journal of oral and dental research - · pdf fileand class i skeletal pattern aged between 18...

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JODR

Journal of Oral and Dental Research

Iraqi Association for

Oral Research

The Official Jouranl of the

Volume 1, Issue 1 2013

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-re-viewed publication with an international editorial board, which give it a unique po-sition 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 re-gional 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 Edi-torial and the Managing Board without whom the successes we had in 2013 would have not been possible.

Dr Anwar R TappuniJODR Editor-in-Chief

JODR Editorial Board

Editor-in-ChiefDr. Anwar R Tappuni, UK

Communication EditorDr. Faaiz Alhamdani, IraqManaging EditorsDr.Elham HazeimAbdulkareem, IraqDr. Rasha Al-Kaabi, IraqDr. AmmarAl-Shammaa, (Deputy), Iraq

Editorial Board

Prof. Shatha Alameer, Baghdad, IraqDr. Moustafa Al-Haboubi, UKProf. Ibtisam Al-Hashimi, Texas, USADr.Mudher Ali, Baghdad, IraqDr. Omar Alnaimi, Newcastle, UKProf. Tahani Al-Sandook, Baghdad IraqProfessor Stephen J. ChallacombeDr. IanCorbett, Newcastle, UKMr. Justin Durham, Newcastle, UKDr. Bashar Hamid, Baghdad, Iraq Prof. Kadhim Jawad Hanau, Baghdad, IraqMr. Colin Hopper, London, UKDr. Saba Kassim, London, UKProf. Wagner Marcenes, London, UKDr. Aghareed Ghanim Mohammed, Melbourne, AustraliaDr. Raid Salim, Erbil, IraqDr. Bahar Jaafar Selivany, Duhok, IraqDr. Ahmed Sultan, London, UKProf. David Williams, London, UKDr. Faraedon M. Zardawi, Sulaimani, Iraq

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Yassir A. Yassir, M.Sc.University of Baghdad, College of Dentistry, Department of Orthodontics, Iraq.Phone #: +964 770 391 9599E-mail: [email protected]

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 coef-ficient test was used to identify correlations between ramus height and other measurements

Ramus height and its Relationship with Skeletal and Dental Measurements

Abstract

Key words: ramus height, skeletal measurements, dental measurements, dentoalveolar heights.

IntroductionIn 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 prac-tice; these can be visualized eas-ily in the cephalogram. Craniofacial skeletal growth is very important in orthodontics, since variations in cra-niofacial morphology are the source of most serious malocclusions, and induction of changes in inter-maxil-lary relationships are fundamental to orthodontic treatment. (Moyers, 1988)Logically, any alteration or adjust-ment of one part of the dentofacial complex will require a like adjust-ment 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 at-tachment for masticatory muscles.

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 max-illary arch and middle cranial fossa is thereby provided. Indeed, the spe-cial developmental significance of the ramus is integral to craniofacial growth. These alterations are in-duced 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 craniofa-cial and dental measurements in a sample of Iraqi adults with dental and skeletal Cl I.

Materials and MethodThe sample included 95 digital true lateral cephalometric radiographs taken in the Orthodontic department at the College of Dentistry, Univer-sity 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 skel-etal patterns (ANB: 2°±2°) (Riedel, 1952), and clinically to have a nor-mal Angle Class I occlusion, with complete permanent dentitions. They were clinically healthy with no craniofacial syndromes or anoma-lies, 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 clini-cally and had a lateral cephalomet-ric radiograph taken by using Plan-meca ProMax radiographic unit. The individual was positioned within the cephalostat with the sagittal plane


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of the orientated vertical, the Frank-fort 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 mea-surements were obtained. Angular measurements were taken directly as they are not affected by magni-fication. Linear measurements, how-ever, 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.

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 ra-mus, 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 anteri-or nasal spine and menton. (Rakosi, 1982)S-Go: Posterior facial height, the distance between sella turcica and gonion. (Rakosi, 1982) MxMDH: Maxillary molar dentoal-veolar 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 den-toalveolar height, the distance be-tween the mesiovestibular cuspid of lower first molar and mandibular plane along the long axis of the mo-lar. (Martina et al, 2005)ANB angle: The angle between lines N-A and N-B. It represents the dif-ference between SNA and SNB an-gles or it may be measured directly as the angle ANB. It is the most commonly used measurement for ap-praising 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. (Ra-kosi, 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 (Go-Me). (Rakosi, 1982)

Figure 1: Cephalometric landmarks and measurements: N: nasion. S: sella

turcica. Ar: articulare. Go: gonion. Me: menton. A: subspinale. B: supramen-

tale. 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).

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Statistical AnalysesThe data were subjected to comput-erized statistical analysis using SPSS (Version 15). The statistical analyses included descriptive statistics with mean values, standard deviation, minimum, and maximum values for continuous measurements. Inferen-tial 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 > 0.05Significant 0.05 ≥ P > 0.01Highly significant ** 0.01 ≥ P > 0.001Very 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 mea-sured in this study, thirteen showed significant differences between gen-ders; 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 fe-males than in males.For males and females, Pearson’s correlation coefficient test (Table 2) revealed significant positive correla-tion for ramus height and posterior facial height, and maxillary and man-dibular 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.

DiscussionThis study aimed to quantify ramus height in skeletal I Iraqi adults and to relate variations in ramal height with a range of craniofacial and den-tal 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-

tively (Burstone et al, 1978). All linear measurements were sig-nificantly higher in males; this finding is in accordance with previous stud-ies by Ali (1988), Al-Sahaf (1991), Al-Attar (2006), and Al-Joubori et al (2009) suggesting that the cranio-facial skeleteon of males is larger in all linear dimensions than in females. This finding may be attributed to the fact that maturation is attained earli-er in females than males with a longer growth period in males. Johannsdot-tir et al (2004) reported that males had consistently larger values for lin-ear dimensional variables, including anterior and posterior facial heights, mandibular length, cranial base di-mensions and nasal bone length. The significantly higher mean values of SN-MP, and SN-PP angles in fe-males than males together with the non-significant difference in PP-MP angle, means that the maxillary and mandibular planes are more down-ward positioned relative to the cra-nial 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 (Dia-mond, 1943; Wylie, 1946) considered ramus height and its effect on inter-maxillary space both anteriorly and posterioly. Diamond (1943) suggest-ed that deficient growth in length of the mandibular ramus is the cause of deficient intermaxillary space. How-ever, Wylie (1946) failed to substan-tiate the contention that development of ramus height is crucially important for the development of intermaxil-lary space, however desirable it may be for satisfactory facial contour. Moreover, Wylie (1946) found non-significant differences between total

Table 1: Descriptive statistics and gender differences

(independent samples t-test)


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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 associ-ated 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 signifi-cant negative correlations between ramus height and angles of man-dibular rotation (SN-MP, PP-MP, and Ar-Go-Me), which compensate the effect of downward mandibular movement with the increase in ramus

height and hence decrease its effect on anterior facial height and inter-maxillary space anteriorly. Isaacson et al (1971) found that the mean height of the ramus was inversely re-lated 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

mainly correlated with posterior in-termaxillary area with a little effect on anterior facial heights, as the in-crease in ramus height is associated with forward rotation of the mandi-ble. The molars will act as a fulcrum for this rotation, which occurs during periods of maximal facial growth.McLaughlin et al (2001) and Prof-fit et al (2007) mentioned that ado-lescent 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 down-ward 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 premo-lars also implies a skeletal growth stimulus with vertical rotation of the

mandible, with concomitant down-ward-backward mandibular rotation. Yousif (2010) found a positive asso-ciation between maxillary and man-dibular molar dentoalveolar heights from the divergency of the jaws in Iraqi males. This finding is in accor-dance with the widespread belief that hyperdivergent facial types have excessive posterior dentoalveolar de-velopment which was also found in different ethnic population (Schen-del 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 de-velopment (Isaacson et al, 1971). On the contrary decreases in maxillary and mandibular posterior dentoalve-olar heights in the permanent denti-tion have been reported by Betzen-berger et al (1999) and Martina et al (2005) in high-angle malocclusions.

Clinical ImplicationsFurther 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 back-ward rotation by increasing the for-ward mandibular rotation with mini-mal effect on anterior vertical facial dimensions. This may be applied dur-ing treating adolescent patient with skeletal Class II caused by small size of the ramus and body of the mandi-ble. 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 acti-vator with subsequent trimming of the interocclusal acrylic portion to enhance the extrusion of the buccal teeth, so that the face can be more harmonized.

Table 2:

Pearson’s correlations coeffi-

cient test for the ramus height

and other measurements

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ConclusionsIn a group of skeletal I Iraqi adults, ramus height was directly correlat-ed with intermaxillary space in the posterior region, and inversely cor-related with angles of mandibular rotation.

References Al-Attar AM (2006). The relation-ship between mandibular antegonial notch depth and craniofacial mor-phology in Iraqi sample aged 18-25 years. A master thesis, Department of Orthodontics, University of Bagh-dad.Ali FA (1988). Skeletodental char-acteristics of some Iraqi children at nine and ten years of age: A cepha-lometric study. A master thesis, De-partment of Orthodontics, University of Baghdad.Al-Joubori SK, Yassir YA, Al-Bustani AI (2009). The relation between ra-mus notch depth and some of the cra-niofacial measurements in different skeletal patterns. J Bagh Coll Den-tistry 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 mecha-nism in high-angle malocclusions: a comparison of subjects in the mixed and permanent dentition. Angle Or-thod 69(1): 27-32.Bibby RE (1980). Incisor relation-ships in different skeletofacial pat-terns. Angle Orthod 50(1): 41-4. Burstone CJ, James RB, Legan H, Murphy GA, Norton LA (1978). Cephalometrics for orthognathic sur-gery. J Oral Surg 36(4): 269-77. In Athanasiou AE (1995). Orthodontic cephalometry. 1st ed. London: Mos-by-Wolfe. p. 248.Diamond M (1943). The ramus as a factor in the development of the den-tal height. J Dent Res 22: 346. Cited by Wylie WL (1946). The relation-

ship between ramus height, dental height, and overbite. Am J Orthod Oral Surg 32(2): 57-67.Enlow DH, Hans MG (1996). Essen-tials 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 ante-rior openbite treated with crib thera-py. 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). Tech-nique and treatment with light wire edgewise appliances. 2nd ed. St. Louis: CV Mosby.Johannsdottir B, Thordarson A, Mag-nusson TE (2004). Craniofacial skel-etal and soft tissue morphology in Iceland adults. Eur J Orthod 26 (3): 245-50.Kucera J, Marek I, Tycova H, Baccet-ti T (2011). Molar height and dento-alveolar compensation in adult sub-jects 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 Medi-cal Publishers, INC. p. 38,39.Proffit WR, Fields HW, Sarver DM (2007). Contemporary orthodontics. 4th ed. Mosby, Inc., an affiliate of El-sevier Inc. p. 564. Rakosi T (1982). An atlas and man-ual cephalometric radiography. Lon-don: Wolfe medical publications Ltd. p. 35-45.Riedel RA (1952). The relation of maxillary structures to cranium in malocclusion and in normal occlu-sion. Angle Orthod 22(3): 142-5. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ (1976). The long face syndrome: verti-cal 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 characteris-tics of anterior open bite in a south-ern 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 dentoal-veolar 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: go-nion. 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: Mx-MDH. 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).

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JOURNAL OF ORAL AND DENTAL RESEARCHAl Hano JODR Issue1, Volume 1, 2013

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]

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 mi-croscopy (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 concentra-tions of DMC laser bleaching system.Key words: Tooth bleaching, Hydrogen peroxide, DMC Laser, Bovine enamel, Color changes, Surface roughness.

Changes In Color And Roughness With Laser Bleaching Using Different Peroxide Concentrations

Abstract

Key words: Tooth bleaching, hidrogen peroxide, DMC Laser, bovine enamel, color changes surface roughness

IntroductionOf paramount importance for human beings in relation to their social, psy-chological and professional needs is minimizing discoloration particular-ly of anterior teeth (Wetter,2004). Different options are available to treat the discolored teeth. They in-clude 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 con-

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 bleach-ing (Heymann, 2005). Since its introduction by Haywood and Hey-mann 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 concen-trations of hydrogen peroxides may show similar teeth whiting results (Götz et al., 2007), higher concen-trations of H2O2 and increased ap-plication 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

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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 dif-ferent bleaching agents, based on the concentration of hydrogen per-oxide ,(Lase PeroxideLite-15%, Lase Peroxide Sensy II - 25% & Lase Peroxide Sensy II - 35%). For effective stain removal, hydro-gen peroxide must be able to move through tooth structure. This is pos-sible since hydrogen peroxide has a low molecular weight that permits proteins denaturing, and will conse-quently increase tissue permeabil-ity and allow the movement of ions through the tooth (McEvoy,1989). The penetration of hydrogen per-oxide 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 advo-cated (Tavares et al. 2009).Until recently, little attention has been given to the influence of the increase of hydrogen peroxide con-centration on the enamel surface textures and color changes within the same experimental unit. Im-provement of discolored teeth may be affected by various concentra-tions of peroxide. In addition, al-teration in enamel surface rough-ness may follow bleaching process as well.

Hypothesis of the study There would be no change in enam-el color and surface roughness after laser bleaching with different per-oxide concentrations.

Objectives:Evaluate bleaching efficacy of la-ser activating system utilizing three different concentration bleaching

agents, (15%,25%&35%) on col-or changes and surface roughness of bovine enamel.

Materials and MethodsThe materials used for preparing the specimens and the equipment used for measuring the color chang-es and surface roughness are shown in Table (1).

Specimens Collection And Prep-

arationForty eight bovine cattle incisors were stored frozen after extraction until their use. Specimens were cleaned and polished with non-fluoridated polishing paste. Roots were cut using a diamond disc with straight-type micro motor hand-piece (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 as-cending-grit water proof silicon carbide papers starting from #400 up to #1,200 under running water (Fig.1). The specimens were ran-domly assigned into two groups, two groups, half is for detecting color changes and the other half is for surface roughness.

Color Changes

Staining procedureSpecimens 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; Ay-aka 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 rough-ness.

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inside the incubator for 7 days at 37°C. Specimens before and after staining are shown in (Fig.2). La-bial 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 Easy-shade Spectrophotometer. The CIE L*a*b* values of enamel surfaces

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 re-search.

Bleaching ProcedureSpecimens were divided into three subgroups according to concentra-tions (15%, 25% & 35%) (n=8). The bleaching procedure was per-formed 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 compar-ison with stained specimen. Color values of L*a*b* were measured at both baseline and after bleach-ing. The difference in L*a*b* val-ue between the baseline and after bleaching were expressed as ΔL, Δa, and Δb respectively. The color difference (ΔE) was calculated ac-cording to the following equation: ΔE=[(ΔL)2+(Δa)2+(Δb)2]1/2

Surface Roughness

Surface Roughness Measure-

mentSpecimens following polishing pro-cedure and after bleaching were used for evaluation of Ra. Such evaluation was conducted by two methods, one considered as con-tact methods via stylus profilom-eter (Surf-Corder SE 1200, Tokyo, Japan) and other as non-contact method using AFM(AA3000, Ang-strom Advanced Inc.USA).The dif-ferences in average (Ra) value be-tween polished and bleached value for each specimen were recorded and analyzed.

Statistical AnalysisMean 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 con-centration. T-test used to compare the difference between polished and bleached surfaces at each con-centration. One way (ANOVA) was used to determine any significant

Fig 1 Crosscut surface of the pre-

pared specimen.

Fig 3 Specimen with masking tape

with a 5 mm-diameter hole

Fig 2 Specimen before and after staining

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difference in the mean of (L*) val-ue & (Ra) value among the various treatment groups followed by Tukey HSD as post hoc comparisons test within various treatment groups.

Results

Color ChangesThe result of T-test revealed that there were significant differences between stained and bleached speci-mens at each concentration, this dif-ferences in L* value were illustrated

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 5: L* value and differences

between stained and bleached

specimens (different letters in-

dicate significant difference)

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

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in fig (5). One way analysis of vari-ance 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 signifi-cant 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 ob-served between 15% and 25% and between 25% and 35%. The results of Tukey test were explained in fig (6).

Surface RoughnessPaired sample T-test was used to compare the difference in surface roughness between polished and bleached surfaces at each concen-tration. The results revealed that there were no significant differences

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

Fig.7: Ra value of polished and bleached groups at each concentration (dif-

ferent letters indicate significant difference)

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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 vari-ous concentrations is given in ta-ble (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 dem-onstrate a significant increase in Ra values with an increase in bleaching agent concentrations. Bleaching with 35% agent pro-duced significantly higher Ra val-ue than 15%.While no difference between 15% and 25% and be-tween 25% and 35% fig (8) .For AFM evaluation of surface rough-ness, the result shows an increase in both numbers and depth of vale

Table.5. Analysis of Variance for the three Groups Ra value

Fig 8. Ra value after bleaching with different concentrations (AB) letter in-

dicate no significant difference

Fig 9 Three dimension (3D) Surface to-

pography of enamel by Atomic Force Micros-

copy (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 Soft-

ware, version V7). :a) Polished enamel sample

Ra = 140 nm. b) Enamel sample after bleach-

ing 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.

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of the enamel subjected to different peroxide concentrations as show in Figures (9).

Discussion Esthetic dentistry has become an increasingly essential require-ment of modern dental practice. Laser teeth whitening is one of the newest and efficient meth-ods available for office teeth whitening. The objective of la-ser bleaching is to achieve ulti-mate bleaching process by using the most efficient energy source while avoiding any adverse ef-fect (Dostalova et al. 2004). On the other hand, the goal of the dental practitioner is to whiten the tooth efficiently with con-trolled 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 prod-ucts and methods (Suyama et al., 2009, Sulieman et al., 2003). An artificial discolored bovine tooth model with tea extract for stain-ing the teeth was applied in this study. It’s based on the discolor-ation model reported by (Sulie-man et al., 2003,2004&2005; Davidi et al, 2008; Polydorou et al., 2009). Many research-ers have preferred to use animal teeth because of the increasing difficulty in obtaining human teeth for dental research, and be-cause of the requirements made by ethics committees about their use. Bovine teeth have been sug-gested as possible substitutes for human teeth because it has been reported that chemical and phys-ical properties of bovine tooth such as composition, enamel density, heat capacity, hardness, dentin tubule density and per-meability are similar to human teeth (Tagami et al., 1989, Es-ser et al., 1998, Fonseca et al., 2004, Reis et al., 2004).

In this study, Spectrophotom-eters (Vita Easyshade) were used for the evaluation of the color change. The Easyshade is an intraoral contacting spec-trophotometers that can supply parametric data (L*,a* & b*) which could be easily applied for statistical analysis. The pos-sible 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 eval-uated the influence of high per-oxide 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 re-sults 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 rem-ineralizing 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 per-oxide 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 sub-sequently 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 con-centration was observed in this study. These results imply that regardless of the peroxide con-centration provided with Lase II system, the bleaching process was successful at the applied time protocol. Such a result con-firms the company claims that even low concentrations of per-oxide when activated with laser could produce a substituent dif-ference in color toward greater lightness (Marvin et al., 2009). The analysis of variance shows a significant difference between groups (15%,25% & 35%). ex-posure of the teeth enamel to higher peroxide concentration (35%) produce higher lightness values (higher L*) when com-pared with low concentration (15%, 25%). This indicates that there is a relation between in-creasing peroxide concentration and color changes. This could be explained by the amount of free radicals such as oxygen (O•) and hydroxyl (OH−). Therefore, high-er concentrations will produce higher amounts of free radicals and consequently higher light-ness. This coincides with the finding by Sulieman et al. (2004) who compared the in vitro tooth bleaching efficacy of gels con-taining 5–35% peroxide. This study found that with high per-oxide 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

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sensitivity. In the present study, the degree of lightness ΔL grad-ually increased in all groups by increasing peroxide concentra-tions, 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 chang-es in ΔE value among different concentrations dependent on the amount of free radical release as excessive amount is expect-ed to be released with higher peroxide concentration. Such a phenomenon was also observed by other studies (Sulieman et al., 2003,2004&2005; Da-vidi,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 signifi-cantly higher than those values without bleaching treatment for both 25% and 35% concentra-tion. Although the 15% did not show significant difference in Ra value but the mean compari-son revealed an increase in val-ue. This study demonstrates that there is a relationship between the surface roughness value and an increase in peroxide concen-trations, where exposure of the teeth enamel to 35% hydrogen peroxide during office bleaching produced higher roughness val-ues when compared with 25% and 15% hydrogen peroxide. Such observation was also ap-plicable 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. How-ever, this might be guided clini-

cally by the discoloration de-gree. Recent advances in the bleaching process always focus on the lower peroxide concen-tration agents even when the treatment time is prolonged (Joiner, 2006). Hydrogen per-oxide at lower concentration did not have a major effect on the enamel structure and this coin-cides with the finding of (Oltu and Gurgan, 2005,McCracken and Haywood, 2004) who found a significant Ca²+ loss of enam-el after treatment with differ-ent peroxide solution. The pres-ence of hydration shell makes the enamel crystal electrically charged and can therefore at-tract ions. Free radicals that emit from hydrogen peroxide during bleaching are able to play a part in demineraliza-tion and cause Ca²+ loss from enamel crystals. Lewinstein et al, (2006) came to the conclu-sion, 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 ex-posing enamel to high peroxide concentration (25% and 35%) significantly increased (Ra) val-ue in comparison to unbleached enamel Fig (9). Also differ-ent concentrations of peroxide produced significantly different (Ra) value. This result was con-sistent with the result of pro-filometer 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 over-come such effect but this is not recommended in deep discolor-ation where mild color improve-ment will be obtained.You can delete the blue para-graphs as suggested by reviewer

ConclusionsColor changes and surface rough-ness of bovine enamel were in-fluenced by the use of DMC la-ser bleaching system. Higher peroxide concentration produces higher color changes and surface roughness value.

ReferencesAyaka KISHI1, Masayuki OT-SUKI1, Alireza SADR2, Masaomi IKEDA3 and Junji TAGAMI. Ef-fect of light units on tooth bleach-ing with visible-light activating titanium dioxide photocatalyst. Dental Materials Journal 2011; 30(5): 723–729.Baljeet Singh Hora , Amandeep Kumar , Rajinder Bansal , Manu Bansal , Taruna Khosla , Anu-pam Garg. Influence Of Mcinnes Bleaching Agent On Hardness Of Enamel And The Effect Of Rem-ineralizing Gel Gc Tooth Mousse On Bleached Enamel - An In Vi-tro Study. Indian journal of dental science. Vol. 4 | Issue 2page : 13-16,2012.Berger SB, Cavalli V, Ambrosano GM, Giannini M. Changes in sur-face morphology and mineraliza-tion level of human enamel follow-ing in-office bleaching with 35% hydrogen peroxide and light irra-diation. Gen Dent 2010;58:e74-e79. Davidi MP, Hadad A, Weiss EI, Domb A, Mizrahi B, Sterer N. The effect of a mild increase in tem-

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perature on tooth bleaching. Quin-tessence Int 2008; 39: 771-775.Dostalova T, Jelinkova H, Housova D, Sulc J, Nemec M, Miyagi M, Brugnera Junior A, Zanin F. Diode laser-activated bleaching. Braz Dent J 2004;15:SI3–SI8.Dostalova T, Jelinkova H, Housova D. Whitening of teeth using laser radiation support. Prakt zub Lék 2003;51:75-82.Esser M, Tinschert J, Marx R . Material characteristics of the hard tissues of bovine versus hu-man teeth. Dtsch Zahnarztl Z 1998; 53: 713-717.Fonseca RB, Haiter-Neto F, Fer-nandes-Neto AJ, Barbosa GAS, Soares CJ. Radiodensity of enam-el and dentin of human, bovine and swine teeth. Arch Oral Biol. 2004;49(11):919-22.Götz H, Duschner H, White DJ, Klukowska MA. Effects of elevat-edhydrogen peroxide ‘strip’ bleach-ing on surface and subsurface enamel including subsurface histo-morphology, micro-chemical com-position and fluorescence changes. J Dent. 2007;35:457-66.Heymann HO. Tooth whitening facts and fallacies. Br Dent J. 2005;198:5-14Haywood VB, Heymann HO. Nightguard vital bleaching. Quin-tessence Int 1989; 20: 173-176.H¨useyin Tezel,CigdemAtalayin, Ozlem Erturk, and Ercument Karasulu. Susceptibility of Enam-el Treated with Bleaching Agents to Mineral Loss after Cariogenic Challenge. International Journal of Dentistry Volume 2011, Article ID 953835, 8 pages.Joiner A. The bleaching of teeth: a review of the literature. J Dent 2006; 34: 412-419.Joiner A. Tooth colour: a review of the literature. Journal of Dentist-ry 2004;32(Suppl. 1):3–12.Lewinstein I, Fuhrer N, Churaru N, Cardash H. Effect of different peroxide bleaching regimens and

subsequent fluoridation on the hardness of human enamel and dentin. Journal of Prosthetic Den-tistry 2006;92:337–42.Marvin K. Bright, White, and Sen-sitive: An Overview of Tooth Whit-ening and Dentin Hypersensitivity. Dentistry Today.com. 2009 Sept.McEvoy : Chemical Agent for Removing Intrinsic Stains from Vital Teeth. Current Techniques and Their Clinical Applications. Quintess Int 1989; 20:379-384.McCracken MS, Haywood VB. Demineralization effects of 10 percent peroxide. Journal of Den-tistry 2004;24:395–8.Oltu U¨ ., Gu¨ rgan S. Effects of three concentration of perox-ide on the structure of enamel. Journal of Oral Rehabilitation 2005;27:332–40.Polydorou O, Hellwig E, Hahn P.The efficacy of three different in-office bleaching systems and their effect on enamel microhard-ness. Oper Dent 2008; 33: 579-586.Reis AF, Giannini M, Kavaguchi A, Soares CJ, Line SR. Comparison of microtensile bond strength to enamel and dentin of human, bo-vine, and porcine teeth. J Adhes Dent. 2004;6(2):117-21. Sulieman M, Addy M, Macdonald E, Rees JS. The bleaching depth of a 35% hydrogen peroxide based in-office product: a study in vitro. Journal of Dentistry 2005;33:33–40.Sulieman M, Addy M, MacDonal E, Rees JS. The effect of hydro-gen peroxide concentration on the outcome of tooth whitening: an in vitro study. Journal of Dentistry 2004;32:295–9.Sulieman M. An overview of bleaching techniques. 1. History, chemistry, safety and legal aspects. Dental Update 2004;31:608–16.Sulieman M, MacDonald E, Rees JS, Addy M. Comparison of three in-office bleaching systems based on 35% hydrogen peroxide with

different light activators. Ameri-can Journal of Dental Research 2005;18:194–6.Shannon H, Spencer P, Gross K, Tira D. Characterization of enamel exposed to 10% carbamide perox-ide bleaching agents. Quintessence International 1993;24:39–44.Suyama Y, Otsuki M, Ogisu S, Ki-shikawa R, Tagami J, Ikeda M, Kurata H, Cho T. Effects of light sources and visible lightactivated titanium dioxide photocatalyst on bleaching. Dent Mater J 2009; 28: 693-699.Sulieman M, Addy M, Rees JS. Development and evaluation of a method in vitro to study the effec-tiveness of tooth bleaching. J Dent 2003; 31: 415-422.Tagami J, Tao L, Pashley DH, Horner JA. The permeability of dentine from bovine incisors in vitro. Arch Oral Biol 1989; 34: 773-777.Tavares M, Stultz J, Newman M, Smith V, Kent R, Carpino E, et al. Light augments tooth whit-ening with peroxide. Journal of the American Dental Association 2009;134:167–75.Vasconcelos, Cunha, Borges, Machado, Santos. Tooth whiten-ing with hydrogen/carbamide peroxides in association with a CPP-ACP paste at different pro-portions. Australian Dental Jour-nal. Volume pages 213–219, June 2012.Watts A, Addy M. Tooth dis-coloration and staining: a re-view of the literature. Br Dent J 2001;190:309 –16.Wetter NU, Barroso MC, Pelino JEP. Dental bleaching efficacy with diode laser and LED ir-radiation: an in vitro study. La-sers in Surgery and Medicine 2004;35:254–8.Ziebolz D, Helms K, Hannig C, At-tin T. Efficacy and oral side effects of two highly concentrated tray-based bleaching systems. Clin Oral Investig. 2007;11:267-75.

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JOURNAL OF ORAL AND DENTAL RESEARCHAlsandook JODR Issue1, Volume 1, 2013

Tahani A. Alsandook, PhD.Dean of College of Dentistry/University of Mosul/Mosul/[email protected] A. Al-Haideri, MSc.Assistant Lecturer in Oral and Maxillofacial Surgery Department /College of Dentistry /University of Mosul/ Mosul/Iraq.

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 vi-sual 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 anes-thesia with minimal paraesthesia is required. Validation and replication of these study findings should be considered in future research.

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

Abstract

Key Words: Local Anesthesia, Tramadol, Lidocaine, Adrenaline, New Local Anesthesia, Analgesia.

IntroductionCompression was the first method of local anesthesia used in the an-tiquity. Cold, as local anesthesia, was widely used until 17thCentury (Franco, 2007). The natural Cocaine was the first drug used as local an-esthetic agent at about the end of 18thCentury, unfortunately the seri-ous side effects of this drug made the researchers to look for safe drugs (Calvey and Williams, 2008). In the

last century a group of safe local an-aesthetics 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 lo-cal anesthetics continued (Yagiela et al, 2004).Tramadol HCL is a centrally acting

opioid(Shipton, 2000), with a rela-tively low addiction incidence. Clini-cally it is effective for the treatment of moderate to severe pain such as, postsurgical pain, obstetric pain, ter-minal cancer pain and pain of coro-nary 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 power-ful 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 pos-ses local anesthetic action equiva-lent to that of Lidocaine, it will be more superior than lidocaine as it will provide postoperative analgesia.

Patients and MethodsA randomized, double-blind study was conducted at Oral and Maxil-lofacial Surgery Department/Col-lege of Dentistry/Mosul University, between May2011 and September 2012. The study was approved by the local academic committee accord-ing to relevant guidelines. The pur-poses of the study were explained to all patients included in the study and written informed consent was obtained from all participants. Pa-tients were informed that their par-ticipation is voluntarily and their withdrawal from the study at any time will not affect the provisional of their treatment. Inclusion crite-ria were as follows: 18 to 45years of age, any gender, all patients were to undergo elective minor oral surgical procedures in the lower molars, in-cluding: conventional tooth extrac-tion, 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

of the study.Exclusion criteria included history of compromised medical status, his-tory 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 ini-tial dose of one dental cartridge, 1.8 ml, from drug A (Lidocaine (36mg) and epinephrine (0.0225mg) (New Stetic-Colombia)) for convention-al tooth extraction, this dose was doubled in case of surgical removal of impacted tooth and periapical surgery. Group B: each patient re-ceived initial dose of one dental cartridge, 1.8 ml, from drug B (tra-madol 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 sur-gical removal of impacted tooth and periapical surgery.The studied drug in group B was prepared by an independent inves-tigator in Pharmacology Depart-ment/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 infe-rior alveolar nerve was used for lo-cal anesthetics administration by us-ing 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 ap-pearance of lip parasthesia.Data collectionSample characteristics: included age and socioeconomic status of patients and oral health. Intraop-eratively:Onset of anesthesia:Immediately after injection (consid-ered 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 separa-tion 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 assis-tant. 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 opera-tion was recorded.Duration of the surgery: recorded duration represented the time in-terval from the incision/or gingival separation to the placement of last stitch/or completion of tooth extrac-tion.

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Number of cartridgesThe total number of used cartridges were recorded for each procedure in both groups.Postoperatively:Duration of anesthesia: which was the time interval between the ap-pearance of lip paresthsia and its disappearance, as reported by the patient.Recording of adverse effect:Nausea and vomiting are com-mon adverse effects of tramadol HCL(Cossmann et al., 1997). Per-sistent 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 vari-ables (cartridges number, degree of pain, duration of surgery, duration of anesthesia), Mann-Whitney U Test was used to compare the non-parametric variables (nausea and vomiting).The level of significance was set at ≤0.05.

ResultsThe study conducted on 124 pa-tients of moderate socieo-economic status,18-45 years age, 65 female and 59 male. Each group involved 25 case of surgical removal of mesi-ally impacted lower wisdom and 36 conventional extraction any of low-er molars and 1 periapical surgery at the lower first molar.

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 signifi-cant difference between the two groups(P = 0.728, f= Independent-Samples T-Test showed no statis-tically significant difference be-tween 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 de-gree of freedom).Onset of anesthesia: the fastest on-set 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 high-est mean onset (3.145) minute was recorded in group (B), while the lowest mean onset (2.951) was re-corded in group (A). Table (1).The statistical analysis of the assumed data using Independent-Samples T-Test indicates no significant differ-ence (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 re-corded in 56 cases in group A and in 55 cases in group B. The high-est mean(0.2096) was recorded in group (B), while lowest mean (0.1935) presented in group (A).

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Table (1).The analysis of the data statistically by using Independent-Samples T-Test resulted in a no significantdifference(p=0.895,F=.048;GroupA(n=62),m/SD=0.1935/±0.697);GroupB(n=62),m/SD=0.2096/±0.656; 124 is the sample size and (0.00014) is the degree of free-dom).Duration of surgery: the maximum duration recorded was (55) min-utes, which presented in group (B), while the minimum was (4) min-utes which recorded in both groups. The highest mean (14.11) minutes was recorded in group (B) while the lowest (12.77) minutes was re-corded in group (A).Table (1). As a result of statistical analysis of the data by using Independent-Samples T-Test, there was no significant dif-ferences in the durations of opera-tions 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

T-Test showed significant differ-ence 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 de-gree of freedom).Adverse effects:Regarding the adverse effects (nau-sea and vomiting) which were re-corded 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-Whit-ney U Test, demonstrated that there was no significant difference presented among the two groups ( P= 0.240).

DiscussionThe objective of the current study was to compare the onset and du-ration of local anesthetic action of tramadol Hcl (with adrenaline) and Lidocaine HCL (with adrenaline) in

minor oral surgery.It has been demonstrated that tram-adol HCL 5% has a local anesthetic effect similar to that of prilocaine 2% when used intradermally for excision of soft tissue lesions (Al-tunkaya et al, 2003; Kargi et al, 2009). Other studies showed that tramadol HCL has a local anes-thetic 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 stud-ies 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 pro-cedures when infiltrated to suscep-tible 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-

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esthetic effect with that of lidocaine HCL, furthermore, no published ar-ticle was noticed in this regard to compare our result with it.Tramadol HCL is a synthetic cen-trally acting opioid, it is clinically effective for the treatment of mod-erate to severe pain with a relative low addiction incidence. In acute therapeutic use, tramadol HCL pro-duces analgesia against multiple pain conditions such as postsurgi-cal pain, obstetric pain, terminal cancer pain, and pain of coronary origin, and it has been used as adju-vant therapy in anesthesia(Shipton, 2000).Tramadol HCL may have local an-esthesia like activity because of its nerve conduction blocking po-tency. Clinical and laboratory stud-ies of opioids, such as tramadol, have shown that local anesthetic effects of opioids typically cannot reversed by pretreatment with nal-oxone (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 opi-oid, meperidine, and the local anes-thesia lidocaine (Brau et al, 2000). In this study there was no signifi-cant difference between tramadol and lidocaine groups in the, volume of local anesthetic solution admin-istrated to produce local anesthe-sia 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

considered a disadvantage due to discomfort associated with local an-esthesia.Future research implicationsFurther studies are required to validate, replicate our findings and to evaluate pharmacokinetics and mechanism of action of locally ad-ministrated tramadol hydrochloride.

ConclusionTramadol HCL can be used as al-ternative to lidocaine HCL in com-bination with adrenaline to achieve local anesthesia in situation where lidocaine HCL is contraindicated or when adequate local anesthe-sia with minimal parasthesia is re-quired.

ReferencesAltunkaya H, Ozer Y, Kargi E, Ozko-cak I, Hosnuter M, Demirel CB, Ba-buco O. (2004) The postoperative an-algesic effect of tramadol when used as subcutaneous local anesthetic. AnesthAnalg; 99:1461-4.Altunkaya H., Ozer Y., Kargi E. an-dBabuccu O,(2003) Comparison of local anaesthetic effects of trama-dol with prilocaine for minor surgical procedures , Br J Anaesth; 90: 320-2.Brau ME., Koch ED., Vogel W., Hempelmann, G. (2000) Tonic Block-ing 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-Black-well;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., Gu-nay 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. EurJPharma-col;, 439:77-81.Natalini G, Rosano A, Franschetti ME, et al. (2006)Variations in arte-rial blood pressure and photoplethys-mography during mechanical ventila-tion. 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) Tramad-ol: 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);Studies with different types of visual analog scales for measurement ofpain. ClinPharmacol Ther;34:234–9.Tsai YC, Chang PJ, Jou IM (2001)Direct tramadol application on sci-atic nerve inhibits spinal somatosen-sory evoked potentials in rats. Anesth Analg;92:1547-1551.Yagiela, JA, Dowd FJ, Neidle EA. Pharmacology and therapeutics for Dentistry. 5th ed.St Louis: Mosby; 2004.

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JOURNAL OF ORAL AND DENTAL RESEARCHHussein JODR Issue1, Volume 1, 2013

1Alaa S. Hussein, M.Sc; 2Mohamed I. Abu-Hassan, PhD; 3Robert J. Schroth, PhD; 4Aghareed M. Ghanim, PhD1Department of Pediatric Dentistry, Faculty of Dentistry, Universiti Teknologi MARA (UiTM), Malaysia. 2Depart-ment 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. HusseinEmail: [email protected]

Understanding parental perceptions about early childhood oral health is important in order to develop effective preventive mea-sures 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 inter-viewer-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 modi-fication 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.

Parent’s Perception On The Importance Of Their Children’s First Dental Visit (A Cross-Sectional Pilot Study In Malaysia)

Abstract

Key Words: Early Childhood Caries; Primary Teeth; First Dental Visit; Behaviour Modification; Perception.

IntroductionEarly Childhood Caries (ECC) is a severe disease affecting the teeth of infants and toddlers. Generally, it of-ten 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 preva-lent chronic infectious childhood dis-ease in several developed and devel-oping countries (Hallet, 2000). In the developed world, 1–12% of children younger than six years of age are be-

lieved to have ECC (AAPHD, 2004), whereas the prevalence of ECC is as high as 70% in some developing coun-tries (Milnes, 1996) and Indigenous populations (Schroth et al., 2005; Thomson et al., 2002). Malaysia shares a similar concern about ECC among its preschool popu-lation. Nationwide, the epidemiologi-cal dental survey of 5 year old children showed high caries prevalence rang-ing 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 preva-lence 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 effec-tive preventive measures since par-ent’s health beliefs, behaviours, and practices usually have a direct influ-ence on their children’s dental health. Several studies have correlated par-ents’ oral status or attitudes towards dentistry with their children’s oral status (Saied Moallemiz et al., 2008;

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Akpabio et al., 2008; Schroth et al., 2007; Okada et al., 2002). It has been reported that parents with more posi-tive 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 car-ies (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 prac-tices are also important in preventing premature loss of primary teeth and can effectively reduce the risk of fu-ture decay in permanent teeth (Al-Shalan et al., 1997).Early dental visits are another essen-tial preventive practice for young chil-dren. It allows dental professionals to detect early caries lesions, evaluate dental development, provide antici-patory guidance and dietary counsel-ling, and motivate parents towards adopting preventive behaviours (Ra-mos-Gomez et al., 2002). Moreover, exposing children to the dental office at an early age helps them to adapt and become familiar with dental en-vironment possibly improving the likelihood of better behaviour and tol-erance with future dental treatment (Casamassimo and Warren, 2005).Therefore, this pilot study was un-dertaken to evaluate parental views about the importance of primary teeth, timing of the child’s first den-tal visit, appropriate treatment for decayed primary teeth, and the need for behaviour modification during the first visit.

Materials and MethodsApproval for the study was obtained

by the Human Ethics Committee at the Universiti Teknologi MARA (UiTM), Malaysia. The population be-ing studied was parents who brought their children for oral examination and dental treatment at the Paedi-atric Dental Clinic of the university. The clinic is generally open to public and also serves children of university staff. However, most participants rep-resented in this study were non-aca-demic 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 par-ticipated in this study.All parents were interviewed by one dental nurse to answer a close-ended interviewer-administered question-naire (modified questionnaire of Al-Shalan, 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 ef-fects 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 hy-giene 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 incom-plete or completed by someone other than the parent. Hence only 96 ques-tionnaires were analyzed. Collected data was entered into an electronic database and analyzed with SPSS Version 10 (Chicago, Illinois). De-scriptive, frequency and Chi-Square analysis were performed.

ResultsThe demographic information of the participants is presented in Table 1. Almost half of the respondents be-longed to the 31-40 years of age group (47%), with the majority being mothers (63.5%). Most of the partic-ipants had at least two children below 12 years of age in their family unit. Regarding the importance of the pri-mary 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 un-treated caries in primary teeth can

Table 1 Demographic charac-teristic of participants

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have on the permanent teeth and general health and well-being of chil-dren. 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 den-tal 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 recom-mended time for a first dental exami-nation 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 per-

ceptions relating to follow-up dental visits, a high percentage of partici-pants (68.7%) preferred to revisit the dentist for regular follow-up for their children even if the chief com-plaint had been completely managed (Table 3).Despite this, there were still a notice-able 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 modifi-cation 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 ed-ucated 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 respon-dents 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 re-spondents’ sex and age in relation to the/ with regards the timing of child’s first dental visit (p= 0.69, 0.07 re-spectively).

DiscussionParents and family members are con-sidered the primary source for knowl-edge about child rearing and health habits for children, which undoubt-

Table 2 Percentage distribution of parents’ knowledge about timing of first visit, main reason for coming to dental clinic and follow up visit

Table 1 Percentage distribution of parents’ awareness about importance of primary teeth and preference for treatment of caries

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edly has a long-term influence in de-termining 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 at-titudes about the importance of pri-mary 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 (Casamas-simo 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 prevent-ing 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 be-fore or shortly after the eruption of first tooth. Presently, the American Academy of Paediatric Dentistry (AAPD) recommends that an in-fant’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, dur-ing this time parents should receive counselling and anticipatory guid-ance on appropriate oral hygiene procedures, minimizing harmful in-fant feeding practices, oral habits, fluorides, as well as general dietary counselling related to oral health

(AAPD, 2008).If dental caries in primary teeth is left untreated, different complica-tions can arise such as pain, oral infection, problems with eating and sleeping, malnutrition, and altera-tions in growth and development (Clarke et al., 1999, Schroth et al., 2009, Schroth et al., 2012, Schroth et al., 2013) and possible of ear-ly loss of teeth (Kagihara et al., 2009). Early extraction of primary teeth might lead to short-term ef-fects 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 Cana-dian study indicated that parents who believed baby teeth were im-portant had children with signifi-cantly 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 at-tributed to the fact that parents usually believe these teeth eventu-ally exfoliate and are replaced by permanent teeth. We may suggest from our findings that dental pro-viders 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 prevent-ing 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 par-ents 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 vis-it. Increasing the awareness of par-ents of this is important. Parents may find it difficult to get current information if dentists and physi-cians are not knowledgeable and do not support and endorse this rec-ommendation. Stijacic et al (2008) reported that many dentists are un-aware about this recommendation and this might mean that informa-tion 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 real-istic approaches to preventing car-ies. We recently published results of

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a survey of dentists in Malaysia that also demonstrated that many den-tists are also unfamiliar with these professional recommendations for early preventive dental visits (Hus-sein 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 par-ents 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 underestima-tion 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 fam-ily’s time. Generally, the discipline of paediat-ric dentistry does not advise on per-forming any operative procedures during first visit if there is no im-mediate 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 in-troduction to dental care, reduce stress for children and parents, and

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 creat-ing possible fear and rejection of dental treatment in their children. Our findings are consistent with Al-Shalan (2003), who reported that a majority of parents preferred to start with behaviour modification during the first visit. Despite this, there were still noticeable par-ticipants (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 appoint-ments inconvenient. In general, all parents should be introduced to be-haviour 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 accep-tance 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 im-portant early evidence on parental views relating to early childhood oral health, our study was not with-out limitations. First, the sample size was considered to be small be-cause the university’s dental clinic is newly established and the patient pool is still growing. Second, it was conducted in one locality. This lim-its how generalizable our findings are with other parents in Malay-sia. 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 educa-tion level, occupation, ethnicity, and household income that would pos-sibly influence their knowledge and attitudes towards early childhood oral health. At present, local infor-mation about parental perceptions of childhood oral health care is in-sufficient. This work provides need-ed 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.

ConclusionThis pilot study revealed that many parents were aware about the im-portance of primary teeth, but that this was not universal. However, the majority were unaware of the cor-rect timing for a child’s first dental examination. A noticeable number of participants were also uncertain about the importance of starting with behaviour modification coun-selling at the first dental visit. An-ticipatory guidance and promoting early dental visits by 12 months of age are important for maintaining healthy primary teeth.

ReferencesAkpabio A, Klausner CP,Inglehart MR (2008). Mothers’/guardians’ knowledge about pro-moting children’s oral health. J Dent Hyg 82: 12.Al Shalan TA, Erickson PR, Har-die NA (1997). Primary incisors decayed before age 4 as a risk factor for future dental caries.

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Pediatr Dent 19:73-141.Al-Shalan TA (2003). Factors affecting Saudi parents’ percep-tion of their children’s first den-tal visit. J Contemp Dent Pract 4: 1-8.American Academy of Paediat-ric Dentistry (2008). Guideline on infant oral health care. Pedi-atr Dent 30:90-93.American Association of Public Health Dentistry (2004). First oral Health Assessment Policy, adopted, May, 2004.Casamassimo PS and Warren JJ (2005). Examination, Diagnosis, and Treatment planning of the Infant and Toddler. In: Pinkham JR. Paediatric Dentistry Infan-cy: Through Adolescence. 4thed. New York: Elsevier Inc. pp. 206-219.Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P (1999). Malnourishment in pop-ulation of young children with severe early childhood caries. Pediatr Dent 21: 109-113.Eijkman MAJ, Howvink B, De-With C (1978). Some aspects of patient education by dentists of mothers with young children. Neth Dent J 85: 6-33.Fayl SA (2005). Treatment and dental caries in the preschool child. In: Welbury RR, Duggal MS, Hosy MT: Paediatric Den-tistry. 3rded. New York: Oxford University Press Inc. pp. 131-146.Hallett KB (2000). Early child-hood caries. A new name for an old problem. Ann R Australas Coll Dent Surgery 15:268-275.Hussein AS, Schroth RJ, Abu-Hassan MI (2013). General Dental Practitioners’ Views on Early Childhood Caries and Tim-ing of the First Dental Visit in Selangor, Malaysia. Asia Pac J Public Health (Epub ahead of print).Kagihara LE, Miedehauser VP

and Stark M (2009). Assess-ment, management and preven-tion of ECC. J Am Acad Nurse Pract 21:1-10.Mattos-Graner RO, Rontani RM, Gaviao MB, and Bocatto HA (1996). Caries prevalence in 6-36 month old Brazilian chil-dren. Community Dent Health 13: 96-8.Meera R, Muthu MS, Phaniba-bu M, Rathnaprabhu V (2008). First Dental Visit. J Indian Soc Pedod Prev Dent 26:68-71.Milnes A (1996). Description and epidemiology of nursing car-ies. J Public Health Dent 56: 38-50.Okada M, Kawamura M, Kaihara Y, Matsuzki, Kuwahara S, Ishidori H, Miura K (2002). Influence of par-ent’s oral health behaviour status of their school children in an ex-ploratory study employing a causal modelling technique. Int J Paedi-atr Dent 12: 101-108.Oral Health Division, Ministry of Health Malaysia (2007). The Na-tional Oral Health Survey of Pre-school Children 2005 (NOHPS 2005). Oral Health Status and Treatment Needs. Government printers, Kuala Lumpur.Poulsen S (2003). Child’s first den-tal visit. Int J Paediatr Dent 13: 264-5.Ramos-Gomez F, Jue B, Bonta CY (2002). Implementing an infant oral care program. J Calif Dent As-soc 30: 752-61.Saied Moallemi Z, Murtomaa H, Tehranchi A, Vitranen J (2008). Oral health behaviour of Iranian mothers and their 9 year old chil-dren. Oral Health Prev 5: 263-269.Schroth RJ, Brothwell DJ, Moffatt ME (2007). Caregiv-er knowledge and attitudes of preschool oral health and early childhood caries (ECC). Int J Circumpolar Health 66:153-167.Schroth RJ, Harrison RL, Mof-

fatt ME (2009). Oral health of Indigenous children and the in-fluence of early childhood caries (ECC) on childhood health and wellbeing. Pediatr Clin North Am. 56: 1481-1499.Schroth RJ, Jeal NS, Kliewer E, Sellers EAC (2012). The rela-tionship between vitamin D and Severe Early Childhood Caries (S-ECC): a pilot study. Int J Vi-tam Nutr Res 82: 53-62.Schroth RJ, Levi J, Kliewer E, Friel J, Moffatt ME (2013). As-sociation between iron status, iron deficiency anaemia, and severe early childhood caries: a case-control study. BMC Pediatr Feb 7; 13:22.Schroth RJ, Moore P, Brothwell DJ (2005). Prevalence of early childhood caries in four Manito-ba communities. J C Dent Assoc 71: 567.Skeie MS, Espelid, Riordan PJ, Klock KS (2008). Caries incre-ment in children aged 3-5 years in relation to parents’ dental at-titudes: Oslo, Norway 2002 to 2004. Comm Dent Oral Epidemil 36: 441-50.Stijacic T, Schroth RJ, Lawrence HP (2008). Are Manitoba Den-tists Aware of the Recommenda-tion for a First Visit to the Den-tist by Age 1 Year? J Can Dent Assoc 74:903.Thomson WM, Williams SM, Dennison PJ, Peacock DW (2002). Were NZ’s structural changes to the welfare state in the early 1990s associated with a measurable increase in oral health inequalities among chil-dren? Aust NZ J Public Health 26:525-530.Tinanoff N, O’Sullivan DM (1997). Early childhood caries. Overview and recent findings. Pediatr Dent19: 12-16.Watt RG (2002). Parental knowledge and attitudes to oral health. Br Dent J 193: 651-654.

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JOURNAL OF ORAL AND DENTAL RESEARCHHatim JODR Issue1, Volume 1, 2013

Nadira A. Hatim, MSc., 1Amrah Y. Al-Jammal, MSc.University of Mosul, College of Dentistry, Prosthodontics Department, Mosul-Iraq. Corresponding Author:Prof. Nadira A. HatimEmail: [email protected]

Fluoride containing mouth rinses, and toothpastes have been reported to decrease the corrosion resistance of titanium.Salva-dora 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: Weight-ing 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.

Effect Of Salvadora Persica Extracts On Titanium Alloy Surface Topography

Abstract

Key Words: Surface Topography, Titanium, Siwak, Salvadora Persica, Kin Mouth Wash, Corrosion, Titanium Alloy

IntroductionThere are hundreds of alloys avail-able for dental restoration. The ma-jor 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 im-plants in consequence of their good biocompatibility, excellent corrosion resistance, and appropriate mechan-ical properties, the most common Ti alloy, Ti-6Al-4V(Park and Kim, 2000; Mandl et al, 2005).Titanium (Ti) is also used in pros-thetic dentistry to manufacture

crowns, and multiple unit fixed res-torations, and in orthodontic dentist-ry to produce Ti brackets, and dental arch wires (Harzeret al, 2001).The metallic biomaterials follow the general patterns for metal degra-dation in environmental situations. Metals undergo chemical reactions with non-metallic elements in the environment to produce chemical compounds. Commonly these prod-ucts 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 cav-ity varies according the prophylac-tic 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 tempera-ture, 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 den-tifrices at different concentrations.

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The effects of fluoride on the corro-sion behavior of titanium and its al-loys have been presented by several authors (Walkeret al, 2005; Mabil-leauet 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 demon-strated that extracts of Salvadora persica possess various anti plaque, anti periopathic, anti caries, anti in-flammatory, and antimycotic effect (Daroutet al, 2000; Monforteet al, 2001).Salvadora persica(Siwak)is a chew-ing stick that derived from Arak tree which is used as cleaning teeth in which a variety of chemical com-ponents have been identified in sal-vadora persica. Some researchers have reported that it contains tri-methylamine, 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 ex-traction 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 MethodsThe material was used in this study was commercially pure titanium grade 2 (Orotic, 1 o t 3754, Bio Ti G2 >99.779). The correct composi-tion of this material checked before usage by high intensity x- rays (X-Met 3000 TX, Oxford instruments). Sixty samples were designed accord-ing to ADA specification No. 14 (ADA,

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 accord-ing to the manufactures instructions.All cast specimens were cleaned us-ing 50-μm aluminum oxide airborne particle abrasion for 15 second to remove investment debris. The speci-mens were machined with carboran-dum 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 grind-er machine (Denta rapid, Germany) with rouge material were used to obtain smoother, and mirror surface, then ultrasonically cleaned in etha-nol for 15 min, and washed with dis-tilled 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 ster-ile 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 consum-ing was ± 90 min. The extract was stored in sterile screw capped vials, in the refrigerator until needed for use, and then freshly prepared in dis-tilled water immediately before use at a concentration of 1% (Al-Kou-baisi, 2001; Darmani et al, 2003).In order to measure the fluoride con-centration in prophylactic agent such as (kin® tooth paste, kin® mouth wash, Siwak® tooth paste, Salvado-ra persicasiwak wash), the standard calibration curve for the fluoride was established. The standard solutions were prepared according to the di-lution 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 pre-pare a solution with concentration 1000 ppm. of fluoride ion, 3.5 gm. of NaF was dissolved in 1000 ml of de-ionized water (molecular weight of F is 9 molecular weight of Na is 23).wt=(23+9)/9wt= 3.5 gmThe other solutions were prepared by diluting this main blank, to pre-pare concentrations: 5, 10, 15, 20 and 25ppm (Martinet al, 1968). Three ml of each concentration buff-ered three ml of total ionic strength adjusting buffer (TISAB). The fluo-ride concentrations of each buffered sample were measured by the radi-ometer with the fluoride ion selec-tive electrode (Ion meter, 3340, Jen-way). The mill volt (mv.) readings of the device plotted against the log concentrations of the fluoride (Log c) to obtain the standard curve (Fig-ure 1).The regression equation of fluoride concentration (Nernst equation) (Dawood, 2008):mv= 39.2+5.91 Logc mv:millivolt reading. c: concentra-tion 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 elec-trode, and then the reading from the device was pointed to the standard calibration curve to obtain the fluo-ride concentration for each one. Total ionic strength adjusting buffer (TISAB):The material was prepared by add-ing 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. TI-SAB was used to buffer the storage solution pH and decomplex fluoride

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(Martinet al, 1968; Mody and Thom-as, 1981).Four cleaning agents containing fluoride pH should be check before

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 Sal-vadora 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 sam-ples were removed from the F- con-taining medium, thoroughly washed with distilled water and dried. Our

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 prophy-lactic 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

very fine tip, served as a probe tip, was in contact with silicon cantile-vers (type: P/N 910M-NSC36).Can-tilevers 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

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 ma-chine (gunal, wP300020), at cross-head 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 statis-tics included, Duncan, and Dennett’s multiple range tests, Independent t-tests were considered significant at p ≤ 0.05, and Paired Samples test were used. The statistical results were considered significant at p ≤ 0.05.

RESULTSSurface TopograghyThe value of mean of root mean square of roughness, standard devia-tion, Dennett’s and Duncan tests of control, and four treated groups for 3 months treatment are shown in Fig-ure (3 A & B). The samples treated with Siwak® paste display more in-crease of root mean square of rough-ness (±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), Salva-dora 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 Salva-dora persicasiwak wash, and kin®

Figure (1) Standard calibration curve.

Figure (2) Experimental design of the study

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paste groups only, as shown in Table (1).Three dimension (3D) surface to-pography measured by AFM, for each treatment samples of cpTi at three, and six months were shown in Figures (4).

Weighting of the samplesThe mean value of weight of four treatment groups and standard de-viation 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 strengthMean value of deflection of control and four treated groups and stan-dard 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 de-creased. The samples treated with kin® wash had a low deflection at force (40N), and (35N) respec-tively, which means that the ductile property of this group was slightly decreased. Computer program ap-plication of load –deflection dia-gram of control, kin® wash, Sal-vadora persicasiwak wash, kin® paste, and Siwak® paste samples for three and six months treatment are shown in Figure (6).

Figure (3)Value of root mean square of roughness, ±standard devia-tion and multiple comparisonsrange testsfor surface topography of cpTi samples.

Table (1): Independent sample t-test between three and six months treatment of cpTi samples.

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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

Figure (4) Surface topography for cpTi samples for all treated groups after 3 and 6 months treatment.

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Figure (5) Mean and ± standard deviation and multiple compari-sonsrange tests for deflection of cpTi samples for three and six months treatment.

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Figure (6 ) Computer program application of load –deflection diagram for all groups of cpTi sample for three and six months treatment.

DiscussionThe 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 sur-face topography of titanium alloys that are in agreement with our re-sults. When using NaF the concen-

tration was >0.1%, the protective-ness 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 sur-face. 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 sur-face in fluoride environment, it dis-sociates 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. Titani-um 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

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with this study, this could be due to the use of profilmeter in measure-ment of surface roughness of cpTi specimens exposed to solutions con-taining fluoride (pH 7.0) at different concentrations and with different immersion protocols were statisti-cally similar. Huang, (2003) inves-tigated the effects of F- concentra-tions 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 titani-um specimen>s solution containing fluoride decreased in comparison with that in a solution not containing fluoride. The rate of corrosion of ti-tanium in acidic medium was clearly higher than that in the solution con-taining fluoride in neutral media, these findings agreed with Kinani et al, (2008); and Bhola et al, (2010).In an attempt to find the differ-ence in weight of cpTi samples be-fore and after three and six months treatment with four treated groups that was proposed in this study, The results showed no significant differ-ence at (P ≤ 0.05) in weight before and after three months, but showed a significant difference before and after six months treatment for Si-wak toothpaste groups only. These findings are in agreement with Ba-same and White (2000); Schiff et al. (2004), who concluded, fluoride ions are known to interfere in tita-nium which causes changes in the protective passive properties of the oxide layer over the metal. The role played by fluoride towards the thin-ning of the metal oxide layer de-pends on the concentration and pH of the solution, which causes a sub-stantial decrease in corrosion resis-tance and increase in the oxide layer capacitance. The samples treated with Siwak toothpaste showed loss of weight after six months treat-

ment due to role of fluoride towards the thinning of the metal oxide layer. The differences between the trans-verse strength of four treatment groups for three, and six months treatment of cpTi samples, that was proposed in this study, were in agree-ment 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 protec-tive 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 hy-drogen absorption, and associated with mechanical property changes in fluoride environment. Liu, (2007) assessed the influence of a fluori-dated medium on the mechanical properties of NiTi wires, and con-cluded that prolonged contact with fluoride ions is harmful to the me-chanical properties of NiTi wires. This study indicated that bending stress changed the corrosion prop-erties, and surface characteristics in a simulated intra oral environment. The scanning electron microscopic analysis showed evidence of pitting corrosion, which confirms the ac-tion 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 mini-mum number of cycles established.

Conclusionsiwak® toothpaste seems to have more effect on both weight and roughness of cpTi compared to al-cohol extract of salvadora persica siwak wash and Kin® toothpaste af-ter three and six months treatment. Acknowledgment: I wish to thank the staff in the Lab of Postgraduate of Prosthodontic department, Col-lege of Dentistry-University of Mo-sul, and Dr. Adawiya J. Haidar head of Nano- Research Center and his staff in University of Technology.

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odontol 29(5): 411-420.Darout IA, Christy AA, Skaug N and Egeberg P (2000). Identification and Quanitifaction of Some Poten-tially Antimicrobial Aniomic Compo-nents in Miswak Extract. Ind J Phar-macol 32:11-14.Dawood A (2008). The effect of ph on fluoride release and surface hardness of glass ionomer based restorative material. M.sc, Thesis, University of Mosul collage of dentistry.Fernández MLD and Cortizo MC (2000). Electrochemical behavior of titanium in Fluoride-containing saliva. J App Electrochem 30(1): 95-100.Harzer W, Schroter A, Gedrange T and Muschter F (2001). Sensitivity of titanium brackets to the corro-sive influence of fluoride-containing toothpaste and tea. Angle Orthod 71(2):318–323.Hearn E (1971). Mechanics of Mate-rials: An introduction to the mechan-ics of elastic and plastic deformation of solids and structural components. Pergamon International Library.Huang H (2003). Effect of fluoride and albumin concentration on the corrosion behavior of Ti-6Al-4V alloy. Biomater 24: 275–282.Kaneko K, Yokoyama K, Moriyama K, Asaoka K, Sakai J and Nagumo M (2003). Delayed fracture of beta titanium orthodontic wire in fluoride aqueous solutions. Biomater 24(12): 2113-2120.Kao T, Ding J, He H, Chou Y and Huang H (2007). Cytotoxicity of orthodontic wire corroded in fluoride solution in vitro. Angle Orthod 77: 349-354.Kinani L, Najih R and Chtaini A (2008).Corrosion Inhibition of Tita-nium in Artificial Saliva Containing Fluoride. Leonardo J Sci 12: 243-25.Lee T, Huang T, Lin S, Chen L, Chou M and Huang (2010). Corrosion Re-sistance of Different Nickel-Titanium Archwires in Acidic Fluoride-con-taining Artificial Saliva. Angle Or-thod 80(3):547–553.Liu I (2007): Effect of Load Deflec-

tion on Corrosion Behavior of NiTi Wire. J Dent Res 86(6): 539-543LiuJS,Wang Q, Lv C, Sun JN, Chen ZQ, Gao N(2009).Elemental release from Ni-Cr dental alloy in artificial saliva and saline solution. Mat Sci forum 610(20): 1164-1167.Mabilleau G, Bourdon S, Joly-Guillou ML, Filmon R, Basle MF and Chap-pard D (2006). Influence of fluoride, hydrogen peroxide and lactic acid on the corrosion resistance of commer-cially pure titanium. Acta Biomater 2(1):121-129.Mandl S, Gerlach J and Rauscenbach B (2005). Surface modification of NiTi for orthopaedic braces by plas-ma immersion ion implantation. Surf Coat Technol 196: 293–297.Martin S, Frants A, James W and Ross J (1968). Use of total ionic strength adjusting buffer determina-tion of fluoride in water supplies. J Anal. Chem7:1169-1170.Mody J and Thomas D (1981). Ion selective electrodes in analytical chemistry, 2nd edition, Henery freez-er, New York, ch 10: 369-370.Monforte M, Miceli N, Mondello M, Sanogo R and Rossitto A (2001). Antiulcer Activity of Salvadoera Per-sica on Experimental ASA-Induced Ulcer in Rats. Inter J Pharmacog-nosy39(4):289-292Noguchi T, Takemoto S, Hattori M, Yoshinari M, Kawada E and Oda Y(2008). Discoloration and dissolu-tion of titanium and titanium alloys with immersion in peroxide- or fluo-ride-containing solutions. Dent Mater J 27: 117-123.Park J and Kim Y (2000). Metal-licbiomaterials. 2ndEd. In: Bronzino JD, editor. The Biomedical Engineer-ing Handbook. Boca Raton: CRC Press and IEEE Press, 2ndEdition;Vol. 1: p 5, 37, 11.Ribeiro R, Noriega J, Dametto F and Vaz L (2007). Compressive fatigue in titanium dental implants submitted to fluoride ions action .J Appl Oral Sci15(4): 299-304.Samuel A, Mahanani S and Arirf M (2007). The effectiveness of salva-

dora persica at removing tea and chlorhexidine stain. Elective project DDS USM, Kelantan, Malaysia.Schiff N, Grosgogeat B, Dalard F, and Lissac M (2002). Influence of fluo-ride content and pH on the corrosion resistance of titanium and its alloys. Biomater 23(9):1995-2002.Schiff N, Grosgogeat B, Lissac M and Dalard F (2004). Influence of fluo-ridated mouth-washes on corrosion resistance of orthodontics wires. Bio-mater; 25(19):4535-4542.Stajer A, Ungvari K, Istvan K. Pel-socziM, Polyanka H, OszkoA and Turzo K (2008). Corrosive effects of fluoride on titanium: Investigation by X-ray photoelectron spectroscopy, atomic force microscopy, and human epithelial cell culturing. J Biomed Mater Res Part A 451-458.Summerlin N (1981). Chemistry for the life science dilution problems.1st edition r.h inc. New York chaps 7:158.Tajima K, Miyawaki A, Nagamatsu Y, Kakigawa H and Kozono Y (2005). Electropolishing of titanium and its alloys for miller finishing. J Jpn Dent Mater 24(406): 60-64.Toniollo M,Tiossi R, Macedo, Re-nata A, Rodrigues C, Ribeiro R and Mattos D (2009). Effect of fluoride-containing solutions on the surface ofcast commercially pure titanium. Braz Dent J 20(3): 279-300.Walker MP, White RJ and Kula KS (2005). Effect of fluoride prophy-lactic agents on the mechanical properties of nickel-titanium-based orthodontic wires. Am J Orthod Den-tofacial Orthop 127(6): 662-669.Walker P, Ries D, Kula K, Ellis M, Fricke B (2007). Mechanical prop-erties and surface characterization of Beta Titanium and Stainless Steel orthodontic wire following topi-cal fluoride treatment. Angle Ortho 77(2): 342-348.Yokoyama K, Kaneko K, Moriyama K, Asaoka K, Sakai J and Nagumo M (2005). Delayed fracture of Ni-Ti su-per elastic alloys in acidic and neutral fluoride solutions. J Biomed Mater Res 69: 105-113.

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JOURNAL OF ORAL AND DENTAL RESEARCHKhalaf JODR Issue1, Volume 1, 2013

Dr. Hanan Abdul- RahmanKhalaf, M.Sc., Department of Prosthodontics, college of Dentistry, university of [email protected]

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 differ-ent concentrations by weight to PMMA on certain mechanical properties. Material and Methods: Tensile strength, elonga-tion, 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.

Effect Of Siwak On Certain Mechanical Properties Of Acrylic Resin

Abstract

Key Words: Pmma, Mechanical Properties, Additives, Impact Strength, Tensile Strength, Transverse Strength

IntroductionPoly 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 ade-quate strength. It can reproduce surface details accurately and can be easily re-paired (Eiichi and Kenji, 2001).However, the mechanical strength of acrylic resin is not sufficient to main-tain the longevity of dentures (Uzunet al, 1999). The problem that occurs with denture base is fracture caused by fac-tors such as poor fit of the denture base,

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 strength-en 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 addi-tion, different types of fibers were incor-porated into acrylic denture base in order to enhance it is physical and mechani-cal 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 Ken-ji,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 den-tal materials also used as reinforcing agents in industry. Several studies inves-tigated the effect of the addition of un-treated 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

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that could be due to the different chemi-cal composition of Siwak sticks. (Al-Bagiehet al 1994, Al -Nidawi 2004).The chemical proportion of Siwak was determined by the following procedures: Chemically the air dried stem bark of Si-wak 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, phos-phorous and silica.•Sulphur and vitamin-C (ascorbic acid-C6H8O6).•Small amounts of tannins, saponins, fiavenoida and sterols.Tri-methylamine and alkaloid have anti-bacterial effects also the fluoride con-tent 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 (Al-Bagiehet 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.

Materials and MethodsSiwak preparationSalvadorapersica(miswaak) were dried by storing these sticks in a des-iccator for three weeks. After each week the sticks were weighted by electrical sensitive balance with ac-curacy of (0.0001g), fig (1).When a constant weight was at-tained it was assumed that the sticks were dried completely. Then these sticks were ground by using an elec-trical 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

screw top containers with sacs of silica gel granules in the tops.

Specimens’ FabricationThe control specimens were pre-pared by mixing PMMA powder with MMA liquid (triplex hot Ivo-clarVivadent, 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 propor-tions 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/βcmβ^2) for 5 minutes and processed ac-cording to the manufacture’s rec-ommendations. 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

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, manu-ally 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.

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 testFive 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 us-ing an Instron testing machine (Ji-anQiao) at maximum load 2000 kg , maximum speed 25-500 cycle/ min-ute and accuracy 0.03% (figure 3).According to the ASTM specifica-tion, D638M (Cucciet al, 1998).Tensile strength = maximum-load/crosssectionalarea =(F(N))/(A(mm^2))

Figure (1) Electrical sensitive balance

Fig (2) preparation of Siwak, A:storage, B: peeling and C: grinding

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Transverse Strength TestUniform molds were made by invest-ing machined rectangular stainless steel standards (65 ×10 ×2.5 mm length, width and depth respective-ly) according to ADA specification no.12, ISO 1567.The three point transverse test was conducted by po-sitioning the specimen on the bend-ing fixture using Ley-bold-Harris hy-draulic 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 be-tween the supports allowing deflec-tion until fracture occurred. Five specimens of each concentra-tion 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 mmB=the width of test specimen in mm. D=the height of test specimen in mm.Impact Strength TestFor 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

used to determine the relative resis-tance of acrylic resin specimens. A pendulum of 5 joules testing ca-pacity was used to strike the speci-mens, the charpy impact strength of un notched specimens was reported in KJ/m². It is given by the equation:Impact strength= A/(X.Y)× 10³A= 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 TestThe rectangular specimens (20×10×10 (mm) according to ASTM- D695 were subjected to compressive load until failure .The maximum load of the testing ma-chine selected was 7.5 KN applied through hydraulic compressive press. The compressive strength was calcu-lated 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 testThe rectangular acrylic specimens with the dimensions (65×10×2.5 mm) underwent the surface rough-ness test by using an analyzing sur-face roughness tester (TR220 por-table roughness tester, Beijing, time high technology. Ltd, China) device. The mean value for the four read-ings 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 pow-der on the physical and mechanical properties of acrylic resin, the level of significance was set at β=0.05.

ResultsThe results of infra-red (IR) spec-tra 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-modified-Siwak 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

Fig (3) A tensile testing machine, B test acrylic specimens (original pictures)

Fig (4): IR spectrum of PMMA, A control group, B modified group (PMMA with Siwak

S= 3FI/2bd²

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change in elongation mean values was found among studied groups, table (1).

Further analysis using LSD test re-vealed highly significant differences were between control group with groups B and D, while the differ-ence 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 differenc-es 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

revealed that no differences were found between the studied groups (control and experimental groups),

at P > 0.05.Comparison between the results of the control and the experimental groups showed that addition of Si-wak powder to PMMA results in a highly significant difference of the

impact strength mean values, table (3).Further analysis using LSD test re-vealed 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 experimen-tal 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 re-vealed that no significant difference was found between control group with group C, while the differences with groups B and D were highly sig-nificant at P < 0.01.Regarding the surface roughness of the control and experimental groups, it was found that there was no statis-tical 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 con-trol group with the studied groups (B,C,D) and the differences among various concentrations of Siwak (BC, BD and CD) were also not sig-nificant at P > 0.05

Table (1) Tensile strength and elongation for the control and the experimental groups

Table (2) Transverse strength (N/mm²) for the control and the experi-mental groups

Table (3) Impact strength (KJ/m²) for the control and the experimen-tal groups

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DiscussionAltering a material to optimize a single property may consequently in-troduce deleterious effects on other properties, However in this study, ad-dition 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 down-grading 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 Si-wak powder ratio increased which in turn limits the addition of additives greater than 5% by weight.Also the result revealed a non sig-nificant change in the mean values of elongation test ( How much the samples stretched before breaking)

for the experimental groups with dif-ferent 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 meth-acrylate 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 parti-cles 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 pa-rameter 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 pow-der 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 configu-ration 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 addi-tive 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 ad-dition of different concentrations of Siwak powder (3%, 5% and 7%) by weight to the heat polymerizing acrylic resin did not affect the sur-face 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).

ConclusionOn 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 re-vealed an adverse effect on most of mechanical properties tested except transverse test.

Table (4) Compressive strength (N/mm²) for the control and the ex-perimental groups

Table (5) surface roughness (µm) for the control and the experimen-tal groups

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