the permanent force generated by a lever and a constant load shape the force profile of the
device.
Results: The construction principle and schemas of the chewing simulator are presented.
Conclusion: The chewing simulator is able to reproduce the main mechanical characteristics of the
chewing cycle. Among the various possible application of the device is worth mentioning: various researches of
the wear resistance of dental materials, studies of adhesion and micro-leakage, abrasiveness of toothbrushes
and toothpastes.
1
Dipl. Eng.
2
Assistant professor, Department of Prosthetic Dentistry, Faculty of Dental Medicine – Sofia.
44
Introduction
The data regarding the wear resistance of dental
materials is an important characteristic of all
restorative materials used in dentistry. In our previous
publication (1) we presented the desired working
parameters of a chewing simulation device based on
the characteristics of the existing chewing simulators
created in different universities and research centers
throughout the world, as well as on the recent studies
of the chewing cycle which explain this process in a
different way.
The experiment should allow us to reproduce: an
area of abrasion (three-body wear) and an area of
attrition (two-body wear). In order to reproduce the
first type of wear most authors use loads of 20N and
different artificial food media, while for the second
type the different research teams use different loads,
the most often cited in literature being devices using
loads of 50N.
The simulated chewing should be able to reproduce
the stages of the chewing cycle and the corresponding
dynamic loading curve.
- Initial contact between the teeth with a definite
small load (occurring during normal occlusion
between the vestibular cusps of the upper and the
lower teeth)
- Sliding of teeth to the position of central
occlusion (accompanied with an increase in the
loading force and reaching its maximum values)
- Stage of grinding of the food occurring
between the functional cusps of the upper and the
lower teeth (according to the occlusal theory by Le
Gall (2). The values of the loading force remain
comparatively high but lower than the maximum
values.
An important characteristic of the chewing
simulator is the possibility to carry out the
experiments both in water and in an artificial food
medium. Other chewing simulation devices also
possess such a feature, for instance those created in
the Universities of Oregon and Bordeaux – UVSB2
(3) and OSHU (4).
Another important factor for making the simulation
similar to the real process of chewing is the separation
of the tested specimens at the end of each cycle,
which allows the artificial food to enter between the
tested surfaces. Such a feature possesses, for example,
the simulator of the University in Poznan (5).
The possibilities for programming and adjustment
of the contact time, the speed, the distance between
the specimens and the length of the sliding path allow
a wide range of experiments tobe carried out by the
device. The exact values of these parameters have
been discussed in detail in a previous publication (1).
These are among the most significant parameters of
the chewing simulator (6).
It is considered an advantage if the chewing
simulator can work both with antagonists made of
natural tooth cusps (standardized – such as those used
in the OSHU simulator (4) or non-standardized – used
in the simulator of the Zurich University (7)) and with
standard antagonists (most often made of ceramic
materials with a definite hardness and shape (8)).
The parallel testing of several specimens in several
chambers of the chewing simulator reduces the time
of the experiment and the variation in the results (9).
From a technical viewpoint an important
characteristic of the device is the automatic control of
the completed and the remaining cycles and an
automatic turn-off after all cycles have been
completed.
In our opinion one of the most important
characteristics of the simulator is its flexibility – the
constructionally determined possibility for quick and
easy change of each of the above parameters.
The aim of the scientific research is the creation of
an original chewing simulator which meets all the
above mentioned requirements.
Construction and working principle of the chewing
simulator
In collaboration with the engineers Ivan Ivanov and
Hristo Angelov (working for the Sintcom company)
who were responsible for the technical construction of
the device, we developed the following cyclogram
describing the desired mode of work of the device
during the simulation of the chewing cycle.
45
Figure 1: A cyclogram presenting the movement of
the antagonist against the tested specimen (upper
curve), the change of the speed (the middle curve) and
the load profile during one chewing cycle (lower
curve).
On the cyclogram (fig.1) the following parameters
are presented: the movement of the antagonist in two
axes during one
chewing cycle (the uppermost curve – in the first
portion the antagonist has descended and is in contact
with the specimen while in the second portion it has
separated from the specimen, as required by the task
assignment). The second curve presents the change in
the sliding speed of the antagonist along the surface of
the specimen (the middle curve). The lowermost curve
in fig.1 represents the change of the loading force of
the antagonist while moving along the surface of the
specimen. The three parameters change synchronously
during one simulated chewing cycle. In this way the
programmed loading curve meets both the
requirement for separate zones of simulation of
abrasion and attrition and the requirement for
simulation of the three stages of the chewing cycle as
described above.
The type of movement is – reciprocating
movement (unidirectional sliding) of the specimen
(and) the antagonist along a closed rectangular
trajectory/cycle which is composed of four phases:
1. Descending of the antagonist towards the
specimen (closing) which reproduces the initial
contact between the vestibular cusps of the antagonist
teeth during the chewing cycle.
2. Sliding between the specimen and the
antagonist accompanied by an increase in the loading
force between the two elements (this corresponds to
the loading curve and the sliding from the point of
initial contact to the position of central occlusion. As
it has been explained, in the position of CO the load
reached its maximum value). According to the
functional occlusal concepts developed by Prof.
LeGall this stage is followed by sliding of the teeth
during the “Cycle out” under a loading force lower
than the maximum (2). Many studies on mastication
and the chewing cycle, which were cited and
discussed in our previous publication (1), have given
evidence of such a contact.
Figure 2: Schematic presentation of the working
cycle of the antagonist according to the above
cyclogram. The antagonist slides along a
standardized specimen made of the tested material.
3. Opening – separation of the antagonist from
the specimen (it corresponds to the end of the occlusal
stage of the chewing cycle)
4. Return of the system in a starting position
(corresponds to the preparation of the dentition for a
new occlusal stage)
The working parameters of the device have been
set as follows:
- Length of the sliding path – 7mm
- Maximum distance between the specimens –
2mm
- Average descending speed – 2,55 – 51 mm/sec
- Average speed of separation – 2,60 – 52
mm/sec
- Average sliding speed – 1,4 – 28 mm/sec
- Average speed of reverse movement – 1,4 – 28
mm/sec
- Loading force – 0-70N
46
- Change of the loading force during the sliding
motion –0 – 30N
- Number of cycles – 1 – 1 000 000
- Frequency – 0,1 – 2Hz
- Number of specimens tested simultaneously/
Number of testing chambers – 4
- Power supply – 220V
After setting the above parameters we continued
with the conceptual development of a construction
project. The device was designed by engineer Ivan
Ivanov on the “Solid Works” software program.
A carriage - 2 containing the tested specimens is
mounted on the base (fig.3) of the simulator. Each
specimen is made of the tested material which is
cured/sintered in a metal ring according to the
manufacturer’s instructions.
Its surface is then
polished and the specimen is secured in a tray, which
is fixed on the mobile carriage - 2.Through a driving
crank the latter is connected with the driving unit –
3.Using a cam system and an eccentric bushing, the
driving unit puts in synchronous motion both the
carriage and the yoke – 4. The antagonist is fixed to
the yoke by a holder. The system for automatic
control includes an inductive transducer – 5, which
transmits impulses to a counter controlling the number
of test cycles. The figure represents only the yoke, the
load and the cam block of chamber1. In the real
simulator these details are 4 – one for each of the
tested specimens which are visible in the tray on fig.3.
Figure 3: Simplified scheme of the chewing
simulator and its main components: 1 – base, 2 –
carriage, 3 – driving unit, 4 – yoke, 5 – inductive
transducer
Figure 4: Schematic view of the chewing simulator (a side view). On the figure are presented: the carriage
consisting of: a soleplate – 6; linear ball bushings –7; cylindrical guides – 8; consoles – 9; tray – 10; the
specimens – 16; the clamps – 11, the rocker – 13; the drawbar – 12; the eccentric bushing - 15
Fig.4 represents a side view of the machine. The
carriage shown on fig.3 consists of a soleplate 6 which
through linear ball bushings - 7, cylindrical guides – 8
and consoles – 9 is precisely fixed to the base of the
simulator. The tray – 10, in which the specimens - 16
are fixed, is positioned on the carriage. The tray can
be moved in a canal in the base – 6 and is fixed to the
base by clamps – 11.This allows several experiments
to be carried out on one specimen, as the tray can be
moved and fixed in different positions perpendicularly
47
to the plane on fig. 4. Through the driving unit the
carriage is connected to the rocker – 13. The rocker is
also hinged to the drawbar – 12 of the carriage. The
carriage is connected to the spindle of the driving unit
through an eccentric bushing – 15. Thus the length of
the sliding movement of the carriage is calculated as
the double value of the eccentricity of the eccentric
bushing – in this case 3,5mm. This allows for an easy
alteration of the sliding path of the specimen and the
antagonist, corresponding to the length of the contact
between the antagonist teeth during the chewing
cycle.
Conclusion
The described chewing simulator reproduces the
desired mechanical parameters and the load profile of
the chewing cycle.
Reference
1. Chakalov I. Analysis of the characteristics of
the chewing process. Rationale for the parameters and
principles of the in vitro chewing simulator. Problems
of dental medicine vol. XXXVI/2010 part II; p.69-80.
2. Le Gall MG, Lauret JF: Occlusion et function,
uneapprochecliniquerationnelle, CdP Editions 2002.
3. Lasserre JF. Thèse pour le Doctorat
d’Universite de Bordeaux2. Mention Sciences
Biologiques et Médicales. Option Sciences
Odontologique. Recherches sur l'usure dentaire et
évaluation "in-vitro" de biomateriaux restaurateurs
avec le simulateur d'usure UVSB2. 2003.
4. Condon J.R, Ferracane J.L. Evaluation of
seven commercial composites using new in vitro wear
simulator. Dent Mater 1996; (7); 12:218-226.
5. Koczorowski R, Wloch S. Evaluation of wear
of selected prosthetic materials in contact with enamel
and dentin. J Prosthet Dent. 1999; 81(4):453-459
6. Heintze SD: How to qualify and validate wear
simulation devices and methods. Dent Mater. 2006
(8);22(8):712-34.
7. Krejci I, Lutz F, Reimer M. Wear of
CAD/CAM ceramic inlays: restorations, opposing
cusps, and luting cements. Quintessence International,
1994; 25:199-207
8. Shortall AC, Xiao QH, Marquis PM Potential
countersample materials for in vitro simulation wear
testing. Dent Mater 2002; 18 246-254.
9. Söderholm KJM, Lambrechts P, Sarret D, Abe
Y , Yang MCK , Labella R ,Yildiz E, Willems G.
Clinical wear performance of eight experimental
dental composites over three years determined by two
measuring methods. Eur J Oral Sci 2001:109:273-281
Chakalov I.
Department of Prosthetic Dentistry,
Faculty of Dental medicine , MU-Sofia
48
Prosthetic dentistry
Construction of the “Sofia” chewing simulator. Basic modules, principle of
functioning and possible applications. – Part II
I. Ivanov 1 I. Chakalov 2
SUMMARY
Objective: Part II of this paper presents the basic modules, the principle of functioning and possible
applications of the “Sofia” chewing simulator.
Material and methods: The chewing simulator was designed on the “Solid Works” software, allowing for
planning, visualization, and motion simulation of all the components of the device long before it was created.
The original construction principle of the device, designed to obtain a dynamic force curve of the physiological
chewing cycle, was the application of magnetic field generated by a permanent magnet and a rotating laser-cut
cam made of a ferromagnetic material. The variation in the distance between the cam and the magnet in
addition to the permanent force generated by a lever and a constant load, result in the dynamic force profile of
the device.
Results: Part II of the paper presents the schemas of the basic modules, the way of functioning and the
researches made possible with the use of the “Sofia” chewing simulator.
Conclusion: The chewing simulator is able to reproduce the main mechanical characteristics of the
physiological chewing cycle. Among the various possible application of the device is worth mentioning: various
researches of the wear resistance of dental materials, studies of adhesion and micro-leakage, abrasiveness of
toothbrushes and toothpastes.
1
2
dipl.eng.
– Assistant professor, Department of Prosthetic Dentistry, Faculty of Dental Medicine – Sofia.
49
Introduction
Part I of this publication presented the mechanical
parameters of the physiological chewing cycle which
served as a basis for the development and construction
of the “Sofia” chewing simulator. The original
construction principle, the dynamic load profile and
several schemes of the device were also presented.
Purpose
Part II of the publication presents a detailed
schematic view of the basic modules of the machine,
as well as its working principle and possible
applications.
The chewing simulator was first designed and
constructed on the “Solid Works” software. The
unique aspect in its design is the creation of a dynamic
load profile similar to that of the physiological
chewing cycle. It is obtained through the application
of a magnetic field generated by a constant magnet
and a rotating laser-cut cam made of a ferromagnetic
material. The variation in the distance between the
magnet and the cam in addition to the force generated
by a lever and a constant load, result in the dynamic
load profile of the device.
Results
The basic modules in the construction of the
chewing simulator are the driving unit, the cam block,
the yoke, the capsule holder with the antagonist and
the magnet block.
The driving unit consists of a spindle – 21 on
which the cam block – 18, the eccentric bushing – 19
and the disk wheel – 20 are fixed. The spindle is put
to motion by a self-aligning coupling -17 driven by a
reductor motor (“Maxcon” 148867 PGL U). The
driving unit is mounted on the base of the chewing
simulator.
Figure 5: Schematic view of the driving unit of the
machine
Figure 6: Schematic view of the cam block of the
machine
The cam block consists of the supporting bushing –
34 on which the lifter cam – 35 (allowing separation
of the antagonist and the tested specimen at a precise
moment of the chewing cycle) and the anchor – 37 are
mounted. The anchor is made of a ferromagnetic
material which interacts with the constant magnet
fixed on the yoke (presented in more detail on the next
scheme). The specific profile of the anchor is laser-cut
and serves to obtain a variable force due to the
variating distance between its periphery and the
magnet block – 28 (presented on fig.9).The figure
represents: the capsule holder with the antagonist
tooth/sphere – 27; unit containing the capsule holder –
24, holder of the magnet block – 25, back roller – 29;
constant load – 28; arm of the yoke – 22; bracket – 21.
The elements presented on fig. 7 are mounted on the
50
arm of the yoke – 22 and the position of each element
on the arm can be independently adjusted.
This allows for the adjustment of the load by
changing the length of the lever arm. The arm of the
yoke is hinged to the bracket – 21, which is fixed to
the base of the chewing simulator.
Figure 7: Presents the construction of the capsule
holder with the antagonist
Figure 8: Presents the construction of holder of
the capsule with the antagonist
Fig. 8 represents: the antoagnist – 27 (it can be a
tooth cusp, natural enamel or as shown on the figure –
standard antagonist made of ceramic material), a
capsule holding the antagonist – 30, fixing screws –
31 and – 32 which serve to fix the capsule at a definite
height.
The magnet block – 25 contains constant Neodimic
magnets (generating together with the anchor – 37,
fig. 6, the dynamic load profile of the chewing cycle).
The magnet holder contains a back roller - 29 which
slides along the lifter cam – 35, fig. 6, and is
responsible for the separation of the antagonist and the
specimen at the end of each chewing cycle.
Working principle of the chewing simulator
The spindle of the driving unit (fig. 5) creates a
rotating movement which is transformed into a
reciprocating movement by the rocker (presented in
part I). In this way the carriage (fig. 3, part I)
containing the specimens begins a reciprocating
movement with a length of the driving path equal to
the doubled eccentricity of the eccentric bushing – 19
(fig.5). At the same time the lifter cam ( - 35, fig. 6)
mounted on the same spindle periodically lifts or
drops the arm of the yoke, so when the specimen
moves towards the driving unit the antagonist slides
along its surface (sliding path). When the carriage
moves in the opposite direction the lifter cam and the
back roller have separated the antagonist from the
surface of the specimen (backward motion). During
the stages of the chewing cycle corresponding to the
transitional parts of the lifter cam, a gradual ascending
or descending of the antagonist towards the surface of
the specimen is carried out. During the sliding of the
antagonist along the specimen surface, the normal
loading force is a sum of the constant force,
determined by the load and the lever arm (fig. 1, part
I) and the variable force obtained by the variation in
the distance between the rotating ferromagnetic
anchor (- 37, fig. 6) and the block of constant
Neodimic magnets (- 28, fig. 9) attached to the rocker
(presented with all its componentson fig. 7). This
working principle featuring the desired parameters
from the cyclogram on fig. 1, part I, is a result of the
synchronous action of the three basic components –
the eccentric bushing – 19, the lifter cam – 35 and the
anchor – 37. The vertical movements of the antagonist
– its ascending and descending towards the specimen,
are carried out during the transitional stages, when the
roller moves along the transitional parts of the lifter
cam. These stages take up from the actual length of
the sliding path and that is why their duration is as
short as possible, following the principle of
“minimum acceleration” during the ascending and the
descending of the sphere towards the specimen. The
normal friction load of the antagonist on the surface of
the specimen changes during the sliding path, as it is
shown on the lower curve on the cyclogram (fig. 1,
part I). The starting and the final values of the load are
reached predominantly during the transitional stages
of descending and separation of the sphere from the
specimen. On the cyclogram (fig. 1, part I) this curve
is presented as a broken line and this is only a
51
schematic representation while the real process
includes a gradual transition between the different
segments. The cyclogram on fig. 1, part I, graphically
represents the work of the simulator during the testing
of different dental restorative materials used in the
daily practice. The device possesses a functional
flexibility which allows different (and practically
unlimited) load interactions between the antagonist
and the specimen to be obtained, depending on the
specific needs of the experiment.
Possible application of the “Sofia” chewing
simulator
The chewing simulator allows the change of
different parameters, construction elements and the
alteration of the conditions during the simulated
chewing act. This gives possibilities for numerous
scientific experiments to be carried out not only on the
problem of wear but also on microleakage, adhesion,
surface roughness, toothbrush and dentifrice abrasion.
Some of the possibilities for scientific research are:
• Studying the influence of the maximum
loading on the tested surface and the wear
mechanisms induced
• Studying the influence of different,
dynamically changing load profiles on wear
• Studies with different materials used as
antagonists - standardized/non-standardized enamel,
different standard or custom-made ceramic materials
• Abrasiveness of new materials on tooth enamel
• Studying the influence of the sliding path –
how the occlusion is related to the degree of wear of
the dentition
• Studies of the influence of different (food)
medium on wear
• Studies comparing the action of the different
wear mechanisms
• Studies of the wear caused by different
toothbrushes and toothpastes
• Cyclic loading and studying the materials’
fatigue, adhesion and microleakage
Conclusion
The chewing simulator reproduces the basic
mechanical parameters of the chewing cycle and gives
many possibilities for scientific research. From the
numerous possible applications of the machine worth
mentioning are: various experiments on the wear
resistance of dental materials, studies of adhesion and
microleakage, studies of toothbrush/dentifrice
abrasion.
Reference
1. Chakalov I. Analysis of the characteristics of
the chewing process. Rationale for the parameters and
principles of the in vitro chewing simulator. Problems
of dental medicine vol. XXXVI/2010 part II; p.69-80.
2. Le Gall MG, Lauret JF: Occlusion et function,
une approche Clinique rationnelle, CdP Editions 2002.
3. Lasserre JF. Thèse pour le Doctorat
d’Universite de Bordeaux2. Mention Sciences
Biologiques et Médicales. Option Sciences
Odontologique. Recherches sur l'usure dentaire et
évaluation "in-vitro" de biomateriaux restaurateurs
avec le simulateur d'usure UVSB2. 2003.
4. Condon J.R, Ferracane J.L. Evaluation of
seven commercial composites using new in vitro wear
simulator. Dent Mater 1996; (7); 12:218-226.
5. Koczorowski R, Wloch S. Evaluation of wear
of selected prosthetic materials in contact with enamel
and dentin. J Prosthet Dent. 1999; 81(4):453-459
6. Heintze SD: How to qualify and validate wear
simulation devices and methods. Dent Mater. 2006
(8);22(8):712-34.
7. Krejci I, Lutz F, Reimer M. Wear of
CAD/CAM ceramic inlays: restorations, opposing
cusps, and luting cements. Quintessence International,
1994; 25:199-207
8. Shortall AC, Xiao QH, Marquis PM Potential
countersample materials for in vitro simulation wear
testing. Dent Mater 2002; 18 246-254.
9. Söderholm KJM, Lambrechts P, Sarret D, Abe
Y , Yang MCK , Labella R ,Yildiz E, Willems G.
Clinical wear performance of eight experimental
dental composites over three years determined by two
measuring methods. Eur J Oral Sci 2001:109:273-281.
Chakalov I.
Department of Prosthetic Dentistry,
Faculty of Dental Medicine - MU Sofia
52
Orthodontics
Epidemiological study of the orthodontic status and permanent canine eruption in
children and adolescents aged between 7 and 18 years
H. Arnautska1 and V. Krumova 2
SUMMARY
Introduction: Formation of the permanent dentition starts with the first permanent molar after 6 years age
or with the change of incisors and ends with erupting and development of the roots of the second permanent
molar.
It is shown in the literature that canines are the second impacting teeth in frequency after the third molars.
The data of several authors varies between 0,9% to 3,3%. The prevalence of maxillary canine retention, gives
us a reason to conduct an epidemiological study.
The aim of the epidemiological study was to determine the incidence of dental and jaw anomalies in
different age groups from 7 to 18 years and problems with erupting of their permanent canines.
The presence of different dental and jaw anomalies in our study group of 1175 children was significantly
higher – 945 (80,43%) of all examinations. The improper canine eruption in both jaws was observed in 229
(24,23%) children of all cases of children and adolescents with malformations. There is significantly higher
percentage of cases with abnormal I dental Angle class – 559 (47,57%) compare to other classes.
Dental-jaw anomalies occur in very large numbers of children in the early formation of the permanent
dentition and maintain this high rate of growth until the completion of the jaws. The maxillary canines are
particularly important for the proper formation of permanent teeth because they complete their development
late and have the longest path of eruption treatment for forming and maintaining an intact permanent dentition.
Key words: impacted canines, epidemiological survey, occlusion anomalies
1
2
Assistant at the Department of Paediatric Dental Medicine and Orthodontics, Faculty of Dental Medicine, Varna
Professor, D.M.Sc., Head of Department of Orthodontics, Faculty of Dental Medicine, Sofia
53
Introduction
Development of permanent dentition starts with the
eruption of first permanent molars or replacement of
incisives after the age of 6 years and completes with
the eruption of second permanent premolars and
development of their radices. During this continuous
period, many etiologic factors may influence the
eruption of permanent teeth, which impose the
necessity of duly prophylactic examinations.
In terms of dentition development, canine teeth
form early and erupt late, as the total time of their
eruption is the longest, compared with these of all
other teeth.
In the literature, canines are indicated to be the
second, regarding incidence of impaction, after the
wisdom teeth. Data on frequency of canine impaction,
presented by a number of authors, range from 0.9% to
3.3% (1, 2, 5, 10, 13), while in private orthodontic
practice, even a higher percentage has been reported
(12). Frequency of canine impaction varies among
different populations and it is 5 times higher in
individuals of the Caucasian race, compared with
individuals of the Asian race (8). Unilateral impaction
is more common (16), while bilateral impaction is
significantly rarer. According to Bishara (7),
bilaterally impacted canines account for 8-10% of the
total number of impacted canines.
Palatal impaction is more common than vestibular
impaction and in a number of publications, the ratio
between them is estimated to vary from 2:1 to 9:1 (10,
5, 17); the incidence of mandibular canine impaction
is lower than this of the other teeth.
Several authors have shown that abnormal eruption
is
associated
with
additional
orthodontic
deformations, such as hypodontia of the lateral
incisive (3, 6, 15, 16), persisting deciduous canines
(8), presented sagittal deformations (4, 15).
Varying data of both incidence and pattern of
canine impaction gave us grounds to conduct an
epidemiological study of problems related with canine
impaction and orthodontic status of children and
adolescents aged between 7 and 18 years.
The aim of the conducted epidemiological study
was to determine the incidence of dento-jaw
anomalies and problems related with permanent
canine impaction in students aged between 7 and 18
years.
A total of 1,175 students from first to twelfth grade
at two schools in Varna city were randomly examined.
They were distributed into three age groups, based on
traced dentition development: the first group included
7-9-year old children (early mixed dentition), the
second group comprised 9-12-year old children (late
mixed dentition) and the third group included 12-18year old children (permanent dentition).
The school boards and parents were informed
about the necessity of prophylactic examinations. The
children were examined by using individual pairs of
gloves and individual sterile instruments, where
needed. The examination data were recorded in a
statistical list, used for the performed examinations.
The patterns of deciduous teeth replacement,
occlusal relations according to Angle’s classification
and deviations in permanent canine eruption for both
jaws were diagnosed.
The statistical analysis of results obtained was
performed by using the statistical software SPSS 5.0
for Windows. The χ² test was used to compare
qualitative variables and the correlation analysis was
applied to examine the inter-variable relations and to
determine the inter-variable relationship. Student’s
criterion (t) was used for the comparative analysis of
data and determination of a statistical difference
between the variables studied.
The distribution into age groups and the relevant
occlusal deviations are presented in table 1.
54
Relevant occlusal
deviations
Age groups
7 – 9 y.
9 – 12 y.
12 – 18 y.
All ages
Examined
children
n
268
414
493
1175
%
22.81
35.23
41.96
100.00
Without
Dento-jaw
anomalies
n
%
28
10.45
73
17.63
129 26.17
230 19.57
Dento-jaw
anomalies
Class I
n
%
142
52.99
196
47.34
221
44.83
559
47.57
Dento-jaw
anomalies
Class II
n
%
96
35.82
142 34.30
135 27.38
373 31.75
Dento-jaw
anomalies
Class III
n
%
2
0.75
3
0.72
8
1.62
13
0.94
Total
Dento-jaw
anomalies
n
%
240
89.5
341
82.37
364
73.83
945
80.43
Table 1: Distribution into age groups and relevant occlusal deviations
The different number of children into the
individual age groups corresponded to the relevant
number of students in both schools. As shown in the
table, the number of children in the second and third
age group was similar, which enabled us to assess
canine eruption-related problems in a greater sample
of children. The 7-9-year age group was smaller,
because of the lower number of students at this age in
both schools.
The results show that out of 1,175 children
examined, a very low percentage of children in the
three groups presented no deformations, in both terms
of tooth arrangement and occlusal relations.
A total of 230 children had no dento-jaw
anomalies, a result that shows that only 19.57% of the
examined children presented an occlusal status
corresponding to a favourable prognosis for
appropriate dentition arrangement. In the 12-18-year
adolescents with permanent dentition, this percentage
was higher (26.17%), since many of them had already
undergone orthodontic treatment or duly prophylaxis.
with DJA
without DJA
25,40%
36,10%
12,20% 31,70%
0%
20%
40%
7 - 9 y.
38,50%
56,10%
60%
9 - 12 y.
80%
100%
12 - 18 y.
Figure 5: Distribution of children, based on
presented dento-jaw anomalies, among individual age
groups
The number of children with dento-jaw anomalies,
as shown on figure 1, increased with increasing the
age, as the percentage of children with presented
deformations was the highest (38.52%) in the 12-18year age group. There was no, however, a statistical
correlation between the age and types of presented
deformations.
The data obtained show that in the three age
groups, generally, a significantly low percentage of
children (0.75% - 1.62%) had Class III deformations,
which are the most problematic for appropriate
dentition arrangement.
Our results support the opinions of several authors
(2, 9, 15) that in ectopic canine eruption, different
malpositions of teeth are of essential significance
rather than sagittal relations of the jaws.
The distribution of permanent canine eruption
among the individual age groups is presented in table
55
Late
eruption
of 313
313
Age
groups
Class I
Total
children with
deformations
Class II
Without
space
313
313
Palato
position
Class III
Without
space
313
313
Palato
position
With
out
space
313
313
Total –
children with
problems
with canines
Palatp
position
n
n
%
n
%
%
7 – 9 y.
240
25.40
6
2.54
8
3.33
9–12 y.
341
36.08
43
12.61
18
12-18y.
364
38.52
49
13.46
30
All ages
945
100.0
98
%
n
4
1.66
-
5
13
3.81
8.24
4
1.10
36
n
21
%
n
%
-
4
1.66
1
0.3
8
1
0.28
21
2
%
n
%
n
4
1.66
2
0.83
-
2.35
3
0.88
4
1.17
5.77
5
1.37
-
-
33
n
12
6
%
n
% n
%
n
% n
%
-
-
-
-
-
-
-
-
-
28
11.67
-
-
-
-
-
-
-
-
-
-
90
26.39
1
0.28
-
-
-
-
-
-
-
-
111
30.49
229
24.23
1
-
-
-
n
-
%
Table 14: Distribution of permanent canine eruption among the individual age groups
For both jaws, the results show that abnormal
canine eruption was observed in 229 (24.23%) out of
the 945 children and adolescents with deformations.
The highest percentage (48.50%) of children with
problematic canine eruption was registered in the 1218-year age group (Figure 2).
100,00%
88,30%
69,50%
50,00%
0,00%
11,70%
7 - 9 y.
other deformations
problematic canines 12.20%39,30%
other deformations
29,60% 35,10%
48,50%
35,30%
0% 20% 40% 60% 80% 100%
7 - 9 y.
9 - 12 y.
12 - 18 y.
Figure 6: Distribution of occlusal deviations and
canine eruption deviations among individual age
groups
A tendency of an increasing incidence of
problematic canine eruption from 11.70% to 30.50%
was observed in the 7-9-year age group and 12-18year age group, respectively, compared with the
frequencies of occurrence of other deformations
(χ2 = 27.98, p < 0.05) (Figure 3).
73,60%
26,40%
9 - 12 y.
30,50%
12 - 18 y.
problems with canines
Figure 7: Tendencies of abnormal canine eruption
and other deformations with increasing the age.
Our results comply with the opinions of several
authors (3, 14) that there is a need of the earliest
possible prophylactic measures for duly removal of
several etiologic factors related with abnormal canine
eruption and for monitoring the appropriate dentition
arrangement (11, 12).
The results of mandibular canine eruption are of
particular interest, since in our country, there are
almost no studies on this issue. In 56 (7.24%) of the 918-year old children with deformations, problems
were observed with the eruption of mandibular
permanent canines, which should had already erupted
(t = 13.81, p < 0.05).
In the 12-19-year age group, where the maxillary
canines should be already erupted, difficulties in
canine eruption or respective ectopic positions were
56
found in 76 (20.88%) of the children, which shows
that in this study group, every fifth child will
experience problems in achieving an intact dentition
arrangement (r = 0.27, p < 0.05).
Problems with maxillary canine arrangement
increase with increasing the age, compared with these
of mandibular canine arrangement (χ2 = 20.76,
p < 0.05), the latter being most common among the
children aged between 7-9 years (figure 4).
3,60%
12 - 18 y.
9 - 12 y.
56,60%
7 - 9 y.
0%
20%
maxillary canines
withot space
23,30%
40%
60%
18,80%
21,50%
42,80%
35,70%
1,8
31,50%
63,10%
80%
1,3
100%
mandibular canines
palatal position
Figure 8: Distribution of canine
deviations among individual age groups
eruption
In contrast, palatal positions of maxillary canines
were not observed in the youngest age group,
although the great space deficit in the dental arch, a
fact that is associated with the eruption time of
maxillary canines. Although slight, an increase of
palatal positioning was observed in the older age
groups, despite the small space deficit in the dental
arch. The increasing percentage of cases with ectopic
canines shows that despite jaw development at this
age, the autoregulation of canine position remains
impossible and, therefore, one of the most serious
problems for appropriate dentition arrangement.
The results of the performed epidemiological study
gave us grounds to conclude the following:
1. The presented incidence of various dento-jaw
anomalies in the study groups of 1,175 children was
significantly high: 945 (80.43%) of all children
examined (χ2 = 29.76, p < 0.05).
2. A significantly higher percentage of cases with
Class I deformations according to Angle’s
classification was observed, compared with these of
the other classes: 559 (47.57%) of the children,
compared with the other classes (t = 13.33, p < 0.05).
3. A significantly higher percentage (24.23 %) of
children with problems in maxillary and mandibular
canines was observed (t = 8.40, p < 0.05).
4. No children with Class III-related problems in
permanent canine eruption were found in the study
groups.
Conclusion
Dento-jaw anomalies occur in a great number of
children even in the beginning of permanent dentition
arrangement; this high incidence remains unchanged
till completion of jaw growth. Permanent canines,
having the longest path to move through and reach
their normal place in the dental arch and having the
longest eruption time, are of crucial importance for
the appropriate dentition arrangement. The results
obtained show that duly prophylactic measures are
needed for normal canine eruption and orthodontic
treatment is required for the appropriate arrangement
and maintenance of an intact permanent dentition.
Reference
1. Апостолова В.
Честота, клинична
характеристика и причини за възникване на
аномални
положения
на
третите
зъби.
Дисертация, С., 1974, 313 c.
2. Ганева Зл.
Лечение на някои ЗЧД чрез
изваждане на постоянни зъби. Дисертация, С.,
1971, 224 c.
3. Baccetti, T. A controlled study of associated
dental anomalies. Angle Orthod., 1998; 68: 267-274.
4. Basdra, E. K., Kiokpasoglou M., Stellzig A.
The Class II division 2 craniofacial type is associated
with numerous congenital tooth anomalies. Eur. J.
Orthodontics, 2000; 22:529–535.
5. Bass, T. B. Observations on the misplaced
upper canine tooth. Dent. Practit., 1967; 18:25-33.
6. Becker, A.
Palatal canine displacement:
guidance theory or an anomaly of genetic origin.
Angle Orthod., 1995; 65:13-7.
7. Bishara, S. E. Impacted maxillary canines: a
review.
Am. J. Orthod. Dentofacial Orthopedics,
1992; 101: 159-171.
8. Bishara, S. E.
Clinical management of
impacted maxillary canines. Semin. Orthod., 1998;
4:87-98.
9. Dachi, S. F., Howell F. V. A survey of 3874
routine full mouth radiographs. Oral Surgery, Oral
Medicine, Oral Pathology, 1961, 14:1165-1169.
57
10. Ericson S., Kurol J.
Radiographic
examination of ectopically erupting maxillary canines.
Am. J. Orthod. Dentofacial Orthopedics, 1987; 91:
483-492.
11. Ericson S., Kurol J.
Early treatment of
palatally erupting maxillary canines by extraction of
the primary canines. Eur. J. Orthodontics, 1988; 10:
283–295.
12. Ferguson J. W. Management of the unerupted
maxillary canine. Br. Dent. J., 1990;169:11-7.
13. Grover P. S., Lorton L. The incidence of
unerupted permanent teeth and related clinical cases.
Oral Surg. Oral Med. Oral Pathol., 1985; 59:420-5.
14. Jacoby, H. The etiology of maxillary canine
impactions. Am. J. Orthodontics, 1983, 84: 125-132.
15. Langberg, B. J., Peck S.
Adequacy of
maxillary dental arch width in patients with palatally
displaced canines.
Am. J. Orthod. Dentofacial
Orthopedics, 2000b, 118: 220–223.
16. Oliver, R. G., Mannion J. E., Robinson J. M.
Morphology of the maxillary lateral incisor in cases of
unilateral impaction of the maxillary canine. Br. J.
Orthod., 1989; 16:9-16.
17. Thilander, B., Jakobsson S. O. Local factors
in the impaction of maxillary canine. Acta Odontol.
Scand., 1968, 26: 145–168.
Prof. Dr. V. Krumova
Department of Orthodontics,
Faculty of Dental Medicine,MU – Sofia
1 St.G.Sofiiiski str., Sofia, 1431
58
Public Dental Health
Demographic processes and structure of the dental practices as prerequisites for
market development of the dental services in Bulgaria
K. Tzokov1, L. Katrova¹
SUMMARY
The aim and social characteristics of this study is to demonstrate the influence of demographic of the
population on the development of dental practices and the market of the dental services.
Material and Methods: Secondary data analysis.
Results: During the last two decades the population in Bulgaria, especially bellow 65, has been steadily
decreasing while the number of dentists markedly increased. The change in the structure of dental practices is
presented by an increase of the number of general dentistry group practices, a decrease of the number of
individual and group practices for specialized dental care and a decrease of the number of dental centers, is
observed. For the period of20 years only 1/3 of the specialist positions were fulfilled. Utilization of the Dental
Health Service is about twice lower than the utilization in EU.
Conclusion:
1. Sustained trends of decrease of the number of the population and the prevalence in aging population
groups, correlate negatively with the increasing number of dentists.
2. Prevalence of aging groups implies increase of treatment needs but not automatic increase of the demand
for dental services.
Key words: demography, dental care facilities, utilization of the dental health service, dental care market .
1
·MU -Faculty of Dental Medicine, Sofia, Department of Public Health
59
Introduction
Demographic data on Bulgaria for the last 20 years
show a steady trend towards reducing the number of
the population, aging group prevalence and uneven
distribution of the population through the country
[12]. Contrary to the reduction of the population's
number, the number of dentists for the same period
increased [1,14]. In the same time, the dental delivery
system in Bulgaria for the same period, evolved from
100% public in almost 100% private practice [9].
Dentists now work in a real market environment with
elements of regulation 1. Along with the introduction
of new market relationship the dental practices
structure is changing as well [6]. A number of new,
and yet unexplored socio-economic conditions
aroused. As a result the access to dental care was
affected and the utilization of health services
consequently diminished [10].
The aim of this study is to demonstrate the
correlation between demographic and social changes
in the population and the development of dental
practices by the country as a whole and by regions and
how these processes influence the formation of dental
care market for the period 2000-2010. In connection
with the set objective the following tasks were
formulated:
1. Brief presentation of demographic data on the
population
2. Brief presentation of data on dentists and dental
practices
3. Brief overview of changes in the structure of
dental practices.
4. Utilization of the dental service
1. Presentation of demographic data on the
population by regions
According to the official sources of demographic
data, (NHIC and NSI) the number of the population of
Bulgaria decreased significantly for the study period
of 20 years (between 2000 and 2010) [14]. The study
of the demographic situation by regions confirmed the
existence of the leading common problem for the
country as a whole -reduction of the number of
Bulgarian population. The distribution of the
population over the regions is uneven. Against the
general trend of reduction of the population, the
regions of Bourgas and Sofia region retain a relatively
constant number of population. Increase of the
number of the population is observed in the cities of
Sofia and Varna. (Fig. 1) [12]
The study is based on the analysis of secondary
data. Data were issued from the official publications
of the NCHI 2, the NSI 3, the BgDA 4 and the review of
literature following keywords 5.
Figure 9: Change of the number of the population in
Bulgaria and some region
1
A minimal package of dental services is covered by a public
fund (National Health Insurance Fund) and a fixed rate of prices
is voted every year upon the Frame Contract between the
profession and the Fund.
2
National Center for Health Information
3
National Statistical Institute
4
Bulgarian Dental Association
5
Demography, Medical institutions for dental care, utilization
of dental health service, dental market
60
The age structure of the population, presented in
Table 1, shows a slow but stable trend towards
decrease of the number of young people and a
considerable increase in population over 65. The
number of the working population gradually
decreased from 2000 to 2005 years, then slowly
increased and remained stabilized in recent years. The
percentage of working population is significantly
higher in cities, while the villages are more or less
depopulated. The unemployment rate for Bulgaria is
Year
Age group
0-17
1970
1995
2000
2005
2007
2008
2009
27.5
22.0
19.5
17.5
16.9
16.7
16.7
18-64
65+
Total population
62.8
9.7
62.8
15.2
64.1
16.4
59.6
22.9
65.8
17.3
65.9
17.4
65.8
17.5
1970
1995
2000
2005
2007
2008
2009
28.1
22.9
20.0
17.7
17.1
16.9
16.8
65.3
65.6
67.7
68.7
65.0
69.1
68.9
relevant to the population purchase power, in
particular the search for dental services. The
underemployment and unemployment rate is touching
young and low educated people. The share of longterm unemployed (2 or more years) is going up [4,13].
2. Information on dentists and dental practices
The concentration of population in more
densely populated areas is expected to generate bigger
treatment needs. These areas are attractive to dentists
too. The regions of Sofia-city, Plovdiv, Varna have a
consistent number of dentists and unfavorable
dentists/patients 'ratio [14]. According to NHIC data
after sustainable increase of the number of dental
practitioners for the period (19802000) (from 4839 to
6778) the number of dentists now keeps its level
(Fig.2).
6.6
11.5
12.3
13.6
13.9
14.0
14.3
1970
26.8
60.0
13.2
1995
20.1
57.0
22.9
2000
18.6
56.3
25.1
2005
17.0
57.4
25.6
2007
16.5
57.9
25.6
2008
16.3
58.1
25.6
2009
16.1
58.2
25.7
Table 1: Dynamic of the process of urbanization by
age groups distribution
Figure 2: Change of the number of dental
practitioners for the period 2000-2010
61
3. Overview of changes in the dental practice
A review of official data on dental practices
shows that for the period from 2000 to 2007 the
number of the individual general dental practices
increased, followed, by a decrease between 2007
and 2009. Constantly growing is the number of the
general dentistry group practices. The number of
Table 2: Outpatients clinics for dental care, dental practices
individual and group practices for specialized dental
care was going down. The number of dental centers,
registered a decline, while relatively constant
remained the number of medico dental centers
(Table 2). For 20 years period only 371 dentists
have acquired specialty, which represents less than
one third of the group of retiring specialists `(7).
62
4. Utilization of the Dental Health Service:
According to BgDA only 45% of patients had
visited a dentist during the previous year, while in
EU countries the percentage varies from 88% to
71% [3].
Conclusion
1. The long term trend for decrease of the total
number of the population correlate negatively with
the increasing number of dentists in Bulgaria.
2. The prevalence of aging population implies
some potential increase of the dental needs, but the
low purchase power is stopping the demand for
dental services.
3. Research should be focused on the dental
service's utilization and the dental practices'
preparedness to respond the real demand for dental
services.
Reference
1.
Катрова,
Л.Г.П.
Стоматологичната
професия–състояние и перспективи. ЛТД
Пъблишинг София, 1998, 290 с.
2. Катрова, Л. Кр. Цоков, Цв. Катрова.
Промяната на социално–професионалния статус
на стоматолозите в България в хода на здравната
реформа. ИМАБ 2002 том 8 №1, стр. 18-21.
3. НЦЗИ, Кратък Статистически Справочник
– здравеопазване, електронно издание – 2000,
2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008,
2009, 2010 г.
4. Гладков, Ол. Eвробарометър. 02. 2010,
тема-Орална здраве.
http://ec.europa.eu*public_opinion/archives/ebs/
ebs_330_eu.pdf
5. http//www.nsi.bg/census2011/index.php –
НСИ, преброяване 2011г.
6. Регистър на БЗС-списък на членовете по
районни колегии 2000 – 2010г.
7. Katrova L. P. Bojinov, I. Mihailova. Oral
Health Care reforms in Bulgaria during the period
of transition. Oral health and Dental Management in
the Black Sea Countries, Vol. VI, 2007, No 4, pp 38, ISSN: 1396-5883.
8. Катрова Л., Хр. Кисов. Ученето през целия
живот - задължение или привилегия за лекаря по
дентална
медицина,
продължаващото
следдипломно образование – задължение или
привилегия за факултетите по дентална
медицина. Проблеми на денталната медицина,
XXXVI, 2010, №2, с.28-36, ISSN: 0323-9403.
9. Katrova L. Leading trends in dental profession
demography in Bulgaria for the period 1996-2008
(OP112). 14 Congress of BASS, 9th Scientific
Congress of the BgDA. 6-9 May 2009 Varna
(доклад).
10. Шипковенска Е., Методология на научноизследователската работа, Здравна политика и
мениджмънт, 2011, том 11, №1, ISSN 1313-4981.
11. Катрова Л., Папанчев Г. и др.
Удовлетворяване на потребностите от лечение
на кариеса и неговите усложнения в условията
на здравно осигуряване, Проблеми на
стоматологията, том ХХХ/2004, с. 63-68, ISSN
0323-9403.
12. Катрова, Л. Професионално-демографски
аспекти
на
структурната
реформа
в
стоматологията Стоматол. преглед, т. 29, 1998,
№2, с. 11-28.
13. Катрова, Л., М. Грашкина. Използваемост
на стоматологичната здравна служба в
преходния период. (1999-2000), т. 27, 2000 с.
115-125, ISSN 0323-9403.
14. Катрова Л. Генерационна мобилност в
зъболекарската професия, приемственост и
перспективи Soc. Med. Sofia, 17, 2009, No 3, с.
29-32, ISSN: 1310-1757.
15.
Ранчов
Г.
Биостатистика
и
биоматематика:
концепции,
методи,
приложения. София, 2008 ISBN: 978-954-910849-1.
16. Регистри на БЗС за 2008, 2009, 2010, 2011.
17.http://www.bzs.bg/site/index.php?option=co
m_content&task=view&id=964&Itemid=664.
Dr. Kr. Tsokov
Department of Public Health
1, St. G. Sofiiski Blvd., 1431, Sofia
Phone: +359 889 25 17 88
63
Review
Children with special health care needs and prevention of oral diseases in this
population
L. Doichinova1
SUMMARY
Oral health of children with disabilities requires more attention than usual and is a real challenge to the
dental professional and his team. There are a number of reasons, which necessitate children with disabilities to
be subject to dental medicine special care. Their oral health differs from that of their normal coevals, for
example higher incidence of periodontal diseases in children with Down syndrome, teeth abrasion in children
with cerebral palsy.
The prevention of dental diseases in children with special health care needs should have higher priority than
in healthy children.
Treatment planning and dental care delivery may require modifications depending on the patient’s abilities,
possible future cooperation and home care.
The preventive measures should be encouraged and personal instruction respectively performed, as well as
screening and preventive individual programs should be developed in order to minimize the oral problems with
this population.
Dental professionals, dealing with such patients, must have a lot of imagination, inventiveness and
flexibility. Individual adaptation and modification of the traditional procedures is necessary, as well as
patience, calmness and politeness while working with special needs patients.
Key words : Special needs children, oral health, education, communication, behavioral problem
1
Assistant professor, MU-Sofia, Faculty of Dental Medicine, Department of Pediatric Dental Medicine
64
Introduction
Childhood is a period, marked by dynamic
processes of growth and development of the child’s
organism and complex processes of setting up the
functions of oral structures. The congenital and early
acquired defects in the child’s organism affect the
individual development. Anomalies change the entire
life activity of the child including adequate oral
structures construction, which worsens oral health.
Preventive measures in these cases, such as rational
nutrition, fluoride preventive measures and oral
hygiene are of vital importance for its improvement.
Each community has a group of children with
disabilities, which put them in an unfavorable
situation compared to the others. Some of them have
deviations in their oral health, such as higher
incidence of periodontal diseases in children with
Down syndrome, tooth abrasion in children with
cerebral palsy, higher rates of untreated caries, more
missing teeth. The higher risk of oral disease
development in children with developmental problems
turns prevention into even more vital priority
compared to other children. Their treatment is difficult
as it requires special conditions and may need a lot of
time, spent in specialized clinics and multi-purpose
hospitals. Quite often it is held only in “cases of
emergency” (1).
Investigations show that about 500 million people
worldwide have some disability.
NSSI (National Social Security Institute) statistics
state that in Bulgaria there are 850,000 disabled
individuals, 147 000 of them being children with
specific abilities, those permanently handicapped
reaching 30,000 (per expert evaluation). The
inadequate development of alternative services and
care for children with special needs and support of
their families determines the large number of those,
raised in social homes within the system of various
ministries in isolation and completely inappropriate
conditions. Per data of a study, held by the State
Children Protection Agency (SCPA), the number of
institutionalized children with mental retardation,
psychic, physical and sensory disabilities is 18,695,
11,776 of them in institutions of MOES (Ministry of
Education and Science), 5,440 in such institutions of
Ministry of Labor and Social Care (MLSC) and 1,479
in such, managed by the Ministry of Health (MOH).
The high degree of their institutionalization results in
strong reduction of the possibilities to provide good
health care, including dental care and prevention.
The maturity of society is illustrated by its attitude
to the poor and the handicapped.
Each country is obliged to take care of the health of
every man, its top priority being those who most badly
need such care.
Our society has its pending duty to children and
people with disabilities.
Social and medical aspects of dental care in
children with special needs
Per the definition, adopted by the Board on Clinical
Activities to the American Academy of Pediatric
Dentistry (AAPD) in 2004 “certain people have
special health care needs if they have problems in
their physical, mental, sensory, behavioral, cognitive
or emotional development, which limits their
functions and necessitate medical management, health
care intervention and/or use of special services or
programs. This condition may be manifested in the
process of individual development or be acquired and
results in limitations of carrying out daily self-care
activities or significant restrictions in major life
activities. Health care of patients with special needs
exceeds the routine practice and requires specialized
knowledge, better awareness and attention, as well as
adjusting to these requirements.” (26).
According to AAPD the main objective of pediatric
dental medicine is to attain maximum health level for
all children, including those with special health care
needs (27).
The special dental care needs of this group of
children are determined by the existing barriers to oral
care delivery and by the increased risk of oral disease
development. The barriers, restricting normal oral care
for children with physical, psychic, sensory and
emotional handicaps are define by objective and
subjective prerequisites (18).
One of the objective factors worth mentioning is
lack or deficit of financial resources in the majority of
the families of these children, as they predominantly
rely on state funding for payment of their medical or
dental service (77).
Other factors, limiting the access of this population
to dental care are the demand of more time, dedicated
by the family to get the service needed, the limited
transport resources to the dental office or center and
65
all the difficulties, caused by it, requiring specially
adjusted vehicles and appliances, facilitating the move
(77).
Generally these children don’t have adequate
access to private health insurance in getting health
services (18).
A major subjective factor, substantially limiting
oral care application in this unique population of
children is the inability to understand, cooperate and
take responsibility for the preventive procedures and
treatment, protecting their oral health (87, 77).
Other factors, which may hinder the access of these
patients to dental care are language or cultural
barriers. (27).
Children with special needs have lower protective
factors and inappropriate behavior as to oral diseases
(6).
Lack of information and knowledge on oral
diseases and their consequences on behalf of the
parents, the general practitioner or the dental doctor
might also be one reason of limiting preventive dental
care (26).
Other series of circumstances, such as longer time
for feeding, special diets, using food as reward, oralmotor or general motor dysfunctions, resulting in poor
oral hygiene, insufficient addition of systemic
fluorides, over-commitment of parents/guardian with
child's disabilities, as well as parental or institutional
ignorance and/or negligence of oral health put
disabled children in the high risk group for the
development of oral diseases (82, 88).
Patients with special needs may demonstrate higher
degree of anxiety during dental manipulations than
those without disabilities, which can adversely
influence the frequency of dentist appointments and
consequently their oral health (50, 78, 49).
In their study Oredugba et al report that a very
small number of dentists have adequate knowledge on
treatment of children with special needs, irrespective
of their gender, age or dental practice location (70).
Historically many of these patients get dental care
in special homes and state institutions (87). The trend
nowadays is the children with special needs to get
dental care in standard dental centers or by doctors in
private dental practices (35).
The existing Act on People with Disabilities in the
US sets the dental office as place of public
significance. Avoidance to treat patients with special
needs may be treated as discrimination and violation
of a federal and/or state law (27, 35). The regulations
require by the practicing dentists to ensure physical
access to their dental practices, such as ramps for
wheelchairs, parking places for handicapped, special
rails, etc. (35).
The Faculty of Dental Medicine in the University
of Seattle, Washington has a special program DECOD
- Dental Education in Care of Persons with
Disabilities, which provides dental health care to over
2000 disabled patients annually. Approximately 60%
of them have severe disabilities, such as mental
retardation, cerebral palsy or autism. The University
has a program awarding scientific degrees to students,
who monitor the treatment planning of populations
with special needs. There are short-term and longterm specializations with scholarships and additional
self-training modules with video tapes for those
students, interested to learn how to provide dental care
to this unique group of the population. The students
work regularly with their lecturers from the faculty in
social homes for at least one semester (43). The
American Association of Faculties in Dental Medicine
develops curricula with specific guidelines on dental
care for people with disabilities (43).
The US Commission on Dental Accreditation
(CODA) includes in the accreditation standards
training on delivery of oral health care to people with
special health care needs (62).
Supporting methods and means in providing
oral care to disabled children
During the treatment and preventive procedures of
patients with special needs it is of substantial
significance to have an assessment of the mental
status or the degree of intellectual function in order to
be able to establish good communication (50). A
patient, who does not communicate verbally, can
maintain communication in a number of untraditional
ways. In case of unsuccessful communication one
should look for the most effective way of establishing
a contact with such problematic patients (35). The
effective communication is of prime importance for
patients/parents with hearing problems, which can be
attained by a variety of methods and techniques,
including interpreters, written materials and lips
reading (65). Getting information on the way a patient
with intellectual or physical difficulty communicates
66
is an important goal in the overall work of the dental
doctor (50). Many patients are likely to have not only
hearing difficulties, but also difficulties related to
speech and/or language. The receptive language (what
is being heard/accepted) and the expressive language
(what is being said) are frequently speech/language
areas, which raise problems (67, 50). The ability to
follow instructions, learn new things and articulate
desires and needs may be difficult for some patients
with intellectual and physical difficulties (50). Many
of them rely on verbal or non verbal prompting, others
do not understand language, which differs from the
verbal one and that is why it is important for the
dental specialist to know the way, in which the patient
establish communication (67, 68, 50). Some of the
patients need supporting aids such as Alpha Smart
(small portable computer) or system of picture
communication
P.E.C.S.
(Picture
Exchange
Communication System) (50). The latter is an
alternative technique for those, having low or no
verbal skills. The booklet consists of pictures on
expressing desires, observations and feeling. It grows
with the growth of the patient, adding more words and
pictures and helps a lot to those, who do not speak
(50). Such patients have a wide range of behavioral
and emotional problems, the impulsiveness and the
low annoyance threshold being frequently present (67,
50, 68). They often loose speech or physical control
and may need physical/verbal prompts to trigger the
necessary reaction or calm them down (50, 68). As to
speech they may use inappropriate language or speak
when the time is not appropriate. As to physical signs
they may pinch themselves or others, slam their head
in the wall, bite themselves or bite others or cause
vomiting (50).
Behavior management of patients with special
needs may be another challenge to the dentist and
his/her team. Stubborn, repetitive behaviors are often
manifested in individuals with mental retardation and
such with purely physical disabilities and normal
intellectual capacity. These behaviors may hinder safe
treatment in the dental office (27). The protective
stabilization can be of help to patients, where the
traditional behavior management techniques are
insufficient (23). In cases when this is not enough for
delivering qualitative dental care, the behavior
management choice left is relevant sedation or general
anesthesia (13, 12, 81).
For proper diagnose and effective treatment
planning it is necessary to have an accurate,
comprehensive and correct medical history (27). The
medical history information should include also what
may annoy or calm down the patients, since it is
important for the delivery of dental care (50, 67, 68,
22). Getting acquainted with the medical history of
the patient with special needs is of great importance
also for reducing the risk of worsening his medical
condition by dental care delivery(27).
In the US it is recommended for an appointment of
patient with special needs the dentist to be acquainted
with and strictly follow the requirements of Health
Insurance and Accountability Act and the Act on
People with Disabilities, related to dental practices
(35, 36). The first one guarantees patient privacy
protection, while the second prevents any disabilityrelated discrimination.
When working with these patients it is also
necessary to have a well-documented informed
consent, given by the patient himself or someone,
eligible to do so and it should be recorded in the
patients’ record, proven by an enclosed informed
consent form, signed in the presence of the dental
professional (23, 20).
Prevention of Oral Diseases in Disabled
Children
Preventive dental care to disabled children is
limited as they either don’t look for it or the dental
professional don’t treat them except for cases, when
alleviating the pain symptom is badly needed (67, 22,
68). Treatment is carried out only in “case of
emergency” and the service level is not at all good (1).
While for the normally developing children dental
interventions are accepted with not so pleasant
feelings, for those with special health care needs
irrespective of their nature - preventive measures or
dental treatment - they are characterized by complete
lack of collaboration (22, 1).
The issue about organizing the oral disease
prevention with this group of children should be
considered very seriously due to lack of capability to
take own decisions referring to their own health (1).
Parallel to that it is established that oral diseases are
second in significance after the severe general
condition of the children with special needs (22).
67
They are exposed to higher risk of developing oral
diseases (86, 32), while oral health is an integral part
of general health and wellbeing of each individual
(27). Oral diseases may further jeopardize the health
of the patient with special needs and therefore
prevention is needed (86).
For this group of patients the chronic character of
tooth caries and periodontal disease may cause
complication of the underlying disability (70, 42, 48).
The tooth caries incidence is higher compared to
their healthy peers, almost 2/3 of children with mental
retardation
and
physical
handicaps
being
institutionalized and having inadequate access to
dental care (88, 39, 90).
For many children with special needs the risk of
caries development is larger due to poor oral hygiene
and worsened general health (8).
Large part of them are unable to maintain
independent oral care (67, 68, 8, 22), while others
cannot brush their teeth properly due to mental and/or
physical problems (22, 67, 8, 68). In such cases the
parents or caretakers should be trained and prepared to
take responsibility to conduct oral hygiene care at
home, which is important in order to ensure proper
and regular control of daily oral care (22, 67). It is
necessary to show oral hygiene technique and
procedures, including proper positioning of the
disabled person (27, 20). In developing home oral
hygiene programs it is necessary to choose the most
suitable position of the patient and the caretaker
provided independent brushing is impossible (22, 8,
67).
According to Nowak (67) and other authors,
because of the serious risks of its early onset, parents
should get all the necessary information on prevention
of incipient tooth caries, learn what is their role in the
process of ensuring the dental health of their own
child and strictly follow the recommendations of both
the pediatrician and the dental professional (8, 22, 68).
Besides the key etiological factors, namely plaque
bio-film, diet and time, there are also additional
factors contributing to the development of tooth caries
in children with special health care needs such as:
hypoplasia of the enamel, its morphological changes,
compressed front, carbohydrate diet, consumption of
sweets, snacks, soft food, lack of collaboration,
mental deficit, physical limitations, lack of funds,
institutionalization and lack of care (67).
More and more caries management strategies
emphasize on the concept of caries development risk
assessment (73, 88, 64, 72). For children with special
needs it should be done, because they face higher risk
of developing oral diseases as a result of their
disability (68).
The caries risk assessment should be performed
periodically in order to assess all the changes in the
risk status of the child with special needs (27, 32, 73).
It serves as basis for caries management strategy (28,
37, 31, 34) and allows proper clinical decisions to be
taken for these children (91).
The caries risk assessment tool (CAT) is based on a
set of physical factors, such of environment and
general health factors and represents a dynamic tool,
which can be periodically assessed and revised when
data require such revisions (33, 45, 46, 88, 91). In
Bulgaria such caries development risk assessment tool
was also developed by Rashkova et al. which is easy
to use and examines the oral environment risk factors
and their connection to certain pathology noticed in
the oral cavity (72).
The contemporary dynamic carious process
understanding outlines the possibility of stationing it
while still in its active stage at any moment prior to
the stage of cavitation (4, 7). The caries activity
assessment is considered to be most important in
assessing the carious process (4).
Most of the studies do not report lesions without
cavitation (91, 58, 47) though such lesions have their
proven value for the projected estimation (490).
With the existing possibility of detecting tooth
caries in its incipient stages (lesions having the shape
of a white spot) the dental professional can help
preventing tooth cavitation (53, 85, 4).
It is proven that by the application of amorphous
calcium phosphate (АСР) and casein-phosphopeptides
(СРР) that re-mineralization of the incipient caries in
the subsurface enamel layer is possible (7). It is
established that even if there is progression of the
process with clinically detectable lesion, its
development can be inhibited and the lesion remain
stable for months and years ahead(9). Such lesion can
be re-mineralized by eliminating the cariogenic
factors: plaque bio-film, change of diet and improving
the activity of the protective factors (fluoride,
increased saliva flow, re-mineralizing agents) (9, 7,
10).
68
There are available scientific data that chewing
gums with Хylitol and Sorbitol help reducing the
tooth caries risk and are very useful to disabled
persons (74, 76, 59). Studies reveal that those
preferring chewing gum with Xylitol register highest
reduction of caries development risk (61, 60, 71, 54,
55, 57).
Xilitol is sugar substitute, which has excellent
effect for tooth caries prevention. (61, 60, 71, 59, 21,
52, 86, 75, 74, 76, 82, 56, 54, 55, 57, 84, 80, 19, 79).
There are reports on long-term effect of the use of
chewing gum and sweets rich in Xylitol, rendering
also favorable effect on the newly erupted teeth. It is
established that within one year after regular use of
rich in Xilitol chewing gums caries development risk
drops by 93%, while the teeth having erupted within
two years after the subjects stop using this product
show 88% reduction of this risk (52). The necessity of
recommendations on the efficient dose and frequency
of using chewing gum or sweets with Хylitol for
patients with special needs is emphasized (21, 86, 61).
The combination of fluorides and Хylitol suppress the
growth of Streptococcus mutans (57, 84, 79). The
combination of fluoride toothpaste and use of Хylitol
in chewing gums, sweets or as toothpaste and mouth
rinse ingredient has even better caries protective effect
(76, 82).
In cases of xerostomy, which is frequent side effect
of drugs, prescribed to disabled persons, Xilitol has
excellent effect, as it increases the saliva flow (19)
and strongly reduces the acidogenic potential of the
plaque bio film (57, 84, 19, 79). It is established that it
also strengthens the tooth enamel by stimulating the
re-mineralization effect of saliva, facilitates the
absorption of calcium by the tooth surface and reduces
the ability of microorganisms to stick to it (59, 57, 84,
79, 19).
It is reported that the polyoles, natural sugar
substitutes – sorbitol, manitol and xilitol – are difficult
to be dissolved by the oral cavity microorganisms (55,
57). Streptococcus mutans can successfully dissolve
only sorbitol and manitol, but not th xilitol, which is
identically sweet as sugar and satisfy the need of
getting sweet food, at the same time significantly
reducing the tooth caries risk (61, 60, 71, 59, 21, 52,
86, 75).
Dental team prime responsibility is to provide
information and training of the patient and caretaker,
which should end up by drafting an individual
prevention plan, tailored to his/her individual
demands, and if needed also by developing a
therapeutic plan relevant to the specific oral cavity
condition, which to ensure the patient’s oral health
protection and promotion (22). It is underlined that the
oral health of such persons is affected by various
social-demographic factors, living conditions and the
severity of the specific disability (69).
What is being recommended is the individual
prevention program and new appointments schedule
with the dental professional for prevention to happen
only after caries risk assessment as well as assessment
of the patient’s oral health needs. The treatment and
prevention methods and techniques to be used should
be explained to the patient and the parent (27, 20).
Based on the answers provided by parents to
structured questionnaire on the oral health of their
children, the majority of them (94%) supports the
recommendations and advice for oral disease
prevention and thinks that there should be explanation
of the risks, which oral disease can have on general
health (69). The necessity to give basic consultations
on the appropriate diet, oral hygiene maintenance and
fluoride supplements, free of charge, is also
underlined (38). One of the most preferred sources of
these advice and consultations is the family dentist
(51). Parental support of regular dental check up
examinations is extremely high, the prevailing opinion
indicating that the children with special needs should
have such regular check up exams more frequently
(38).
In the process of conducting such plaque bio film
management program it is recommended to include
also appropriate consultation on the child‘s diet and to
explain the existing relation between the refined
carbohydrates and oral health both to the parents and
the tutors, asking for their cooperation (22). The food
regimen of such patients should be discussed and
instructions for changing it should be provided aiming
at a long-term preventive effect on oral diseases (35).
The dental professional should encourage noncariogenic diet and inform the patient/parent about the
high cariogenic potential of oral pediatric medicines,
rich in sugars and diet supplements, rich in
carbohydrates (87, 20). It is recommendable to
explain to the parents that rewarding the child with
something “sweet” creates high caries development
69
risk, due to maintaining low pH of the saliva for a
longer period between meals. Some children have
poorer self-cleaning potential, due to weak muscle
activity and coordination, as well as eventual saliva
quality changes (68). The incentives for the children
with special needs should include presents, praises
and other privileges (6). The carbohydrate intake
between meals should be eliminated and the
consumption of sucrose and other highly cariogenic
food should be limited, which is obligatory
requirement in developing the diet recommendations
to such children (22, 68, 67).
It is absolutely recommended to pay attention to
the adverse effects (xerostomy and gingival
hyperplasia), of various drugs, used for the treatment
of these children (27). There are various ways of
managing these adverse effects: stimulating the
residual saliva secretion with Pilocarpin, water intake
in small sips, sucking ice cubes or lemon sugar-free
sweets, artificial saliva such as Glandosane, Orhana,
Luborant, Biotene (mouth rinse, spray, chewing gum,
toothpaste) (68).
The application of fluorides (fluoride toothpastes
and gels, fluoride varnishes and solutions, fluoride
mouth rinses, fluoride polishing pastes) is still the
most effective and widely used tooth caries preventive
method and an obligatory measure for children with
disabilities, as they face higher tooth caries
development risk (5, 67, 68, 24, 20, 22).
The periodontal diseases come second after tooth
caries and the risk assessment of their development is
vital for the prevention, diagnostics and treatment of
disabled children (4). The risk factors for their
development are present in children with Down
syndrome, intellectual deficit and all cases of
disturbed balance between local and systemic factors
(67, 4). Naka et al. studied the distribution of 10
selected periodonto-pathologic bacteria types in
plaque bio-film samples, taken from disabled children
(mental retardation, cerebral palsy and autism) the
most
frequently
detected
types
being
Capnocytophaga sputigena (28,3%), followed by
Agregatibacter actinomycetemcomitans (20,9%) and
Campylobacter rectus (18,2%). Eikenella corrodens,
Capnocytophaga achracea, Prevotella nigrescens
were less presented, while Treponema denticola,
Tannerella forsythia and Prevotella intermedia were
rarely detected, but for individuals having such
bacteria types the likelihood of developing periodontal
disease was high. Porphyromonas gingivalis was not
found in any of the study participants. Usually this
type is most frequently found in subjects with Down
syndrome. The individuals with Campylobacter
rectus, have higher depth values of the periodontal
pockets, as well as higher gingival index and total
number of bacteria types (63).
Due to the neglected oral hygiene in disabled
children it is recommendable to use sealants in order
to reduce the risk of tooth caries development on their
occlusal tooth surfaces (68, 67, 22).
Conclusion
Criterion on the social-economic development
level of a given community is its attitude to the people
with special needs, who are unprivileged compared to
the rest of the population.
The sporadic scientific papers in Bulgaria (16, 17,
15, 11, 2, 3, 14, 13, 12, 81, 10) have modest
contribution to this topical issue. Up till now we do
not avail of complete information on the dental status
and oral diseases, present in these children and
nothing has been done in the direction of preventing
oral diseases within this population. They have much
larger necessity of undertaking oral disease preventive
measures, due to the high risk of their onset compared
to that in their healthy peers, because they have
limited own capacity to maintain oral care. The
preventive and treatment dental manipulations is
imperative due to the fact that large part of the parents
and caretakers of these children neglect their
importance because of lack of understanding,
insufficient or lacking financial resources, serious
need of more child-dedicated time on behalf of the
family, lost parental employment possibilities, which
leave aside the preventive dental care.
Prevention is the most affordable way of ensuring
good oral health, especially in patients with
disabilities, since they need multiple care procedures
due to their systemic condition.
The need of oral disease preventive care for
children with problems has higher priority than in
their normal peers, because the oral disease, its
pathological implications and treatment within this
population group is complicated and expensive even
more so in those cases when operation under general
anesthesia is needed.
70
Criterion on the social-economic development
level of a given community is its attitude to the people
with special needs, who are unprivileged compared to
the rest of the population.
The sporadic scientific papers in Bulgaria (16, 17,
15, 11, 2, 3, 14, 13, 12, 81, 10) have modest
contribution to this topical issue. Up till now we do
not avail of complete information on the dental status
and oral diseases, present in these children and
nothing has been done in the direction of preventing
oral diseases within this population. They have much
larger necessity of undertaking oral disease preventive
measures, due to the high risk of their onset compared
to that in their healthy peers, because they have
limited own capacity to maintain oral care. The
preventive and treatment dental manipulations is
imperative due to the fact that large part of the parents
and caretakers of these children neglect their
importance because of lack of understanding,
insufficient or lacking financial resources, serious
need of more child-dedicated time on behalf of the
family, lost parental employment possibilities, which
leave aside the preventive dental care.
Prevention is the most affordable way of ensuring
good oral health, especially in patients with
disabilities, since they need multiple care procedures
due to their systemic condition.
The need of oral disease preventive care for
children with problems has higher priority than in
their normal peers, because the oral disease, its
pathological implications and treatment within this
population group is complicated and expensive even
more so in those cases when operation under general
anesthesia is needed.
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Adress for correspondence:
Liliya Doichinova
Department of Pediatric Dental Medicine
Faculty of Dental Medicine, MU – Sofia,
St.G.Sofiiski №1, 1431 Sofia,
74
Review
Treatment of oral lesions in HIV and AIDS
A. Krasteva1, Vl. Panov 2
SUMMARY
It is of a great importance that dental professionals interestеd in oral medicine can diagnose oral
manifestations of HIV and thus could suggest appropriate treatment to control the lesions. In the coming future
HIV- infection would be diagnosed by a rapid test in the mouth. Dental practitioners should continue being in
collaboration with the other specialists in order the optimal oral therapy.
Key words: HIV, oral lesions,dentists
1
Department of Pharmacology and Toxicology, Faculty of Pharmacy, Medical University, Sofia, Bulgaria
Department of Conservative and Paediatric Dentistry, Faculty of Dental Medicine, Medical University
“Prof. Dr. P. Stoyanov”, Varna, Bulgaria
2
75
Introduction
Since HIV discovery in 1981 many people have
been infected worldwide. The virus affects all
socioeconomic, racial, ethnic and sexual communities
and continues to cause morbidity and mortality. By
the end of 2010 in Bulgaria 1252 persons with HIV
are already registrated, but in reality they are at least 3
times more (15). Over 65% of newly registered HIVpositive were found in free consultation dental
practices in Sofia and Plovdiv, half of them were aged
between 15 and 29 years, in between 32% were druginjections users and 20% are homosexual (15).
30 years after the epidemic onset the oral changes
profile in HIV patients differs significantly from that
in the beginning. Populations at risk change over time.
Increasingly women and minorities become infected
(15).
Associated oral lesions are of particular importance
representing markers for disease progression and for
the degree of immunosuppression. It is a fact that oral
changes also influence quality of life of the patients
(7).
Advances in medicine and technology have been
contributing to early HIV diagnosis − by express tests
of studied materials (saliva etc.) and to the
introduction of new drug combinations for HIVpositive patients. At the same time it should be noted
that new generation drugs can cause other changes in
oral cavity (ulcers, taste changes, xerostomia) (7).
The aim of the present review is to present the
current trends in oral lesions treatment in HIV patients
and to discuss the place of the dental practitioner in
oral signs diagnosis and therapy.
HIV-ASSOCIATED ORAL MANIFESTATIONS
Candidiasis
Very often oral candidiasis is the first sign of HIV
infection, reaching 90% of infected. In these patients,
there are four forms of candidiasis: 1)
pseudomembranous candidiasis, 2) erythematous
candidiasis, 3) angular cheilitis, 4) hyperplastic
candidiasis. Oral candidiasis is one of the earliest
manifestations of infection among drug-addicted and
is a major predictor of risk of AIDS and death. It is
considered that oral candidiasis develops either due to
the correlation between HIV and Candida either from
dysfunction of local immunity, overlying cellmediated immunity deficit or decreased level of CD4+
cells. In the recent years, many studies were reported,
which is coincided with the increased importance and
awareness of this opportunistic infection in HIVinfected drug-addicted (4).
In 59% of patients in North and South America,
China and India (19) oral candidiasis is the most
common identified lesion in the oral cavity (5, 6).
Data for Cuba show that only 11% of patients suffer
from oral candidiasis (3).
It is reported that candidiasis is the most common
lesion in both groups of heterosexuals (44%) and
injection drug users (28%) (13).
Hairy leucoplakia
Hairy leucoplakia as an early pathognomonic sign
very often occurs as a white patches on the tongue
sides, often with underlying candida infection. The
infectious agent responsible for these lesions is
Epstein-Barr virus, located in epithelial cells. The
incidence of hairy leukoplakia in Brazil is higher than
candidiasis – about 25% of patients are affected (5) as
it is in other countries of the America (6).
Heterosexual patients suffer 3 times more of hairy
leukoplakia (33%) compared with injection drug users
(10%) (13). In patients under 35 years the presence of
oral hairy leukoplakia is a strong predictor of HIV
infection (19).
Sarcomatosis Kaposi
Predilection sites for Kaposi's sarcoma are hard and
soft palate, where the lesions are symmetrical, but
there are cases affecting the parotid glands and tongue
- lesions are asymptomatic bluish-black. Bone lesions
may cause swelling of the overlying soft tissue which
resembles periapical abscess (15).
Periodontal diseases
Gingivitis associated with AIDS is described as
linear gingival erythema, which bleeds easily and has
a small red lesions around marginal edge of the gums
and alveolar mucosa. Chronic gingivitis is the most
common disease in HIV-infected and AIDS patients
(43.8%). Clear improvement of gingival inflammation
was seen in 78.2% of patients following a physical
therapy (9). 15% of HIV-positive in South Africa
manifested ulcerative gingivitis (1).
Hodgkin's B- cell lymphoma
It represents as quick augmentation is soft tissue
mass. Overlying mucosa stay intact. The tumor has a
thick consistency - at palpation the feeling is like "fish
76
meat", do not have characteristic hardness "like stone"
as in cutaneous carcinomas (15).
Herpes simplex virus (Herpes simplex virus,
HSV)
Herpes simplex cheilitis and herpes simplex
stomatitis are very common in the early stages of
HIV-infection, but only 6% of chronic patients in
Brazil (5) and 7.4% in Cuba have manifestations (3).
Cytomegalovirus (CMV)
Oral findings in cytomegalovirus are represented
by deep ulcers on the lips, tongue, pharynx or oral
mucosa. Cytomegalovirus infection often is a reason
for xerostomia (8).
Human papilloma virus (HPV)
It occurs with multiple warts (pink lesions with
papillary surface − a type of cabbage) with
predilection sites in the median line of hard and soft
palate, gingiva (15).
Atypical ulcerations
In healthy subjects, aphthous ulcers usually appear
only on the nonkeratinized surfaces in the mouth,
while in immunocompromised patients (including
those with AIDS), these ulcers can occur anywhere. In
HIV patients aphthous ulcers are very painful,
surrounded by red flare and the size is greater than 1
cm in diameter. Unhealed ulcers in HIV patients may
result in generalized aphthous stomatitis, infections
(tuberculosis, herpes simplex type I, cytomegalovirus)
or neoplasm. Ulceration can occur as a result of
acquired neutropenia. The incidence of aphthosus
lesions in Brazil and Cuba since 2000 is 5-6% of
infected patients (3, 5).
Molluscum contagiosum is a viral infection of the
skin, sometimes of the mucous membranes, often
occurring in HIV-positive patients. It is characterized
by small pearls, unilaterally arranged papules with a
predilection spot eyelids (15).
Seborrheic dermatitis is often localized on the
scalp and face. Lesions are white scaly patches or
spots, there may be an element of erythema or
inflammation (15).
Bacillary angiomatosis is associated with bacteria
of the genus Bartonella. It occurs on the face as a
subcutaneous nodule or as a bud (15).
Combinations of oral manifestations such as
angular cheilitis and hairy leukoplakia, and angular
cheilitis
and
pseudomembranous
candidiasis,
candidiasis pseudomembranous and hairy leukoplakia
are considered pathognomonic for HIV (1).
Other lesions associated with HIV and AIDS are
melanotic hyperpigmentation, second in frequency
of the most common oral manifestation in India with
an incidence of 34.6% (19) and 18.3% in Nigeria (20).
In China in 14.8% of infected is observed ulcerative
(aphthous) stomatitis, keratosis or pyogenic
granuloma (3, 6, 12, 14, 17, 21).
Oral lesions which help for disease monitoring
are oral candidiasis and hairy leukoplakia (4, 10,
14, 15, 16). Such manifestations 6 months after
starting treatment for AIDS correspond to still low
level of CD4 + T-cells. Candidiasis seems to be a
better predictor of non-immune and viral response to
treatment (10). According to some authors candidiasis
remains most frequent (46%) in the absence of
recovery of immune competence (14). If candidiasis
continues to manifest in treated patients, most
probably there is a problem of patient adherence or a
lack of effect could be speculated (4).
HIV - ANTIRETROVIRAL THERAPY −
modern therapy lines and adverse events with oral
localization.
Antiretroviral therapy does not destroy the virus of
HIV. However,
it delays the development of
infection. The introduction of powerful treatment
change the clinical status of the normal lesions and
others, specific to antiretroviral treatment appear
occur in oral cavity, such as:
• oral lesions;
• changes in taste;
• xerostomia.
During the treatment it must be counted also
parotid glands enlargement, observed in 60% of cases
with recovery of immune competence (inflammatory
syndrome restoration of immune competence), 3
months after highly active antiretroviral therapy (14).
77
Oral
lesions
Oral
candidiasis
Linear
gingival
erythema
Hairy
leucoplakia
NUG
Treatment
Comments
Local therapy
Nystatin oral gel every 6-8h, for 10-14 days
Nystatin cream every 12h, for 10-14 days
BioGaia prodentis – 1 tabls. After teeth brushing
morning and evening for about 30 days.
Systemic therapy
Nystatin tabl. 400 000 – 600 000 IU every 6h
Different forms of candidiasis may exist
simultaneously;
Hyperplastic candidiasis require systemic
treatment;
Ketoconazole 200-400 mg daily
Fluconazole 50-100 mg daily
Itraconazole 200 mg daily, for 7 days
Amphotericin B 10 mg every 6h for 10 days
Ketoconazole can interact with other drugs,
metabolised CYP P450 3A4 (Lopinavir,
Ritonavir);
Amphotericin B is a drug of choice in azoleresistant infections. It could be applied locally;
Prophylaxis
Fluconazole 100 mg daily, prolonged treatment
BioGaia prodentis lozenges – 1 tablet after teeth
brushing morning and evening for about 30 days.
Long-term concomitant treatment with local
fluoride is needed in order to counteract the
sugar in some antifungal agents;
Dentures should be removed during treatment;
Local therapy
Scaling and root surface
Chlorhexidine gluconatе solution 30 sec, each
12h
Local therapy
Podophyllin resins 1–2 applications on the
affected areas every 2 week
Retinol
Surgical removal
Systemic treatment
Acyclovir 800 mg each 4–6h for 14 days
Famciclovir 500 mg each 8h for 5–10 days
Valacyclovir 1000 mg each 8h for 5–10 days
Local therapy
Lesions cleaning
Prophylaxis recommended with a brush, dental
floss and rinse;
The use of antifungal agents may be useful;
Washing with iodine solutions
Chlorhexidine gluconatе – rinse each 12 h
After treatment discontinuations, recurrences
occur;
Changes disappearance was observed in
Zidovudine tretament;
Long-term use of Chlorhexidine causes teeth color
changes, tongue, the filling, taste changes,
desquamation of the epithelium and inflammation;
Systemic treatment
Metrоnidazole 250 mg each 8h or 500 mg each
12h for 7-10 days
Clindamycin 150 mg each 6h or 300 mg each 8h Metrоnidazole should not be co-administrated
for 7 days
with Didanosine or Zalcitabine because of
peripheral neuropathy aggravation
Necrotizing
Amoxicillin clavunate 500 mg each 12h for 7
stomatitis
days
Table 1: Treatment of oral lesions associated with HIV-infection
NUP
78
Oral lesions
Angular
cheilitis
HSV
Treatment
Local therapy
Nystatin – Triamcinilone ointment after meals and at bedtime
Clotrimazole 1 % cream
Micinazole 2% cream each 12h for 1–2 weeks
BioGaia prodentis lozenges – 1 tablet after teeth brushing
Systemic treatment
Acyclovir 800 mg every 4h for 10 days
Isoprinosine 50mg/kg for 10-14 days
In resistant infections Foscarnet 24–40 mg/kg each 8h
Comments
Lesions heal slowly because of the frequent
opening of the mouth;
Foscarnet is the drug of choice for Acyclovirresistant infections;
When taking Acyclovir plenty of water should be
drunk;
Topical treatment for labial and perioral herpes can
be applied;
Gancyclovir, Valacyclovir or Famciclovir could be
also administrated;
Local therapy
It is recommended that good oral hygiene and food
intake of sugar to prevent caries development;
Rinse with liquids with high alcohol content should
be avoided due to dryness of mucous membranes;
Xerostomia
Parotid gland
enlargement
Oral ulcers
(recurrent
aphthae)
Oral verruca
Chewing or sucking on sugar-free candy
Frequent sips of water
Artificial saliva
Fluoride
BioGaia prodentis lozenges – 1 tablet after teeth brushing
Systemic treatment
Pilocarpine 5 mg – 7,5 mg p.o. every 8h before meals
Systemic treatment
NSAIDs
Analgetics
Antibiotics
Corticosteroids
Local therapy
Аloclair – spray or gel
Gengigel – gel
Triamcinolone pasta with Carboxymethilcellulose
Betamethasone 0,5 mg in 10 ml water for mouth rinse every 4h
Betamethasone-spray
Fluocinoide pasta each 4h
Dexamethasone elixir for mouth rinse
Systemic treatment
Prednisone 30-40 mg/d with dose-decreasing for a mouth
Thalidomide 200 mg daily – in resistant to local treatment
Local therapy
Podophyllin resins 1-2 applications on the affected areas each
6h for long-term
Surgical
Laser ablation
Cryotherapy
Systemic treatment
Cimetidine - 600 mg each 6h, for months
Isoprinosine 500 mg/kg, for 14 consecutive days, for 6
consecutive months
Interferone alfa – 3 millions weekly for several weeks
Table 15: Oral lesions treatment, associate with HIV
Surgical removal for aesthetic reasons may be
needed;
Major aphthous ulcers usually require systemic
steroids;
Aphthous ulcers are exacerbated under stress;
Fe, folic acid and vitamin В 12 to be examined;
Dexametasone can be used in the presence of
multiple ulcers;
Thalidomide should be applied only on severe and
frequent reсurrences
It is not applied in pregnancy;
Frequent recurrences;
Combination treatment should be discussed;
79
Role of dental practitioner in oral lesions
diagnosis and therapy in hiv-positive patients
Detailed examination of the oral cavity should be
an essential element of the primary and secondary
visits of all HIV-infected patients since more than
1/3 of them do not discuss their oral health at the
first contact with health professionals and do not
disclose or even suspect the presence of typical oral
lesions associated with disease.
M. Pereyra et al. reported that over 90% of HIVinfected have at least one oral manifestation of the
disease and believe that clinically significant lesions
require adequate treatment (16). Other studies focus
on oral health of infected subjects − dental status,
oral hygiene level, etc. In 2010, A. Santo and
partners present the dental status of 101 Portuguese
infected with HIV, aged 22-71 years. The mean
DMFT index was 16.44 ± 8.42. Greater need for
dental surgery had those with index DMFT> 17 and
those who are HIV-positive more than five years
(18).
In long-term follow-up of oral health quality of
life of women infected with HIV, and those at risk
of infection is found that it is with about 10% worse.
Affected quality of life rather is associated with the
condition of teeth, the presence of periodontal
disease, smoking and cocaine use, but not to the
infection itself (11).
The role of the dental practitioner goes in two
directions: on one hand in the diagnosis of oral
signs, and on the other - in their proper response, as
changes in the mouth cause additional discomfort
for patients and worsen their quality of life.
Modern recommended therapeutic protocols for
treatment of oral lesions in HIV-patients are
presented in Table 1 and 2.
COMMENT:
Literature data indicate that the percentage of
HIV-positive individuals with at least one
manifestation of the disease in the oral cavity is up
to 90%. These facts determine the important place of
the dental practitioner in the team of professionals
monitoring these patients.
We would like to emphasize that the detailed
examination of the oral cavity should be included in
the initial, primary review of the patient and should
be also repeated in each of the following visits in all
HIV-infected.
Dental practitioner should not only recognize and
diagnose the typical oral manifestations of the
disease, but he should also give recommendations
for dental health improvement of these individuals
and to be able to treat the manifestations in the oral
cavity. Dental practitioner should be aware that the
dynamics of oral lesions in order therapy to be
properly monitored. It will be of a great help not
only to dental practitioners, but also to the patients, a
specialized dental clinical center to be established
for primary dental examinations and treatment of
patients at risk. On the one hand, dental specialists
will be more competent giving closer advices to
HIV-infected and other patients will know where to
find adequate care for their condition. Also negative
speculations will be avoided while these individuals
hide their illness because of fear treatment to be
refused. Such dental centers should be established
initially in the Faculty of Dental Medicine in the
country - Sofia, Plovdiv and Varna, to focus only on
the contingent risk patients − patients with HIV, and
hepatitis B and C.
80
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A. Krasteva
e-mail: [email protected];
Tel.: +359 889 507 245

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