Vol 20 No. 1

Transcription

Vol 20 No. 1

Scientific Journal Published by the
College of Dentistry – University of Baghdad
Vol. 20 No.1 2008
ISSN
ISSN
1680-0087
A biannual peer reviewed published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Ali Hussain AlKhafaji B.D.S., M.Sc. D (UK)
Editorial secretary: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
Editorial Board:
National Members
International Members
Prof. Dr. Nazar Talabani PhD
Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. Fakhri Al-Fatlawi MSc
Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Athraa Yahiai MSc, PhD
Prof. Dr. Adel Farhan M.Sc.
Assist. Prof. Dr. Amer Maki MSc
Assist. Prof. Dr. Lekaa Mahmood MSc,
Assist. Prof. Dr. Abbas Sabri MSc, PhD
Assist. Prof. Dr. Wesal Al-Obaidi MSc
Dr. Jamal Abid MSc
Board of editorial consultants:
1- Prof. Dr. Haitham Al-Azzawi MSc
9- Prof. Dr. Widad Al-Naqash MSc
2- Prof.Dr. Salem El-Samarai PhD
10- Assist. Prof. Akram Faisal Al-Huwaizi MSc, PhD
3- Prof. Dr. Waleed Al-Hashemi MSc
11- Assist. Prof. Dr. Bashar Hamed MSc, PhD
4- Prof. Dr. Nidhal Hussein MSc
12. Assist. Prof. Lamia Al-Naqeeb MSc
5- Prof. Dr. Ahlam Hamed MSc
13- Assist. Prof. Jamal Aziz MSc
6 Prof. Dr. Zainab Al-Dahan MSc, PhD -
14- Assist. Prof. Natheer Hashim MSc, PhD
7 Prof. Khulood Al-Safi MSc, PhD -
15- Assist. Prof. Kadim Al-Soudani MSc
8 Prof. Riyad Al-Qaisi MSc, PhD
16- Assist. Prof. Asma Tahsin MSc
Computer executives: Dr. Mushriq Fawzi, Dr. Dhea Hussain
Dr. Mustafa Munam, Dr. Samer Aun
Linguistic referee: Prof. Dr. Hussain Faisal Al-Huwaizi
Administrative secretary: Hadeel Abdul Wahab.
For consultation, please contact:
Website: www.baghdentistry.com
E-mail: [email protected]
Telephone: (+9641)4169375 Fax: (+9641)4140738
i
Contents
i
Editor and Editorial Board
ii
Contents
iv
About the College
vi
Instructions for the Authors
Restorative Dentistry
1
Effect of modified Carisolv gel on shear bond strength of repaired light cure composite and compomer
restorations. Rasha H. Jihad, Haitham J.Al-Azzawi
5
A comparative study of the sealing ability of two different obturation techniques with and without the use of
sealers. Ahmed G. Subhy, Raghad A. Mohammed
8
14
16
Thermal expansion of prepared dental base-metal casting alloys. Mohammed T. Al-khafagy
The effect of bleaching agent on the micro hardness of composite resins. Saif Alarab A. Alajwadi
Assessment of consistency and compressive strength of glass ionomer reinforced by different amount of
hydroxyapatite. Mohammed R. Al-jabouri, Raghad A. Mohammed
Oral Diagnosis
21
24
28
Enhancement of bone induction after implantation of amelogenin protein and its active sub-protein. Riyadh O.
Alkais
Comparison of amelogenin sub-proteins osteoinductive activity (Histopathological study). Riyadh O. Alkaisi
Evaluation of lipid-bound sialic acid tumor marker in sera of acute lymphocytic (ALL) patients. Abdul Wahab
R. Hamad, Nazar G.A. Talabani, Fawaz Al-Swad
ii
31
34
Oral findings and health status among elderly Iraqi patients (aged 65 and above). Fawaz Al-Aswad
Prevalence of trigeminal neuralgia among patients with orofacial pain. Taghreed F. Zaidan
Oral and Maxillofacial Surgery and Periodontology
37
45
49
Periodontal treatment with combined: mechanical therapy plus low-energy laser irradiation compared to scaling
and root planning. A clinical and microbiological spilt mouth study. Khulood A. Al-Safi
Reliability of family history report among relatives of aggressive periodontitis patients. Alaa O. Ali, Saif S.
Saliem, Hala Algobory.
The effect of smoking on periodontal health status salivary composition. Lekaa M. Ibrahem
52
Periodontal health status and biochemical study of gingival creviculer fluid among diabetics and non diabetic
(Comparative study). Lekaa M. Ibrahem, Raghad F. Abaas
58
Evaluation of periodontal abscess clinically and microbiologically. Lekaa M. Ibrahem
62
The clinical and socio-cultural evaluation of the effects of oral contraceptives on periodontal condition.
Maha Abdul Aziz
69
Evaluation of the effect of low energy laser on gingivitis. Alaa Omran, Ali H. Abbas
Orthodontics, Pedodontic, and Preventive Dentistry
71
Mandibular dental arch parameters in Down's Syndrome patients with Class I occlusion. (A comparative
study). Nidhal H. Ghaib, Dheaa H. Abd Awn, Mustafa M. Al-Khatieeb
77
Comparison of the forces generated by steel, nickel titanium and elastomeric separators. Akram F. AlHuwaizi
86
The role of environmental versus genetic factors on tooth and dental arch dimensions in a twin sample.
Nagham M.J. Al- Mothaffar, Salwa H.A. Al- Baghdady
94
Role of the horizontal activator in Class II i malocclusion treatment. Ali I. Al-Bustani, Sami K. Al-Joubori,
Hayder F. Saloom
iii
100
Characteristics of malocclusion in Iraqi orthodontic patients overjet and overbite variations (Comparative
study). Iman Al-Shikli, Bashaer B.M. Nouri
104
Influence of different recycling protocols on load deflection of nickel titanium orthodontic wire (An in vitro
study). Mustafa M. Al-Khatieeb
110
114
The Theses of postgraduate students from 2006-2007
Middle East Conferences Calendar 2008
About the College
The college started the academic year with 200 students in the first year, 205 students in the second
year, 195 students in the third year, 198 students in the forth year and 220 students in the fifth year. This
totals the number of undergraduate students to 1018.
The postgraduate division accepted 51 students and they are divided to the following specialties:
Prosthetics
Preventive Dentistry
Orthodontics
Conservative Dentistry
Periodontics
Oral Pathology
Dental Radiology
Oral Microbiology
Total
Diploma Master Total
4
3
7
2
6
8
13
13
10
10
2
2
4
4
4
2
2
2
2
8
42
50
In Memory
In the beginning of the year 2008 and with deep sorrow, the college of dentistry lost two of its well
known members of staff in the department of maxillofacial surgery and they were assistant prof Dr.
Munther Murhij (The Dean) and Dr. Hameed Al-Ani.
Congratulation
Prof Dr. Ali Al-Khafagi was appointed dean of the college in February. We hope that his post would
enable him to improve the college and return it to its past standard.
Prof. Dr. Hussain F. Al-Huwaizi was nominated as a member in the editorial board of the Journal of
American Dental Association-Arabic Version (JADA). This post will facilitate Iraqi researchers to submit
their researches for publication in this well known journal.
iv
Golden Jubilee Graduation Ceremony for the undergraduate students
The academic year of 2007-2008 marks golden jubilee graduation of students from our
college. The fifth year students celebrated their graduation with the presence of the dean
Professor Ali Al-Khafaji who headed the college council in this event.
v
Instruction for the Authors
The biannual peer reviewed published Journal of the College of Dentistry accepts manuscripts that address
all topics related to dentistry. Manuscripts should be prepared in the following manner:
Typescript. Type the manuscript on A4 white paper, with margins of 25 mm. Type the manuscript with
English language font (Times New Roman) and the sizes are as follows:
1) Font size 18 and Bold for the title of the manuscript.
2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION,.etc.
3) Font size 12 and Bold for the names and addresses of the author/s.
4) Font size 10.5 for the text of all the article, tables and legends of the figures.
Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand
corner.
Title of the paper:
The title should be written with a capital letter for the first word as (Effect of the retention and
stability….etc).
The name of each author with her/his academic degrees should follow the title. The address, phone, fax, and email of author responsible for correspondence about the manuscript should be typed.
Abstract and key words. The abstract should contain no more than 250 words. The abstract should be
divided to the following categories: Background: (It contains a brief explanation about the problem for which
the research was done as well as the aim of the study), Materials and methods:, Results:, and
Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article.
Text. The body of the manuscript should be divided into sections preceded by appropriate headings
(INTRODUCTION, MATERIALS AND METHODS, RESULTS, DISCUSSION) which are written in bold and
capital. Major headings should be typed in bold and the first letter should be capital at the left hand margin;
subheadings should be not bold but underlined and appear at the left hand margin with only the first letter of
each word capitalized.
References. References are placed in the text using the Vancouver system (Numbering system). Number
references consecutively in the order in which they are first mentioned in the text. Identify references in the text,
tables, and figures by Arabic numerals, and place them in parentheses within the sentence as superscription ex.
(2)
.
Use the style of the examples given below in listing the references:
Book
1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9th ed. St.
Louis: CV Mosby; 1985. p.312-23.
Journal article
4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9.
Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g. Table 1).
Cite each table in the text in the order in which it is to appear.
Figures and illustrations. All figures must have a title placed below the figure. Identify figures with
Arabic numbers (e.g. Figure 1). They must be placed on a separate page and numbered to correspond with the
figures. If the article contains illustrations submit three clear unmounted glossy photographs and write the
author’s name and the figure’s number at the back of each illustration.
The article should not exceed 10 pages. The author should submit three copies of the article (one original
and two copies) and a (CD) containing the article.
vi
J Bagh College of Dentistry
Vol. 20(1), 2008
Effect of modified…
Effect of modified Carisolv gel on shear bond strength of
repaired light cure composite and compomer restorations.
Rasha H. Jihad, B.D.S., M.Sc. (1)
Haitham J.Al-Azzawi B.D. S., M.Sc. (2)
ABSTRACT
Background: This in vitro study evaluated the effect of modified Carisolv gel on the shear bond strength of delay
repaired light cure Helio Progress composite with Excite bond and Dyract≡eXtra compomer with Prime & Bond NT.
Materials and Methods: Thirty specimens of Helio Progress composite and thirty specimens of Dyract≡eXtra
compomer of (6mm diameter & 3mm depth) were aged for one week at 37 C˚. The aged substrate surfaces were
abraded by coarse Al2O3 Sof-Lex discs and subjected randomly to different surface treatments: Modified Carisolv
gel, phosphoric acid gel (control) and combination of both, with two different bonding agents Excite bond with
composite and Prime & Bond NT with compomer.Repair was done by using a standardized translucent plastic straw
(3mm diameter & 6mm length) and light cured. All specimens were stored in deionized distilled water for 24 hours.
Each specimen was subjected to a shear force at a crosshead speed of 0.5 mm/min using a universal testing
machine until failure. ANOVA and student t-test were used to analyze the bond strength values.
Results: All surface treatment methods showed highly significant difference compared to control (p<0.001). Surface
treatment with combination of modified Carisolv gel and phosphoric acid gel resulted in the strongest repairs. Helio
Progress composite showed high bond strength than Dyract≡eXtra compomer, however, the difference is statistically
not significant (p>0.05). Different bonding agents did not show a significant difference (p>0.05) in bond strength
values.
Conclusions: Different combinations of surface treatments and bonding agents affect shear bond strength
differently. The highest shear bond strength values were achieved with modified Carisolv gel alone and combination
of modified Carisolv gel and phosphoric acid gel, whereas the lowest values were obtained with phosphoric acid gel
alone as a surface treatment agent.
Keyword: Carisolv, Repair, Compomer, Bond strength. (J Bagh Coll Dentistry 2008; 20(1) 1-4)
INTRODUCTION
During the late 1970s chemo-mechanical
caries removal (CMCR) became a complementary
method to the conventional burs to provide less
invasive technique for caries removal by applying
a solution to the outer infected, destroyed and
non-remineralizable carious dentine in order to
soften this layer, thereby making it easier to
remove using special hand instruments (1)
Modified Carisolv gel consists of 0.5% NaOCl
that is mixed with a gel containing three different
amino acids (glutamic acid, lucine and lysine),
and has a pH value of 11.0 (2)
As a result of modern preparation techniques
associated with common restorative materials,
such as composite resins and compomers, total
removal of an old restoration may not always
occur when treating secondary carious lesions(2)
provided that the main part of the restoration is
satisfactory and the defect is a localized and a
well-delineated one(3). Carisolv gel will therefore
often come into direct contact with these
materials, as well as in situations when caries is
excavated from a tooth adjacent to a tooth with an
earlier restoration (2)
A surface deterioration due to degradation
and erosion of resin matrix and/or filler particles
might result in increased surface roughness,
resulting in increased plaque adhesion.
Furthermore, if a restoration material surface is
changed with respect to surface roughness and/or
surface energy, it will probably influence the
adhesion of the secondary restoration material to
the old one (4). The repair of an existing
restoration has been considered a viable and less
costly alternative to complete replacement, but
there is a possibility that repair may lead to an
unacceptably weak restoration (3). To ensure
bonding between the repair and the existing
restoration, many clinicians consider some sort of
mechanical roughening, etching and coating the
old restoration with enamel/dentine bonding
agents and silane coupling agents to advance
surface wetting and chemical bonding (5, 6). This
study was designed to:
1- Assess the effect of modified Carisolv gel on
the shear bond strength of repaired composite
and compomer restorations.
2- Determine and compare the shear bond strength
of repaired light cure composite and compomer
with different bonding agents with and without
using modified Carisolv gel.
(1)Assist. Lecturer, Department of Conservative Dentistry,
College of Dentistry, University of Baghdad.
(2) Professor, Department of Conservative Department, College
of Dentistry, University of Baghdad.
1
Vol. 20(1), 2008
strengths were calculated and recorded in Mpa
units.
One-way ANOVA test and student t-test were
used to determine the significance of the shear
bond strength among the groups.
MATERIALS AND METHODS
Blocks of cold cure acrylic resin (25x25x10)
mm each one contain a cylindrical hole (6mm
diameter, 3mm depth) at the center of one of its
square faces will act as a mold for restorative
material sample(7).
Thirty specimens were filled with microfilled
light cure Helio Progress composite resin (Ivoclar
Vivadent, Germany) shade A2 and the others
were filled with Dyract≡eXtra compomer
(Dentsply, Germany) shade A2 were prepared.
All the samples were stored in deionized
distilled water in a constant temperature incubator
(Memmert, Germany) at 37C° for one week (8).
The surface layer was abraded by the first size of
Sof-Lex discs (Fini Disc, USA) (coarse aluminum
oxide abrasive discs).The discs were used with a
slow speed hand piece (W&H, Austria) rotated
approximately at 20000 rpm in a circular
movement in one direction only and without
water cooling for 20 seconds (9).
Samples of material A filled with Helio
Progress composite and bonded with Excite bond
(Ivoclar Vivadent, Germany) applied according to
the manufacturers' instructions; while those of
material B filled with Dyract≡eXtra compomer
and bonded with Prime & Bond NT
(Dentsply,Gemany) applied according to the
manufacturers' instructions.
Specimens of each material were divided
randomly into three equal groups according to the
type of surface treatment they received. Some
groups received modified Carisolv gel alone
(Mediteam Company, Sweden) applied for 10
minutes (2), others received phosphoric acid gel
alone and others received combinations of
modified Carisolv gel and phosphoric acid gel
followed by application of bonding agents and
repair procedure that involves the placement of
(3mm diameter and 6mm length) cylindrical piece
of standardized translucent plastic straw that have
been filled with the restorative material according
to manufacturers' instructions using a device
especially designed for standardization of
restoration placement. All the specimens were
stored in deionized distilled water, placed in a
constant temperature incubator at 37C° for 24
hours. A dark shade was chosen as the repair
material(D3 for composite,B1 for compomer) (3)
The specimens were clamped in a fixed base
for determination of shear bond strengths using
Universal Testing Machine (Instron 1122,
England). A knife-edged chisel was used to
deliver the shearing force. The bonded cylinders
were placed under continuous loading at 0.5
mm/min until fracture occurred. Shear bond
RESULTS
The mean, standard deviation, minimum and
maximum values in Mpa for all groups are
illustrated in Table 1.
Statistical analysis of data by using the
analysis of variance ''ANOVA'' revealed that there
was a highly significant difference among the
different surface treatments for both composite
(material A) and compomer (material B) (Tables
2, 4).
Further investigation using student t-test
showed that there was a highly significant
difference between Carisolv treated groups and
acid treated groups also a highly significant
difference between combination treated groups
and acid treated groups for both composite and
compomer materials, however, there was no
significant difference between Carisolv treated
groups and combination treated groups for both
composite and compomer materials (Tables 3, 5).
Using student t-test, there was no significant
difference between acid treated groups and no
significant difference between Carisolv treated
groups, however, there was a significant
difference between combinations treated groups
for both composite and compomer materials
(Table 6).
Table 1: Mean, standard deviation,
minimum and maximum values in Mpa for
all groups
Groups N
A1
A2
A3
B1
B2
B3
10
10
10
10
10
10
Mean
10.977
14.705
15.225
10.817
13.599
13.898
SD
Min.
Max.
value
value
0.881
2.046
1.546
0.795
1.148
0.601
10.12
12.65
12.92
9.21
12.13
13.22
12.59
18.08
17.89
11.76
15.48
14.87
DISCUSSION
During removal of secondary caries with
Carisolv, the resin-based restorative material
adjacent to the caries lesion is also exposed to
Carisolv, understanding of its chemical effect on
these restorative materials is very important to
understand the treatment and subsequent bonding
processes(2).
2
Vol. 20(1), 2008
surface roughness results in increase repair bond
strength.
Effect of combination of Carisolv and
phosphoric acid
It was found from this study that combination
treatment result in significantly higher repair
shear bond strength. This can be attributed to that
Carisolv capable of causing degradation and
erosion of both resin matrix and filler particles, so
it may be expected that combination of Carisolv
and acid treatment will cause complete cleaning
and freeing of the uncleanable firmly adhered
smear layer in the microcracks in the matrix
results in better penetration of the bonding agent
increasing repair bond strength.
Effect of phosphoric acid
Results of this study show that surface
treatment with phosphoric acid gel yielded
significantly lower shear bond strength for both
composite and compomer materials. This might
be attributed to that treatment of the substrate
surface with acid resulted in exfoliation of some
of the surface fillers that has been disturbed and
their silane interface breakdown during the
friction of the finishing discs and created surface
voids that decrease the wetting ability of the
bonding agent, thus it does not create a
mechanically retentive surface (10) in addition to
that after loss of filler particles due to acid
treatment, the surface will has more organic
character that is more resistant to acid attack(11)
resulting in an increased contact angle and
decrease in surface roughness ,this may result in
decrease in repair bond strength(2).
Furthermore, after acid treatment, there was
upper porous zone of residual smear layer that
impede the resin penetration in addition to the
presence of large sized residual hydrophilic silica
thickeners that was left on the surface even after
thorough rinsing, these remnant of silica
thickeners will form bridge linkages with silica
nanofillers of Excite and Prime &Bond NT to
form aggregates that will limit the monomer
penetration into the microscopic surface(12). These
results agree with results obtained by Latta and
Barkmeier (10); Brosh et al (13); Lucena-Martin et
al (5)
Effect of Carisolv
Carisolv results in significantly higher repair
shear bond strength when compared to groups
treated with phosphoric acid alone for composite
and compomer restorative material. This result
could be explained as follows:
Table 2: ANOVA test comparison among
(A) groups
Groups Mean SD df
F
Sig.
10.977 0.881
A1
14.705 2.046
A2
2 21.903 HS
15.225 1.546
A3
When the substrate surface is treated with
Carisolv gel, it was suspected that it will be able
to cause a breakdown of the silica framework of
these restorations leading to chemical corrosion
and loss of filler particles (14). In addition to that
high PH solution of Carisolv will increase the
matrix hydrolysis resulting in degradation of the
polymers and residual monomers by oxidation
and hydrolysis; resulting in polymer chain
scission. Furthermore, unreacted monomers from
incomplete polymerization and elements from the
filler particles may be dissolved from the material
(15)
this might increase the surface energy and / or
14.705 15.225
13.596 13.898
16
14
10.817
10.977
12
Helio Progress
Mean
10
(composite)
Dyract Ξ eXtra
8
(compomer)
6
4
2
0
group
A1
group group
A2
A3
group
B1
group group
B3
B2
Figure1: Bar chart showing mean shear
bond strength values in Mpa for all groups
Table 3: Student t-test among (A1, A2, A3)
groups
Mean
difference
3.728
A1&A2
4.248
A1&A3
0.52
A2&A3
Groups
tvalue
5.292
7.548
0.641
df Sig.
18 HS
18 HS
18 NS
HS: Highly significant difference (P<0.01)
NS: No significant difference (P≥0.05)
S: Significant difference at level (p<0.05)
Comparison between composite & compomer
The mean shear bond strength of composite
material is higher than that of compomer but the
difference is statistically not significant, it may be
related to the differences in the vapour pressure of
the solvent of the bonding agent used. Higher
vapour pressure of Prime & Bond NT results in
easier solvent evaporation, as the solvent
concentration decrease the viscosity of the
adhesive system increase, thus decrease the
wetting ability of the substrate surface and the
penetration of the bonding agent to the
microcracks in the matrix (16). This result is in
agreement with Lima et al that proved that
acetone based adhesives are more sensitive to
solvent loss. It may also be related to the presence
of HEMA in Excite bond which is a low
3
Vol. 20(1), 2008
3. Shahdad SA, Kennedy JG. Bond strength of repaired
anterior composite resins: an in vitro study. J Dent
1998; 26(8):685-94.
4. Carlen A, Nikdel K, Wennerberg A, Holmberg K,
Olsson J. Surface characteristics and in vitro biofilm
formation on glass ionomer and composite resin.
Biomaterials 2001; 22: 481-7.
5. Lucena-Martin CL, Lopez SG, de Mondelo JR.' The
effect of various surface treatments and bonding agents
on the repaired strength of heat-treated composites. J
Prosth Dent 2001; 86: 481-8.
6. Kallio TT, Lastumäki TM, Vallittu PK. Bonding of
restorative veneering composite resin to some
polymeric composites. Dent Mater 2001; 17(1):80-6.
7. Al-Hashimi AG.' The shear bond strength of an
immediate and delay repaired light-cure composite
restoration (in vitro study). A master thesis, Department
of Conservative Dentistry, University of Baghdad;
2001.
8. Benderli YG, Koray F, Turan N.' Bond strength of a
resin composite to a polyacid-modified resin composite
under different conditions. Quintessence Int 2002; 33:
770-5.
9. Barbosa SH, Zanata RL, Navarro MF, Nunes OB.'
Effect of different finishing and polishing techniques on
the surface roughness of microfilled,hybrid and
packable composite resins. Braz Dent J 2005; 16 (1):
39-44.
10. Latta MA, Barkmeier WW.' Bond strength of resin
cement to cured composite inlay material. J Prosthet
Dent 1994; 72(2):189-93.
11. Sales D, Sae-Lee D, Matsuya Sh, Ana ID.' Short-term
fluoride and cat ions release from polyacid-modified
composites in a distilled water, and an acidic lactate
buffer. Biomaterials 2003; 24(10):1687-96.
12. Tay FR, Moulding KM, Pashley DH. Distribution of
nanofillers from a simplified step adhesive in acid
conditioned dentin. J Adhesive Dent 1999; 1:103-17.
13. Brosh T, Pilo R, Bichacho N, Blutstein R. Effect of
combinations of surface treatments and bonding agents
on the bond strength of repaired composites. J Prosthet
Dent 1997; 77(2): 122-6.
14. Arvidsson A, Milleding P, Wennerberg A. The
influence of a chemomechanical caries removal solution
on the topography of dental ceramic materials.
Biomaterials 2002; 23: 3977-83.
15. Øilo G.' Biodegradation of dental composites/ glassionomer cements. Adv Dent Res 1992; 6: 60-4.
16. Reis AF, Oliveira MT, Giannini M, De Goes
MF,Rueggerberg FA. The effect of organic solvents on
one-bottle adhesives' bond strength to enamel and
dentin. Oper Dent 2003; 28(6):700-6.
17. Lima FG, de Moraes RR, Demarco FF, Pino FA,
Powers J. One-bottle adhesives: in vitro analysis of
solvent volatilization and sealing ability. Braz Oral Res
2005; 19(4):1-10.
18. Cura C, Saraçoğlu A, Çötert HS. Effect of different
bonding agents on shear bond strengths of compositebonded porcelain to enamel. J Prosthet Dent 2003, 89:
394-9.
19.Vankerckhoven H, Lambrechts P, Vanbeylen M,
Davidson CL, Vanherle G. Unreacted methacrylate
groups on the surfaces of composite resins. J Dent Res
1982; 61(6):791-5.
20. Azarbal P, Boyer DB, Chan KC. The effect of bonding
agents on the interfacial bond strength of repaired
composites. Dent Mater 1986; 2: 153-5.
molecular weight (130) hydrophilic monomer that
improve wetting of the substrate surface by the
resin (6).
Furthermore, higher filler content in Prime &
Bond NT result in increase its viscosity reducing
the wetting ability and penetration of the
monomers (18). In addition to that, colloidal silica
in nanometric size in Prime & Bond NT these
fillers have a high surface energy agglomerating
by itself forming clusters that are too large to
infiltrate, preventing good wetting.
Moreover, Helio Progress is a low viscosity
material, thus, it has more wettability and better
penetration to micro irregularities of the substrate
surface increasing the repair bond strength (6).
This result is in consistent with the result of
Vankerckhoven et al.(19); Azarbal et al. (20)
Table 4: ANOVA test comparison among (B)
groups
Groups
B1
B2
B3
Mean SD df
F
Sig
10.817 0.795
13.599 1.148
2 37.428 HS
13.898 0.601
Table 5: Student t-test among (B1, B2, B3)
groups
Mean
t-value df Sig.
difference
6.297 18 HS
B1&B2 2.7820
3.088
9.77 18 HS
B1&B3
0.299
0.729 18 NS
B2&B3
Groups
Table 6: Comparison between composite and
Compomer with different three surface
treatments
Surface
treatment
Acid
Carisolv
Carisolv+Acid
Group
A1
B1
A2
B2
A3
B3
Mean
tdf Sig
difference value
0.167
0.426 18 NS
1.106
1.491 18 NS
1.327
2.529 18 Sig
REFERENCES
1. Burrow MF, Bokas J, Tanumiharji M, Tyas MJ.
Microtensile bond strengths to caries-affected dentine
treated with Carisolv. Aust Dent J 2003; 48(2):110-4.
2. Arvidsson A, Örtengren U, Wennerberg A. Influence of
chemo-mechanical caries removal on the surface
topography of dental composite resin and glass-ionomer
materials: an in vitro study, Acta Odontol Scand 2004;
62:137-42.
4
Vol. 20(1), 2008
A comparative study…
A comparative study of the sealing ability of two different
obturation techniques with and without the use of sealers.
Ahmed G. Subhy B.D.S., M.Sc. (1)
Raghad A. Mohammed B.D.S., M.Sc. (2)
ABSTRACT
Background: The final stage of endodontic therapy is complete obturation of the root canal system to provide as
perfect as possible at the cementodentinal junction of the apical foramen. The purpose of this in vitro study was to
evaluate the sealing ability of injection molded thermoplasticized gutta percha and lateral condensation techniques
with and without the use of sealers.
Materials and Methods: Forty freshly extracted adult human maxillary central incisors with complete formed apices
were utilized in this study. The teeth were randomly divided into four groups for evaluation of the apical seal. Group
(1) lateral condensation gutta percha technique without sealer, (2) lateral condensation gutta percha technique
with sealer, (3) Injection molded thermo plasticized gutta percha without sealer, (4) injection molded
thermoplasticized gutta percha with sealer. Groups 1 through 4 were obturated as specified. All of the teeth were
immersed in flourescine dye for 48 hours, then they were removed from the dye for microleakage measurement.
Results: The results showed no significant differences between groups 1 and 3 and between groups 2 and 3 (p>0.05),
but there were highly significant differences between groups 1 and 3 (p<0.01).
Conclusion: Sealer was found to be an essential part of the thermo plasticized gutta percha and lateral
condensation techniques. Thermo plasticized system with sealer had significantly less apical leakage than others. The
highest amount of leakage was significantly seen with lateral condensation without sealer.
Key words: Obturation techniques, sealer, microleakage. (J Bagh Coll Dentistry 2008; 20(1)5-7)
INTRODUCTION
Agreement has been made that this technique
represents high level of success, only when used
with sealer (6). Although lateral condensation of
gutta percha is in common use, a new warm gutta
percha delivery system has been introduced (7).
The thermo plasticized injection gutta percha
method appears promising as a new and rapid way
to fill the root canal system of straight or gently
curved canals (1). The injection molded gutta
percha technique is effective over other
techniques because it minimizes patient
discomfort, reduces compact procedure time and
has accurate temperature control for precise
consistent viscosity (2).
The primary goal of successful endodontic
therapy is complete obturation of the root canal
space, after it has been adequately prepared and
sterilized to prevent any pathosis of endodontic
origin. Solid core filling material such as gutta
percha had been used to obturate the root canals in
conjunction with a sealer to provide a hermetic
seal and prevent apical leakage (1). It has been
shown that the thoroughness with which the root
canal system is sealed is a major determinant in
endodontic success (2).Many materials have been
used as root canal fillings over the years, but a
material in paste form in conjunction with gutta
percha seems to be the most widely accepted
combination of materials in use (3). Different
techniques and approaches are available that
depend on the size of the prepared canal, the final
shape of the preparation and irregularities within
the canal, but the overriding factor is operator
preference (4).
The lateral condensation technique is
relatively uncomplicated which requires a single
armamentarium, and the philosophy of the lateral
compact technique depends upon the fitness of
perfect filling of the core in the apical third of the
root canal (5).
Forty freshly extracted adult human maxillary
central incisors with completely formed apices
fixed in 10% formalin were utilized in this study.
The teeth were randomly divided into four groups
for evaluation of the apical seal, Group (1) lateral
condensation without sealer, Group (2) lateral
cndensation with sealer (Dorifill, Dorident,
Austria), Group (3) thermoplasticized gutta
percha (Unitek, Courtesy of Obtura/ Sparatn
USA) without sealer, Group (4) thermoplasticized
gutta percha with sealer.
The selected teeth were soaked in 5.25%
NaOCl for 24 hours to remove any organic debris,
then scrubbed with a brush, rinsed and stored in
distilled water. Access was completed and
(1) Assistant Lecturer, Department of conservative dentistry,
University of Baghdad
(2) Lecturer, Department of conservative dentistry, University of
Baghdad
5
Vol. 20(1), 2008
Means of leakage
(mms)
working length was established 1mm short of the
apical foramen after a no. 15 file was visualized
beyond the foramen. Hand files (Stainless, Kerr
Corp.,Italy) were used in progressive sizes until
the apical preparation was instrumented to a no.
45 file. All instruments were accompanied by
5.25% NaOCl as an irrigant solution. A step back
procedure was then accomplished with files and
gates Glidden drill (Union Broach Co. Germany),
so that a 23 gauge needle of the obtura syringe
would fit within 6 mm of the apex. A no. 20 file
was passed through the foramen until visualized,
the file was removed and the irrigant was forced
through the apical opening. After drying, three
coats of nail polish were applied to the roots but
not covering the apical foramen, then the irrigant
was again forced through the apical constriction
to ensure patency. Groups 1 through 4 were
obturated as specified; the access openings were
closed with amalgam (Degussa, Germany) and the
sealer was allowed to set for 48 hours.
All the obturated teeth were then
radiographed mesiodistally and buccolingually to
determine if they were properly condensed. All
the roots were then immersed in fluorescence dye
(Baket Bot Corp. England) for 48 hours, and then
the teeth were removed from the dye and washed.
Cross sections were made using a diamond disc at
1, 3, 5 and 7 mm from the apex and were
evaluated under a dissecting microscope supplied
with a micrometer gauge (Wild, Heerbrugg,
Switzerland). The presence or absence of dye
penetration between the gutta perga and dentin
and any fractures present were recorded for each
section. The groups were compared by using a
one way analysis of variance test (9).
RESULTS
The data of this in vitro study are displayed in
Table 1 and Figure 1
Table 1: Statistical analysis of the mean
leakage in (mms) for the experimental
groups
Group Type of technique
1
2
3
4
Lateral
cond.
without
sealer
Lateral cond. with sealer
Obtura without sealer
Obtura with sealer
No.
of
teeth
mean
10
4.7
10
10
10
2.2
4.1
1.8
5
thermop. with sealer
4
thermop. without sealer
3
lat. Cond. with sealer
2
lat. Cond. without sealer
1
0
group 1
group 2
group 3
group 4
Figure 1: Bar chart graph representing the means of leakages in (mms)
component of the root canal filling in order to
achieve a three dimensional obturation of the root
canal space (11). Group 4 (thermo plasticized gutta
percha with sealer) demonstrated the least amount
of leakage, which agrees with the study's
conclusions that when used in conjunction with a
sealer, thermo plasticized gutta percha provides an
adequate seal (12). The obturation groups without
sealer revealed the highest amount of leakage, this
result is also in agreement with a study done by
Michanowicz.&Czonstkowsky. (12) These positive
results are probably due to the sealer's ability to
fill voids missed by gutta percha and to it's
lubricant action. Skinner and Himel (9) showed
that whether or not vertical compaction was used
One way analysis of variance test was
performed to test the differences between the
means of leakage among the experimental groups.
Group 1 and group 3 showed no significant
difference in leakage (p>0.05), also there was no
significant difference between groups 2 and 4. On
the other hand, there was a highly significant
difference between groups 1 and 3 as compared
with groups 2 and 4 (p<0.01).
DISCUSSION
The search for the ideal root canal filling
material as determined by Grossman's criteria is a
continuous one (10). It is well established that the
sealer cement is an extremely important
6
Vol. 20(1), 2008
6. Haris GZ, Dickey DJ, Leub RG. Apical seal:
Mcspadden vs. lateral condensation. J Endod 1982;
8(6):275-6.
7. Johnson WB. A new gutta percha technique. J Endod
1978; 4:184-92
8. Lee QC, Chang Y, Hellmenth ME. Dimensional
stability of thermo sensitive gutta percha. J Endod 1997;
23(9):579-82.
9. Skinner RL, Himel VT. The sealing ability of injection
molded thermo plasticized gutta percha with and
without the use of sealers. J Endod 1987; 13(7):315-7.
10. Chohayeb A, Chow LC, Tsaknis PJ. Evaluation of CP
as a root canal sealer-filler material. J Endod 1987;
13(8):235-9
11. Wu MK, Tigos E, Wesselink PR. An 18-month
longitudinal study on a new silicon based sealer,RSA
Roekoseal: A leakage study in vitro. Oral Surg Oral
Med Endod 2002; 94:499-502.
12. Michanowicz A, Czonstkowsky M. Sealing properties
of an injection thermo plasticized low temperature
(70`C) gutta percha: a preliminary study. J Endod
1984; 11:71-4.
in conjunction with the obtura system did not
make a significant difference in leakage when
used in large straight canals. There was no
significant difference between groups 2 and 4
probably due to the presence of sealers.
REFERENCES
1. Schafer E, Olthoff G. Effect of three different sealers on
the sealing ability of both thermafil obturators and cold
laterally compacted gutta percha. J Endod 2002;
28:638-42.
2. Ingle JI, Taintor JF. Endodontics 4th ed. Philadelphia,
Lea and Febigers 1994, p. 345
3. Eldeep ME. The sealing ability of injection molded
thermo plasticized gutta percha. J Endod 1985; 6:84-9
4. Green HA, Wong M. Comparison of the sealing ability
of four obturation techniques. J Endod 1990; 16:423-8
5. Lugarsy AA, Yee F. Root canal obturation with gutta
percha, SEM comparison of vertical compaction and
automated thematic condensation. J Endod 1982;
8(3):120-5.
7
Vol. 20(1), 2008
Thermal expansion…
Thermal expansion of prepared dental base-metal
casting alloys.
Mohammed T. Al-khafagy, B.D.S., M.Sc., Ph.D.(1)
ABSTRACT
Background: The aim of the study was to evaluate the linear thermal expansion of prepared Ni-Cr and Co-Cr dental
base-metal casting alloys which were prepared locally in Iraq and compare with other conventional alloys.
Materials and methods: Cylindrical shape wax specimen were prepared of 15mm length and 5mm diameter which
were invested in phosphate-bonded investment material and casted by using induction casting machine. The liner
thermal expansion was tested by using Iraqi made dialometer in which the furnace was set to reach from room
temperature to 950 °C in a rate of 10 °C per minute.
Results: The prepared Ni-Cr and Co-Cr alloys showed a higher linear thermal expansion than the conventional alloys,
however, statistical analysis revealed non significant differences regarding the Co-Cr alloys and highly significant
difference regarding the Ni-Cr alloys.
Conclusion: In comparison of locally made and other conventional alloys, Co-Cr alloys statistically revealed no
difference while Ni-Cr alloys showed a difference.
Key words: Thermal expansion, Co-Cr alloy, Ni-Cr alloy. (J Bagh Coll Dentistry 2008; 20(1)8-13)
INTRODUCTION
because of the extended cooling range to room
temperature (4).
Eden et al measured the fit of castings made
from Ni-Cr and precious metal alloys, in an
attempt to quantify possible differences in casting
accuracy among these classes of PFM alloys and
to evaluate of the both physical and technique
variable on the fit of cast dental crowns. The
results showed that Ni-Cr castings were
consistently undersized and the casting size was
dependent on the melting point of the alloy, with
casting diameter decreasing linearly with
increasing melting point under fixed mold
conditions (5).
Duncan evaluated and compared the casting
accuracy of four Ni-Cr alloys with ceramic
precious casting alloy using high heat phosphatebonded investment which was determined to be
acceptable for all alloys with manufacturer’s
instructions. The results showed that the least
discrepancy of fit was found in the precious alloy,
and the Ni-Cr alloys tested did not cast as
consistently as the precious alloy. It was
suggested that the casting accuracy might be
related to the amount of casting shrinkage that
occur in each alloy type, alloy compositions and
technique parameters (6).
The alloy should have a coefficient of thermal
expansion closely matching that of porcelain
veneer. High melting point is necessary to
withstand fusing temperature of the applied
porcelain and chemical compatibility with the
porcelain is essential as the alloy must not contain
any element likely to discolor the porcelain during
firing or undergo other undesirable reactions (5,7).
A modified investing technique, which
involves hand mixing of widely, used phosphatebounded investment and the use of more resilient
The escalating cost of gold contributed to the
widespread use of base-metal casting alloys for
fabrication of dental prosthesis. The popularity of
base-metal alloys is further enhanced by their
resistance to corrosion, reduced weight, and
generally more favorable physical properties than
those of gold.
The accuracy of fit of a casting depends
primarily on the ability of the investment material
to compensate for the shrinkage of the alloy,
which occurs on casting, an imbalance between
expansion and shrinkage of the alloy and
investment material is one of the causes of
unsatisfactory cast.
If casting shrinkage compensation is
inadequate, the undersized coping will fail to seat
fully and poor casting accuracy score will result.
Casting shrinkage compensation is dependent on
many factors that are unrelated to the alloy itself
that include investment type, amount of silica
solution used in mixing the investment, burnout
temperature, investment cooling down after
casting and so forth (1,2).
Alloy casting undergoes considerable
contraction when cooling from the casting
temperature to room temperature. Such
contraction may result in a casting with very poor
fit and shortage at the margin (3).
The melting temperature of the alloy has a
considerable role in thermal expansion and
contraction as explained by Marsaw et al who
stated that the high melting temperature of Ni- Cr
alloy results in greater thermal contraction
(1) Lecturer, Department of Prosthodontics, College of Dentistry,
University of Kufa.
8
Vol. 20(1), 2008
A study by Lombardas et compared the
vertical marginal accuracy of lost wax castings
produced with the conventional casting technique
using a metal ring with that of a technique using a
ringless system. The results showed that the
castings of the ringless technique provided less
vertical marginal discrepancy than the casting
produced with the conventional metal ring
technique (10).
The purpose of this study was to determine
the linear thermal expansion of the prepared Ni-Cr
and Co-Cr alloys and compared with two
conventional Ni-Cr and Co-Cr alloys.
and thicker ring liners, permitted routine
fabrication of oversized castings from a wide
range of Ni-Cr alloys (5).
Some manufacturers have produced new
investment materials specific for their alloys or
have recommended modifications in investment
technique, because the investment materials may
not be able to totally compensate for the
contraction of the alloy constituents (8).
Engelmen et al demonstrated that it was
possible to eliminate metal casting ring when
using phosphate-bounded investment to provide
greater expansion of the investment mold and
thus, provide a more precise fit for base-metal
alloy castings. They concluded that the ringless
casting simplified technique for all of the alloys
by eliminating not only the metal rings, but also
the use of ring liners and the water bath (9).
Four types of base-metal casting alloys were
used in this study. The chemical compositions and
the melting point of each alloy were listed in table
(1).
Table 1: The melting points and the composition of conventional and experimental dental basemetal casting alloys in weight percentage.
Alloy Name
CB Blando 72
Melting point oC*
Composition
72.8 Ni, 4.9 Cr, 12.3 Cu, others 10.0
1215
Prepared Ni-Cr 72.9 Ni, 4.9 Cr, 0.2 Fe, 5.6 Mo, 3.96 Si, 12.3 Cu
Wirocast
33 Co, 30 Cr, 5 Mo, 29 Fe, max 0.35 C, miscellaneous Si, Mn
Prepared Co-Cr 62 Co, 30 Cr, 5.5 Mo, 2 Si, 0.3 Mn ,0.2 C
1250-1260
1460
1480-1490
*The melting points of the conventional alloys were determined by the manufacturer instructions while the prepared
alloys were obtained from the study results of the Al-Khafagy (11).
The prepared Ni-Cr and Co-Cr dental basemetal casting alloys were prepared in the
laboratory by Al-Khafagy by using simple
technique and equipments (11).
A cylindrical shaped specimens were
prepared in a dimension of 15 mm length and 5
mm diameter. Three samples were prepared for
each type of alloy.
The wax pattern was invested in Rema Exact
investment (Dentarum, Germany) by using the
vacuum mixer machine (Bego, Germany). The
burnout and casting procedure were performed
according to manufacturer instructions regarding
the conventional alloys and as described by AlKhafagy regarding the experimental alloys. The
induction casting machine (Manfredy, Italy) was
used in this study to minimize casting variability.
After casting, the mold was cooled over night
and then the specimen was devested and air
braded with 60 μm aluminum oxide abrasive to
remove any remaining investment. Each specimen
was examined for any casting defect and when
present, the specimen was discarded and replaced
by another one.
Linear thermal expansion has been tested
using Iraqi-made dialometer (figure 1). The
device was calibrated in 2002 in AL-Raya
Company using pure copper 99.99% and in the
Iraqi Atomic Energy Commission using fused
vitrous silica. Similar design of dialometer was
used by Al-Saady to test the linear thermal
expansion of different types of investment
materials (12).
Figure 1: Iraqi-made dialometer.
The furnace was set to reach from room
temperature to 950 oC in a rate of 10 oC per
9
Vol. 20(1), 2008
minute. The readings of dial gage were recorded
for each 50 oC interval (figure 2), so the curve of
linear thermal expansion was obtained from
increased temperature versus increased length of
the specimen. The percentage of the linear
thermal expansion was obtained from the
following equation:
Linear thermal expansion=Change in length
/Original length *100 %
Change in length=reading of the dial gage in μm.
Original length was measured by new sensitive
vernia and multiplies by 1000 to get the length in
μm.
Figure 2: The dial gauge.
RESULTS
Tables 2A and B represent the mean and the
standard deviation of the linear thermal expansion
for the conventional and experimental dental
base-metal casting alloys.
Table 3 represents the t-test between the
prepared Co-Cr alloy and the Wirocast alloy
which showed non significant differences along
the change in temperatures. Figure 3 represent the
linear thermal expansion of the experimental and
conventional Co-Cr base-metal casting alloys in
which there was a relative similarity between the
two curves.
Regarding the Ni-Cr alloys it has been found
that the prepared Ni-Cr alloy showed a higher
mean value of the linear thermal expansion than
the CB Blando conventional alloy. Statistical
analysis revealed highly significant differences
along the change in temperatures except at 50 oC
and 150 oC it was non significant and at 100 oC
and 950 oC it was significant differences table 4.
Figure 4 represents the linear thermal expansion
of the experimental and conventional Ni-Cr basemetal casting alloys in which there was a clear
difference between the two curves.
The prepared Co-Cr alloy was showed
relatively higher linear thermal expansion at 950
C than the Wirocast alloy. However the t-test
revealed non significant differences between the
two groups.
2.5
Pre pa re d Ni-Cr
CB Bla ndo 72
2.5
Pre pa re d Co-Cr
W iroca st
2
2
1.5
1.5
1
1
0.5
9
0
0
8
0
0
7
0
0
6
0
0
5
0
0
4
0
0
3
0
0
2
0
0
Figure 4: Linear thermal expansions curves
of the prepared Ni-Cr and CB Blando 72
alloys
Figure.3: Linear thermal expansion curves
of the prepared Co-Cr and Wirocast alloys
1
0
0
9
0
0
8
0
0
7
0
0
6
0
0
5
0
0
4
0
0
3
0
0
2
0
0
1
0
0
0
0
0
0
0.5
10
Vol. 20(1), 2008
Table 2A: mean and standard deviation of linear thermal expansion
of prepared Co-Cr and Wirocast alloys
Temp
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
950
prepared Co-Cr alloy
S1
S2
S3 mean S.D.
0.000 0.000 0.000 0.000 0.000
0.008 0.008 0.006 0.007 0.001
0.063 0.053 0.010 0.042 0.028
0.173 0.173 0.181 0.175 0.005
0.318 0.218 0.210 0.248 0.060
0.494 0.404 0.400 0.433 0.053
0.678 0.658 0.501 0.613 0.097
0.824 0.724 0.747 0.765 0.052
0.980 0.980 0.810 0.923 0.098
1.129 1.119 1.201 1.150 0.045
1.267 1.208 1.256 1.243 0.031
1.380 1.301 1.480 1.387 0.090
1.522 1.522 1.501 1.515 0.012
1.627 1.787 1.591 1.669 0.104
1.745 1.845 1.645 1.745 0.100
1.863 1.962 1.773 1.866 0.095
1.980 2.102 1.901 1.995 0.101
2.125 2.130 2.056 2.104 0.042
2.278 2.289 2.178 2.249 0.061
2.443 2.505 2.401 2.450 0.052
S1
0
0.007
0.078
0.176
0.313
0.498
0.674
0.776
0.96
1.078
1.184
1.352
1.486
1.588
1.756
1.866
1.933
2.109
2.274
2.415
Wirocast
S2
S3 mean
0
0 0.000
0
0 0.002
0.082 0.086 0.082
0.196 0.02 0.131
0.325 0.345 0.328
0.509 0.505 0.504
0.662 0.647 0.661
0.823 0.803 0.801
1.039 0.949 0.983
1.137 1.058 1.091
1.274 1.196 1.218
1.372 1.333 1.352
1.533 1.509 1.509
1.67 1.603 1.620
1.803 1.756 1.772
1.917 1.85 1.878
2.019 2 1.984
2.149 2.141 2.133
2.294 2.317 2.295
2.431 2.45 2.432
S.D.
0.000
0.004
0.004
0.096
0.016
0.006
0.014
0.024
0.049
0.041
0.049
0.020
0.024
0.044
0.027
0.035
0.045
0.021
0.022
0.018
Table 2B: mean and standard deviation of linear thermal expansion
of prepared Ni-Cr and CB Blando 72 alloys
Temp
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
950
prepared Ni-Cr alloy
S1 S2 S3 mean S.D.
0
0
0 0.000 0.000
0 0.02 0.03 0.017 0.016
0.06 0.05 0.04 0.049 0.010
0.16 0.18 0.16 0.167 0.012
0.36 0.36 0.35 0.359 0.006
0.54 0.54 0.52 0.534 0.012
0.73 0.71 0.69 0.709 0.020
0.92 0.89 0.88 0.896 0.021
1.12 1.08 1.04 1.078 0.038
1.27 1.24 1.24 1.247 0.018
1.42 1.38 1.35 1.383 0.032
1.56 1.52 1.5 1.524 0.029
1.68 1.63 1.62 1.645 0.034
1.82 1.77 1.8 1.795 0.021
1.93 1.85 1.88 1.887 0.038
1.97 2.1 2.03 2.034 0.065
2.07 2.19 2.13 2.127 0.058
2.15 2.27 2.27 2.229 0.069
2.25 2.35 2.36 2.319 0.064
2.32 2.43 2.49 2.413 0.083
11
S1
0
0.015
0.113
0.184
0.294
0.45
0.6
0.784
0.941
1.098
1.274
1.384
1.49
1.588
1.705
1.815
1.921
2.019
2.137
2.235
CB Blando 72
S2
S3 mean
0
0 0.000
0
0 0.005
0.086 0.074 0.091
0.172 0.152 0.169
0.266 0.243 0.268
0.4 0.368 0.406
0.545 0.568 0.571
0.725 0.745 0.751
0.901 0.898 0.913
1.05 1.019 1.056
1.168 1.196 1.213
1.337 1.345 1.355
1.47 1.486 1.482
1.568 1.603 1.586
1.666 1.678 1.683
1.784 1.8 1.800
1.89 1.925 1.912
1.968 2 1.996
2.109 2.105 2.117
2.227 2.196 2.219
S.D.
0.000
0.009
0.020
0.016
0.026
0.041
0.028
0.030
0.024
0.040
0.055
0.025
0.011
0.018
0.020
0.016
0.019
0.026
0.017
0.021
Vol. 20(1), 2008
Table 3: t-test between prepared Co-Cr and Wirocast alloys
Temp
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
950
Prepared Co-Cr.
Mean
S.D.
0.000
0.007
0.001
0.042
0.028
0.175
0.005
0.248
0.060
0.433
0.053
0.613
0.097
0.765
0.052
0.923
0.098
1.150
0.045
1.243
0.031
1.387
0.090
1.515
0.012
1.669
0.104
1.745
0.100
1.866
0.095
1.995
0.101
2.104
0.042
2.249
0.061
2.450
0.052
Wirocast
Mean S.D.
0.000
0.002 0.004
0.082 0.004
0.131 0.096
0.328 0.016
0.504 0.006
0.661 0.014
0.801 0.024
0.983 0.049
1.091 0.041
1.218 0.049
1.352 0.020
1.509 0.024
1.620 0.044
1.772 0.027
1.878 0.035
1.984 0.045
2.133 0.021
2.295 0.022
2.432 0.018
t
2.030
-2.460
0.804
-2.208
-2.308
-0.855
-1.084
-0.934
1.685
0.754
0.659
0.369
0.739
-0.445
-0.204
0.164
-1.089
-1.245
0.556
T test
df p
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
0.112
0.070
0.467
0.092
0.082
0.441
0.339
0.403
0.167
0.493
0.546
0.731
0.501
0.679
0.849
0.877
0.338
0.281
0.608
Sig.
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Table 4: t-test between prepared Ni-Cr and CB Blando 72 alloys
Prepared Ni-Cr CB Blando 72
T test
Temp Mean
S.D. Mean S.D.
t
df p Sig.
0.000
0.000
0
0.017 0.016 0.005 0.009 1.137 4 0.319 NS
50
0.049 0.010 0.091 0.020 -3.265 4 0.031 S
100
0.167 0.012 0.169 0.016 -0.232 4 0.828 NS
150
0.359 0.006 0.268 0.026 6.002 4 0.004 HS
200
0.534 0.012 0.406 0.041 5.127 4 0.007 HS
250
0.709 0.020 0.571 0.028 6.988 4 0.002 HS
300
0.896 0.021 0.751 0.030 6.787 4 0.002 HS
350
1.078 0.038 0.913 0.024 6.358 4 0.003 HS
400
1.247 0.018 1.056 0.040 7.539 4 0.002 HS
450
1.383 0.032 1.213 0.055 4.649 4 0.010 HS
500
1.524 0.029 1.355 0.025 7.634 4 0.002 HS
550
1.645 0.034 1.482 0.011 7.940 4 0.001 HS
600
1.795 0.021 1.586 0.018 13.221 4 0.000 HS
650
1.887 0.038 1.683 0.020 8.323 4 0.001 HS
700
2.034 0.065 1.800 0.016 6.072 4 0.004 HS
750
2.127 0.058 1.912 0.019 6.106 4 0.004 HS
800
2.229 0.069 1.996 0.026 5.522 4 0.005 HS
850
2.319 0.064 2.117 0.017 5.299 4 0.006 HS
900
2.413 0.083 2.219 0.021 3.897 4 0.018 S
950
(5)
. However, the statistical analysis revealed non
significant differences regarding the Co-Cr alloys
and highly significant regarding the Ni-Cr alloys.
Practically, the prepared Co-Cr dental basemetal casting alloys may be invested and casted
by using the same investment materials and
techniques that have been used for the
DISCUSSION
In general, the linear thermal expansion of the
prepared base-metal casting alloys was higher
than the conventional alloys and this might be
related to the higher melting point of the
experimental alloys which may increase the linear
thermal expansion, and this agree with Eden et al
12
Vol. 20(1), 2008
5. Eden GT, Franflin OM, Powell JM, Oitta Y, Dickson G.
Fit of porcelain fused to metal crowen and bridge
casting. J Dent Res 1979; 58 (12): 2360-8.
6. Duncan JD. The casting accuracy of nickel – chromium
alloys for fixed prostheses. J Prosthet Dent 1982; 47 (1):
63-8.
7. Bates JF, Knapton AG. Metal and alloy in dentistry.
International Metals Reviews, Metal Society and the
American Society for Metal Review 1977: 215 (March):
39-60.
8. Thomson DH. A study of the effect of an increased
mold temperature on the casting ability of some non
precious alloys for porcelain veneer. J Prosthet Dent
1982; 48 (1): 52-8.
9. Engelman MA, Zamaloff V, Engelman GL. Casting
without metal ring unimpeded expansion of the
investment mold. Quint of Dent Technol 1985; 9 (1):
29-33.
10. Lombardas P, Cabunaru A, Mc Alarncy ME,
Toothaker RW. Dimensional accuracy of castings
produced with ringless and metal ring investment
system. J Prosthet Dent 2000; 84 (1): 27-31.
11. Al-Khafagy MT. Evaluation of some properties of
prepared dental base-metal alloys (Ph.D. thesis) College
of Dentistry, University of Baghdad 2003.
12. Al-Sa`ady AA. Development and assessment of a new
Iraqi phosphate bonded investment used in fixed
prosthodontics. (Ph.D. thesis) College of Dentistry,
University of Baghdad 2003.
conventional alloys without significant possible
changes in the linear thermal expansion of the
such an alloys. While, the prepared Ni-Cr alloy
need a modified investing technique such as the
use of thin ring liner or the use of another
investment material in order to provide less
expansion of the investment mold and thus,
provide a more precise fit for prepared Ni-Cr
dental base-metal casting alloy.
REFERENCES
1. O`Connor RP, Mackert JR, Myers ML, Parry EE.
Castability, opaque masking, and porcelain bonding of
17 porcelain fused to metal alloys. J Prosthet Dent
1996; 75 (4): 367-74.
2. Galyori DM, Thornton L. Improving marginal
adaptation for type III gold castings. J Prosthet Dent
1997; 77: 559-63.
3. Harikesh P, Shetty P, Patil NP, Jagdish HG. An
investigation into the effect of solidification shrinkage
on distortion of casting on flexural strength of various
solders for base-metal alloys. A laboratory study. Indian
J Dent Res 2000; 11(1):19-26.
4. Marsaw FA, de Rijk WG, Hesby RA,Hinman
RW,Pellew GB. Internal volumetric expansion of
casting investment. J Prosthet Dent 1984; 52 (3):361-6.
13
Vol. 20(1), 2008
The effect of bleaching…
The effect of bleaching agent on the microhardness
of composite resins
Saif Alarab A. Alajwadi B.D.S., M.Sc. (1)
ABSTRACT
Background: The aim of this in vitro study was to evaluate the effect of H2O2 bleaching agent on the microhardness of
composite resins
MATERIALS AND METHODS: Twenty samples were made from two types of composite resins then divided into 2 groups .The
microhardness value (VHV) was determined for each sample of the two groups before or and after treatment with 35%
H202 bleaching agent using microhardness tester.
RESULTS: The statistical analysis of the results using one way ANOVA and paired t test indicated that there is a significant
reduction In microhardness of 3M after bleaching application and there is a non significant reduction in microhardness of
Tetric ceram.
CONCLUSION: Within the limit of this in vitro study, it can be said that 35% H2O2 has no significant effect on the
microhardness of Tetric ceram composite resins while can reduce the microhardness of 3M composite resins .
Key words: Bleaching, hardness. (J Bagh Coll Dentistry 2008; 20(1)14-15)
INTRODUCTION
and a cover slide placed and pushed with 200 g load to
extrude excess materials and produce a flat surface (¹³).
A light curing machine was used to achieve
polymerization of composite resins, the tip of the light
curing machine was put over the tip of the cover slide
(0.5mm) (¹).curing times was 60 seconds (¹) for each
composite resins sample which stored in 95% humidity
and 37oC. Environment was controlled according to
ADA specification NO (27) (¹6) in an incubator.
The twenty samples were then divided into 2
groups: 10 samples of 3M composite resins and 10
samples of Tetric Ceram (Vivadent)
The microhardness value (reported as Vickers
hardness number ) was determined for each sample of
groups 1,2 before and after the treatment with 35%
H2O2 using microhardness tester determination of
hardness by indentation of pyramid diamond (Vickers
principle). The method consisted of forcing a square
based diamond pyramid in to the even smooth surface
to be tasted, the hardness value number is defined as
the ratio of the load in kilogram (0.5kg) to the surface
area of indentation in square millimeter, the later
calculated by measuring the length of the diagonals of
indentation (¹) the hardness number is determined by
the formula of Lakthin (¹) MHN =1.8544P⁄ D2
An important milestone in the history of
modern restorative dentistry was the development
of light cured composite resins for direct
procedures(¹).The physical properties are closely
related to the degree of convention and hardness
measurements(²).Resins composite have increase
strength following to a higher filler contents,
modification in the organic matrices and a greater
degree of polymerization that improve their
mechanical and physical properties(³).One of the
main resin that patient seek esthetic dental
treatment is a real or perceived. Various methods
of vital bleaching have been developed and used
over the years until recently; most bleaching
methods have used a strong oxidation agent (30%
to 35% H2O2) in combination with heat or light
source. Several studies have establisher the safety
and efficiency of the bleaching agents (6). However,
although several studies have not reported
significant changes, others indicated that the
physical and mechanical properties of certain
restorative materials may be affected the hardness
of composite resins exposed to bleaching agent
have been reported increase (9), decrease (10), or be
un changed (¹¹). The depth sensing microhardness
tester was recently introduced for characterization
of dental composite (¹²) the aim of this study is to
investigate the effect of H2O2 bleaching agent on
the microhardness of composite resins.
P .LOAD IN KRAM
D Is the length of diagonal in microns
2 indentations were made for each composite sample
then the average of measurement was calculated.
The results were statistically evaluated using one way
analysis of variance and paired t test
Twenty samples of composite resins were
prepared using a prefabricated mold which filled
with composite resins using a plastic instrument,
over the composite a transparent celluloid strap
RESULTS
(1) Assistant lecturer, Department of Conservative Dentistry, College
of Dentistry, University of Baghdad
14
Statistical analysis of data using analysis of
variance ANOVA (table 1) revealed that there is a
very high significant differences (p<0.001)
between groups of both 3M and Tetric ceram
Vol. 20(1), 2008
before and after H2O2 application, by using
paired t test (tables 2,3). The results show that
there is a significant reduction in microhardness
values of 3M after H2O2 application while there
is non significant reduction in microhardness
values of Tetric ceram after H2O2 application.
Table 1: ANOVA table
F-test P-value Sig
3M before 77.18 0.000 HS
78.85 0.000 HS
3M after
Tetric before 602.21 0.000 HS
Tetric after 623.76 0.000 HS
diffuse ,the more softening it would cause to the
material .As 3M composite resins showed more
softening after treatment with 35% H2O2 this mean
that H2O2 has the ability to diffuse through this
composite resins very easily.
REFERENCES
1.
2.
*P<0.0001 High significant
Table 2: t-test between 3M before & after
3.
t-test P-value Sig
1.271 0.235 NS
D1
4.311 0.002 S
D2
D1+D2/2 4.792 0.001 S
4.550 0.001 S
qw
4.
5.
*P>0.05 Non significant
**P<0.05 significant
6.
Table 3: t-test between Tetric before & after
D1
D2
D1+D2/2
Hmm
t-test P-value Sig
0.519 0.616 NS
0.802 0.443 NS
0.612 0.555 NS
0.651 0.531 NS
7.
8.
9.
DISCUSSION
10.
In these last years industry worked in order to
improve the physical and mechanical properties of
composite (19). A concern exists about the effect of
bleaching on the microhardness or restorative
materials. This in vitro study was conducted to
evaluate the effect of bleaching on the surface
microhardness of composite resins for the two
types of composite resins which contain across
linking agent of low molecular weight monomer
(dimethacrylate monomer such as triethyline
glycol dimethacrylate) which is chemically and
structurally similar to methacrylate, and therefore
may be incorporated into growing polymer chains,
glycol dimethacrylate possesses two double bonds
per molecule of glycol dimethacrylate. As a result
an individual molecule of glycol dimethacrylate
may serve as a bridge or a cross member that
unites two polymer chain (²º) .The oxygen free
radicals that result from the breakdown of H2O2
may break the bond between the polymer chain
and the molecules of glycol dimethacrylate. If only
one bond is broken this will decrease the hardness
of the material and soften the composite resin
materials. The severity of the effect of bleaching
gel depend on it is ability to diffuse or penetrate
through the composite resins surfaces, especially
through it is organic matrix. H2O2, the more it can
The effect of bleaching…
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
15
Flavio HB aguiar, Aline TB, Braceiro, Glaucia MB
Ambrosano Jose Lovadino. Hardness and diametral tensile
strength of a hybrid composite resin polymerization with
different modes and immersed in ethanol or distilled water
media. Dental materials 2005; 21: 1098-103
Park SH, Krejci I, Lutz F. Microhardness of resin
composites polymerized by plasma arc or conventional
visible light curing. Operative Dentistry 2002; 27,30-7
Say EC, Civelek A, Nobecourt A, Ersoy M, Guleryuz C.
Wear and microhardness of different resin composite
materials. Operative Dentistry 2003; 2805: 628-34.
Goldtien RE. Diagnostic dilemma: To bond laminate or
crown. Int J Periodont Res Dent 1987; 7(5):9-29.
Goldstein RE. In office bleaching: where we came from,
where we are today. JADA1997; 128(4): 11-8.
Leonard RH. Efficacy, longevity, side effects, and patient
perceptions of night guard vital bleaching. Compend contin
enduc dent 1998; 19(8):766-81.
Monaghan P, Lim E, LautenSchlager E. Effect of home
bleaching preparation on composite resins color. J
Prosthetic Dent 1992; 68:575-8.
Rotstein I, Cohenca N, Mor C. Effect of carbamide
peroxide and hydrogen peroxide on the surface morphology
and zinc oxide levels of IRM fillings. Endod dent traumatol
1995; 11:279-83.
Cooley RL, Burger KM. Effect of carbamide peroxide on
composite resins. Quintessence Int 1991; 22:817-21.
Bairley S, Swift E. Effect of home bleaching products on
composite resins. Quinntessence Int 1992; 23(7):489-94.
Nathoo SA, Chmielewski MB, Kirkup RE. Effect of
Colgate platinum professional tooth whitening system on
microhardness of enamel. Dentin and composite resins.
Compend contin educ dent suppl 1994; 15(17): 627-30.
Chung SM, Yap AUJ. Effects of surface finish on
indentation modulus and hardness of dental composite
restoratives. Dental Materials 2005; 21: 1008-16.
Beatty MW, Swartz ML, Moore BK, Phillips RW, Roberts
TA. Effect of micro filler fraction and saline treatment on
resin composite properties. John Wiley and sons 1998; Inc.
Craig RG.Restorative dental materials.10th edition.
St.Louis: Mosby year book, Inc., ch10, 1997; 257.
Craig RG.O. Brien Wj, Power JM. Dental materials
(properties and manipulations).6th edition. St. Louis: Mosby
year book, Inc, ch4, 1996.
New American dental Association. Specification No.27 for
direct filling resins. Council on dental materials and
devices. JADA1977; 94(6):1191-4.
Microhardness testing. Mechanical Testing, Metal
Handbook.9th ed., vol8, 1985.
Lakthin Y. Engineering physical metallurgy 6th printing:
Mir publisher. 80, 1997.
Rapisarda E, Casella G. Evaluation of mechanical flexural
properties of different composite resins. Operative
Dentistry 2006; 4:102-3
Philips RW.Skinner science of dental material.7th ed.USA,
1973.
Vol. 20(1), 2008
Assessment of consistency and…
Assessment of consistency and compressive strength of
glass ionomer reinforced by different amount of
hydroxyapatite
Mohammed R. Al-jabouri B.D.S, M.Sc., PHD (1)
Raghad A. Mohammed
B.D.S, M.Sc. (2)
ABSTRACT:
Background: Glass ionomers have good biocompatibility and the ability to adhere to both enamel and dentin.
However, they have certain demerits, mainly low tensile and compressive strengths. Therefore, this study was done
to assess consistency and compressive strength of glass ionomer reinforced by different amount of hydroxyapatite.
Materials and Methods: In this study hydroxyapatite materials were added to glass ionomer cement at different
ratios, 10%, 15%, 20%, 25% and 30% (by weight). The standard consistency test described in America dental
association (ADA) specification No. 8 was used, so that all new base materials could be conveniently mixed and the
results would be of comparable value and the compressive strength test described by British standard specification
for zinc polycarboxylate cement was used in this study.
Results: Different consistencies of materials produced a disc of varying sizes. The amount of the powder (in milligram)
was mixed with 0.5 ml of liquid to produce a consistency giving a disc of 3 cm±1mm in diameter were 500 mg for
glass monomer cement, 450 mg for glass ionomer cement reinforced by 10%, 5% and 30% of hydroxyapatite and
350 mg for glass ionomer cement reinforced by 20% and 25% of hydroxapatite. The results showed that the glass
ionomer cement reinforced by hydroxyapatite has higher compressive strength than conventional glass ionomer.
Conclusion: The addition of hydroxyapatite to conventional glass ionomer requires less powder to liquid ratio.
Addition of hydroxyapatite to glass ionomer cement increased its compressive strength.
Key words: Consistency, compressive, Glass ionomer, Hydroxyapatite. (J Bagh Coll Dentistry 2008; 20(1) 16-20)
Because of their limited strength and wear
resistance, glass ionomers are indicated generally
for the restoration of low stress areas where
caries activity potential is of significant concern
(2,5)
.Therefore, hydroxyapatite materials were
added to improve the consistency and
compressive strength of GIC. Glass ionomer
cements have the ability to adhere to
hydroxyapatite resulted in a variety of clinical
application in dentistry (6).
In the formation of calcium polyacrylate
hydroxyapatite cement, the hypothesis was that
calcium phosphate would rapidly hydrolyze in
the presence of polyacrylic acid to form cement.
PAA, tetra-calcium phosphate and dicalcium
phosphate were reacted together at 38 degree
resulting in hardness masses (7). Recently glass
ionomers reinforced by hydroxyapatite were
added to improve the physical and mechanical
properties of glass ionomer cement.
Therefore, the present study has been
undertaken to evaluate and assess the
consistency and compressive strength of glass
ionomer reinforced hydroxyapatite
INTRODUCTION
Glass ionomer cements have been widely
used by the professions for the past two decades
due to their chemical adhesion to both enamel
and dentin and the additional benefit of
continuous fluoride release throughout life of the
restoration (1). The glass ionomer is a
combination
of
silicate
and
modified
polycarboxylate cement, and the product offers
advantages of both but with little or none of their
negative features.
The powder is similar in composition to that
associated with silicate cement whereas the
liquid resembles the composition used for
polycarboxylate cements (2). Glass ionomer
undergoes two stages of reaction during the
setting process, the first occurs during the initial
five minutes when the reaction between the
powder and liquid forms a silaceous
hydrogel.The second stage requires about 24
hours and occurs when a polysalt matrix
completely surrounds all of the initial reaction
products (3). Kent and Wilson (4) reported that
fine grained glasses produce a stronger cement
and they showed that the finer the powder
particles, the shorter the working time and faster
the setting time.
Preparation of Hydroxyapatite
In this study a synthetic Hydroxyapatite was
prepared by using 250 ml of 0.02 moles of Ca
(AC)2 added drop by drop to 150 ml of boiling
solution of 0.1 moles of Na2HhPO4.The PH
should be 9 throughout the procedure (8,9).
(1) Lecturer, Department of Conservative Dentistry, College of
Dentistry, Baghdad University
(2) Lecturer, Department of Conservative Dentistry, College of
Dentistry, Baghdad University
16
Vol. 20(1), 2008
The prepared hydroxyapatite was added to
the powder of glass ionomer cement at different
weight percentage (10%, 155, 20%, 25% and
30%) and the mixed powders were agitated for
one to one and half hour to get homogenous
powders
Sample grouping
Six groups were used in this study (15
samples for each group in each test) as shown in
Table 1:
Table 1: The experimental and control
groups of the base materials.
Glass ionomer without
Group I (control)
Hydroxyapatite
Group II
Glass ionomer with 10%
(Experimental)
Hydroxyapatite
Group III
(Experimental)
Hydroxyapatite
Group IV
(Experimental)
Hydroxyapatite
Group V
(Experimental)
Hydroxyapatite
Group VI
Glass ionomer with
(Experimental)
Hydroxyapatite
The method of consistency test was
performed for each base material by trial
amounts of powders that were mixed with 0.5 ml
of liquid of Glass ionomer.Then the mixed
materials were placed inside glass tube with the
aid of a glass rod to get 0.5 ml of the mixed
materials. Then the base materials were delivered
from the glass tube to be deposited on a cement
slab. Three minutes after mixing, the flat glass
plate 20 gm and weight 100 gm were placed
carefully and centrally on to the soft cement
which spreads out into a disc between the glass
plates then ten minutes after mixing was started,
measurement of the average of the major and
minor diameters of the slumped disc was
recorded. The average weight of powder used in
three such determinations that produce a disc of
3 cm ±1mm in diameter was the amount of
powder used to make a mix of standard
consistency.
Compressive strength test
Specimens of the base materials were
prepared as cylinders of 4 mm in diameter and 6
mm in length which were prepared by using a
stainless steel mold and kept in water bath at
37±1`oC and 90-100% relative humidity at two
intervals; 24 hours and 1 week (7 days) after
mixing. The compressive strength was
determined by using compressive strength
testing machine at speed of 1mm/minutes, the
load was applied on the long axis of the
specimens. The compressive strength was
measured for each specimen by detecting the
force that caused early sign of fracture of the
specimen (11).
Consistency test
A special apparatus was used in this test in
which a standard 0.5 ml of liquid
(polycarboxylic acid) was mixed with different
weights of the powders to detect a suitable
weight of powder of the experimental base
material that can be mixed to get a proper
consistency for these new base materials.This
apparatus consists of the following parts (10):
1. Glass tube (inner diameter of 6.6mm)
2. A heavy rubber plug accurately seated inside
the glass tube to the desired position by the
glass rod.
3. A thin cellophane sheet enveloping the rubber
plug to prevent the adherence of the cement.
4. A glass rod 5.9 mm in diameter to force the
rubber plug and the soft cement from the tube
with one end at a distance from its end there is
thickening which act as depth gauge to seal the
rubber plug at the desired distance to measure
0.5ml of the mixed cement.
5. A flat glass plate approximately 20 gm.
6. A standard 100 gm weight piece.
7. Cement slab.
RESULTS
Consistency test
It was found that different consistencies of
materials produce a disc of varying sizes that
amount of the powder in milligram which can be
mixed with 0.5 ml of polycarboxylic acid to
produce a consistency giving a disc of 3
cm±1mm in diameter were 500 mg for the group
I, 450 mg for the group II, III and group VI and
350 mg for group IV and group V, as shown in
table 1 and figure 1.
17
Vol. 20(1), 2008
Table 2: Relations between the disc diameter of the mixed base materials and the weight of the
powder that mixed with 0.5 ml of polycarboxylic acid (liquid).
Weight of
Disc mean
powder diameter (cm
(mg)
of group I)
3.93±0.15
200
3.78±0.03
250
3.75±0.02
300
3.62±0.02
350
3.34±0.13
400
3.38±0.08
450
2.9±0.05
500
2.63±0.15
550
2.20±0.10
600
2.45±0.21
650
Disc mean
diameter (cm
of group II)
3.82±0.15
3.79±0.04
3.76±0.02
3.60±0.10
3.40±0.05
2.95±0.05
2.96±0.15
2.78±0.03
2.72±0.03
2.45±0.23
Milligram of
powder of Glass
ionomer and
Glass ionomer
reinforced by
Hydroxyapatite
Disc mean
diameter (cm
of group III)
3.94±0.02
3.91±0.04
3.73±0.02
3.62±0.03
3.20±0.02
2.94±0.02
2.82±0.07
2.62±0.02
2.33±0.12
1,84±0.04
Disc mean
diameter (cm
of group IV)
3.90±0.02
3.74±0.02
3.60±0.02
3.00±0.02
3.03±0.06
2.87±0.03
2.52±0.02
2.48±0.03
2.35±0.09
1.87±0.76
Disc mean
diameter (cm
of group V)
3.80±0.10
3.60±0.05
3.42±0.03
3.00±0.05
2.86±0.06
2.65±0.10
2.10±006
1.72±0.03
1.40±0.17
1.10±0.05
Disc mean
diameter (cm
of group VI )
3.85±0.10
3.75±0.08
3.60±0.01
3.50±0.13
3.20±0.10
2.90±0.10
2.35±0.05
2.42±0.03
1.90±0.10
1.20±0.17
600
500
400
300
200
100
0
1st Qtr 2nd 3rd Qtr4th Qtr 5 th
Qtr
Qrt
6 th
Qrt
The groups of Glass ionomer and Glass
ionomer reinforced by Hydroxyapatite
Figure 1: Weight of powder (mg) of experimental and control groups that can be mixed with 0.5
ml of liquid to get disc of 3 cm ±1mm (standard consistency).
One way ANOVA test for all tested group
showed that there was statistically significant
differences among the groups (Table 4). LSD
statistical test to compare between each paired
groups tested at the end of one day (table 5)
showed that there was statistical significant
difference between most compared paired groups
except when we compare the group II and group
III showed there was no statistical significant
difference.
Table 3: Means and standard deviations of the ultimate compressive strength of all tested
groups at the end of first day.
Compressive strength test
The result showed that glass ionomer cement
reinforced by 30% hydroxyapatite has the
highest compressive strength. At the end of one
day the glass monomer without reinforcement by
hydroxyapatite has the lowest values at both
periods at the end of one day and the end of one
week as shown in table 3 and figure 2.
Groups Mean (MPa)
58.1
I
60.6
II
62.5
III
64.6
IV
66.1
V
84.9
VI
18
SD
2.34
2.09
2.52
2.59
2.33
4.36
Vol. 20(1), 2008
90
80
70
Ultimate
60
compressive 50
40
strength
30
(MPa)
20
10
0
groupgroupgroupgroupgroupgroup
I
II
III
IV
V
VI
The groups of Glass ionomer and
Glass ionomer reinforced by
Hydroxyapatite
Figure 2: Ultimate compressive strength at the end of first day
LSD statistical test to compare each paired
groups tested at the end of one week that there
was statistical significant difference between
most compared paired groups except when we
compared the group II and group III. We also
compared group IV with group VI and group V
with group VI and showed there was no
statistical significant difference.
Table 5: LSD statistical test to compare
between the groups tested at the end of first
day.
Comparison Mean Difference Sig.
-2.51*
0.017
I * II
-4.71*
0
I * III
-6.55*
0
I * IV
-7.98
0
I*V
-26.77
0
I * VI
-1.87
0.073
II * III
-4.04
0
II * IV
-5.48
0
II * V
-24.27
0
II * VI
-2.18
0.037
III * IV
-3.61
0.001
III * V
-22.40
0
III * VI
-1.44
0.166
IV * V
-20.22
0
IV * VI
-18.79
0
V * VI
Table 4: ANOVA test of the compressive
strengths of the tested groups at the end of
first day.
Source
Between
groups
Within
groups
Total
Sum of
square
DF
Mean
square
6927.96
5
1385.6
663.56
84
7.9
759,52
89
F
Sig.
175.4 0.0
* The mean difference is significant at the 0.05 levels.
D.F. = degree of freedom P-value=probability
DISCUSSION
In recent years great emphasis upon
aesthetic dentistry led to the advent of tooth
colored restorative materials like Glass monomer
cement (9).There has been an attempt to use GIC
as restorative material. Because of its inferiority
in mechanical properties, such as strength,
modulus of elasticity and low resistance to wear
and pressure, this material has not been used in
occlusal surfaces (10). Hence different amounts of
hydroxyapatite materials were added to improve
the compressive strength and also to obtain
proper consistency of glass ionomer cement.
Thus, a study was undertaken to assess the
compressive strength and consistency of glass
ionomer reinforced by different amount of
hydroxyapatite.
According to consistency
Consistency of the materials detected
primarily by powder/liquid ratio. In this study
different consistencies of the six base materials
were obtained. In group I GIC without HA,
needs high amount of powder (weight=500mg)
to produce a disc zone 3cm±1mm, but in groups
IV and V needs less amount of powder
(weight=350mg) to produce the same disc zone.
In groups II, III and VI needs (weight=450mg)
19
Vol. 20(1), 2008
of powder to produce the disc zone. Therefore
we conclude that the addition of different
amounts of (HA) is important point to improve
the consistency of GIC material. This might be
due to the reaction occurring between
polycarboxylic acid and Hydroxyapatite to form
a hardened mass called calcium polyacrylate
hydroxyapatite cement.Tenttuisen and Brown (7)
agreed with our results, showing that in the
formation of Ca polyacrylate HA cement, the
hypothesis was that calcium phosphate would
rapidly hydrolyze in the presence of polyacrylic
acid to form cement. Wilson (11) explained the
interaction between polyacrylate ions and HA
that polyacrylate ion becomes irreversible
attached to the surface of HA by displacing
existing ions. The mechanism is not one of
simple ion exchange, since calcium ions are
displaced by the phosphate ions.
According to compressive strength
Traditional GIC has low resistance to wear,
low compressive strength and an early
susceptibility to moisture contamination (12).
Hydroxyapatite materials were added in different
amounts to increase the compressive strength of
glass ionomer cement. In group VI glass ionomer
cement with 30% hydroxyapatite showed the
highest value of compressive strength (84.9MPa)
which was significantly different from all other
groups. In group I traditional GIC the results
showed the lowest value of compressive strength
(58.1MPa). In groups II, III, IV, V the
compressive strength will increase sequence in
relation to the increased amount of
hydroxyapatite as show in table 3.The increase in
compressive strength might be due to the
chemical reaction between polycarboxylic acid
and hydroxyapatite.Yoshida (13) found that
polycarboxylic acids, regardless of conc./ph,
either adhere to or decalcify HA, depending on
the dissolution rate of the respective calcium
salts in acid solution. We concluded that the
addition of HA to glass ionomer cement will
increase its compressive strength.
REFRENCES
1.
Sadasiva K, Subbarao CV, Kandaswamy D.
Comparative study of surface finish of conventional
glass ionomer cement with fast setting glass ionomer
cement (in vitro study). J Cons Dent 1999; 2(2): 62-6.
2. Sturdevant MC, Roberson MT, Heymann OH,
Sturdevant RJ. The art and science of operative
dentistry, 3rd Ed, 1995 Mosby, Inc. p. 581-3
3. Lunfelder FK. Glass ionomer cement clinical
developments. JADA 1993; 124: 62-4.
4. Wilson AD, Kent BE. A new translucent cement of
dentistry. The glass ionomer cement. Brit Dent J 1972;
132:133-5.
5. Swift EJ. Effects of glass ionomers on recurrent caries.
Oper Dent 1989; 14:40-3.
6. Lee QC, Harandi L, Cobb MC. Evaluation of glass
ionomer as an endodontic sealant: An in vitro study. J
of Endo 1997; 23(4):209-12.
7. Tenttuisen KS, Brown PW. The formation of
hydroxyapatite ionomer cements at 38 degree. J Dent
Res 1994; 73(3):598-603 (abstract).
8. Al-Bssam K S .The mineralogy and Geochemistry of
the marine sedimentary phosphate deposites of Iraq
and other areas in the middle east PHD thesis, Wales
University, College Cardiff, Department of mineral
exploitation, 1974.
9. Ayman A, Gerald K, Eileen H. Class II composite
resin restorations using glass monomer liners,
microleakage study. J Clin Pedi Dent 1996;21(1):6770.
10. Hamilton IR. Effects of flouride on Enzymatic
Regulation of Bacterial Carbohydrate Metabolism.
Caries Res 1977; 11:262-91
11. Wilson AD, Prosser HJ, Powis DM. Mechanism of
adhesion of polyacrylate cement to Hydroxyapatite. J
Dent Res 1983; (62):590-2.
12. Patil AC, Bhagwat SV. Antibacterial effects of glass
ionomers on carious dentin-an in vivo study. J Cons
Dent 2000; 3 (2):65-74.
13. Yoshida Y, Van Meerbeek B, Lambrechts P, Okazaki
M. Adhesion to and decalcification of HA by
carboxylic acids. J Dent Res 2001; (80):1565-9.
20
Vol. 20(1), 2008
Enhancement of bone…
Enhancement of bone induction after implantation of
amelogenin protein and its active sub-protein.
Riyadh O. Alkais, B.D.S, M.Sc., PhD (1)
ABSTRACT
Background: Amelogenin (AM),a major enamel matrix protein(EMP),is a potent bone morphogenic protein which
can enhance bone formation, and contains an active sub-protein(AAS).
Materials and methods: Twenty adult Syrian hamsters were grouped into 2, groups. Two holes were induced in the
mandible of each animal and 3 mgs of AM &AAS were applied in each whole of, group 1 and group 2 respectively.
Animal scarifying was done after 3, 7, 14, 21 and 28 postoperatively, serial sections were prepared and slides were
examined by light microscope.
Results: Comparison of osteoinductive activity of whole AM protein (complex) with that of its intermediate molecular
weight sub-protein (active sub-protein (AAS) revealed that the osteoinductive process was more accelerated after
AM application than that after AAS application
Conclusions: Other AM sub-proteins may act collectively with AAS to represent the excellent osteoinductive activity
of AM protein.
Key words: Amelogenin, bone morphogenic factor, active sub-protein. (J Bagh Coll Dentistry 2008; 20(1) 21-23)
INTRODUCTION
Enamel matrix protein secreted by
ameloblasts is free from collagen and contains
water & two categories of proteins: Amelogenin
and Enamelin.AM components are lost from the
maturing fetal bovine enamel matrix, while
Enamelin components appear to be conserved (1).
Both proteins can be found in all stages of
enamel development (2). Many AM sub-proteins
were shown in the acid (45-5) Mr region by
using a flourogram of 2 dimensional
polyacrylamide gel electrophoresis and immunoprecipitated by the anti-amelogenin sera (3). In a
recent study, we have shown that the bone
morphogenetic activity of EMP is due to
Amelogenin protein rather than Enamelin
protein, and that AM contains at least 3 subproteins of:high, intermediate and low molecular
weights (4). However, no information concerning
the comparison of the osteoinductive ability of
AM as a whole protein(complex) with that of its
sub-proteins especially of intermediate molecular
weight which we showed that it is the active subprotein and named it the active AM sub- protein
(AAS) (4), to have a better idea regarding the
exact nature& function of each. Therefore, the
aim of this study was to compare the healing
process efficiency the osteoinductive capability
of both AM&AAS when implanted separately.
Isolation of Active AM sub-protein: AAS was
isolated by gel filtration chromatography &
polyacrylamide gel electrophoresis of AM protein
complex according to Weber&Osborn method (5).
MW standards were: Bovine serum albumin
(67,000), ovalbumin (43,000), Carbonic anhydrase
(30,000), Soya bean trypsin inhibitor (20,000) and
Lactalbumin (14,000). Gel was scanned (Gilford
model 250 spectrophotometer) at 590nm.
Animal grouping & Proteins implantation:
Twenty adult Syrian hamsters were employed in
this study and grouped into 2 groups, then 3 mgs
of AM protein(complex) and o AAS were applied
separately
in
small
cavities(2mm
in
diameter)drilled in both sides of the animals
mandibles
of
group
1
and
group2
respectively(Table 1).
Table 1: Animals groups
Group No. Used material Animals No.
1
AM protein
10
2
AAS
10
Animal scarifying was done after 3, 7, 14, 21
and 28 postoperatively, then after fixation and
decalcification, serial (5mm) crosssections were
prepared and stained with Mayer's Haematoxylin
&Eosin (H&E).Three slides were examined from
each specimen for the histopathological
examination using light microscope.
Isolation of Amelogenin protein: AM was
isolated from EMP of bovine fetuses according
to Termin et al method (3).
RESULTS
The SDS-gel electrophoresis picture of AM
complex indicated that it consist of 3 clear bands
of about 45,25 and 18-5 KD.Forty cavities were
created in the mandibles of 20 hamsters,3 animals
died during the study period (2 animals from group
____________________________________________________
(1) Professor, Department of Oral Diagnosis, College of
Dentistry, Baghdad University.
Oral Diagnosis
21
Vol. 20(1), 2008
1 and 1 animal from group2). No toxic or allergic
reactions were shown in the surviving animals.
The histopathological examination revealed a
more accelerated healing process with a rapid
new bone formation in group 1 compared with that
of group 2(Fig.1, 2) Table 2 summarized the
histopathological features of the examined groups.
Table 2: Chronological order of various healing processes
Group1
Group2
Healing process
(AM complex)
(AAS)
7 14 21
28
7 14 21
Blood clot organization
+
+
Inflammatory cells appearance
+
+
Fibroblast appearance
+
+
Endothelial cells appearance&new b.v.
+
+
Osteoplastic appearance
+
+
Osteoid formation
+
+
Osteoclastic appearance
+
+
Complete filling of the bony defect
+
28
+
A
B
Figure 1: Histological image of group 1 (AM protein complex) 14 days(A)& 21 days (B) after
implantation. New bone formation with many b.v.&progressive osteogenesis can be seen in
(A).The bone defect was completely filled with mature bone in (B).(H&E X 100).
Figure 2: Histological image of group 2 (ASS) after 21 days of implantation showing a slower
healing process and new bone formation ,osteogenesis is in progress mainly around the old bone
spicules(arrow).(H&E X 100)
shown the treatment with EMP results in the
DISCUSSION
formation of new layer of a cellular cementum
Enamel matrix protein have been recently
with inserting collagen fibers and the formation of
introduced as a new modality in regenerative
new alveolar bone(6). Heijl et al, mentioned that the
treatment (Orthopaedic,Maxillo-facial surgery
results from a controlled trial study have
and Dental implantation) (4). Histopathological
demonstrated that the treatment of intrabony
data from animals and human studies have
Oral Diagnosis
22
Vol. 20(1), 2008
periodontal defects with EMP leads to significant
gain of clinical attachment level and bone
regeneration as observed in the radiographs (7)
and Sculean et al also confirmed such results (8).
In a recent study, we have shown that the
bone morphogenic activity of amelogenin is
mainly due to one of its sub-proteins which is the
intermediate molecular weight type(AAS)(4).The
present study indicates that the treatment of bony
defects with AM or AAS results in a significant
acceleration of the healing process and mainly of
new bone formation. However the study showed
that there are significant differences between the
2 modalities and revealed that the healing
process & new bone formation was more
accelerated with AM in comparison with AAS
application. So it seems that the other AM subproteins enhance the bone morphogenic activity
of AAS inside the AM complex, which means
the 3 sub-proteins can work collectively and
cooperatively to represent the fantastic
osteoinductive activity of AM protein.
Oral Diagnosis
REFERENCES
1. Eastoe JE. Enamel protein chemistry, past, present and
future. J Dent Res 1979; 58B: 753.
2. Tencate AR. Oral histology, development, structure and
function, 4th ed.St .Louis: Mosby: 1994; p.224.
3. Termin JD. ,Belcourt AB .Properties of dissociatively
extracted fetal tooth matrix proteins. J Biol Chemistry
1980; 255: 20 : 9760-8.
4. Alkaisi RO. Biochemical, immunological and
histopathological studies on the osteoiduction activity
of fetal bovine enamel matrix proteins and their
possible therapeutic applications. PhD thesis.
University of Baghdad, college of Dentistry 1999.
5. Weber K, Osborn M. The reliability of molecular weight
determinations by Dodecyle Sulfate-polyacrylamide
gel electrophoresis. J Biol Chem 1969; 244: 4400-12.
6. Hammarstrom L. Enamel matrix, cementum
development and regeneration. J Clin Periodontol
1997; 24: 658-68.
7. Heijl L. Periodontal regeneration with enamel matrix
derivative in one human experimental defect. A case
report. J Clin Periodontal 1997; 24: 693-5.
8.
Sculean
A, Reich
E. Treatment of intrabony
periodontal defects with an enamel matrix protein
derivative (Endogen). A report of 32 cases. Int J
Periodontics Restorative Dent 1999.
23
Vol. 20(1), 2008
Comparison of amelogenin…
Comparison of amelogenin sub-proteins osteoinductive
activity (Histopathological study)
Riyadh O. Alkaisi B.D.S, M.Sc., PhD
(1)
ABSTRACT
Background: Enamel matrix proteins (EMP) represent one of the most effective members of the bone morphogenic
protein (BMP) family.
Materials and methods: Chemical isolation of AM followed by isolation of AM sub-proteins was done using gel
filtration chromatography and polyacrylamide gel. Beside that the histopathological pictures after the application of
each AM sub-proteins in a bony defect created in the mandible of hamsters were observed.
Results: Only the intermediate molecular weight sub-protein (application showed a rapid healing process and new
bone formation.
Conclusions: Among the 3 AM sub-protein only the intermediate one represents the bone morphogenic factor.
Key words: Enamel matrix proteins, AM sub-proteins. (J Bagh Coll Dentistry 2008; 20(1)24-27)
INTRODUCTION
Amelogenin was isolated for the first time by
Eostoe in 1979(1). As soon as secreted it
undergoes a series of modifications leading to the
existence of AM complex in the 20-25 Kilo
Dalton (KD) range. Enamel matrix proteins have
recently been introduced as a new modality in
enhancing the healing process and bone
formation by acting as a bone morphogenic
protein, so can be used clinically in Orthopaedic,
Maxillo-facial surgery, periodontology and in
implantation(2). It was shown that the osteogenic
activity of EMP is due to the effect of AM rather
than other EMPs(2). Isolation of proteins and their
sub-proteins can be done by using the
physiochemical techniques, for instance, gel
filtration chromatography (3) and electrophoresis.
Applying such techniques for AM protein
showed 3 peaks of high, intermediate and low
no
molecular
weights
(mw)(2).However,
investigations were available comparing the
osteoinductive activity of such AM sub-proteins.
Therefore, the aim of this study was to compare
the histopathological features of these subproteins in order to specify the responsible one
for the osteoinductive ability of AM protein.
Bovine serum albumin (67,000), ovalbumin
(43,000), Carbonic anhydrase (30,000), Soya bean
trypsin inhibitor (20,000) and Lactalbumin
(14,000). Gel was scanned (Gilford model 250
spectrophotometer) at 590nm.
Animal grouping &Proteins implantation: A
total of 40 adult Syrian hamsters were employed in
this study and grouped into 4 groups (Table 1).
Table 1: Hamsters grouping
Group
No. of
Implanted material
No.
animals
High AM sup-protein
10
1
Interm. AM sup10
2
protein
Low AM sup-protein
10
3
Nothing(control)
10
4
Surgical procedure: After giving local anesthesia
(0.3 ml ketamine hydrochloride), a small cavity
was drilled inside both sides of the animal
mandibular bone (2mm in depth & diameter).Then
3 mgs of each sub-protein was applied in each
cavity of group1, 2, and 3. Nothing was applied in
group 4 cavities (control).
Histopathological
examination:
Animal
scarifying was done after 3, 7, 14, 21, and 35 days
postoperatively by a lethal dose of 1 ml ketamine
hydrochloride. After separating the mandibles,
fixation and decalcification were done and the
specimens were taken from both side of each
mandible and reduced in size to the site of
implantation, then prepared and embedded in
paraffin wax. Serial (5mm) cross sections were
prepared and stained with Mayer's Haematoxylin
& Eosin (H&E). Three slides were examined from
each specimen for the histopathological
examination using light microscope.
Amelogenin
sub-proteins
isolation:
Amelogenin was isolated from the EPM of
unerupted crowns of bovine fetuses according to
Termin et al method (4). Then gel filtration
chromatography and polyacrylamide gel
electrophoresis of AM protein was done
according to Weber & Osborn method (5) using
these standards:
___________________________
(1) Professor, Department of Oral Diagnosis, College of
Dentistry, Baghdad University.
Oral Diagnosis
24
Vol. 20(1), 2008
No toxic or allergic reactions were shown in the
surviving
animals.
The
histopathological
examination revealed a more accelerated healing
process with a rapid new bone formation in group
1 compared with that of group 2 (Figures1,2).
Histopathological examination showed that
the healing process was uneventful in all groups'
specimens. Only group 2 (intermediate Am)
showed rapid healing process and new bone
formation (Figure 1) compared to control
group(Figure 3),while group1(high AM) showed a
slower healing process compared with group 2 and
control (Figure2,3), finally group3 (low m.w)
showed retardation of the healing process with no
bone formation during the period of this study
(Figure 4).
Table 3 summarized the histopathological
features of the examined groups.
RESULTS
The SDS-gel electrophoresis picture of AM
complex indicated that it consists of 3 clear
bands of about 45, 25 and 18-5 KD. Eighty
cavities were created in the mandibles of 40
hamsters, and 5 animals died during the study
period (Table2).
Table 2: Dead animals in different groups
Group No. of dead
No.
animals
0
1
1
2
2
3
2
4
A
B
Figure 1: Histological image of group 2 (intermediate m.w)after 14 days(A)& 21 days after
implantation(B). New bone formation with many b.v.&progressive osteogenesis can be seen in
(A)and rapid osteogenesis with more mature new bone formation in (B).(H&E X 100).
A
B
Figure 2: Histological image of group 1 (High AM sub-protein)after 14 days (A) & 21 days after
implantation (B), showing slow healing process and early formation of fibro-osteoid tissue in (A)
and progressive osteogenesis in(B).(H&E X 100).
Oral Diagnosis
25
Vol. 20(1), 2008
Figure 3: Histological image of group 4 (control)after 21days of implantation, showing persistent
fibrosis, fibro-osteoid tissue&progressive osteogenesis (H&E X 100).
A
B
Figure 4: Histological image of group 3 (Low AM sub-protein)after 14 days(A)& 21 days after
implantation(B),showing slow organization of blood clot(which contains inflammatory cells&few
blood vessels) with early fibrous tissue formation in(A),while in(B) partial replacement of blood
clot by fibrous tissue around the old bone spicules can be seen with no sign of.(H&E X 100).
Table 3: Chronological order of various healing processes
Group1
High AM
Group2
Interm. AM
Group 3
Low AM
Group 4
Healing process
Blood clot organization
Inflammat. cells appearance
Fibroblast appearance
Endothelial cells appearance
&new b.v.
Osteoblastic appearance
Osteoid formation
Osteoclastic appearance
Complete filling of the bony
defect
7 14 21 28 35
+
+
+
7 14 21 28 35
+
+
+
+
+
+
+
+
7 14 21 28 35 7 14 21 28 35
+
+
+
+
+
+
+
*
*
*
+
+
**
+
*
+
+
+
**
*= Never
**=Incomplete
Hubbell,et al (6)
collagenous fractions of dentine, bone and
osteosarcoma (1,9). In 1995, we found that EMP
extracted from bovine fetus represents a potent
BMP, and later we showed that AM protein was
responsible for the osteoinductive activity of
EMP(2).
Hammarstrom, mentioned that EMP can be
introduced as a new modality in regenerative
periodontal treatment(7) and Sculean et al,
confirmed Hammarstrom results (8). However no
DISCUSSION
Bone morphogenic proteins received
increasing attention and became a focus of
research over the last 20 years. They represent a
unique set of differentiation factors that can
induce new bone formation at implantation site
instead of changing the growth rate of preexisting bone which most growth factors and
cytokines do. BMPs were extracted from many
tissues like decalcified bone matrix, non-
Oral Diagnosis
26
Vol. 20(1), 2008
information were available regarding the
comparison of bone-inductive effects of each
AM sub-[protein which we believed to be very
important for the understanding of the
osteoinductive capability of AM protein, so we
implanted each sub-protein in many created bony
cavities and examined their capability by
histopathological techniques. The results of this
study showed that the bone morphogenic activity
of AM is due to its intermediate m.w sub-type
which activates the healing process significantly
leading to rapid new bone formation. Finally the
low m.w type showed retardation of the healing
process with no bone formation during the period
of this study (35 days). All these findings were
compared with the control group. The conclusion
of the present studies was that the intermediate
m.w sub-protein represents the active AM subprotein. Further studies concerning the
comparison of bone morphogenic activity after
the application of whole AM protein&its active
sub-protein to have a clear idea about the real
action and rules of AM and its sub-protein is
recommended.
Oral Diagnosis
REFERENCES
1.
Eastoe J E. Enamel protein chemistry, past, present
and future. J Dent Res 1979; 58B:753.
2.
Alkaisi RO.
Biochemical, immunological and
histopathological studies on the osteoiduction activity
of fetal bovine enamel matrix proteins and their
possible therapeutic applications. PhD thesis.
University of Baghdad, college of Dentistry 1999.
3. Alkaisi RO. Immune complex disease. MSc thesis
submitted to Brunel university, London, 1983; 65.
4. Termin JD, Belcourt AB. Properties of dissociatively
extracted fetal tooth matrix proteins. J Biol Chemistry
1980; 255: 20 : 9760-8.
5. Weber K, Osborn M. The reliability of molecular weight
determinations by Dodecyle Sulfate-polyacrylamide gel
electrophoresis. J Biol Chem 1969; 244: 4400-12.
6. Hubbell AO, Austran LT. Extraction wounds &
therapeutic agents an experimental study. JADA 1941;
28: 658-8.
7. Hammarstrom L. Enamel matrix, cementum,
development and regeneration. J Clin Periodontal 1997;
24: 658-8.
8. Sculean A, Donosw K. Comparison of enamel matrix
protein and bioabsorbable membrane in the treatment
of intrabony periopdontal defects. J Periodontol 1999;
70: 3.
9. Urist MR, Litze A. A bovine low molecular weight bone
morphogenic protein BMPfraction. Clin Orthop 1982;
162: 21a: 232.
27
Vol. 20(1), 2008
Evaluation of lipid-…
Evaluation of lipid-bound sialic acid tumor marker in sera
of acute lymphocytic (ALL) patients
Abdul Wahab R. Hamad Ph.D.
Nazar G.A. Talabani Ph.D. (2)
Fawaz Al-Swad Ph.D (3)
(1)
ABSTRACT
Background: Lipid-bound sialic acid (LSA) concentration was determined in the sera of 90 patients with acute
lymphocytic leukemia (ALL) and 50 controls (30 normal subjects and 20 chronic non-malignant diseases). The aim of
this work is to determine the reference values for serum sialic acid in healthy subjects and in patients with acute
lymphocytic leukemia.
Materials and Method: All of serum sample were collected by venepuncture and kept frozen (-20 C°) until analyzed,
then a spectrophotometric technique is used for the estimation of the concentration of sialic acid marker in sera.
Results: The mean sialic concentration in healthy individuals was 132 mg/ml and that in chronic non-malignant
disease was 171.1 mg/ml, where as, the concentration of (LSA) in 90 cancer patients with (ALL) was 270.3 mg/ml.
Conclusion: Both cancer patients with (ALL) and patients with chronic non-tumor disease can cause an elevation in
the concentration of sialic acid values in serum as compared to healthy individuals.
Keywords: Sialic acid, tumor marker, acute lymphocytic leukemia. (J Bagh Coll Dentistry 2008; 20(1)28-30)
INTRODUCTION
Sialic acid is an acetylated derivation of
neuraminic acid. (1) It is attached to nonconducting residue of carbohydrate chains of
glycoprotein and glycolipids. Glycoproteins and
glycolipids are cell surface constituents containing
N-acetylnuraminic acid (Sialic acid) as a common
terminal saccharide. Aneoplasm often has an
increased concentration of sialic acid on the tumor
cell surface and this may be due to the fact that
aberrant glycosylation process in tumor cells may
contribute to the biosynthesis of the carbohydrate
structures so that malignant or transformed cells
contain increased levels of sialic acid on their
surface. Cell shape, anchorage and growth rate
have been shown to influence the sialic acid
content of the cell (2).
The suggested biological functions of sialic
acid include: Stabilizing the concentration of
glycoprotiens and cellular membrane, assisting in
cell to cell recognition and interaction,
contributing to membrane transport, affecting the
function of membrane receptors providing binding
sites of ligands, influencing the function stability
and survival of blood glycoprotein’s, regulating
the permeability of the basement membrane of
glomerul(3).
The serum LSA concentration has been
reported to be potentially useful as a
complementary Tumor marker (4).
Elevated concentration of sialic acid has been
observed in several types of cancer include breast
cancer, gynecological cancer, prostate cancer,
colorectal cancer, neuroendocrine tumors,
myeloma, and lung cancer(5), in addition to
myocardial infarction, diabetes and inflammatory
disorder(6-7).
However, Kalela (8) reported the association of
the elevation of serum sialic acid and
metalloproteinase-9 with lipid profile and
inflammatory marker in heart disease, while
Ponnio(9) suggested that the concentration of sialic
acid was a potential marker for alcohol abuse.
Nikkar (10) reported a significant change in
lipid profile associated with LSA, which can be
used for the follow up risk factors and monitoring
coronary heart disease prevention activity.
Cancer patients have an increased LSA
concentration, which coordinate positively with
the degree of metastasis and are useful in
monitoring and treatment (6). In another study
conducted by Croke et.al (11) they showed that the
increase in serum sialic acid in patients with
multiple myeloma were highly significant
compared with control group.
The aim of the work is to determine the
reference value for the concentration of serum
sialic acid in healthy subjects and in patients with
ALL.
Serum LSA was measured using the method
that was developed by Katopoids et. al(12).
The experiments were conducted using
unhemolyzed sera obtained from 90 patients with
(1) Professor, College of Medicine, University of Nahrain.
(2) Professor, College of Dentistry, University of Sulaimaniya.
(3) Lecturer, Department of Oral Diagnosis, College of Dentistry,
Oral Diagnosis
28
Vol. 20(1), 2008

Mean and S.D. (270.3 ± 6.306) for ALL.
Mean and S.D. (170.84 ± 4.121) for chronic
non malignant, (Figure 2). It is evident from the
results in table 1 that the LSA concentration in all
the 90 patients with ALL were significantly
higher when compared with normal control group
and they were in the range of 240-290 μg/ml with
the mean value of 270.3 μg/ml.
acute lymphocytic leukemia (ALL) with age
range from 20-60 years. All patients were
diagnosed in college of medicine Al.Nahrain
university though the year 2001, and the blood
sera were also collected from 30 age matched
healthy volunteers and 20 patients with disease
other than tumors (Rheumatoid, arthritis and joint
disease).
The sera samples were studied immediately
after collection or otherwise frozen at -20 °C until
used.
Procedure
One ml of serum was mixed with 3 ml of
distilled water and extracted with 30 ml of 50%
chloroform: 50% methanol mixture. The sample
was centrifuged, and the aqueous layer containing
LSA was precipitated with phosphotungstice acid.
After centrifugation the supernatant was discarded
and the precipitate suspended in distilled water.
One ml of resorcinol reagent was added and the
sialic acids determination was done by the
spectrophotometric procedure at 580 nm.
DISCUSSION
Lipid bound sialic acid concentrations in
healthy subjects have been determined with
several methods in a number of studies. There are
many methodological and other factors that can
influence the measured LSA concentrations in
reference individuals. Age, sex, smoking and use
of contraceptive pills may affect serum LSA
concentration (9).
Sialic acid is of major importance in cell
biology because of the external position of LSA
on glycoproteins and glycolipids, and on the outer
cell membranes. Sialic acid participates in the
stabilization of the conformation of glycoproteins
and cellular membrane (13).
Furthermore, the negative charge present in
sialic acid means that the compound takes part on
binding and transports of positively charged
molecules and in the attraction and repulsion of
the cells and molecules(14). It also contributes to
the regulation of the permeability of the basement
membrane on glomeruli (13).
An elevation of LSA has been reported in
majority of children with leukemias(15) in adults
with acute myeloid leukemia, chronic myeloid
leukemia(16), acute lymphoblostic leukemia(17),
chronic
lymphocytic
leukemia(18)
and
(19) (20)
. The results of this work are in
lymphomas
agreement with those obtained by katopodis(4)
who found that the average level of LSA in sera
of leukemic patients was 305 μg/ml, lymphoma
287 μg/ml, Hodgkin’s disease 342 μg/ml and
melanoma 269 μg/ml. These results allowed him
to conclude that the LSA levels in these diseases
are significantly higher when compared with
normal control group 160 μg/ml.
Further analysis of LSA was done by
Bhargava et.al (21) on patients with leukemia,
lymphoma, pancreas and lung cancers. They
found that the level of LSA was significantly
higher in cancer patients especially with active
disease as compared with healthy control.
In view of the above, the elevation of LSA in
serum of leukemeic patients is not surprising.
However, the mechanism is very complex and can
be related to the intensified cell metabolism and
RESULTS
Data for LSA concentration in the sera of
chronic non-malignant patients, normal subjects
and cancer patients are presented in table 1.
Table 1: Measurements of LSA (μg/ml) in
the sera of patients with ALL, chronic nonmalignant and control groups
Mean + SD No. Age (years)
ALL
262.6 ±14.9 38
20-30
270.1 ± 14.8 19
30-40
261.8 ± 15.8 25
40-50
275.0 ± 11.7 9
50-60
90
Total
Chronic non
malignant
171.1 ± 15.6 6
20-30
166.6 ± 13.3 8
30-40
174.8 ± 10.9 6
40-50
20
Total
Normal
control
135.5 ± 11.9 10
20-30
136 ± 10.38 10
30-40
132 ± 6.7 10
40-50
30
Total
The results shown in the table 1 demonstrate
non significant different among age groups
examined so data were pooled together for the 4
age groups with:
Mean and S.D. (132 ± 2.179) for control.
Oral Diagnosis
29
Vol. 20(1), 2008
increased
serum
sialytransferase
activity
expressed by the tumor cells (22) (23).
Elevated LSA concentration has also been
reported in patients with chronic non-malignant
disease as compared with healthy individuals.
This was within the agreement with the previous
studies conducted by Seider(15), Okennedy(18) and
Brockhauen(24). They reported that LSA
concentration was elevated in patients with
bacterial infections and rheumatoid arthritis. This
increase in serum LSA concentration may
occurred through changes in the biosynthesis and
post-translational glycosylation processing of the
acute-phase glycoprotiens in the liver (25).
15. Seider A, Graf N, Sitzmann FC. Wertigkeit der Sialin
saurebestimmung in serum bei kinder, Padiatoc Padol
1992; 27:43-6.
16. Patel PS, Adhvoryu SG, Baxi BR. Tumor marker in
leukemia: evaluation of serum levels of different
forms of sialic acid, Regan isoenzyme and lactate
dehydrogenase. Int J Biol marker 1991; 6:177-82.
17. Patel PS, Adhvarn SG, Balar DB. Serum glyconjugates
in patients with anemia and myeloid leukemia. Tumor
1988; 74:639-44.
18. Okennedy R, Berns G, Moran E, Symyth H, Carroll K,
Thornes RA, O’Brien A, Fennelly J, Butler M. A
critical analysis of the use of sialic acid determination
in the diagnosis of malignancy. Cancer Lett 1991;
58:91-100.
19. Shamberger RJ. Serum sialic acid in normals and in
cancer patients. J Clin Chem Clin Biochem 1984;
22:647-51.
20. Voigtmann R, Pokorny J, Meinshausen A. Evaluation
and limitations of the lipid-associated sialic acid jest
for the detection of human cancer. Cancer 1989; 64:
2279-83.
21. Bhargava AM, O’Donnell T, Birl PP, Greco JE.
Plasma lipid bound sialic acid (LSA) in cancer and
non-cancer patients. Clin Chem 1984; 30(6):940.
22. Van Dijk W, Pos O, Van der stell ME, Moshage HJ,
Yap SH, Dente L. Baumann P. Inflammation-induced
changes in expression and glycosylation of genetic
variants of α1-acid glycoprotein. Studies with human
sera, primary cultures of human hepatorytes and
transgenic mice. Biochem J 1991; 276:343-7.
23. Kanan A, Sultherland DR, Fibach E, Matta KL.
Human leukemic myeloblasts and myleoblastoid cells
contain the enzyme cytidine 5-monnphosphate-Nacetylenuraminic acid-Gal Bt 3 Ga LNA α(2-3)sialytransferase. Cancer Res 1990; 50-5003-7.
REFERENCES
1. Crook MA, Couchman S, Tutt P. Plasma fibrinogen
and its relationship to plasma sialic acid in non-insulin
dependent diabetes mellitus. Blood Coagul
Fibrinolysis 1996; 7: 586-9.
2. Yogeeswaran G. Cell surface glycolipids and
glycoproteins in malignant transformation. Adv
Cancer Res 1983; 38:289-350.
3. Schauer R, Kelm S, Reuter G, Roggentin P, Show L.
Biochemistry and role of sialic acid. New York,
plenum publishing Corp; 1995; PP: 67-75.
4. Katopodis N. Lipid-associated sialic acid for detection
of human Cancer. Cancer Res 1982; 42: 5270-2.
5. Fleisher M, Dnistrain AM, Sturgeon CM, Lamer ZR,
Wittliff JL. Practice guidelines and recommendations
for use of tumor markers in the clinic. In. Diamandis
EP, Fritsche HA, Lilja H, Chan DW, Schwartz MK,
editors. Tumor marker: physiology pathobiology,
technology, and clinical applications. Washington,
DC: AACC press; 2002.P.33-63.
6. Sillanaukee P, Ponnio M, Jaa Skeloinen IP. Occurrence
of sialic acid in healthy humans and different disorder.
Eur J Clin Investing 1999; 29:413-25.
7. Dogan H, Passoglu H, Ekinciler Tatlisen N. A
comparatire study o total protein and total lipid
associated serum sialic acid level in patients with
Behcet’s disease and control groups. Acta Ophthalmol
1992; 790-7.
8. Kalea A, Ponnio M, Kovivu TA, NiKKar ST.
Association of sialic acid and metalloproteinase-9
with lipid inflammatory marker in heart disease. Eur J
Clin Invest Res 2000; 30 (12):99-104.
9. Ponnio M. Serum and saliva sialic acid in alcoholic.
Alcohol Clin Exp Res 1999; 23(6): 1060-4.
10. Nikkar ST. Serum cholesterol among membrane of the
finish parliament. Prev Med 1999; 28(13): 260-3.
11. Croke. BJ. Biomed Sci. 1996; 53(3):85-6.
12. Katopoids N, Hirshout Y, Stock C. Spectroscopic
assay of total lipid sialic acid in plasma of cancer
patients and healthy individual. Proc Am Assoc
Cancer Res 1982; 21:182.
13. Schauer R. Achievements and challenges of sialic acid
research. Glycoconj. J 2000; 17:485-99.
14. Crook MA, Couchman S, Tuttp. Plasma fibrinogen
and its relationship to plasma sialic acid in noninsulin-dependent diabetes mellitus. Blood Coagul
Fibinolysis 1996; 7:586-9.
Oral Diagnosis
24. Brockhausen I, Yang JM, Burchell, Whitehouse C,
Toylar PJ. Mechanisms underlying aberrant
glycosylation of MUCI mucin in breast cancer. Eur J
Biochem 1995; 233:607-17.
25. Plucinsky MC, Riley WM, Prorok JJ, Alhadeff JA.
Total and lipid associated serum sialic acid levels in
Cancer patients with different primary sites and
differing degrees of metastatic involvement. Cancer
1986; 58:2680-5.
30
Vol. 20(1), 2008
Oral findings and health…
Oral findings and health status among elderly Iraqi
patients (aged 65 and above)
Fawaz Al-Aswad B.D.S., M.Sc., Ph.D (1)
ABSTRACT
Background: The study hypothesis was that elderly patients with many concomitant disease and drugs would have
different oral diseases, thus epidemiological information about their oral health is urgently needed in geriatric dental
care for diagnosis treatment and prevention.
Objective: To obtain base line information on the prevalence of oral problems and disease in elderly Iraqi patients.
Materials & Method: The study group consisted of 83 (43 males and 40 females) elderly patients, they were examined
to evaluate the oral health status.
Result: of 83 patients who verbalized their complaints 72% complained of dry mouth, 42% had burning mouth
syndrome and 48% had oral mucosal lesion. The commonest oral finding was denture stomatitis 30%.
Conclusion: These data suggest that there was considerable unmet dental need with significant oral disease in this
target group.
Key words: Denture stomatitis, Candidosis, elderly patients. (J Bagh Coll Dentistry 2008; 20(1) 31-33)
INTRODUCTION
Another survey conducted in 1993 on 3479
elderly found that 93 percent of edentulous had
oral problem and 61 percent of the dentate had oral
problem. (15) Gift (16), reported that only 15 percent
of the residents of nursing home survey were
described as having excellent or very good oral
health, while other study reported that
approximately one third of community dwelling
elderly have untreated coronal or root caries and
other oral health problems including periodontal
disease, attrition, un replaced missing teeth,
abrasion and erosion.(17) Other reports give
evidence that more than 45.9% of elderly patients
had one or more oral mucosal lesion (18)
Therefore, the present study was conducted
since no extensive studies have been made in Iraq
to obtain information on the oral status conditions
among elderly patients and to investigate the
relationship between the finding in relation to age
and gender.
Geriatric dentistry is a branch of dentistry
concerned with dental care for aging populations.
The frail elderly need a special care because they
suffer from extensive oral disease, have medical
problems that complicate the oral health, and also
because their age and state of health complicate
their diagnosis and treatment (1). In addition older
patients are less likely than younger patients to
report symptom complaints, and often they are
completely unaware of pathology that would
create dramatic symptoms in younger patients. In
one study of older adults, more than half of 20
potentially serious medical systems were never
reported to health professional (2).
Systemic disease may directly or indirectly
harm the oral cavity by altering saliva, which
play an essential protective role in the mouth (3),
or by the side effect of the medication (4). On the
other hand, a number of significant age related
changes occurred, fortunately most of these
normal aging changes do not cause oral disease
(5,6)
, instead it is the cumulative effects of both
oral and systemic disease that account for the
extensive pattern of oral disease among the
elderly (7,8).
During the last decade several studies were
done to determine the oral conditions of the older
adults (9-13). Berkey (14), in a comprehensive
review of oral health studies of elderly published
between 1970 and 1989 described the
compromised oral health status of nursing home
residents.
Up to 70 percent of residents had unmet oral
(decay), poor oral hygiene, periodontal disease
and soft tissue lesion.
The sample
The study sample consisted of 83 patients of
both genders with age range from 65–80 referred
to the college of dentistry, university of Baghdad,
from November 2005 to June 2006, they were
examined to detect the oral health status including
the complaining of dry mouth, Burning mouth
syndrome and oral mucosa lesions.
The following questions have been shown to
help to identify people with, or at risk of
developing salivary gland hypofunction:
- Dose the amount of saliva in your mouth seems
to be little, too much or you do not notice it?
- Do you have any difficulties during swallowing?
- Does your mouth feel dry when eating a meal?
(1) Lecturer, Department of Oral Diagnosis, College of
Dentistry, University of Baghdad.
Oral Diagnosis
31
Vol. 20(1), 2008
- Do you slip liquids to aid in swallowing dry
food? (19).
Table 3: distribution of the sample according
to the OML
Male
N=43
n %
Denture stomatitis 11 25.5
1 2.3
Herptic infection
0 0.0
Candidosis
3 6.9
Trumatic ulcer
0 0.0
Actnic cheilites
1 2.3
Leukoplakia
Denture hyperplasia 0 00
16 37.2
Total
∗∗
H.S
RESULTS
Type of lesion
The sample consisted of 83 patients, and they
were 43 (51.8%) males and 40 (48.1%) females.
The mean age of the total sample 71.1 years, the
mean age for males was 71.1 and for females
71.5 years. Table 1 shows the age distribution by
gender of the total sample.
Oral complain
Hyposalivation was the main oral symptom
observed in both genders 60 patients (72%), with
a statistically significant difference between
males and females, burning sensation observed in
35 patients (42%). On application of chi–square,
there was a significant difference when males
compared to females (table 2).
Oral mucosal lesions (O.M.Ls)
Clinical examination revealed that 48% of total
elderly people have (O.M.Ls) the most common
lesions observed was denture stomatitis and the
prevalence of total (O.M.Ls) was higher for
women than men, with a highly significant
difference (table 3)
Table 1: Age and gender distribution of the
sample
Male Female Total
N=43
N=40
N=83
Age group
65 – 70
70 – 75
75 – 80
Total
n
20
7
16
43
%
46.5
16.3
37.2
100
n
15
20
5
40
%
37.5
50.0
12.5
100
n
35
27
21
83
∗
∗∗
Chi – square=8.086 P= 0.04, P< 005 significant.
Chi – square=6.556 P< 0.001. Highly significant
DISCUSSION
Information on the oral health of elderly
population in a number of countries is available
but, no data is available or published on the elderly
population of Iraq.
Hyposalivation a very common symptom
seems to be related to polyuria and the
involvement of the parenchyma of the major
salivary gland (19). This study showed that the
hyposalivation is the major complaint in elderly,
which may occur because older subjects may have
chronic medical conditions or due to medication.
Such a result is within the agreement of the results
obtained from other studies.(20-25)
The result showed that 42% of the elderly
patients complain of BMS, however this finding is
higher than that reported by Pajukoski and (26) and
Berydahl (27) who presented the prevalence rate of
15% and 12.2% respectively. Our explanation for
that is, those elderly people may ignore their oral
health and loss their appetite which led to poor diet
and malnutrition, and because post menopausal
hormonal changes may add to the existing
problem.
On the other hand, studies carried by Moskona
(28)
, showed that the most frequent complaint was
pain associated with wear of denture, and other
studies showed that dental caries is the most
significant problem facing older patients (29-31).
The overall prevalence of O.M.Ls was 48%,
which does not reflect its real prevalence among
Iraqi elderly due to unrepresentativeness, however
it could be used as a preliminary indicator to
%
42.2
32.5
25.3
100
Table 2: Distribution of the sample
according to the oral complain
Male
N=43
Female
N=40
n %
14 35.0
2 5.00
2 5.00
2 5.00
2 5.00
0 0.00
2 5.00
24 60.0
Traumatic ulceration was observed in relation
to the poor conditions of denture in 5 cases and 2
cases of actinic cheilities were diagnosed.
Proliferative lesions were observed in 2 cases
represented by fibrous hyperplasia (confirmed by
biopsy) associated to the use of prostheses
. Only 2 cases of candidosis which was
pseudo– membranous type were not related to the
use of prosthesis. Three cases of herpetic
infection were detected on the maxillary lip,
without any recent history of this infection by
other patients of both groups.
Female
N=40
n % n %
Hyposalivation
N=60 (72%) 37 61.7 23 38.3
BMS
11 31.4 24 68.6
N=35 (42%)
S∗
Oral Diagnosis
32
Vol. 20(1), 2008
13. Shah N. Need for gerodontology education.
Gerodontobgy 2005; Jun: 22: 2: 104–5.
14. Berkey DB, Bery RG, Ethinger RL, Meskin LH.
Research review of oral health status and service use
among institutionalized older adults in the United
States and Canada. Spec Care Dentist 1991; 11: 131–6.
15. Beck JD, Hunt RJ. Oral health status in the United
States, problems of special patients. J Dent Educ 1985;
49: 6: 407–25.
16. Gift Hc, Cherry–Peppers G, Oldakowski RJ. Oral
health status and related behaviors of nursing home
residents. Gerodentolgy 1995; 1997: 14: 98-9.
17. Centers for Disease control and prevention, National
center for Health statistics. Third national health and
nutrition examination survey (1988 -1994). Available at
http//www.cdc.gov/nchs/abuntmajor/nhanes/nh3data.htm. Accessed March 26,2001.
18. Avcu N, Ozbek M, Kurtoglu E, Kansu O, Kansu H.
Oral finding and health status among hospitalized
patients with physical disabilities, aged 60 or above.
Arch Gerontol Geriatr 2005; Jul–Aug: 41:1: 69–79.
19. Mahvash NAVAZesh. How can oral health care
providers determine if patients have dry mouth? J Am
Dent Assoc 134: 5: 613–8.
20. Locker D, Matear D, Stephens M, Jokoris A. Oral
health related quality of life of a population of
medically compromised elderly people. Community
Dent Health 2002; Jun: 19: 2: 90–7.
21. Chiqppelli F, Bauer J, Speckman S, Prolo P, Edgoton
M, Armenian C, Dickmoyer J, Harper S. Dental needs
of the elderly in the 21st century.
22. Pajukoski H, Meurman JH, Snellman Grohn S,
Keiranen S, Sulkava R. Salivary flow and composition
in elderly patients referred to an acute care. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1997; Sep:
83: 3: 265–71.
23. Locker D. Xerostomia in older adults; a longitudinal
study. Gerodontology 1995; June: 12: 1: 18–25.
24. Narhi TO. Prevalence of subjective feelings of dry
mouth in the elderly. J Dent Res 1994; Jan: 73: 1: 20–5.
25. Rhodus NL, Brown J. The association of Xerostomia
and inadequate intake in older adults. J Am Diet Assoc
1990; Dec: 90: 12: 1688–92.
26. Pajukoski H, Meurman JH, Halunen P, Sulkave R.
Prevalence of subjective dry mouth and burning mouth
in hospitalized elderly patients and out patients in
relation to saliva, medication, and systemic disease.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2001; 92: 641-9.
27. Berydahl M, Bergdahl J. Burning mouth syndrome:
Prevalence and associated factors. J Oral Pathol Med
1999; Sep: 28: 8: 350–4.
28. Moskona D, Kaplan I. Oral health and treatment needs
in non–institutionalized elderly population: experience
of a dental school associated geriatric clinic.
Gerodontology 1995; Dec: 12: 12: 95–8.
29. Saunders RH Jr, Meyerowitz C. Dental Caries in older
adults. Dent Clin North Am 2005; Apr: 49: 2: 293–308.
30. Anusavice KJ. Dental Caries: Risk assessment and
treatment solutions for an elderly population. Compend
Contin Educ Dent 2002; Oct: 23: (10 Suppl): 10–20.
31. Ra OA, Sequeira P, Peter SR, Jeev A. Oral health
status of the institutionalized elderly in Mangalora,
India. J Dent Res 1999; Ap–Jun: 10: 2: 55-61.
32. Taiyeb ALi, Razak IA, Raga Latifah RJ, Zain RB. An
eqidemiological survey of oral mucosal lesions among
elderly. Gerodontology 1995; Jul: 12.
present time. This finding was slightly higher
that reported by (17) they reported that 45% of
elderly have (O.M.Ls).
The main lesion observed was denture
stomititis, while other studies showed that the
varicosities of the tongue and Fordyce granules
were mostly found (32).
This variation in the results between the
present study and the studies done by others
could be explained on the basis of several factors
like: (Environmental factors affecting the
population examined, diet, habit of using dental
services, and lack of objective diagnostic
criteria.). Our result explained that denture
wearing may contribute in initiation of the
lesions or the denture may alter the host
response.
In a logistic regression, there was
considerable unmet dental need with significant
oral disease and poor levels of oral and denture
hygiene in this target group.
REFERENCES
1. Beak JD, Hunt RJ. Oral health status in the United
States: problems of special patients. J Dent Educ
1985; 49: 6:407– 25.
2. Gaitz CM, Niederehe G, Wisons NL. Aging 2000:
our health care dentistry. Vol. ll. New York:
Springer. Verlag 1985: 370–80.
3. Mandel ID. The role of saliva in maintaining oral
dental status. J Am Dent 1989; 119: 298–304.
4. Ship JA, Chaves FM. Management of systemic
disease and chronic impairments in older adults: oral
health consideration. Ger Dent 2000; 48: 5: 557–8.
5. Baum BJ, Ship. Oral disorder. In beck J, editor.
Geriatrics review syllabus–A core curriculum in
geriatric medicine. New York; American Geriatrics
society 1991; P. 332–6.
6. Beck, JD. Epidemiology of dental diseases in elderly.
Gerodontology 1984; 3: 5–15.
7. Morse DR, Esposito Jv, Schoor Rs, Wolloams FL,
Furst ML, A review of aging of dental components
and retrospective radiographic study of aging of the
dental pulp and dentin normal health. Quintessence
Int 1991; 22: 711.
8. Kochari D, Gedalia I, Anois J. Effect of conditioning
with fluoride and phosphoric acid on enamel surfaces
as evaluated by scanning electron microscopy and
fluoride incorporation. J Dent Res 1975; 4: 304.
9. Pedersen H, vigild P, Nitschke M, Berley I. Dental
care for aging populations in Denmark, Sweden,
Norway, United Kingdom and Germany. J Dent Educ
2005; sep: 69: 9: 987–97.
10. Doln TA, Tchison K, Huynh TN. Access to dental
care among older adults in the United States. J Dent
Educ 2005; Sep: 69: 9: 961–74.
11. Bailey R, Gueldner S, Ledikwe J, Smiciklas WH. The
oral health of older adult an interdisciplinary
mandate. J Gerontol Nurs 2005; Jul: 31: 7: 11–7.
12. Locker D, Gibson B. Discrepancies between self–
ratings of and satisfaction with oral health in two
older adult populations. Community Dent Oral
Epidemiol 2005; Aug: 33: 4: 280–8.
Oral Diagnosis
33
Vol. 20(1), 2008
Prevalence of trigeminal…
Prevalence of trigeminal neuralgia among patients with
orofacial pain
Taghreed F. Zaidan B.D.S., M.Sc., Ph.D. (1)
ABSTRACT
Back ground: The great majority of patients complaining of pain in and about the face are suffering from some form
of toothache. However, there are many other possible causes of such pain. Trigeminal nerve is the main sensory
nerve supplying the skin of the face and scalp as well as the majority of the oral tissues and many deeper structures.
The aim of this study was to find the prevalence of trigeminal neuralgia among orofacial pain patients.
Materials and Methods: One hundred and ninety seven patients with orofacial pain (111 females and 86 males)
between the age 15-65 years were examined. Each patient was subjected to a questionainer. Some patients
needed x-ray (intra or extra oral radiographs) in order to reach the diagnosis.
Results: The highest number of patients with orofacial pain was that of dental origin (pulpal and periodontal), about
28.5%, next to it was patients with TMJ disorder or myofacial pain 25.5%. Patients with trigeminal neuralgia were 16.3%.
Patients with migraine were 8.6%. Patients with sinusitis were 8.1%. Patients with otitis media were 5.1%, also patients
with a typical facial pain were 5.1%. Finally patients with cluster headache were 3%. The majority of those patients
were of pain on the right side of the face more than the left side. The trigger zones were more frequently occurring
intra orally mainly at the premolar and molar areas (43.7%), trigger zones at the upper lip were in 18.7% of patients
while at the angle of the mouth in 15.5% of the patients, in the cheek 12.5%, and finally at the preauricular area was
9.3%.
Conclusions: The highest number of patients with orofacial pain was of dental origin (pulpal and periodontal), and
TMJ disorder or myofacial pain. The prevalence of trigeminal neuralgia was 16.3% of the patients.
Keywords: Orofacial pain, Trigeminal neuralgia, Dental pain. (J Bagh Coll Dentistry 2008; 20(1)34-36)
INTRODUCTION
Pain attacks start abruptly and last several
seconds but may persist 1 to 2 minutes (7, 8). The
attacks are initiated by non painful physical
stimulation of specific areas (trigger points or
zones) that are located ipsilateral to the pain. After
each episode, there is usually a refractive period
during which stimulation of the trigger zone will
not induce the pain (1, 9). The frequency of attacks
depends on the sensitivity and localization of the
trigger area.
Pain attacks are typically accompanied by ticlike cramps of the facial muscles, therefore the
description "tic douloureux". A tic is an
involuntary contraction or spasm of muscles (8).
Pain is an unpleasant sensory and emotional
experience, and it is always subjective. The
majority of patients complaining of pain in the
orofacial region have an identifiable physical
cause for their pain. (1) To make definitive
diagnosis, it is often necessary to establish a list of
possible differential diagnosis and then to
systematically exclude each by a process of
elimination through diagnostic tests and
investigations (2).
Differentiating between the disorders usually
can be facilitated by determining the location,
stimulus, and characteristics of the pain.
Knowledge of the age and sex predilections of
each disorder can also be helpful (2).
Facial pain or headache may be caused by
toothache (3), but in turn, it can also be mimicked
by several forms of disorders, myofacial pain,
TMJ disorder, migraine, cluster headache, a
typical facial pain and trigeminal neuralgia (4,5), or
may be due to otolaryngologic disease (6).
Trigeminal neuralgia is the most common
type of neuralgia, and it is limited to the
distribution of one or more branches of the
trigeminal nerve (5th C. N.). It is characterized by
unilateral pain attacks, sharp, shooting,
lancinating, electric shock-like, burning and
excruciating.
One hundred and ninety seven patients (111
females and 86 males) between the age of 15-65
years, each with a chief complain of orofacial pain
were examined at the oral medicine clinic, college
of dentistry, University of Baghdad. Samples
were collected in the period from September 1999
to January 2000. Dental history was taken from
each patient; also medical history, history of any
systemic disease, and drug consumption and dose
was taken.
Each patient was required to answer questions
that are important in the differential diagnosis of
this orofacial pain.
These questions are:
1. Location of pain.
2. Behavior: constant, intermittent.
(1) Assist. Professor, Department of Oral Diagnosis, College of
Oral Diagnosis
34
Vol. 20(1), 2008
3. Quality: sharp, dull, throbbing, pricking,
itching, burning, .etc.
4. Severity according to type and dose of
analgesic and does it interfere with sleep?
5. Onset.
6. Duration
7. Intensifying and relieving factors.
8. Area to which pain spreads.
9. Does this pain associated with or preceded
by other symptoms like, nausea, vomiting,
nasal stiffness, visual disturbances…etc.
Intra oral examination was done for each
patient for the presence of caries, gingivitis,
periodontitis, presence of dental filling, etc, using
dental mirror, probe, pair of tweezers and dental
light. Extra oral examination was done for each
patient for the presence of facial swelling,
asymmetry of face, palpable lymph node and
others. TMJ was examined and all muscles of
mastication for tenderness in order to differentiate
between facial pain of dental origin and facial
pain due to TMJ disorder or myofacial pain.
Some patients need intra oral x-ray films
(periapical and occlusal), which aid in diagnosis
specially for patients with orofacial pain of dental
origin, others need an extra oral x-ray films for
TMJ disorders or in case of patients with sinusitis
who needs occipito mental x-ray (waters view).
Women were affected more than men and the
patients with trigeminal neuralgia were of old age.
Also the right side of the face was more
frequently affected than the left side, (19 patients
with pain in the right side of the face and 13
patients in the left side).
Regarding the trigger zones of trigeminal
neuralgia, it usually occurs in the areas of the
distribution of the trigeminal nerve. About 43.7%
of those patients, their trigger zones were intra
orally in the premolar areas (21.8%) and in the
molar areas were 21.8%. Six patients (18.21%)
with trigger zones in the upper lips, five patients
(15.5%) with trigger zones in the angle of the
mouth area, four patients (12.5%) with trigger
zones in the cheek and three patients (9.3%) with
trigger zones at the preauricular region as shown
in tab. 2, so large number of patients with
trigeminal neuralgia with a trigger zones area that
occur intra orally.
Table 1: Major disorders that may involve
facial pain.
Origin
Oral
Musculo
Skeletal
ENTrelated
In this study one hundred and ninety seven
patients (111 females and 86 males) between the
age 15-65 years with mean age of 35-55 years
with orofacial pain, were examined in order to
differentiate their pain. The results of this study
revealed that this orofacial pain was classified
according to it's origin into different disorders.
Patient with trigeminal neuralgia were 32, while
patient with orofacial pain of dental origin
(pulpal, periodontal) were 56, patients of musculo
skeletal origin, TMJ disorder and myofacial pain
were 50, patients with ENT origin pain, (sinusitis
and otitis media were 26 patients (sinusitis were
16 and with otitis media were 10), patients of
vascular origin pain, migraine headache were 17
patients and cluster headache were 6, and finally
patient of psychogenic origin pain (patients with
atypical facial pain) were 10 as shown in table 1
and figure 1, so the highest number of patients
was those patients with orofacial pain of dental
origin, next to it was patients with TMJ disorder
and myofacial pain.
Thirty two patients (16.3%) were diagnosed
as cases of trigeminal neuralgia. They were 20
females and 12 males. The age range of those
patients was 38-65 years with mean age of 47.55
years for females and 51.1 years for males.
Number
%
of patients
Disorder
Neural
RESULTS
Oral Diagnosis
Vascular
Trigeminal
Neuralgia
Dental
(pulpal, periodontal)
TMJ disorders
Myofacial pain
Otitis media
Sinusitis
Migraine
Cluster headache
PsychoGenic
Typical facial pain
32
16.3
56
28.5
50
25.5
10
16
17
6
5
8.1
8.6
3
10
5
60
56
50
40
32
30
16
17
20
6
Migraine
Sinusitis
Otitis
TMJ dis.
Dental(p.p)
0
10
A typical fac.
10
10
Cluster
No. of patients
50
Trigeminal
Disorder
Figure 1: Number of patients with facial pain
with different disorder
35
Vol. 20(1), 2008
males. The age range was 38-65 years with mean
age of 47.5 years. So the incidence of trigeminal
neuralgia was higher in women and increases with
aging also the right side of the face was more
affected than the left side and it is similar to the
results of other investigators who found that
trigeminal neuralgia occurs more frequently in
women (3:2), and onset usually is about the fifth
decade of life (14-16).
Table 2: Distribution of trigger zones among
patients with trigeminal neuralgia.
Number
of patients
6
Upper lip
5
Angle of the mouth
4
Cheek
7
Upper premolar area
7
Upper molar area
3
Pre auricular area
Trigger zones area
%
18.7
15.5
12.5
21.8
21.8
9.3
REFERENCES
1.
2.
DISCUSSION
It is not unusual for a patient to report to a
dental practitioner with orofacial pain of unclear
origin. Without a thorough diagnosis or in the
absence of conclusive findings, a dental
practitioner may be prone to treat the pain as
odontogenic. There are several symptoms of
trigeminal neuralgia that can be mimicked by
odontogenic pain. The presence of trigger points
for trigeminal neuralgia is very important for
differentiation. These trigger zones may occur
intraorally and results in sharp, unilateral,
shooting pain or may occur extraorally. In
addition it is important to remember that other
pathologic entities may result in facial pain. These
include vascular headaches, myofacial pain, and
local disease of the paranasal sinuses, teeth, jaws,
or pharynx (10-12).
In this study the number of patients with
orofacial pain of dental origin (pulpal,
periodontal) was the highest. The next was
patients with TMJ disorder and myofacial pain.
Headache, facial pain, and toothache are
poorly localized and irradiated in distant areas.
Thus toothache often causes facial pain and
headache. (4)
Facial pain of dental etiology is extremely
variable. It may occur as a dull ache or an extreme
lancinating pain. The pain may be constant or
intermittent, spontaneous or brought on by
mastication, percussion, hot, cold, sweet, or air.
The next after facial pain of dental origin was the
orofacial pain of TMJ disorder or myofacial pain.
This pain is due to spasm of the muscles of
mastication and facial muscles which cause sever
facial pain mainly unilateral pain which is
difficult to be differentiated from other disorders
that causes facial pain.
Other investigators found that most of forms
of facial pain remain of neurologic disorder (13).
The prevalence of trigeminal neuralgia among
those patients with orofacial pain was 16.3%, (32
patients). Those patients were 20 females and 12
Oral Diagnosis
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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Lynch, MA, Brightman JV, Greenberg MS.
Burket; Oral medicine, diagnosis & treatment, 9th,
J. B. Lippincott, Philadelphia; 1994; P. 325.
Bell,
WE.
Clinical
management
of
tempromandibulor disorders. Spring field. I1: Year
book medical publishers; 1982; P. 177-89.
Law AS, Lilly JP. Trigeminal neuralgia mimicking
odontogenic pain. JO Surg O Med O Path 1995;
80: 96-100.
Palla S. Headache and teeth, Ther-Umsch; 1997;
54(2): 78-93.
Turp JC, Gobett JP. Trigeminal neuralgia versus
atypical facial pain. J O Surg O Med O Path 1996;
81: 424-32.
Cosenza MJJ. Am Osteopath associ 2000; 100(9):
522-6.
Burchiet KJ, Slavin KV. On the natural history of
trigeminal neuralgia. Neurosurg 2000; 46(1): 1524.
Siegfned J. Trigeminal neuralgia and other facial
pain-diagnosis and therapy. Therumsh 1997;
54(2): 83-6.
Neville BW, Damm DD, Allen CM, Bouquot JE.
Oral and maxillofacial pathology. WB Saunders
Company, Philadelphia; 1995: P 628.
Loeser, JD. Tic douloureux and atypical face pain.
Text book of Pain. Churchill Livingstone. 1999; P.
699-710.
Solomon S, Lipton RB. Facial pain. Neurol Clin
1990; 8: 913.
Kennedy DW, Loury MC. Nasal and sinus pain:
current diagnosis and treatment. Semin neurol
1988; 8: 303.
Preul MC. Historical consideration of the
diagnosis and treatment of facial pain. Neurosurg
Clin N Am 2001; 12(1): 111-26.
Katusic S, Beard CM, Bergstralh EK. Incidence
and clinical features of trigeminal neuralgia. Ann
Neurol 1990; 27: 89-95.
Merskey H, Bogduk N. Classification of chronic
pain. 2nd ed, Seattle, IASP press; 1994. P. 59-60.
Tuniper RP, Glynn CJ. The association between
paroxysmal trigeminal neuralgia and a typical
facial pain. Br J Oral Maxillo facial surg 1999;
37(6): 444-7.
J Bagh Coll Dentistry
Vol. 20(1), 2008
Periodontal treatment…
Periodontal treatment with combined: mechanical therapy
plus low-energy laser irradiation compared to scaling and
root planning. A clinical and microbiological spilt mouth
study.
Khulood A. Al-Safi B.D.S., M.Sc., Ph.D. (1)
ABSTRACT:
Background: The present study is aimed to describe a six- mouths result on selected microbiological and clinical
parameters obtained by subgingival debridement in periodontitis.
Material and Methods: Thirty patients with moderate to advanced periodontal destruction were treated under local
anesthesia and the quadrants were randomly allocated in a spilt-mouth design to receive one of 2 types of
treatment procedure: 1- Scaling and root planning (SRP) using hand instrument, and 2- Scaling and root planning
(SRP) and then irradiated with (Ga As) infrared diode laser. The selected teeth were assessed for microbiological and
clinical variables. Clinical measurements of plague index (PI), gingival index (GI), bleeding on probing (BOP), probing
depth (PD) gingival recession (GR) and clinical attachment level (CAL) were made prior to and at 3 and 6months
after treatment. Subgingival plague samples were taken at each appointment and analyzed using dark field
microscopy for the presence of cocci, non-motile rods, and spirochetes. Differences in clinical parameters and
prevalence of bacterial species were analyzed using the paired t-test.
Result: The mean value of BOP decreased in the laser group (SRP/L) from 59% at baseline to 20% after 6 month (P<
0.001) and in SRP group from 55% at baseline to 25% after 6 months (p<0.001). The mean value of PD decreased in
the laser group from 5.0 0‫ﺯ‬7± mm at baseline to 2.9 0.6± mm after 6 months (P < 0.001) and in SRP group from 5.0 to
0.6 mm at baseline to ± 3.3 0. after 6 months (p<0.001). The mean value of the CAL decreased in the laser group from
6.8± 1.0 mm at baseline to 4.5±1.0 mm after 6 months (P < 0.001) and in the SRP group from 6.9 1.0± mm at baseline to
5.4 1.0± after 6 months (P.(0.001>The reduction of the BOP score and the CAL improvement was significantly higher in
the laser group than in the SRP group (P<0.05، P<0.001, respectively). Both groups showed a significant increase of
cocci and non-motile rods and a decrease in the amount of motile rods and spirochetes.
Conclusions: With in the limits of this study soft laser therapy provided additional microbiological and clinical benefits
over conventional mechanical debridement.
Key words: Low energy laser, scaling, periodontal root planning. (J Bagh Coll Dentistry 2008; 20(1) 37-44)
INTRODUCTION
The high energy lasers (Nd: YAG neodymimdoped: yttrium, aluminum, and garnet) and C02
lasers are limited due to their thermal side effects
(1,2)
whereas the low energy lasers Er:YAG
(eribiumdoped: yttrium, aluminum, and garnet)
and Ga As (gallium arsenide diode laser ) show
efficiency in medical and dental applications
because of its thermomechanical ablation
mechanism and the high absorption of its
wavelength by water (3,4).
Recently, various biostimulatory effects of
low-energy laser irradiation have been reported
and it's possible medical photo-biological and
photo-chemical effect have been investigated by
several researchers، this involves the stimulation
of wound healing (5,6) fibroblast proliferation (7),
collagen synthesis (8) and enhancement of bone
fracture healing (9).
(1) Professor, Department of Periodontics, College of Dentistry,
A primary goal in the treatment of
periodontitis is the removal of bacterial deposits
and halting of the disease progression (10) To
achieve this goal, a complete removal of adherent
plaque, calculus، and infected cementum is
necessary (11). The management of periodontal
disease includes many treatment modalities such
as conventional therapies consisting of surgery
and/or non-surgical methods. In any case, the
purpose of periodontal treatment is to arrest
progressive tissue destruction and to prevent
further attachment loss. (12) Undoubtedly, to
successfully treat periodontitis, we have to find
more effective techniques, surgical as well as nonsurgical, in recent years; the use of laser radiation
has been suggested as an alternative to the
conventional periodontal mechanical therapy. It
was proposed that various advantageous
characteristics inherent in the laser-based root
surface treatment e.g. hemostasis, selective
calculus removal or antibacterial effects, might
lead to improved periodontal therapy. (13-15)
Low power energy laser irradiation produce
biostimulatory effects on cellular proliferation in
Oral and Maxillofacial Surgery and Periodontology 37
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Vol. 20(1), 2008
periodontal ligament (PDL) and alveolar bone
(AB) (enhanced cellularity of PDL and bone
remodeling) (16,17).
The low-power, Ga-As diode laser devices
have been used for experimental and clinical
studies on periodontal treatment, bone formation
and repair (18,19). Today there is considerable
evidence to support scaling and root planning as
one of the most commonly used procedures for
the treatment of periodontal diseases (20). In
searching of more efficient instrumentation, many
investigators have proposed lasers as an
adjunctive and sometimes alternatives, especially
because of their ability to detoxify root surfaces
and ease of use. However, until now no published
data are available concerning the clinical
outcomes following treatment with low-power
Ga-As infra red diode laser when compared to
well established procedures such scaling and root
planning. Therefore the aim of the present study
was to assess the clinical effectiveness of low
energy Ga-As diode laser, after conventional
periodontal therapy (SRP+LR) when compared to
scaling and root planning alone (SRP)
Patient Population
Thirty periodontal patients, aged between 28
to 72 years (mean age 50years), were included in
the study. They were all referred to Periodontal
Department, College of Dentistry, University of
Baghdad، and all participants signed informed
consent forms. Criteria for exclusion from the
study were) periodontal treatment within the last
12 months‫( ( ؛‬systemic diseases which could
influence the outcome of the therapy; 3
pregnancy; or 4) systemic antibiotics within the
last 6 months.
Study Design
The study was performed using a split-mouth
design. A total of 45 maxillary and 30 mandibular
pairs of contra lateral single and multirooted teeth
were included (total 300 sites). Each tooth of each
contra lateral pair exhibited gingival inflammation
with a positive bleeding on probing (BOP),
subgingival calculus and a probing depth (PD)
of>4 mm on at least one aspect of the tooth. In
each contra lateral pair, one tooth was randomly
treated with subgingival scaling and root planning
using hand instrument, while the other tooth was
treated with the same mechanical technique plus
irradiation with (GaAs) infrared diode laser. The
distribution of 2 treatment modalities was equally
divided between the right and left sides. All
patients were treated by the same experienced
operator.
Oral Hygiene Program:
For 4 weeks before treatment all patients were
enrolled in a hygiene program and received oral
hygiene instructions at 2 to 4 appointment as well
as professional tooth cleaning according to
individual needs. A supragingival professional
tooth cleaning was performed at baseline as well
as 3 and 6 months after treatment.
Treatment:
1- The mechanical subgingival instrumentation:
(performed using hand instruments Universal
curettes No. 1/2)
2- Procedure of laser irradiation:
The laser equipment used for this study was
OPTODENT unit which is patented dental for
infrared and laser therapy (CM Scavini C.N.R
physics instue-parma). The OPTODENT unit
presents itself as ideal combination in one single
apparatus of two sections, thus making the system
very versatile in use according to the different
diseases to be treated. Laser irradiation was
administrated locally by placing the end of optical
fiber in intimate contact with the gingival tissues
to prevent reflection of laser beam.
Laser section:
-Gallium arsenide (Ga As) infrared diode laser
-Laser diode peak power:
20 W
-Laser diode average power:
8 mw.
-Average power (in optic fiber):
5 mw.
-Wave length
904nm
-Impulse frequency:
3,000 H2
The laser hand piece was moved manually
along the gingival tissue, during the total time of
laser irradiation procedure which is 10 minutes.
Both groups were treated under local
anesthesia, the instrumentation for both hand
instruments and laser irradiated was performed
until the operator felt that the root surfaces were
adequately debrided and planed.
Clinical Measurements
At the baseline visit and 3 months and 6
months after the last treatment, the following
clinical parameters were measured by one
calibrated periodontist:
- Plaque index (PI) (21)
-Gingival index (GI) (22)
-Probing depth (PD)
-Gingival recession (GR)
-Clinical attachment level (CAL)
-Bleeding
on
probing
was
assessed
simultaneously to the pocket measurements.
Vol. 20(1), 2008
Microbiological Evaluation
The bacterial samples were obtained as
follows:
After
professional
supragingival
tooth
cleaning, a sterile paper point was introduced
through the sulcus as far apically as possible. It
was withdrawn after 30 seconds and then
suspended in a sterile 0.9% sodium chloride
solution. Within 30 minutes, the samples were
evaluated using darkfield microscopy by
classifying cocci, spirochetes, motile and
non-motile rods from 100 to 150 bacteria from
fields selected at random (23).
Statistical Analysis
A software package was used for the statistical
analysis. The paired t-test was used to compare
the mean scores of all investigated clinical
parameters l from the baseline to those after 3
and 6 months for each treatment group.
RESULTS
Clinical Measurements
At the baseline examination, there were no
statistically significant differences in any of
investigated parameters (Table 1,2). Initially the
plaque index was 1.0±0.5 in both groups, at the 3
month examination the plaque scores were
markedly reduced and remained low throughout
the study. No statistically significant difference
was observed between surfaces treated by the 2
methods of instrumentation (Table 1). The
gingival index was significantly reduced in both
treatment groups at the 3 and 6 months
examination compared baseline (P<0.001,
P<0.001، respectively). At the baseline
examination 58% the surfaces in the SRP/LR
group and 56% of the surfaces in SRP group
demonstrated bleeding on probing. Subsequent to
instrumentation,
a
marked
and gradual
improvement of the bleeding scores took place
until 19 % of SRP/LR group and 23% of the SRP
group at the 3 month examination and 15 % of the
SRP/LR group and 22% of SRP group at the 6
month examination was reached a statistically
significant difference could be observed at the 3
months (P<0.05) and the 6 months (P<0.05)
examination between the 2 treatment groups.
Throughout the study, a significant reduction
of the PD and highly significant gain of CAL took
place in both treatment groups (P<0.001). At the
3and 6 month examination the statistical analysis
showed a significant difference for PD (P<0.05,
P<0.001, respectively), CAL (P<0.01، P<0.001
respectively) and GR (P<0.01, P<0.001
respectively) between 2treatment groups (table
2). The effect of both treatments (SRP& SRP/LR)
at different initial probing depths is shown in
figures 1. Initially deeper pockets (>7mm)
showed the greatest changes in PD), CAL, and
GR. Moderately deep pockets (4 to 6mm) showed
moderate improvement, with shallow sites
exhibited the least amount of changes. In
particular, sites with initially deep probing depths
showed more CAL gain, more OR, and deeper
residual PD at baseline and 6 months examination
than sites with initial moderate to shallow PD. In
the SPR/LR group, at 6 months, there was a
means loss of CAL of 0.2 mm for shallow sites, in
contrast to a 0.1mm means gain for moderately
deep sites, and a 3.1 mm means gain for deep
sites. In the SRP group, at 6 months, there was a
mean loss of CAL of 0.6 mm for shallow sites, in
contrast to a 0.7 mm mean gain for moderately
deep sites, and 2.0 mm mean gain for deep sites
(figure2). The difference between 2 groups was
more significant in initially deep pockets
(P<0.001) than in moderate or shallow pockets
(P<0.01, P<0.05 respectively).
Microbiological Evaluation:
Both treatment groups led to a significant
reduction of motile rods and spirochetes and a
significant increase of cocci and non-motile rods
at months (P<0.001) (Figure 4). However, the
total count of the motile rods at the 6 months was
almost identical to the baseline score in both
treatment groups. After 6 months increasing
percentages of spirochetes and decreasing
percentages of cocci and non-motile rods could be
observed in both groups. No significant
differences were observed between the SRP+laser
groups and SRP groups (Figure 4).
DISCUSSION
All investigated parameters such as PI, Gl,
BOP, PD and mean CAL showed a marked
improvement 3 months post-treatment with even
further improvements up to 6 months. The most
obvious changes in the bacterial distribution
occurred in the first 3 months and remained stable
for another 3 months, with the exception of the
motile rods and the spirochetes with slightly
increasing percentages of the total count. These
findings are consistent with results from previous
studies which have shown that the bacterial
recolonization occurs after 3 months (24,25) .
Recently, results from controlled clinical
studies shown that the stability of gained clinical
attachment
following
conventional
and
regenerative periodontal treatment is dependent
upon stringent oral hygiene (26,27). Further more, it
should be pointed out that in the present study, the
Vol. 20(1), 2008
difference between treatment groups was more
significant in deeper pockets than in moderate or
shallow pockets (Figure. 1).
Results from previous studies demonstrated
that subjects with a high percentage of residual
deep pockets (>6 mm) following treatment run a
greater risk of additional attachment loss than
subjects with a small percentage of such residual
pockets (28,29) . In a clinical study evaluating the
clinical assessment of a low-energy laser for soft
tissue surgery and scaling a total of 38 patients
with moderate to advanced periodontitis were
treated (30). Each subject was evaluated on the day
of laser application and after 1, 2 and 3 weeks.
The mean PD was reduced from 5.6± 2.0 mm to
2.6±0.9 mm. These results were statistically and
clinically significant compared to baseline. No
Further details concerning the development of
CAL and GR were given. The obtained mean PD
reduction was higher than that from the present
study. This discrepancy might be explained by
differences in the initial PD. Clinical studies have
demonstrated that the reduction of PD and the
improvement of the CAL after both non-surgical
and surgical periodontal treatment is dependent on
the initial PD ( i.e the greater the initial PD and
CAL, the greater the PD reduction and CAL gain)
(31,32)
. The clinical changes in SRP group were
comparable to those reported in a number of
clinical studies that described the effectiveness of
non-surgical periodontal instrumentation therapy
(20)
.
The moderate increase of gingival recession in
the laser irradiated group may be explained by the
atraumatic use of the fiber tips. Results from
clinical studies have indicated that trauma from
instrumentation may be one reason for an increase
in GR and subsequently, a loss of clinical
attachment following non-surgical periodontal
treatment (28,29). Shallow sites seem to be more
susceptible than deeper sites (Figure 3)
furthermore, it should be pointed out that in the
present study the difference between laser-treated
(SRP/LR) and hand instrumentation without laser
treated (SRP) was much more significant in
deeper pockets than in moderate or shallow
pockets (Figure 1-3).These findings may indicate
that, from a clinical point of view in shallow
pockets, no differences between treatment with
only hard instruments or combined with low-level
laser irradiation can be observed.
Low-energy laser (soft laser) enhanced
cellularity of periodontal ligament and bone
remodeling. GaAs infrared diode laser irradiation
increased proliferative activity of fibroblasts and
osteoblasts as a results of laser biostimulation
effect on these cells (33,34). Low-Power GaAs
diode laser radiation enhanced healing process in
laser treated surgical wound (35,36). So the reason
for the higher CA1 gain measured in the SRP/LR
is probably due to biostimulating effect of GaAs
infrared diode laser irradiation on both fibroblast
and osteoblasts.
The necessity of cementum removal for
accomplishing a successful periodontal therapy is
still controversially discussed in the literature (36)
While some authors consider the removal of the
diseased cementum an important factor for a
successful periodontal therapy, others have
demonstrated the similar histological and clinical
results can be achieved with both, complete
removal of cementum and only polishing of the
root surfaces. Furthermore, the results of a recent
histological study in humans showed that even
periodontal regeneration can be accomplished on
a previously diseased cementum surface, if the
bacterial deposits are mechanically or chemically
removed (36). Thus, it can be anticipated that the
detoxification of the cementum surface seems to
be more important for the outcome of the therapy
than the removal of the entire layer of cementum.
In this context it is important to point to the result
of previous studies which have shown that the
low-power, GaAs diode laser has also high
bactericidal potential (14, 37- 39).
The reason for choosing darkfield microscopy
in the present study was to observe certain
microbiological features that are associated with
healing period, without resorting to extensive
culturing techniques. It is well known that
periodontaly diseased pockets are associated with
a high percentage of spirochetes and motile rods
and a low percentage of cocci and non-motile
rods, while periodontal healthy sites show inverse
relations (23,40). The findings of the present study
have, furthermore, indicated that both therapies
led to significant improvements on the
microbiological level. A lack of correlation
between clinical parameters and the proportions
of spirochetes and motile rods at individual sites
was previously described by other investigators
(41)
. On the other hand, several studies have shown
a clear association between changes in the
proportions of spirochetes and motile rods and
probing depth (42,43).
In conclusion, the results of the present study
indicate that GaAs infrared diode laser irradiation
may represent a suitable adjunctive for) n-surgical
periodontal treatment. Further studies are needed
in order to evaluate the long-term results of this
treatment modality.
Vol. 20(1), 2008
Table 1: Plaque index (PI), Gingival index (GI), and Bleeding on probing (BOP): Mean scores ±
SD, n=30 patients) at baseline and 3 and 6 months.
Baseline 3 month
± SD
± SD P value 6 months P Value
Index/treatment
PI
SRP/LR
SRP
P. value
GI
SRP/LR
SRP
P. Value
BOP
SRP/LR
SRP
P value
0.5± 1.0 0.4± 0.6
0.5± 1.0 0.5 0.7
NS
NS
*
*
0.4± 0.5
0.5± 0.5
*
*
*
2.0± 0.6 0.6±0.6
2.0±0.6 0.7±0.7
NS
NS
~
~
0.3±0.6
0.4±0.7
NS
~
~
~
20%
25%
*
~
~
59%
55%
NS
24%
26%
*
Significance of differences within and between the groups at different time points by t test:
NS P>0.05, *P^0.05 ~ P<0.001.
Table 2: Probing Depth (PD), Gingival Recession (GR), and Clinical attachment (CAL): mean
scores + SD, n=30 patients) at baseline and 3 and 6 months.
Index/treatment
Baseline 3 month
(SD±)
(SD±) P value 6 months P Value
PPD
SRP/ LR
SRP
P value
CAL
SRP/LR
SRP
P value
GR
SRP/LR
SRP
P value
±5.0o.7
0.6±5.0
NS
3.5±0.6
0.7±3.8
+
*
*
2.9 ±0.6
0.7± 3.3
*
*
*
1.0±6.8
1.0±6.9
NS
1.0±5.2
1.1±5.7
~
*
*
4.5±1.0
5.4±1.0
*
*
*
1.4±1.0
1.5±1.0
NS
1.5±0.7
1.9±0.8
~
Ns
*
1.5±0.7
0.8±2.0
*
Ns
*
Significance of differences within and between the groups at different time points by t test
* p<0.0001, +p<0.05 , ~p<0.01.
SRP/L
4.1
3.7
6
> 7 mm
4-6mm
1-3mm
5.8
3
3.8
2.2
SRP/LR
5.8
6
months
months
2
4
3.6
3
> 7 mm
4-6mm
1-3mm
7
5
3.8
7.9
0
9.7
5
0
2.5
0
2
6.3
4
4
mm
6
8
10
0
2
4
6
mm
8
10
12
Figure 1: Plot of mean probing depth at baseline , and 3 and 6 months at sites with initial
probing of 1 - 3, 4 – 6, and > 7mm (n=30 patients).
Vol. 20(1), 2008
5
6
6
1.9
2.6
> 7 mm
4-6mm
5 .7
3.9
2 .8
1-3mm
months
mon ths
2.7
3
3
1.8
5
0
3
2
4
6
> 7 mm
4-6mm
1-3mm
2.3
1. 7
1.6
7. 7
0
0
SRP
2.4
SRP
3 .7
8
1.4
1.3
10
0
mm
1
2
3
mm
6
5.2
5.1
3
5.3
5
2
SRP
7
1.2
6
1.5
> 7 mm
4-6mm
1-3mm
7.7
1.8
3
1.3
0
1.3
1. 4
4
0
2
4
6
mm
8
10
> 7 mm
4-6mm
1-3mm
1.5
1.7
10.6
8.6
0
months
months
Figure 2: Mean clinical attachment level at baseline, and 3 and 6 months at sites with initial
probing depth of 1 - 3 , 4 – 6, and > 7 mm (n=30 patients)
0
12
0.5
1
1.5
2
mm
Figure 3: Plot of mean gingival recession at baseline, and 3 and 6 months at sites with initial
probing depth of 1 - 3 , 4 – 6, and 7 mm (n=30 patients)
SR P Base Line
50%
Laser Base line
L ase r 3 Months
Laser 6 Months
40%
35%
39%
36%
40%
36%
33%
30%
25%
40%
20%
35%
25%
23%
20%
19%
20%
15%
15%
40%
39%
30%
25%
21%
SRP 6 months
45%
45%
40%
45%
SRP 3 months
24%
24%
20%
22% 23%
19%
16%
20%
15%
10%
10%
10%
5%
5%
0%
0%
Cocci
non-motile
rools
motile roods spirochetes
Cocci
non-motile
rools
motile roods spirochetes
Figure 4: Distribution of bacteria at baseline and 3 and 6 months (n=30 patients). Significant
differences within the groups at different time points by t test (*P<0.001 +P<0.01).
Vol. 20(1), 2008
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Vol. 20(1), 2008
Reliability of family history…
Reliability of family history report among relatives of
aggressive periodontitis patients
Alaa O. Ali B.D.S, M.Sc. (1)
Saif S. Saliem B.D.S, M.Sc. (2)
Hala Algobory B.D.S, M.Sc. (3)
ABSTRACT
Background: The aim of this study was to assess the periodontal status among relatives of aggressive periodontitis
(AgP) patients and to evaluate the reliability of the family history report as provided by the proband.
Materals and methods: Fifty AgP patients were identified during 2005/2006 as fulfilling the criteria to be diagnosed as
AgP as outlined in the 1999 international classification system for periodontal disease. These subjects met the clinical
criteria for either localized or generilized AgP.
Results: it was consider that AgP patients should be informed of the genetic nature of their condition and that other
blood relatives could be at risk. The results would suggest that the screening of relatives with a positive family history
could be justified as a standard procedure, but negative family history reports are unlikely to yield significant numbers
of affected relatives and may not be a justifiable use of scarce resources.
Conclusion: The report given by the proband was considered reliable. If the report was positive, it was followed by
diagnosis of periodontitis in 73% of the cases, while if it was negative, periodontitis was absent in 66% of the cases.
Key words: Aggressive periodontitis. (J Bagh Coll Dentistry 2008; 20(1)45-48)
INTRODUCTION
Periodontal disease is wide word disease
which attackes any age at any time; it was two
types of disease, gingivitis and periodontitis.
Early onset periodontitis (EOP) represent a group
of infrequent types of periodontal disease that
have their onset at a young age with rapid
attachment and bone loss which aggregate in
families. The etiology, although unclear, includes
the sum of environmental and genetic factors;
these heritable factors may predispose to altered
inflammatory or immunological processes. (1,2) .
The term EOP is discarded since the term is
too restrictive. It was noted that features of this
form of periodontitis can occur at any age and the
disease is not necessarily confined to individuals
under the arbitrary chosen age of 35 years. The
1999 international workshop for classification of
periodontal diseases and conditions introduced a
new term “aggressive periodontitis” to replace
early onset periodontitis to solve certain
shortcomings to the previous classification (3).
Patients would be diagnosed with AgP they fulfill
the
three
common
criteria
of
rapid
attachment/bone loss, being medically healthy and
the presence of familial aggregation. The stringent
age requirement used previously for early onset
periodontitis is no longer considered to be
essential (3) .
(1) Assistant professor, Department of Periodontics, College of
Dentistry, University of Baghdad
(2) Assistant lecturer, Department of Periodontics, College of
(3) Lecturer, Department of Periodontics, College of Dentistry,
University of Baghdad
Several family studies have indicated that the
prevalence of AgP is disproportionately high
among certain families, where the percentage of
the affected siblings may reach 40-50%. Such a
dramatic familial aggregation of cases indicates
that genetic factors may be important in
susceptibility to AgP (4).
The familial aggregation feature of these
conditions is taken for granted. However if we
examine the literature, we can see that the
percentage of affected relatives of a given
AgP/EOP patients or proband may vary from 8%
in a group of affected Finnish families (5) up to
63% in one Brazilian family (6).These different
results can not only be attributed to differences in
the population, but to differences in the inclusion
criteria, diagnostic criteria, the variable number of
examined relatives and obviously the number of
families included.
In Europe a recent study of one Scottish
Caucasian family with a proband affected by
generalized EOP (7) showed that from the 34
examined relatives, 41% were considered
definitely affected with AgP and further 16%
were probably or possibly affected.
There is still a shortage of more extensive
family studies of AgP in Europe and there is
insufficient data in literature which reflects the
robustness of familial aggregation in AgP. On the
other hand, the diagnosis of a periodontal patient
may be uncertain (between the chronic and the
aggressive form) and the reported family history
may influence the clinician in classifying the
patient one way or the other. However, the
reliability of the report provided by the patient
may often be questionable.
Vol. 20(1), 2008
The aim of this study are firstly to assess the
periodontal conditions of relatives of AgP patients
to ascertain the extent of periodontal breakdown
within affected families and secondly, to assess
reliability of the periodontal family history report
provided by the proband about their relatives.
The college of dentistry/university of
Baghdad is a referee center for subjects, and all
the patients were referred to the department of
periodontics and first seen at a diagnostic clinic.
Fifty AgP patients were identified during
2005/2006 as fulfilling the criteria to be
diagnosed as AgP as outlined in the 1999
international classification system for periodontal
disease (3).These subjects met the clinical criteria
for either localized or generalized AgP (Table 1),
as described in the Consensus Report (8), with the
exception that familial aggregation was not taken
into account. This was because family history was
the factor being considered in this investigation.
All the patients filled out a questionnaire that
included family details, smoking status, medical
status and specific information on signs of
periodontitis for each of their blood relatives. The
patient had to state ‘‘Yes’’ or ‘‘No’’ for the
presence of bleeding gingiva, mobile teeth,
missing teeth or if they knew the blood relative
had ever been diagnosed/treated for periodontal
disease. This information was categorized as a
positive, or negative report on each specific
relative according to the criteria selected (Table
2). If the proband was uncertain about this
information it was classified as dubious. On some
occasions our invitation to the relatives was
declined because of phobia about dentists, being
edentulous, having had previous periodontal
treatment or not being able to attend. At a
screening level, this consisted of an assessment of
oral hygiene and gingival appearance (percentage
of surfaces positive) a full periodontal charting
was recorded including gingival index, probing
depths, attachment level, and recessions and
bleeding on probing at forth points per tooth. The
patient was then sent to the radiology department
to have panoramic radiograph.
Table 1: Diagnostic criteria for probands and relatives, based on the 1999 AAP Classification of
Periodontal Diseases.
Periodontal disease
Localized aggressive
periodontitis
Generalized aggressive
periodontitis
Chronic periodontitis
Gingivitis
Uncertain periodontitis
diagnosis
Edentulous
Healthy periodontium
Diagnostic criteria
Rapid attachment and bone loss in otherwise healthy patients
First molar-incisor presentation with no more than two other teeth affected
At least two permanent teeth affected where at least 1 is a first molar
Lifetime cumulative attachment loss (LCAL) ≥4mm on the affected sites
Rapid attachment and bone loss in otherwise healthy patients
Generalized interproximal attachment loss affecting at least three teeth other
than first molars and incisors
LCAL ≥ 4mm on the affected sites
Amount of attachment and bone loss is in relation to local factors
Most prevalent in adults
Usually slow to moderate progression
Gingival inflammation present, but an absence of significant bone or
attachment loss
Periodontal findings do not fit in any of the aggressive or chronic types of
periodontitis
Patient lost all teeth
Absence of gingival inflammation and attachment/bone loss in a dentate patient
Vol. 20(1), 2008
Table 2: Criteria for categorization of the reported family history, based on the information
provided by the proband on each relative
Patient states
Criteria selected
Relative was diagnosed/treated with periodontal disease or
Positive report
Mobile teeth was present alone or in combination with bleeding gingiva/missing teeth
Relative lost all teeth or
Dubious report Unknown status of the relative or
Bleeding gingiva present alone or in combination with missing teeth
Denial of any sign of periodontal disease or
Negative report
Absence of any sign of periodontal disease but relative may have lost some teeth
RESULTS
Only 20 out of 50 AgP patients had relatives
willing to be examined. This subgroup of 20 AgP
patients will now be termed probands. The mean
age at diagnosis of the proband group was 27.5
year with an age range of 16-45 years. All
probands reported being healthy without any
systemic diseases. The generalized AgP form was
present in 15/20 (75%) and 5/20 (25%) was the
localized AgP of the probands and the
predominant gender was female 17/20 (85%).7/20
(35%) of the probands were current smokers, 6/20
(30%) were former smokers while 7/20 (35%) had
never smoked (Table 3).
The proband group provided family history
report on 101 relatives. Record was gathered for
only 61 of the 101 potentially available first
degree relatives. Sisters and mothers were the
most likely group of relatives to accept our
invitation to attend.
The age range of these relatives at the time of
diagnosis was 16-66 and 40(65.5%) of them were
females. The report previously provided by the
proband about the relatives who were examined
was positive for 15/61 (24.5%), and negative for
33/61 (54.1%) of them (Table 4).
The periodontal status of the 61 examined
relatives described previously was: chronic
periodontitis in 20/61 (32.8%) of the subjects,
gingivitis in 25/61 (41%), healthy periodontium in
10/61 (16.4%) and AgP in 6/61 (9.8%).(table 5)
In the cases where the individual family
history report was either positive or negative
48/61 (78.6%). This was matched to the
subsequent diagnosis of the relative. If they
coincided, the report was considered reliable. This
occurred in 35/48 cases, equivalent to an overall
reliability of 71% when the report was either
positive or negative. Out of the positive reports,
11/15 (73%) were reliable as they were followed
by diagnosis of periodontitis (AgP or chronic).
Out of the negative reports, 22/33 (66%) were
followed by diagnosis of healthy periodontium or
gingivitis (Table 6).
DISCUSSION
The populations examined in this study were
self selected and not random. The probands were
all patients diagnosed by their dentist as having
severe periodontal disease who were referred to a
specialist clinic, where a diagnosis of AgP was
made. The large prevalence of females among the
probands and relatives reflects a greater
willingness for females to attend for
investigations and/or treatment.
Table 3: Comparison of demographic data
between the aggressive periodontitis (AgP)
group and its subgroup the ‘‘Probands’’
AgP
Probands
patients
patients
N
%
N
%
50 100 20 100
Total
16-56 - 16-45 Age range
26
- 27.5 Mean age
30 60 17 85
Femels
20 40
3
15
Males
Generalized AgP 35 70 15 75
15 30
5
25
Loclazied AgP
7
35
Current smokers 15 30
10 20
6
30
Formal smoker
25 50
7
35
Never smoked
Total of reports
101
on relatives
Table 4: Demographic data on the blood
relatives examined.
N
61
Total
61
First degree
40
Females
20
males
15
+ve report
Dubious report 13
33
-ve report
17-66
Age range
%
100
100
65.6
32.8
24.5
21.3
54.1
-
Vol. 20(1), 2008
Table 5: Periodontal diagnosis made for hew
examined blood relatives.
Diagnosis
Localized AgP
Genirilized AgP
Chronic periodontitis
Gingivitis
Healthy periodontium
Total
No.
3
3
20
25
10
61
%
4.9
4.9
32.8
41
16.4
100
Dubious
Negative
Positive
Total
Positive or
negative
positive family history could be justified as a
standard procedure, but negative family history
reports are unlikely to yield significant numbers
of affected relatives and may not be a justifiable
use of scarce resources.
REFERENCES
Table 6: Reliability of the report given by the
proband on the relative: comparison of the
report with the diagnosis made following
examination of the relative (Dx)
Report on
examined relatives N
% of
Matched by
reliability
diagnosis (Dx)
13
33
15
61
22
11
34
66
73
-
48
34
71
Chronic periodontitis was present in 20 out 61
examined relatives. This finding is not similar to
results from other studies such as in hart et al (9),
and Llorente et al (10).
Only 6 out of 61 examined relatives were
diagnosed with AgP. The proportion of AgPaffected subjects among examined relatives in our
study is similar to previously study of Llorente et
al (10), but unlike the reported figures for EOP or
localized juvenile periodontitis in USA. Marazita
et al (4). Possible explanations for the difference
between our relatives affected and the results from
other studies may be the use of different
diagnostic criteria, possible ascertainment bias
(probands and/or relatives), low number of
examined relatives in our study and different
geographical area/ethnicity mix. However, our
AgP relatives is much higher than that reported in
epidemiological studies such as the 0.1% of
localized juvenile periodontitis subjects among a
population of British school children (11).
The good reliability of the family history
report provided by the patients and the low
proportion of AgP cases among examined
relatives in this study, has implications to
planning health care services. We consider that
AgP patients should be informed of the genetic
nature of their condition and that other blood
relatives could be at risk. Our results would
suggest that the screening of relatives with a
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family
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Vol. 20(1), 2008
The effect of smoking…
The effect of smoking on periodontal health status salivary
composition
Lekaa M. Ibrahem B.D.S, M.Sc.(1)
ABSTRACT
Back ground: The purpose of this study was to evaluate the effect of smoking on periodontal status and the salivary
composition.
Materials and Methods: The study groups include 25 healthy subjects, 13 smokers and 12-non-smokers.Periodontal
parameter included PL.I, G.I, CI.S and B.O.P was recorded. Five ml of unstimulated whole saliva was collected before
clinical measurement. Biochemical analysis of salvia was carried out which include thiocyanate, sodium, calcium,
magnesium and potassium.
Results: The smokers exhibited significant difference in mean of PL.I and CI.S (1.47, 1.44) respectively in comparison to
non smoker (1.19, 0.82) respectively. The non smoker exhibited higher percentage of B.O.P (39%) in comparison to
smoker (27%) which is significantly difference. There was no difference in the mean of G.I for smoker in compare to
non smoker (1.21, 1.29) respectively. The biochemical analysis of saliva showed that sodium values were significantly
greater in non smoker (13.89 mEq/I) when compared to smoker (8.99mEq/I). Like wise non smoker exhibited greater
calcium level (7.09 mg/100ml) when compared to smoker (3.43 mg/100ml) and for magnesium was (0,81mEq/I) for
non smoker in comparison with smoker (0,47mEq/I). On contrary smoker showed higher level of thiocyanate and
potassium (1.33 mM , 18.89mEq/I) respectively in comparison with non smoker (0.56 mM, 13.79mEq/I) respectively
Conclusion: Smoker exhibited low level of oral hygiene and greater disease level but reduced calcium, sodium and
magnesium concentration in compare to non smoker
Key words: Smoking, periodontal parameter, saliva and chemistry. (J Bagh Coll Dentistry 2008; 20(1) 49-51)
INTRODUCTION
There is accumulating evidence that smokers
have higher level of periodontal disease than nonsmokers (1-3). A meta analysis of 6 studies has
revealed that the risk for periodontitis in smokers
increases with an odd ratio of 2 .8 (4).Axelsson et
al (5) studied the caries status in a randomized
sample of 1.093 subjects representing periodontal
and different age categories ranging from 35 to 75
years. They found that smoking was significant
risk indicator for tooth loss, attachment loss and
dental caries.
Impairment of the host immune system may
be one factor that explains the higher occurrence
and the severity of periodontitis among cigarette
smokers. Indeed, it has been shown that
polymorph nuclear leukocyte functions such as
chemotaxis, phagocytosis, and oxidative burst are
decreased by substances in cigarette smoke (6, 7),
although over stimulation of salivary neutrophils
has also been reported (8).
Based on the observation that smokers may
present with low level of gingival inflammation, it
has been speculated that the gingival blood flow
in smokers may be less in composition to nonsmokers (9). This would also induce decreased
local host deference.
The effect of smoking on salivary
composition has seldom been studied. MacGregor
and Edgar (10) examined fresh whole saliva in
smokers, who exhibited greater plaque and
calculus formation also had shown elevated
calcium concentration and elevated calcium
phosphate (Ca/ P) ration in plaque. Sew et al (11)
found higher calcium concentration in
periodontitis affected subjects; data were not
available in regard to the effect of smoking on
calcium level in those patients.
MATERIAL AND METHODS
The study group included twenty-five
subjects referred to periodontal department in the
collage of dentistry, Baghdad University, with
rang age 18- 36 years (average 27 years).
Thirteen of the subjects were smokers for at
least four years and not less than 15 cigarettes per
day, while the other twelve subjects were not
smokers or used tobacco in any way for minimum
3 years before the examination. All subjects were
in good general health and were not using any
medications.
The clinical examinations
The following clinical variables were
recorded:- plaque index (PL.I) according to
sinless and Loe 1964 (12), Gingival index (G.I)
according to Loe and silences 1963 (13), Bleeding
on probing B.O.P which was given as the number
of bleeding sites in percentage as a total, and the
simplified calculus index (CI.S) (14)
Vol. 20(1), 2008
Biochemical analysis
Five ml of saliva samples were collected
before clinical measurement usually between 8
a.m and 11 a.m. subjects were instructed not to
consume any food or drink 2 hours before sample
collection. Non-stimulated whole saliva was
collected from the oral cavity where it was
allowed to accumulate at the floor of the mouth
and transferred to a steal glass tube. The
procedure was repeated for approximately 10
minutes. The saliva was stored in small bottles in
deep freezer at temperature-20 oC.
The concentration of salivary thiocyanate was
estimate by using a calorimetric methods (Powell
1945) (15), and the other inorganic institute which
include sodium, potassium calcium and
magnesium were measured by atomic absorption
spectrophotometer.
Statistical analysis
The clinical parameters which include (PL.I,
G.I, CI.S) and biochemical salivary composition
were compared between group (smokers versus
non- smokers) using two- tailed student t. lest. For
the B.O.P, chi-square was used.
RESULT
Periodontal finding
Table 1 showed that the overall mean PL.I for
smoker was 1.47 ±0.70 (mean ± SD) and that for
non- smoker 1.19±0.73. The difference was
statistically significant (p<0.05). On the other
hand, for the gingival status the mean and S.D for
smoker was 1.21±0.66 and 1.29±0.72 for nonsmoker. The difference was not significant
p>0.05. The CI.S for smoker was 1.44 ±0.62 and
for non-smoker was 0.82 ± 0.50 which was
significant (P<0.05).
The percentage of P.0.P for smoker and non
smoker was 27% and 39% respectively (Table 2).
There was significant difference P<0.05.
Biochemical analysis
The mean and SD for the concentration of the
all inorganic constituent of the pooled saliva in
smoker and non-smoker are shown in table .3.
The thiocyanat concentrates was significantly
higher in smoker (1.33±0.21) in comparison to
non smoker (0.56±0.14). Also significant
difference was found in the potassium
concentration for smoker and non smoker
(P<0.05).
The concentration of sodium was higher for
non- smoker (13.86 ±0.08) in comparison to
smoker (8.99±0.35). There was significant
deference between both groups. Like was nonsmoker exhibited 50% greater salivary calcium
level (7.09 ±0.08) compared to (3.43 ±0.06) in
smoke (P< 0.05). The overall salivary magnesium
was relatively low (0.64 m Eq/I). However
smoker exhibited much lower concentration of
magnesium (0.47±0.02) compared to (0.81±0.05)
in non smoker, which was statistically significant
p<0.05.
Table 1: The mean and standard division of
PL.I, G.I and CI.S for smokers and non
smokers
1.47±0.70 Sm
1.19±0.73 Non.sm
1.21±0.66 Sm
G.I
1.29±0.72 Non.sm
1.44±0.62 Sm
CI.S
0.82±0.50 Non.sm
PL.I
Sm = smoker Non sm = non smoker
* = significant P< 0.05
Table 2: The percentage of B.O.P for
smokers and non smokers
B.O.P
27%
Sm
39% Non Sm
Sm = smoker Non sm = non smoker
Table 3: The mean and SD of concentration
of inorganic constituent of saliva in smokers
and non-smokers
Ione
Thriocyanate
mM
Sodium
mEq/1
Ca
mg/100ml
Magnesium
mEq/I
Potassium
mEq/I
Conc.
1.33±0.21
0.56±0.14
8.99±0.35
13.86±0.7
3.34±0.06
7.09±0.08
0.47±0.02
0.81±0.05
18.98±2.2
13.79±2.1
Sm
Non.Sm
Sm
Non.sm
Sm
Non sm
Sm
Non sm
Sm
Non sm
Sm = smoker
Non sm = non smoker
DISCUSSION
The result showed that mean PL.I and CI.S
were significantly higher in smoker in comparison
to non- smoker and this agree with other studies
(16-18)
who found that there is higher level of
plaque and calculus in smoker than non- smoker.
The result showed a reduction in clinical signs of
gingivitis which had been reported in smoker and
this effect had been shown to be independent of
plaque level and this agrees with Bergstrom etal
and Bergstrom and Floderns (19, 20). The study
showed that smoker had less bleeding on probing
in comparison to non-smoker (27%, 37%
respectively) and this agrees with Van Winkehoff
Vol. 20(1), 2008
(21)
and this suggests that nicotine could mediate
its vasoactive effect on local basis and impaired
vascularisation (22) and an inhibition of collagen
and fibronectin production associated with
smoking ( 23 ) .
This study showed thiocyanat level which is
considered as chemical indicator of cigarette
smoking (24) was higher in smokers (1.33 ±0.21)
in comparison to non smokers (0.56±0.14) and it
was statistically significant difference. This
finding agrees with other studies (24-26). The
potassium concentration for smoker was (18.98
±2.21) and for non smokers was (13.79 ±2.09)
and there is significant difference between them
and this agree with Dogon etal (25)
The other inorganic constituent who includes
sodium, magnesium and calcium showed greater
mean value of non-smokers in comparison to
smokers and this agree with Zubai et al (27). This
can be explained that during gingival
inflammation, greater cervical gingival fluid
(C.G.F.) flow was recorded. This increase in
C.G.F secretion may account for the increase
salivary protein and electrolytes of mixed saliva
where C.G.F is one of its sources. (28, 29), and
smokers showed reduced amount of C.G.F. (29).
REFERENCES
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3. Feldman RS, Bravacos JS, Rose CL. Association
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4. Papapanou P. Periodontal disease; Epidemiology.
Ann Periodontal 1996; 1: 1-36
5. Axelsson P, Paulander J, Lindhe J. Relation ship
between smoking and dental calculus in 35-, 50, 65and 75-year-old individuals. J Clin Periodontal 1998;
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6. McGuire JR, McQuade MJ, Ross man JA. Garnick J.
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7. Sasagawa S, Suzuki k, Sakatani T, Fujioka T. Effect
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8. Numabe Y, Ogawa, T, Kamoi H. Phagocyte function
of salivary PMN after smoker or secondary smoking.
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9. Preber H, Bergstrom J. Occurrence of the gingival
bleeding in smoker and non - smoker patients. Acta
Odontol Scand 1985; 43: 315-20.
10. Macgregor ID, Edgar W. Calcium and phosphate
concentration and precipitate formation in whole
saliva from smokers and non- smokers. J Periodont
Res 1986; 21: 429- 33.
11. Sewon LA, Kargallainen SM, Sainio M, Seppa O.
Calcium and other salivary factors in periodontitis
affected subjects prior to treatment. J Clin
Periodontal 1995; 22: 267- 70.
12. Silness J, Loe H. Periodontal disease in pregnancy. II
correlation between oral hygiene and periodontal
condition. Acat Odontal Scand 1964; 22: 121-35.
13. Loe H, Sliness J. Periodontal disease in Pregnancy 1.
Prevalence and severity. Acta Odontol Scand 1963;
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14. Greene JC. The oral hygiene index-development and
uses. J Periodontol 1967; 38: 625.
15. Powell WN. Photoelectric determination of blood
thiocyanates without precipitation of protein. J Lab
Clin Med 1945; 30: 1071-5.
16. Linden GI, Mullary BH. Cigarette smoking and
periodontal distraction in young adults. J Periodontol
1994; 65:718-23.
17. Muller HP, Staderman S, Heinecke A. Longitudinal
association between plaque and gingival bleeding in
smokers and non-smokers. J Periodontol 2002;
29:287-94.
18. Bergstrom J, Eliasson. Cigarette smoking and
alveolar bone height in subjects with high standard
oral hygiene. J Clinic Periodontal 1987; 14: 566-69.
19. Bergstrom J, Eliasson S, Preber H. Cigarette smoking
and periodontal bone loss. J Periodontol 1991; 62:
242-6.
20. Bergstrom J, Floderns-Myrhed B. Co-twin control
study of the relationship between smoking and some
periodontal disease factors. Com Dent and Dent Oral
Epid 1983; 11:113-6.
21. Van Winkehoff AJ, Bosch CJ, Winkel EG, Vander
Reijden WA. Smoking effects on sub gingival micro
flora in periodontitis. J Periodontol 2001; 72: 666-71.
22. Mosely LH, Fnseth F, Goody M. Nicotine and its
effect on wound healing plastic and reconstructive
surgery. J Periodontol 1978; 61:570-5.
23. Tipton DA, Dabbous MK. Effect of nicotine on
proliferation and extra cellular matrix production of
human gingival fibroblasts in vitro. J Periodontol
1995; 66: 1056-64.
24. Russell V, Luerker MD, Terry F, David M. Saliva
thiocayanate: Chemical indicator of cigarette
smoking in adolescents. Am J Public Health 1981;
71: 1320-4.
25. Dogon L, Amdur BH, Bell K. Observation on the
diurnal variation of some inorganic constituents of
the human parotid saliva in smoker and nonsmokers. Arch Oral Biol 1971; 16: 95 .
26. Ferguson DB. Current diagnostic uses of saliva J
Dent Res 1987; 66: 420-4.
27. Zuabi O, Machtei E, Ben-Aryeh H, Ardekian L,
Peled M, Laufer D. The effect of smoking and
periodontal treatment on salivary composition. In
patient with established periodontitis. J Periodontal
1999; 80: 240-6.
28. Griffiths GS, Stern JA, Withon JM, Eaton KA,
Johnson NW. Association between volume and flow
rate of gingival. Crevicular fluid and clinical
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of British mal adolescents. J Clin Periodontal 1992;
19: 464-70.
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of gingival fluid leukocyte elastase activity to
gingival flow rate. J Periodontal 1992; 63: 743-7.
Vol. 20(1), 2008
Periodontal health status…
Periodontal health status and biochemical study of
gingival creviculer fluid among diabetics and
non diabetic (Comparative study)
Lekaa M. Ibrahem B.D.S, M.Sc.
Raghad F. Abaas B.D.S, M.Sc.
ABSTRACT
Background: The aim of this study was to determine the relative influence of diabetes mellitus on periodontal
parameters and to correlate between glucose content of gingival crevicular fluid and blood in diabetics and non
diabetics.
Material and method: The sample composed of 105 participants. Group I composed from 35 healthy subjects, group
II composed from 35 patients were well controlled diabetics and 35 patients were moderately and poorly controlled
diabetics. The periodontal parameters which included Plaque Index (PL.I), Bleeding on probing (BOP) and gingival
fluid flow (GFF) were recorded. For sampling of gingival crevicular fluid (GCF), strips of filter papers were gently
inserted into the selected crevice of 4 teeth, each filter strip was placed in distilled water, and the supernatant was
used for assessment of glucose (GGF) and total protein (PGF).
Results: The mean for GGF was highest in group III (9.972±4.218) and the lowest was for group I (3.34±1.612). For
periodontal parameters the highest value was also for group III, were PL.I was 2.350±0.367 and mean GCF was
3.014±0.545. There was weak correlation between periodontal and biochemical parameters.
Conclusion: Diabetic groups showed significant difference in periodontal parameters compared to control group.
Also significant increase in GGF and PGF compared to control group.
Key words: Diabetes mellitus, gingival crevicular fluid. (J Bagh Coll Dentistry 2008; 20(1) 52- 57)
INTRODUCTION
Diabetes mellitus (DM) is a syndrome
characterized by chronic hyperglycemia is relative
insulin deficiency, resistance or both. It affects
more than 120 million people world wide, and it
is estimated that it will affect 220 million by the
year 2020 (1).
Diabetes and periodontal disease are common
chronic diseases. These diseases are thought to be
associated biologically; a number of reviews and
studies have proposed mechanisms to explain the
relationship including, 1) micro vascular disease,
2) changes in the components of the gingival
crevicular fluid (GCF), 3) changes in the collagen
metabolism, 4) an altered host response, 5) altered
gingival flora, 6) genetic predisposition and 7)
non enzymatic glycation (2-7).
The diabetic patients may be predisposed
disease based on the production of advanced
glycation end products (AGE), which bind to
receptors on specific cells such as the
monocytes(8).
Diabetic patients have been reported to be
more susceptible to gingivitis and periodontitis
than healthy subjects and these diseases are
commonly considered to be oral complications of
diabetes mellitus (9).
(2) Assistant lecturer, Department of Periodontics, College of
Diabetes affects all periodontal parameters
including bleeding scores, probing pocket depth,
and loss of attachment and missing teeth (10). In
fact one study shown that diabetic patients are 5
times more likely to be partially edentulous than
non diabetic subjects. People with type 1 and 2
diabetes appear equally susceptible and
periodontal disease and tooth loss (11).
The flow rate of GCF may be increase about
30-fold in periodontitis compared to healthy
sulcus, however its resting volume increases at the
same time with the formation of gingival pockets,
therefore even through the GCF flow rate when
accurately measured with an electronic device
clearly reflects the periodontal disease process,
the method of fluid collection has to be selected to
provide a clear distinction between the resting
volume and the flow rate of GCF (12).
The glucose content of both the gingival fluid
and the blood of diabetics were significantly
elevated above those seen in the control group.
The glucose content of gingival fluid from the
diabetic also showed significant correlation to the
blood glucose level in each patient (13).
Gingival crevicular fluid capacity to carry
high molecular weight components, such as
protein, has confirmed that gingival fluid is
inflammatory exudates as a result of increase
capillary permeability (14).
The aim of the study was to determine the
relative influence of diabetes mellitus on
periodontal parameters including Plaque index
(PL.I), Bleeding on probing (BOP), and gingival
Vol. 20(1), 2008
creviculer fluid (GCF), and to estimate glucose
and protein contents of gingival fluid in diabetic
and non diabetic patients and correlate between
clinical and biochemical parameters.
MATERIAL AND METHOD
The sample composed of 105 participants,
were carefully informed about the aim of
investigation and they were free to accept or
refuse to be examined. All of them were selected
from subjects attending specialized centre for
endocrinology and diabetes mellitus. The samples
were divided into the fallowing:
• Group I: Includes 35 healthy male without
any history of any systemic disease. The
HbAIc ranged between 4.2%-6.0%.
• Group II: Includes 35 with type 2 diabetic
mellitus, well controlled, the HbAIc were
ranged between 6.1%-7.5% had received
oral hypoglycemic agent for treatment and
visited the centre of endocrinology every
two months for following up and
adjustment of diabetes treatment.
• Group III: Includes 35 with type 2 diabetic
mellitus, moderately and poorly controlled,
the HbAIc were >7.5%, had received oral
hypoglycemic agent for treatment and
visited the centre of endocrinology every
two months for following up and
adjustment of diabetes treatment.
Periodontal assessment
The
periodontal
examinations
were
performed on dental chair; it is recorded on four
sites (mesial, distal, buccal and lingual) for all
teeth except the 3ed molar which was excluded,
the gingival fluid flow was recorded for buccal
site for the teeth 13, 43. If those teeth were
extracted, we were included the adjacent teeth.
The periodontal parameters included Plaque
index (PL.I) (15), Bleeding on probing (BOP) (16)
and gingival fluid flow (GFF) (17).
Sampling of gingival fluid for biochemical
analysis
According to Hara and Loe (18), prior to
sampling, the test teeth (which included 11, 41, 12
& 42) were thoroughly cleaned from plaque
without causing damage to the gingiva. The teeth
and gingiva were carefully dried with blast of air
and maintained in a dry status by means of cotton
rolls placed in the vestibule for 10 minutes before
the collecting of exudates started.
Four previously weighed 1.5x10 mm strips of
filter paper were gently inserted into the selected
buccal crevice of 4 teeth until resistance was felt,
and the strips were left in place for 30 seconds.
The strips were weighed on chemical balance then
transferred and stored at -20 C°. The difference
between the weights of the strips before and after
absorption of exudates was calculated.
On the day of analysis each filter strip was
placed in tube containing 0.7 ml distilled water,
allowed to stand for 15 minutes, vigorously stirred
20-30 times and centrifuged at 10.000 rpm (6800
xg) for 20 minutes. The supernatant was used for
assessment of glucose and total protein.
Assessment of glucose by using Trinder GODPOD kit and the estimation of total protein by
using Biuret colorimetric kits.
For statistical analysis mean and stander
deviation (SD) was used for distractive analysis,
while t-test, Chi-square and personal (r) were used
for inferential statistic.
RESULT
It was shown that the mean of PL.I was
elevated in group II and group III compared to
group I, also the mean of GFF in group II and
group III were greater than in group I as shown in
table 1.
The number and % for BOP were described
in table 2, the sites that bled were scored as 1,
while healthy sites were scored as 0. It was clearly
that the number of bleeding sites in group II and
group III were higher than in group I.
Inter group comparison for PL.I showed that
there was significant difference between group I
and group II, and there was highly significant
difference between group I and group III, while
there was no significant difference between group
II and group III as shown in table 3.
Table 3 presents the inter group comparison
for gingival crevicular fluid. There was highly
significant difference between group I and group
III and between group I and group II while there
was significant difference between group II and
group III.
Inter group comparison for BOP showed that
there was significant difference between group I
and group II and between group II and group III,
while there was no significant difference between
group I and group III as shown in table 4.
The mean for glucose in gingival fluid
(Mg/mg) is presented in table 5, and the highest
mean was shown in group III. This table also
illustrates the total protein in the gingival fluid; it
is highest in group III and lowest in group I.
Inter group comparison for HbAIc, fasting
blood sugar (FBS), glucose in gingival fluid
(GGF), and total protein in gingival fluid (PGF)
for all groups were shown in table 6. There was
highly significant difference between group I and
group II, while a non significant difference was
found for gingival fluid total protein P>0.05.
Comparison between group II and group III
Vol. 20(1), 2008
showed highly significant difference for HbAIc,
FBS, and GGF at P value <0.0001, while there
was significant difference for PGF as shown in
table 6.
Comparison between group I and group III
showed highly significant difference for HbAIc,
FBS and GGF while for PGF was significant at
P<0.05 as shown in table 6.
The correlation between periodontal
parameters (PL.I, BOP and GFF) and biochemical
parameters (GGF, PGF) showed weak or no
correlation as shown in table 7.
Table 1: Mean±SD for PL.I and GFF for all groups
Group I
Group II
Group III
PL.I mean±SD 1.727±0.508 2.132±0.555 2.350±0.367
GFF mean±SD 2.020±0.354 2.575±0.645 3.014±0.545
Table 2: Percentage and number of BOP for all groups
Group I
Group II
Group III
Number
%
Number
%
Number
%
0 2938 83.52% 2189 71.81% 1646 67.74%
691
16.48%
861
28.19%
784
32.26%
1
Table 3: Inter group comparison for mean of PL.I and GFF for all groups
Group I and Group II
Group I and Group III
PL.I
Group II and Group III
GFF
t-test P value Significant
3.236 0.003
S
6.188 0.000
H.S
1.747 0.091
N.S
5.115 0.000
H.S
7.535 0.000
H.S
2.224 0.034
S
Table 4: Comparison for BOP by chi-square for all groups
Chi square P value Significant
12.57
0.009
S
17.60
0.000
HS
14.27
0.006
S
Table 5: Mean ±SD for GGF and PGF for all groups
Group I
Group II Group III
G GF 3.34 ±1.612 5.83 ±2.74 9.973±4.218
PGF 220.1±67.5 246.7±94.4 311.1±125.7
Table 6: The comparison for HBAIc, FBS, GGF and PGF for all groups
HbAIc
FBS
Group I and
G
GF
Group II
P GF
HbAIc
FBS
Group I and
G GF
Group III
P GF
HbAIc
FBS
Group II and
G GF
Group III
P GF
t-test P value Significant
18.09 0.000
H.S
9.371 0.000
H.S
4.476 0.000
H.S
1.052 0.302
N.S
18.066 0.000
H.S
12.009 0.000
H.S
7.622 0.000
H.S
3.085 0.005
S
12.304 0.000
H.S
6.687 0.000
H.S
4.693 0.000
H.S
2.633 0.013
S
Vol. 20(1), 2008
Table 7: Inter group correlation between periodontal and biochemical parameters for all groups
PL.I
BOP
Group I
GFF
PL.I
BOP
Group II
GFF
PL.I
BOP
Group III
GFF
HbAIc
0.096
-0.084
-0.140
-0.025
-0.084
0.313
0.002
0.090
0.012
DISCUSSION
Hyperglycemic conditions result in decrease
cellular proliferation and growth of periodontal
ligament, fibroblast and collagen synthesis.
Patients with diabetes have an increase in gingival
crevicular fluid collagenase activity when
compared to non diabetic(19).
This greater collagenase activity would
suggest increase degrees of collagen breakdown
in the tissue of the diabetic's polymorphonuclear
leukocyte (PMNs) are the primary defense cells of
periodontium. Poorly controlled diabetes is
associated with abnormalities in PMNs functions
such as impaired adherence, chemotaxis and
phagositosis, all of which render the host more
susceptible to infection. Abnormalities in PMNs
function can be markedly improve with insulin
therapy and meticulous control of the disease (1922)
. This may explain why well controlled
diabetics are not at increased risk for periodontitis
(23)
.
The results showed that there was significant
difference between group I and group II and
highly significant difference between group I and
group III and this agree with Pinson (24) who
found that diabetic groups had slightly higher PL.I
mean scores than the control group, but this result
was in disagreement with Hugoson et al (25) who
found that there was no significant difference
between diabetic and non diabetics.
No statistically difference existed in mean
PL.I between group II and group III and therefore
plaque only in part explain the difference in
attachment and bone loss which are indicators of
true periodontal tissue distraction, this was in a
agreement with other studies (20,26) and
disagreement with Harrison (27).There is no
obvious reason for this discrepancy; it is possible
that the health and psychological status of diabetic
lead them to ignore their personal hygiene.
The difference in the amount of gingival
bleeding between group I and group III and
between group I and group II was statistically
FBS
0.014
-0.046
-0.075
-0.417
-0.121
-0.075
0.244
-0.157
-0.209
G GF
-0.215
-2.204
-0.169
0.316
-0.200
-0.246
0.166
-0.084
-0.216
P GF
0.044
-0.144
0.062
0.274
-0.068
0.217
0.159
0.191
-0.087
significant. This was in agreement with Brigdes
and others (10) who found that the diabetes
affected all periodontal parameters including
bleeding score.
There was significant difference in bleeding
on probing between group II and group III, this
was in agreement with other studies (28,29), and
disagreement with Westfelt 1996 (30) who reported
that the change in bleeding on probing was not
found to be related to HbAIc.
The gingival bleeding was observed to
increase as the level of metabolic control
deteriorated (28).The reason for the increased
bleeding in group III could be either due to
inflammation or vascular changes in gingival. The
inflammatory reaction are intensified during poor
metabolic control, as the same amount of plaque
induced more gingival bleeding in group III
compared to group I.
This result showed that there was highly
significant difference between group I and group
II and between group I and group III. This was in
agreement with Ringelberg (31) who reported that
the children with diabetes had significantly more
gingival crevicular fluid flow than non diabetic
children as the diabetic children showed more
gingival inflammation than non diabetic children.
There was a significant difference between group
II and group III; this may be due to steady
increase in the level of inflammation with the
level of metabolic control.
It has been shown the flow of gingival
crevicular is a sensitive parameter of gingival
inflammation. Cimasoni (32) noted a positive
correlation was always found between the clinical
appreciation of gingival inflammation and the
amount of gingival fluid. The results of the
present study agree with the above finding as
there was a steady increase in gingival crevicular
fluid level with the increase of the severity of
periodontal disease.
Inter group comparison between groups
showed elevated glucose level of gingival crevice
Vol. 20(1), 2008
fluid and it was highly significant in diabetic
patients compared with control group. This was in
agreement with Ficara (13) and Hara et at (18). It
appears that elevated blood glucose level
associated diabetes will result in elevated gingival
fluid glucose level. However in normal subjects
with non elevated blood glucose level other
factors appear to be responsible for the gingival
fluid glucose level. Some of glucose may be
accounted by the increase permeability of blood
vessels during inflammation and the concomitant
release of glucose in to the extra vascular
compartment. Some of glucose may also derive
from breakdown products of high molecular
component of gingival tissue and cells (18).
In fact the impaired ability of the body to
completely regulate insulin whether endogenous
or exogenous may contribute to the presence of
increased glucose in the gingival sulcus. In
addition, since the diabetic patients had slight
gingival inflammation, the increase capillary
fragility in the crevicular tissue which produces
the gingival fluid would allow for more glucose in
the gingival fluid due to high concentration in the
blood of these patients.
Inter group comparison for gingival fluid total
protein showed non significant difference between
group I and group II. The difference would not be
expected in the gingival fluid total protein values
of the two groups since the metabolic defect of
diabetics is not reflected on this parameter if the
diabetes was well controlled.
Significant difference was found between
group I and group III, significant difference was
found between group II and group III. The
difference in total proteins in group III may be
due to that most of diabetic patients had gingival
inflammation, the increased capillary fragility in
crevicular tissue which would allow for more
protein in the gingival fluid due to the passage of
high molecular weight substance from the blood
to the gingival sulcus. This was in disagreement
with Ficara (13) who reported that neither the
control group nor the diabetics group showed a
statistically significant difference or correlation
between the blood and the gingival fluid total
protein content.
There was weak correlation between clinical
and biochemical parameters, which was because
the diabetic patient may be predisposed to
periodontal disease based on the production of
advanced glycation end production (AGE), which
bind to receptors on specific cell such as the
monocytes (8). In vitro studies the monocytes from
people with diabetics have shown a hyper
responsive phenotype with over expressive of proinflammatory mediators such as interleukin-1 (IL-
1), tumor necrosis factor (TNF-a), and
prostaglandin (PGE2) (33, 34). So the changes in
periodontal health status are related to
immunoglobulin changes rather than the changes
in glucose and total protein concentration in blood
and gingival crevicular fluid.
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Sastrwijoto SH, Abass F, Abraham-inpjn L, Van der
Valden U. Relationship between bleeding/plaque
ratio, family history of diabetes mellitus and impaired
glucose tolerance. J Clin Periodontal 1999; 17: 55-60
Verna S. C-reactive protein incites athero-sclerosis.
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Engebretson SP, Hey-Hadavi J, Ehrhardt FJ, Hsu D,
Celenti RS, Grbic JT, Lamster IB. Gingival
crevicular fluid level of interleukin-1 beta and
glycemic control in patients with chronic
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Grant-Theule DA. Periodontal disease, diabetes and
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glycation end products. Arterioscl Thromb Biol 2005;
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Salva GE, Spte-Happonen S, Signer RE, Offenbacher
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prostaglandin E2 response to Porphromonas
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literature and dental implication. Compend Contin
Educ Dent 2001; 22(9): 757-60
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Bridge RB, Anderson JW, Saxe SR, Gregory K,
Bridge SR. Periodontal status of diabetic and non
diabetic men: effect of smoking, glycemic control
and socioeconomic factors. J Periodontol 1996;
67(11): 1185-92.
Moore PA, Weyant RJ, Mongelluzzo MB, Myers DF,
Rossie K. Type 1 diabetes mellitus and oral health:
assessment of tooth loss and edentulous. J Public
Health Dent 1998; 58(2): 135-42.
Goodson JM. Gingival crevicular fluid flow. J
Periodontol 2003; 31: 43-5.
Ficara AJ, Levin MP, Grower MF, Kramer GD.
Comparison of glucose and protein content of
gingival fluid from diabetic and non diabetic. J
Periodontal Res 1975; 10: 171-5.
Bang J, Cimasoni G. Total protein in human
crevicular fluid. J Dent Res 1971; 50: 1683.
Silness J, Loe H. Periodontal disease in pregnancy II.
Correlation between oral hygiene and periodontal
condition. Acta Odontol Scand 1964; 22: 112-35.
Carranza FA, Newman MG. Clinical periodontology
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Vol. 20(1), 2008
17. Brill N. The gingival pocket fluid, studies of its
occurrence, composition and effect. Acta Odontol
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18. Hara K, Loe H. Carbohydrate components of gingival
exudate. J Periodont Res 1969; 4: 202-7.
19. Oliver RC, Tervonen T. Diabetes a risk factor for
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20. Oliver RC, Tervonen T, Flynn. Enzyme activation in
crevicular fluid in relation to metabolic control of
diabetes and other risk factors. J Periodontol 1993;
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21. Little JW, Falace DA, Miller CS, Rhodus. Dental
management of medically compromised patient, 5th
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22. Grossi SG, Robert J and Genco. Periodontal disease
and diabetes mellitus: two-way relationship. Ann
Periodontal 1998; 3: 61
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Periodontal disease and type I diabetes mellitus in
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to periodontal pocketing and alveolar bone level. Oral
Surg Oral Med Oral Path 1986; 61: 346-99.
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Linda J. The effect of periodontal therapy in
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31. Ringelberg ML, Dixon DO, Francis AO, Plummer
RW. Comparison of gingival health and gingival
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33. Movlig J, Baek L, Christensen P, Manogue KR,
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JS. Acute phase inflammatory response to
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2000; 79: 49-57
Vol. 20(1), 2008
Evaluation of periodontal…
Evaluation of periodontal abscess clinically and
microbiologically
Lekaa M. Ibrahem B.D.S, M.Sc.(1)
ABSTRACT
Back ground: The aim of this study was to evaluate the characterized well-defined a cute periodontal abscess
clinically and microbiology.
Material & Method: Thirty patients were selected for this study; clinical examination was carried out recording the
following variables: pain, edema, redness, swelling, bleeding on probing, suppuration, tooth mobility and probing
pocket depth. Microbiological samples were taken using dark field microscopy.
Results: The results show that 60% of the abscesses affected untreated periodontits. Ninety percentage of the
patients reported pain and more than 75% of the abscesses had moderate to severe score related to swelling,
edema and redness. Bleeding occurs in all abscesses, while suppuration was detected in 70% and 85% of teeth
presented some degree of mobility the mean associated pocket was 7.1 mm. The microbiological examination
showed that the spirochetes were the predominant bacteria (41.8%) while coccid bacteria were present in lower
number (19.22%)
.
Conclusion: The periodontal abscess has clear clinical characteristics and usually associated with sever e periodontal
distraction. The lesion has a large mass with a large prevalence of periodontal pathogen.
Key words: Periodontal abscess, clinical parameters and microbiology. (J Bagh Coll Dentistry 2008; 20(1) 58-61)
INTRODUCTION
Periodontal abscess has been defined as a
lesion with an expressed periodontal break down
occurring during a limited period of time, and
with easily detectable clinical symptoms (1), with a
localized accumulation of pus (2,3), located within
the gingival wall of the periodontal pocket (3).
The importance of periodontal abscess in
clinical periodontal practice can be summarized
by:
a. Its high prevalence amongst dental
emergencies and its high prevalence in
periodontal patients (4, 5).
b. It is usually closely related with periodontitis
and periodontal pockets affecting not only
untreated patients, but also patients during
active treatment or during maintenance (3, 5, 6).
c. Periodontal abscesses are one of the main
cases of tooth extraction and tooth loss, mainly
in the main-tenancy patient (5, 7)
d. Periodontal abscesses may result in
complications, due to bacteremia, that may
cause infection in distant-locations (8, 9).
There are various reasons why an abscess
occurs in relation to therapy. Smith & Davies (10)
found that periodontal abscess occur immediately
after scaling or after routine prophylaxis, and it
has been related to the dislodging of calculus
fragment. This can be pushed into the tissue (11). It
may also be due to inadequate scaling which will
allow calculus to remain in the deepest pocket
area.
While the resolution of the inflammation at the
coronal pocket area will occlude the normal
drainage and then cause the abscess formation.
Periodontal abscess may occur immediately after
periodontal surgery (3).
Recently a clinical study on guided tissue
regeneration (12) reported that 10 out of 80
controls (non-restorable barrier) and 4 out of 82
tests (bio-absorbable barrier) showed abscess
formation or suppuration at the treated sites.
The periodontal abscess microbiota is usually
indistinguishable from the microflora found in
subgingival plaque in adult periodontits. Newman
and Sims (13) in one study and Hafstron et al (1)
where the microflora of abscesses was compared
to that from periodontitis and healthy sites. The
microflora from abscesses and deep pockets was
similar and harbored higher proportions of
pathogens when compared to micro flora of
shallow pockets.
The aim of study is to evaluate the
characterized a well-defined acute periodontal
abscess clinically and microbiology.
MATERIAL AND METHODS
Patients presenting at Dental College of
Baghdad University in periodontal department
with an acute periodontal abscess were viewed in
this study. The patients were selected on the basis
of following criteria: a. Localized pain, swelling and tenderness
related to a periodontal area.
b. Edema, redness and swelling usually a deep
periodontal pocket, showing bleeding and
suppuration on probing.
Vol. 20(1), 2008
c. Endodontal abscess were excluded based
on radiographic examination and vitality tests.
Non vital teeth were only included if a clear
primary periodontal lesion was detected. The
patient was excluded if they have used antibiotic
drugs in the previous 4 weeks.
Thirty patients were selected with age ranged
from 23 to 55 years old (average 39).
Clinical examination:
Two types of clinical variables were assessed:
a. Subjective
clinical
variables
included
evaluation of pain, edema, redness and
swelling. They were assessed using semiquantitative scale ranging from values (1) non,
(2) mild, (3) moderate and (4) sever. The same
clinical evaluator assessed all the subjective
clinical variables, except for that were selfassessed by the patient, using the same semiquantitative scale described above.
b. Objective
clinical
variables
included
dichotomous variables such as bleeding on
probing, suppuration and tooth mobility
probing depth was measured by using manual
periodontal prob. (Williams probe to the
closest millimeter).
Microbiological study
The sample was collected according to the
method of Listgarden and Hellden (14). A sterile
periodontal curette or spoon excavator was
introduced through the sulcus or pocket orifice as
far apical as possible and the bacterial contents
were removed. If necessary in both situations, the
process was repeated several times to obtain
enough material. The samples were suspended in
0.3 ml of sterile 0.85% sodium chloride solution
containing 1% gelatin by vigorously agitating the
tip of the instrument in the solution. The bacterial
suspensions were dispersed just prior to the
examination by aspirating and expelling the fluid
three times through the disposable tuberculin
syringe attached to 23-gauge needle. One drop of
the suspension was then applied to microscopic
slide and cover slipped. Excess fluid was removed
by inverting the slide over an absorbent surface
and applying moderate pressure. The slide was
then examined by dark field microscopy at
magnification of x1200. If the preparation was too
dense the sample was further diluted with saline
until about 100 to 200 bacteria were present in the
specimen examined. The bacteria were classified
according to the method of listgarden and Hillden
(14)
as follows: coccid cells, spirochetes, motile
rods, straight rods, straight rods, Filaments,
fuseform and cured rods were grouped together
and made up the rest of count.
Date analysis
Microbiology and clinical data were analyzed
using descriptive statistics. Data are gathered
from subjective clinical variables as expressed as
percentage of abscesses/patient in each category.
Quantitative clinical variables gathered as probing
pocket depth, is expressed as mean, S.D and
range. Qualitative clinical variables (bleeding,
suppuration and tooth mobility) are presented as
percentage of abscess positive for each variable.
For microbiological variables percentage of
Morphs types of the bacteria were calculate.
RESULTS
Thirty patients suffering from acute
periodontal abscesses were included in this study.
Eighteen patients (60%) were females and twelve
patients (40%) were males with the mean age was
39 years ranging form 23 to 55.
It has been found that 18 (60%) abscesses
occurred in untreated periodontitis, patients 3
(10%) immediately after basic periodontal
treatment (mostly scaling and root planning), 9
(30%) abscesses developed in patients in the
periodontal maintenance phase. Twenty seven
abscesses (90%) were diagnosed in patients
suffering from moderate to sever periodontits; and
3 (10%) were observed in patients with initial
periodontits. For pain, only 10% of the patients
the abscesses were pain less whereas 63% of the
patient complained from moderate to severe pain,
swelling, edema and redness were observed in all
the cases, with scores of moderate to severe in
90%, 80 % and 73% of the abscesses respectively.
The distribution of the abscesses in each category
is shown in table 1. Bleeding on probing observed
in 100% of the abscesses while the suppuration
and mobility were observed in 70% and 87% of
the cases respectively as shown in table 2. Mean
probing pocket depth was 7.1 mm, ranging from 4
to 11 mm. In 68.7% of the abscesses the
associated pocket was deeper than 6 mm, while in
31.3% the pocket ranged between 4-6 mm as
shown in table 3. For the bacteriological result
showed that the percentage of coccid cells,
spirochetes and motile rods in abscess diagnosed
to be periodontal abscess are shown in table 4.
The spirochetes were the predominant cell type,
with mean proportions of 47.8-10.8% the coccid
cell (mean proportion 19.2-10.6%) were found in
significantly lower proportion, were found in
significantly lower proportion than the
spirochetes. The mean proportion of motile was
7.7-3.9% .
Vol. 20(1), 2008
DISCUSSION
Most effected patients suffered from untreated
periodontitis (60%), 30% of the effected patient
abscess occur during maintenance phase and only
10% of the abscesses occur after periodontal
treatment. The results agree with Herrera et al (15)
who found that 62% abscesses occurred in
untreated periodontitis patients, 24% abscesses
developed in patients in periodontal maintenance
phase and 14% abscesses occurred after basic
periodontal treatment.
In this study, the patient suffering from mild
pain from about 27% while the patients
complained of moderate to severe pain from
about 63 % swelling, edema and redness were
observed in all cases, with scores of moderate
sever in 90%, 80 % and 37% respectively and
agree with Smith and Davies (10) and Herrera et al
(15)
.
This study also detected bleeding on probing
in all abscesses and the level of suppuration is
70% and these results agree with Hafstrom et al (1)
and Herrera et al (15).
Most of the associated pockets in the present
study were deeper than (31.3%) ranged between
4-6 mm. Smith and Davies (10) reported similar
proportion (55% and 35.5% respectively). This
result agrees with Herrera et al (15) who reported
the same proportion (62.1% and 34.4%
respectively). The mean probing depth in this
study (7.1mm) was close to 8.1mm from Herrera
's study (15).
Table 1: Percentage of abscesses in each
category of each subject variable
Type
No
Mild
Pain
Moderate
Sever
No
Mild
Swelling
Moderate
Sever
No
Mild
Edema
Moderate
Sever
No
Mild
Redness
Moderate
Sever
No
3
8
13
6
0
3
13
14
0
6
13
11
0
8
10
12
%
10
27
43
20
0
10
43
47
0
20
43
37
0
27
33
40
Regarding tooth mobility, this study found
85% of the teeth showing some degree of mobility
while Smith and Davies (10) and Herrera et al (15)
reported that the teeth showed mobility forming
about 5.65% and 79% respectively, probably due
to amore severe periodontal destruction, since this
study only included periodontal diseased patients.
For the bacteriological examination, the
technique of dark field analysis can easily be
learned by the dentist or auxiliary personnel and is
simple to carry out. An advantage of the
procedure is that the result can be obtained chair
side in few minutes, so that definitive treatment
can begin at the visit which often is associated
with excruciating pain. In this study, microbial
morph types were found by means of dark field
microscopy, of spirochetes (47.8%) and a low
percentage of cosec (19.2%) and motile rods
(7.7%). The result agree with Trop et al (16) who
found that the occurrence of spirochetes in
periodontal abscesses was 40.6% and low
percentage of coca (19.7) and motile rods (7.5%).
This result is in accordance with Topll et al (17).
Table 2: Percentage of abscesses positive for
each clinical variable.
Clinical variable
Percentage No.
100%
30
Bleeding on probing
70%
21
Suppuration on probing
87%
26
Mobility
Table 3: Mean and percentage of probing
pocket depth affected by periodontal
abscesses.
Probing pocket depth 4-6
>6
68.7% 31.3%
Percentage
Table 4: Mean and SD of bacteria in
periodontal abscesses as determined by dark
field microscopy.
Type of bacteria Mean ± S.D
19.2 ± 10.6
Coccid
47.8 ± 10.8
Spirochete
7.7 ± 3.9
Motile rods
REFERENCES
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2.
3.
4.
Hafstrom CA, Wikstrom KB, Renvert SN, Dahlen
GG. Effect of treatment on some periodontal
pathogens and their antibody levels in periodontal
abscesses. J Periodontol 1994; 65: 1022-8.
Dewitt GV, Gobb CM, Killoy WJ. The acute
periodontal abscess: microbial penetration of tissue
wall. International J Periodontal and Rest Dent 1985;
1: 39-51.
Carranza FJ. Glickman's Clinical Periodontology 7th
edition 1990, Philadelphia WB Saunders Company.
Kaldahl WB, Kalwarf KL, Patil KD, Molvar MP,
Dyer JK. Long-term evaluation of periodontal
therapy: 1. Response to 4 therapeutic modalities. J
Periodontol 1996; 67: 93-102.
Vol. 20(1), 2008
5.
Mcleod DE, Lainson PA, Spivey JD. Tooth loss due
to periodontal abscess irrespective study J
Periodontol 1997; 68: 963-6.
6. Fine DH. Microbial identification and antibiotic
sensitivity testing and aid for patient's refractory of
periodontal therapy. J Clin Periodontol 1994; 21: 98106.
7. Chace RJ, Low SB. Survival characteristics of
periodontal involved teeth: a 40 years study. J
Periodontol 1993; 64: 701-5.
8. Chan CH, McGurk M. Cervical necrotizing fascistic
a rare complication of periodontal disease. British
Dental J 1997; 183: 293-6.
9. Suzuki JB, Delisle AL. Pulmonary actinomycosis of
periodontal origin. J Periodontol 1984; 55: 581-4.
10. Smith G, Davies RM. Acute lateral periodontal
abscess. British Dental J 1986; 161: 176-8.
11. Della Russo MM. The post prophylaxis periodontal
abscess etiology and treatment. International J
Periodontal and Rest Dent 1985; 1: 29-37.
12. Garrett S, Polson AM, Stoller NH, Drisko CL, Caton
JG, Harrold CQ, Bogle Green well H, Lowength RA,
Duke SP, DeRouen TA. Comparison of a
bioabsorbable GTR barrier to a non-absorbable
barrier in treating human class II furcated defect. A
multicenter parallel design randomized single-blind
study. J Periodontol 1997; 68: 667-75.
13. Newman MG, Sins TN. The predominant cultivable
micro biota of periodontal abscess. J Periodontol
1979; 50: 350-4.
14. Lisgarten MA, Hellden. Relative distribution at
bacteria at clinically healthy and periodontal diseased
sites in humans. J Clin Periodontol 1978; 5: 115-32.
15. Herrera D, Rollan S, Gonzalez I, Sanz1 M. The
periodontal abscess (1). Clinical and microbiological
findings. J Clin Periodontol 2000; 27: 387-94.
16. Trope M, Tronstad l, Rosenberg ES, Listgarten MA.
Dark field microscopy as a diagnostic in
differentiating exudates from endodontic and
periodontal abscesses. J Endod 1988; 14: 35-8.
17. Topoll HH, Lange DE, Muller RF. Multiple
periodontal abscesses after systemic antibiotic
therapy. J Clin Periodontol 1990; 17: 268-72.
Vol. 20(1), 2008
The clinical and socio-…
The clinical and socio-cultural evaluation of the effects of
oral contraceptives on periodontal condition
Maha Abdul Aziz B.D.S., M.Sc (1)
ABSTRACT
Background: Human gingival tissues serve as a target for progesterone and estrogen, causing an increase in gingival
inflammation. Therefore, the use of oral contraceptives (OC) might be considered as a predisposing factor for
periodontal disease. The objective of the present study is to evaluate the effects of oral contraceptives on the
periodontium and to investigate the relation between socio-cultural status and periodontal condition.
Materials and methods: Twenty non users women (group 1), 20 OC users for less than 2 years (group 2) and 20 for 2-4
years (group 3) with generally good oral hygiene standards were selected for this study. Plaque index (PLI), gingival
index (GI), probing pocket depth (PPD), bleeding on probing (BOP) and teeth loss were measured. Socio cultural
data including: age, educational level, professional level, number of children, frequencies of dental visits, tooth
brushing and previous periodontal treatment were collected by a questionnaire form.
Results: The percentages of PPD of score (≥4) mm were significantly increased when group 1 was compared with
group 2 and group 3. Similar results were detected by comparing group 1 with group 3 in respect to percentages of
BOP. Also a relationship was observed between percentages of extracted teeth of mothers and number of children
at each group. On the other hand neither of the socio-cultural variables was found to have a statistically significant
effect among the 3 groups nor means of PLI and GI.
Conclusion: Women on contraceptive pills require regular periodontal care programs may help maintain healthy
gingiva and avoid development of sever periodontal problems.
Keywords: Contraceptive pills, socio cultural, periodontal condition. (J Bagh Coll Dentistry 2008; 20(1)62- 68)
INTRODUCTION
Periodontal disease is an infection of the
tissues that support the teeth. Some factors
increase the risk of developing periodontal
disease, one of them is the oral contraception (1).
Hormonal contraceptives use either a combination
of estrogen and progestin or progestin a lone, thus
additional amount of one or two female hormones
are used to disrupt the balance of hormones that is
needed for pregnancy to occur(2), which may
adversely affect the periodontal tissues(3). There
has been speculation about the effects of OC and
sociocultural characteristics on the periodontal
conditions. However several studies demonstrated
a higher tendency towards bleeding and
inflammation (4-7) among women taking OC with
an increase in gingival crevicular fluid (GCF)(4,810)
, PPD (4,11,12) and loss of attachment (5),
additionally alterations in the composition of the
subgingival plaque have also been reported
toward a marked increase in the proportions of
Prevotella intermedia(8,13,14). On the other hand,
another study found that neither sociocultural
status nor the duration of usage significantly
influenced periodontal conditions among OC
users (6).
Sixty married women attending Al-Dowra
General Dental Clinic in Baghdad, with an age
(1) Lecturer, Department of Periodontology, College of Dentistry,
range of 20-45 years with generally good oral
hygiene standards at the time of examination.
They were divided into 3 groups (20 in each)
Group 1: Women in this group had never used
hormonal contraceptive pills.
Group 2: Women used contraceptive pills
regularly for less than 2 years.
Group 3: Women used contraceptive pills
regularly for 2-4 years.
Exclusion criteria were women with any
congenital and systemic diseases or under
medication 4 weeks prior to the study, any form
of on going tobacco use, pregnancy. If there had
been any breaks in continuity in taking the pills.
The clinical examinations were carried on all teeth
except third molars and were conducted using
graduated Williams periodontal probes and mouth
mirrors.
Clinical Assessments
1. PLI: Plaque index system in scale from (0-3)(15).
2. GI: Gingival index system in scale from (03)(16).
3. BOP: Absence or presence of bleeding on
probing (17).
4. PPD: The distance from gingival margin to the
most apical extent of the probe to the nearest
millimeter was recorded.
5. Teeth loss: Number of extracted teeth of
mothers were calculated according to (1-3 and
>3 scale).
Vol. 20(1), 2008
Questionnaire based measures
All participants were asked using a semi
structured questionnaire to give information
about:
- Socio demographic variables included: age,
educational level, professional level and number
of children (1-3 and >3 scale)
- Oral hygiene variables included: frequencies of
teeth brushing, dental visits and previous
periodontal treatment.
RESULTS
In this study the sample consisted of 60
women and was divided into 3 groups (20 in
each).
In relation to educational category there was a
non significant difference among the 3 groups at
each level but the majority of females had
university degree or more in all groups, as shown
in table 1.
The predominant professional level was
employee in all groups. The results were 60%,
65% and 75% but non significant differences
were noticed among the groups at each level
(Table 2).
The frequency of dental visits appears to be
higher in (≥3/6 months) level in all groups. The
results were 65%, 80% and 70%, and the
differences were non significant among the 3
groups in both levels (Table 3).
It seems that frequencies of tooth brushing
non significantly differ among the 3 groups at
each level, where half of the women in group 2
and 45% in groups 1 and 3 brush their teeth (3
times/daily) (Table 4).
It is clear that higher percentages of women
receive previous periodontal care in all groups
(Table 5) with non significant differences were
observed among the 3 groups.
Figure 1 reflects a positive relationship
between the number of extracted teeth of mothers
and number of children borne at each group
especially in group 3 where the results were 35%
and 65% regarding the scale of (1-3) and (>3)
respectively.
It is obvious from Table 6 that all participants
exhibited nearly similar and low means of PLI
with a non significant difference among the 3
groups.
In general results from table 7 revealed a
slight increase in means of GI with increased
periods of medication, where group 3 registered
highest mean of GI 0.77 and 0.65 in group 2 while
in group 1 was 0.50 and the differences were
again non significant between every two groups.
It was found from table 8 and figure 2 that
subjects who had been on OC for 2-4 years had
highest percentage of PPD (35%) regarding
(≥4)mm score than those taking contraceptives for
less than 2 years (25%) or those in the control
group (10%) and the differences were significant
by comparing group 1 with group 2 and group 3
in respect to both scores (<4)mm, (≥4)mm, on the
contrary. Comparison between group 2 and group
3 shows anon significant differences regarding the
above mentioned scores (Table 9).
Finally, percentages of sites with BOP found
to be slightly increased over time due to the
increased duration of medication where they
represent 19.455% in group 3 and 18.245% in
group 2 but it was only 17.35% in group 1 (Table
10 and Figure 3). No significant differences were
noticed by comparing every two groups expect in
comparison between group 1 and group 3 it
differs significantly in relation to both scores 0
and 1 as shown in table 11.
DISCUSSION
We postulate that the level of people
education is an important contributor to PLI.
From this study it appears that the predominant
educational and professional levels were
university degree and employee, so one may
speculate that higher educated groups and
employee might have better oral hygiene
condition because they are more concerned about
their appearance especially from esthetic point of
view and more understanding about oral hygiene
programs therefore, they demonstrated effective
oral hygiene regimens. Findings from the present
study provided evidence to verify the above
mentioned hypothesis, thus over half of the
participants receive previous periodontal care and
attended dental clinic (≥3/6 months) also the
majority brush their teeth (3 times / day). All
these high sociocultural characteristics had a
beneficial effect on PLI and vise versa and
numerous studies support this concept (18, 19). In
contrast Yalcin etal(6) found that sociocultural
status did not significantly influence periodontal
condition. Not surprisingly, there is a positive
relationship between number of children borne
and number of extracted teeth of mothers. This
association was apparent in this study through an
increased risk of being edentulous with an
increased number of children borne due to a
tendency toward lack of mothers’ personal care
which induce neglect oral hygiene regimen.
Our study evaluating apparently more
homogenous population with similar oral hygiene
conditions, nearly equal and low means of PLI in
order to minimize the influence of dental plaque
on the groups.
Vol. 20(1), 2008
It is obvious from the results that means of GI
and percentages of sites with BOP tend to
increase slightly with increased periods of
medication so there was a trend for more
inflammation and bleeding tendency with
prolonged usage of OC. However non significant
differences were noted by comparing every two
groups in respect to mean GI, but a significant
difference was registered when group 1 was
compared with group 3 in regard to BOP.
There are several studies on women receiving
OC in which gingival inflammation was
constantly increased (21, 22), yet Moshchil et al(23)
found no significant influences on periodontal
clinical parameter (GI) when comparing OC users
to non-medicated groups, this finding supported
by our study.
On the contrary, studies by Tilakaratne et al(5)
and Yalcin et al(6) reported that OC users of less
than 2 years and 2-4 years duration had significant
increase in means of GI, also Salameh(4), Hamed
(7)
and Zachariasen et al(9) demonstrated similar
results but the duration of OC intake by
participants was shorter. The above cited studies
are not easy to compare with our study since the
size of the sample, methodology, duration of OC
intake, type of OC drug; sociocultural
characteristics and interpretation of results are
different.
In the present study, an increase in
percentages of women with PPD of (≥ 4)mm were
evident with increased duration of medication. It
was also concluded that comparison between
group 1 with group 2 and group 3 revealed a
significant differences. This result agree with
Salameh(4) in which the percentage of OC pills
users with PPD of (≥4)mm found to be
significantly higher than the non-medicated
control group, and also Klinger et al (11) showed a
significant increase in PPD in women under OC
medication than in the control subjects. While
Yalcin et al(6) and Das et al(12) revealed a non
significant increase in PPD during the duration of
OC usage. On the contrary, Hamed(7)
demonstrated that the percentage of women with
PPD of 4-5 mm was the same for 6 months
duration of taking the drug.
Unique to gingival diseases associated with
sex hormones is that the gingival inflammation
and increased PPD is elicited by relatively small
amounts of dental plaque(24), since hormonal
effects reflect physiological/pathological changes
in periodontium(25).
The physiological changes include dilatation
of gingival capillaries, increase vascular
permeability which result in edema (21, 24-26) and
accumulation of inflammatory cells, in addition to
increased proliferation of newly formed
capillaries in gingival tissue which may explain
bleeding tendency (27). Yet, destruction of gingival
mast cells and the resultant release of histamine
and photolytic enzymes were also observed (25). In
fact, gingival tissue become edematous and
enlarged which may lead to increased pocket
depths (27, 28).
Susceptibility to periodontal infection
increases due to alteration in the immune system
and can be explained by the hormonal changes
observed during taking OC medication (29). Thus
suppression on T-cell activity decreased
neutrophil chemotaxis and phagocytosis, altered
lymphocyte response and depressed antibody
production(25, 27, 30, 31) with increased synthesis of
PGE2(32.33) observed when sex hormones are
present in higher concentrations consequently
these immunologic changes might contribute to
periodontal pathologic conditions observed during
OC intake such as gingivitis and periodontitis(25).
On the other hand the possibility that bacterial–
hormonal interactions may change the
composition of plaque and lead to gingival
inflammation thus sub gingival flora changes to
amore anaerobic flora therefore the relative
increase in the number of Prevotella-intermedia
may be a more sensitive indicator of an altered
systemic hormonal situation which serve as
essential growth factors for these periodontal
pathogens and to coincide with the gingival
bleeding (8, 13,14).
In the light of pervious discussion it might be
concluded that sexual hormones play an important
role in influencing periodontal disease
progression. In addition the influence of sex
hormones can be minimized with good plaque
control that may help maintain healthy gingiva
and avoid development of severe periodontitis in
those receiving contraceptive medications.
Vol. 20(1), 2008
Table 1: Number and percentage of study population according to levels of education
Group1 Group2 Group3 ChiP-value
No. % No. % No. % square
1.000
1 5 1 5 1 5 0.000
Illiterate
NS
0.539
2 10 1 5 1 5 0.377
Primary school
NS
0.763
Secondary school 4 20 5 25 5 25 0.091
NS
0.782
6 30 5 25 6 30 0.077
Diploma
NS
0.851
College or more 7 35 8 40 7 35 0.055
NS
Education levels
Table 2: Number and percentage of study population according to professional levels
Professional Group1 Group2 Group3 ChiPlevels
No. % No. % No. % square value
0.856
Employee 12 60 13 65 15 75 0.033
NS
0.787
8 40 7 35 5 25 0.073
Housewife
NS
Table 3: Frequency distribution of study population according to dental visits
PGroup1 Group2 Group3 ChiNo. % No. % No % square value
<1-2/6months 7 35 4 20 6 30 0.365 0.546 NS
>3/6months 13 65 16 80 14 70 0.022 0.881 NS
Dental visits
Table 4: Frequency distribution of study population according to tooth brushing
Tooth
brushing
Once/day
Twice/day
3 times/day
Group1 Group2 Group3
ChiNo. % No. % No. % square
2
9
9
10 1 5
45 9 45
45 10 50
2
9
9
Pvalue
10 2.769 0.250 NS
45 0.000 1.000 NS
45 2.666 0.277 NS
Table 5: Frequency distribution of study population according to previous periodontal
treatment
Yes
No
No. % No. %
16 80
4
20
Group1
19 95
1
5
Group2
18 90
2
10
Group3
0.111
Chi-square 0.019
P-value 0.995 NS 0.438 NS
Vol. 20(1), 2008
70
65 65
65
60
60
60
% of Children
55
%.of extracted teeth
50
Percentage %
45
40
40
40
35 35
35
30
20
10
0
1-3
>3
Group 1
1-3
>3
1-3
Group 2
>3
Group 3
Figure 1: Relationship between numbers of children and numbers of extracted teeth of mothers
(represented as percentages).
Table 6: Distribution and F-test of mean PLI among the 3 groups
Mean SD
Group1 0.56 0.106
Group2 0.49 0.093
Group3 0.58 0.110
0.725
F-test
p-value 0.344 NS
Table 7: Distribution of mean GI and t-test between every two groups
Group1
Group2
Group3
Between groups
Group1&Group2
Group1&Group3
Group2&Group3
Mean
SD
0.50
0.095
0.65
0.123
0.77
0.146
t-test p-value
1.564 0.362 NS
1.523 0.370 NS
1.474 0.379 NS
Table 8: Number and percentage of PPD for each group
PPD Group1
scores No. %
18 90
<4
2 10
>4
Group2 Group3
No. % No %
15 75 13 65
5
25 7 35
90
90
75
80
<4
>4
65
70
Percentage %
60
50
35
40
25
30
20
10
10
0
Group1
Group2
Group3
Figure 2: Bar-chart of percentages of women with respect to scores of PPD for each group
Vol. 20(1), 2008
Table 9: Chi-square of PPD between every two groups (<4->4)
<4
Chi-square p-value
8.756
0.003 S
Group1&Group2
8.145
0.004 S
Group1&Group3
0.011
0.947 NS
Group2&Group3
Chi-square
p-value
>4
6.593
0.032 S
Group1&Group2
19.231
0.001 S
Group1&Group3
3.155
0.052 NS
Group2&Group3
**P<0.05 Significant
Table 10: Number and percentage of BOP for each group
Scores
0
1
90
Group1
No.
%
1716 82.658
360
17.35
82.658
Group2
No.
%
1622 81.754
362 18.245
81.754
Group3
No
%
1569 80.544
379 19.455
80.544
0
1
80
70
Percentage %
60
50
40
30
19.455
18.245
17.35
20
10
0
Group1
Group2
Group3
Figure 3: Bar-chart of percentages of women with respect to scores of BOP for each group
Table 11: Chi-square of BOP between every two groups (0-1)
0
Chi-square
0.077
Group1&Group2
2.823
Group1&Group3
0.017
Group2&Group3
1
Chi-square
0.022
Group1&Group2
6.376
Group1&Group3
0.032
Group2&Group3
**P<0.05 Significant
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(Gum)
disease
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Taichman LS, Eklund SA. Evaluation of the
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research. Svenska massan exhibition 2003; June 25-28.
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p-value
0.782 NS
0.042 S
0.896 NS
p-value
0.881 NS
0.032 S
0.858 NS
Salameh RM. The periodontal status during
pregnancy and intake of contraceptives. A thesis
presented to the University of Baghdad for the degree of
Master of Science in Periodontics. 2000.
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Tilakaratne A, Soory M, Corea SM, Silva M.
Effects of hormonal contraceptives on the
periodontium, in a population for rural Sri-Lankan
women. J Clin Periodontol 2000; 27(10): 753-7.
6.
Yalcin F, Basegmeze C. The clinical and socio–
cultural evaluation of the effects of oral contraceptives
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on periodontal condition. Istanbul University, Turkey
2002.
7.
Hamed NA. Effects of oral contraceptives intake
on the gingiva. A thesis presented to the University of
Baghdad for the degree of Master of Science in
Periodontics. 2005.
8.
Sooriy amoorthy M, Gower DB. Hormonal
influences on gingival tissues. Relationship to
periodontal disease. J Clin Periodontol 1989; 16(4):
201-8.
9.
Zachariasen RD. The effect of elevated ovarian
on hormones on periodontal health: oral contraceptives
and pregnancy. Women Health 1993; 20(2): 21-30.
10.
Preshaw PM, Mariotti A. Experimental
gingivitis in women using oral contraceptives. J Dent
Res 2001; 80(11): 2011-5.
11.
Klinger G, Dobmeier V. The effect of hormones
on the periodontal condition. clinical studies on 300
female patients. Stomatol – DDR 1979; 29(1): 7-11.
12.
Das AK, Dutta A. Oral contraceptives and
periodontal disease-II, Prevalence a severity. J Ind Dent
Assoc 1971; 43:155.
13.
Nakagaw S, Fujii Hl. A longitudinal study from
pre-puberty to puberty of gingivitis. Correlation
between the occurrence of P. Intermedia and sex
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Klinger G, Eick S. Influence of hormonal
contraceptives on microbial flora of gingival sulcus.
Contraception 1998; 57(6): 381-4.
15.
Silness J, Loe H. Periodontal disease in
pregnancy correlation between oral hygiene and
periodontal condition. Acta Odontol Scand 1964; 22:
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Loe H, Silness J. Periodontal disease in
pregnancy. I. Prevalence and severity. Acta Odontol
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Schrodi J, Recio L. The effect of aspirin on the
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Gamonal JA, Lopez NJ, Aranda W. Periodontal
conditions and treatment needs by CPITN in the 35-44
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Dent J 1998; 48:96-103.
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Funda Y, Esti E. The effect of Socio cultural
status on periodontal conditions in pregnancy. J
Periodontol 2002; 73: 178-82.
20.
Halling A, Bengtsson C. The number of
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Kalkwarf KL. Effect of oral contraceptive
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Pankhurst CL, Waite IM. The influence of oral
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Moshchil AI, Volozhin AI. Status of tissue
mineralization and the periodontium in women with
impaired ovarian function. Akusher: Ginekolo 1991; 10:
71-4.
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Mariotti A. Dental Plaque-induced gingival
diseases. Ann Periodontol 1999; 4:7-17.
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Mascarenhas P, Gapski R. Influence of sex
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Amar S, Chung KM. Influence of hormonal
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Carranza FA, Newman MG. Gingival
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Hansen PJ. Regulation of uterine immune
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Gorden CM, Le Boff MS, Glowacki J. Adrenal
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Ito I, Hayashi T. Physiological concentration of
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El-Attar TM. Prostaglandin E2 in human
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Smith MA, Lucie NP. Progesterone inhibits
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by marrow marcophages. Bri J Haematol 1986; 63: 64958
Vol. 20(1), 2008
Evaluation of the …
Evaluation of the effect of low energy laser on
gingivitis
Alaa Omran B.D.S.,M.Sc.(1)
Ali H. Abbas B.D.S., M,Sc.(2)
ABSTRACT
Background: Surgical lasers have been used in medicine for over a decade in the surgical specialties of the laryngelogy,
dermatology, plastic surgery, urology, gynecology and cardio-vascular surgery. All the clinical applications of laser discussed
previously require the use of relatively high power laser devices. In dentistry laser research and development is in its
embryogenic stage and its use on hard dental structures has been scarcely reported. The treatments of gingivitis by laser
radiation has not investigated; so the aim of the present study was to shed light on the effect of low-energy laser on
gingivitis, and the main indication for the therapeutic affect of laser because of its anti-edematous and antiinflammatory actions.
Materials and Methods: Twenty patients complaining from mild edematous gingivitis affecting the upper six anterior
teeth were divided into two groups 1: 10 laser treated patients' group and 2- 10 patients (control group). The analysis
of the results was according to the criteria of condition worsening, no change or improved and analysis of variance
bleeding (G I) was performed.
Results: Five out of 10 patients exhibited no change while 4 out of 10 were better than from the beginning, while 1 out of 10
was worse than the beginning.
Key word: Soft laser, gingivectomy, gingivitis. (J Bagh Coll Dentistry 2008; 20(1) 69-70)
INTRODUCTION
The term "Laser" is an acronym derived from
"light amplification by stimulated emission of
radiation" and that the energy produced by a laser, is a
function of the type of substance that is being stimulated
to emit, the radiation. Since laser was first developed
by Maiman in 1960 there have been many
investigations
of
its
possible
medical
applications.
The use of laser in its relationship to dentistry
is a relatively new tool. Surgical lasers have been
used in medicine for over a decade in the surgical
specialties of the laryngology, dermatology, plastic
surgery, urology, gynecology and cardio-vascular
surgery. All the clinical applications of laser
discussed previously require the use of relatively
high power laser devices.
Gingivitis is one of the most common complaints
in dental practice; and more than 90% of the
population suffers from periodontal disease. Clearly
laser can not improve the patient oral hygiene, nor can
it remove plaque and for this reason, the
dissemination of information, good patient
motivation and of course scaling of dental calculus must
be from the basis of treatment. However, patients often
have difficulty in maintaining good teeth hygiene
because of bleeding and pain, and for such patients
they can helped by laser treatment of each papilla,
after which the patient can be sent home, after a day
or so, the patient return for further treatment, at which
time it will be possible to depurate thoroughly, because
(1) Assistant lecturer, Department of Periodontology, College of
Dentistry, Univ. of Baghdad.
(2) Lecturer, Department of Oral and Maxillofacial Surgery,
College of Dentistry, Univ. of Baghdad.
of the anti-inflammatory and anti edematous effect of
low-energy laser will have reduced bleeding from the
inflamed gingiva and also reduced pain. Therefore,
the quality of time depuration will be improved
and the treatment will take less time because
subgingival tarter will be for more visible owing to
the elimination of the psudo-pockets.
Aims of the Study
The aim of the present study was to shed light
on the effect of low-energy laser on gingivitis, and
the main indication for the therapeutic affect of laser
because of its anti-edematous and antiinflammatory actions.
This investigation was carried on 20 patients
attended College of Dentistry, University of
Baghdad, chosen according to the following criteria :1- Patient age over than 21 years.
2- Minimal calculus.
3- Scores inflammation mild gingivitis "scores 2".
4- Intact crestal lamina dura.
5- No radiographic evidence of bone defect.
The 20 patients who complained from mild
edematous gingivitis affecting the maxillary six
anterior teeth divided into two groups:1- Laser treated group:
Ten patients were treated by low-energy 1. R
904 nm laser (Gallium Arsenid laser). Irradiatiot
was made to the gingiva by continuous beam of
laser fix*5 minutes for each papilla and labial
gingival margin, then the patient was given another
4 laser treatments on alternate days. During
treatment after 5 days we checked the gingival
index of the anterior teeth, then after finishing the
Vol. 20(1), 2008
treatment. The result was achieved by direct
observation and inter-viewing patients to know
how much they complained from their symptoms,
"bleeding from the gums and pain.
2- Control group:
This group consists of 10 patients, and these
patients were given instructions and motivation in
the first day and in the second day we did scaling
and polishing for the maxillary anterior teeth only
and after 10 days the results were achieved by the
same way as in the treated group.
The analysis of the results was according to
the following criteria: the condition was
worsening, no change and improved and it was
performed using analysis of variance bleeding (G
I)
RESULTS AND DISCUSSION
The result of this study was, by inter viewing
patients treated by laser who complained from mild
gingivitis mean of gingival index (score 2). Five out of
10 patients had no change while 4 out of 10
experienced better results than from the beginning,
while 1 out of 10 was worse.
By clinical examination (table 2) 4 out of 10
patients experienced a mean gingival index (0.5)
which was the lowest score while one patient still had
mild gingivitis which is score 2. This means that the
patient responded to laser treatment while there is no
significant difference between treated group and control
group. The laser treatment decreases the pain and
inflammation to help the patient who has gingivitis
for motivation and to improve oral hygiene. Many
studies reported that the low-energy laser has anti
inflammatory effect who suggested that the effect of
low-energy laser depends on the fact that laser
penetrates the tissues fluid (1-3). The energy may be
absorbed where the concentration of fluid is highest and
thus more easily absorbed by inflamed and oedematous
tissues. Since the low-energy laser has these effects we
tried it to reduce the inflammation and thus to
reduce the gingivitis.
Mester reported on the use of low-energy laser
radiation to stimulate tissue repair. (4) The effect of lowenergy laser has shown that it improves healing of
injured tissues by stimulation of fibroblasts
proliferation, increased vascularzation and accelerated
epithelization of the irradiated area in the early healing
period (5-7). These finding are supported by other
studies as Escola et al. who claimed that He-Ne laser
has a beneficial action on the processor kiratnization of
gingival tissues of following tooth extraction. (8) Takeda,
suggested that low-energy laser has a beneficial effect
on initial bony wound healing. (9). Others
suggested the use of laser for reduction of
gingivitis and patient's complaint due to the antiinflammatory and analgesic effect of laser as suggested
Evaluation of the …
by (1,11).
Table 1: Mean of gingival index during
treatment (aftrer 5 days)
Laser treated group Control group
No. of
Mean
No. of
Mean
patients
of GI
patients of GI
0
0
1
0
2
0.5
2
0.5
3
1
4
1
2
2
2
1.5
3
1.5
2
1.5
10
1 + 0.79
10
1 + 0.79
No Significance differnce for P 0.5, T=0, df= 8.
Table 2: Mean of gingival index after
treatment
Laser treated group Control group
No. of
Mean
No. of Mean
patients
of GI patients of GI
4
0,5
1
2
3
1
5
0.5
1
2
2
1
2
1.5
1
1.5
0
0
2
0
10
1 + 0.79
10
1 + 0.79
No Significance differnce for P 0.5, T=0, df= 8.
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structural tissues gingival irradiate soft-laser heliumneom. Brit Dent J 1985; 165: 221-5
9. Takeda Y. Irradiation effect of low-energy laser on
alveolar bone after tooth extraction. Int J Oral
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10. Petra WS. Studies on the effectiveness of a soft laser.
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11. Sackin, Sembokuyal Arakawak. Double-blind test
forbioestimulation effects on pain relief by diode laser.
Physics Abstr 1990; 93: 4187
Vol. 20(1), 2008
Mandibular dental …
Mandibular dental arch parameters in Down's Syndrome
patients with Class I occlusion. (A comparative study)
Nidhal H. Ghaib B.D.S., M.Sc. (1)
Dheaa H. Abd Awn B.D.S.,M.Sc.(2)
Mustafa M. Al-Khatieeb B.D.S., M.Sc. (3)
ABSTRACT
Background: The aim of this study was to find out the dental arch form for patients with Down's syndrome and to
compare the mandibular dental arch parameters of those patients with the corresponding norms, and to gain a
correlation between the maxillary and mandibular arches for the Down's syndrome patients from previous study.
Subjects and methods: A total sample of 50 patients with Down's syndrome was examined with an age ranged
from14-18 years. The mandibular dental arch parameters were compared with another group, control, on student of
an intermediate school matching with the age and Angle's classification (Class I). Study models for the maxillary and
mandibular arches were constructed, and then dental arch measurements were carried out and evaluated.
Results: The mandibular arch parameters for the patients with Down's syndrome showed significantly smaller mean
values than the control group for both genders with the males had greater values in inter arch distance and length,
with high correlation between the maxillary and mandibular jaws. The wide arch form is the dominated arch form
while the flat is the least to appear.
Conclusion: The growth pattern of dental arches in Down's syndrome patients is proportionally reduced when
compared with those of norms, with a symmetrical configuration. Hence all arch forms are presented with different
distribution.
Keyword: Down's syndrome, Dental arch parameter, Genetic influence. (J Bagh Coll Dentistry 2008; 20(1) 72-77)
INTRODUCTION
Malocclusion is an irregularity of the teeth or
malrelationship of the dental arches beyond the
accepted range of normal (1,2) . Many etiological
factors may affect the dental arch development
and may be associated with the presence of
dentofacial anomalies whether of a facial or
dental origin (3).
Down's syndrome is a disease associated
with subnormal mentality in which an extreme
wide variety of anomalies and functional
disorders may occur. This disorder was first
described by John Langdon Down, and the
condition has typical physical features and
multisystem anomalies (4).
Two different hypotheses have been
proposed to explain the mechanism of gene
action in Down syndrome: developmental
instability (loss of chromosomal balance) and
gene dosage effect (5). According to the gene
dosage effect hypothesis, the genes located on
chromosome 21 have been over expressed in
cells and tissues of Down's syndrome patients,
and this contributes to the phenotypic
abnormalities (6).
Down's syndrome is the most common
autosomal
abnormality
and
occurs
in
approximately 1 case per 700 live births.
(1) Professor, department of orthodontics, college of dentistry,
(2) Lecturer, department of orthodontics, college of dentistry,
3) Assistant lecturer, department of orthodontics, college of
dentistry, University of Baghdad.
Orthodontics, Pedodontics and Preventive Dentistry 72
It accounts for about one third of all
moderate and severe mental handicaps in schoolaged children; it has been reported in people of
all races for both genders. The characteristic
morphologic features of mongolism can be
recognized immediately at birth, but they are
obvious in children older than 1 year. Some
dermatological features increase with advancing
age (7).
The major features of Down syndrome are as
follows:
• Mental retardation- Mild to severe,
intelligence quotient (IQ) of 25-50.(8)
•
Characteristic head appearance- Small head
(brachycephaly), flat faces with increased
interoccular distance (hypertelorism), depressed
nasal bridge, flat occiput, and broad short neck.
•
Occular anomalies - Narrow and upward and
outward slating of the rima palpebrarum (80%).
•
Oral features - Small mouth (relatively) with
protrusion of the tongue (macroglossia) and
difficulty in eating and speaking, scrotal tongue,
hypoplasia of the maxilla, delayed tooth eruption,
juvenile periodontitis, and cleft lip or palate
(rare) (9,10)
Causes
Three cytogenic variants cause Down's
syndrome.
• Trisomy 21
• Chromosomal translocation
• Mosaicism
Approximately 25-30% of patients with
Down's syndrome die during the first year of life.
Vol. 20(1), 2008
The most frequent causes of death are respiratory
infections (bronchopneumonia) and congenital
heart disease (6). The life expectancy of patients
with Down's syndrome is slightly reduced.
Traditional metric studies of the dental arch
form based on linear analysis have focused on
age changes and esthetic control. Some of the
analysis have been used for purposes as age
changes, gender variation, and environmental
changes, in addition to its important in the
diagnosis
and
treatment
an
incipient
malocclusion (11). Although ideal dental arch has
no single or universal form, it may possess vital
determinants of the role of growth pattern in
developing arch form which in term affect other
type of malocclusion.(12)
There are very limited studies regarding arch
size dimensions in Down's syndrome patient.
Ghaib (13) found that the maxillary arch
dimensions of patient with Down's syndrome
were smaller and narrower than control group.
The cephalometric analysis revealed length
deficiency of the anterior cranial base with an
anteroposterior deficiency of maxillary arch
,regular but hypoplastic growth, and a diminished
anteroposterior growth of the mandible (3) .
The aims of the study are to compare the
mandibular dental arch parameters of the Down's
syndrome patients with the corresponding norms
and to find the dominate arch form and to gain a
correlation between the maxillary and
mandibular dental arches.
SUBJECTS AND METHOD
Patients attending the center of health care
for Down's syndrome (Hibbat-Allah) in Baghdad
City were clinically examined. Among 150
patients with Down's syndrome, only 50 patients
were selected who consisted of 25 male and 25
female and fulfilled the criteria of the sample
selection which are:
1. They are known cases of Down's syndrome
Iraqi nationality with an age ranged 14-18
years.
2. Full complement of permanent dentition
excluding the third molar.
3. Class I molar occlusion, free of local factors
distribute irregularity of dental arch, no heavy
filling or build up.
4. No marked facial asymmetry.
The control group consisted of healthy
students in the intermediate school having the
same criteria used for the selection of the study
group (14,15).
I. Dental arch dimension measurements
Certain tooth related points were marked
bilaterally with sharp pencil on the study cast to
facilitate the identification of the landmarks that
will be used for measuring the dental arch
dimensions.
The following landmarks were used due to
their reconcilability:
1. Incisal point (I): The point midway between
the incisal edges of the central incisors (16,17).
2. Canine point (C): The cusp tip of the right
and left permanent canines (18).
3. Mesiobuccal cusp tip (M): The mesiobuccal
cusp tip of the right and left permanent first
molars (19,20) .
4. Mesiolingual cusp tip (ML): The
mesiolingual cusp tip of the right and left
permanent first molars (17).
5. Premolar cusp tip (P): The buccal cusp tip of
the right and left second premolars (19).
Dental arch dimension (Figure 1)
Several linear measurements were implicated
to determine the dental arch width, length and
segmental measurements.
1. Dental arch width
•
Inter-canine (CC) distance: The linear
distance from the cusp tip of one canine to the
other canine (21, 22).
•
Inter first molar distance (MM lingual):
The linear distance between the mesiolingual
cusp tip of the right and left first molars (23).
•
Inter first molar distance (MM buccal):
The linear distance between the mesiobuccal
cusp tip of the right and left first molars (17).
•
Inter premolar distance (PP): The linear
distance between the buccal cusp tip of the right
and left second premolars (23).
2. Dental arch segmental measurement
•
Right incisal canine distance: The linear
distance from the incisal point to the right canine
cusp tip (24).
•
Left incisal canine distance: The linear
distance from the incisal point to the left canine
cusp tip (24).
•
Right Canine molar distance: The linear
distance from the right canine cusp tip to the
right mesiobuccal cusp tip of the first permanent
molar (16,25) .
•
Left Canine molar distance: The linear
distance from the left canine cusp tip to the left
mesiobuccal cusp tip of the first permanent molar
(16,17,25)
.
II. Anterior dental arch form measurements
Mandibular arch form was determined by
applying the approach of Raberin et al26 that
categorize the mandibular dental arch into five
forms with simple modification. Each arch form
Vol. 20(1), 2008
has characteristic percentage deviation values of
certain ratios.
Narrow: All (vertical/transverse ratios) are
positive.
Wide: All (vertical ransverse ratios) are negative.
Mid: None of the ratios significantly deviate
from the average.
Pointed: Only ratio A has intensively noticeable
higher than the average.
Flat: Only ratio A has intensively noticeable
mandibular than the average.
The vertical / transverse ratios are
A: Vertical canine distance /inter canine distance.
B: Vertical molar distance /inter molar distance.
C: Vertical premolar distance /inter premolar
distance.
Statistical analysis was carried out using
SPSS program version 12 in which the
descriptive statistic (mean and standard
deviation), and inferential statistic by student’s t
test and Pearson correlation coefficient were
carried on.
RESULTS
Table 1 reveals the descriptive statistics for
the collected data (male and female) in Down's
syndrome patient.
There is no significant difference (p>0.05)
between the left and right sides in both genders
(table 2). However, males exhibited a significant
increase (p<0.05) in intermolar and intercanine
and vertical molar distance as shown in table 3.
Table 4 shows the significant level between
the Down's syndrome patient and the control
group. The former shows a significant decrease
(p<0.05) in the posterior region as the intermolar,
vertical molar distance and the canine molar
distance.
There is a highly positive correlation
between the mandibular and the maxillary jaws,
from previous study which is presented in table
5.
The mandibular jaw demonstrates all the
arch forms, anteriorly, proposed by Raberin et al
(26)
with the wide form 44% being the dominating
one followed by the mid 20% then the narrow
16% and the pointed 11% to be the least with the
flat arch form 9% as shown in table 6 and figure
2.
DISCUSION
1. Dental arch parameters
The extent of mental deficiency in
individuals with Down's syndrome has often
been exaggerated in the literature and this may
have caused the orthodontist to shy away from
treating these patients, and this may brought the
studies on them to be very limited. Down's
patients
exhibited
subsequent
stationary
mandibular growth due to macroglossia, reduced
muscle tonicity and habitual mouth breathing
which lead to a high incidence of Cl.III basal
relation. All these causes jeopardized the authors
to apply a data base to figure out the behaviors of
the disease on the mandibular jaw parameters.
There are different types of Down's syndrome
with wide range of variety in mental and physical
anomalies (6). It is important to understand that
the growth pattern of the Down's syndrome
patients has a different range associated with the
age, and the growth spurt may be delayed but
with a very slow rate. However, in norms, the
intercanine and canine-molar distance will be
stable at the age of 13 years (23,24) .
The results showed a non significant
difference between the left and right sides in both
genders, that demonstrated symmetrical dental
arch dimensions for the Down's syndrome
patients, a fact supported by many studies (3,13)
Males with Down's syndrome demonstrate a
non significant increase in most of the linear
measurements than female and with a significant
level with others. Similar results appear in the
control group, and this agrees with many results
counted from norms (25,27-29). This may explain a
similarity in growth behavior of the jaws in
Down's syndrome patients and normal
population.
Since the intercanine and intermolar
distances are the parameters used for several
purposes especially the growth changes and
growth behavior (17), these results suggested a
proportional reduced growth of the jaws in
Downs syndrome with a symmetrical arch
dimensions ,this is truth not only in mandibular
jaw, but on the maxillary jaw as well (13,27,28).
Although the genetic implication of a disease
is not a promising issue; few studies reported
some explanations of the genetic impaction on
Down's syndrome patient. Cohen (29) depended
on the cellular and tissue mosaicism that
enhances the different features of Down's
Syndrome in which there is a mixture of genes.
Normal and abnormal in different cells or tissue
of the same type may dominate the general
features especially that of ectodermal and
endodermal in origin, resulted in different
physical disorders as overall undergrowth and
development of skull and body texture,
craniofacial structures, abnormality in skin and
hair fissurated tongue, small teeth ,…..etc.
The control group exhibited anticipated
larger values with a significant difference in
Vol. 20(1), 2008
some parameters when compared with the study
group in both sides of the different gender. This
may attribute to the above causes in addition to
the fact that those patients had high incidence of
hormonal disorders especially hypothyroidism
which represent a faulty development as it occurs
in early life (3,30-32).
2. Anterior arch form
It was found that the dominate arch form for
those patients is the wide form which means that
the vertical canine distance was relatively
reduced rather than increased inter canine width.
This is true when we compare the arch form with
the least prevalence of dental crowding (12) .
Probably the dominated wide arch resulted
from the resultant of the exterior and interior
muscle forces in which there is hypotonic
activity in the perioral musculature with
relatively wide tongue.
Figure 1: The mandibular dental arch dimension.
Table 1: Mandibular jaw parameters for persons with Down's syndrome
Male
Measurements
I-C(incis-canine)Rt.
I-C(incis-canine)Lft.
C-M(canine-mol)Rt.
C-M(canine-mol)Lft.
IC(Vertical)
IP(Vertical)
IM(Vertical)
MM(buccal)*
CC
PP
MM(lingual)
mean
13.9
14
20.7
20.6
5.4
10.3
23.2
45.7
27.4
36
36.6
S.D
0.94
1.00
1.34
1.43
1.54
1.69
1.84
1.92
0.91
2.08
1.17
Female
Measurements
I-C(incis-canine)Rt.
I-C(incis-canine)Lft.
C-M(canine-mol)Rt.
C-M(canine-mol)Lft.
IC(perpendicular)
IP(perpendicular)
IM(perpendicular)
MM
CC
PP
MM((lingual)
mean
13.44
13.44
20.44
20.33
5.33
11.89
20.78
40.22
24.00
32.00
31.78
S.D
0.63
0.63
1.01
0.87
1.00
2.42
2.17
1.52
1.22
2.15
2.92
*the intermolar distance from the mesiobuccal cusp tip. All measurements in mm
Table 2: Comparison between the genders in both sides in Down's syndrome
I-C right
I-C left Reliability C-M right C-m left Reliability
mean S.D mean S.D r value Sig, mean S.D mean S.D r value Sig.
13.9 .94 14 .63 .847 NS 20.7 1.34 20.6 1.01 .709 NS
male
female 13.4 1.0 13.4 .63 .992 NS 20.4 1.43 20.3 .87 .883 NS
(P<0.05)ٍ d.f=48; N.S= non significant (p>0.05) ; S=Significant
Table 3: Comparison between male and female in Down's syndrome
Male
Female
Sig.r value
mean S.D mean S.D
27.4 .91 24 1.22 0.042 S
C-C
M-M(lingual) 36.6 1.17 31.7 5.92 0.005 S
I-M (Vertical) 23.2 1.84 20.7 2.17 0.028 S
(P<0.05)ٍ ٍ d.f=48; N.S= non significant (p>0.05); S=Significant
Vol. 20(1), 2008
Table 4:Comparison between the control group and patient with Down's syndrome
Control
Parameter
Down's
Mean S.D Mean S.D
C-M(canine-mol)Rt.
C-M(canine-mol)Lft.
Male
IM(Vertical)
MM(lingual)
C-M(canine-mol)Rt.
C-M(canine-mol)Lft.
Female
IM(Vertical)
MM(lingual)
24.2
24.8
25.3
40.5
24.7
24.3
24.9
38.1
1.2
1.2
1.1
2
1.2
1.1
1.5
2
20.7
20.6
23.2
36.6
20.4
20.3
20.7
31.8
1.3
1.4
1.8
1.1
1.0
0.8
2.1
2.9
Sig.
r value
0.021 S
0.017 S
0.036 S
0.025 S
0.026 S
0.009 S
0.028 S
0.002 S
(P<0.05)ٍ N.S= non significant (p>0.05) , S=Significantٍ d.f=48;
Table 5: Correlation between the maxillary and mandibular jaws in Mongolic patient
parameters
maxillary jaw mandibular jaw
female
male female male
I-C(incis-canine) 16
C-M(canine-mol) 22
43.6
MM
30.4
CC
15.8
21.5
42.1
30
13.9
20.6
36.6
27.4
13.3
20.3
31.78
24
r
.979
High
correlation
Table 6: Arch form for Down's syndrome patient (in percentage)
Down's
control
Narrow Wide Mid Pointed Flat
16
44
20
11
9
24
19
18
19
18
1
2
3
4
5
Figure 2: Pie chart to define the percentage distribution of the anterior arch form of Down's
syndrome patients (1;narrow , 2;wide , 3;mid , 4;pointed , 5;flat)
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Vol. 20(1), 2008
Comparison of the Forces …
Comparison of the forces generated by steel, nickel titanium
and elastomeric separators
Akram F. Al-Huwaizi
B.D.S., M.Sc., Ph.D. (1)
ABSTRACT
Background: This study compared stainless steel spring, NiTi spring, and elastomeric ring separators for their initial
force of separation and after a tooth separation of up to 0.8mm.
Materials and Methods: The five types of separators used were TP spring, Truflex springs, NiTi springs (Ortho
Technology), Dentalastics (Dentaurum), Alastik (3M Unitek) separators. The testing apparatus consisted of a
framework holding two acrylic teeth in contact; the upper tooth attached to a calibrated micrometer that controls
the amount of separation between the teeth by fractions of a millimeter and the lower tooth attached to an
electronic balance that registers the force of separation after inserting a separator between the two teeth. After
registering the initial force of separation, the micrometer was adjusted so that the contact area was opened up to
0.8mm in increments of 0.1mm and the separating force was measured.
Results: Dentalastics exerted the highest force levels and NiTi springs showed the lowest force values; while Alastik,
Truflex and TP separators were in the middle. When the teeth where separated incrementally 0.1mm at a time, Truflex
and NiTi springs showed a gradual drop in the separation force, both elastomeric separators showed a steep drop
from their high initial forces to a relatively high remaining force at 0.8mm separation, while TP springs gave the
steepest drop that fell below 50 grams at 0.3-0.5mm separation.
Conclusions: Truflex springs gave moderate initial separation forces that remained effective even at 0.8mm
separation.
Keywords: NiTi separators, TP springs, elastomeric separators. (J Bagh Coll Dentistry 2008; 20(1):78-86).
INTRODUCTION
Separation is an orthodontic procedure aiming
at slightly loosening the tight interproximal
contacts between teeth to create space for the
fitting of orthodontic bands by forcing or
wedging the teeth apart usually for one week (1).
The ideal separator should be easy to place in
any contact, create little or no discomfort initially
and during the separation period, and generate
enough space for banding (at least .25mm),
thereby making the fitting of the band to the
tooth easy (2,3). Moreover, the separator should be
easily cleaned, be radiolucent, and not be lost or
dislodged (4).
The main types of separators are brass wire,
latex elastics (Maxian separators), elastomeric
modules or thread, stainless steel and NiTi
springs (TP, Sep-Clip, and Neet springs). Latex
and brass separators are not as popular as they
once were (2,4,5). Separating springs exert a
scissors action above and below the contact.
Elastomeric separators ("doughnuts") surround
the contact point and squeeze the teeth apart (6).
The vertical legs of the Sep-Clip and Neet spring
are divergent, so that the force against the
proximal walls of the adjacent teeth would cause
the spring to self-seat in a gingival direction (3).
Elastomeric separators seem to work best in
children and adolescents, because adult patients
commonly have tight contacts, sharp amalgam
restorations, and improperly formed crowns with
broad contacts.
(1) Assistant Professor, Department of Orthodontics, College of
Orthodontics, Pedodontics and Preventive Dentistry
Spring separators are often used in adults
because they can be inserted between teeth that
are impossible to fit with elastomeric separators
(7)
.
From the patient's perspective, spring
separators are easier to tolerate, both when they
are being placed and removed, and as they
separate the teeth. These separators tend to come
loose and may fall out as they accomplish their
purpose, which is their main disadvantage and
the reason for leaving them in place only a few
days. Elastomeric separators are more difficult to
insert, but are usually retained well when they are
around the contact, and so may be left in position
for somewhat longer periods (3,6). Sep-Clip and
Neet spring are best used with rather long clinical
crown and where the soft tissue does not
completely fill the gingival embrasure, to prevent
the loops impinging upon the soft tissue causing
discomfort to the patient (2).
Pain of moderate intensity occurs during the
separation period, and so analgesics and soft food
can be recommended. The highest intensity of
pain is reached a day after placement of
separators and gradually subsided after 5-7 days
(4,8-12)
. Commonly selected words to describe the
pain are "annoying," "sore," and "tight" (13).
Administration of 400mg of oral ibuprofen an
hour before and again 6 hours after separator
placement alleviates pain at 2 hours and at
bedtime after treatment and is better than 1 gram
paracetamol or 650mg aspirin (14-17).
When soreness of the teeth does occur, the
patient can get relief by rinsing with water as
warm as they can comfortably hold in the mouth.
78
Vol. 20(1), 2008
Soft wax can be used to shield any sharp edges of
metal separators that might inadvertently
protrude (2).
Localized periodontitis has also been
associated with subgingivally positioned
orthodontic separators therefore radioopaque
elastomeric separators with bright colors are
recommended for easier identification (4,18-20).
Another investigation demonstrates that the only
orthodontic treatment procedure that causes a
significant bacteraemia is separator placement
(21)
.
Few comparative clinical studies have
investigated the separation effect of these
separators. Hoffman (22) examined four types of
separators and concluded that plastic separators
gave the best performance; they provided
adequate early separation and continued to
separate, with the teeth rarely sensitive during
either separation or band fitting. They remained
clean and, unless removed by the patient,
remained in place. Elastomeric separators were
the least painful. Latex elastic separators were
the most painful, the most frequently lost,
sometimes disappearing sub-gingivally below the
contact or even removed by the patient himself.
They left the teeth most sensitive to band-seating
pressure. The only positive characters were the
cleanliness and the rapid separation that was
gained within one day. TP springs gave adequate
separation after one day and was maintained
thereafter. They were difficult for the
uncooperative patient to pull out and collected
the most debris as their coil trapped food and
were difficult to clean.
McGann (3) conducted an informal clinical
trial on 18 randomly selected patients to compare
Neet and TP springs, where TP springs showed
more initial discomfort but produced slightly
more space (.36mm) than Neet springs (.32mm)
after 5-8 days.
Cureton and Bice (7) found that elastomeric
separators consistently produced greater amounts
of separation mesial and distal to the maxillary
and mandibular first molars in adult patients than
Neet or TP springs did after 9-12 days.
Elastomerics also produced the fewest
separations of less than .05mm and were the
most reliable, with only about 2% loss rate.
However, these separators produced the most
patient discomfort when chewing and can be
difficult to place, especially when large Class II
amalgams are present. Neet springs were lost (5-
7%) more than either TP springs (3-5%) or
elastomeric separators (3-4%) and 5-6% of Neet
springs became rotated. More patients
complained about the TP springs (20%) than
about Neet springs (8%) or elastomerics (1%).
The most common complaints were that the
spring felt loose, the loops irritated the jaw, the
spring irritated the tongue, and it was difficult to
brush the teeth.
Bondemark et al. (4) after 5 days of separation
found that TP springs cause less separation
(0.3±0.08mm) than elastomeric separators
(0.4±0.1mm). TP springs were less painful and
lost more often than elastomeric separators.
In addition to the uses of separators to create
space before banding, they have been used in
orthodontics to separate molars to facilitate their
intrusion (23), separate teeth prior to stripping or
filling to ensure a good smooth contact areas (2427)
, create space in which clasps or crossover
wires of removable appliances will fit (1),
temporarily fill lingual sheaths of molar band
which can be uncomfortable and trap food when
empty (28), hold transpalatal bars, quadhelix and
lip bumper securely in the lingual sheaths (29-30),
correct ectopic first permanent molars (5,31-34) or
partially impacted second or third molars (35),
make low-profile composite buttons (36), and be
placed on the axle of a bite jumper to decrease lip
irritation (37).
They have also been used in other fields to
realign teeth before restorative procedures (38-40),
aid in extraction erupted teeth (41), aid in
detection of cavitation in carious approximal
surfaces in vivo (42), relief bruxism and temporomandibular disorder symptoms (43-44), initiate
tooth movement (45-48), or to induce pain (49-53) in
experimental studies.
Studies on separators have only focused on
the amount of separation and pain perception.
Because some procedures require prolonged use
of separators this study was conducted to
measure the force of separation with the teeth in
contact and after separation of 0.1 to 0.8mm.
Separators:
The separators used in this study were all new
and recently received from the manufacturer. The
properties of the five tested types of separators
are listed in table 1 and they are shown in figure
1.
79
Vol. 20(1), 2008
Table 1: Properties of the tested types of separators.
Gp.
A
Brand
Self-locking separating
Springs
Material
Cross-section
Tempered
.020” round
stainless steel
.016”x.022”
NiTi
rectangular
B
Truflex separating springs
C
NiTi separator springs
NiTi
Round
D
Dentalastics® separators
Elastomeric
Round
Elastomeric
Round
TM
E
Alastik Radiopaque
separators (SX)
TP spring
Truflex
Manufacturer
Serial No. Remarks
TP Orthodontics,
1544062 Medium
LaPorte, IN, USA
Ortho Technology,
600-436
Narrow
Florida, USA
Ortho Technology,
700-111
Molar
Florida, USA
Dentaurum, Pforzheim,
774-200-01 Posterior
Germany
3M Unitek,
406-086
Monrovia, CA, USA
NiTi
Dentalastics
Alastik
Figure 1: The separators used in the study viewed under a magnification of x5.
Testing apparatus:
It was designed and manufactured by the researchers
to evaluate the amount of force exerted by a
separator inserted between two teeth (Fig. 2). It
consists of:
1. A rigid framework consisting of a 12mm thick
upper acrylic plate fixed by four 12mm wide
studs to the lower metal plate being parallel to
each other. Rubbers stands were attached to
secure the apparatus and prevent slippage on the
bench during testing.
2. Electronic semi-micro analytical precision
balance (sensitivity 0.001g, Sartorius AG,
Gottingen, Germany) fixed to the lower metal
plate of the framework by four screws. In the
middle of the weighing pan of the balance a
vertical screw was fixed with cyanacrylate
adhesive.
3. A micrometer fixed in the center of the upper
acrylic plate. A vertical screw was attached to the
lower movable shaft of the micrometer opposing
the screw on the weighing pan of the balance.
4. Brass connectors were fitted to the upper and
lower vertical screws (attached to the micrometer
and balance). Each connector held an acrylic
tooth fixed by acrylic resin and a tightened lateral
screw (Fig. 3A). After testing, the teeth were
replaced by other pairs of teeth. The four pairs of
acrylic teeth making the four tested contact areas
are:
a) upper second premolar and first molar making the
upper mesial contact area (UM)
b) upper first and second molars making the upper
distal contact area (UD)
c) lower second premolar and first molar making the
lower mesial contact area (LM)
d) lower first and second molars making the lower
distal contact area (LD)
By rotating the upper calibrated part of the
micrometer clockwise, the lower movable shaft
moves down, approximating the two teeth to each
other, and vice versa (Fig. 3B).
Method of testing:
The testing apparatus was seated on a flat table to
prevent any measurement error of the balance, and
the pair of teeth representing the contact area was
screwed in. The balance was switched on to read
zero, and the micrometer was turned clockwise till
the two teeth touched indicated by the positive
reading of the balance. Then the micrometer was
turned counterclockwise till zero reading was
obtained.
A
B
C
D
Figure 2: Testing apparatus, A. the
micrometer, B. upper and lower connectors
with the teeth fixed inside, C. weighing pan, D.
electronic balance.
80
C
A
Vol. 20(1), 2008
elastomeric separators to return to their original
shape then the reading of the balance was registered
representing the force with the teeth in contact.
Then
the
micrometer
was
turned
counterclockwise to open the contact area 0.1mm
successively and other readings were recorded until
0.8mm separation. Finally, the separator was
removed, the balance reset to zero, and the same
procedure was repeated for all the 200 tested
separators (10 per group, 5 separator types, and 4
contact areas).
Statistical analysis:
Data were analyzed using the Statistical Package
of Social Science, version 15 (SPSS Inc., Chicago,
Illinois, USA). ANOVA and the post hoc Scheffe
tests were used to examine any significant difference
between the groups. P values of less than 0.05 were
regarded as statistically significant.
B
Figure 3: Two teeth fitted in the connectors
being in contact (A) or separated (B).
A separator was inserted by using separating
pliers for elastomeric separators or Weingart
Universal pliers (Dentaurum) for the metal springs
(Fig. 4). Five minutes were allowed for the
TP spring
Truflex
NiTi
Dentalastics
Alastik
Figure 4: The five separator types in place with teeth in contact.
RESULTS
With the teeth in contact, Dentalastics exerted the
highest force levels and NiTi separators showed the
lowest force values; while Alastik, Truflex and TP
springs were in the mid-range (Table 2 and Figure
5).
When ANOVA test was used to examine the
differences between the contact areas, statistically
significant difference were found between the
readings of the four contact areas for all the five
separator types. Post hoc Scheffe test also showed
statistically significant differences between the
contacts mesial and distal to the first molar and
between opposing contact areas. This was with a few
exceptions regarding the difference between the
contacts mesial and distal to the upper first molar for
TP springs and between the contacts mesial and
distal to the lower first molar for both elastomeric
separators (Dentalastics and Alastik) as shown in
table 2.
Concerning the difference between separators,
ANOVA test also showed significant differences
between the forces exerted by the five separator
types for each contact area (p<0.001). When Scheffe
test was used to examine the difference between
each two separator types, statistically significant
differences were found with only a few exceptions
between the midrange force separators (Alastik,
Truflex and TP springs) as shown in table 3.
When the teeth where separated incrementally
0.1mm at a time, Truflex separators showed a slow
drop in the separation force (especially in the lower)
which remained above 50 grams for all the contact
areas except for the lower distal contact area. NiTi
separators also showed a gradual decline of
separation force which fell below 50 grams at 0.70.8mm separation for the upper and at 0.4-0.6mm
separation for the lower teeth (Table 4 and Figure 6).
TP springs gave a steeper curve that fell below
50 grams at 0.5-0.7mm separation for the upper and
at 0.3-0.4mm separation for the lower teeth. On the
other hand, both elastomeric separators showed a
81
Vol. 20(1), 2008
steep drop from their high initial forces to a
relatively high remaining force at 0.8mm separation
especially for the upper teeth, while for the lower
teeth forces fell below 50 grams at 0.7mm separation
for the Dentalastics and at 0.5mm separation for
Alastik separators (Table 4 and Figure 6).
The above differences were all statistically
significant when tested by ANOVA test. However,
Scheffe test revealed significant differences between
successive teeth separations for the amount of force
exerted by the five tested separator types until
0.2mm separation for Truflex and NiTi separators,
0.4-0.6mm separation for TP springs, and 0.7mm
separation
for
the
elastomeric
separators
(Dentalastics and Alastik) as shown in table 5.
DISCUSSION
This laboratory setup simulates but does not
duplicate the clinical condition regarding factors
which affect the force generated by the separators
involving temperature and humidity. The presence
of saliva plays a lubricating effect on the separators
and water sorption may accelerate the force decay of
elastomeric separators. In this study, almost all
variables were constant except for the separator
type, size of the contact area, and separation
distances. The discussion of the findings will be
concentrated on these factors.
Elastomeric separators showed higher force
levels, TP springs being in the middle and NiTi
separators presented low force values. This finding
agrees with previous researches that reported NiTi
separators to cause less teeth separation and less
pain with the exception of immediate pain thought to
be a result of the long arms of the NiTi spring
impinging on the soft tissue (3,4,7). Since, there is a
direct relationship between the amount of force and
the amount of pain (6), pain can be considered as an
indicator of the amount of force exerted by the
separators.
Generally, the separation forces were higher in
the upper arch than the lower and this may be
explained by the broader flatter contact areas of the
upper posterior teeth than their opposing lower teeth
(54)
. So, separator inserted in
the upper arch are
stretched more and the greater the extension causes
greater force. However, the differences between the
contact areas (mesial and distal) were not consistent
for all the 5 tested separator types. This agrees with
the clinical findings of Bondemark et al. (4) who
reported that the separation at the contact areas
mesial and distal to the upper first molars did not
differ significantly.
For all separator types and in the four contact
areas, there was force decay after each separation by
0.1mm each time. This can be explained that when
the teeth are in contact the separator encircle the
contact area in the maximum stretch. When the teeth
are separated away by 0.1mm distance, this will
decrease the circumference of the contact area i.e.
decrease the tightness, as a result there will be stress
relaxation in the separator, and the force will
decrease as a result.
There is a noticeable variation in the amount of
separation forces between separators from the same
bag especially for Truflex and NiTi separators as can
be noted from their relatively high standard
deviation values in comparison to the mean force.
This can be due to that these springs did not seem to
seat on the tooth in a repeatable manner giving a
degree of subjectivity.
Although the space necessary for fitting bands
for a fixed appliance is approximately 0.25mm (3,4),
the extent of separation was studied till 0.8mm
because in some reports on treatment of ectopically
erupted molars extended separation is necessary and
a jumbo separator has been introduce. Also, the
intensity of pain was gradually reduced, but still
more than 40% of the teenagers reported some pain
after 1 week (11).
Nickel titanium alloy separators (Truflex and
NiTi separators) showed a shallow drop in the
separation force with increased teeth separation.
This decrease showed non-significant statistical
difference between successive readings after a
separation of 0.2mm. This gradual drop may be
attributed to the super-elasticity of this alloy. In spite
of the above they both gave enough forces for
separation even after 0.5-0.7mm separation which
can be because of their divergent legs pushing the
adjacent teeth apart (3). However, Truflex gave
significantly higher forces than NiTi separators
which may be because of Truflex being made of
rectangular wire and having shorter legs than NiTi
separators.
TP springs gave a steeper curve to 0.4-0.5mm
separation where forces diminished. This may be
because it is made of 0.5mm wire having little or no
effect after 0.5mm separation. Hence, these springs
should not be left in place after a separation of
0.5mm as it may be lost.
Both elastomeric separators showed sharp drops
from their high initial forces to retain effective force
levels at 0.8mm separation especially for the upper
teeth. This finding agrees with the data of Cureton
and Bice (7) and Bondemark et al. (4) who found that
elastomeric separators gave larger tooth separation
and were more consistent than TP and Neet springs.
This shows that elastomeric separators are best used
separators are to be used for a long time till the
appointment of banding or for correcting ectopically
erupting molars (34).
82
Vol. 20(1), 2008
Table 2: Descriptive data of the force exerted by the separators with the teeth in contact with the
difference between contact areas by ANOVA and Scheffe tests.
UM
UD
LM
LD
ANOVA
Scheffe test
Mean SD Mean SD Mean SD Mean SD
Sig. UM-UD LM-LD UM-LM UD-LD
NS
*
***
***
TP spring 521.969 26.122 504.07613.337 240.61019.531 271.69124.226 ***
***
***
***
***
Truflex 433.656 23.145 531.97629.680 349.48429.330 226.48534.412 ***
***
***
***
***
NiTi 224.440 14.962 261.76113.951 160.67614.588 105.12017.222 ***
***
NS
***
***
Dentalastics 774.955 26.135 657.58727.377 475.88230.708 477.97138.787 ***
**
NS
***
***
Alastik 614.154 44.270 559.53227.214 289.95714.099 273.85217.025 ***
NS, not significant; * p<0.05; *** p<0.001
TP spring
800
Truf lex
700
Group 1
TP spring
TP spring
TP spring
TP spring
Truflex
Truflex
Truflex
NiTi
NiTi
Dentalastics
NiTi
Dentalastics
600
Force (grams)
Table 3: Difference between the forces exerted
by the different separator types for each
contact area by Scheffe test.
Alastik
500
400
300
200
100
0
UM
UD
LM
LD
Contact area
Figure 5: Mean force exerted by the separators
with the teeth in contact.
Group 2
Truflex
NiTi
Dentalastics
Alastik
NiTi
Dentalastics
Alastik
Dentalastics
Alastik
Alastik
UM
***
***
***
***
***
***
***
***
***
***
UD
NS
***
***
***
***
***
NS
***
***
***
LM
***
***
***
***
***
***
***
***
***
***
LD
*
***
***
NS
***
***
*
***
***
***
NS, not significant; * p<0.05; *** p<0.001
Table 4: Descriptive data of the force exerted by the separators according to the amount of tooth
separation.
LD
LM
UD
UM
Separator
TP spring
Truflex
NiTi
Dentalastics
Alastik
TP spring
Truflex
NiTi
Dentalastics
Alastik
TP spring
Truflex
NiTi
Dentalastics
Alastik
TP spring
Truflex
NiTi
Dentalastics
Alastik
Amount of separation
0.0mm
0.1mm
0.2mm
0.3mm
0.4mm
0.5mm
0.6mm
0.7mm
0.8mm
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
522.0 26.1 416.1 43.9 275.0 24.9 161.8 20.0 76.4 11.9 34.3 11.1 10.7 6.8 0.0 0.0 0.0 0.0
433.7 23.1 315.3 23.4 280.3 21.3 256.1 19.4 231.7 20.9 212.9 15.8 191.5 11.5 173.4 19.2 159.4 16.0
224.4 15.0 150.4 11.1 129.6 7.6 102.2 11.8 86.4 7.6 76.5 6.2 71.1 7.4 34.5 8.7 16.6 5.6
775.0 26.1 684.6 21.0 598.2 23.3 494.8 55.9 434.2 22.9 345.5 20.6 267.5 16.8 194.1 16.1 131.8 10.1
614.2 44.3 509.6 42.2 416.3 33.8 330.5 32.4 253.9 28.9 183.0 26.3 126.4 18.4 84.6 9.4 58.4 8.2
504.1 13.3 415.5 14.8 330.5 11.6 273.3 16.2 198.7 7.9 124.4 5.5 77.8 4.0 2.2 2.9 0.0 0.0
532.0 29.7 445.5 29.0 395.4 27.0 344.5 36.0 264.3 26.7 182.4 36.2 125.1 19.4 83.5 26.9 55.2 20.7
261.8 14.0 165.3 5.5 146.7 12.5 132.9 14.4 113.9 13.3 97.6 10.8 77.2 8.7 56.8 11.7 37.2 5.4
657.6 27.4 563.5 45.0 482.5 47.3 405.0 51.4 338.6 50.9 279.0 46.0 219.8 35.7 160.2 29.3 109.4 23.2
559.5 27.2 481.1 34.0 403.6 30.0 335.2 28.4 274.8 27.5 212.1 21.7 161.9 15.7 105.9 11.6 70.3 7.2
240.6 19.5 140.5 23.6 69.8 16.0 12.5 14.1 1.8 5.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
349.5 29.3 226.8 24.5 199.6 20.8 178.2 16.9 150.9 16.5 127.8 14.3 101.2 17.0 75.3 17.0 62.0 17.0
160.7 14.6 114.5 15.1 102.6 17.9 83.8 18.7 65.0 16.7 54.8 18.7 39.4 17.1 32.0 20.3 17.6 14.5
475.9 30.7 422.2 33.9 352.8 36.5 280.9 36.4 209.9 27.1 141.7 20.1 86.3 16.6 41.3 11.6 7.5 4.1
290.0 14.1 218.8 10.7 164.7 14.2 111.7 8.0 77.9 6.6 44.4 2.7 15.8 2.9 0.0 0.0 0.0 0.0
271.7 24.2 201.0 37.5 131.2 26.6 64.1 20.2 13.7 14.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
226.5 34.4 170.6 30.9 141.3 25.9 111.4 19.0 85.6 16.7 64.0 20.9 51.0 19.9 38.1 14.0 22.1 9.0
105.1 17.2 78.5 16.3 64.1 12.9 53.2 13.5 47.4 10.3 39.6 10.2 31.9 7.4 24.9 5.3 16.0 5.0
478.0 38.8 416.5 28.0 341.9 28.8 271.3 24.0 203.8 22.2 136.6 17.1 90.6 11.7 46.3 10.3 23.5 6.1
273.9 17.0 214.4 18.2 165.6 15.7 120.2 12.2 79.4 10.9 46.5 10.7 16.8 5.2 3.2 3.6 0.0 0.0
83
Vol. 20(1), 2008
800
800
UM
UD
700
TP spring
Truflex
700
TP spring
Truflex
600
NiTi
600
NiTi
Dentalastics
500
Alastik
400
300
Force (grams)
Force (grams)
Dentalastics
500
Alastik
400
300
200
200
100
100
0
0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.0
0.1
0.2
0.3
Separation Distance
800
0.5
0.6
0.7
0.8
800
LM
LD
700
TP spring
Truflex
700
TP spring
Truflex
600
NiTi
600
NiTi
Dentalastics
500
Alastik
400
300
Force (grams)
Force (grams)
0.4
Separation Distance
Dentalastics
500
Alastik
400
300
200
200
100
100
0
0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.0
0.1
0.2
0.3
Separation Distance
0.4
0.5
0.6
0.7
0.8
Separation Distance
Figure 6: Mean forces generated by the five separator types at different levels of teeth separation (in
mm) for the four contact areas.
Table 5: Difference between successive teeth separations for the amount of force exerted by the five
tested separator types by ANOVA and Scheffe tests.
Contact
area
UM
UD
LM
LD
Separator ANOVA
Scheffe test (Gp. 1 - Gp. 2)
type
Sig.
0-.1mm .1-.2mm .2-.3mm .3-.4mm .4-.5mm .5-.6mm .6-.7mm .7-.8mm
***
***
***
***
***
*
NS
NS
NS
TP spring
***
***
NS
NS
NS
NS
NS
NS
NS
Truflex
***
***
**
***
NS
NS
NS
***
*
NiTi
***
***
***
***
**
***
***
***
**
Dentalastics
***
***
***
***
***
**
*
NS
NS
Alastik
***
***
***
***
***
***
***
***
NS
TP spring
***
***
NS
NS
***
***
*
NS
NS
Truflex
***
***
NS
NS
NS
NS
NS
*
NS
NiTi
***
*
*
NS
NS
NS
NS
NS
Dentalastics
***
***
***
***
***
***
*
**
NS
Alastik
***
***
***
***
NS
NS
NS
NS
NS
TP spring
***
***
NS
NS
NS
NS
NS
NS
NS
Truflex
***
***
NS
NS
NS
NS
NS
NS
NS
NiTi
***
***
***
***
***
*
NS
NS
Dentalastics
***
***
***
***
***
***
***
*
NS
Alastik
***
***
***
***
***
NS
NS
NS
NS
TP spring
***
***
NS
NS
NS
NS
NS
NS
NS
Truflex
***
NS
NS
NS
NS
NS
NS
NS
NiTi
***
***
***
***
***
***
*
*
NS
Dentalastics
***
***
***
***
***
***
***
NS
NS
Alastik
NS, not significant; * p<0.05; ** p<0.01; *** p<0.001
84
Vol. 20(1), 2008
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Vol. 20(1), 2008
The role of environmental …
The role of environmental versus genetic factors on tooth
and dental arch dimensions in a twin sample
Nagham M.J. Al- Mothaffar B.D.S., M.Sc. (1)
Salwa H.A. Al- Baghdady B.D.S., M.Sc. (2)
ABSTRACT
Background: Genetic variability and heritability were estimated for mesiodistal tooth diameters and dental arch
dimensions to evaluate the relative influence of genetics and environment on them and to determine if monozygotic
and dizygotic twin can be differentiated on the basis of comparison between these parameters.
Materials and methods: A sample of 32 pairs of monozygotic twin (13 males and 19 females) and 30 pairs of dizygotic
twin (12 males and 18 females), both groups age range was 13-23, were selected. Both mesiodistal crown dimension
and dental arch parameter were identified and the data was analyzed through two main quantitative genetic
approaches, simple variance analysis (f ratio) and classical correlation analysis (falconer's formula).
Results: the maxillary left central incisors was the common tooth which has high genetic variability and strong
heritability estimate in total twin sample and in male and female twin pairs, A potential source of common
environment contribution to tooth size was found in male twin pairs while females were appeared to have an impact
on dental arch dimension.
Conclusions: the maxillary left central incisors may be useful as an additional tool for zygosity determination along
with other trait, while dental arch dimensions are not recommended for zygosity diagnosis. Common environment
revealed an effect on teeth in males and on dental arch dimension in females.
Keywords: twin, genetics, tooth diameter and dental arch. (J Bagh Coll Dentistry 2008; 20(1)87-94)
INTRODUCTION
Genetics research has been used in dentistry
to evaluate the inheritance potential of numerous
orofacial traits. Significant and major genetic
effects have been reported for the mechanisms
that
influence
intra-alveolar
dental
development,(1) mesiodistal tooth dimension,(2,3)
buccolingual tooth dimension,(4) morphologic
variation in permanent molar teeth,(5) the
Carabelli cusp trait,(6,7) cleft lip/palate,(8) as well
as various other aspects of the craniofacial
complex.(9)
The fact that many traits or characteristics of
clinical interest are familial (run in families) has
been recognized since the earliest days of
dentistry and medicine. However, it has been
most
expeditious
to
concentrate
on
environmental factors that contribute to disease,
paying relatively little attention to individual
differences either in disease susceptibility or in
the traits that relate to the disease process. (10)
For over 100 years, twin studies have served as
a basic tool in evaluating the relative contribution
of genetic and environmental factors (11,12) as it
serve as a unique resource for evaluating the
interactions between genetic and environmental
effects, helping to provide a more scientifically
based rationale for orthodontic treatment.(13)
(1) Assist. Professor at the Department of Orthodontics, College
of Dentistry, University of Baghdad.
(2) Specialist in the ministry of health
However, the twin method is limited in several
ways, not only because it is difficult to obtain a
sufficient number of twin pairs, but also because it
can be difficult to establish zygosity and confirm
that environmental factors are in fact the same for
both members of a twin pair.(14)
This twin study was performed to evaluate the
relative influence of genetics and environments on
tooth and dental arch dimensions. Also, to
determine if monozygotic (identical) and dizygotic
(non-identical) twins can be differentiated on the
basis of comparison of tooth size and dental arch
dimensions.
The sample of this study composed of 32 pairs
of monozygotic twins (13 males and 19 females)
and 30 pairs of like-sexed dizygotic twins reared
together (12 males and 18 females), opposite-sex
dizygotic twin pairs were excluded automatically
because of the effect of sex differences within a
pair on tooth and dental arch dimensions.(2,15,16)
The two twin groups had the same age range (1323y) since the diversity in ages of monozygotic
and dizygotic twins leads to an incorrect
assessment of genetic influences. If the dizygotic
group belongs to an older age group than that of
the monozygotic group, an overestimate of the
genetic influence is obtained as differences due to
environmental factors will tend to increase with
time. Therefore, a uniformity in age is essential in
the two groups, though a younger dizygotic than
monozygotic group is permissible as it would
Vol. 20(1), 2008
result in an underestimation which is preferable
to an overestimation of the genetic influence.(17)
In respect with mesiodistal tooth dimensions, at
13 years old, most permanent teeth completed
their eruption in the oral cavity (except third
molar) and corrections for age were not
considered necessary since the final size of dental
crowns is determined before emergence of the
teeth into the oral cavity, and any teeth
displaying significant wear at measurement sites
were excluded from subsequent analyses.(16,18)
Mesiodistal Crown Diameter
This measurement was made directly on dental
casts and included the mesiodistal diameter of
the 24 maxillary and mandibular teeth, measured
from the central incisor to the first permanent
molar in each quadrant.
Dental Arch Dimensions
Inter-Canine Width (I-C): Horizontal distance
between the cusp tips of the right and left
permanent canines.
Inter-First Molar Width (I-M): Horizontal
distance between the mesio-buccal cusp tips of
the right and left first permanent molars.
Vertical Canine Distance (VCD): The vertical
distance
from
the
inter-incisal
point
perpendicular to the inter-canine width at the
cusp tips.
Vertical Molar Distance (VCD): The vertical
distance
from
the
inter-incisal
point
perpendicular to the Inter-first molar width.
Anterior Alveolar Palatal Width (AAP): Horizontal
distance between right and left permanent
canines from the mid point on the gingival
margin palataly.
Palatal Width (PW): The linear distance between
the mesio-lingual cusp tips of the right and left
first permanent molars.
Posterior Alveolar Palatal Width (PAP): Horizontal
distance between right and left first permanent
molars from a point on the gingival margin
palataly and in relation to mesiopalatal cusp tip.
Palatal Length (PL): This distance is equivalent
to vertical molar distance at the mesio-lingual
cusp tips of the first permanent molars.
Palatal Depth (PD): The vertical distance from a
point at line joining the mesio-lingual cusp tips
of the first permanent molars to the
corresponding palatal vault in the midline.
The statistical analysis included:
• Genetic variability estimation (F ratio)
To analyze the differences between mean
intrapair variance of different groups (MZ vs. DZ
in total sample and in male and female) for tooth
and dental arch measurements. This ratio is a test
for hereditary component of variability. Absence
of significance concerning this ratio could be
attributable to large environmental influences on
monozygotic twins or small genetic variability
between dizygotic twins. (F=V DZintrapair / V
MZintrapair).(17,19)
• Heritability estimate (Falconer’s formula): To
quantify the relative importance of genetic and
environmental influences on trait variation, and
this included: (20,21)
Heritability (h2): Referred to proportion of
variance attributable to genetic influence and it
was estimated as twice the difference between the
MZ and DZ twins correlations [h2=2(rMZ - rDZ)]
Common (shared) environment (c2): Referred
to proportion of variance due to environmental
factors shared between twins such as
socioeconomic status, parenting style, childhood
diet or peer influences shared by both adolescent
twins, etc…and it was estimated as twice the DZ
correlation minus the MZ correlation [c2 =2rDZ rMZ].
Unique (not shared) environment (e2): Referred
to proportion of variance due to environmental
factors not shared between twins such as accidents,
differential parental treatment, differential prenatal
exposure ,etc…and it was estimated as 1 minus
heritability plus common environment [e2= 1 -( h2
+ c2)].
The classic twin study, in which MZ and DZ
twins are reared together in the same family, is one
of the most powerful designs for estimating genetic
and environmental effects, since both members
have been raised in the same home, major
nutritional and other environmental factors are
similarly reduced to a practical minimum for
human studies. This approach is based on the fact
that MZ twins are genetically identical and thus the
correlation between genotypes is one, whereas DZ
twins only share one-half of their genes on average.
By definition, the common environment is shared
by both individuals of a pair, so it is assumed to be
equal for both DZ and
MZ twins reared together. Random environment
is unique for each individual.(22)
Genetic and Heritability Estimation
Human dental crowns are complex structures
without simple genetic or environmental
determination, but mathematical modeling of data
from family studies is now providing a more
complete picture of their ontogeny.(16) Two main
quantitative genetic approaches had been used by
researchers seeking to clarify the causes of
observed variation in the human dentition: A
simple variance analysis (F ratio) 2,17,19,23 and
classical
correlation
analysis
(Falconer’s
formula).(24)
Vol. 20(1), 2008
Table 1: Comparison between monozygote and
dizygote in mesiodistal tooth diameter and dental
arch dimensions.
Tooth
no. / side
1
2
3
4
5
6
1
2
3
4
5
6
Genetic variability
Falconer’s formula
MZ
DZ
F
h2
c2
e2
UR
0.017
0.080
4.635
0.354
0.598
0.047
UL
0.020
0.170
8.306
0.780
0.183
0.037
UR
0.035
0.094
2.683
0.347
0.543
0.110
UL
0.032
0.102
3.230
0.484
0.437
0.079
UR
0.017
0.072
4.211
0.450
0.456
0.094
UL
0.018
0.046
2.633
0.361
0.552
0.088
UR
0.018
0.062
3.385
0.472
0.402
0.127
UL
0.020
0.067
3.300
0.789
0.121
0.091
UR
0.031
0.065
2.091
0.331
0.505
0.165
UL
0.039
0.046
1.182
0.392
0.448
0.160
UR
0.044
0.099
2.277
0.321
0.618
0.061
UL
0.048
0.096
1.993
0.388
0.557
0.055
LR
0.019
0.048
2.545
0.653
0.230
0.118
LL
0.030
0.056
1.839
0.586
0.242
0.172
LR
0.017
0.032
1.825
0.410
0.484
0.106
LL
0.025
0.030
1.218
0.258
0.599
0.143
LR
0.029
0.068
2.314
0.264
0.628
0.107
LL
0.028
0.058
2.056
0.325
0.562
0.113
LR
0.013
0.037
2.800
0.442
0.515
0.043
LL
0.015
0.047
3.197
0.432
0.515
0.053
LR
0.034
0.107
3.121
0.446
0.447
0.107
LL
0.034
0.131
3.899
0.533
0.361
0.106
LR
0.050
0.109
2.183
0.678
0.275
0.047
LL
0.023
0.072
3.059
0.609
0.355
0.037
0.266
0.218
Dental arch dimensions
upper
lower
In the present study, the genetic variability (F
ratio) was found to have higher significant
differences in mesiodistal tooth dimension of
maxillary central incisors and in right canines
(Table 1), which means that the causes of
variability in these teeth is mostly due to their
genes, while absence of significances concerning
this ratio in the remaining teeth could be
attributed to large environmental influences on
monozygotic twins or small genetic variability
between dizygotic twins.(19)
Horowitz et al found that there is a strong
genetic component of variability of the four
maxillary and four mandibular incisor teeth and
the
differences
between
members
of
monozygotic and dizygotic twin pairs are
statistically significant for all of these teeth and
he found that the canine teeth (except for the
mandibular right one) gave an evidence of much
less hereditary component of variability. In this
study, the maxillary central incisors and
especially the left one (as in Horowitz study)
showed significant genetic variability and the
canines had the least hereditary component of
variability except for the maxillary left canine. (2)
Recalculating the amount of genetic
influences by using Falconer’s formula,
heritability (h2) in maxillary teeth was found to
have high values in left central incisor and left
first premolar (0.780 and 0.789) whereas in
mandibular teeth, high values were found in right
central incisors and in right and left first molars
(0.653, 0.678 and 0.609). This result agrees with
Dempsey and Townsend who found high
heritability value in maxillary left central incisor
and left first premolar (89 and 85) and in
mandibular right central incisors and in right and
left first molars (83, 88 and 89). (16)
The variation in estimates of heritability among
studies reflects the different statistical approaches
used, and probably also the different population
from which samples were drawn since there may
have been greater environmental effects within
some than others.18
Therefore, heritability analysis was performed
separately by using two different statistical
approaches: Falconer’s formula and an analysis
of variance, then the results were compared and
there is no doubt that the shared one had been
chosen. Accordingly, the left central incisor is
the tooth which had both high component of
variability and strong heritability. The
differential heritability with position in incisors
was distinct and this evidence was also reported
by Dempsey et al . (18)
I-C
0.573
I-M
VCD
1.687
2.943
0.516
1.022
2.000
1.958
0.462
0.444
0.094
0.341
0.358
1.049
0.907
0.012
0.081
VMD
0.747
0.905
1.212
0.870
0.043
0.087
AAP
0.453
1.533
3.387
0.477
0.321
0.202
PAP
0.604
2.460
4.074
0.419
0.472
0.109
PW
1.010
2.434
2.409
0.447
0.432
0.122
PL
0.481
0.798
1.658
0.730
0.216
0.053
PD
0.485
2.169
4.470
0.413
0.397
0.190
I-C
0.513
1.140
2.222
0.711
0.201
0.088
I-M
1.179
3.315
2.812
0.473
0.416
0.111
VCD
0.208
0.498
2.392
0.807
0.088
0.106
VMD
0.395 1.430 3.617 0.855 0.018 0.127
All measurements are in mm and for f ratio: Degree of
freedom=61, * Significant at 0.05 ≥ p > 0.01, ** Significant at 0.01
≥ p > 0.001. Falconer’s formula: high value is either with bold font
or with under line and inclined
In male twin pairs (Table 2), the genetic
variability (F ratio) was significant in maxillary
right and left central incisors, left first premolar
Vol. 20(1), 2008
Table 2: Comparison between male monozygote
and dizygote in mesiodistal tooth diameter and
dental arch dimensions.
Tooth
no. / side
1
2
3
4
5
6
1
2
3
4
5
6
Genetic variability
MZ
DZ
F
h2
c2
e2
UR
0.012
0.113
9.304
0.509
0.458
0.034
UL
0.017
0.153
8.907
0.639
0.329
0.032
UR
0.036
0.051
1.436
0.114
0.633
0.254
UL
0.021
0.043
2.034
0.247
0.616
0.137
UR
0.022
0.024
1.086
0.614
0.267
0.119
UL
0.024
0.037
1.503
0.471
0.411
0.119
UR
0.021
0.036
1.733
0.153
0.712
0.134
UL
0.018
0.093
5.082
0.748
0.166
0.086
UR
0.027
0.103
3.819
0.715
0.161
0.124
UL
0.036
0.053
1.462
0.275
0.529
0.196
UR
0.048
0.115
2.397
0.364
0.587
0.049
UL
0.078
0.123
1.568
0.497
0.446
0.057
LR
0.024
0.038
1.585
0.678
0.195
0.127
LL
0.052
0.061
1.163
0.571
0.193
0.237
LR
0.022
0.050
2.221
0.788
0.088
0.124
LL
0.036
0.048
1.314
0.762
0.062
0.176
LR
0.032
0.086
2.708
0.103
0.772
0.125
LL
0.027
0.067
2.461
0.293
0.572
0.135
LR
0.021
0.029
1.340
0.132
0.800
0.069
LL
0.025
0.028
1.117
0.347
0.588
0.064
LR
0.038
0.120
3.120
0.441
0.450
0.109
LL
0.024
0.181
7.636
0.823
0.105
0.072
LR
0.029
0.035
1.206
0.549
0.412
0.039
LL
0.016
0.050
3.084
0.321
0.654
0.025
I-C
0.432
1.246
2.882
0.117
0.528
0.355
I-M
1.026
2.934
2.860
0.735
0.160
0.105
VCD
0.434
0.297
0.686
0.865
0.074
0.060
VMD
0.481
0.720
1.497
0.962
0.004
0.034
AAP
0.542
1.124
2.073
0.845
0.000
0.155
PAP
0.447
4.139
9.260
0.472
0.356
0.172
PW
0.835
2.305
2.759
0.795
0.033
0.173
PL
0.237
0.690
2.906
0.876
0.105
0.019
PD
0.691
3.470
5.019
0.761
0.062
0.177
I-C
0.844
0.546
0.647
0.880
0.023
0.097
I-M
1.125
4.623
4.109
0.437
0.438
0.125
VCD
0.153
0.611
3.994
0.883
0.075
0.041
upper
lower
and in mandibular left second premolar, while in
female twin pairs (Table-3); the significant
differences in variance were found in maxillary
left central incisors, right canine, right first
premolar and in mandibular right and left first
premolar. In the study of genetic variation in
maxillary and mandibular anterior teeth
Dempsey et al found that the genetic variation in
maxillary left central incisors in male and female
twin pairs were equal while, the heterogeneity
were found in maxillary right central incisor. (18)
Concerning the heritability estimation ( h2), in
males the higher value was found in upper left
central incisor, right canine, left first premolar
and right second premolar. In the mandible it was
high in right central incisor, right and left lateral
incisor and left second premolar. In females
heritability estimate (h2) was high in the upper
left central incisor, right and left first premolar,
and in the lower right and left central incisors,
right and left first molars. Obviously the
maxillary left central incisor was the shared tooth
between male and female twin pairs since it
possessed the high genetic variability and high
heritability estimate.
Thus, the compatibility between males,
females and total sample related to the genetic
variability of maxillary left central incisor, for
instance, we can add this tooth to the other
diagnostic traits which make the differentiation
between zygosity (MZ and DZ twins) possible in
case when the complicated and expensive
methods (which are more reliable) are not
feasible.(25)
In dental arch dimensions, all variances in MZ
twin pairs were less than that of DZ twin pairs
(Table 1) and this comes in agreement with
Corruccini and Potter who found that MZ
similarity exceeded that shown by DZ twins in
arch size, shape and occlusion. (26) A polygenic
mode of inheritance is generally accepted for the
range of dental arch variations.(27-29) The classic
work of Lundström on twins also indicated a
stronger genetic than environmental component
for variations.(30)
However, advances in methodology have
provided new insight into the role of genetics
versus environment in determining arch and
palatal dimensions.
The results of genetic variability estimation (F
ratio) between MZ and DZ twin groups (Table 1)
revealed non-significant differences in all arch
dimensions except for posterior alveolar palatal
width and palatal depth.
VMD
0.565 2.062 3.652 0.780 0.036 0.184
≥ p > 0.001. Falconer’s formula: high value is either with bold font
or with under line and inclined.
Shapiro stated that the greater contribution of
genetic factors was to variance of palatal height
(depth) in comparison with length (23) and Boraas et
Vol. 20(1), 2008
Table 3: Comparison between female monozygote
and dizygote in mesiodistal tooth diameter and
dental arch dimensions.
Tooth
no. / side
1
2
3
4
5
6
1
2
3
4
5
6
Genetic variability
MZ
DZ
F
h2
c2
e2
UR
0.019
0.060
3.178
0.259
0.689
0.053
UL
0.024
0.184
7.757
0.779
0.187
0.035
UR
0.034
0.120
3.564
0.495
0.439
0.066
UL
0.040
0.126
3.121
0.597
0.340
0.063
UR
0.014
0.106
7.399
0.499
0.411
0.090
UL
0.014
0.055
3.961
0.413
0.511
0.076
UR
0.018
0.074
4.232
0.689
0.198
0.114
UL
0.022
0.053
2.401
0.783
0.130
0.086
UR
0.034
0.038
1.102
0.111
0.703
0.186
UL
0.041
0.043
1.044
0.269
0.594
0.137
UR
0.043
0.094
2.195
0.508
0.423
0.068
UL
0.027
0.085
3.161
0.484
0.466
0.050
LR
0.017
0.052
3.159
0.881
0.008
0.111
LL
0.017
0.056
3.316
0.850
0.036
0.114
LR
0.015
0.022
1.441
0.249
0.661
0.090
LL
0.016
0.018
1.094
0.131
0.779
0.091
LR
0.029
0.059
2.036
0.498
0.383
0.119
LL
0.030
0.055
1.820
0.412
0.459
0.129
LR
0.007
0.042
6.053
0.693
0.283
0.024
LL
0.008
0.062
7.508
0.510
0.449
0.042
LR
0.034
0.102
3.022
0.424
0.471
0.105
LL
0.041
0.096
2.345
0.333
0.539
0.128
LR
0.067
0.164
2.460
0.882
0.073
0.045
LL
0.029
0.088
3.041
0.838
0.118
0.044
Upper
Lower
al indicated significant genetic influence in arch
width,(31) while Riquelme and Green found that
the palatal width, depth and length dimensions
revealed a significant component of hereditary
variability.(19) The findings of Falconer’s formula
for dental dimensions, the results were in contrast
with that of variance analysis (F ratio). Higher
heritability were found in maxillary lengths
(VCD, VMD and PL), mandibular inter canine
width and lengths (VCD and VMD). This comes
in line with Corruccini and Potter who found that
arch length was more heritable than inter-molar
breadth.(26)
In male twin pairs, significant differences and
of genetic variability were found in posterior
alveolar palatal width and palatal depth, the same
as total sample, whereas non-significant (F
ratios) in maxillary anterior length and in
mandibular inter canine width (Table 2). The
male MZ twins showed higher variance than
male DZ twins for these two dimensions and this
was clarified by Sharma and Corruccini who
found that the MZ twin pairs have higher
variance than DZ twin pairs in some arch and
palatal dimensions and they explained the reason
that this may be occur due unequal
environmental variance rather than greater MZ
genetic variation,(32) or in the word of
Kempthorne and Osborne: it is due to
competitive forces that are different for
zygosities.(33)
In contrast, heritability estimate (h2) in male
twin pairs was high in all dimensions except for
maxillary inter-canine width, posterior alveolar
palatal width and mandibular intermolar width.
For that reason, the shared dimension in male
twin pairs which had a high genetic variability
and high heritability estimate was palatal depth,
the same result of the total sample.
In female twin pairs, the genetic variability was
high in anterior alveolar palatal width and palatal
depth and in mandibular inter canine width and
mandibular length (Table 3), while heritability
estimate (h2) was found to have higher values in
maxillary inter-canine width and lengths (VCD,
VMD and PL), and in mandibular widths (I-C
and I-M) and length (VMD). Therefore, the two
mandibular dimensions I-C and VMD were
considered the shard dimensions in female twin
pairs which had both high genetic variability and
high heritability estimate.
Actually there was no shared dimension with
both high genetic variability and heritability
between male and female twin pairs, for that
reason dental arch dimensions were not
recommended for zygosity diagnosis in twins
and this agrees with Riquelme and Green who
I-C
0.698
1.711
2.452
0.607
0.176
0.217
I-M
1.068
1.434
1.343
0.459
0.445
0.096
VCD
0.295
0.377
1.275
0.697
0.207
0.095
VMD
0.920
1.062
1.154
0.880
0.004
0.116
AAP
0.417
1.753
4.207
0.265
0.452
0.283
PAP
0.736
1.428
1.940
0.290
0.586
0.124
PW
1.182
2.374
2.009
0.294
0.567
0.139
PL
0.607
0.893
1.471
0.707
0.209
0.085
PD
0.305
1.277
4.189
0.219
0.579
0.202
I-C
0.261
1.550
5.940
0.750
0.186
0.064
I-M
1.260
2.660
2.111
0.714
0.170
0.116
VCD
0.247
0.430
1.742
0.338
0.457
0.204
VMD
0.231
1.074
4.647
0.840
0.075
0.086
≥ p > 0.001. Falconer’s formula: high value is either with bold
font or with under line and inclined
concluded that palatal width, height and length
couldn’t be used as a diagnostic aid in
determination of twin zygosity.(19)
Vol. 20(1), 2008
Environmental contribution to variability
It is indisputable that genetics plays an
important role in determining tooth size, other
research suggested, however, that the
environmental influence on tooth morphology is
great and perhaps of even greater significance
clinically than inheritance. Evidence from twin
studies had shown that when inheritance is the
same but environment differs to some degree,
bilateral concordance is lower. (34) In general,
environmental factors ranged from climate,
nutrition, and life style to oral dental pressure
habits, muscle malformation and orthodontic
treatment.(35)
In total twin sample, Falconer’s formula (Table
1) provided evidence of common environmental
influences (c2) on the maxillary right central and
lateral incisor, left canine, right second premolars
and right and left first molars. The Falconer’s
formula provided evidence of common
environmental influences on teeth with high
values of (c2), since the DZ correlations were
almost as high as those for MZ twins in these
teeth. This is in accordance with Dempsey and
Townsend (2001) who indicted common
environmental variation in mesiodistal dimension
of the maxillary first molars. (16) The first molar
is exceptional among permanent teeth because it
begins to calcify at birth, or soon after. The softtissue phase, during which a tooth's form is still
malleable, ends with completion of calcification.
If any aspect of the uterine environment affects
tooth crown size, it might be expected to
manifest itself as a common environmental
factor, and most likely would be expressed in the
deciduous teeth and permanent first molars.
In relation to environmental influence on tooth
size, Dempsey et al stated that one potential
source of shared environmental contribution to
tooth size is the hormonal composition of the
uterine environment. In humans, males have
larger teeth on average than females.(18) If
androgens contribute to increased tooth size and
are able to diffuse from one twin to the other,
then we might predict an increased similarity in
dental dimensions of males DZ twins compared
with females DZ twins (Table 2,3). This would
be reflected in statistical analyses as a common
environmental effect in males. Indirect evidence
for hormonal exchange between human twins
arises from a preliminary study of opposite-sexed
twins, in which we noted a trend toward larger
teeth in females with twin brothers, than in
females with twin sisters.(36)
In the maxillary and mandibular four anterior
teeth, the DZ correlations were greater than half
the MZ correlations for all variables especially
for maxillary lateral incisors in males and for
mandibular lateral incisors in females, and this
disagrees with Dempsey et al, who found the DZ
correlations were greater than half the MZ
correlations for all variables especially for all
central incisors in males and for the lower central
incisors in the females. (18)
There is experimental evidence from studies on
animals that the size and shape of teeth may be
modified by environmental factors during the
period of dental development. Other than gross
changes such as enamel hypoplasia consequent to
developmental insults, subtle changes have been
induced by dietary modifications. An alteration in
mineral, vitamin, or protein content in the maternal
diet of rats and their detectable effects on molar
size in the offspring have been reported.(37,38)
Another specific non-genetic factor, maternal
effect on molar size of offspring in the house
mouse, has been reported.(39) This maternal effect
was further shown to be composed of prenatal and
postnatal maternal effects.(40)
The effect of common environment (c2) was
moderate to low in all dental arch dimensions. In
general, it had a greater effect on arch width (total,
males and females groups) with an exception of
females having higher values and other effects on
palatal depth and lower anterior arch length.
So far the common environment appears to have
an impact on dental arch dimensions especially for
females. Though the unique environment (e2) had
their higher values in maxillary inter canine width
(0.217) and anterior alveolar palatal width (0.283),
again with higher and more pronounced affects in
females which are extended to involve palatal
depth and the anterior length of the mandible. Hu
et al, who studied heritability of dental arch
dimensions, found that there were few significant
variability differences between sons and daughters,
and between upper and lower for each variable.(41)
Sex chromosomal involvement was not confirmed,
but maternal effects were found to be more evident
in daughters than in sons, for both arches.
Comparisons among the heritability of overall and
of anterior arch dimensions indicated that size of
the anterior part of the dental arch might be less
resistant to environmental factors, especially in
case of the lower arch.
In conclusion Since the maxillary left central
incisor was the common tooth which had high
percentage genetic variability and strong
heritability estimate in total twin sample and in
male and female twin pairs, so we can add it to the
other diagnostic traits which make the
differentiation between zygosity (MZ and DZ twin
pairs) possible in case when the complicated and
expensive methods (which are more reliable) are
Vol. 20(1), 2008
not feasible, while dental arch dimensions are not
recommended for zygosity diagnosis in twins.
When heritability is high and variation is mostly
due to genes, then monozygotic twins will be
closer in any given trait than dizygotic twins, on
the other hand, when heritability is low and
variation is mostly due to the environment, then
monozygotic twins will be as different in any
given trait from one another as dizygotic twins.
On average, DZ male twin pairs have higher
correlation coefficients than DZ female twin
pairs. This may be attributed to the intra-uterine
hormonal diffusion (androgens) from one twin to
the other, which may be considered a potential
source of shared environmental contribution to
tooth size. Anterior part of the dental arch might
be less resistant to environmental factors than
posterior part, especially in case of the lower arch
and common environment appears to have an
impact on dental arch dimensions especially for
females. Sex chromosomal involvement was not
confirmed, but maternal effects were found to be
more evident in females than in males for both
arches.
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Vol. 20(1), 2008
Role of horizontal…
Role of the horizontal activator in Class II i malocclusion
treatment
Ali I. Al-Bustani B.D.S., M.Sc.(1)
Sami K. Al-Joubori B.D.S., M.Sc. (1)
Hayder F. Saloom B.D.S., M.Sc. (2)
ABSTRACT
Background: The conflict in opinions about the dental and skeletal changes induced by class II malocclusion
activator therapy is still present. The aim of this study was to assess the skeletal and/or dental outcomes of
treating moderate-severe skeletal class II division 1 malocclusion by the activator.
Materials and Methods: The sample consisted of pre and post treatment records (cephalometric radiographs)
of 11 Iraqi adolescent patients (7 females 10-11 years old, and 4 males 12-13 years old).
Results: The results showed significant skeletal and dental changes that reflected significant improvements in
the cardinal features of class II (overjet, overbite, ANB angle, and lower anterior facial height).
Conclusion: Correction of the overjet, overbite, and ANB angle in moderate-severe skeletal class II i cases by
the activator into normal range values may be at the expense of unfavorable lower incisors proclination and ii
angle which are very important for stability of treatment result. The activator can induce skeletal changes that
reflect improvements in the antero-posterior and vertical relationships of class II i malocclusion (downward and
forward growth of the mandible, remodeling of glenoid fossa, in addition to the rotation of maxillary and
mandibular bases). Acrylic loading and acrylic trimming done in the activator are responsible for the dramatic
dental changes that can sometimes contribute to the skeletal improvements (extrusion of lower posterior teeth,
relative intrusion of incisors, overjet and overbite correction, and changing positions of points A and B).
Keywords: Skeletal class II, horizontal activator, myofunctional appliance. (J Bagh Coll Dentistry 2008; 20(1) 95100)
INTRODUCTION
Alteration of the patient’s facial profile
has been a challenge for orthodontists over the
years. Many investigations have been carried
out to evaluate the possibilities of growth
modification with orthopedic appliances.
However, the results have generally been a
subject of debate since there is little scientific
evidence so far that an orthodontist is able to
significantly alter the inherited complex
craniofacial skeleton of the growing child on a
permanent basis as compared to the
dentoalveolar changes that have generally
been found to be more stable.(1-3)
Orthopedic appliances provide a new
muscular and functional environment for the
facial bones that encourages growth changes
of either the mandible or the maxilla.(4)
Headgears, activators, and Herbst
appliances have proven to be valuable tools in
their clinical results. Sagittal discrepancies
between mandible and maxilla can be
corrected adequately.
However, it remains questionable whether
the results of this kind of therapy can be
attributed to skeletal effects rather than to
dentoalveolar compensation.(2,3)
(1) Lecturer, Dept. of Orthodontics, College of Dentistry,
(2) Assistant Prof., Dept. of Orthodontics, College of
The aim of this study was to determine the
sagittal and vertical skeletal and dental changes
induced by the horizontal activator as an
outcome of an Iraqi sample treatment.
The sample consisted of 22 lateral
cephalometric radiographs of 11 Iraqi
adolescent patients [7 females 10-11 years old,
and 4 males 12-13 years old]. Pre and post
treatment cephalograms have been taken for
every subject. The sample subjects have been
selected from patients attending the orthodontic
clinic in the hospital of the college of dentistry,
Baghdad University according to the following
criteria:
1Patient’s age at least 1 year before the
maximum growth spurt (which is 12 years for
females and 14 years for males(5)).
2Good general health status.
3No history of previous orthodontic
treatment.
4Moderate-severe skeletal class II i
malocclusion due to mandibular retrognathy
(ANB>7 degrees).
5Horizontal growth pattern (clinically
reduced lower facial height).
All the steps of horizontal activator fabrication
and clinical management were done according
to the recommendations of Graber et al.(6) Upper
Vol. 20(1), 2008
111 man : Angle between lower incisor
axis and mandibular plane.(7)
12ii angle : Interincisal angle between
upper and lower central incisor axes.(7)
The cephalometric analysis included the
following linear and angular measurements:
(Figures 1 and 2 respectively)
# Linear measurements:
1Go-Me : Extent of mandibular base.(7)
2Co-Gn : Mandibular length.(8)
3Co-Go : Length of ascending ramus.(7)
4ANS-PNS : Extent of maxillary
base.(7)
5N-Me : Anterior facial height.(7)
6N-ANS : Upper anterior facial
height.(9)
7ANS-Me : Lower anterior facial
height.(9)
8S-Go : Posterior facial height.(7)
9S-Ar : Lateral extent of cranial base.(7)
10Ar-Go: Length of ramus representing
lower posterior facial height.(9)
# Angular measurements:
1SNA: Anteroposterior position of
maxilla.(7)
2SNB: Anteroposterior position of
mandible.(7)
3ANB: Difference between SNA and
SNB.(7)
4N-S-Ar: Saddle angle.(7)
5S-Ar-Go: Articular angle.(7)
6Ar-Go-Me: Gonial angle.(7)
7N-S-Gn : (Y-axis) Angle between SN
line and S-Gn line, anteriorly.(7)
8Inclination angle : Angle between the
Pn line ( perpendicular line on Se-n plane
drown from soft tissue nasion ) and the
maxillary plane.(7)
9MMP angle : Angle between
maxillary and mandibular planes.(7)
101 max : Angle between upper incisor
axis and maxillary plane.(7)
RESULTS
Table 1 shows the descriptive and
inferential statistics for the pre and post
treatment linear cephalometric measurements, in
addition to the overjet and overbite. Paired t-test
has been applied to examine the statistical
significance of change between the pre and post
treatment readings. All the linear variables that
represent mandibular measurements showed an
increase in the mean value after treatment
(mandibular base, mandibular length, length of
the ramus and ascending ramus). The increase in
these measurements was statistically highly
significant, excepting the mandibular base
which showed a statistically non significant
increase in mean value. Unlike the mandible, the
maxillary base showed a slight decrease in its
post treatment mean value which was
statistically non significant.
The total anterior facial height showed a
slight non significant increase, with a non
significant decrease in the upper anterior facial
height, while a significant increase of the lower
anterior facial height mean value after treatment.
All the posterior facial height measurements
showed statistically significant changes after
treatment by a significant increase of the total
posterior facial height, significant decrease of
the upper posterior facial height, and a highly
significant increase of the lower posterior facial
height. Both of the overjet and overbite showed
a highly significant reduction from severe into
normal range values.
Table 2 shows the descriptive and
inferential statistics for the pre and post
treatment angular cephalometric measurements.
Vol. 20(1), 2008
All the angles showed highly significant
changes after treatment, excepting 3 angles:
the articular and interincisal angles reduced
non significantly with a non significant
increase in the Y-axis angle. The SNB, gonial,
inclination, MMP, and 1 Man angles showed a
highly significant increase in mean values
after treatment, while a highly significant
reduction has been demonstrated by the SNA,
ANB, saddle, and 1 max angles.
DISCUSSION
It is well known that clinical studies that
take long treatment time are somewhat
difficult to be carried out due to the factor of
patient cooperation (especially in case of
children and adolescents). In this study, the
planned sample number was 25-30 adolescent
patients. Unfortunately, only 11 patients have
been followed up successfully due to:
1Lack of cooperation of many of the
patients to continue the treatment and follow
the instructions.
2The hard unstable situations that our
country passed through, which played a major
role in small sample collection.
However, our sample number is
comparable to many similar studies done in
well stable and advanced countries.(10-13) In a
previous Iraqi study, the skeletal and dental
changes induced by the horizontal activator
have been investigated by treating MILD
skeletal class II cases.(14) A major shortcoming
in studies that deal with mild skeletal
malocclusion treatment is the confusion
between treatment changes and natural
individual growth changes.(1) For this reason,
our study verified the clinical outcomes of
horizontal activator therapy by treating
Moderate-Severe cases in order to highlight
the treatment changes over growth changes.
## Linear measurements analysis:
Among the mandibular measurements, an
exclusive behavior was demonstrated by the
mandibular base (Go-Me) which showed a non
significant increase after treatment. This slight
increase may be attributed to the non
significant activator influence on mandibular
base and/or the horizontally directed growth
pattern. On the other hand, the highly
significant increase demonstrated by the
mandibular length (Co-Gn), Co-Go, and ArGo reflects the significant effect imposed by
the activator on these variables. The increase
in mandibular length, ramus length, and length
of ascending ramus results in downward and
forward movements of the mandible
demonstrating the skeletal influence of the
activator. These findings come in agreement
with those of other researchers.(1,15-17) The
muscular elastic properties play a positive
important role in a favorable neuromuscular
response to the forward positioning of the
mandible induced by the activator by straining
the soft tissues and muscles attached to the
condyles stimulating the growth centers
there.(18-20)
On the contrary, the restraining effect of the
activator on maxillary base growth explains the
non significant decrease in its post treatment
mean value, a finding which is supported by
many authors.(1,2,6,21) Other researchers found a
slight increase in maxillary base after treatment
and they attributed that to posterior growth of
maxillary base, however, this increase was also
statistically non significant.(14,22) A non
significant decrease was shown by the upper
anterior facial height (N-ANS) which may be
due to the non significant effect of activator on
midface structure as reported by other
researchers.(8,14,23) Whereas a significant
increase was shown by the lower anterior facial
height (ANS-Me) which is attributed to the
highly significant increase in the gonial and
MMP angles and this will be discussed later on.
These changes resulted in an increase of the
total anterior facial height (N-Me), however, it
was statistically non significant.
The upper posterior facial height (S-Ar) was
reduced significantly after treatment due to the
anterior displacement of the condyle in the
glenoid fossa (a marked skeletal effect exhibited
by the highly significant reduction of the saddle
angle), while the lower posterior facial height
(Ar-Go) showed a highly significant increase
after treatment (which has been discussed
previously). These changes resulted in a
significant increase of the total posterior facial
height (S-Go). These findings come in
agreement with those reported by other
researchers.(15,24,25)
The overjet demonstrated a dramatic
improvement from severe class II into normal
range value. Overjet reduction can be attributed
to: (1) A highly significant retroclination of
upper incisors, (2) A highly significant
proclination of lower incisors (induced by the
acrylic of the activator) with anterior positioning
of lower incisors (induced by the downward
forward movement of the mandible with the
highly significant increase of SNB angle). So,
major dentoalveolar and less skeletal changes
contributed to the overjet reduction. The same
Vol. 20(1), 2008
explanation has been mentioned by other
researchers.(1,2,26)
Table 1: Descriptive and inferential statistics for pre and post treatment linear data,
overjet, and overbite.*
Pre treatmenPost treatment Mean differenc Paired t-tes
Variable Mean SD
Mean
SD Mean S.error t d p Sig
71.22
1.5 -0.41 0.631 -0.6 1 0.5 NS
Go-Me 70.818 1.806
109.52
0.7 -3.045 0.638 -4.7 1 .00 HS
Co-Gn 106.48 1.659
53.855
2.6 -3.364 0.746 -4.5 1 .00 HS
Co-Go 50.491 2.321
54.036
1.5 0.291 0.555 0.521 .61 NS
ANS-PN 54.327 1.798
118.67
4.6 -1.464 1.065 -1.3 1 .19 NS
N-Me 117.20 3.578
53.255
2.0 0.836 0.439 1.901 .08 NS
N-ANS 54.091 1.700
68.082
3.7 -2.591 0.878 -2.9 1 .01 S
ANS-Me 65.491 2.452
76.727
4.9 -2.573 0.957 -2.6 1 .02 S
S-Go 74.155 4.131
36.845
1.3 0.791 0.338 2.341 .04 S
S-Ar 37.636 2.263
44.736
2.4 -4.236 0.562 -7.5 1 .00 HS
Ar-Go 40.5 1.483
3.118
0.7 8.955 0.378 23.71 .00 HS
Overjet 12.073 1.509
2.145
0.5 3.836 0.219 17.51 .00 HS
Overbite 5.982 0.700
* Statistical significance at p< 0.05
* Measurements in millimeters
Table 2: Descriptive and inferential statistics for pre and post treatment angular data.*
Variable
SNA
SNB
ANB
N-S-Ar
S-Ar-Go
Ar-Go-Me
N-S-Gn
Inc. angle
MMP angl
1 Max
1 Man
ii angle
Pre treatmen
Mean SD
81.309 1.346
71.236 1.353
9.636 1.963
128.7 0.927
141.45 2.055
125.18 1.537
71.382 1.262
86.127 1.512
25.882 1.216
119.36 2.511
92.973 4.261
114.52 1.037
Post treatment Mean differenc Paired t-test
Mean
SD Mean S.error t d p Sig
79.3
2.25 2.009 0.315 6.3 1 0.00 HS
75.627
1.55 -4.39 0.543 -8.01 0.00 HS
3.318
0.68 6.318 0.593 10. 1 0.00 HS
127.47
1.00 1.227 0.256 4.81 0.00 HS
141.16
3.59 0.291 0.558 0.5 1 0.61 NS
127.2
3.26 -2.03 0.558 -3. 1 0.00 HS
71.9
1.67 -0.51 0.362 -1.41 0.18 NS
87.864
1.74 -1.73 0.534 -3.21 0.00 HS
28.455
0.98 -2.57 0.562 -4. 1 0.00 HS
110.58
3.66 8.782 0.907 9.6 1 0.00 HS
100.52
4.71 -7.55 0.563 -131 0.00 HS
113.92
4.16 0.600 1.389 0.4 1 0.67 NS
* Statistical significance at p< 0.05
The overbite has also been changed from
deep bite into normal range value. This can be
attributed to: (1) Over eruption of lower
posterior teeth leading to opening of the bite
anteriorly,(6,27) (2) Relative intrusion of
incisors by acrylic loading of their incisal
edges,(6) and (3) Anterior translation of the
mandible (discussed previously).
## Angular measurements analysis:
Highly significant reduction was shown
by the SNA angle. It has been reported that
point A position is influenced by upper
incisors retroclination induced by the activator
leading to a decrease in SNA angle.(1,2) The
SNB angle showed a highly significant
increase which can be explained by the
downward and forward stimulation of
mandibular growth, in addition to the
proclination and anterior positioning of lower
* Measurements in millimeters
incisors.(1,2,28) These changes in the SNA and
SNB angles resulted in a highly significant
reduction of the ANB angle from severe class II
value into normal class I value. However, it
must be kept in mind that this ANB reduction
was not a pure skeletal improvement due to the
significant dentoalveolar contribution.
A highly significant decrease was shown by
the saddle angle, while the articular angle
showed non significant decrease. The reduction
in these angles is related to S-Ar decrease
(mentioned previously) which has been
explained by the anterior displacement of the
condyle with remodeling of the glenoid
fossa.(15,24,25)
The gonial angle showed a highly
significant increase, while there was a non
significant increase in the Y-axis angle. The
increase in these angles reflects the clockwise
Vol. 20(1), 2008
rotation of the mandible which may be
attributed to the forward and downward
growth of the mandible, in addition to the
extrusion of lower posterior teeth (as discussed
previously).
The clockwise rotation of the mandible
played an important role in the highly
significant increase of the MMP angle due to
the clockwise canting of the mandibular plane.
The second important role came from the
anticlockwise canting of the maxillary plane,
as it has been reported that the restraining
effect imposed by the activator on the anterior
growth of the maxilla may enhance the
posterior growth of the maxillary base leading
to anticlockwise canting of the maxillary
plane.(22) This phenomenon will clearly
explain the highly significant increase of the
inclination angle.
Before treatment, the ii angle was of low
value due to the severe proclination of upper
incisors rather than the lower incisors which
were nearly in normal relation to the
mandibular plane. After treatment, in spite of
the highly significant upper incisors
retroclination, the ii angle remained of low
value which is due to the highly significant
proclination of lower incisors in spite of their
acrylic capping. So, we agree with the opinion
that acrylic capping can restrict but not prevent
proclination of lower incisors.(1-3)
REFERENCES
1- Cura N, Sarac M, Ozturk Y, Surmeli N.
Orthodontic and orthopedic effects of activator,
activator-HG combination, and Bass appliances:
a comparative study. Am J Orthod Dentofac
Orthop 1996; 110: 36-45.
2- Aelbers CMF, Dermaut LR. Orthopedics in
orthodontics: Part 1, fiction or reality- a review
of the literature. Am J Orthod Dentofac Orthop
1996; 110: 513-9.
3Dermaut LR, Aelbers CMF. Orthopedics
in orthodontics: Part II, fiction or reality- a
review of the literature. Am J Orthod Dentofac
Orthop 1996; 110: 667-71.
4Isaacson KG, Reed RT, Stephens CD.
Functional orthopedic appliance. Oxford,
England; Blackwell scientific publications, 1990.
5Al-bustani AI. The dental maturation and
chronological age in relation to the skeletal
maturation as indicators for the pubertal growth
estimation. M. Sc. Thesis, University of
Baghdad, Iraq, 2002.
6Graber TM, Rakosi T, Petrovic AG.
Dentofacial
orthopedics
with
functional
appliances. St. Louis, The C.V. Mosby company,
1985.
7Rakosi T. An atlas and manual of
cephalometric radiography, London, Wolfe
medical publications, 1982.
8-
Janson G, Silva CC, Bergersen EO,
Henriques JF. Eruption guidance appliance effect
in treatment of ClassII div 1 malocclusion. Am J
Orthod Dentofac Orthop 2000; 117: no.2 February
original articles.
9Biggerstaff RH, Allen RC, Tuncay OC,
Berkowitz J. A vertical cephalometric analysis of
the human craniofacial complex. Am J Orthod
1977; 72(4): 398-405.
10Owen AH. Morphological changes in
sagittal dimension using Frankel appliance. Am J
Orthod Dentofac Orthop 1981; December: 573603.
11Ramadan A, Abdel-Fattah EB, AbdelKader. Change in hyoid bone position following
activator treatment. Egyptian Orthod J 1993; 7:
257-62.
12Yamin C, Woodside DG, Sectakof PA. The
action of the type of functional appliances on the
activity of masticatory muscles. Am J Orthod
Dentofac Orthop 1997; 1: 560-72.
13Tallgren A, Christiansen R, Ash M. Effect
of myofunctional appliance on orofacial muscle
activity and structures. Am J Orthod Dentofac
Orthop 1998;3: 249-58.
14Al-Rawi RA. Skeletodental modulation for
horizontal activator treatment for skeletal II and
dental class II div.1. M. Sc. Thesis, University of
Baghdad, Iraq, 2005.
15Luder HU. Effects of activator treatmentevidence for the occurrence of 2 different types of
reaction. Eur J Ortho 1981; 3: 205-22.
16Kadry W, Afifi H, Hafez A. Clinical study
for evaluation of 3 myofunctional appliances in
treatment of Class II div.1 malocclusion. Egyptian
Orthod J 1993; 7:297-367.
17Graber TM, Vanarsdail R. Orthodonticscurrent principles and techniques. Third edition,
St. Louis, Philadelphia, London, 2004.
18McNamara JA. Neuromuscular and skeletal
adaptation to altered function in orofacial region.
Am J Orthod 1973; 64: 578-606.
19Ahlgren J. Early and late electromyographic
response to treatment with activator. Am J Orthod
1978; 74: 88-93.
20Aufder HJ. Electromyographic recording of
lateral pterygoid muscle in activator treatment of
class II div.1 malocclusion cases. Eur J Ortho
1980; 2: 161-70.
21Vargervik K, Harvold EP. Response to
activator treatment in class II malocclusion. Am J
Orthod Dentofac Orthop 1985; 88: 242-51.
22Graber TM, Swain BF. Orthodontics-current
principles and techniques. The C.V. Mosby
company,1985.
23Janson G, Pereira ACJ, Bergersen EO.
Cephalometric evaluation of the eruption guidance
appliance in class II div.1 treatment. JCO 1997;
31: 299-306.
24Williams S, Melsen B. Condylar
development and mandibular rotation and
displacement during activator treatment. Am J
Orthod Dentofac Orthop 1982; 81(4): 320-6.
25Rabie B. Functional appliance therapy
accelerates and enhances condylar growth. Am J
Orthod Dentofac Orthop 2003; 123(1): 40-8.
Vol. 20(1), 2008
26-
Panchers H. Cephalometric analysis of
skeletal and dental changes contributing to Class
II correction in activator treatment. Am J Orthod
27Ahn JG, Schnieder BJ. Cephalometric
appraisal of post treatment vertical changes in
adult orthodontic patients. Am J Orthod
28Gianelly A, Petras J, Boffa J. Condyle
position and Class II deep bite malocclusion. Am
J Orthod Dentofac Orthop 1989; 96: 428-32.
Vol. 20(1), 2008
Characteristics of malocclusion…
Characteristics of malocclusion in Iraqi orthodontic
patients overjet and overbite variations
(Comparative study)
Iman Al-Shikli B.D.S. M.Sc.(1)
Bashaer B.M. Nouri B.D.S. M.Sc. (1)
ABSTRACT
Background: The aim of the study was to determine the variations of overbite and overjet in a group of patients
needing orthodontic treatment and compare them with a previous Iraqi study.
Materials and Methods: A number of 1550 pretreated orthodontic patients were clinically examined intra orally for
certain occlusal features as overjet, overbite anterior openbite and anterior crossbite of ages, one year to more than
thirteen years of age.
Results and Conclusion: No significant differences were found between males and females among all variables.
Overjet values were normal at stages of deciduous dentition and the distribution of both increased and decreased
overjet values were high at mixed and permanent dentition stages. The distribution of anterior crossbite was low.
Conclusion: There was a significantly high distribution of increased overjet and overbite in the total age group, in
addition to a significant increase in the distribution of anterior crossbite indicating an increase in the severity of
malocclusion during the last decade.
Keywords: Overjet, overbite, malocclusion. (J Bagh Coll Dentistry 2008; 20(1)101-104)
INTRODUCTION
Occlusal variations in the anterior region of
the mouth are mainly determined by the degree of
overjet and overbite. Overjet is defined as
horizontal overlap of the incisors, which are the
thickness of the upper edges. (1) According to a
previous Iraqi study, normal overjet and overbite
range was considered 1-4 mm as measured by
Kinnan (2).
Overbite is defined as the vertical overlap of
the incisors. Normally the lower incisal edge
contacts the lingual surface of the upper incisors
at or above the cingulum (1) and they also measure
1-4 mm in Iraqi population that was also
measured by Kinnan (2).
Epidemiological and comparative studies
were conducted on the prevalence of overjet and
overbite anomalies among various populations (313)
.
This study is to determine the degree of
variations in overjet and overbite measured in a
group of pretreated orthodontic patients in need of
orthodontic treatment due to their effect on
orthodontic diagnosis, and proper treatment
planning and compare the results with a previous
Iraqi study to estimate the severity of such
anomalies.
The sample examined represented a group of
1550 pretreatment orthodontic patients who
attended the orthodontic department in the college
of dentistry, among which 64 percent were
females and 36 percent were males.
The age range varied from 1-30 years and
was divided into seven age groups. The
distribution of the sample according to gender and
age are shown in table 1.
Data were obtained from direct clinical
examination of the patients, and complete records
were registered.
Overjet and overbite were measured by a
modified gauge introduced by Kinnan (2) and
using the same criteria which is as follows:
Greater than 4 mm overjet or overbite was
considered increased, less than 1mm was
considered decreased. A decreased overbite
including anterior openbite was considered a
single occlusal anomaly (Table 3), then for
comparative reasons anterior openbite was
considered as a separate entity (Table 4). Any
patient having an overbite less than zero was
considered openbite, and similarly decreased
overjet including reversed overjet was considered
a single anomaly (Table 2) and then reversed
overjet was considered separately (Table 4). Any
patient having an overjet less than zero was
considered a reversed overjet.
After achievement of data, results were to be
compared with Kinaan’s study in 1980. (2) Chisquare test was used to compare the various total
values of overjet and overbite according to
gender.
(1) Assistant lecturer, Department of Orthodontic, College of
Vol. 20(1), 2008
Chi-square test was also used to compare the
total values of overjet, overbite, anterior openbite
and anterior crossbite with the previous Iraqi
study.
RESULTS
The statistical analysis according to gender
showed no significant differences regarding the
values of overjet and overbite among all age
groups and similar results were obtained
regarding anterior crossbite and anterior openbite.
as shown in figures 1 and 2. Regarding the
various age groups the following was observed:
It was noticed that the distribution of increased
overjet was low at the stage of deciduous
dentition rising at both stages of mixed and
early permanent dentition. (Table 2)
The distribution of decreased overjet was also
low at the stage of deciduous dentition tending
to increase at the stage of both mixed and
permanent dentition. (Table 2)
Overbite measurements didn’t show evident
variations throughout all age groups. (Table 3)
Regarding anterior openbite it was clear to
have a high distribution at stages of deciduous
and mixed dentition tending to decrease at the
stage of permanent dentition. (Table 4)
Measurements of anterior crossbite involving a
single tooth was high at stages of mixed and
permanent dentition, while anterior crossbite for
more than two teeth was high at stages of
deciduous and mixed dentition. (Table 4)
When comparing the results of total age
groups with Kinnan’s study (2) the following were
observed (Table 5):
Overjet variations.
Normal overjet rates were significantly low
compared to the previous study (p<0.05) while
increased overjet was significantly higher
(p<0.05), and rates of decreased overjet
showed non- significant variations (P>0.05).
Overbite variations.
Similarly normal overbite rates were
significantly low (p<0.05) when compared to
the previous Iraqi study and increased overbite
was significantly high (p<0.05) while
decreased overbite showed non- significant
differences (P>0.05).
Anterior openbite.
It showed no significant differences compared
to Kinaan’s study, while anterior crossbite
showed significantly high rates (p<0.05)
DISCUSSION
This study showed non-significant differences
according to gender among all variables taken into
consideration that are overjet, overbite, anterior
crossbite and anterior openbite.
Considering
overjet
values
previous
epidemiological studies on population in general
show non significant differences according to
gender (10,12).
In regard to overbite values non significant
differences were found according to gender which
coincide with the findings of Abdulla and Batayine
but do not agree with findings of Alhuwazi (13),
Cons et. al (14). and Al-dailami (11).
Anterior openbite was high at stages of
deciduous and mixed dentition and that could be
attributed to certain habits as finger and thumb
sucking. Variations in anterior crossbite could be
attributed to mandibular growth as it is known on
the average, mandibular prognathisim increases
with age and the range of variation is large. (15)
The comparative results showed a decrease in
normal overjet values and increased overjet was
significantly much higher indicating that the
severity of malocclusion has greatly increased.
The same is applied to overbite variations and
there was a significantly high rate of increased
overbite, which also indicates that the
characteristics of malocclusion are deteriorating.
Anterior crossbite was significantly much
higher indicating that more complicated
orthodontic treatment is required in addition to the
necessity of interceptive and preventive
orthodontic programs.
This situation of severe malocclusion features
could be attributed to many social problems that
have provoked in the Iraqi community during the
last decade as financial problems in addition to the
lack of dental and educational programs.
Table 1: The distribution of the sample
according to gender and age
Age
1-5
6-10
11-15
16-20
21-25
26-30
>30
Total
Females
No. %
76 7.65
131 13.18
287 28.87
272 27.36
128 12.88
65 6.54
35 3.52
994 100
Males
No. %
28 5.04
94 16.91
123 22.12
184 33.09
79 14.21
31 5.58
17 3.06
556 100
Total
No. %
104 6.71
225 14.52
410 26.45
456 29.42
207 13.35
96 6.19
52 3.35
1550 100
Vol. 20(1), 2008
Table 2: The distribution of patients according to their overjet values and age
Age
1-5
6-10
11-15
16-20
21-25
26-30
>30
Total
No.
55
80
107
163
95
33
18
551
Normal
%
52.9
35.6
26.1
35.7
45.9
34.4
34.6
35.5
No.
35
104
220
201
72
43
20
695
44.84
Increased
%
33.7
46.2
53.7
44.1
34.8
44.8
38.5
44.8
No.
14
41
83
92
40
20
14
304
Decreased
%
13.5
18.2
20.2
20.2
19.3
20.8
26.9
19.6
44.66
45
40
36.16
Males
34.51
Females
35
Percentage
30
25
20.81
18.98
20
15
10
5
0
Normal
Increased
Decreased
Figure 1: The distribution of patients according to their overjet values and gender.
Table 3: The distribution of patients according to their overbite values
Age
1-5
6-10
11-15
16-20
21-25
26-30
>30
Normal
No. %
31 29.8
63 28
125 30.5
130 28.5
64 30.9
32 33.3
15 28.8
Increased
No. %
46 44.2
103 45.8
189 46.1
240 52.6
106 51.2
51 53.1
23 44.2
Decreased
No. %
27 26.0
59 26.2
96 23.4
86 18.9
37 17.9
13 13.5
14 26.9
60
50.09
49.08
50
Males
Females
Percentage
40
28.59
29.75
30
21.31
21.34
20
10
0
Normal
Increased
Decreased
Figure 2: The distribution of patients according to their overbite values and gender.
Vol. 20(1), 2008
Table 4: The distribution of patients according to values of anterior openbite and anterior
crossbite.
Age
Anterior openbite
1-5
6-10
11-15
16-20
21-25
26-30
>30
Total
No.
21
37
58
19
9
6
5
155
%
20.2
16.4
14.1
4.2
4.3
6.3
9.6
10
Anterior crossbite
1 tooth >2 teeth
No. % No. %
4 3.8 30 28.8
77 34.2 53 23.6
149 36.3 94 22.9
151 33.1 59 12.9
85 41.1 20 9.7
24 25.0 18 18.8
13 25.0 14 26.9
503 32.5 288 18.6
Table 5: The comparative statistical results of Kinans and the present study.
Overjet
Normal
Increased
Decreased
Overbite Normal
Increased
Decreased
Anterior
openbite
Anterior
crossbite
Kinnans Present Chi
p-value Significance
study % study % square
56
35.5
6.535 0.011
S
25
44.8
5.135 0.023
S
19
19.6
1.572 0.2099
NS
56
29.7
5.384 0.020
S
21
48.9
2.642
0.49
S
23
21.4
1.568 0.2104
NS
7
10
1.158
0.2087
NS
37
51.1
5.291
0.001
S
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Farah ME. The orthodontic examination of
children aged 9 and 10 years from Baghdad Iraq: a
clinical and radiographic study. Master thesis, collage
of Dentistry, Baghdad University, Iraq.
9.
Abdullah NM. Occlusal features and perception
a sample of 13-17 years old adolescents. Master Thesis,
College of Dentistry, University of Baghdad, Iraq, Iraq
1996.
10.
Brunelle JA, Bhat M, Lipton JA. Prevalence and
distribution of selected occlusal characteristics in the
US population 1988-1991. J Dent Res 1996; 75 (spec.
iss) 706-13.
11.
Al-Dailami MMY. Occlusal features in a sample
of Yemeni students aged 10-15 years. Master Thesis,
College of Dentistry, Baghdad University of Iraq, 2000.
12.
Alhuwaizi AF, Al. Mulla AA, Al-Alousi WS.
The overjet of Iraqi 13 years old (A national survey)
Iraqi. J of Oral and Dental Sciences 2004; 3: 38-46.
13.
Alhuwaizi AF, Al-Mulla AA, A-Alousi, WS.
The Overbite of Iraqi Teenagers (A National survey)
Iraqi.Orthod J 2005; 1: 1.
14.
Cons NC, Mruthyunjaya YC, Pollard ST.
Distribution of occlusal traits in a sample of 1337
children aged 15-18 residing in upstate New York Int
Dent J 1978; 28(2) 154-64
15.
Bjork A. Prediction of mandibular growth
rotation. Am J Orthod 1969; 39-53.
16.
Foster TD 1982. A textbook of orthodontics 2nd
ed. Blackwell Scientific Publications Oxford.
17.
Bastayine FAM. Occlusal features and
perception of occlusion of Jordanian adolescents a
comparative study with an Iraqi sample. Master Thesis,
Collage of Dentistry, University of Baghdad, Iraq 1997.
Vol. 20(1), 2008
Influence of different…
Influence of different recycling protocols on load deflection
of nickel titanium orthodontic wire (An in vitro study)
Mustafa M. Al-Khatieeb
B.D.S., M.Sc.(1)
ABSTRACT
Background: The purpose of this study was to investigate the changes in the load deflection of nickel titanium
orthodontic wire after different recycling protocols.
Materials and methods: A spooled 0.014 inch nickel titanium orthodontic wire was separated into 7 groups: as
received condition (T0, control group), treated in artificial saliva for 4 weeks (T1), treated in artificial saliva and
autoclaved (T2), treated in artificial saliva and dry heated (T3), treated in artificial saliva and disinfected by
glutaraldehyde (T4), treated in artificial saliva and disinfected by iodophor (T5) and treated in artificial saliva and
disinfected by chlorhexidine(T6). The changes in the load deflection were observed by special test apparatus based
on 3-point bending mechanism.
Results: The findings of the current study showed that there was highly significant difference in mean load deflection
of nickel titanium wire between all recycling protocols (P< 0.0001). The recycling by sterilization of the wire by heat
autoclave or disinfection by chlorhexidine both showed high mean load deflection values which were closer to the
control, while the disinfection by glutaraldehyde or iodophor showed intermediate load deflection values, and the
sterilization by dry heat showed lowest mean load deflection value.
Conclusions: The different recycling protocols could decrease the load deflection value and this could be due to
corrosive degenerative changes of the passive TiO2 film on the wire and subsequently detrimental effect on load
deflection. Sterilization by the heat autoclave or disinfection by chlorhexidine both seem to be the best recycling
protocols because both showed least detrimental effect on the load deflection because those protocols showed
high mean load deflection values which were closer to the control, while the disinfection by glutaraldehyde or
iodophor both showed intermediate detrimental effect on the load deflection because those showed intermediate
load deflection value, and sterilization by the dry heat seems to be the worst recycling protocols because it showed
highest detrimental effect on the load deflection because it showed lowest mean load deflection value among all
examined recycling protocols.
Key words: Recycling, load deflection, nickel titanium wire. (J Bagh Coll Dentistry 2008; 20(1)105-110)
INTRODUCTION
Nickel titanium orthodontic wires have been
attractive because of their unique properties of
high springback and low stiffness while
maintaining good strength (1). These properties
make the wires resistant to permanent
deformation so that the wires return to their
original shape after clinical usage, their high cost
has hampered their universal appeal. As a
consequence both the cost factor and the
retention of elastic properties of being return to
their original form have prompted some
clinicians to reuse these arch wires (2-5).
To minimize the potential health hazard to
the patient who receives either new or recycled
wires since these new wires are frequently
packed in individual sealed bags in order to
avoid cross-contamination .The instruction on
the wrapper generally advise sterilization of the
bag and/or disinfection of the wire if additional
protection is required, and to minimize the
potential health hazard to the patient who
receives a recycled wires, therefore accepted
techniques of sterilization or disinfection must be
adopted (6,7) and their effects on the wires must
be known..
Since 1980s, studies have been undertaken to
investigate the possibility of changes in
orthodontic wires resulting from sterilization.
But till now no clear literature exists concerning
the reuse of the wires following treatment with
currently accepted heat sterilization or cold
disinfection techniques.
However, both in vivo and in vitro studies
suggest that nickel titanium is susceptible to a
pitting–type corrosion attack, and most
chemicals used for disinfection or sterilization
processes are corrosive and attack metals that
are immersed or placed in them (5, 8-10) .
In light of the fact that nickel titanium wire
is being reused, in the present study the
fundamental load deflection of this wire is tested.
The main aims of the present study were:
1. To evaluate the changes in load deflection of
nickel titanium orthodontic wire after
incubation in artificial saliva and the
consequences of sterilization or disinfection
protocols for assessment the efficacy of their
reuse.
2. To determine which the best sterilization or
disinfection protocol is that maintains the load
deflection of nickel titanium orthodontic wire
intact from deterioration.
(1) Assistant Lecturer, Department of Orthodontics, College of
Vol. 20(1), 2008
Orthodontic Wire: The orthodontic arch wire
used is 0.014 inch (0.35 mm) spooled round
nickel–titanium orthodontic arch wire (supplied
by Ortho-Organizers Company);
Media: The immersion media that were used in
the present study can be classified into test and
control includes:
Chemical disinfectants (test): considered as the
most popular classes approved by the American
Dental Association (ADA)(11).
. 2 % acid glutaraldehyde (Banicide);(Pascal
Intentional Corp.;Bellevue ;Wash.;USA).
.
Iodophor (Wescodyne); (West Chemical
Products Inc.;N.Y; USA).
. 2 % Chlorhexidine gluconate ; (Al-Mansour
pharmaceuticals; Iraq)
Artificial saliva (control): 1.44 gm/l Na HCO3
,0.21gm/l Ca Cl2 and 0.46 gm/l NaH2PO4
were diluted in 1000ml deionized water and
continuous stirring with electromagnetic stirrer
and pH monitored with pH meter until required
pH(7)was reached (12) .
Equipment: The heat sterilization equipment
tested, considered as the most accepted heat
sterilization procedures by the ADA include (6):
.Memmert
dry
heat
sterilizer
(Schwaback,W.Germany ).
. Dako steam autoclave (Dako –Line,Germany).
Methods
A new test apparatus was specially designed (13)
(Figure 1) based on the mechanism of three-point
bending test (10, 13, 14, 16, 17, 18). The wire tested was
spooled 0.014 inch round nickel titanium arch
wire cut into 70cut pieces. The length of each
piece was 4cm (19). Then these 70 cut pieces of
the wire were separated into 7 examination
groups “10 cut pieces for each examined group”
,one control group(T0,n=10) as received
condition “with out any treatment” and six
experimental test groups, wires in the 1st
experimental test group (T1,n=10) were exposed
to artificial saliva(ASA) after being placed in
AFMA-Dispo inert plastic container of 10 ml
capacity and maintained in an incubator at 37o C
for 4 weeks (5); wires in the 2nd experimental test
group (T2,n=10)were subjected to the same
artificial saliva and incubation treatment for 4
weeks, cleaned by a piece of clean cotton then
sterilized by steam autoclave at 121oC (250oF)
and 15-20 psi for 20 minutes (4,5) ; wires in the 3
rd
experimental test group (T3,n=10)were
subjected to the same artificial saliva and
incubation treatment for 4 weeks, cleaned by a
piece of clean cotton then sterilized by dry heat
at 180oC(355oF) for 60 minutes (4) ; wires in the
4th experimental test group (T4,n=10) were
incubation treatment for 4 weeks , removed and
cleaned by a piece of clean cotton
then
immersed in acid glutaraldehyde “Banicide”
(AG)after being placed in the inert plastic
container for 10 hours (3) ; wires in the 5th
experimental test group (T5,n=10) were
incubation treatment for 4 weeks , removed and
cleaned by a piece of clean cotton
then
immersed in iodophor “Wescodyne” after being
placed in the plastic container for 10 hours (3)
;wires in the 6th experimental test group
(T6,n=10) were subjected to the same artificial
saliva and incubation treatment for 4 weeks ,
removed and cleaned by a piece of clean cotton
then immersed in Chlorhexidine after being
placed in the plastic container for 10 hours, then
after each group, any cut piece of the wire
cleaned by a piece of clean cotton and tested by
the following steps [in coincidence with threepoint bending test fixture configuration]:
1- The arch wire is ligated centrally to brackets
[Ultratrimm edgewise 0.022x0.030 inch Supplied
by Dentaurum Company] using ligature elastics
[Supplied by Dentaurum Company] (interbracket distance was 14mm) (20).
2- A stable compression force is applied through
the force gauge “170gm” [Supplied by Anthogyr
,France] .
3- The amount of deflection was measured by
mounted sensitive dial gauge [Supplied by
HENRI HAUSER-BIENNE- SUISSE].
Then write down the specified reading in the
dial gauge (load deflection), after the data was
collected from the dial gauge, the data was
analyzed statistically to know the effect of
recycling on nickel titanium arch wire load
deflection, after comparing with the control
group.
A. The changes in load deflection of Ni -Ti
arch wire:
The as received (T0) and the immersed in
artificial saliva “ASA” (T1) Ni -Ti arch wires:
The mean load deflection of the as received Ni Ti arch wire(T0) is similar to that after the
immersion in ASA(T1) and considered of highest
mean deflection values among all examined
groups, the range of load deflection is 0.02
,which is considered to be high, this means that
the flexibility of the as received or immersed in
ASA Ni-Ti arch wire is still high and not
affected, this expressed by the same mean load
deflection value of Ni-Ti arch wire, as shown in
table 1 and figure 2.
Vol. 20(1), 2008
The steam heat autoclave sterilized Ni -Ti arch
wire (T2): The mean load deflection of Ni -Ti
arch wire after sterilization by the heat autoclave
(T2) is one of the high values among all
examined groups, the range of load deflection is
0.02 and this value is similar to that of the as
received controlled (T0) and immersed in
ASA(T1) wires in being high, this means that the
flexibility of Ni -Ti arch wire is not highly
affected after the heat autoclaving sterilization
procedure and this is approved by one of the
highest mean load deflection value among the
experimental test groups as shown in table 1 and
figure 2.
The dry heat sterilized Ni -Ti arch wire (T3):
The mean load deflection of Ni -Ti arch wire
after sterilization by the dry heat is the lowest
mean deflection value among all examined
groups, the range of load deflection is 0.01 and
this value which is also the lowest value, this
means that the flexibility of Ni –Ti arch wire is
low and this is approved by lowest mean load
deflection value among all experimental groups
as shown in table 1 and figure 2.
.
The chemical glutaraldehyde disinfected Ni -Ti
arch wire (T4): The mean load deflection of Ni Ti arch wire after disinfection by glutaraldehyde
is considered to be intermediate among all
examined groups, the range is 0.015 and this
value is considered as low value among the
experimental test groups, this means that the
flexibility of the wire is low also, and this
expressed by reduction in mean load deflection
value among the experimental test groups as
shown in table 1 and figure 2.
The chemical iodophor disinfected Ni -Ti arch
wire (T5): The mean load deflection of Ni -Ti
arch wire after disinfection by iodophor is also
considered to be intermediate among all
examined groups; the range is 0.015 and as low
as that in case of disinfection with glutaraldehyde
if compared with the remaining experimental
groups, this means that the flexibility of the wire
is low also after disinfection of Ni -Ti arch wire
with iodophor , and this expressed by reduction
in mean load deflection value as shown in table 1
and figure 2.
The chemical Chlorhexidine disinfected Ni -Ti
arch wire (T6): The mean load deflection of Ni Ti arch wire after disinfection by chlorhexidine is
one of the high values among all examined
groups, the range of load deflection is 0.02, and
so both the mean and range are similar to that in
case of sterilization of the wire by steam heat
autoclave and closest to the as received
controlled wire, this means that the flexibility of
the wire in case of T6 is not highly affected ,this
is approved by one of the highest mean load
deflection value among the experimental test
groups as shown in table 1 and figure 2.
B. Mean comparison for the load deflection:
Comparison between all examined groups:
The result of the F test by ANOVA table as
demonstrated in table 1 shows that there is a
highly significant difference between all
examined groups (T0, T1, T2, T3, T4, T5 and
T6) for the mean load deflections of Ni-Ti arch
wires at P< 0.0001, this is due to the lowest
mean deflection value in case of T3, intermediate
mean deflection values in cases of T4 and T5,
high mean deflection values in cases of T2 and
T6, and highest mean deflection values in cases
of T0 and T1 .We can deduce that some
recycling protocols could decrease the load
deflection of Ni -Ti arch wire and this could
agree with previous reports (20, 21, 22) This
probably due to the surface interruption,
oxidation and pitting which may lead to
subsequent
degradation
in
mechanical
performance of Ni -Ti arch wire.
Comparison between 2 different recycling
protocols:
Student t-test between two different
recycling protocols for the mean load deflections
of Ni-Ti arch wires was performed as shown in
table 2, the results of this test show that there is
no significant difference between T0 and T1, this
is due to the fact that titanium and its alloys are
easily passivated metals due to the thin stable
titanium oxide (TiO2) layer which was formed
within nanoseconds of exposure to air, thus
preventing further diffusion and penetration of
oxygen, resulting in excellent corrosion
resistance and this surface oxide does not
breakdown under physiological conditions or
tissue simulated fluoids such as the ASA (23 ,24)
therefore there was no detrimental effect on load
deflection and subsequently no significant
difference in mean load deflection of Ni-Ti arch
wire between T0 &T1 and this could agree with
other studies (5,25).
There is no significant difference between
T0 and T2, and this is due to the fact that
sterilization by the heat autoclave shows no
detrimental changes in the load deflection. This
is probably due to the sterilization by the heat
autoclave not adversely affects the titanium
oxide layer which was formed therefore there
was no detrimental effect on load deflection and
subsequently no significant difference in mean
load deflection of Ni-Ti arch wire between T0
&T2 and this is in accordance with other reports (
4 ,7) .
Vol. 20(1), 2008
There is highly significant difference
between T0 and T3, this is due to the fact that
sterilization by the dry heat could adversely
affect the titanium oxide layer which was formed
therefore there was a detrimental effect on load
deflection, and subsequently a highly significant
difference in mean load deflection of Ni-Ti arch
wire between T0 &T3 and this could agree with a
study (10) and disagree with another (4) .
There is significant difference between T0
and T4 or T5, this is due to the fact that the
disinfection by glutaraldehyde or iodophor shows
detrimental changes in the load deflection, this is
probably due to the disinfection by
glutaraldehyde or iodophor adversely affects the
titanium oxide layer of Ni-Ti arch wire which
was formed therefore there were detrimental
effects on load deflections because of corrosion,
and subsequently significant differences in mean
load deflections of Ni-Ti arch wire between T0
&
T4
or
T5
and
this
shows
disagreement with other study (26).
T0 and T6, and this is due to the fact that the
disinfection by chlorhexidine shows no
detrimental changes in the load deflection
probably because it does not adversely affect the
titanium oxide layer of Ni-Ti arch wire which
was formed.
T1 and T2 or T6. This is due to the fact that
sterilization by the heat autoclave or disinfection
by chlorhexidine shows high mean load
deflection value if compared with the highest
mean load deflection value of Ni-Ti arch wire
after immersion in ASA.
between T1and T3; this is due to the fact that
sterilization by the dry heat shows lowest mean
deflection value among all examined groups if
compared with the highest mean load deflection
value after immersion in ASA.
There is significant difference between T1
and T4 or T5. This is due to that the disinfection
by glutaraldehyde or iodophor shows
intermediate mean load deflection if compared
with that of highest value after immersion in
ASA.
between T2 and T3. This is due to the fact that
sterilization by the heat autoclave shows high
mean load deflection value if compared with
that of lowest value after sterilization by the dry
heatThere is no significant difference between T2
and T4, T5 or T6, and this is due to the fact that
sterilization by the heat autoclave or disinfection
by chlorhexidine both show high mean load
deflection values if compared with the
intermediate mean load deflection values of NiTi arch wire after disinfection by glutaraldehyde
or iodophor respectively
between T3 and T4, T5 or T6; this is due to the
fact that sterilization by the dry heat shows
lowest mean deflection value if compared with
the intermediate mean load deflection values of
glutaraldehyde or iodophor, and high value after
disinfection by chlorhexidine respectively.
T4 and T5 or T6, and this is due to the fact that
disinfection by glutaraldehyde or iodophor shows
intermediate mean load deflection if compared
with the high value after disinfection by
chlorhexidine. There is no significant difference
between T5 and T6 and this could be due to the
intermediate mean load deflection of Ni-Ti arch
wire after disinfection by iodophor and the high
value after disinfection by chlorhexidine
respectively.
Figure 1: Magnified view of the loading cell
of the test apparatus .
1: By pass vertical stud. 2: Dynamometer
3: Dial gauge. 4: Arch wire. 5: Bracket. 6: Ligature elastic.
0.05
0.048
0.048
0.044
0.045
0.043
0.042
0.044
0.04
0.035
0.03
0.03
0.025
0.02
0.015
0.01
0.005
0
T0
T1
T2
T3
T4
T5
T6
Different recycling protocols
Figure 2: Bar-chart for the mean load
deflection of Ni-Ti arch wire after different
recycling protocols
Vol. 20(1), 2008
Table 1: Descriptive and comparative
statistics for the load deflection of Ni-Ti
orthodontic wire after different recycling
protocols.
Group
T0
Mean
ANOVA
SD Min Max Range
(mm)
(F test)
.048 .00580 .040 .060 .020
T1
.048
.00580 .040 .060
.020
T2
T3
T4
T5
T6
.044
.030
.043
.042
.044
.00459
.00550
.00483
.00486
.00459
.020
.010
.015
.015
.020
.040
.020
.040
.040
.040
.060
.030
.055
.055
.060
13.687
pvalue
.000
**
N=10 for each group df=69 ** = High significant
(P<0.0001)
Table 2: Mean comparison for the load
deflection of Ni-Ti arch wire between 2
different recycling protocols by using
student t-test.
Groups
t-test
p-value
T0 vs T1
T0 vs T2
T 0 vs T3
T0 vs T4
T0 vs T5
T0 vs T6
T1 vs T2
T1 vsT3
T1 vs T4
T1 vs T5
T1 vs T6
.000
1.924
7.121
2.305
2.508
1.924
1.924
7.121
2.305
2.508
1.924
5.955
.474
.709
.000
-5.399
-5.169
-5.955
.231
-.474
-.709
1.000
.070
.000 **
.033 *
.022 *
.070
.070
.000 **
.033 *
.022 *
.070
.000 **
.641
.487
1.000
.000 **
.000 **
.000 **
.820
.641
.487
T2 vs T3
T2 vs T4
T2 vs T5
T2 vs T6
T3 vs T4
T3 vs T5
T3 vs T6
T4 vs T5
T4 vs T6
T5 vs T6
Vs:Versus.
df=18
*: Significant (P<0.05)
**: High significant (P<0.0001)
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By: Ibtehaj Samea' Amir
Supervised by: Assist. Prof. Dr. Amer H. M. Khamas
9Shear Bond Strength of Endodontic Sealers to Dentin and Gutta Percha(In Vitro study)
By: Meaad Abdulrazak Al-Ani
10The Influence of Three different Photo-Activation Method and Polishing On wear resistance of two
types of Composites. (In Vitro Study)
By: Zainab Mohammed Kamal
Supervised by: Prof. Dr. Ali H. Al-Khafaji
11The adaptability of three different gutta percha obturation techniques: thermafil, System B/Obtura and
Lateral condensation (in vitro study)
By; Samer Aun Al-Shimmary
Supervised by: Prof. Dr. Hussain Al-Huwaizi
12The effect of dowel space preparation on the apical seal of Resilon & Gutta-percha Obturation materials
(An in vitro comparative study)
By: Saleh Mwaffaq Fadhel Al-Kasaki
111
Supervised by:Prof. Dr. Abdul Kareem Al-Azzawi
13Effect of soldering on shear bond strength of porcelain fused to metal (In vitro study)
Conservative dentistry.
By: Ahmed Ghanim Mehdi
Supervised by: Assist. Prof. Dr. Adel Farhan Ibrahim
Oral Diagnosis
14Histological study of the effect of steroidal and non steroidal drugs on maxillary sinus.
Oral Histology & Biology
By: Sahar Khanam Alias Al-kazaz
Supervised by: Prof. Dr. Athraa Yahya Al-hijazi
15The Effects of the Iraqi Propolis on the Bone Healing of the Rabbit’s Mandible.
Oral Histology and Biology
By: Bushra Habeeb Ahmad
Supervised by: Dr. Shatha S. Mohammed,
Dr. Tahani A. G. Al-Sandook
16Bcl–2 & Bax mRNA In Situ Hybridization (ISH) Expressions in Squamous cell carcinoma of oral
cavity
Oral Pathology
By: Marwa Bassim
Supervised by: Assist Prof. Dr. Lehadh M. Al – Azzawi
17- Histological Study of Bone Healing Using Organic Bovine Bone in Combination with Platelet Rich Plasma
(An Experimental Study in Rabbit)
Oral Histology
Supervised by: Dr. Shatha S. Mohammed, Dr. Rafah S. Ayoub
18The value of digital dental panoramic tomography in the identification of common carotid artery
calcification among Iraqi sample at risk of cerebrovascular accident
Oral and Maxillofacial Radiology
By: Asmaa Basheer Rasheed AL-Suffar
Supervised by: Assistant Prof. Dr. Asmaa Tahseen Uthman
19Oral health status of Iraqi diabetic patients salivary & microbial analyses.
Doctor of Philosophy in Oral Medicine
By: Abdullah Ibrahim Hamad Al-Sagri
Supervised by: Assist. Prof. Dr. Riyadh Othman Alkaisi
20Glycoconjugates
Profile
in
Hyperplastic,
Dysplastic
and
Neoplastic
Lesions
of the Oral Mucosa.
Doctor of Philosophy in Oral Pathology
By: Nadia Sabri Yass
Supervised by: Dr. Suad A. Al-Ani, Dr. Anam R. Al-Salihi
Periodontics
21Evaluation of periodontal disease and C-Reactive protein as predictive risk factors for cardiovascular
disease development
Periodontics
By: Dr. Abdul- Karim Abd Ali Al - Muhammadawi
Supervised By: Prof.Khalid Merza
22Effects of Supervised Chlorhexidine Mouthrinse for School Children Suffering from Gingivitis ( A
Clinical Study)
Periodontic Dentistry
By: Ragheed Tawfeek Salman
Supervised by: Assist. Prof. Dr. Likaa Mahmood Ibrahem
Orthodontics
23- The effects of three mouthwashes on the load deflection and surface characteristics of nickel titanium
archwires (in vitro study)
Orthodontic
By: Ammar Salem
Supervised by: Prof. Nidhal Hussein, Dr. Thair Al-Zubaidi
112
24The Relationship of Overbite, Cant of Occlusal Plane and Incisor Inclination in Normal & Deep bite
Malocclusion: A Cephalometric Study.
Orthodontics
By: Hamsa Kh. Tarik
Supervised by: Prof. Dr. Fakhri Abid Ali
25- The role of environmental versus genetic factors on tooth and dental arch dimensions in a twin sample.
Orthodontics
By: Salwa Hazim
Supervised by: Dr. Nagham Al-Muthaffar
26Comparison of the Forces Generated by Different Types of Elastomeric Separators (An In-Vitro Study)
Orthodontics
By: Hossam Ibrahim Kadhum
Supervised by: Akram Faisal Al-Huwaizi
27An experimental and artificial neural network prediction of cross section and activation distance effect
on T-spring force system.
Orthodontics
By: Noor M. Hasan
Supervised by: Prof. Dr. Nidhal Hussein, Dr. Baraa I. Kazem
28Dentoalveolar Compensation in Relation to Mild Skeletal Discrepancies
Orthodontics
By: Mohammed Nahidh Mohammed Hassan
Supervised by: Assist. Prof. Dr. Nagham Al-Mothaffar
29Rate of Force Decay for Different Types of Extra-Oral Elastics (A Comparative in Vitro Study)
Orthodontics
By: Anas K. Al-Qasim
Supervised by: Prof. Dr. Nidhal H. Ghaib
30The Effect of Different Orthodontic Elastomeric Ligatures on Frictional Resistance (An in-vitro study)
Orthodontics
By: Khalid Mohammed Obaid
Supervised by: Prof. Dr. Nidhal H. Ghaib
31Assessment of the correlation between mandibular corpus axis and mandibular plane in measuring
mandibular growth rotation in different skeletal classes (A Cephalometric Cross sectional study)
Orthodontics
By: Osama S. Sadik Al-Ibrahim
Supervised by: Prof. Dr. Fakhri Abid Ali
32The Antibacterial Effects of licorice Extracts on Streptococci and Mutans Streptococci in Comparison
to Chlorhexidine. (In vitro and in vivo study)
By: Nada Riadh Abdul-Razzaq Al-Shaibani
Supervised by: Prof. Dr. Wael Sulaiman Al-Alousi
33Oral health status and treatment needs among fifteen year old students of Babylon governorate Iraq.
By: Hassan Ali Al- jebouri
Supervised by: Prof – Dr. Mohammad Al- Caesy
34Protein-Energy Malnutrition in Relation to Oral Health Condition Among 6 and 9 Year Old Primary
School Children in Sulaimania City in Iraq
By: Mohammed Kais Mahmood Droosh
Supervised by: Ass. Prof. Dr. Ban Sahib Diab
35Oral health status among 15 year old School students in Suilimania city - Iraq
Preventive Dentistry.
By: Qayssarr R. Abdul-Razzaq
Supervised by: Prof. Dr. Mohammed AL-Caesy
36Effect of Garlic Extracts on Streptococci and Mutans Streptococci, in Comparison to Chlorhexidine
Gluconate. (A comparative in vitro and in vivo study)
113
By: Jinan Mohammed Rashad Al-Alousi
Supervised by: Prof. Sulafa K. El-Samarrai
37Effect of Water Extracts of Black and Green Tea on the Microhardness and Microscopic Features of
Initial Caries-Like Lesion of Permanent Teeth, Compared to Fluoridated Agent
By: Rand Salih Al-Ubaidi
Supervised by: Prof. Dr. Sulafa K. El – Samarrai, Prof. Dr. Ahlam H. Mageed
38Effect of Garlic Extracts on Streptococci and Mutans Streptococci, in Comparison to Chlorhexidine
Gluconate (A comparative in vitro and in vivo study)
By: Jinan Mohammed Rashad Al-Alousi
Supervised by: Prof. Sulafa K. El-Samarrai
39Selected Salivary Constituents among 16-18 Years Patients with β Thalassemia Major in Relation to
Oral Diseases
Preventive Dentistry.
By: Hanaa Salman Al-Jobouri
Supervised by: Prof. Mohammed Al-Qaisy
40- Dental Caries and Salivary Mutans Streptococci Level among a Group of Mothers and their Children in
Relation to Feeding
By: Nuha Shawkat El – Shamare
Supervised By: Dr. Wesal Al – Obaidi
41- Dental erosion among 11-12 years old schoolchildren in Baghdad city (Iraq)
By: Raya Rashid Al-Dafaai
Supervised by: Prof. Dr. Zainab Al- Dahan
43Effect of Salts Supplemented to Citric Acid on the Surface Roughness and Microscopical Feature of the
Dentin of Permanent Teeth (In Vitro Study)
Pediatric Dentistry
By: Shayma Abdullah Hanoon
Supervised By: Prof.Dr.Ban A.Salih, Prof.Dr.Athraa Y.Al-Hijazi
114
Middle East and International Calendar of Conferences 2008
March 4-6
AEEDC Dubai 2008-Dubai International exhibition Dubai U.A.E
March 10-13
19th Saudi Dental Society Conference for Dental Technology & Research Hilton Jeddah, K.S.A
Email: Sdensoc2ksu.edu.sa
www.sdsam.org
March 16-18
Kuwait Dental Conference
March 19-21
Jordan Dental Association International Congress
March 25-28
Cairo University 1st International Dental Conference-CUIDC
Entitled Dental Education between Past &Future
Marriot Cairo Hotel, Cairo, Egypt
Website: www.dentistry.cu.edu.eg
April 2-4
The Alexandria Oral Implantology Association (AOIA) International Congress Alexandria, Egypt
Email: [email protected]
Website: www.aoiaegypt.com
April 12-14
The 12th Saudi Itrnational Dental Meeting “Interating Science into Dental Practice “
King Saudi University, Riyadh, Kingdome of Saudi Arabia
Website: www.ksudm.com
April 22-24
Misurata Oral Health Conference and Exhibition-Misurata, Libya
Email:[email protected]
Website :www.ldc.com.ly
May 5-8
Saudi Healthcare and Saudi Hospital ,Jeddah Iternational Exhibition and Convention Center Jeddah, Saudi
Arabia
Website aexpos.com
May 6-10
30 Asia Pacific Dental Congress -30th APDC-The Power of Multi-disciplinary Approach for Clinical
Excellence
Central World Plaza, Bangkok Thailand
Website: www.apdc2008.com
115
June 18-22
The Syrian Dental Association Scientific Conference & the International Dental Exhibition and
Conference- Damascus, Syria
Website:www.syrianmedicare.com
30 June – 5 July
15 International Turkish Dental Association 15th TDA
Lutfi Kirdar Kongre ve Sergi Sarayi Askeri Muze,ve Kulter Merkezi
ISTANBUL TURKY
Website: yuzyil.web.tr
September 24-27
FDI Annual World Dental Congress, Stockholm, Sweden
Email:[email protected]
Website:fdiworldental.org
October 16-18
The Beirut International Dental Meeting 2008
Website: www.LDA.org.lb/BIDM2008
October 16-19
ADA Annual session, San Antonio, USA
Website: ada.org
October 28-31
The Alexandria International Dental Congress
Website: aidc-egypt.org
116

Vol 20 No. 1

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