JODR Volume 01-Issue 01, 2013 - Iraqi Association For Oral Research

Transcription

JODR
Volume 1, Issue 1 2013
Journal of Oral and
Dental Research
The Official Jouranl of the
Iraqi Association for
Oral Research
ISSN 2310-6417
Dr Anwar R Tappuni
JODR Editor-in-Chief
It is with great pleasure that I present
the first issue of the Journal of Oral and
Dental Research, one of the milestone
achievements of the Iraqi Association for
Oral Research, the Iraqi Division of the
IADR. The JODR is a periodic, peer-reviewed publication with an international
editorial board, which give it a unique position amongst the scientific publications
in the region. The JODR is the first online
scientific publication in Iraq, which proved
to be valuable in publicising the dental
research in the country. In line with our
mission to promote the dental and oral
research in the Middle East and Africa
region, a special consideration is given to
articles reporting research results of regional significance. We would welcome
submission of case reports or research
results from this region referring to any
aspect of oral or maxillofacial research.
I would like to take this opportunity to
thank the authors who have put their faith
in the Journal and shared their work on its
pages. My sincere thanks go to the Editorial and the Managing Board without
whom the successes we had in 2013 would
have not been possible.
JODR
Editorial Board
Editor-in-Chief
Dr. Anwar R Tappuni, UK
Communication Editor
Dr. Faaiz Alhamdani, Iraq
Managing Editors
Dr.Elham HazeimAbdulkareem, Iraq
Dr. Rasha Al-Kaabi, Iraq
Dr. AmmarAl-Shammaa, (Deputy), Iraq
Editorial Board
Prof. Shatha Alameer, Baghdad, Iraq
Dr. Moustafa Al-Haboubi, UK
Prof. Ibtisam Al-Hashimi, Texas, USA
Dr.Mudher Ali, Baghdad, Iraq
Dr. Omar Alnaimi, Newcastle, UK
Prof. Tahani Al-Sandook, Baghdad Iraq
Professor Stephen J. Challacombe
Dr. IanCorbett, Newcastle, UK
Mr. Justin Durham, Newcastle, UK
Dr. Bashar Hamid, Baghdad, Iraq
Prof. Kadhim Jawad Hanau, Baghdad, Iraq
Mr. Colin Hopper, London, UK
Dr. Saba Kassim, London, UK
Prof. Wagner Marcenes, London, UK
Dr. Aghareed Ghanim Mohammed,
Melbourne, Australia
Dr. Raid Salim, Erbil, Iraq
Dr. Bahar Jaafar Selivany, Duhok, Iraq
Dr. Ahmed Sultan, London, UK
Prof. David Williams, London, UK
Dr. Faraedon M. Zardawi, Sulaimani, Iraq
JODR
JOURNAL OF ORAL AND DENTAL RESEARCH
Yassir JODR Issue1, Volume 1, 2013
Ramus height and its Relationship with Skeletal and
Dental Measurements
Yassir A. Yassir, M.Sc.
University of Baghdad, College of Dentistry, Department of Orthodontics, Iraq.
Phone #: +964 770 391 9599
E-mail: [email protected]
Abstract
Background: The purpose of this study was to assess mandibular ramus height and to assess the relationship of ramus
height with various craniofacial and dental measurements in a sample of Iraqi adults with skeletal and dental Class
I.
Materials and method: The sample consisted of 95 Iraqi adults (54 females and 41 males) having normal occlusion
and Class I skeletal pattern aged between 18 and 31 years. Each individual was subjected to clinical examination
and digital true lateral cephalometric radiography. The radiographs were analyzed using AutoCAD 2007 software
computer program to determine ten linear and seven angular measurements. Descriptive statistics were obtained
and independent samples t-test was performed to evaluate the gender differences, while Pearson’s correlation coefficient test was used to identify correlations between ramus height and other measurements
Key words: ramus height, skeletal measurements, dental measurements, dentoalveolar heights.
Introduction
In orthodontics skeletal growth is
emphasized more than other aspects
of craniofacial development, perhaps
because the methods for its study
were developed earlier. Knowledge
of skeletal morphology and growth
is routinely applied in clinical practice; these can be visualized easily in the cephalogram. Craniofacial
skeletal growth is very important in
orthodontics, since variations in craniofacial morphology are the source
of most serious malocclusions, and
induction of changes in inter-maxillary relationships are fundamental
to orthodontic treatment. (Moyers,
1988)
Logically, any alteration or adjustment of one part of the dentofacial
complex will require a like adjustment by another part of the complex
for its own accommodation and so
on. (Bibby, 1980)
The main significance of the ramus
of the mandible is in providing attachment for masticatory muscles.
4
However, the ramus is also integral
to placing the corpus and dental
arch into harmonious relationship
with the the maxilla and other facial
structures. Correct relationships are
maintained by critical remodeling
and adjustments in ramus alignment,
vertical length, and anteroposterior
dimensions. A best fit with the maxillary arch and middle cranial fossa
is thereby provided. Indeed, the special developmental significance of
the ramus is integral to craniofacial
growth. These alterations are induced by osteogenic, chondrogenic,
and fibrogenic connective tissues
receiving local input control signals
producing progressive compensatory
changes in the shape and size of the
ramus. (Enlow and Hans, 1996)
The purpose of this study was to
evaluate the relationship between
ramus height and various craniofacial and dental measurements in a
sample of Iraqi adults with dental
and skeletal Cl I.
Materials and Method
The sample included 95 digital true
lateral cephalometric radiographs
taken in the Orthodontic department
at the College of Dentistry, University of Baghdad. All individuals were
Iraqi adults (54 females and 41
males), their age ranged between 18
to 31 years. They were determined
radiographically to have Class I skeletal patterns (ANB: 2°±2°) (Riedel,
1952), and clinically to have a normal Angle Class I occlusion, with
complete permanent dentitions.
They were clinically healthy with no
craniofacial syndromes or anomalies, such as a cleft lip and palate.
Subjects were excluded if they had
a history facial trauma or previous
orthodontic, orthopedic or surgical
treatment.
Each individual was examined clinically and had a lateral cephalometric radiograph taken by using Planmeca ProMax radiographic unit. The
individual was positioned within the
cephalostat with the sagittal plane
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Figure 1: Cephalometric landmarks and measurements: N: nasion. S: sella
turcica. Ar: articulare. Go: gonion. Me: menton. A: subspinale. B: supramentale. ANS: anterior nasal spine. PNS: posterior nasal spine. U6: point upper
1st molar. L6: point lower 1st molar. 1: S-N. 2: S-Ar. 3: Ar-Go. 4: Go-Me.
5: N-Me. 6: N-ANS. 7: ANS-Me. 8: S-Go. 9: MxMDH. 10: MdMDH. 11:
ANB. 12: SN-MP. 13: SN-PP. 14: PP-MP. 15: N-S-Ar (Saddle angle).
16: S-Ar-Go (Articular angle). 17: Ar-Go-Me (Gonial angle).
of the orientated vertical, the Frankfort plane horizontal, and the teeth
in centric occlusion. The radiographs
were analyzed using the AutoCAD
2007 software computer program
to calculate the angular and linear
measurements. After importing the
picture to the AutoCAD program,
points and planes were determined,
and then the angular and linear measurements were obtained. Angular
measurements were taken directly
as they are not affected by magnification. Linear measurements, however, were divided by a scale for each
picture to adjust for magnification.
The scale was obtained depending
on the measurement from the ruler
in the nasal rod.
ISSN 2310-6417
Cephalometric measurements (Fig.
1)
S-N: It is the anteroposterior extent
of anterior cranial base, the distance
between sella turcica and nasion.
(Rakosi, 1982)
S-Ar: Posterior cranial base, the
distance between sella turcica and
articulare. (Rakosi, 1982)
Ar-Go: Length or height of the ramus, the distance between articulare
to gonion. (Rakosi, 1982; Jarabak
and Fizzel, 1972)
Go-Me: Extent of mandibular body,
the distance between gonion and
menton. (Rakosi, 1982)
N-Me: Total anterior facial height,
the distance between nasion and
menton. (Rakosi, 1982)
N-ANS: Upper anterior facial
height, the distance between nasion
and anterior nasal spine. (Rakosi,
1982)
ANS-Me: Lower anterior facial
height, the distance between anterior nasal spine and menton. (Rakosi,
1982)
S-Go: Posterior facial height, the
distance between sella turcica and
gonion. (Rakosi, 1982)
MxMDH: Maxillary molar dentoalveolar height, the distance between
the mesiovestibular cuspid of upper
first molar and palatal plane along
the long axis of the molar. (Martina
et al, 2005)
MdMDH: Mandibular molar dentoalveolar height, the distance between the mesiovestibular cuspid
of lower first molar and mandibular
plane along the long axis of the molar. (Martina et al, 2005)
ANB angle: The angle between lines
N-A and N-B. It represents the difference between SNA and SNB angles or it may be measured directly
as the angle ANB. It is the most
commonly used measurement for appraising anteroposterior disharmony
of the jaws. (Riedle, 1952; Steiner,
1953)
SN-MP angle: The angle between
the S-N plane and the mandibular
plane. (Rakosi, 1982)
SN-PP angle: The angle between
the S-N plane and the palatal plane.
(Hang et al, 1990)
PP-MP: The angle between palatal
plane and mandibular plane. (Rakosi, 1982)
N-S-Ar: Saddle angle, between the
anterior and the posterior cranial
base. This angle formed at the point
of intersection of the S-N plane and
the S-Ar plane. (Rakosi, 1982)
S-Ar-Go: Articular angle, formed at
the point of intersection of the S-Ar
plane and the Ar-Go plane. (Rakosi,
1982)
Ar-Go-Me: Gonial angle, formed at
the point of intersection of Ar-Go
plane and the mandibular plane (GoMe). (Rakosi, 1982)
5
JODR
Statistical Analyses
The data were subjected to computerized statistical analysis using SPSS
(Version 15). The statistical analyses
included descriptive statistics with
mean values, standard deviation,
minimum, and maximum values for
continuous measurements. Inferential statistics include the independent
samples t-test to compare variables
between both genders. The Pearson’s
correlation coefficient test was used
to assess relationships between the
ramus height and other craniofacial
and dental measurements.
The following levels of significance
were used:
Non-significant
NS P > 0.05
Significant
0.05 ≥ P > 0.01
Highly significant ** 0.01 ≥ P >
0.001
Very highly significant *** P ≤
0.001
Results
Descriptive statistics for males and
females are illustrated in Table 1,
with independent samples t-test was
used to assess gender differences.
Out of the sixteen variables measured in this study, thirteen showed
significant differences between genders; the ANB angle was used to
discriminate the sample as skeletal
Class I and was not included as a test
variables. All linear measurements
were significantly higher in males,
while angular measurements showed
non-significant differences between
males and females, except for the
SN-MP, SN-PP, and N-S-Ar angles
which were significantly higher in females than in males.
For males and females, Pearson’s
correlation coefficient test (Table 2)
revealed significant positive correlation for ramus height and posterior
facial height, and maxillary and mandibular molar dentoalveolar heights.
Significant negative correlations
were noted for SN-MP, PP-MP, and
Ar-Go-Me angles. Ramus height in
females showed a significant positive
correlation with N-S-Ar angle, and a
significant negative correlation with
S-Ar-Go angle.
Discussion
This study aimed to quantify ramus
height in skeletal I Iraqi adults and
to relate variations in ramal height
with a range of craniofacial and dental measurements. The mean values
for ramus height reported in the
present study for females (45.08
±4.1 mm) and males (51.41 ±4.47
mm) are close to those described by
Burstone et al who reported mean
values of 46.8 ±2.5 mm and 52 ±4.2
mm for females and males, respec-
Table 1: Descriptive statistics and gender differences
(independent samples t-test)
6
tively (Burstone et al, 1978).
All linear measurements were significantly higher in males; this finding
is in accordance with previous studies by Ali (1988), Al-Sahaf (1991),
Al-Attar (2006), and Al-Joubori et
al (2009) suggesting that the craniofacial skeleteon of males is larger in
all linear dimensions than in females.
This finding may be attributed to the
fact that maturation is attained earlier in females than males with a longer
growth period in males. Johannsdottir et al (2004) reported that males
had consistently larger values for linear dimensional variables, including
anterior and posterior facial heights,
mandibular length, cranial base dimensions and nasal bone length.
The significantly higher mean values
of SN-MP, and SN-PP angles in females than males together with the
non-significant difference in PP-MP
angle, means that the maxillary and
mandibular planes are more downward positioned relative to the cranial base in females compared to
males; this may relate to a caudal
jaw growth rotation in females. The
significantly higher N-S-Ar angle in
females denotes the more backward
position of the female mandible.
Given that the lower facial height
tends to be shorter as the severity of
the overbite increases, and the total
anterior facial height is affected in
essentially the same fashion by the
degree of overbite as in lower facial
height. Two previous studies (Diamond, 1943; Wylie, 1946) considered
ramus height and its effect on intermaxillary space both anteriorly and
posterioly. Diamond (1943) suggested that deficient growth in length of
the mandibular ramus is the cause of
deficient intermaxillary space. However, Wylie (1946) failed to substantiate the contention that development
of ramus height is crucially important
for the development of intermaxillary space, however desirable it may
be for satisfactory facial contour.
Moreover, Wylie (1946) found nonsignificant differences between total
ISSN 2310-6417
height and hence decrease its effect
on anterior facial height and intermaxillary space anteriorly. Isaacson
et al (1971) found that the mean
height of the ramus was inversely related to the SN-MP angle. In other
words, the ramus was shortest in the
high angle group and longest in the
low angle group.
We may conclude from this study
that the increase in ramus height
provides space for the eruption of
molars, or that the eruptions of
molars during growing age lead to
compensating ramus growth. In both
cases the increase in ramus height
Table 2:
Pearson’s correlations coefficient test for the ramus height
and other measurements
facial height, lower facial height, and
intermaxillary space in the molar
region with respect to ramus height,
measured either from the condylar
head to the gonial angle, or from the
semilunar notch to the lower border
of the mandible.
The findings of present study showed
that the increase in ramus height in
both genders were associated with
increase in intermaxillary space in
the molar region, illustrated by the
highly significant positive correlation
with maxillary and mandibular molar
dentoalveolar heights. However the
increase in ramus height was associated with a non-significant increase
in total anterior and lower facial
heights, suggesting a limited effect of
ramus height on the intermaxillary
space in anterior region. This finding
may be explained by highly significant negative correlations between
ramus height and angles of mandibular rotation (SN-MP, PP-MP,
and Ar-Go-Me), which compensate
the effect of downward mandibular
movement with the increase in ramus
ISSN 2310-6417
mainly correlated with posterior intermaxillary area with a little effect
on anterior facial heights, as the increase in ramus height is associated
with forward rotation of the mandible. The molars will act as a fulcrum
for this rotation, which occurs during
periods of maximal facial growth.
McLaughlin et al (2001) and Proffit et al (2007) mentioned that adolescent patients can tolerate molar
extrusion, because any extrusion is
compensated by vertical growth of
the ramus, but in adults this extrusion
tends to rotate the mandible downward and backward, also helping to
address increased overbite. Graber
et al (1985) reported that during
the growth period, tooth eruption can
be stimulated in the posterior and
inhibited in the anterior segments.
The vertical growth component in
the condylar and sutural areas is also
amenable to therapeutic influence.
Extrusion of the molars and premolars also implies a skeletal growth
stimulus with vertical rotation of the
mandible, with concomitant downward-backward mandibular rotation.
Yousif (2010) found a positive association between maxillary and mandibular molar dentoalveolar heights
from the divergency of the jaws in
Iraqi males. This finding is in accordance with the widespread belief
that hyperdivergent facial types have
excessive posterior dentoalveolar development which was also found in
different ethnic population (Schendel et al, 1976; Janson et al, 1994;
Tsang et al, 1998; Martina et al,
2005; Kucera et al, 2001) and that
the hypodivergent facial types have
deficient posterior dentoalveolar development (Isaacson et al, 1971). On
the contrary decreases in maxillary
and mandibular posterior dentoalveolar heights in the permanent dentition have been reported by Betzenberger et al (1999) and Martina et al
(2005) in high-angle malocclusions.
Clinical Implications
Further studies are required to study
the effect of increase in vertical
measurements of the molars and the
ramus during growth to detect the
possibility of treating patients with a
steep mandibular plane and average
or reduced facial height by extrusion
of molars to compensate for backward rotation by increasing the forward mandibular rotation with minimal effect on anterior vertical facial
dimensions. This may be applied during treating adolescent patient with
skeletal Class II caused by small size
of the ramus and body of the mandible. This relationship often results in
a decreased posterior facial height, a
steeper mandibular plane angle, an
increased ANB angle, a normal SNA
angle with a decreased SNB angle,
an increased angle of convexity, and
an increased overjet. The treatment
can be achieved by the use of activator with subsequent trimming of
the interocclusal acrylic portion to
enhance the extrusion of the buccal
teeth, so that the face can be more
harmonized.
7
JODR
Conclusions
In a group of skeletal I Iraqi adults,
ramus height was directly correlated with intermaxillary space in the
posterior region, and inversely correlated with angles of mandibular
rotation.
References
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notch depth and craniofacial morphology in Iraqi sample aged 18-25
years. A master thesis, Department
of Orthodontics, University of Baghdad.
Ali FA (1988). Skeletodental characteristics of some Iraqi children at
nine and ten years of age: A cephalometric study. A master thesis, Department of Orthodontics, University
of Baghdad.
Al-Joubori SK, Yassir YA, Al-Bustani
AI (2009). The relation between ramus notch depth and some of the craniofacial measurements in different
skeletal patterns. J Bagh Coll Dentistry 21(4): 104-8.
Al-Sahaf NH (1991). Cross-sectional
study of cephalometric standards and
associated growth changes. A master
thesis, Department of Orthodontics,
University of Baghdad.
Betzenberger D, Ruf S, Pancherz H
(1999). The compensatory mechanism in high-angle malocclusions: a
comparison of subjects in the mixed
and permanent dentition. Angle Orthod 69(1): 27-32.
Bibby RE (1980). Incisor relationships in different skeletofacial patterns. Angle Orthod 50(1): 41-4.
Burstone CJ, James RB, Legan H,
Murphy GA, Norton LA (1978).
Cephalometrics for orthognathic surgery. J Oral Surg 36(4): 269-77. In
Athanasiou AE (1995). Orthodontic
cephalometry. 1st ed. London: Mosby-Wolfe. p. 248.
Diamond M (1943). The ramus as a
factor in the development of the dental height. J Dent Res 22: 346. Cited
by Wylie WL (1946). The relation-
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ship between ramus height, dental
height, and overbite. Am J Orthod
Oral Surg 32(2): 57-67.
Enlow DH, Hans MG (1996). Essentials of facial growth. W.B. Saunders
Company. p. 58.
Graber TM, Rakosi T, Petrovic AG
(1985). Dentofacial orthopedics
with functional appliances. The C.V.
Mosby Company. p. 104, 383.
Huang GJ, Justus R, Kennedy DB,
Kokich VG (1990). Stability of anterior openbite treated with crib therapy. Angle Orthod 60(1): 17-24.
Isaacson JR, Isaacson RJ, Speidel
TM, Worms FW (1971). Extreme
variation in vertical facial growth
and associated variation in skeletal
and dental relations. Angle Orthod
41(3): 219-29.
Janson GRP, Metaxas A, Woodside
DG (1994). Variation in maxillary
and mandibular molar and incisor
vertical dimension in 12-year old
subjects with excess, normal, and
short lower anterior face height. Am
J Orthod Dentofac Orthop 106(4):
409-18.
Jarabak JR, Fizzel JA (1972). Technique and treatment with light wire
edgewise appliances. 2nd ed. St.
Louis: CV Mosby.
Johannsdottir B, Thordarson A, Magnusson TE (2004). Craniofacial skeletal and soft tissue morphology in
Iceland adults. Eur J Orthod 26 (3):
245-50.
Kucera J, Marek I, Tycova H, Baccetti T (2011). Molar height and dentoalveolar compensation in adult subjects with skeletal open bite. Angle
Orthod 81(4): 564-9.
Martina R, Farella M, Tagliaferri
R, Michelotti A, Quaremba G, van
Eijden T (2005). The relationship
between molar dentoalveolar and
craniofacial heights. Angle Orthod
75(6): 974-9.
McLaughlin RP, Bennett JC, Trevisi
HJ (2001). Systemized orthodontic
treatment mechanics. 1st ed. Mosby
International Ltd. p. 132.
Moyers RE (1988). Handbook of or-
thodontics. 4th ed. Year Book Medical Publishers, INC. p. 38,39.
Proffit WR, Fields HW, Sarver DM
(2007). Contemporary orthodontics.
4th ed. Mosby, Inc., an affiliate of Elsevier Inc. p. 564.
Rakosi T (1982). An atlas and manual cephalometric radiography. London: Wolfe medical publications Ltd.
p. 35-45.
Riedel RA (1952). The relation of
maxillary structures to cranium in
malocclusion and in normal occlusion. Angle Orthod 22(3): 142-5.
Schendel SA, Eisenfeld J, Bell WH,
Epker BN, Mishelevich DJ (1976).
The long face syndrome: vertical maxillary excess. Am J Orthod
70(4): 398-408.
Steiner CC (1953). Cephalometrics
for you and me. Am J Orthod 39(10):
729-55.
Tsang WM, Cheung LK, Samman N
(1998). Cephalometric characteristics of anterior open bite in a southern Chinese population. Am J Orthod
Dentofac Orthop 113(2):165-72.
Wylie WL (1946). The relationship
between ramus height, dental height,
and overbite. Am J Orthod Oral Surg
32(2): 57-67.
Yousif HA (2010). Molar dentoalveolar heights’ association with some
vertical craniofacial measurements
in class I skeletal pattern. J Bagh
Coll Dentistry 22(4): 96-101.
Figure 1: Cephalometric landmarks
and measurements: N: nasion. S:
sella turcica. Ar: articulare. Go: gonion. Me: menton. A: subspinale. B:
supramentale. ANS: anterior nasal
spine. PNS: posterior nasal spine.
U6: point upper 1st molar. L6: point
lower 1st molar. 1: S-N. 2: S-Ar. 3:
Ar-Go. 4: Go-Me. 5: N-Me. 6: NANS. 7: ANS-Me. 8: S-Go. 9: MxMDH. 10: MdMDH. 11: ANB. 12:
SN-MP. 13: SN-PP. 14: PP-MP. 15:
N-S-Ar (Saddle angle). 16: S-ArGo (Articular angle). 17: Ar-Go-Me
(Gonial angle).
ISSN 2310-6417
Al Hano JODR Issue1, Volume 1, 2013
Changes In Color And Roughness With Laser Bleaching
Using Different Peroxide Concentrations
Fadi Al Hano, MSc; Ma>an Nayif, PhD.
Mosul University, College of Dentistry/ Department of Conservative Dentistry, Iraq.
Corresponding author:
Fadi Al Hano
Email: [email protected]
Abstract
Purpose: The use of different H2O2 concentrations for in-office bleaching has been questioned. Thus, the aim of this
study was to evaluate the efficiency of laser bleaching on color changes and surface roughness of bovine enamel with
different peroxide concentrations.
Materials and methods: Forty eight bovine incisors cleaned and labial surface polished up to #1200. Half of them were
artificially stained with black tea and divided into three subgroups and bleached according to the concentration of H2O2
(15%, 25% and 35% ) (n=8). Specimens were bleached with laser hybrid system (DMC Whitening Lase II, Sao Paulo,
Brazil). CIE Lab color system was used to evaluate color using Vita Easyshade Spectrophotometer (Ivoclar Vivadent,
Liechtenstien). The remaining specimens were used for surface roughness evaluation following bleaching. The enamel
roughness (Ra) values were measured by Stylus Profilometer (Suf-Corder SE 1200, Tokyo, Japan) and Atomic force microscopy (AA3000,Bosten,USA) before and after bleaching. Data were analyzed with Paired sample T-test to evaluate
color changes and Ra values at each concentration. ANOVA and Tukey test were used to evaluate the difference between
the groups with different bleaching agent concentrations. All tests were computed at 5% significance level.
Results: Significant increases in degree of lightness (L*) values observed following bleaching at all concentrations.
Different concentrations of peroxide produced significantly different Ra values. Bleaching with 35% agent produced
significantly higher L* value than 15% but similar to 25%. Exposing enamel to high peroxide concentration (25% and
35%) significantly increased Ra value in comparison to unbleached enamel.
Conclusion: Color changes and surface roughness of bovine enamel were influenced by hydrogen peroxide concentrations of DMC laser bleaching system.
Key words: Tooth bleaching, Hydrogen peroxide, DMC Laser, Bovine enamel, Color changes, Surface roughness.
Key words: Tooth bleaching, hidrogen peroxide, DMC Laser, bovine enamel, color changes surface roughness
Introduction
Of paramount importance for human
beings in relation to their social, psychological and professional needs is
minimizing discoloration particularly of anterior teeth (Wetter,2004).
Different options are available to
treat the discolored teeth. They include bleaching, direct or indirect
composite veneer and full crowns.
With keeping over all philosophy
of tooth restorations, conservation
should be given first to the bleaching
of the teeth. Bleaching has gained
popularity with many techniques
by utilizing different peroxide conISSN 2310-6417
centrations and activation sources
(Watts,2001).
Donald’s medical dictionary defines
bleaching as “the act or process of
removing stains or color by chemical
means” (Haywood,1989). A number
of methods have been described for
the bleaching of vital teeth (Joiner,
2006). However, basically, there are
three techniques: in-office, over the
counter bleaching, and home bleaching (Heymann, 2005). Since its
introduction by Haywood and Heymann 1989, several products have
been employed for bleaching. These
products are mainly available in gels
containing several concentrations of
hydrogen peroxide (Ziebolz et al.
2007). Although different concentrations of hydrogen peroxides may
show similar teeth whiting results
(Götz et al., 2007), higher concentrations of H2O2 and increased application times may cause enamel
surface alterations, such as loss of
mineral content and increase surface
roughness (Al-Salehi et al. 2007).
One of the newest advancement
in the field of in-office bleaching
techniques is laser application and
there are many types of lasers. The
most recent laser activating system
9
JODR
is Whitening Lase II DMC hybrid
system which is a combination of
infrared laser with LED in one
light so is provided best result with
less time and sensitivity. Whitening
Lase II provided is with three different bleaching agents, based on
the concentration of hydrogen peroxide ,(Lase PeroxideLite-15%,
Lase Peroxide Sensy II - 25% &
Lase Peroxide Sensy II - 35%).
For effective stain removal, hydrogen peroxide must be able to move
through tooth structure. This is possible since hydrogen peroxide has a
low molecular weight that permits
proteins denaturing, and will consequently increase tissue permeability and allow the movement of ions
through the tooth (McEvoy,1989).
The penetration of hydrogen peroxide and the possible effect of the
bleaching on the enamel structure
must be considered by restorative
dentists because in instances where
bleaching of the enamel and/or
dentin has been unsuccessful or
not accepted clinically, masking of
the discolored crown with acid etch
veneering technique has been advocated (Tavares et al. 2009).
Until recently, little attention has
been given to the influence of the
increase of hydrogen peroxide concentration on the enamel surface
textures and color changes within
the same experimental unit. Improvement of discolored teeth may
be affected by various concentrations of peroxide. In addition, alteration in enamel surface roughness may follow bleaching process
as well.
agents, (15%,25%&35%) on color changes and surface roughness
of bovine enamel.
Materials and Methods
The materials used for preparing
the specimens and the equipment
used for measuring the color changes and surface roughness are shown
in Table (1).
Specimens Collection And Preparation
Forty eight bovine cattle incisors
were stored frozen after extraction
until their use. Specimens were
cleaned and polished with nonfluoridated polishing paste. Roots
were cut using a diamond disc with
straight-type micro motor handpiece (NSK, Tokyo,Japan). Pulpal
tissue was removed by a reamer.
Pulp chambers were irrigated with
5 mL of 5% sodium hypochlorite to
remove any tissue remnants, then
washed and dried. Labial surfaces
were polished to create a smooth
and flat enamel surface with ascending-grit water proof silicon
carbide papers starting from #400
up to #1,200 under running water
(Fig.1). The specimens were randomly assigned into two groups,
two groups, half is for detecting
color changes and the other half is
for surface roughness.
Color Changes
Staining procedure
Specimens artificially stained by
immersion of two grams of black
tea (Lipton, India)was immersed
in 100 mL of boiled water for five
minutes (Sulieman et al.,2003; Ayaka et al., 2011 ). Specimens were
immersed in the solution and stored
Table.1. The materials used for preparing the specimens and the
equipment used for measuring the color changes and surface roughness.
Hypothesis of the study
There would be no change in enamel color and surface roughness after
laser bleaching with different peroxide concentrations.
Objectives:
Evaluate bleaching efficacy of laser activating system utilizing three
different concentration bleaching
10
ISSN 2310-6417
Fig 1 Crosscut surface of the prepared specimen.
Fig 2 Specimen before and after staining
were recorded prior to bleaching
and considered as a baseline data.
Each specimen was measured three
times, then the average value was
considered for calculation. In order
to decrease the variation between
the specimens, only the specimens
which showed an L* value between
45 and 65 were included in the research.
Bleaching Procedure
Fig 3 Specimen with masking tape
with a 5 mm-diameter hole
inside the incubator for 7 days at
37°C. Specimens before and after
staining are shown in (Fig.2). Labial surfaces of stained specimen
were covered with a masking tape
with a 5 mm-diameter hole to fit
the probe of Spectrophotometer
(Fig.3).
The CIE L*a*b* color system
was applied for the evaluation of
color changes by using VITA Easyshade Spectrophotometer. The CIE
L*a*b* values of enamel surfaces
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Specimens were divided into three
subgroups according to concentrations (15%, 25% & 35%) (n=8).
The bleaching procedure was performed using Whitening Lase II,
DMC (810nm wavelength diode
laser mix with LED) according to
manufacture. Figure (4) shows the
specimens bleached with different
peroxide concentrations in comparison with stained specimen. Color
values of L*a*b* were measured
at both baseline and after bleaching. The difference in L*a*b* value between the baseline and after
bleaching were expressed as ΔL,
Δa, and Δb respectively. The color
difference (ΔE) was calculated according to the following equation:
ΔE=[(ΔL)2+(Δa)2+(Δb)2]1/2
Surface Roughness
Surface Roughness Measurement
Specimens following polishing procedure and after bleaching were
used for evaluation of Ra. Such
evaluation was conducted by two
methods, one considered as contact methods via stylus profilometer (Surf-Corder SE 1200, Tokyo,
Japan) and other as non-contact
method using AFM(AA3000, Angstrom Advanced Inc.USA).The differences in average (Ra) value between polished and bleached value
for each specimen were recorded
and analyzed.
Statistical Analysis
Mean for all groups before and
after bleaching were recorded
and the data was analyzed Table
(2&3). Paired Sample T-test was
used to evaluate color changes and
surface roughness between stained
and bleached surfaces at each concentration. T-test used to compare
the difference between polished
and bleached surfaces at each concentration. One way (ANOVA) was
used to determine any significant
11
JODR
Fig 4 Color changes following bleaching with three different concentrations of H2O2. (a) Before bleaching of the
experimental surface. (b) After bleaching with peroxide 15%. (c) After bleaching peroxide 25%. (d) After bleaching
peroxide 35%.
Fig 6. L* value after bleaching with
different concentrations
(AB) letter indicate no significant
difference.
Table.2. Mean (L* value) and Standard Deviation of stained and bleached
Groups
Fig 5: L* value and differences
between stained and bleached
specimens (different letters indicate significant difference)
12
difference in the mean of (L*) value & (Ra) value among the various
treatment groups followed by Tukey
HSD as post hoc comparisons test
within various treatment groups.
Results
Color Changes
The result of T-test revealed that
there were significant differences
between stained and bleached specimens at each concentration, this differences in L* value were illustrated
ISSN 2310-6417
Table.3. Mean (Ra) value and Standard Deviation of polished and bleached Groups at different concentrations
Table.4. One Way Analysis of Variance for L* value among various H2O2 concentrations
in fig (5). One way analysis of variance for (L*) value between various
concentrations is given in table (4).
The results revealed that there was
a significant difference in the mean
of L* value between the various
treatment groups. Tukey multiple
comparisons demonstrate a significant increase in L* values with an
increase in peroxide concentrations.
Bleaching with 35% agent produced
significantly higher L value than
15% .While no difference was observed between 15% and 25% and
between 25% and 35%. The results
of Tukey test were explained in fig
(6).
Surface Roughness
Fig.7: Ra value of polished and bleached groups at each concentration (different letters indicate significant difference)
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Paired sample T-test was used to
compare the difference in surface
roughness between polished and
bleached surfaces at each concentration. The results revealed that
there were no significant differences
13
JODR
Table.5. Analysis of Variance for the three Groups Ra value
Fig 8. Ra value after bleaching with different concentrations (AB) letter indicate no significant difference
in (Ra) value between polished
and bleached groups at peroxide
15%. A significant difference in
(Ra) values was observed between
polished and bleached groups at
peroxide 25% & 35% fig (7).
One way analysis of variance for
surface roughness between various concentrations is given in table (5). The results revealed that
there were a significant difference
in the mean of Ra value between
the various treatment groups. The
Tukey multiple comparisons demonstrate a significant increase
in Ra values with an increase in
bleaching agent concentrations.
Bleaching with 35% agent produced significantly higher Ra value than 15%.While no difference
between 15% and 25% and between 25% and 35% fig (8) .For
AFM evaluation of surface roughness, the result shows an increase
in both numbers and depth of vale
Fig 9 Three dimension (3D) Surface topography of enamel by Atomic Force Microscopy (AFM) were made with areas of 10 µm2
captured with a slow scan rate(0.1 Hz). Nano
roughness (Ra, in nanometers) was measured
with proprietary software (Nano scope Software, version V7). :a) Polished enamel sample
Ra = 140 nm. b) Enamel sample after bleaching with 15% H2O2. Ra = 150.4 nm. c)
Enamel sample after bleaching with 25% H2O2
Ra = 190.74 nm. d) Enamel sample after
bleaching with 35% H2O2 Ra = 200.44 nm.
14
ISSN 2310-6417
of the enamel subjected to different
peroxide concentrations as show in
Figures (9).
Discussion
Esthetic dentistry has become an
increasingly essential requirement of modern dental practice.
Laser teeth whitening is one of
the newest and efficient methods available for office teeth
whitening. The objective of laser bleaching is to achieve ultimate bleaching process by using
the most efficient energy source
while avoiding any adverse effect (Dostalova et al. 2004). On
the other hand, the goal of the
dental practitioner is to whiten
the tooth efficiently with controlled peroxide concentration
but with no morphological and
chemical changes of enamel. To
date, numerous in vitro models
have been used to evaluate the
efficacy of tooth bleaching products and methods (Suyama et al.,
2009, Sulieman et al., 2003). An
artificial discolored bovine tooth
model with tea extract for staining the teeth was applied in this
study. It’s based on the discoloration model reported by (Sulieman et al., 2003,2004&2005;
Davidi et al, 2008; Polydorou
et al., 2009). Many researchers have preferred to use animal
teeth because of the increasing
difficulty in obtaining human
teeth for dental research, and because of the requirements made
by ethics committees about their
use. Bovine teeth have been suggested as possible substitutes for
human teeth because it has been
reported that chemical and physical properties of bovine tooth
such as composition, enamel
density, heat capacity, hardness,
dentin tubule density and permeability are similar to human
teeth (Tagami et al., 1989, Esser et al., 1998, Fonseca et al.,
2004, Reis et al., 2004).
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In this study, Spectrophotometers (Vita Easyshade) were
used for the evaluation of the
color change. The Easyshade
is an intraoral contacting spectrophotometers that can supply
parametric data (L*,a* & b*)
which could be easily applied
for statistical analysis. The possible changes related to in-office
different
peroxide-containing
bleaching agents are capable of
causing alteration in enamel at
high concentrations (for example
35%) as well as the degree of
lightness. Previous studies evaluated the influence of high peroxide concentration like 35%
on enamel surface roughness
and color changes (Dostalova et
al. 2003) it was found that high
concentrations produce a great
improvement in color especially
in deep discoloration but such
improvement will affect enamel
surface roughness. The reason for
these changes could be related
to loss of Ca+² ion by the action
of hydroxyl group of peroxide gel
(Berger et al., 2010). These results are in consistent with our
results for color changes and
surface roughness where there
is a slight surface modification
after laser-assisted bleaching
in-office procedure especially
in high concentration. In such a
case, we recommend using remineralizing products to overcome
such enamel destruction like
Gc Tooth Mousse on bleached
enamel (Baljeet et al.,2012;
Vasconcelos et al.,2012). The
mean (L*) value obtained after
bleaching the stained teeth was
greater than the stained one.
This indicates that hydrogen peroxide solution was able to react
and activate in the presence of
laser beam. Such activation will
produce active free radicals that
act as a potent oxidant and subsequently react with and cleaves
the bound of chromophores lead-
ing to alteration of pigments in
the enamel and dentin and the
lightening effect is achieved.
The improvement in the degree
of lightness between stained and
bleached specimens at each concentration was observed in this
study. These results imply that
regardless of the peroxide concentration provided with Lase
II system, the bleaching process
was successful at the applied
time protocol. Such a result confirms the company claims that
even low concentrations of peroxide when activated with laser
could produce a substituent difference in color toward greater
lightness (Marvin et al., 2009).
The analysis of variance shows
a significant difference between
groups (15%,25% & 35%). exposure of the teeth enamel to
higher peroxide concentration
(35%) produce higher lightness
values (higher L*) when compared with low concentration
(15%, 25%). This indicates that
there is a relation between increasing peroxide concentration
and color changes. This could be
explained by the amount of free
radicals such as oxygen (O•) and
hydroxyl (OH−). Therefore, higher concentrations will produce
higher amounts of free radicals
and consequently higher lightness. This coincides with the
finding by Sulieman et al. (2004)
who compared the in vitro tooth
bleaching efficacy of gels containing 5–35% peroxide. This
study found that with high peroxide concentration, the number
of gel applications required to
produce uniform bleaching was
decreased. From the results of
our study and Sulieman’s study
we can suggest that whitening
result can be obtained in a short
period of time by utilizing high
peroxide concentrations. The
short time of gel applications
might decrease post-operative
15
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sensitivity. In the present study,
the degree of lightness ΔL gradually increased in all groups by
increasing peroxide concentrations, while (Δa) and (Δb) that
represent the degree of redness
and yellowish showed a gradual
decrease. This behavior of color
improvement resulted from the
fact that the homogenous changes in ΔE value among different
concentrations dependent on the
amount of free radical release
as excessive amount is expected to be released with higher
peroxide concentration. Such a
phenomenon was also observed
by other studies (Sulieman
et al., 2003,2004&2005; Davidi,2008; Polydorou et al.,
2009). It should be noted that
a mean for (ΔE) value for all
three peroxide concentrations
was differed statistically. In the
present study, the mean surface
roughness (Ra) value obtained
after bleaching was significantly higher than those values
without bleaching treatment for
both 25% and 35% concentration. Although the 15% did not
show significant difference in
Ra value but the mean comparison revealed an increase in value. This study demonstrates that
there is a relationship between
the surface roughness value and
an increase in peroxide concentrations, where exposure of the
teeth enamel to 35% hydrogen
peroxide during office bleaching
produced higher roughness values when compared with 25%
and 15% hydrogen peroxide.
Such observation was also applicable when comparing the
roughness value between 15%
and 25% groups. Accordingly,
low peroxide agent should be
selected whenever possible to
avoid the possible drawback
associated with increasing the
peroxide concentration. However, this might be guided clini-
16
cally by the discoloration degree. Recent advances in the
bleaching process always focus
on the lower peroxide concentration agents even when the
treatment time is prolonged
(Joiner, 2006). Hydrogen peroxide at lower concentration did
not have a major effect on the
enamel structure and this coincides with the finding of (Oltu
and Gurgan, 2005,McCracken
and Haywood, 2004) who found
a significant Ca²+ loss of enamel after treatment with different peroxide solution. The presence of hydration shell makes
the enamel crystal electrically
charged and can therefore attract ions. Free radicals that
emit from hydrogen peroxide
during bleaching are able to
play a part in demineralization and cause Ca²+ loss from
enamel crystals. Lewinstein et
al, (2006) came to the conclusion, that peroxide could cause
demineralization in enamel at
low and high concentrations.
Another study concluded that
higher concentrations of H2O2
caused more Ca²+ loss than
lower concentrations (Hüseyin
Tezel et al.,2011). Atomic force
microscopy revealed that exposing enamel to high peroxide
concentration (25% and 35%)
significantly increased (Ra) value in comparison to unbleached
enamel Fig (9). Also different concentrations of peroxide
produced significantly different
(Ra) value. This result was consistent with the result of profilometer analysis. Our results
showed changes in superficial
enamel after hydrogen peroxide
treatment which affected the
highly mineralized enamel even
at low (15%) concentration.
More detectable changes was
observed with higher peroxide
concentration (25% & 35% ).
It is recommended to perform
tooth whitening by using low
concentration of hydrogen and a
short treatment time to reduce
the possible destruction but to
bring about the required change
in color. This might be applied
for mild discoloration to overcome such effect but this is not
recommended in deep discoloration where mild color improvement will be obtained.
You can delete the blue paragraphs as suggested by reviewer
Conclusions
Color changes and surface roughness of bovine enamel were influenced by the use of DMC laser bleaching system. Higher
peroxide concentration produces
higher color changes and surface
roughness value.
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Alsandook JODR Issue1, Volume 1, 2013
A Pilot Double Blinded Clinical Trial to Compare between
Tramadol HCL and Lidocaine HCL as Local Anaesthesia amongst
Hospital-outpatient Adult Dental Attendees Mosul-Iraq
Tahani A. Alsandook, PhD.
Dean of College of Dentistry/University of Mosul/Mosul/Iraq.
[email protected]
Yahya A. Al-Haideri, MSc.
Assistant Lecturer in Oral and Maxillofacial Surgery Department /College of Dentistry /University of Mosul/ Mosul/
Iraq.
Abstract
Aim of the study: The aim of the current study is to compare the local anesthetic action of tramadol HCL (with adrenaline) and
lidocaine HCL (with adrenaline) in minor oral surgery.
Method: A double blind study including 124 patients, requiring minor oral surgery (conventional tooth extraction, surgical
removal of impacted teeth and periapical surgery) in the lower molar teeth, allocated randomly into two groups:
Group A (n=62), in which each patient received initial dose of one dental cartridge, 1.8ml, from drug A (36mg of Lidocaine
HCL with (0.0225mg) adrenalin), for conventional tooth extraction, doubled in case of surgical removal of impacted tooth and
periapical surgery.
Group B (n=62) received one dental cartridge, 1.8ml, from drug B (50 mg of tramadol HCL and (0.0225mg) adrenalin diluted
to 1.8 ml by distilled water), again this dose was doubled in case of surgical removal of impacted tooth and periapical surgery.
For each patient the onset of anesthesia, number of cartridges used, duration of surgery and the degree of pain (with a 10-cm visual analog scale VAS), had been recorded during the operation.Postoperatively, the patients were instructed to record exactly
when the parasthesia disappear and any adverse effects such as nausea and\or vomiting on the first day of operation.
Result: there was no significant difference between the two study groups in the number of cartridges (1.33/±0.510, 1.37/±
0.519)nor the onset of anesthesia(2.95/±1.46, 3.14/±1.31) minutes, intraoperative pain (0.1935/±0.697, 0.2096/±0.656),
duration of surgery (12.77/±10.51, 14.11/±11.66) minutes, and side effects. However there was a significant difference in
duration of anesthesia(153.14/±35.10, 117.11/±26.88) minutes, where the group A achieved longer duration of action of local
anesthesia.
Conclusion: These study findings suggested that Tramadol HCL can be used as alternative to Lidocaine HCL in combination
with adrenaline to achieve local anesthesia in situation where Lidocaine HCL is contraindicated or when adequate local anesthesia with minimal paraesthesia is required. Validation and replication of these study findings should be considered in future
research.
Key Words: Local Anesthesia, Tramadol, Lidocaine, Adrenaline, New Local Anesthesia, Analgesia.
Introduction
Compression was the first method
of local anesthesia used in the antiquity. Cold, as local anesthesia,
was widely used until 17thCentury
(Franco, 2007). The natural Cocaine
was the first drug used as local anesthetic agent at about the end of
18thCentury, unfortunately the serious side effects of this drug made the
researchers to look for safe drugs
(Calvey and Williams, 2008). In the
18
last century a group of safe local anaesthetics have been introduced such
as Lidocaine 1948 which is the most
commonly used local anaesthetics
till now, mepicaine 1957, prilocaine
1960, bupivacaine 1963 (Rahn and
Ball, 2001), however, because no
drug is currently devoid of potential
toxicity the search for new better local anesthetics continued (Yagiela et
al, 2004).
Tramadol HCL is a centrally acting
opioid(Shipton, 2000), with a relatively low addiction incidence. Clinically it is effective for the treatment
of moderate to severe pain such as,
postsurgical pain, obstetric pain, terminal cancer pain and pain of coronary origin (Scott and Perry, 2000).
In the last decade few researches
prove that tramadol HCL can be
used as local anesthesia in minor
soft tissue procedures (Altunkaya
etal, 2003),
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Most patients attend dental clinics
suffer from pain. So relief of this
pain is the most important objective
of those dentists and it is a critical
point in their success. On the other
hand it is preferable, by the patient,
to reduce the amount of pain killer
intake post operatively i.e. it is ideal
if the anesthesia used have a powerful analgesic activity and relatively
for a long period. Indeed, the use of
Tramadol HCL will be beneficial in
patients with certain circumstances
e.g., children. Therefore, from this
point of view, if, Tramadol HCL posses local anesthetic action equivalent to that of Lidocaine, it will be
more superior than lidocaine as it
will provide postoperative analgesia.
Patients and Methods
A randomized, double-blind study
was conducted at Oral and Maxillofacial Surgery Department/College of Dentistry/Mosul University,
between May2011 and September
2012. The study was approved by the
local academic committee according to relevant guidelines. The purposes of the study were explained
to all patients included in the study
and written informed consent was
obtained from all participants. Patients were informed that their participation is voluntarily and their
withdrawal from the study at any
time will not affect the provisional
of their treatment. Inclusion criteria were as follows: 18 to 45years of
age, any gender, all patients were to
undergo elective minor oral surgical
procedures in the lower molars, including: conventional tooth extraction, surgical removal of impacted
third molar and periapical surgery.
Patients were assigned sequential
numbers in the order in which they
were enrolled, and received their
allocated treatment according to a
computer-generated randomization
schedule prepared before the start
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of the study.
Exclusion criteria included history
of compromised medical status, history of allergy or hypersensitivity to
the drugs used in this trial, pregnant
or lactating females.
Patients were assigned into 2
groups of treatment; sample size
was 62 subjects per group:
Group A: each patient received initial dose of one dental cartridge, 1.8
ml, from drug A (Lidocaine (36mg)
and epinephrine (0.0225mg) (New
Stetic-Colombia)) for conventional tooth extraction, this dose was
doubled in case of surgical removal
of impacted tooth and periapical
surgery. Group B: each patient received initial dose of one dental
cartridge, 1.8 ml, from drug B (tramadol HCL 50mg, according to the
recommended dose in BNF 2005,
and epinephrine (0.0225mg)) for
conventional tooth extraction, again
this dose was doubled in case of surgical removal of impacted tooth and
periapical surgery.
The studied drug in group B was
prepared by an independent investigator in Pharmacology Department/College of Dentistry/Mosul
University, who was not involved in
the surgical procedure . The label
removed from cartridges of drug A,
so cartridges of both drugs (A and
B) had a similar appearance, coded
and blinded to the investigator and
subjects.
The same investigator performed
all the surgical procedures without
having any idea about the type of
anesthesia to be used. Block of inferior alveolar nerve was used for local anesthetics administration by using disposable dental needle gauge
(-27-), length (-32mm) mounted
on dental syringe. Anesthetizing of
long buccal nerve was delayed and
done after being sure that the block
anesthesia was success i.e. after appearance of lip parasthesia.
Data collection
Sample characteristics: included
age and socioeconomic status of
patients and oral health. Intraoperatively:
Onset of anesthesia:
Immediately after injection (considered as time zero) to the time that
the patient feel parasthesia on his
lip, this time interval was recorded
to be the onset of inferior alveolar
nerve block anesthesia.
Measuring of pain intensity: The
first incision and/or gingival separation was performed three minutes
after administration of long buccal
nerve block, this time was selected
to achieve optimal local anesthetic
effect. The patient was instructed to
inform the investigator by moving
or rising his left hand at any time
during operation if pain was felt.
The degree of pain was evaluated
with a 10-cm visual analog scale
(VAS) (Sriwatanakul et al, 1983).
Before starting the treatment, the
investigator explained the VAS to
the subjects. The VAS consist of an
interval scale ranging from zero,
representing no pain or discomfort
to 10, representing maximum pain.
The mean of the VAS scores during
the operation was calculated and
recorded by dental chair side assistant. During the surgery, when the
VAS exceeded 3 points, additional
half cartridge (0.9ml) of the same
drug was injected into the surgical
site, and the total number of the
cartridges used during the operation was recorded.
Duration of the surgery: recorded
duration represented the time interval from the incision/or gingival
separation to the placement of last
stitch/or completion of tooth extraction.
19
JODR
Number of cartridges
The total number of used cartridges
were recorded for each procedure
in both groups.
Postoperatively:
Duration of anesthesia: which was
the time interval between the appearance of lip paresthsia and its
disappearance, as reported by the
patient.
Recording of adverse effect:
Nausea and vomiting are common adverse effects of tramadol
HCL(Cossmann et al., 1997). Persistent nausea (defined as the urge
to vomit lasting for more than 30
minutes) and two or more episodes
of vomiting were treated with IV
injection of 10mg metoclopramide.
Nausea and vomiting were recorded
using a three point ordinal scale (0
= none, nausea = 1, and vomiting
= 2). Patients were reviewed after
24 hours and information about the
duration of anesthesia and adverse
effects was recorded.
Data analysis: spss program version
(11.5) on Pentium IV computer was
used to analyze the obtained data.
Independent-Samples T-Test was
used to compare parametric variables (cartridges number, degree of
pain, duration of surgery, duration
of anesthesia), Mann-Whitney U
Test was used to compare the nonparametric variables (nausea and
vomiting).The level of significance
was set at ≤0.05.
Intraoperative data:
Number of cartridges: the results
revealed that only one patient from
each group was required additional
injection, the maximum numbers
of used cartridges were recorded
in both groups which were (3), the
minimum (1) was recorded in the
two groups. Table (1).
Independent-Samples
T-Test
showed no statistically significant difference between the two
groups(P = 0.728, f= IndependentSamples T-Test showed no statistically significant difference between the two groups(P = 0.728,
f= 0.290; Group A(n=62), m/
SD=1.33/±0.510);Group B(n=62),
m/SD=1.37/± 0.519. 124 is the
sample size and (0.0009) is the degree of freedom).
Onset of anesthesia: the fastest onset of action was recorded in group
(A) which was (0.1) minute and the
slowest one which was (7) minutes
recorded in both groups. The highest mean onset (3.145) minute was
recorded in group (B), while the
lowest mean onset (2.951) was recorded in group (A). Table (1).The
statistical analysis of the assumed
data using Independent-Samples TTest indicates no significant difference (p=0.440, F= 0.551; Group A
(n=62), m/SD=2.95/±1.46); Group
B (n=62),m/SD=3.14/±1.31; 124 is
the sample size and (0.0048) is the
degree of freedom).
Intra operative pain: the maximum
VAS score(4)was recorded in group
(A), while the minimum (0) was recorded in 56 cases in group A and
in 55 cases in group B. The highest mean(0.2096) was recorded
in group (B), while lowest mean
(0.1935) presented in group (A).
Results
The study conducted on 124 patients of moderate socieo-economic
status,18-45 years age, 65 female
and 59 male. Each group involved
25 case of surgical removal of mesially impacted lower wisdom and 36
conventional extraction any of lower molars and 1 periapical surgery
at the lower first molar.
20
ISSN 2310-6417
Table (1).
The analysis of the data statistically
by using Independent-Samples TTest resulted in a no significantdif
ference(p=0.895,F=.048;GroupA(
n=62),m/SD=0.1935/±0.697);Gro
upB(n=62),m/SD=0.2096/±0.656;
124 is the
sample size and
(0.00014) is the degree of freedom).
Duration of surgery: the maximum
duration recorded was (55) minutes, which presented in group (B),
while the minimum was (4) minutes which recorded in both groups.
The highest mean (14.11) minutes
was recorded in group (B) while
the lowest (12.77) minutes was recorded in group (A).Table (1). As a
result of statistical analysis of the
data by using Independent-Samples
T-Test, there was no significant differences in the durations of operations among the study groups.
recorded in group (B). Table (2).
The highest mean (153.14) minutes
was recorded in group (A) while the
lowest (117.38) minutes recorded
in group (B). Table (2).
Statistically Independent-Samples
ISSN 2310-6417
T-Test showed significant difference between the two groups(p=0
.01,F=2.254;GroupA(n=62),m/SD
=153.14/±35.10);GroupB(n=62),
m/SD=117.11/±26.88; 124 is the
sample size and (0.249) is the degree of freedom).
Adverse effects:
Regarding the adverse effects (nausea and vomiting) which were recorded in the first 24 hours after
surgery the study revealed that,
there were only two observation of
nausea in group A, while in group B
four observation of nausea and one
of vomiting were recorded. Table
(3).
Statistical analysis of the data by
using non parametric Mann-Whitney U Test, demonstrated that there
was no significant
difference presented among the
two groups ( P= 0.240).
Discussion
The objective of the current study
was to compare the onset and duration of local anesthetic action of
tramadol Hcl (with adrenaline) and
Lidocaine HCL (with adrenaline) in
minor oral surgery.
It has been demonstrated that tramadol HCL 5% has a local anesthetic
effect similar to that of prilocaine
2% when used intradermally for
excision of soft tissue lesions (Altunkaya et al, 2003; Kargi et al,
2009). Other studies showed that
tramadol HCL has a local anesthetic activity similar to, but weaker
than that of lidocaine HCL(Mert et
al, 2002; Mert et al, 2006).
The current study was correlated
with these studies in that tramadol
HCL has local anesthetic effect, but
it should be noted that the present
study involved soft tissue incision
and bone removal while other studies involved only soft tissue surgery.
The evidence obtained in this study
demonstrates that tramadol HCL
exhibits local anesthetic effect that
enables oral surgeon to perform
pain free minor oral surgical procedures when infiltrated to susceptible neurons.
To our best of knowledge this is the
first study in which tramadol HCL
used as local anesthesia in minor
oral surgery and comparing its an-
21
JODR
esthetic effect with that of lidocaine
HCL, furthermore, no published article was noticed in this regard to
compare our result with it.
Tramadol HCL is a synthetic centrally acting opioid, it is clinically
effective for the treatment of moderate to severe pain with a relative
low addiction incidence. In acute
therapeutic use, tramadol HCL produces analgesia against multiple
pain conditions such as postsurgical pain, obstetric pain, terminal
cancer pain, and pain of coronary
origin, and it has been used as adjuvant therapy in anesthesia(Shipton,
2000).
Tramadol HCL may have local anesthesia like activity because of
its nerve conduction blocking potency. Clinical and laboratory studies of opioids, such as tramadol,
have shown that local anesthetic
effects of opioids typically cannot
reversed by pretreatment with naloxone (Tsai et al, 2001). The lack
of antagonizing ability of naloxone
is considered to be obvious because
the effects of tramadol HCL on the
nerve conduction are more likely
mediated by a non-opioid receptor
mediated mechanism. In addition it
has been reported that there is no
competition for a common binding
site on the Na-channel between opioid, meperidine, and the local anesthesia lidocaine (Brau et al, 2000).
In this study there was no significant difference between tramadol
and lidocaine groups in the, volume
of local anesthetic solution administrated to produce local anesthesia nor the onset of anesthesia,
intraoperative pain using VAS, and
side effect. However there was a
significant difference in duration of
anesthesia. Where Lidocaine group
achieved longer duration of action
of local anesthesia. Yet this effect
22
considered a disadvantage due to
discomfort associated with local anesthesia.
Future research implications
Further studies are required to
validate, replicate our findings and
to evaluate pharmacokinetics and
mechanism of action of locally administrated tramadol hydrochloride.
Conclusion
Tramadol HCL can be used as alternative to lidocaine HCL in combination with adrenaline to achieve
local anesthesia in situation where
lidocaine HCL is contraindicated
or when adequate local anesthesia with minimal parasthesia is required.
References
Altunkaya H, Ozer Y, Kargi E, Ozkocak I, Hosnuter M, Demirel CB, Babuco O. (2004) The postoperative analgesic effect of tramadol when used
as subcutaneous local anesthetic.
AnesthAnalg; 99:1461-4.
Altunkaya H., Ozer Y., Kargi E. andBabuccu O,(2003) Comparison of
local anaesthetic effects of tramadol with prilocaine for minor surgical
procedures , Br J Anaesth; 90: 320-2.
Brau ME., Koch ED., Vogel W.,
Hempelmann, G. (2000) Tonic Blocking Action of Meperidine on Na+ and
K+ Channels in Amphibian Peripheral
Nerves . Anesthesiology; 92: 147–
155.
Calvey TN, Williams NE. Principles
and Practice of Pharmacology for
Anaesthetists. 5th ed.Wiley-Blackwell;2008: pp.: 149-169, 195-227.
Cossmann M., Kohnen C., Langford
R., McCartney C. (1997): Tolerance
and safety of tramadol use: results of
international studies and data from
drug surveillance. Drugs; 53 Suppl. 2:
50-62.
Franco CD. Local Anesthetic, Manual
of Regional Anesthsia. Second ed.
Chicago, IL; 2007: 12-30.
Kargi E., Isıkdemir A., Tokgöz H.,
Erol B., Isıkdemir F., Hancı V.,
Payaslı C .(2009): Comparison of
Local Anesthetic Effects of Tramadol
With Prilocaine During Circumcision
Procedure [abstract]. Urology; ISSN:
1527-9995 .
Mert T. , Gunes Y., Ozcengiz D., Gunay I., Polat S. (2006) Comparative
effects of lidocaine and tramadol
on injured peripheral nerves. Eur J
Pharmacol;543:54-62.
Mert T., Gunes Y., Guuen M., Gunay
I., Ozcengiz D.(2002) Comparison of
nerve conduction blocks by an opioid
and local anesthetic. EurJPharmacol;, 439:77-81.
Natalini G, Rosano A, Franschetti
ME, et al. (2006)Variations in arterial blood pressure and photoplethysmography during mechanical ventilation. Anesth Analg;103:1182–88.
Rahn R, Ball B. Local anesthesia in
dentistry -Articaine and epinephrine
for dental anesthesia. 1 st ed. Seefeld,
Germany: 3M ESPE AG; 2001.
Scott LJ., Perry CM. (2000) Tramadol: a review of its use in perioperative
pain. Drugs; 60 (1): 139-76.
ShiptonEA. (2000) Tramadol present
and future. Anesth Intensive Care.;
28:363-74.
Sriwatanakul K, KelvieW, Lasagna
L, CalimlimJF,Weis OF, Mehta G(
1983);
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pain. ClinPharmacol Ther;34:234–9.
Tsai YC, Chang PJ, Jou IM (2001)
Direct tramadol application on sciatic nerve inhibits spinal somatosensory evoked potentials in rats. Anesth
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Dentistry. 5th ed.St Louis: Mosby;
2004.
ISSN 2310-6417
Hussein JODR Issue1, Volume 1, 2013
Parent’s Perception On The Importance Of Their Children’s
First Dental Visit (A Cross-Sectional Pilot Study In Malaysia)
1Alaa S. Hussein, M.Sc; 2Mohamed I. Abu-Hassan, PhD; 3Robert J. Schroth, PhD; 4Aghareed M. Ghanim, PhD
1Department of Pediatric Dentistry, Faculty of Dentistry, Universiti Teknologi MARA (UiTM), Malaysia. 2Department of Restorative Dentistry, Faculty of Dentistry, Universiti Teknologi MARA (UiTM), Malaysia. 3Department of
Pediatrics & Child Health, Faculty of Medicine and Department of Preventive Dental Science, Faculty of Dentistry,
University of Manitoba, Canada. 4Melbourne Dental School, University of Melbourne, Australia.
Corresponding author:
Dr. Alaa S. Hussein
Abstract
Understanding parental perceptions about early childhood oral health is important in order to develop effective preventive measures since parents’ health behaviours and practices usually have a direct influence on their children’s dental health. The aim of
this pilot study was to evaluate parental views about the primary teeth, first dental visit, and use of behaviour modification at
the time of a first clinical visit. Materials and Methods: This was a cross-sectional study conducted among parents who brought
their children to the Paediatric Dental Clinic at Universiti Teknologi MARA, Malaysia. Parents completed a close-ended interviewer-administrated questionnaire (n=110). The questionnaire had eleven items addressing knowledge and attitudes towards
the importance of primary teeth, effects of early extractions, and the main reason to visit the dentist for the first time. It also
assessed views on appropriate treatment for decayed primary teeth, methods used to prepare children for their dental visit, and
the timing of first dental visit. Data were analyzed using descriptive, frequency and Chi-Square analysis. Results: Overall, 82.3%
of parents recognized the importance of primary teeth. However, only (12.5%) were aware that the first dental examination
should be by age 12 months. Regarding treating primary teeth with decay, 47.9% thought that these teeth should be restored,
whereas 37.5% believed extractions were appropriate. Two-third of parents (67.7%) had agreed to promote behaviour modification during the first visit if their children had no pain. Conclusion: Many parents realised the importance of primary teeth,
however, lacked the sufficient knowledge on how to appropriately deal with these teeth with caries and the recommended time
for first dental visit. Hence the parents must receive appropriate anticipatory guidance and also need to appreciate the benefits
of early dental visit to the oral health and well-being of children.
Key Words: Early Childhood Caries; Primary Teeth; First Dental Visit; Behaviour Modification; Perception.
Introduction
Early Childhood Caries (ECC) is a
severe disease affecting the teeth of
infants and toddlers. Generally, it often first affects the primary maxillary
incisors and then can later progress to
involve primary molars (Tinanoff and
O’Sullivan, 1997). ECC remains a
serious public health problem and has
been deemed the single most prevalent chronic infectious childhood disease in several developed and developing countries (Hallet, 2000). In the
developed world, 1–12% of children
younger than six years of age are beISSN 2310-6417
lieved to have ECC (AAPHD, 2004),
whereas the prevalence of ECC is as
high as 70% in some developing countries (Milnes, 1996) and Indigenous
populations (Schroth et al., 2005;
Thomson et al., 2002).
Malaysia shares a similar concern
about ECC among its preschool population. Nationwide, the epidemiological dental survey of 5 year old children
showed high caries prevalence ranging from 87.1% in 1995 to 76.2% in
2005. Likewise, the caries score for
the primary teeth, ranged from 5.8 in
1995 to 5.5 in 2005(Oral Health Di-
vision, 2007). Although caries prevalence and rates have shown a modest
decline over this ten year period, the
decline has not been significant.
Understanding parental perceptions
about early childhood oral health is
important in order to develop effective preventive measures since parent’s health beliefs, behaviours, and
practices usually have a direct influence on their children’s dental health.
Several studies have correlated parents’ oral status or attitudes towards
dentistry with their children’s oral
status (Saied Moallemiz et al., 2008;
23
JODR
Akpabio et al., 2008; Schroth et al.,
2007; Okada et al., 2002). It has been
reported that parents with more positive attitudes towards dentistry and
oral health were more likely to have
children with better dental health
(Eijkman et al., 1978). For instance,
parents who believe that primary
teeth are important are more likely
to have children who do not have caries (Schroth et al., 2007). Skeie et al.
(2008) reported that parents’ positive
dental attitudes resulted in children
with fewer carious teeth, better oral
hygiene, and having received more
dental care. Parents’ oral health
knowledge and good dental care practices are also important in preventing
premature loss of primary teeth and
can effectively reduce the risk of future decay in permanent teeth (AlShalan et al., 1997).
Early dental visits are another essential preventive practice for young children. It allows dental professionals to
detect early caries lesions, evaluate
dental development, provide anticipatory guidance and dietary counselling, and motivate parents towards
adopting preventive behaviours (Ramos-Gomez et al., 2002). Moreover,
exposing children to the dental office
at an early age helps them to adapt
and become familiar with dental environment possibly improving the
likelihood of better behaviour and tolerance with future dental treatment
(Casamassimo and Warren, 2005).
Therefore, this pilot study was undertaken to evaluate parental views
about the importance of primary
teeth, timing of the child’s first dental visit, appropriate treatment for
decayed primary teeth, and the need
for behaviour modification during the
first visit.
Approval for the study was obtained
24
by the Human Ethics Committee
at the Universiti Teknologi MARA
(UiTM), Malaysia. The population being studied was parents who brought
their children for oral examination
and dental treatment at the Paediatric Dental Clinic of the university.
The clinic is generally open to public
and also serves children of university
staff. However, most participants represented in this study were non-academic staff of the university whose
children attended the dental clinic.
Dental treatment is free for children
in Malaysia. Informed consent was
obtained from each parent who participated in this study.
All parents were interviewed by one
dental nurse to answer a close-ended
interviewer-administered questionnaire (modified questionnaire of AlShalan, 2003). The questionnaire
was tested to ensure that it was valid
and comprehensive. The demographic
details were taken from the parents
included questions such as parents’
relationship to the child, parental
age, marital status, and the number of
children in the family below 12 years
of age. The questionnaire had eleven
items addressed parental perception
included information about knowledge
and attitudes of parents towards: the
importance of primary teeth the effects of untreated caries involving
them, the effects of early extraction
of primary teeth, and the main reason
to visit the dentist for the first time.
It also assessed parental views on
the best treatment option for decayed
primary teeth, the use and timing of
behaviour modification (e.g. oral hygiene instructions and acclimatizing
a child to the dental environment),
methods used by parents to prepare
their children for a visit to the dental
clinic, and the timing of first dental
examination.
A total of 110 questionnaires were
completed by participants; 14 were
excluded because they were incomplete or completed by someone other
than the parent. Hence only 96 questionnaires were analyzed. Collected
data was entered into an electronic
database and analyzed with SPSS
Version 10 (Chicago, Illinois). Descriptive, frequency and Chi-Square
analysis were performed.
Results
The demographic information of the
participants is presented in Table 1.
Almost half of the respondents belonged to the 31-40 years of age
group (47%), with the majority being
mothers (63.5%). Most of the participants had at least two children below
12 years of age in their family unit.
Regarding the importance of the primary dentition, a majority of parents
(82.3%) recognized the importance
of primary teeth in the child’s life and
to overall health and development.
In addition, many parents (60.4%)
were aware of the effects that untreated caries in primary teeth can
Table 1 Demographic characteristic of participants
ISSN 2310-6417
Table 2 Percentage distribution of parents’ knowledge
about timing of first visit, main reason for coming to
dental clinic and follow up visit
have on the permanent teeth and
general health and well-being of children. Only 49% of parents indicated
that the early loss of primary teeth
may affect the eruption of permanent
teeth, which may subsequently lead
to malocclusion. With regards to the
best treatment choice for primary
teeth with caries, 37.5% of parents
considered extraction to be the best
treatment if a child experienced dental pain (Table 2).
In relation to parent’s perception of
the timing of the first dental visit, very
few (12.5%) correctly predicted the
first year of child’s life as the recommended time for a first dental examination whereas the majority (87.5%)
were unaware (Table 3). When asked
what should be the reason for a first
dental visit; more than half (58.3%)
reported that it should be for a dental
check-up. Regarding parental perISSN 2310-6417
Table 1 Percentage distribution of parents’
awareness about importance of primary teeth
and preference for treatment of caries
ceptions relating to follow-up dental
visits, a high percentage of participants (68.7%) preferred to revisit
the dentist for regular follow-up for
their children even if the chief complaint had been completely managed
(Table 3).
Despite this, there were still a noticeable number of respondents (31.3%)
who thought that there was no need
to visit the dentist again if their child’s
complaint had been addressed.
Concerning parents’ views about the
use of behaviour modification (i.e.
promoting behaviour change) during
a child’s first dental visit, two-thirds
of parents (67.7%) agreed that it
should begin with behaviour modification when the child has no dental
concerns. However, nearly one third
(32.3%) disagreed.
When parents were asked about the
best approach to successfully bring
children to dentist for the first time,
8.1% appeared to have previously educated and prepared their children at
home, 11.5% of them do not tell the
child about the dental visit, whereas
10.4% used force to bring their child
to the dental clinic.
Chi-Square analysis comparisons was
made between sex and age of respondents and whether they did or did not
agree with a first dental visit by one
year of age. The results showed no
significant differences between respondents’ sex and age in relation to
the/ with regards the timing of child’s
first dental visit (p= 0.69, 0.07 respectively).
Discussion
Parents and family members are considered the primary source for knowledge about child rearing and health
habits for children, which undoubt-
25
JODR
edly has a long-term influence in determining a child’s oral health status
(Watt, 2002). They are considered
the key persons in achieving the best
oral health outcomes and assuring
wellbeing for children. This pilot study
assessed parental knowledge and attitudes about the importance of primary teeth and the first dental visit in
Selangor, Malaysia. To the best of our
knowledge, it is the first local study
of its kind in Malaysia and Southeast
Asia that examines parental views on
early childhood oral health care.
Maintaining healthy primary teeth
is essential to a child’s overall oral
and general development (Casamassimo and Warren, 2005). Plans for
a child’s early dental examination
and establishing proper oral health
behaviours and routines at an early
age can certainly assist in preventing the initiation of dental diseases
throughout life. Previously, Poulsen
(2003) showed that prevalence of
dental caries at age one year was
close to zero, but increased to 8%
by age two years. Mattons-Graner
et al (1996), on the other hand,
reported detecting many lesions
within the first 18 months of life.
These studies show that caries can
be prevented in the very young age
if children are brought for care before or shortly after the eruption of
first tooth. Presently, the American
Academy of Paediatric Dentistry
(AAPD) recommends that an infant’s first oral health visit should
be within six months of the eruption
of first primary tooth and no later
than age 12 months. Further, during this time parents should receive
counselling and anticipatory guidance on appropriate oral hygiene
procedures, minimizing harmful infant feeding practices, oral habits,
fluorides, as well as general dietary
counselling related to oral health
26
(AAPD, 2008).
If dental caries in primary teeth is
left untreated, different complications can arise such as pain, oral
infection, problems with eating and
sleeping, malnutrition, and alterations in growth and development
(Clarke et al., 1999, Schroth et al.,
2009, Schroth et al., 2012, Schroth
et al., 2013) and possible of early loss of teeth (Kagihara et al.,
2009). Early extraction of primary
teeth might lead to short-term effects like problems in eating and
speaking, and long-term effects like
mal-alignment of permanent teeth
and increased risk of malocclusion
in later (Kagihara et al., 2009).
While the majority of participants
in this study were aware about
the importance of primary teeth
(82.3%), there were still slightly
more than quarter (26%) who
did not recognize consequences of
early loss of primary teeth on the
permanent dentition. This is crucial
since such parental awareness can
have long-term effects on childhood
oral health. Interestingly, a Canadian study indicated that parents
who believed baby teeth were important had children with significantly lower caries rates than those
who believed otherwise (Schroth
et al., 2007). Furthermore, 37.5%
of parents in our study considered
extraction as the best treatment
for primary teeth; this may be attributed to the fact that parents
usually believe these teeth eventually exfoliate and are replaced by
permanent teeth. We may suggest
from our findings that dental providers can play a significant role
in educating and increasing the
awareness of parents about child’s
oral health. At the same time, they
must address the potential problems
such as cost of treatment, time,
child’s lifestyle and well-being, and
the consequences of early loss if the
parents are being reluctant to have
their child’s primary teeth treated
for decay.
The timing of the first dental visit is
another essential means of preventing ECC. The present study showed
low parental awareness (12.5%) of
the recommended time for this visit.
Most parents thought that this first
visit should occur at 3 or 6 years
of age. This may because more parents believed that primary teeth
are not fully erupted at 12 months
of age and hence no need to see
dentist. Others may have thought
that disease cannot affect teeth
at this early age, while others may
feel a young child is too difficult to
manage and will be uncooperative.
Our results agree with Al-Shalan
(2003) and Meera et al. (2008)
who found most of participants
were unaware of the recommended
time for first preventive dental visit. Increasing the awareness of parents of this is important. Parents
may find it difficult to get current
information if dentists and physicians are not knowledgeable and do
not support and endorse this recommendation. Stijacic et al (2008)
reported that many dentists are unaware about this recommendation
and this might mean that information regarding the appropriate age
of first dental visit is not getting
to parents and the public. A survey
of dental and medical providers as
well as specialists in Malaysia may
be required to uncover their views
and biases relating to infant and
preschool oral health. This can also
be used to get more feedback about
parents from the providers’ point of
view in order to develop more realistic approaches to preventing caries. We recently published results of
ISSN 2310-6417
a survey of dentists in Malaysia that
also demonstrated that many dentists are also unfamiliar with these
professional recommendations for
early preventive dental visits (Hussein et al., 2013).
A positive finding in the present
study was that a high percentage
of parents (58.3%) first brought
their child to the dental clinic for a
check-up rather than to deal with a
dental problem. This may be a sign
that parents have good knowledge
to take their children for a check-up
before any dental problems arise.
Moreover, a good number of parents showed a willingness to return
to the dentist for follow-up even if
their child’s chief dental complaint
was
addressed.
Nevertheless,
31.3% reported that there was no
need to see dentist again; this could
be attributed to the underestimation of the value of follow-up visits
or having little spare time to take
children for additional visits. In
fact, proper timing of early dental
check-ups might lessen the stress,
cost, and better manage the family’s time.
Generally, the discipline of paediatric dentistry does not advise on performing any operative procedures
during first visit if there is no immediate chief complaint. Instead,
behaviour modification towards
dental care and acclimatization
to the clinic environment should
be carried out to develop good
relationships between all parties
(Casamassimo and Warren, 2005).
Early behaviour orientation is an
important practice towards best
treatment for children because the
first visit is usually associated with
fear and anxiety and hence dentist
should aim to provide a friendly introduction to dental care, reduce
stress for children and parents, and
ISSN 2310-6417
install lifetime positive attitudes
towards dental health (Fayl, 2005).
Overall, 67.7 % of respondents
had positive views on this topic and
were willing to schedule an extra
appointment dedicated for more
behaviour insight to avoid creating possible fear and rejection of
dental treatment in their children.
Our findings are consistent with AlShalan (2003), who reported that
a majority of parents preferred to
start with behaviour modification
during the first visit. Despite this,
there were still noticeable participants (33.3%) who were not
willing to accept this concept. This
might be attributed to their busy
work and family schedules, which
would prevent them from attending
further visits or make such appointments inconvenient. In general, all
parents should be introduced to behaviour modification during the first
visit or in early sessions, whether a
chief complaint is reported or not.
This is important to develop good
relationship and a positive acceptance of oral health care. It is also
recommended that parents should
prepare their young children for
dental visits beforehand to make
the visit less anxiety provoking.
While this pilot study yields important early evidence on parental
views relating to early childhood
oral health, our study was not without limitations. First, the sample
size was considered to be small because the university’s dental clinic
is newly established and the patient
pool is still growing. Second, it was
conducted in one locality. This limits how generalizable our findings
are with other parents in Malaysia. Despite this, we still showed
that parental awareness relating to
oral health was limited. It is most
likely that public awareness is even
lower. Other limitations include the
lack of demographic information
of the parent, such as their education level, occupation, ethnicity, and
household income that would possibly influence their knowledge and
attitudes towards early childhood
oral health. At present, local information about parental perceptions
of childhood oral health care is insufficient. This work provides needed preliminary evidence of parental
knowledge and attitudes towards
oral health condition of children,
despite the limitations. Regardless
of these limitations, our survey was
based upon a previously published
and validated survey tool developed
by Al-Shalan (2003) and collected
essential data that can be used to
assist in caries prevention activities
to our population.
Conclusion
This pilot study revealed that many
parents were aware about the importance of primary teeth, but that
this was not universal. However, the
majority were unaware of the correct timing for a child’s first dental
examination. A noticeable number
of participants were also uncertain
about the importance of starting
with behaviour modification counselling at the first dental visit. Anticipatory guidance and promoting
early dental visits by 12 months of
age are important for maintaining
healthy primary teeth.
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ISSN 2310-6417
Hatim JODR Issue1, Volume 1, 2013
Effect Of Salvadora Persica Extracts On Titanium Alloy Surface
Topography
Nadira A. Hatim, MSc., 1Amrah Y. Al-Jammal, MSc.
University of Mosul, College of Dentistry, Prosthodontics Department, Mosul-Iraq.
Corresponding Author:
Prof. Nadira A. Hatim
Abstract
Fluoride containing mouth rinses, and toothpastes have been reported to decrease the corrosion resistance of titanium.Salvadora persica has been recently introduced in two forms: tooth paste (Saudi Arabia) and mouth wash. The influence of these
products on Titanium Alloy Surface Topography has not been tested before. Aim of the study: To compare between the effects
of Salvadora persica(Siwak® toothpaste and its alcoholic extract), with fluoride containing tooth paste (kin® toothpaste) and
kin® mouth wash on the corrosion of pure titanium grade 2 (cpTi). Materials and methods: Alcoholic extract of Salvadora
persicawas prepared, and tested on sixty weighted samples of cpTi divided into 4 experimental groups. Samples in the control
group were immersed in distilled water. In the first experimental group, samples were treated with Kin® tooth paste. For the
2nd experimental group, samples treated with Kin® mouth wash. Samples in the 3rd experimental group were treated with
Siwak® toothpaste. The final experimental group was treated with extract of Salvadora persica. These samples were subjected
to surface topography (AFM) and transverse strength tests before, after three, and six months of treatments. Results: Weighting test showed no significant difference (p≤0.05) between the mean values of four treated groups of cpTi samples before, and
after 3 months. However, there was a significant difference (p<0.05)between cpTi before and after 6 months treatment with
Siwak® tooth paste. Surface topography showed a statistically significant difference between root mean square roughnesses of
cpTi samples after 3, and 6 months of treatment. Transverse strength also showed a statistically significant difference between
the mean value of cpTi between the treated and control groups after three months and six months.
Conclusions:Siwak® toothpaste seems to have more effect on both weight and roughness of cpTi compared to alcohol extract
of Salvadora persicaand Kin® toothpaste.
Key Words: Surface Topography, Titanium, Siwak, Salvadora Persica, Kin Mouth Wash, Corrosion, Titanium Alloy
Introduction
There are hundreds of alloys available for dental restoration. The major factors affecting alloys selection
are: economics, physical properties,
casting technique, corrosion, and
biocompatibility(Liu et al, 2009).
Titanium (Ti), and its alloys, are
widely used as medical, or dental implants in consequence of their good
biocompatibility, excellent corrosion
resistance, and appropriate mechanical properties, the most common
Ti alloy, Ti-6Al-4V(Park and Kim,
2000; Mandl et al, 2005).
Titanium (Ti) is also used in prosthetic dentistry to manufacture
ISSN 2310-6417
crowns, and multiple unit fixed restorations, and in orthodontic dentistry to produce Ti brackets, and dental
arch wires (Harzeret al, 2001).
The metallic biomaterials follow the
general patterns for metal degradation in environmental situations.
Metals undergo chemical reactions
with non-metallic elements in the
environment to produce chemical
compounds. Commonly these products are called as corrosion products.
One of the primary requisites of any
metal, or alloy to be used within the
human body is to be biocompatible,
and hence it should not form or help
in forming any such products which
may deteriorate the metal itself and
be harmful (Adyaet al, 2005).
Fluoride level in the oral cavity varies according the prophylactic treatment. Fluoride is used up
to 1000ppm. in the toothpastes, and
mouth rinses: Elmex®, Meridol®
and Acorea® close to 2000ppm. with
the aim of eliminating enamel stains
(Fernández and Cortizo, 2000;Schiff
et al, 2004).
The oral environment contributes
to corrosion because of its temperature, pH variation, humidity, oxygen
presence, and food decomposition.
Fluoride is one of the chemicals that
can alter alloy surface and mainly
presents in mouthwashes, and dentifrices at different concentrations.
29
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The effects of fluoride on the corrosion behavior of titanium and its alloys have been presented by several
authors (Walkeret al, 2005; Mabilleauet al, 2006).
Salvadora persica(Siwak), is a
medical plant whose roots, twigs, or
stems have been used for centuries
as oral hygiene tools in many parts
of the world particularly in Saudi
Arabia. Many studies have demonstrated that extracts of Salvadora
persica possess various anti plaque,
anti periopathic, anti caries, anti inflammatory, and antimycotic effect
(Daroutet al, 2000; Monforteet al,
2001).
Salvadora persica(Siwak)is a chewing stick that derived from Arak tree
which is used as cleaning teeth in
which a variety of chemical components have been identified in salvadora persica. Some researchers
have reported that it contains trimethylamine, Salvadorine, chloride,
fluoride, silica, sulphur, mustard oil,
and vitamin C(Daroutet al, 2002;
Samuel et al, 2007).
This study aims to evaluate the effect
of commercial cleaning agents (kin®
mouth wash, kin® and siwak® tooth
paste with fluoride, and alcoholic extraction of Salvadora persica which
has been prepared in this study to
be used as mouth wash) for 3, and 6
months treatment, on commercially
pure titanium grade 2 (cpTi) by
studying nanotopography of treated
(cpTi) investigated by atomic force
microscope (AFM), and to evaluate
transverse strengthof treated (cpTi)
by a universal testing machine.
Materials And Methods
The material was used in this study
was commercially pure titanium
grade 2 (Orotic, 1 o t 3754, Bio Ti
G2 >99.779). The correct composition of this material checked before
usage by high intensity x- rays (XMet 3000 TX, Oxford instruments).
Sixty samples were designed according to ADA specification No. 14 (ADA,
30
1995) (20mm×10mm×0.6)±0.1mm
length, width, and thickness. The wax
pattern was done using casting wax
(Plastodent-se, Degussa, Germany).
The casting was carried out in the
casting machine (Spee cast, 220M,
orotic).The melting temperature for
cpTi grade 2 (1668°C), was according to the manufactures instructions.
All cast specimens were cleaned using 50-μm aluminum oxide airborne
particle abrasion for 15 second to
remove investment debris. The specimens were machined with carborandum wheels, and special stone burs
using the grinder and followed by
rubber wheels. The specimens were
ground wet with 180, 400, 600, 800,
1000 and 2000 grit silicon carbide
papers. A high speed polishing grinder machine (Denta rapid, Germany)
with rouge material were used to
obtain smoother, and mirror surface,
then ultrasonically cleaned in ethanol for 15 min, and washed with distilled water (Tajimaet al, 2005).
Eight hundred Salvadora persica
chewing sticks were cut by using a
sharp knife, ground to the powder
with commercially available food
blender. 120ml of 60% ethanol were
added to 40gm of powder in a sterile well capped flask, left for 3 days
at room temperature at 25º C and
then filtered using No.l filter paper.
The extract was autoclaved at 37°C
until it became dry, the time consuming was ± 90 min. The extract was
stored in sterile screw capped vials,
in the refrigerator until needed for
use, and then freshly prepared in distilled water immediately before use
at a concentration of 1% (Al-Koubaisi, 2001; Darmani et al, 2003).
In order to measure the fluoride concentration in prophylactic agent such
as (kin® tooth paste, kin® mouth
wash, Siwak® tooth paste, Salvadora persicasiwak wash), the standard
calibration curve for the fluoride was
established. The standard solutions
were prepared according to the dilution law for solutions (Summerlin,
1981).
Therefore, dissolving 1 gm in 1000
ml of deionized water, will obtain
a solution with concentration 1000
ppm. of NaF (main blank). So to prepare a solution with concentration
1000 ppm. of fluoride ion, 3.5 gm. of
NaF was dissolved in 1000 ml of deionized water (molecular weight of
F is 9 molecular weight of Na is 23).
wt=(23+9)/9
wt= 3.5 gm
The other solutions were prepared
by diluting this main blank, to prepare concentrations: 5, 10, 15, 20
and 25ppm (Martinet al, 1968).
Three ml of each concentration buffered three ml of total ionic strength
adjusting buffer (TISAB). The fluoride concentrations of each buffered
sample were measured by the radiometer with the fluoride ion selective electrode (Ion meter, 3340, Jenway). The mill volt (mv.) readings of
the device plotted against the log
concentrations of the fluoride (Log
c) to obtain the standard curve (Figure 1).
The regression equation of fluoride
concentration (Nernst equation)
(Dawood, 2008):
mv= 39.2+5.91 Logc
mv:millivolt reading. c: concentration of fluoride ions fluoride.
Concentration of prophylactic agent
such as tooth paste, and mouth wash
was measured by using a radiometer
with the fluoride ion selective electrode, and then the reading from the
device was pointed to the standard
calibration curve to obtain the fluoride concentration for each one.
Total ionic strength adjusting buffer
(TISAB):
The material was prepared by adding 500 mi of deionized H2O to 57
ml of analytical reagent (AR) grade
glacial acetic acid, 58 gm of (AR)
grade NacCl and 0.03 gm of sodium
citrate The solution was titrated to
pH 5.0-5.5 using (AR) grade 5 M
NaOH. The solution was cooled and
then diluted to 1 liter volume. TISAB was used to buffer the storage
solution pH and decomplex fluoride
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(Martinet al, 1968; Mody and Thomas, 1981).
Four cleaning agents containing
fluoride pH should be check before
Figure (1) Standard calibration
curve.
application time corresponds to the
accumulated effect of regular usage
of six months treatment for wash
and paste. These treatment periods
seem to be too long, but if we take
into consideration that these prophylactic solutions are not rinsed after
application, then we may think about
shorter cumulative periods (Hearn,
1971).
Surface topography of the cp Ti
grade 2 samples was measured by
AFM (AA300, Angstrom Advance
Inc, scanning probe microscope)
(Lee et al, 2010). The sample was
fixed to a scanning piezo with three
translator degrees of freedom. A
square of roughness was calculated
for each sample in all the groups.
The total samples (60) are divided
into control and four treated groups
were weighted by digital balance
(0.0001g, accuracy) (A&d company
limited, Japan), and then, recorded
the weight before and after three
and six months treatment.
Transverse strength of each sample
was tested by a universal testing machine (gunal, wP300020), at crosshead speed of 0.5 mm/min (Hearn,
1971).
Statistical methods used to analyze,
and assess the results via SPSS V.
11.5 for Windows descriptive statistics included, Duncan, and Dennett’s
multiple range tests, Independent ttests were considered significant at
p ≤ 0.05, and Paired Samples test
were used. The statistical results
were considered significant at p ≤
0.05.
RESULTS
Surface Topograghy
Figure (2) Experimental design of the study
the storage time by using Digital pH
meter (Philips Company, Japan).
The storage period of the samples
in four cleaning agents was shown
in Figure (2): Kin® wash and Salvadora persicasiwak wash were used
for one and a half hour, and for kin®
paste and Siwak® paste used for 9
hours, after the immersion, the samples were removed from the F- containing medium, thoroughly washed
with distilled water and dried. Our
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very fine tip, served as a probe tip,
was in contact with silicon cantilevers (type: P/N 910M-NSC36).Cantilevers with spring constants of 0.95
and 1.75 N/m were used, scanning
the surface of the specimen. Three
readings were made in each sample,
and 3D images with areas of 10 µm2
were captured. The value of root
mean square of roughness (Ra) was
determined via the AFM software
program and mean of root mean
The value of mean of root mean
square of roughness, standard deviation, Dennett’s and Duncan tests of
control, and four treated groups for 3
months treatment are shown in Figure (3 A & B). The samples treated
with Siwak® paste display more increase of root mean square of roughness (±23.6nm) after 3 months
treatment, Salvadora persicasiwak
wash (±16.5nm), kin® paste (±
14.6nm), and kin® wash (±13.3nm)
when compared with control sample.
While
for six months, Siwak® paste display
biggest increase root mean square
of roughness (±24.2nm) followed
by kin® paste (± 21.6nm), Salvadora persica siwak wash (±18nm),
and kin® wash (±14.3nm). When
compared with three and six month’s
treatment, there was a significant
difference at (P ≤ 0.05) for Salvadora persicasiwak wash, and kin®
31
JODR
paste groups only, as shown in Table
(1).
Three dimension (3D) surface topography measured by AFM, for
each treatment samples of cpTi at
three, and six months were shown in
Figures (4).
Weighting of the samples
The mean value of weight of four
treatment groups and standard deviation before and after three and
six months treatment are shown in
Table (2).
Pair samples test shows significant
difference at (P ≤ 0.05) in weight
of siwak toothpaste only after 6
months, while in the other three
treatment groups, no a significant
difference recorded before and after
six months treatment as shown in
Table (3).
Transverse strength
Figure (3)Value of root mean square of roughness, ±standard deviation and multiple comparisonsrange testsfor surface topography of
cpTi samples.
Table (1): Independent sample t-test between three and six months
treatment of cpTi samples.
32
Mean value of deflection of control
and four treated groups and standard deviation, Dunnett’s test was
utilized to compare the difference
in deflection of four treated groups
with control groups, Duncan test
shows a significant difference at (P
≤ 0.05) between mean values of
four treated groups after three and
six months treatments as shown in
Figure (5).
The samples treated with Siwak®
paste had a high deflection at force
(25N) for 3 months and (20N) for
six months, which means that the
ductility of this group were decreased. The samples treated with
kin® wash had a low deflection at
force (40N), and (35N) respectively, which means that the ductile
property of this group was slightly
decreased. Computer program application of load –deflection diagram of control, kin® wash, Salvadora persicasiwak wash, kin®
paste, and Siwak® paste samples
for three and six months treatment
are shown in Figure (6).
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33
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34
ISSN 2310-6417
Figure (4) Surface topography for cpTi samples for all treated groups after 3 and 6 months treatment.
Table (2) Mean values and standard deviation of weight of cpTi samples before and after 3 and 6 months
treatment.
Table (3) Pair samples test of weight of cpTi samples before and after six months
ISSN 2310-6417
35
JODR
Figure (5) Mean and ± standard
deviation and multiple comparisonsrange tests for deflection of
cpTi samples for three and six
months treatment.
36
ISSN 2310-6417
Figure (6 ) Computer program application of load –deflection diagram for all groups of cpTi sample
for three and six months treatment.
Discussion
The difference between the sur-
face topography of cpTi samples
of four treatment groups for three,
and six months treatment, showed
a significant difference between
four treated groups when compared
with control group, and with them
for three and six months treatment.
There was a significant difference
at (P ≤ 0.05) between three and six
month>s treatment for Salvadora
persicasiwak wash and kin® paste
groups samples only.
Yokoyama (2005) and Kaoet al
(2007) studied the effect of fluoride
ions concentration, and pH on surface topography of titanium alloys
that are in agreement with our results. When using NaF the concenISSN 2310-6417
tration was >0.1%, the protectiveness of TiO2 on Ti was destroyed by
F-, leading to the severe corrosion
of titanium.
Stajer et al., (2008) investigated
effects of (F-) containing caries
preventive prophylactic rinses, and
gels on surface topography of cpTi
were investigated by AFM. So high
fluoride concentrations, and acidic
pH impair the corrosion resistance
of titanium (Ti). Aqueous 1% NaF
(pH 4) strongly corroded the surface. AFM indicated an increase
in roughness (Ra) of the surfaces:
10-fold for the NaF solution and
smaller for the gel or a mouthwash
(250 ppm F-) pH 4.8. These above
studies are in agreement with the
results of the present study that Sal-
vadora persicasiwak wash at (pH
4.5), and Siwak® paste at (pH 6.0)
showed more effect than kin® past
(pH 6.5) on surface topography of
cpTi samples.
This effect could be destructive to
the oxide layer over the metal surface in fluoride environment, it dissociates into Na+ and F- ions. The
F- ion becomes hydrofluoric acid
partially, depending upon the pH of
the solution and attacks the passive
film over the metal surface. Titanium fluoride compounds are formed
because the fluoride ions bound to
titanium or titanium oxide surface
degrade in the solution (Kaneko,
2003; Noguchi et al, 2008).
Mabilleau et al, (2006); and Toniollo
et al, (2009) were in disagreement
37
JODR
with this study, this could be due to
the use of profilmeter in measurement of surface roughness of cpTi
specimens exposed to solutions containing fluoride (pH 7.0) at different
concentrations and with different
immersion protocols were statistically similar. Huang, (2003) investigated the effects of F- concentrations on the corrosion resistance of
Ti alloy in acidic media (pH 5.0).
The results showed that when the
NaF concentration was >0.1%, a
fluorotitanate complex was formed
on the Ti surface, which destroyed
the stable TiO2 layer.
The corrosion resistance of titanium specimen>s solution containing
fluoride decreased in comparison
with that in a solution not containing
fluoride. The rate of corrosion of titanium in acidic medium was clearly
higher than that in the solution containing fluoride in neutral media,
these findings agreed with Kinani et
al, (2008); and Bhola et al, (2010).
In an attempt to find the difference in weight of cpTi samples before and after three and six months
treatment with four treated groups
that was proposed in this study, The
results showed no significant difference at (P ≤ 0.05) in weight before
and after three months, but showed
a significant difference before and
after six months treatment for Siwak toothpaste groups only. These
findings are in agreement with Basame and White (2000); Schiff et
al. (2004), who concluded, fluoride
ions are known to interfere in titanium which causes changes in the
protective passive properties of the
oxide layer over the metal. The role
played by fluoride towards the thinning of the metal oxide layer depends on the concentration and pH
of the solution, which causes a substantial decrease in corrosion resistance and increase in the oxide layer
capacitance. The samples treated
with Siwak toothpaste showed loss
of weight after six months treat-
38
ment due to role of fluoride towards
the thinning of the metal oxide layer.
The differences between the transverse strength of four treatment
groups for three, and six months
treatment of cpTi samples, that was
proposed in this study, were in agreement with Walker et al.(2007) who
suggested that using topical fluoride
agents with Ni-Ti and β Titanium
wire could decrease the functional
unloading mechanical properties of
the wire, mechanical property of
beta-Ti and Ni-Ti wire degradation
after acidulated fluoride agent, and
neutral fluoride exposure, although
the acidic pH of fluoride agents,
and concentration is considered an
important factor in the breakdown
of the titanium-based alloy protective oxide layers leading to potential
hydrogen absorption, and associated
with mechanical property changes.
This is in agreement with the result
of the present study, but only differs
in the type of material that had been
used.
The results in the present study
could be due to the breakdown of
the titanium-based alloy protective
oxide layers leading to potential hydrogen absorption, and associated
with mechanical property changes
in fluoride environment. Liu, (2007)
assessed the influence of a fluoridated medium on the mechanical
properties of NiTi wires, and concluded that prolonged contact with
fluoride ions is harmful to the mechanical properties of NiTi wires.
This study indicated that bending
stress changed the corrosion properties, and surface characteristics in
a simulated intra oral environment.
The scanning electron microscopic
analysis showed evidence of pitting
corrosion, which confirms the action of fluorides on the surfaces of
the studied biomaterial. The results
agreed with Ribeiro et al.(2007)
who suggested that it is not possible
for a cpTi implant to fracture with
one cycle only due to the ductil-
ity of titanium, and concluded that
fluoride ions negatively influenced
the resistance to fatigue of implant
abutment sets, and that fracture
occurred before reaching the minimum number of cycles established.
Conclusions
iwak® toothpaste seems to have
more effect on both weight and
roughness of cpTi compared to alcohol extract of salvadora persica
siwak wash and Kin® toothpaste after three and six months treatment.
Acknowledgment: I wish to thank
the staff in the Lab of Postgraduate
of Prosthodontic department, College of Dentistry-University of Mosul, and Dr. Adawiya J. Haidar head
of Nano- Research Center and his
staff in University of Technology.
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Mubeen A and Saluja B (2005). Corrosion in titanium dental implants:
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Al-Koubaisi A (2001). The effect
of alcoholic extraction of salvadora
persica (Miswak) on dental plaque
formation a 5-day clinical Trial. M.sc,
Thesis, University of Baghdad, Iraq.
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39
JODR
Khalaf JODR Issue1, Volume 1, 2013
Effect Of Siwak On Certain Mechanical Properties Of Acrylic
Resin
Dr. Hanan Abdul- RahmanKhalaf, M.Sc.,
Department of Prosthodontics, college of Dentistry, university of Baghdad..
[email protected]
Abstract
Background: (PMMA) has been used in dental prosthetic devices for almost 70 years; three features have contributed for its
success: excellent appearance, simple processing technique and easy repair. However, the resistance to impact and fracture of
PMMA during function is low. Various methods for enhancing strength of the acrylic resin denture bases have been reported.
This study was designed to evaluate the effect of adding Siwak powder with average particle size of (75 µm) in three different concentrations by weight to PMMA on certain mechanical properties. Material and Methods: Tensile strength, elongation, transverse strength, impact strength, compressive strength and the surface roughness of heat- polymerized acrylic resin
specimens were evaluated for both the control group A (0%) and the experimental groups. These groups consisted of acrylic
resin mixed with different proportions of Siwak powder B (3%), C (5%) and D (7%) by weight. Stainless steel samples with
dimensions of (65 mm, 12.5 mm, 2.5 ± 0.03 mm) length, width, and thickness were constructed for testing tensile strength and
elongation of acrylic resin. Other uniform molds were made by investing machined stainless steel standards (65 mm 10 mm, 2.5
mm) for testing denture base materials in surface roughness and these specimens were reused for transverse deflection test.
For testing the impact strength and compressive strength of acrylic resin, wax patterns (60 mm,10 mm, 10 mm) and (20 mm,10
mm, 10 mm) length, width, thickness were prepared. Results: Siwak powder (5%) did not greatly affect the tensile strength
and compressive strength (P = 0.05). The addition of Siwak powder at ratio of (3%) did not greatly affect impact strength of
the experimental group in comparison to the control group, while the addition of (7 %) Siwak powder revealed a significant
decrease in tensile strength, impact strength and compressive strength in comparison to the control group. Conclusion: Addition
of low concentrations (3%, 5%) Siwak to the heat polymerizing acrylic resin did not affect significantly the tested mechanical
properties.
Key Words: Pmma, Mechanical Properties, Additives, Impact Strength, Tensile Strength, Transverse Strength
Introduction
Poly methyl methacrylate (PMMA) is
one of the most widely used materials
in modern prosthodontics. It is widely
known due to its simplicity in use and
acceptable esthetics (McCabe, 2001)
.Other features that account for its
popularity are good color stability, low
water sorption, low solubility and adequate strength. It can reproduce surface
details accurately and can be easily repaired (Eiichi and Kenji, 2001).
However, the mechanical strength of
acrylic resin is not sufficient to maintain the longevity of dentures (Uzunet
al, 1999). The problem that occurs with
denture base is fracture caused by factors such as poor fit of the denture base,
40
poorly balanced occlusion and stress on
denture base after years of use (Eiichi
and Kenji 2001, Jagger and Harison
2002, Charles and Thomas, 1993).
There were many attempts to strengthen polymers using different procedures,
such as modification of the matrix or
incorporating some strengtheners in the
polymers (Uzunet al 1999, Fernada and
Simonides 2009, Ismail 2007).In addition, different types of fibers were incorporated into acrylic denture base in order
to enhance it is physical and mechanical properties (Solnit 1991, Gutteridge
1988) e.g. carbonated (graphite) fibers
(De Boer et al 1984, Bjork et al 1986),
aramidic fibers (Mullarky,1985), woven
metal and glass fibers (Eiichi and Kenji,2001), silica-glass fibers(Meric and
Ruyter, 2005,Mathewet al, 2000). Glass
fibersimpregnated in silane coupling
agent (Vallittu 1977, Freilichet al 1998,
Soderholm and Shang 1993) were used
to enhance the flexural resistance.
Other studies tried to improve certain
mechanical properties of acrylic resin
by the addition of nano sized fillers e.g.
Tio2, Zno2 (S-Y Chen, 2010, Laura S.
et al, 2011).
Silica is commonly used filler in dental materials also used as reinforcing
agents in industry. Several studies investigated the effect of the addition of untreated and novel surface treated silica
on transverse bend and impact strength
of acrylic resin denture base materials.
Several studies showed that Siwak has
antimycotic and antibacterial effects
ISSN 2310-6417
that could be due to the different chemical composition of Siwak sticks. (AlBagiehet al 1994, Al -Nidawi 2004).
The chemical proportion of Siwak was
determined by the following procedures:
Chemically the air dried stem bark of Siwak is extracted with 80% alcohol and
then extracted with ether, this showed
that it is composed of: (Al-Mostehye t al
2002, Marghalani 2010).
•Tri-methylamine.
•An alkaloid which may be Salvadoran.
•Chlorides.
•High amount of fluoride, calcium, phosphorous and silica.
•Sulphur and vitamin-C (ascorbic acidC6H8O6).
•Small amounts of tannins, saponins,
fiavenoida and sterols.
Tri-methylamine and alkaloid have antibacterial effects also the fluoride content protects the teeth from cariogenic
bacteria.
There was a substantial amount of
silica in the Siwak sticks which help in
cleaning the teeth because it acts as an
abrasive material to remove stain (AlBagiehet al, 1994).
The aim of this study was to evaluate the
effect of adding natural anti-microbial
material contained unmodified silica on
certain mechanical properties of poly
methyl methacrylate.
Siwak preparation
Salvadorapersica(miswaak) were
dried by storing these sticks in a desiccator for three weeks. After each
week the sticks were weighted by
electrical sensitive balance with accuracy of (0.0001g), fig (1).
When a constant weight was attained it was assumed that the sticks
were dried completely. Then these
sticks were ground by using an electrical grinding machine, figure (2).
The size of the largest particles was
obtained initially by sieving to the
most suitable size could be selected
was 125 µm the sieving was done to
75 µm by using selected sieves. The
collected powder was stored in
ISSN 2310-6417
Figure (1) Electrical sensitive
balance
temperature for 30 minutes followed
by complete cooling of the flask with
tap water for 15 minutes before
deflasking .The acrylic specimens
were removed from the flask, manually buffed under water and finished
using sand paper of grit 400 (fine).
Polishing was accomplished by using
the rag wheel and dental pumice.
Conditioning of the specimens
After polishing, the specimens were
stored in distilled water at 37o C for
2 days before testing according to
ADA specifications no. 12 and 17.
Fig (2) preparation of Siwak, A:storage, B: peeling and C: grinding
screw top containers
with sacs of silica gel granules in the
tops.
Specimens’ Fabrication
The control specimens were prepared by mixing PMMA powder
with MMA liquid (triplex hot IvoclarVivadent, Liechtenstein) at ratio
of (2.5/1w/v) and heat polymerizing.
For the experimental samples poly
methyl methacrylate was mixed with
siwak powder in different proportions 3%, 5% and 7% (w/w) and the
process for the control was followed.
The resin was packed into the stone
molds in flasks which were placed in
a hydraulic press (100 kpa/〖cm〗^2)
for 5 minutes and processed according to the manufacture’s recommendations. The processing was
performed by placing the clamped
flasks in a cold water bath which
was heated up to 100oC and then
boiled for 45 minutes. The flasks
were allowed to cool slowly at room
In order to simulate oral conditions.
All the measurements for the acrylic
resin specimens were done using
digital vernier before testing the
mechanical properties of the acrylic
samples.
Tensile strength and elongation
test
Five dumbbell-shaped specimens for
each concentration were prepared
in dental flasks with preformed
stainless steel metal dies length of
65 mm, width 10 mm and thickness
2.5 mm. The tensile strength and
elongation tests were performed using an Instron testing machine (JianQiao) at maximum load 2000 kg ,
maximum speed 25-500 cycle/ minute and accuracy 0.03% (figure 3).
According to the ASTM specification, D638M (Cucciet al, 1998).
Tensile strength = maximumload/crosssectionalarea
=(F(N))/
(A(mm^2))
41
JODR
S= 3FI/2bd²
Fig (3) A tensile testing machine, B test acrylic specimens (original
pictures)
Transverse Strength Test
Uniform molds were made by investing machined rectangular stainless
steel standards (65 ×10 ×2.5 mm
length, width and depth respectively) according to ADA specification
no.12, ISO 1567.The three point
transverse test was conducted by positioning the specimen on the bending fixture using Ley-bold-Harris hydraulic press, consisting of 2 parallel
supports, 50mm apart. The full scale
load was 7.5 KN, and the load was
applied by rod placed centrally between the supports allowing deflection until fracture occurred.
Five specimens of each concentration were tested and the transverse
strength was calculated as follow:
S= 3FI/2bd²
S=transverse strength (N/mm²)
F=maximum load in N.
I=the supporting width in mm
B=the width of test specimen in
mm.
D=the height of test specimen in
mm.
used to determine the relative resistance of acrylic resin specimens.
A pendulum of 5 joules testing capacity was used to strike the specimens, the charpy impact strength of
un notched specimens was reported
in KJ/m². It is given by the equation:
Impact strength= A/(X.Y)× 10³
A= is the impact energy in joules.
X=is the width dimension of the
specimen, in mm.
Y= is the height dimension of the
specimen, in mm.
Compressive Strength Test
The
rectangular
specimens
(20×10×10 (mm) according to
ASTM- D695 were subjected to
compressive load until failure .The
maximum load of the testing machine selected was 7.5 KN applied
through hydraulic compressive press.
The compressive strength was calculated in N/mm², from the following
equation:
Compressive strength= (f(N))/
(b×d(mm2))
F=force in N.
b=width of the specimens in mm.
d=depth of the specimens in mm.
Surface roughness test
The rectangular acrylic specimens
with the dimensions (65×10×2.5
mm) underwent the surface roughness test by using an analyzing surface roughness tester (TR220 portable roughness tester, Beijing, time
high technology. Ltd, China) device.
The mean value for the four readings of the sensible needle on the
surface of the tested material was
dependent.
One way ANOVA analysis and LSD
test were used to assess the effect of
adding different ratios of siwak powder on the physical and mechanical
properties of acrylic resin, the level
of significance was set at α=0.05.
Results
The results of infra-red (IR) spectra were obtained by analyzing the
characteristic vibrations of peaks
which revealed the interaction of
a non-modifiedSiwak additive with
PMMA acrylic resin. Fig (4) showed
a chemical bond of a non-modifiedSiwak additive with PMMA (change
the shape of adsorption peaks of c
= o)
There was a significant difference in
the mean values of tensile strength
for studied groups, no significant
Impact Strength Test
For testing the Charpy impact
strength, the molds were made by
investing rectangular wax pattern
(50mm length×10 mm width ×10
mm thickness) in flasks with type
IV dental stone (Bluejey extra hard
stone Type IV ,Italy), according to
ISO 179, for un notched specimens.
Charpy’s impact testing machine was
42
Fig (4): IR spectrum of PMMA, A control group, B modified group
(PMMA with Siwak
ISSN 2310-6417
change in elongation mean values
was found among studied groups,
table (1).
revealed that no differences were
found between the studied groups
(control and experimental groups),
Table (1) Tensile strength and elongation for the control and the
experimental groups
Table (2) Transverse strength (N/mm²) for the control and the experimental groups
Further analysis using LSD test revealed highly significant differences
were between control group with
groups B and D, while the difference with group C was significant at
P<0.01.
Concerning the differences among
various concentrations of Siwak, the
result of LSD test showed that the
differences between B, C and B, D
were significant while the differences between C, D groups were highly
significant at P < 0.05.
For elongation test no significant
differences were found among the
tested groups, at P>0.05.
The results showed that the increase
in transverse strength mean values
for studied groups were statistically
in significant, table (2).
Further analysis using LSD test
ISSN 2310-6417
at P > 0.05.
Comparison between the results of
the control and the experimental
groups showed that addition of Siwak powder to PMMA results in a
highly significant difference of the
impact strength mean values, table
(3).
Further analysis using LSD test revealed that significant differences
were found between control group
with group B, and highly significant
differences between the control
group and groups C and D, at P <
0.01.
Concerning the differences among
various concentrations of Siwak, the
result of LSD test showed that the
differences between the experimental groups (B, C, and D) were not
significant, at P > 0.05.
Table 4, present the compressive
strength values. The differences
in the mean values of the studied
groups were significant.
Further analysis using LSD test revealed that no significant difference
was found between control group
with group C, while the differences
with groups B and D were highly significant at P < 0.01.
Regarding the surface roughness of
the control and experimental groups,
it was found that there was no statistical significant difference between
the surface roughness mean values
concerning various concentrations
(3%, 5% and 7%) of Siwak powder.
LSD test revealed that no significant
differences were found between control group with the studied groups
(B,C,D) and the differences among
various concentrations of Siwak
(BC, BD and CD) were also not significant at P > 0.05
Table (3) Impact strength (KJ/m²) for the control and the experimental groups
43
JODR
Table (4) Compressive strength (N/mm²) for the control and the experimental groups
Table (5) surface roughness (µm) for the control and the experimental groups
Discussion
Altering a material to optimize a
single property may consequently introduce deleterious effects on other
properties, However in this study, addition of 5% Siwak powder did not
result in a highly significant change
in tensile strength of experimental
poly methyl methacrylatecompared
to the control group, this result
could be explained that some kind of
physical adhesion result from downgrading of the free energy between
two surfaces (Siwak additive and
PMMA acrylic resin) with different
surface tensions (Howard,2008) .
The reduction in the tensile strength
mean value was noticed as the Siwak powder ratio increased which in
turn limits the addition of additives
greater than 5% by weight.
Also the result revealed a non significant change in the mean values
of elongation test ( How much the
samples stretched before breaking)
44
for the experimental groups with different ratios of Siwak powder when
compared to the control group , this
could be explained that the addition
of Siwak powder may increase the
toughness of the poly methyl methacrylate resin.
Regarding the transverse strength,
there is an increase in the mean
values of tensile strength compared
to the control group indicating the
Siwak addition did not substantially
alter these measurements; this could
be attributed to good distribution of
the Siwak powder. The Siwak particles enter between the linear chains
of the polymer; segmental motions of
these chains are restricted result in
improvement of transverse strength
(Mohammed 2009, Nejatina 2007).
Impact strength is an important parameter as it can reflect the contact
force required to cause fracture in
a denture under situations such as
accidental dropping. In the present
study, the difference of the of impact
strength at the ratio 3% Siwak powder was statistically significant in
comparison to the control group. The
significant reduction in the mean
value of impact strength at ratios
of 5% and 7% could be due to the
differences in the testing configuration and specimen geometry this
finding disagree with the findings of
previous investigations (Mohammed
2009, Ihab and Moudhaffar, 2011).
The compressive strength mean
value at the ratio 5% Siwak powder
showed a non significant difference
over the control group, this result
is in agreement with (Mona et al,
1994).
The improvement in the impact
strength and compressive strength
at low concentrations of Siwak additive could be related to good bonding
between the matrix and the additive
which could be due to interfacial
shear strength between the additive
(Siwak) and the matrix (PMMA)
(Ihab and Moudhaffar, 2011).
Also it was determined within the
parameters of this study that the addition of different concentrations of
Siwak powder (3%, 5% and 7%)
by weight to the heat polymerizing
acrylic resin did not affect the surface roughness significantly, this may
be related to the filler particles size
and shape which has a great effect
on the surface roughness parameters
of the composite series (Mona and
Mohamed 1994).
Conclusion
On the basis of the results arrived at
the study, it was concluded that the
incorporation of Siwak powder at
ratios of 3% and 5% by weight into
the heat polymerizing acrylic resin
does not adversely affect its physical
and mechanical properties tested in
this study while incorporation of 7%
Siwak powder by weight into the
heat polymerizing acrylic resin revealed an adverse effect on most of
mechanical properties tested except
transverse test.
ISSN 2310-6417
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JODR Volume 01-Issue 01, 2013 - Iraqi Association For Oral Research

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