vol 17 no. 2

Letter From The Editor

Dear colleagues,

Since the last issue of the journal, several

progressive changes occurred in the college. These

include installation of the Dimax all in one system,

the laser unit and the nitrous oxide oral sedation unit,

in addition to the continuation of the advanced

educational program to the general practitioners and

the staff of the college.

We are aiming for more events that promote the

scientific and academic standard of our college by

our staff who are working hard to reach such a goal.

Best regards.

Nazar G. A. Talabani, BDS, PhD

Dean of the College of Dentistry,

University of Baghdad

i

A quarterly published scientific journal of the College of Dentistry,

University of Baghdad.

Editor in chief: Prof. Dr. Nazar G. A. Talabani PhD

Editorial secretary: Prof. Dr. Hussain Faisal Al-Huwaizi MSc, PhD

Editorial Board: Prof. Dr. Khalid Mirza FDSRCS

Prof. Dr. Wael Al-Alousi MSc

Prof. Dr. Mohammed K. Bazirgan MSc

Prof. Dr. Maan R. Zakaria MSc

Prof. Dr. Sulafa K. El-Samarai MSc,PhD

Assist. Prof. Dr. Balkees Taha Garib MSc,PhD

Assist. Prof. Dr. Natheer Al-Rawi MSc,PhD

Lecturer Dr. Abbas Faisal Al-Huwaizi MSc,PhD

Board of editorial consultants: A number of university staff and

consultants from the Ministry of

Health.

Computer executives: Dr. Isaac Alber

Dr. Abdul Baset Ahmad

Administrative secretary: Hadeel Abdul Wahab.

For consultation, please contact:

Website: www.baghdentistry.com

E-mail: [email protected], [email protected]

Telephone: (+9641)4169375

Fax: (+9641)4140738

ii

mailto:[email protected]

mailto:[email protected]

Contents Letter from the Editor i

Editor and Editorial Board ii

Contents iii

Instructions for the Authors vi

About the College of Dentistry viii

Assessment of the effectiveness of the manufactured chemo-mechanical caries removal on caries removal. Musab H. Saeed,Haitham J. Al-Azzawi, Amer M. Al-Ani.

Restorative Dentistry

1

An evaluation the sealing ability of a three retro-filling materials. Raghad A. Mohammed. 5

A finite element analysis of the effect of different margin designs and loading positions on stress concentration in porcelain veneers. Hussain F. Al-Huwaizi. 8

Electromyographic evaluation of the activity of masseter and anterior fibers of temporalis in mandibular rest position. Widad A. Al-Nakkash, Fakher S. Al-Ani, Zainab S. Al-Fehaidi. 13

Influence of occlusal schemes on the stress distribution in upper complete denture in centric and eccentric relation. Abdalbasit A. Fatihallah.17

Histopathological examination of the chemomechanical caries removal effect on the human pulp. Musab

H. Saeed, Haitham J. Al-Azzawi, Amer M. Al-Ani. 21

Removal of mercury contamination from the dental clinic with metal backing for X-ray film. Angham G. AL-Hashimi. 24

Strength, hardness, corrosion evaluation and computer-aided designing of cobalt–-chromium molybdenum maxillary major connectors: Part II. Nadira A Hatim, Ahmed A Al–Ali. 28

iii

Oral Pathology,Oral medicine, and Dental Radiology

Quantitative Analysis of Trace Elements in Saliva of Oral Cancer Patients from Iraq. Natheer H. Al-Rawi, Nazar G. A. Talabani 32

Clinical effect of low level laser therapy on healing of recurrent aphthous ulcer and oral ulceration in Behcet’s disease. Muhannad A. Kashmoola, Hadeel Salman, Mukaram M. Al-Waez. 36

The value of fine needle aspiration cytology in the diagnosis of oral and jaw lesions in patients with plasma cell dyscrasias. Bashar H. Abdullah 41

Evaluation of the efficacy of alum suspension in treatment of recurrent ulcerative ulceration. Tagreed S. ALtaei, Raja H. AI-Jubouri. 45

The interrelation of medical history and temporomandibular joint disorders (TMD) in Iraqi patients. Wajnaa F. Qassim. 49

Histological changes in tongue of rabbits with iron deficiency state. Ban Abd – Al Ghani 53

Densitometric evaluation of E-speed film with three different developing solutions. Mouna Al Safi, Ruqayya S. AL Qizweeny, Jamal A. Abid Al –Rhida. 56

The histochemical effects of the administration of hydrocortisone sodium succinate upon the periodontium of albino rats' experimental study. Asmaa Siddeek Al-Douri 59

Oral and Maxillofacial Surgery and Periodontology

Periodontal status during pregnancy. Bacima Ghafory 64

Periodontal condition and attachment loss among patients with spinal cord injuries in comparison with a non - injured patients. Maha S. Al-Rubaie. 69

The relationship between restoration and furcation involvement in molar teeth. Wassan Al-Zaidi. 74

Gingival fluid status in improperly restored and non restored teeth. Hala.A.Al-Jubory. 77

iv

v

Soft tissue impingement and lip form in Iraqi teenagers Akram F. Al-Huwaizi,Wael S. Al-Alousi, Ausama A. Al-Mulla 80

Gingival health status among 3-5 years old children in Al-Edwania village, Baghdad. Wesal A. Al-Obaidi. 84

The effect of oral respiration on the dental occlusion in patients with respiratory tract allergies. Sundus M. Bezzo 87

Orthodontics, Pedodontic, and Preventive Dentistry

Congratulations and Acknowledgement

Evaluation of the complications due to delayed management of trauma to anterior teeth. Lubab J. Mohammed 93

Instruction for the Authors The quarterly published Journal of the College of Dentistry accepts

manuscripts that address all topics related to dentistry. Manuscripts should be prepared in the following manner:

Typescript. Type the manuscript on A4 white paper, with margins of 25 mm. Type the manuscript with English language font (Times New Roman) and the sizes are as follows: 1) Font size 18 and Bold for the title of the manuscript. 2) Font size 14, Bold and capital letters for the headings as ABSTARCT,

INTRODUCTION,.etc. 3) Font size 12 and Bold for the names and addresses of the authors. 4) Font size 11 for the text of all the article, tables and legends of the figures.

Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand corner. Title of the paper:The title should be written with a capital letter for every word as (Effect of the

retention and stability….etc). The name of each author with her/his academic degrees should follow the title. The address, phone, fax, and e-mail of author responsible for correspondence about the manuscript should be typed.

Abstract and key words. The abstract should contain no more than 250 words. The abstract should be divided to the following categories: Background: (It contains a brief explanation about the problem for which the research was done as well as the aim of the study), Materials and methods:, Results:, and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article.

Text. The body of the manuscript should be divided into sections preceded by appropriate headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS, DISCUSSION) which are written in bold and capital. Major headings should be typed in bold and the first letter should be capital at the left

vi

hand margin; subheadings should be not bold and appear at the left hand margin with only the first letter of each word capitalized.

References. References are placed in the text using the Vancouver system (Numbering system). Number references consecutively in the order in which they are first mentioned in the text. Identify references in the text, tables, and figures by Arabic numerals, and place them in parentheses within the sentence as superscription ex. (2). Use the style of the examples given below in listing the references: Book

1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9th ed. St. Louis: CV Mosby; 1985. p.312-23. Journal article

4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9.

Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g. Table 1). Cite each table in the text in the order in which it is to appear.

Figures and illustrations. All figures must have a title placed below the figure. Identify figures with Arabic numbers (e.g. Figure 1). They must be placed on a separate page and numbered to correspond with the figures. If the article contains illustrations submit three clear unmounted glossy photographs and write the author’s name and the figure’s number at the back of each illustration.

The article should not exceed 10 pages. The author should submit three copies of the article (one original and two copies) and a (CD) containing the article.

vii

About the College of Dentistry

Scientific Events in the College of Dentistry The second 3 months of this year were rich in the scientific events in the

college or outside with the participation of the staff of the college. The scientific events are as follows: 1) Continuing education course in oral diagnosis.

This course was organized in 2/4/2005 by the continuing education committee. This course concentrated on the latest advances in oral diagnosis and oral cancer. Fifty one participants attended the course from the college and from the Ministry of Health. Eleven of the staff of the department participated in the course. 2) Continuing education course in operative dentistry.

This course was organized in 30/4/2005 in the Conservative dentistry department. The participants in this course were 42 attendants and 4 lecturers. The lecturers attending the course were Prof Nagham Al-Shimari, Prof Inas Esa, Dr. Ali Mamdooh, and Dr. Ali Abdul Wahab. 3) Lecture about "Patient dentist relation".

Prof Dr. Fadhil Salman Al-Qudsi performed a lecture about the relation between the patient and the dentist. This lecture was designed for the new graduates and members of the teaching staff of the college. 4) Lecture about "Laser in Dentistry".

Dr. Ali Shukur presented a lecture entitled "laser in dentistry" to the staff of the college. This lecture included all the aspects of use of laser in dentistry. 5) Continuing education course in orthodontics.

The Iraqi orthodontic association organized a course in removable appliances. Many of the staff of the orthodontic department headed by Prof. Dr. Usama Al-Mulla presented lectures to the attendants who reached 42 attendant. The lecturers were Prof Dr Fakhri Al Fatlawi, Assistant Prof Dr Akram Al-Huwaizi (secretary general of the association) and Assistant professor Wesam Isa Laso.

viii

Announcements In 2005, the continuing education program is going to start at 13/2/2005 to

24/12/2005 in the college of dentistry, university of Baghdad. Any dentist is welcomed to attend the lectures and clinical presentations of the latest updates in dentistry. Please contact Prof Dr. Hussain Faisal Al-Huwaizi, head of the continuing education program and assistant dean fro the higher studies and scientific affairs for any inquiry about the courses. The courses are as follows:

- Paedodontics and Preventive Dentistry at 13/2/2005 - Endodontics at 27/2/2005 - Oral Diagnosis at 2/4/2005 - Operative Dentistry at 30/4/2005 - Nitrous oxide sedation at 8/10/2005 - Orthodontics at 22/10/2205 - Fixed prosthodontics at 12/11/2005 - Dental Implantology at 19/11/2005 - Periodontics at 3/12/2005 - Prosthodontics at 24/12/2005

ix

J College Dentistry Vol. 17(2) 2005 Assessment of the effectiveness…

Assessment of the effectiveness of the manufactured chemo-mechanical caries removal on caries removal

Musab H. Saeed BDS, MSc, PhD.(1)

Haitham J. Al-Azzawi BDS, MSc.(2)

Amer M. Al-Ani Ph.D. (3)

ABSTRACT Background: Chemo mechanical caries removal systems has been discussed as an alternative to conventional caries removal. This study assesses the efficacy of a chemo- mechanical caries removal technique in caries removal. Material and methods: Forty five decayed extracted human teeth were used in the present study. After initial opening through the enamel, different concentrations of the chemo-mechanical caries removal solution were placed in the cavity and excavation of the caries was performed. Results: After probing and visual inspection, with the use of the DIAGNOdent caries detecting device, and after histological examination, the concentrations of 0.5% and 0.7% were shown to be equally effective in removal of caries and more potent than the 0.2% concentration. Conclusion: 0.5 % concentration of the manufactured chemo- mechanical caries removal is the optimal concentration that can be used in dentinal caries removal. Keywords: Chemo-mechanical caries removal. (J Coll Dentistry 2005; 17(2):1-4 ) INTRODUCTION

In every field of dentistry, an awareness of the importance of preserving tooth tissue, combined with a patient-friendly approach, is becoming self-evident. It has been shown that invasive operative treatment often leads increasingly to further invasive treatment. Wherever possible the tissue should be preserved, invasive treatment should be kept to a minimum and natural tissue replaced with artificial substitutes only when it is absolutely unavoidable (1).

Chemo mechanical caries removal systems (CMCR) have been discussed as an alternative to conventional caries removal with round burs in a slow-speed hand piece, with Chemo mechanical caries removal ,sound and carious dentine are clinically clearly separated, which means that only the cario1us tissue is removed, no sound tooth substance is sacrificed or damaged unnecessarily, the restoration is smaller, the remaining tooth substance is not weakened by the loss of sound tooth structure and the life of the tooth is not compromised and the cavity is no deeper than necessary, which means that there is less risk of harming the pulp (2).

According to the question about the

(1) Lecturer, Department of Conservative Dentistry, College of

Dentistry, University of Baghdad. (2) Professor, Chairman of the Department of Conservative

Dentistry, College of Dentistry (3) Professor, Ministry of industry.

effectiveness of (CMCR) this study assessed the efficacy of the new developed chemo- mechanical caries removal in caries removal. MATERIALS AND METHODS

Forty five decayed human teeth extracted from different patients were used in the present study. The reason for extraction is for orthodontic purpose and for periodontal disease. The carious lesions were detected at routine dental visit. All lesions were opened, without enamel coverage and carious dentin was easily accessible through the cavity openings. None of the cavities extended into the pulp, and then the teeth were stored at 37Co in a water thermostat inside an incubator.

The teeth were numbered and assigned to one of three groups; each group consisted of 15 teeth (10 as test teeth and 5 as control teeth). Three bottles were prepared from each concentration; each bottle was use for 5 teeth from each group. The three bottles have the same color which is, orange (one of them contain amino acid + normal saline which is used as control material).

The blind technique was used in this test. The chemo-mechanical caries removal solution was prepared by mixing the powder of amino acid with the different concentrations of the sodium hypochlorite. The three concentrations that were used in this study were A: 0.2%, B: 0.5%, and C: 0.7%

The three bottles that were prepared from each concentration have the same color. One of

Restorative Dentistry 1


them contains a control material ( amino acid + normal saline). When these samples were ready they were placed in a porcelain jar.

Caries excavation was performed using the three concentrations by handling it using spoon excavator according to caries volume. Each concentration was used for each group as mentioned below. A: 0.2%: A1=5 teeth, A2=5 teeth, A3=5 teeth B: 0.5%: B1=5 teeth, B2=5 teeth, B3=5 teeth C: 0.7%: C1=5 teeth, C2=5 teeth, C3=5 teeth

The hand excavation was performed until the cavity was considered free of caries. The most common criteria for determining that a cavity is free from caries are the color & surface texture of the dentine and the fact that a sharp probe does not catch (3), the use of DIAGNOdent caries detecting device (4), and finally the histological examination (5) The excavation procedure was timed from the first application of the chemo-mechanical caries removal until the cavity was considered caries free, and the time ranged between 7-20 minutes.

After the treatment the material was washed with water and air stream & the teeth were stored in water thermostat in 37Co to start the test to see the presence or absence of caries.

RESULTS The results of probing and visual inspection of 0.2 %, 0.5 %, 0.7 % (CMCR)

A1and A3 is regarded as a control group for the statistical analysis of the experimental group of 0.5 % concentration and experimental group 0.7 % concentration.

Analysis of the data is needed to examine the difference between different pairs of group, hence the data was analyzed statistically by applying the student-T-test that showed in table 1. The results of the DIAGNO dent of 0.2 %, 0.5 %, 0.7 % (CMCR)

The result showed that 0.5%, 0.7% (CMCR) were effective in removing carries-n group B & C. in spite of 0.2 % (CMCR) did not remove all the caries in group The results of the histological examination of 0.2 %, 0.5 %, 0.7 %(CMCR):

In the histological examination also the result showed that 0.5%, 0.7% (CMCR) were effective in removing carries in group B & C. in spite of 0.2 % (CMCR) did not remove all the caries in group

Table 1: T-test between each two groups

in probing and visual inspection.

Groups T-value Significant Level

(A1+A3)&(B2+B3) 6.128 H.S (B2+B3)&(C1+C3) 0.00 N.S (A1+A3)&(C1+C3) 6.128 H.S

Table 2: T-test between each two groups in DIAGNOdent test.

Groups T-value SignificantLevel

(A1+A3)&(B2+B3) 6.332 H.S (B2+B3)&(C1+C3) 0.00 N.S (A1+A3)&(C1+C3) 6.332 H.S

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

M ea n of the control & e x pe ri m e nta l groups in

the probing & visua l inspe cti on

A 1+A 3 B 2+B 3 C1+C3

Figure 1: Histogram showing the mean of the control group (A1+A3), 0.5 % concentration

experimental group (B2+B3) and 0.7 % concentration experimental group (C1+C3) in probing and visual inspection.



0

0. 5

1

1. 5

2

2. 5

M e a n of the co n to l & e x pe ri m e nta l g ro u p s in

D IA GNOd e n t te st

A 1+A 3 B 2+B 3 C1+C 3

Figure 2: Histogram showing the mean of the control group (A1+A3), 0.5 % concentration

experimental group (B2+B3) and 0.7 % concentration experimental group (C1+C3) in DIAGNOdent test.

Table 3: T-test between each two groups in the histological examination

Groups T-value Significant Level(A1+A3)&(B2+B3) 9.00 H.S (B2+B3)&(C1+C3) 0.00 N.S (A1+A3)&(C1+C3) 6.194 H.S

0

0.5

1

1.5

2

2.5

Mean of the control & experimental groups in

the histological examination

A1+A3 B2+B3 C1+C3

Figure 3: Histogram showing the mean of the control group (A1+A3), 0.5 % concentration experimental group (B2+B3) and 0.7 % concentration experimental group (C1+C3) in the

histological examination DISCUSSION 0.2% concentration group:

It is shown that there is no significant difference in caries removal between the experimental group and the control group in all the tests that have been done in the efficacy assessment of this concentration. Therefore, this study has shown that at a concentration of

0.2% of the (CMCR) no caries have been removed (enamel and dentinal caries).

As far as our knowledge, there are no available data concerning the efficacy assessment of caries removal at such concentration. 0.5% concentration group

It has been shown that there is highly



significant difference in caries removal between this group and the control group in the entire test that has been done in the efficacy assessment of this concentration. However enamel caries was not removed, probably this is due to fact that the 0.5% (CMCR) used in this study has removed dentinal caries only. This result complies with Cederlund et al., (5) who evaluated caries – dissolving efficacy of carisolv in vitro. After excavation with carisolv he found that all dentin surface was caries free, however about 60% of his sample showed enamel caries, which may be because the (CMCR) has only remove dentinal caries. The results of this study is totally in agreement with the result done by Banerjee et al.,(6) who concluded that carisolv excavation removed adequate quantities of dentinal caries and there is a significant difference between carisolv excavation group and hand excavation group. 0.7% concentration group

The assessment of 0.7% (CMCR) showed that there is highly significant difference in caries removal between this group and the control group in the entire test that has been

done in the efficacy assessment of this concentration. Nevertheless, there was no significant difference in caries removing when comparing 0.5% (CMCR) and 0.7% (CMCR). REFERENCES 1- Haak R, Wicht M J, Noack M J. Does

chemomechanical caries removal affect dentine adhesion? Eur J Oral Sci 2000; 108(5):449-55.

2- Dammaschke T, Stratmann U, Mokrys K, Kaup M, Ott KHR. Reaction of sound and demineralised dentine to Carisolv in vivo and in vitro. J Dent 2001; 30(1):59-65.

3- Kidd EA, Joyston-Bechal S, Beighton D. The use of a caries detector dye during cavity preparation: A microbiological assessment. Br Dent J 1993; 10: 174: 245- 8.

4- Hieawy AH, Saeed MH. Evaluation of a laser based caries detection device (in vitro study). J Coll Dent 2001; 8: 16-23.

5- Cederlund A, Lindskog S, Blomlöf J. Efficacy of Carisolv-assisted caries excavation. Int J Periodontics Restorative Dent 1999; 19 (5):465-9.

6- Banerjee A, Kidd EAM, WatsonTF. Scanning electron microscopic observations of human dentine after mechanical caries excavation. J Dent 2000; 28(3):79-86.


J College Dentistry Vol. 17(2) 2005 An evaluation the sealing …

An evaluation the sealing ability of a three retro-filling materials

Raghad A. Mohammed, B.D.S., M.Sc. (1) ABSTRACT Background: Retro end filling is important to establish a seal between the root canal space and the periapical tissue. The purpose of this in vitro study was to evaluate the quality of seals obtained with various retro-grade filling materials using dye penetration method of micro leakage measurement. Materials and methods: Forty extracted human single rooted teeth were used. Following root canal obturation, 30 teeth were divided into three experimental groups and each group was subjected to one of the three filling techniques: a\cold burnishing of gutta percha, b\calcium phosphate cement, c\super EBA cement. The remaining 10 teeth were considered as a control group. The teeth were placed in methylene blue dye for a period of 10 days after which they were washed, sectioned and the apical dye penetration measured. Results: The results showed that (CPC) and super EBA cement demonstrated less dye penetration than other experimental groups; the difference was statistically significant as compared with groups 1 & 4 and not significant as compared between groups 2&3. Conclusion: A general trend was observed that the apical leakage was found in all teeth but with different degrees, some leaked more than others, dye penetration was more with the cold burnished gutta percha. Keywords: Retro-filling materials, sealing ability, dye penetration. (J Coll Dentistry 2005; 17(2): 5-7)

INTRODUCTION

The objective of obturation in endodontic is total obliteration of the root canal system and to develop a fluid tight seal at the apical foramen. It has been shown that the thoroughness with which the root canal system is sealed is a major determinant in endodontic success (1). The purpose of retro end filling is to establish a seal between the root canal space and the periapical tissue (2). According to Gartner and Dorn (3), a suitable root end filling material should be (a) non toxic, (b) able to prevent leakage of bacteria and their products, (c) non-carcinogenic, (d) biocompatible with host tissue, (e) in soluble in tissue fluids, f\dimensionally stable, (g) unaffected by moistening during setting, (h) easy to use and radiopaque.

It is important for proper root end preparation that the endodontic surgeon has a thorough knowledge of the root canal morphology of the tooth being treated (4).

Historically, the quality of apical seal obtained by using the retro filling materials has been evaluated by the penetration of a dye and scanning electron microscope and other techniques (5). Dye penetration techniques and radio isotopes are the most frequently methods used (6). (1) Assistant lecturer, Department of Conservative Dentistry ,

College of Dentistry, University of Baghdad.

Abdal and Reteif have proposed guidelines with regard to biocompatibility and physical characteristics of reverse filling materials. (7) CPC has the potential of being a better root canal sealer-filler because it’s high biocompatibility and adheres to the root canal surface (8). Brown and Chow reported that calcium phosphate powder when mixed with water hardens into cements which have similar chemical composite and crystal structures to those of tooth and bone material. (9) Super EBA cement is modified zinc oxide eugenol cement mixed to thick clay like consistency shaped into small cones and attached to the cavity of root end preparation by using spoon excavator (10). The purpose of this study was to examine the quality of seals obtained with various retrograde filling materials using a dye penetration method of a microleakage measurement. MATERIALS AND METHODS

Forty extracted human anterior teeth with single canal were used in this study. Following extraction, remnants of the PDL were removed by placing the teeth in a solution of 5.25% sodium hypochlorite. Then the teeth were stored in sterile normal saline (1). The crowns were removed by using diamond disc bur. Root canal length was determined by using a no. 15-K-File (Kerr Corp, Italy) inserted inside canal until it became visible at the apical foramen, this length minus 1mm, was recorded as the



working length. The root canals were enlarged at working length to a minimum size of no.55K-File used in a circumferential motion with 2.6 solution of NaOCl as an irrigant (9) During the progression from one file to the next size, the patency of apical foramen was maintained by passing the tip of no. 15 K-File through the foramen. The gates glidden drills were used for flaring the coronal two thirds of the canal, then the roots were stored in normal saline till the obturation (10). From 40 extracted teeth, 30 teeth were selected randomly and obturated by using lateral condensation technique, then excess gutta-percha (Dia Dent International, Korea) was removed from the coronal portion of the canal with a heated glick no.1 (Union Broach) instrument and the access was sealed with cavit (Premier Dental Products Co., Norristown). The teeth were stored in 100% humidity for 48 hours at room temperature to allow time for the cement to set (1). Endodontic surgery was performed by removing 2mm of the root apices in a plane perpendicular to the long axis of the teeth with a special bur operated at high speed with water coating, and then the teeth were divided randomly into three groups consisting of 10 teeth in each group. In group 1, exposed gutta- percha obturation material was burnished with an amalgam burnisher. In group 2, the teeth received a class 1 apical preparation, and 2mm depth using a tapered fissure bur, and the super EBA cement (Harry C. Bosworth Co., Skokie, IL) was placed. In group 3, by placing CPC (Alpha Dental Products Co., USA) in the apical preparation. Following retrograde procedure the teeth were again stored in 100% humidity at room temperature for 24 hour. The remaining 10 unobturated teeth (group 4) served as controls and were treated in the same manner as the teeth in other experimental groups except following biomechanical instrumentation and the resection of the root tips, no reverse filling were inserted. A small cotton pellet was placed into the coronal orifices of all the teeth and the access sealed with cavit. A string of brass wire was tied around the coronal aspect of each root, two layers of sticky wax (Kerr/ Sybron) were coated leaving only the resected surface exposed, then stored for 24 hour at 100% humidity at room temperature .Apical portion of teeth were suspended in test tubes, each tube contained 1 ml of a 1% solution of methylene blue dye for 10 days to allow sufficient time

for possible leakage (11). The teeth were washed for 1 hour and left to dry. The wax was removed from the root surfaces and longitudinal grooves were cut into the labial and lingual surfaces and sectioning of the teeth was done. The gutta-percha in the root canals was removed and the amount of linear dye penetration was measured from the resected surface to the most coronal portion of the root canals to which the leakage had occurred. The measurement was done with aid of a stage micrometer under a dissecting microscope (Wild, Heerbrugg, Switzerland, magnification x 6). RESULTS

Statistical comparison of apical leakage in the experimental groups are shown in Table 1

Table 1: Mean and standard deviation of the experimental groups

One way analysis of variance (ANOVA)

test was performed to test the differences between the means of leakage among the experimental groups as shown in Table 2.

Table 2: ANOVA test

SS: sum of squares, df: degree of freedom, M: mean of squares, F value: MS (between groups) / MS (within groups).

The results showed that there was a statistical significant difference between groups 4 and 1 as compared with groups 2 and 3 but there was no significant difference between groups 2 and 3. The measurements of the dye penetration into the root canals of the experimental groups where represented in Figure 1.

Group Type of Material No. of Teeth Mean SD

1 Cold burnished

gutta percha (cbgp)

10 2.73 0.814

2 Super EBA cement 10 0.68 0.216

3 CPC 10 0.57 0.1784 Control 10 8.92 2.673

Source of variation SS df M=SS/df F

value Between groups 276.46 3 92.15 Within groups 67.38 36 1.87 Total 343.84 39

49.27



Figure 1: Bar chart graph to compare the mean leakage for the experimental groups. DISCUSSION

Endodontic surgical techniques involves the placement of a filling material in properly resected and prepared root apices for the purpose of creating a fluid tight seal (12) .Dow and Ingle (13) suggested that failure of the apical seal may be a significant factor in determining whether clinical treatment succeeds. A significant difference in leakage was discovered when cold burnished gutta-percha was compared with the super EBA cement and CPC and there was no significant differences of the sealing ability between super EBA cement and CPC, the sealing ability of CPC slightly less than super EBA cement. Chohayeb and Chow (14) showed that CPC appears to be devoid of dimensional changes during setting and provides superior adaptation to the canal surface allowing a better hermetic seal of the apical foramen and accessory canals located in the apical third of root. Knell and Wefel (15) proved that CPC to be a biocompatible material because of its similarity to dentine could act as its own apical barrier. Several investigators have previously reported that EBA cement to provide excellent seals as retro fillings measurement of microleakage over time demonstrated cold burnished gutta-percha doesn’t provide

adequate seal as reported (16). Qynick and Qynick examined two clinical samples histologically with the scanning electron microscope and found super EBA cement to be biologically compatible. (17)

REFRENCES 1- Shaw CS, Bedge EA. The apical sealing efficacy of

two reverses filling techniques versus cold burnished gutta percha. J Endo 1989, 15(8): 350-4.

2- Dow PR, Ingle JI. Isotope determination of root canal failure. Oral Surg 1985, 8:1100-4.

3- Abdal AK, Reteif DH. The apical seal via retro-surgical approach. Oral Surg 1982, 53:614-21.

4- WeineFS. Endodontic therapy 4th ed. St. Louis: CV Mosby Co. 1998, p. 324.

5- Choheyab A, Chow CL. Evaluation of CPC as a root canal sealer-filler material. J Endo 1987, 13(8):384-7.

6- Gruninger SE, Chow LC. Evaluation of the biocompatibility of new CP setting cement. J Dent Rest 1984, 65:200-5.

7- Ginebram P, Fernandez E. Setting reaction and hardening of an apatite CPC. J Dent Rest 1997, 76(4):905-12.

8- Kenneth T, Ronald W. Longitudinal evaluation of the seal of endodontic retro fillings. J Endo 1990, 16(7):307-12.

9- Arnes DE, Adam WR, Decastro RA. Endodontic surgery, ed. Philadelphia, Harper and Row 1981, 1-13.

10- Bramwell JD, Hicks ML. Sealing ability of four retro filling techniques. J Endo 1986, 12:95-100.

11- Matloff IR, Jensen JR, Tabibi A. A comparison of methods used in root canal seal ability studies. Oral Surg 1982, 53:203-8.

12- Ingle JI, Taintor JF. Endodontic 4th ed. Philadelphia, Lea and Febiger, 1994, p. 584.

13- Ingle JI, Backland L. Endodontic 5th ed. London, BC Decker Inc., 2002, p.718.

14- Krell KF, Wefel JS. A CPC root canal sealer scanning electron microscope. J Endo 1984, 10:571-6.

15- Brown WE, Chow LC. New CP setting cement. J Dent Rest 1983, 62:672-7.

16- Dorn SO, Gartner AH. A retro grade filling material (a retro spective success-failure study of analysis superEBA cement and IRM). J Endo 1990, 16:391-4.

17- Qynick J, Qynick T. A study of a new material for retrograde filling. J Endo 1978; 4:203-7.


J College Dentistry Vol. 17(2) 2005 A finite element analysis…

A finite element analysis of the effect of different margin designs and loading positions on stress concentration in

porcelain veneers.

Hussain F. Al-Huwaizi B.D.S., M.Sc., Ph.D. (1)

ABSTRACT Background: During mastication, stress may concentrate in points in the porcelain veneer which may lead to clinical failure. This study examined whether different finishing lines and different loading positions affect the bond of the porcelain veneers. Materials and methods: A 2- dimensional finite element model was made. Location and magnitude of maximum Von Mises and shear stresses were calculated in porcelain veneer. Results: Stress was concentrated in the butt finishing line more than the deep chamfer and chamfer finishing lines. Stress was concentrated in the incisal portion more than in the cervical portion of the porcelain veneer. The incisal loading exerted stress more than the bonding strength of the bonding agent, and more than the cervical and middle third loading. Conclusion: The best stress distribution was formed around the deep chamfer finishing line. Clinical failure is inevitable in the butt finishing line and incisal loading. Incisal edge fracture of the porcelain veneer may be due to debonding of the bonding agent to the enamel and later fracture of the porcelain veneer Keyword: Finite element, porcelain veneers (J Coll Dentistry 2005; 17(2):8-12)

INTRODUCTION

Porcelain veneers are used to treat discolored teeth, or teeth with minimal loss of the incisal edge. (1, 2)

The success rate of porcelain veneers was clinically evaluated to range from 75-100% (3-7). Factors affecting long term success of porcelain veneers are age, gender of the patient and fabrication techniques (6). The use of rubber dam isolation or number of years in service did not influence the rate of success. Therefore, failure in porcelain veneers seems to be associated with changes in bonding condition and / or the magnitude of incisal load (8).

The advanced bonding agents and techniques have given high bonding strength, hence improving bond of the porcelain veneer efficiently to the tooth structure.

The marginal design of the finishing line was studied to verify the stress concentration by the use of 2 dimensional finite element analysis (9, 10), but none emphasized clearly on the degree of stress concentration on different finishing lines and nearby points.

The purpose of this study was to examine the distribution of stresses in porcelain veneers in different tooth preparation finishing line designs (cervically and incisally) according to different positions of masticatory force loading.

(1) Professor, Department of Conservative Dentistry, College of Dentistry, University of Baghdad.

MATERIALS AND METHODS The finite analysis was conducted using the

ANSYS 5.4 finite element package (Swanson Analysis System, Housten, Pennsylvania) with a pentium 4 processor (2.4 GHz).

Two dimensional finite element models of porcelain veneers on teeth with intermediate layers of bonding agent, and composite resin were designed according to the size of an average maxillary central incisor. The abutment was considered to be homogenous.

The dimensions of the preparation for the porcelain veneers were drawn according Rufenacht in1992, where 0.3 mm was prepared cervically, 0.5 mm in the middle and 0.7 mm incisally. The porcelain veneer preparation was all within enamel.

Three types of finishing lines incisally and cervically were drawn to create models and as follows:

Group I: Butt finishing line. Group II: Deep chamfer finishing line. Group III: Chamfer finishing line. The composite resin was drawn to be 100

um thick (12) and the bonding agent was 1 um thick. (8)

The model was divided into 5 main areas representing porcelain laminate, composite cement layer, enamel bonding layer, enamel and dentine, while the pulp was assumed as a nul element (Fig. 1).



Figure 1: The model of tooth and porcelain veneer.

The properties for the material used in the

study are listed in table 1. The models were meshed into elements ranging from (14622-18940) as is shown in figure 2.

Table 1: Materials’ properties. (8)

Material Esthetic Modulus

(GPa) Poisson’s

Ratio Porcelain 70 0.19 Composite cement

6 0.4

Resin 5 0.4 Enamel 84 0.33 Dentin 19 0.31

The load of 50 N at 60o labiocervically was

applied at 3 different sites (lingual slope of incisal edge, the junction of the incisal and middle third, and at the beginning of the cingulum).

The stress distribution was measured in 9 different points from the incisal to the cervical finishing lines as is presented in figure 3. Stress concentration was studied by Von Mises and shear tests at three different layers:

A: Junction between the bonding agent and enamel.

B: Junction between the composite resin layer and bonding agent.

C: Junction between the porcelain veneer and composite resin.

Figure 2: Meshing of the model into elements. RESULTS Stress due to incisal third force

By the Von Mises stress analysis (table 2), all the types’ of finishing lines gained stress above 30 MPa in most of the examined points (points 2 and 8)

DCH finishing line expressed a much less stress when compared to the butt finishing line which showed at point 2A stress of 325 MPa. This reading was more than at point 2B by 9 times but in the DCH finishing line the difference between the two points was comparable.

The incisal finishing lines gained stress much more than in the cervical finishing lines.

By the shear stress analysis (table 3), DCH and CH finishing line revealed a third of the stress gained in the butt finishing line that revealed stress at point 2A of 96.7 MPa.

At point 2B, stress at the DCH and CH finishing line increased with a decrease in points 2A and 2C, which is inversely proportional to that of the butt finishing line.

Stress at point 8 decreased at the DCH and CH finishing lines when compared with the butt finishing line and was placed under tension.



Figure 3: Stress concentration measured in 9

different points

Stress due to middle third force In comparison with the incisal third force,

stress dramatically decreased at the incisal region (points 1, 2, 3)

Von Mises test emphasized that the least stress was exerted upon the DCH finishing line when compared with the other finishing lines

At point 2A butt finishing line stress was found to be 6 times more than point 2B while in the DCH and CH finishing lines the difference was minimal.

The only points having stress exceeding 30 MPa were point 8A and 8C and 9C butt finishing line. At point 8 DCH and CH finishing lines, stress decreased at A and increased at B while butt finishing line showed stress at point 8A 7 times more than point 8B

The shear test revealed that DCH finishing line gained the least stress. Stress decreased dramatically especially in the incisal finishing line points and to a less degree in the cervical finishing line points where point 8 A butt finishing line gained stress of 25.9 MPa.

At point 2A butt finishing line the stress concentrating in this point was 11 times more than point 2B, while in DCH finishing line this difference was comparable.

Stress due to cervical third force

By the use of Von Mises stress analysis, DCH gained the least stress when compared with CH and butt finishing lines. The highest stress concentration was found to be in the

cervical finishing lines points (points 7, 8, 9) while points 1, 2, 3 gained very much less stress.

9 8 At points 2A butt finishing line stress was 7

times more than point 2B while in CH and DCH finishing lines the difference was comparable.

7

The shear test revealed that stress was very minimal in the incisal and cervical points for all the types of finishing lines. At point 2A butt finishing lines stress was found to be 13 times more than 2B while in DCH and CH finishing lines, the difference was comparable.

6

5

4 DISCUSSION

This study examined the stress concentration in different preparations of finishing lines for porcelain veneers.

3

2 The DCH finishing line was found to be the

best finishing line to disperse the stresses exerted by masticatory forces. The CH finishing line was comparable to the DCH in different points of the porcelain veneer, but the butt finishing lines concentrated stress around it to a degree that sometimes stress was beyond adhesive bonding strength values.

The incisal force exerted very high stress that was mostly concentrated in the incisal finishing lines and much less in the cervical finishing lines regardless of the type of finishing lines. This conclusion agrees with Troedson and Derandin in 1999 (8) and in 1995 (13), who found that small stress difference was found at the cervical finishing line.

Stress was found most in the bonding agent layer (A) and was more than toleration as many authors found that the maximal bonding and shear strength to enamel did not exceed 35 MPa (14, 15). Therefore, it can be concluded that most of the failures start by a debonding of the adhesive layer at the incisal region, hence leaving the porcelain veneer debonded and the inner layer of the porcelain veneer at tension and as tensile strength of porcelain is about 25 MPa the high readings at the porcelain veneer layer (C) in all the types of finishing lines are higher. Therefore, the incisal edge region will be prone to fracture. This conclusion agrees with a study performed by Touati et al in 1999 (16), on the percentage of porcelain veneer failures. He found that 90% of the veneers’ fractures affect the incisal edge or angles.

The middle third force distributed the stress evenly in the incisal and middle areas of the porcelain veneer, but stress still was concentrated in the cervical region in the butt

1



finishing line. The DCH and CH cervical finishing lines decreased the stress to below 30 MPa.

The cervical third force exerted very minimal stress on the porcelain veneer least in the incisal region and slightly more in the cervical region.

It can e concluded that a patient with a moderate or deep overbite is compatible with porcelain veneer more than a patient with edge to edge incisal relation or minimal overbite.

Table 2: Von Mises stress analysis in Mpa of porcelain veneers with different finishing lines and

force application sites.

Incisal Third Force Middle Third Force Cervical Third Force A B C A B C A B C 1 138 71.1 9.3 1 1.7 0.9 0.1 1 0.5 0.2 0.003 2 325.5 35.5 99.6 2 8.5 1.2 3.4 2 1.5 0.19 0.49 3 35.8 11.1 36.6 3 6.4 6.1 5.5 3 1.4 1.3 1.1 4 23.8 9.7 44 4 3.1 1.6 4.4 4 6 4.9 4.6 5 30.1 9.7 34.8 5 1.9 0.7 3.0 5 6.8 4.4 7.2 6 19.2 4.2 29.7 6 9.5 9.5 8.4 6 7.9 7.2 7.5 7 26.3 5.8 47.2 7 14.1 8.2 20.2 7 5.9 5.2 5.9 8 116.7 18.3 77.5 8 73.7 11.1 38.9 8 27.4 4.1 12.2

But

t Fin

ishi

ng L

ine

9 23.3 14.9 63 9 12.8 8.2 32.2 9 4.7 3 11 A B C A B C A B C

1 149.6 71.8 9.3 1 0.5 0.3 0.2 1 0.07 0.3 0.005 2 55.9 37.8 45.6 2 2 1.4 1.7 2 0.29 0.2 0.28 3 34.9 9.8 36.2 3 6.4 6 5.5 3 1.4 1.2 1.1 4 23.3 9.2 43.7 4 2.8 1.5 4.4 4 6.2 4.8 4.6 5 29.9 9.4 35 5 1.8 0.6 3.0 5 6.6 4.3 7.1 6 19.1 4.0 24.8 6 9.3 9.3 8.3 6 7.7 7.1 7.1 7 21.9 5.0 45.9 7 12.1 7.7 19.7 7 5.6 4.9 5.8 8 27.9 26.2 47.7 8 11.6 13.1 24.6 8 3.9 4.1 7.9

Dee

p ch

amfe

r Fi

nish

ing

Lin

e

9 25.6 12.9 59.5 9 13.9 7.1 30.4 9 5.1 2.6 10.3 A B C A B C A B C

1 149.6 71.6 9.2 1 0.4 0.1 0.2 1 0.9 0.44 0.006 2 55.9 42.9 48.6 2 1.8 1.5 1.8 2 0.27 0.2 0.29 3 35 9.3 30.4 3 6.4 6 5.5 3 1.4 1.2 1.1 4 23.2 9.2 44.7 4 2.8 1.5 4.5 4 6.2 4.8 4.6 5 30.1 9.3 34.6 5 1.8 0.6 3 5 6.6 4.2 7.1 6 21.2 3.8 25.6 6 9.4 9.3 8.1 6 8 7.1 7.1 7 20.9 5.4 56.7 7 13.2 7.1 23.8 7 6.8 4.5 6.3 8 34.9 36.1 48.0 8 17.5 18.2 24.3 8 5.4 5.7 7.7 C

ham

fer

Fin

ishi

ng L

ine

9 44.1 20.9 47.8 9 23.1 11.8 24.3 9 8 4.1 8.4 REFERENCES 1- Christensen GJ. The state of the art in esthetic

restorative dentistry. J Am Dent Assoc 1997; 128: 1315-7

2- Calamia JR. The current status of etched porcelain veneer restorations. J Phlipp Dent Assoc 1996; 47: 35-41.

3- Christensen GJ, Christensen RP. Clinical observations of porcelain veneers: a three year report. J Esthet Dent 1991; 3: 174-9.

4- Nordbo H, Rygh-Thoresen N, Henaug T. Clinical performance of porcelain laminate veneers without incisal overlapping: 3- year results. J Dent 1994; 22: 342-5.

5- Denissen HW, Wijnhoff GF, Veldhuis AA, Kalk W. Five-year study of all-porcelain veneer fixed partial dentures. J Prosthet Dent 1993; 69: 464-8.

6- Dunne SM, Millar BJ. A longitudinal study of the clinical performance of porcelain veneers. Br Dent J 1993; 175: 317- 21.

7- Garber D. Porcelain laminate veneers: ten years later. Part I: tooth preparation. J Esthet Dent 1993; 5: 56-62.

8- Troedson M, Derand T. Effect of margin design, cement polymerization, and angle of loading on stress in porcelain veneers. J Prosthet Dent 1999; 82: 518-24.

9- Magne P, Douglas WH. Optimization of resilience and stress distribution in porcelain veneers for the



treatment of crown-fractured incisors. Int J Perio Rest Dent 1999; Dec; 19(6): 543-53.

10- Magne P, Douglas WH. Design optimization and evolution of bonded ceramics for the anterior dentition: a finite-element analysis. Quintessence Int 1999; Oct; 30(10): 661-72.

11- Rufenacht CR. Fundementals of esthetics. Quintessence Books 1992 1st ed. p. 334.

12- Rufenacht CR. Fundementals of esthetics. Quintessence Books 1992 1st ed. p. 335.

13- Troedson M, Derand T. Photoelastic experiments on facings laminated to teeth. Acta Odontol Scand 1995; Aug: 53(4): 270-4.

14- Fruits TJ, Duncanson MG Jr, Miller RC. Bond strengths of fluoride-releasing restorative materials. Am J Dent 1996; Oct; 9(5): 219-22

15- Sussenberger U, Cacciafesta V, Jost-Brinkmann PG. Light-cured glass ionomer cement as a bracket adhesive with different types of enamel conditioners. J Orofac Orthop 1997; 58(3): 174-80.

16- Touati B, Miara P, Nathanson D. Esthetic dentistry and ceramic restorations. Martin Dunitz publ. 1999; p.169.

Table 3: Shear stress analysis in Mpa of porcelain veneers with different finishing lines and force

application sites.

Incisal Third Force Middle Third Force Cervical Third Force A B C A B C A B C 1 20.7 -2.09 -3.2 1 0.02 -0.003 0.004 1 0.008 0.0008 -0.001 2 96.7 13.3 53.04 2 2.35 0.2 -1.1 2 -0.4 -0.03 0.2 3 17.3 2.3 17.6 3 -1.1 -0.89 -1.6 3 0.2 0.5 -0.022 4 7.9 -0.36 19.6 4 -1.7 -0.89 -2.42 4 -2.3 -1.6 -2.4 5 8.2 -1.5 10.7 5 -0.9 -0.4 -1.4 5 -3.9 -2.2 -3.9 6 4.1 -0.13 7.25 6 4.8 4.7 4.5 6 2.7 3.4 1.9 7 2.1 -0.24 4.4 7 5.5 4.68 5 7 3.1 3 2.4 8 33.6 2.3 -26.4 8 25.9 2.7 -12.24 8 10.5 1.27 -3.5

But

t Fin

ishi

ng L

ine

9 -0.17 -0.4 -6.76 9 -0.1 -0.23 -3.46 9 -0.04 -0.09 -1.1 A B C A B C A B C 1 33.6 -7.1 -3.2 1 0.01 -0.004 0.018 1 0.018 -0.0035 -0.002 2 29.8 19.2 24.6 2 -0.4 -0.37 0.04 2 0.04 0.07 0.06 3 17.1 2.2 17.6 3 -0.9 -1.2 0.15 3 0.1 0.02 -0.02 4 7.5 -0.24 19.4 4 -1.6 -0.8 -2.4 4 -2.3 -1.5 -2.4 5 7.8 -1.6 10.4 5 -0.9 -0.4 -1.4 5 -3.8 -2.1 -3.8 6 4.2 -0.17 5.9 6 4.7 4.6 4.4 6 2.7 3.4 2.1 7 1.6 -0.26 4.4 7 4.4 5.02 3.14 7 3.1 2.8 2.4 8 -9.6 -7.4 -9.7 8 -3.1 -4.3 0.48 8 0.4 -0.8 -1.2

Dee

p ch

amfe

r Fi

nish

ing

Lin

e

9 2 -1.95 -6.3 9 1.8 -3.2 0.39 9 0.3 -0.3 -1.1 A B C A B C A B C 1 33.4 -6.9 -3.15 1 -0.09 0.0005 0.009 1 0.022 -0.004 -0.002 2 30.1 18.6 24.6 2 -0.17 -0.46 -0.4 2 0.06 0.084 0.07 3 17.4 2.36 30.7 3 -1.15 -0.904 -1.14 3 0.15 0.02 -0.02 4 7.5 -0.23 20 4 -1.6 -0.81 -2.45 4 -2.3 -1.5 -2.4 5 8 -1.6 10.7 5 -0.9 -0.36 -1.36 5 -3.8 -2.1 -3.9 6 4.8 -0.2 6.14 6 4.8 4.7 4.3 6 2.6 3.4 2.02 7 0.8 -0.5 5.4 7 6.3 4.05 4.935 7 3.86 2.6 2.2 8 -8.1 -8.95 -10.1 8 -6.1 -3.32 -3.7 8 -0.96 -0.9 -1.2 Cha

mfe

r F

inis

hing

Lin

e

9 3 -3.1 -5.2 9 1.6 -1.61 -2.63 9 0.55 -0.5 -0.9


J College Dentistry Vol. 17(2) 2005 Electromyographic evaluation…

Electromyographic evaluation of the activity of masseter and anterior fibers of temporalis in mandibular rest position

Widad A. Al-Nakkash(1)

Fakher S. Al-Ani (1)

Zainab S. Al-Fehaidi (1)

ABSTRACT Background: This study was conducted to evaluate the activity in anterior fibers of temporalis and masseter muscles at habitual rest position of the mandible and to determine the range of minimum muscle activity for these two muscles, using electrophysiological study; EMG power spectrum analysis. Materials and method: The sample consisted of 31 Iraqi dental students (11 males and 20 females) from undergraduate and postgraduate students, at the College of Dentistry, Baghdad University. Results: The results of this study indicated that the anterior fibers of temporalis muscle showed higher EMG activity than that for masseter muscle in habitual rest position and at different interocclusal distances and the interocclusal distance of 2-4mm showed the best clinical rest position to be used in prosthodontic treatment. Conclusion: The EMG activity of the masticatory muscles varies from to another. Keywords: Electromyography, Temporalis,mandibular rest position (J Coll Dentistry 2005; 17(2): 13-16 )

INTRODUCTION

The determination of physiologic rest position of the mandible is of highly importance in almost all fields of dentistry. (1)

The rest position of the mandible is endogenously determined, that it is independent of the presence or absence of teeth and that it remains stable throughout the life of the individual. (2)

Rest position of the mandible has anatomic and physiologic arrangement. The muscles attached to the mandible act with each other to make a defence reflex mechanism to prevent any damage to the mandible or maxilla from unexpected force. (3)

EMG has opened the possibility of studying the muscular action in the head and neck region in a recordable quantitative manner. (4)

MATERIAL AND METHODS

Thirty one dentate subjects were chosen from undergraduate and postgraduate students at the College of Dentistry, Universit1y of Baghdad. The group included 20 females & 11 males, age ranging from (22-34) years of age.

All subjects had to fulfill the following criteria: Class I Angle's classification, no signs or symptoms of TMJ dysfunction, no history of orthodontic treatment, full complement of teeth,

(1) Department of Prosthodontic, College of Dentistry, University

of Baghdad.

good periodontal condition, and no teeth attrition. Faraday gauge apparatus was used to increase quantitatively the vertical dimension of mouth opening. This gauge consisted of three parts. (Figure 1).

Figure 1: Faraday Gauge apparatus

EMG data was collected by using EMG

device (Dantec). Disposable surface electrodes secured in standard position on the right anterior fibers of temporalis and on the right masseter muscles. (Figure 2 a, b) Ground electrode was attached to the wrist of the right arm of the subject. The power spectral analysis program was used for studying the muscular activity in habitual rest position and at different vertical dimensions from (2-20) mm interocclusal distances (Figure 3).



Figure 2a: The position of surface electrodes

Figure 2b: The position of surface electrodes

ESULTS is presented in table 1 and figure

3.

h anterior fibers of

ude parameters (am

Table 1: The amplitude range and paired amined subjects to compare between the two muscles.

tem le M

RAll the data Anterior fibers of temporalis showed a

significant higher values at (P<0.001) and (P<0.05) EMG amplitude than those for masseter muscle during habitual rest position as well as at different interocclusal distance.

The amplitude values for bottemporalis and masseter tend to decrease

gradually with an increasing interocclusal distance to minimum value at 10mm interocclusal distance for anterior fibers of temporalis & at 6mm interocclusal distance for masseter muscle (Figure 4 a, b). This value is then increased with further graded interocclusal distance to a maximum value at interocclusal distance 20mm for both anterior fibers of temporalis & masseter muscles.

This is true for all amplitplitude range, root mean square & mean

rectified value).

t-test for the ex

asseter

muscle Anterior fibers of

porlis musc(Amp.Rg) (Amp.Rg.)

Position of mandible t-test p-value Sig.

Mean ±SD Mean ±SD Habitual 41.7 ±7.5 27.4 ±6.7 13.143 0.000 HS 2 mm 39.8 ±7.2 28.4 ±5.7 9.445 0.000 HS 4mm 38.1 ±8.4 28.1 ±6.7 6.371 0.000 HS 6 mm 37.0 ±9.3 25.1 ±6.3 7.432 0.000 HS 8 mm 36.1 ±8.9 26.2 ±8.4 5.558 0.000 HS 10 mm 34.9 ±8.6 27.7 ±9.4 3.188 0.003 S 12 mm 35.1 ±9.92 27.4 ±9.0 3.448 0.002 S 14 mm 36.7 ±10.0 31.3 ±7.9 2.600 0.014 S 16 mm 39.4 ±10.8 34.6 ±8.2 2.509 0.018 S A? wm 45. 0 ± 8.3 35.5 ±7.5 3.309 0.002 S 20mm 48.1 ±10.6 41.7 ±7.9 3.604 0.001 S *P> 0.05 non significant

***p<0.001 High significant

**p<0.05 significant



Figure 3: Bar graph of habitual interrocclusal distance

DI

r movement rather than

se of stre

their ndons in counter balancing the gravity.

F

a) anteri muscle seter muscle .

Interocclusal distances (mm)

Habitua

SCUSSION The higher values for anterior fibers of

temporalis than those for masseter in habitual rest position and at different interocclusal distances means that the activity of anterior fibers of temporalis in all these positions is higher than that for masseter muscle (Figure 4 a, b) this was due to the fact that the motor units activated in anterior fibers of temporalis are of a large size, than those in masseter muscle which are of a smaller size (5). The higher activity in anterior fibers of temporalis in habitual rest position is related to the fact that it's main function is to elevate the mandible (act as a jaw positioner) while, masseter muscle action is mainly for power communition (for clenching) rather than elevation (6). At all interocclusal distances, the activity in anterior temporal fibers is higher than that in masseter. This is related to the fact that anterior fibers of temporalis are arranged and positioned fo

power communition. (6)

These results come in agreement with (7, 8). The reduction in activity in each muscle with

further increasing of interocclusal distance can be explained from anatomical point of view which, implicate that during gradual mouth opening there is firstly posterior shift of the jaw which cause a decrease in the distance between the mandible & maxilla, therefore, there will be a decrease in stretching, leading to a decrease in the electrical activity. On further opening, the articular surface of the mandible will press on the articular eminence leading to an increase in the distance between the mandible & zygomatic arch hence reflecting itself as an increase in the electrical activity (9). This relationship is important from physiological aspect that the force of contraction depends on the decrea

Am

plitu

de

tching (length-tension relationship). (10)

This reduction in activity appears as useful one, but in reality it is not be because this reduction causes many problems with normal function such as speech, deglutition & swallowing. (11) Therefore, in construction of complete denture, or partial denture we should not rely on the minimum electrical activity recorded in habitual rest position or interocclusal distance ranging between (2-4)mm. These results come in agreement with Garink, and Ramfjord and disagree with Yemm, and Berry who stated that the rest position of mandible by the viscoelastic properties of the muscles &te

igure 4: The electromyography chart of theor fibers of the temporalisand b) mas

2 4 6 8 1 1 1 1 1 205

101520253035404550

S1

Habitual Interocclusal distances

Am

(mm)

plitu

de r

ange

0

5

1

1

2

2

3

3

4

4

2 4 6 8 10 12 14 16 18 20



REFERENCES ShpuntofF H, ShpuntofF W. A study of physiologic 1.

2.

3.

6.

7.

r Joint disorders. J of oral Rehab 1999; 26:33-41.

rest position and centric position by electromyography. J Prosth Dent 1956; 6:621-8. Ballard CF. Consideration of the physiological back ground of mandibular posture and movement. D Pract 1955; 6: 80-9. Niswonger, ME Obtaining the vertical relation in edentulous cases that existed prior to extraction. J Am Dent Assoc 1938; 25:1842-1847.

4. Garink, J, Ramfjord PS. Rest position. J Prosth Dent 1962; 12:895-910.

5. Walton TN. Disorders of voluntary muscles, 4th ed. Churchill Living Stone 1981. Rahn AO, Heartwell CM. Text Book of Complete Dentures. 5Thed.. Lippincot Williams and Willkins.1993 Liu.ZJ, Yamagata 1C, Kashare Y, Ito G. Electromyograhic examination of Jaw muscles in relation to symptoms and occlusion of patients with tempromandibula

8. Tasi CM, Chou SL, Gale EN, Mccall WD. Human masticatory muscle activity and jaw'' position under experimental stress. J of Oral Rehab 2002; 29:44-50.

9. Sarnat BG, Iaskin DM. The reinpro mandibular joint: A Biological basis for clinical paratice.1992; 4th ed. 61-75.

10. Seefley, Stephens and Tate. Anatomy and physiology. 2nd ed. Mosby Year book Inc.1992: 271-296.

11. Michelotti A, Farella M, Vollaro S, Martina R. Mandibular rest position and electrical activity of masicatory muscles. J Prosth Dent 1997; 78:48-53.

12. Manns A, Mirralles R, Guerrero F. The changes in electrical activity of the postural muscles of the mandible upon varying the vertical dimension J Prosth Dent 1981; 45 :438-445.

13. Yemm R, Berry DC. Passive control in mandibular rest position. J Prosth Dent 1969; 22:30-36.

14. Sggobi CR, Bezin F. Electromyographic study of masseter and suprahyoid muscles in mandibular rest position. J of Oral Rehab 1998; 25:676-679.


J College Dentistry Vol. 17(2) 2005 Influence of occlusal…

Influence of occlusal schemes on the stress distribution in upper complete denture in centric and eccentric relation

A bdalbasit A. Fatihallah, B.D.S., M.Sc.. (1)

ABSTRACT Background: This study was aimed to identify the sites of maximum stresses in both balanced and lingualized occlusion in centric and eccentric relation Materials and Methods: Two sets of complete denture constructed and a load of 60 N applied to sites of occlusal contacts so the Von-mises stresses produced from this load applied collected. Results: Balanced and lingualized occlusal schemes compared in centric and eccentric relation, both mean and standard deviation for the calculated stresses compared at the crest of the ridge, buccal flange and mid-palatal suture. Conclusion: Both balanced and lingualized occlusion transmit minimal pressure at the mid-palatal suture and with the concentration of stresses at the crest of ridge in centric, while at the working side balanced occlusion produced greater pressure than lingualized scheme and at balancing side vice versa occur. Keywords: Finite element, three dimensional analysis, complete denture. (J Coll Dentistry 2005; 17(2): 17-20)

INTRODUCTION The denture stability and the restoration of

physiologic function "mastication" is the most important factor to be considered in complete denture construction the arrangement of the denture teeth and the occlusal schemes are important factors in denture stability and function.(1)

The amount of strains and subsequently the stresses in functioning dentures caused by using various posterior teeth of different occlusal configuration has not been satisfactorily investigated so that many attempts have been made to determined which occlusal form produced the greater stress per unit pressure (2)

The physiologic condition of the supporting tissue must be maintained in healthy condition which a prime request when constructing an oral prosthesis, the changes which is take place in these tissues might be due to the unequal distribution of functional forces over it. (3)

There is a great relationship between the width of occlusal table and the pressure produced over the supporting mucosa and even the sites and the number of occlusal contacts (4)

Devan define the denture stability as the forces of occlusion that do not alter substantially the positional relationship of the artificial teeth to the underlying bone. For a denture to be stabilized the interposed mucoperiostium must not be subjected to a state of torque. (5)

(1) Assistant lecturer, Department of Prosthodontics, College of

dentistry university of Baghdad.

Occlusal contacts occurring during voluntary lateral jaw movement vary in regard to location and number these variation are reflected in therapeutic technique through the two well known but apposed concept" Canine protected occlusion and group function occlusion". (6)

Ortman stated that complete denture occlusion is the closure of maxillary and mandibular denture in centric relation and through out the range of functional and non-functional movements of the mandible occlusion must be developed to function efficiently and with least amount of trauma to the underlining supporting tissues. (7)

It's obviously desirable that we should try to reduce the incidence of fatigue failure to a minimum, so that two ways of choice available: 1. There are alternative materials of greater

inherent resistance to flexural fatigue. 2. Reduction of the fatigue failure though is to

reduce the stress borne by the denture. (8) Craig stated that FEM stress analysis is

valuable for analyzing complex geometries and it can determine stress/strains through out a three dimensional component. In this method a finite number of discrete structural elements are inter connected at finite number of points or nodes, these finite element are formed when the original structure is divided into a number of approximately shaped sections with the section retaining the actual properties of the real materials. (9)

Darber et al conducted a study to examine the stress distribution at the tooth denture base interface of acrylic resin teeth (10)



Table 1: Material properties used in the FEM.

Materials Young's modulus (MPa)

Poison's ratio Authors

Tooth 2.65 x 10^3 0.35 Craig (9)

Acrylic resin

denture base

2.65 x 10^3 0.35 Craig (9)

Mucosa 7.5 0.45 Larabee(14)

debonding from the denture base. They

found that when load was applied to upper incisors the maximum tensile stresses were concentrated within the body of the tooth & not at the tooth denture base interface and calculated stresses at the interface was relatively low, and Darber et al found that irrespective to the type of acrylic resin used, the maximum tensile stresses were found at the palatal aspect of the interface. (11)

MATERIALS AND METHODS The samples consist of two groups of upper complete dentures; the first group represents the balanced occlusal schemes while the second group represents the lingualized occlusal schemes. The model was drawn on a grid paper after sectioning of the original upper denture mesial and distal to the upper first molar so that a section was made crossing the palate to the other side of the denture then the following steps take place:

1. The mesial and distal area of the denture base were drawn on a grid paper with its exact dimensions through super imposition of them on the grid paper, x and y coordinate system obtained for a specific key points to both mesial and distal areas of the denture base.

2. The distance between the mesial and distal area of the denture base block section obtained by the means of Vernier which represent the Z-value in space that change the model from two dimensional to three dimensional model.

3. The mesial and distal areas were joined at their key points by lines then the lines converted to areas and the areas converted to volumes which represent the denture base.

4. Modeling of the tooth was made by the aid of Verniea through obtaining the real dimension with the selection of specific key points.

5. the mucosal thickness under the denture was supposed to be 1.5mm (1)

6. The model "tooth, denture base and mucosa" glued together in order to act as one unit through ANSYS options when applying the boundary conditions.

Materials properties used in this FEM are shown in Table 1 and the element used is a 3-dimensional brick shape element. The Load was applied to the upper posterior teeth According to the site of contacts with the opposing artificial lower posterior teeth in centric and eccentric relation, the load applied to each set equal to 60 N (Figure 1,2,3 and 4) .(12 ,13)

The maximum principle stresses obtained at a specific selected node, which located at the crest of the ridge, buccal flange and the mid palatal suture.

Figure 1: The site of occlusal contact in balanced occlusion in centric relation

Figure 2: The site of occlusal contact in lingualized occlusion in centric relation

Figure 3: The site of occlusal contact in Balanced occlusion in eccentric relation



Figure 4: Represents the site of occlusal contact in lingualized occlusion in eccentric

relation RESULTS

Comparing stresses generated at centric occlusion in balanced and lingualized occlusal schemes: Examination of the results obtained from the FEM through applying Von mises theory of failure and obtains the stresses at specific selected nodes located at the crest of the ridge, mid-palatal suture and buccal flange, results shows that the highest stress values at the crest of the ridge “15.371 KPa, 0.961 KPa in balanced and lingualized occlusal schemes respectively”. Table 2,3; Fig. 5,6

Table 2: Values of stress including mean for

balanced occlusion (KPa) Mean Std Crest of Ridge 21.138 2.831 Mid-palatal Suture 0.0205 0.006

Cen

tric

O

cclu

sion

Buccal Flange 15.371 1.702 Ridge Crest Working 21.138 2.831 Ridge Crest Balancing 11.702 1.127 Mid-palatal Suture 0.0113 0.005 Buccal Flange Working 15.371 1.702 E

ccen

tric

O

cclu

sion

Buccal Flange Balancing 17.882 2.495

Table 3: Values of stress including mean for lingualized occlusion (KPa)

Mean Std Crest of Ridge 14.03 1.395 Mid-palatal Suture 0.054 0.001

Cen

tric

O

cclu

sion

Buccal Flange 0.861 0.159 Ridge Crest Working 9.004 1.966 Ridge Crest Balancing 12.49 1.511 Mid-palatal Suture 0.136 0.016 Buccal Flange Working 11.43 2.710 E

ccen

tric

O

cclu

sion

Buccal Flange Balancing 5.988 0.489

Comparing stresses generated at eccentric occlusion in balanced and lingualized occlusal schemes.

Generally speaking for both working and balancing side, the mean stress values in the lingualized occlusal scheme much less than those generated in the balanced occlusal scheme. While for mid-palatal suture no considerable changes takes place. (Table 2,3; Figure7, 8) DISCUSSION

Comparing stresses generated at centric occlusion in balanced and lingualized occlusal schemes: The stresses generated in lingualized occlusal scheme are considerably less than those generated in balanced occlusal scheme, this may be due to number of occlusal contact reduced so that there is only a one centric stopper between upper and lower antagonist teeth in case of lingualized occlusion." this is in agreement with Ohgori et al (1) who conducted a study to show the influence of occlusal schemes on the pressure distribution under a complete denture by comparing fully balanced and lingualized occlusion using pressure transducer attached to simulated dentures. (Figure 5,6) No changes take place at the mid-palatal suture when comparing the values of stresses in both occlusal schemes (Table 2 and 3). When comparing stresses in lingualized and balanced occlusal schemes generated at eccentric occlusion: Table 2 and 3 show that stresses generated at the mid-palatal suture reduced in fully balanced occlusion than that in lingualized occlusal schemes due to the fact that: 1. The position of the upper posterior teeth is

rather tilted buccally than centered over the ridge crest so that the buccolingual position of the posterior teeth will affect the stress distribution and consequently the stress reaching the midline of the denture.

2. The site of occlusal contacts, in that only the palatal cusp of the upper posterior teeth contact the fossa and central groove of the lower posterior teeth.

Stresses generated at the working side at the crest of the ridge and buccal flange for balancing occlusion seems to be more than that for the lingualized occlusal scheme due to the number of occlusal contact increased. For the



balancing side at the crest of the ridge vice versa occur, while at the buccal flange the

same results take place this is may be due to the sites of occlusal contacts differ. Fig. 7,8

Figure 5: Three-dimensional model represents stress contours in balanced

occlusal scheme at centric occlusion. (KPa)

Figure 6: Three-dimensional model represents stress contours in lingualized

occlusal scheme at centric occlusion. (KPa) REFERENCES 1. Ohguri T, Kawano F, Ichikawa T, Matsumoto N.

Occlusal scheme and pressure under complete denture. The International Journal of Prosthodontic 1999; 12(4): 353-8.

2. Kelsey CR, Coplostz , Schoonmarker M. The effect of occlusal forms on pressure and bending during mastication with complete denture. J Prosth Dent 1976; 55 (2): 312.

3. Lambrecht JR, Kydd WL. A functional stress analysis of the maxillary complete denture base. J Prosth Dent 1962; 12(5): 865-72.

4. Roedema WH. Occlusal table width and pressure under denture. J Prosth Dent 1976; 36:24-34.

5. Devan MM. The concept of neotrocentric occlusion as related to denture stability. JADA 1954; 48: 165-8.

6. Woda A, Vegneron P, Douglas K. Non functional and functional occlusal contact. A review of literature. J Prosth Dent 1979; 42(3): 335-41.

Figure 7: Three-dimensional model represents stress contours in balanced occlusal scheme at eccentric occlusion.

(KPa)

Figure 8: Three-dimensional model represents stress contours in lingualized occlusal scheme at eccentric occlusion.

(KPa)

7. Ortman HR. Role of occlusion in complete denture prosthetic. J Prosth Dent 1971; 27(1): 121-37.

8. Johnson W. A study of stress distribution in complete upper denture. The dental practitioner 1965; 15(31): 374-6.

9. Craig R. Restorative dental material.10th ed. Mosby St. Louis 1997: 59-103.

10. Darber UR, Huggett R, Harrison A, William K. The tooth denture base bond stress analysis using FEM. Eur Dent J 1993; 1(3): 117-20.

11. Darber UR, Huggett R, Harrison A, William K. Finite element analysis of stress distribution at the tooth denture base interface of acrylic resin teeth debonding from denture base. J Prosth Dent 1995; 74(6): 591-4.

12. Rahn AO, Heartwell CM. Textbook of complete denture. Ed 5 Philadelphia, Lea and Febiger, 1993.

13. Boucher. CO. Swenson's complete denture. Ed 6 St. Louis, C.V. Mosby co.1970: 567.

14. Larrabee W, Glat J. A finite element method of skin deformation. Laryngoscope 1986; 96:413-19.


J College Dentistry Vol. 17(2) 2005 Histopathological examination…

Histopathological examination of the chemomechanical caries removal effect on the human pulp

Musab H. Saeed B.D.S., M.Sc., Ph.D. (1)

Haitham J. Al-Azzawi B.D.S., M.Sc. (2)

Amer M. Al-Ani Ph.D (3)

ABSTRACT Background: Chemo mechanical caries removal systems have been discussed as an alternative to conventional caries removal. This study examines the effect of the chemo- mechanical caries removal material on the human pup. Material and methods: Forty eight maxillary first premolars from twenty four patient ( 18 male and 6 male) were studied and selected from patients need orthodontic treatment .class V cavity was done in each tooth and the material put inside the cavity for 20 sec, the extraction procedure done after 20minutes, 24 hours and 4 days . Results: The histological examination of 0.5 % Chemo-mechanical caries removal at the three periods showed that there is no significant effect on the pulp of the tooth. Conclusion: 0.5 % concentration of the manufactured chemo- mechanical caries removal can be used in dentinal caries removal safely with out any adverse effect on the pulp Keywords: Chemo-mechanical caries removal. (J Coll Dentistry 2005; 17(2): 21-23)

INTRODUCTION The consumer demands of dental care

increases with regards to esthetic expectations and comfort of treatment. The dental profession has progressed towards practicing preventive dentistry and adopting tooth-preserving procedures such as remineralizing non-cavitated lesions, sealant restorations, porcelain veneers and dentine bonded crowns (1). This response to advances in materials science, showed that restorations are not permanent and that the re-restorations sequence is not only expensive but also destructive. This has led to descriptions such as the repeat restoration cycle and the realization that a restoration should be as minimal and biologically based as possible (2).

Over recent years, the dental profession has shifted towards practicing preventive dentistry and adopting more conservative and tooth-preserving procedures.

Such progression is considered to be a response to the decline in the level of dental caries and advance in materials science. This shift in caries management will continue over the coming decades, based on rational clinical and scientific principles (3-5).

According to the question about the effect of 0.5% (CMCR) in the pulp, this study assesses its effect in the pulp. (1) Lecturer, Department of Conservative Dentistry, College of

Dentistry, University of Baghdad. (2) Professor, Head of the Department of Conservative Dentistry,

College of Dentistry, University of Baghdad. (3) Professor, Ministry of industry.

MATERIALS AND METHODS Sample preparation:

To examine the effect of the chemo- mechanical caries removal material on the human pulp and see the changes on the pulp during the application of the chemo-mechanical caries removal material, forty eight maxillary first premolars from 24 patients, 18 male and 6 female, 17 to 23 years of age (mean age 20 years) were studied and selected from patients needing orthodontic treatment involving bilateral maxillary first premolar extraction.

The scheduled extractions were postponed for 20 minutes for group I, 24 hours for group II and 4 days for group III to use the teeth as a test and control for the experiment. The maxillary left first premolars were used as a control group for each group.

The teeth were numbered and divided to three groups; each group consisted of 16 teeth (8 as test teeth & 8 as control teeth).

Group I: 20 minutes. Group II: 24 hours. Group III: 4 days. Cavity preparation

Local anesthesia was given to the patient to perform the Class V cavity in the middle third of the buccal aspect of the right & left upper maxillary first premolar the dimension of the cavity was 3×2×2 mm (wide- mesiodistally × depth-buccolingually × high-occlusogingivally) the cavities were done by using carbide fissure bur no. 330 in a high speed hand piece with proper water cooling, one bur for each 5 cavities is used. (4,5).


J College Dentistry Vol. 17(2), 2005 Histopathological examination…

0 10 20 30 40 50 60 70 80 90

%

Severe inflammationl Figure 1: Distribution frequency of the 0.5% experimental and control subgroups of group

I. (P value = 0.674 P>0.05)

Applying the materialAfter mixing the material (0.5% Carisolv) in

the porcelain jar we carry it with a spoon excavator or with an insulin disposable plastic syringe with out it’s needle and place it in the Class V of each tooth for 20 minutes & then the material was washed with water and air stream and finally dry it with air only. After that all the teeth were filled with light cure composite using light cure device for 40 seconds curing time

The extraction procedure Moderate inflamation The extraction was done for all the teeth as

following: Group I: After 20 minutes from applying the material. Group II: After 24 hours from applying the material. 0.5% Control Group III: After 4 days from applying the material.

At the end of the experimental period the test and control teeth were extracted with forceps under local anesthesia. Sections were stained with hematoxylin and eosin.

0

10

20

30

40

50

60

70

80

90

%

Severe inflammation

0.5%

Moderate inflamation

Figure 3: Distribution frequency of the 0.5% experimental and control subgroups of group

III. (P value = 0.606 P>0.05)

0

Figure 2: Distribution frequency of the 0.5% experimental and control subgroups of group

II. (P value = 0.642 P>0.05) Histological Preparation:

All the extracted teeth were immediately fixed in 10% neutral buffered formalin solution for 48 hours, demineralized for 8 weeks using 10% formic acid.

The specimens were checked for complete decalcification using Oxalate test (6). Then the specimens were washed under running tap water for one hour, dehydrated, cleared and embedded in paraffin wax and step serially sectioned parallel to the long axis starting from the mesial surface with the microtome set to 4mm. The teeth were sectioned in a buccolingual direction parallel to the long axis of the tooth

For histological examination, sections were selected from each group in the bucco-lingual direction, 16 sections from each group. All the

Histological Examination To describe the findings or the changes that

happened in the pulp the following criteria were used: 0- Indicates absence of inflammation where the

odontoblast layer appeared normal. 1- Indicates moderate inflammation where there

was reduction in the number of the disintegrated odontoblast, presence of localized inflammatory lesions, tissue infiltration of polymorphonuclear leukoocyte and macrophage

2- Indicate severe inflammation where the pulp tissue was mostly necrotic and the odontoblasts were completely disintegrated. All sections were blinded i.e. the examiner

had no knowledge of whether the sections for evaluation emanated from test or control group. RESULTS

The result of the effect of the 0.5% concentration on the pulp is shown in figures (1, 2, 3) to compare the severity of the inflammation in each group.

Control

12

43

56789 Absence of inflamation

Modrte inflamation

0.5% Control

%


J College Dentistry Vol. 17(2), 2005 Histopathological examination…

The principles of the distributions frequency are applied for the presentation of the data that based on percentages while the determination of the significance between. The sub group in each group will be calculated using the chi-square. Group I:

The group was the control and experimental teeth that have been extracted after 20 minutes from application the material.

In the 0.5 % experimental sub group 7 cases (87.5%) have score 2 (sever inflammation and 1 case (12.5%) have score 1(moderate inflammation).

In the control sub group 7 cases (87.5%) have score 2 (sever inflammation and 1 case (12.5%) have score 1 (moderate inflammation). Group II:

The group was the control and experimental teeth that have been extracted after 1 day from application the material.

In the 0.5 % experimental sub group 7 cases (87.5%) have score 1 (moderate inflammation and 1 case (12.5%) have score 2 (severe inflammation).

In the control sub group 5 cases (62.5%) have score 1 (moderate inflammation and 3 cases (37.5%) have score 2 (severe inflammation). Group III:

The group that the control and experimental teeth have been extracted after 4 days from applies the material.

In the 0.5 % experimental sub group 7 cases (87.5%) have score 0 (absence of inflammation and 1 case (12.5%) have score 1 (moderate inflammation).

In the control sub group 6 cases (75%) have score 0 (absence of inflammation and 2 cases (25%) have score 1 (severe inflammation).

Chi-square test was used to compare the significance between the 0.5% experimental subgroup and the control subgroup in group I, II, III. DISCUSSION

The 0.5% (CMCR) had been investigated by examining its effect on the human pulp after 20 minutes, 24 hours and four days from its use that showed:

There is no significant difference between the 0.5% experimental group and control group at the three periods (20 minutes, 24 hours, and 4 days). This indicates that the 0.5% (CMCR) didn’t have any adverse effect on the human

dental pulp. The result of this study complies with the result of the study done by Dammaschke et al in 2001 (7), but they used Wistar rat molar with a direct contact of carisolv to the pulp for 1,10, and 20 minutes there result show that the pulpal and predentine fibrils as well as the dentine fibrils appeared to be intact and did not differ significantly from the controls. The present study also agrees with the result of the study done by Young and Bongenhielm in 2001 (8) who used Sprague- Dawley incisors and molars but the carisolv was directly applied to the exposed pulp tissue for 30 minutes. The result show there is no significant difference in the cellular response in both test teeth and controls. REFERENCES 1 Anusavice KJ. Treatment regimens in preventive and

restorative. J Am Dent Assoc 1995; 126: 727-43. 2- Elderton RJ. New approaches to cavity design with

special reference to the class II lesion. Br Dent J 1985; 421-7.

3- Morrow LA, Hassall DC, Watts DC, Wilson NHF. A chemomechanical method for caries removal. Dent Update 2000; 27(8):398-401.

4- Al-Huwaizi AF. Assessment of micro leakage of Amalgam restorations lined by silver varnish. Master thesis, University of Baghdad, 1997.

5- Al-Aubousi MM. Mocroleakage assessment of bounded conventional amalgam restoration located at enamel and root surface. Master thesis, University of Baghdad,1999.

6- Linda L. Laboratory manual of histochemistry 1985; Raven press page 331.

7- Dammaschke T, Stratmann U, Mokrys K, Kaup M, Ott KHR. Reaction of sound and demineralised dentine to Carisolv in vivo and in vitro. J Dent 2001; 30(1):59-65.

8- Young C, Bongenhielm U. A randomised, controlled and blinded histological and immunohistochemical investigation of Carisolv on pulp tissue. J Dent 2001; 29(4):275-281.


J College Dentistry Vol. 17(2) 2005 Removal of mercury…

Removal of mercury contamination from the dental clinic with metal backing for X-ray film

Angham G. AL-Hashimi B.D.S, M.Sc (1)

ABSTRACT Background: Mercury in dental clinic has been recognized as a potential health hazard. This evaluated the removal of Hg spills from different surface in dental clinic with tin in the metal backing for dental x-ray film. Materials and Methods: Hg 90 drops (each one of 0.2 g) placed on 9 different surfaces in the dental clinic, and were divided into: Group I (protective surfaces) subgroup 1 (mask) subgroup 2 (gloves) subgroup 3 (dental apron) Group II (dental instrument and equipment) subgroup 1 (metals, for example, the metal tray of sterilizer) subgroup 2 (dental chair unit) subgroup 3 (wet surfaces, for example, the vacuum suction tank of the sucker). Group III (other clinical surfaces) subgroup 1 (working bench) subgroup 2 (the floor) subgroup 3 (the carpet). The metal backing for x-ray film (0.4 g) placed on each Hg spill, and the time of adsorption was recorded in seconds using a digital timer. Results: The results showed adsorption of Hg spills to the metal backing for x-ray film in all groups except in the crevice of the carpet. Group I subgroup 2 showed the faster interaction (7.1 + 2.828 sec.) while group II subgroup 3 showed the slowest interaction (90.3 + 20.981 sec.). Conclusion: Hg spills on dental protective surfaces can be removed easily, while the most difficult spills to be removed were on the wet surface. Furthermore, Hg spills in crevis of the carpet can not be removed. Keywords: Mercury, metal backing, x-ray film. (J Coll Dentistry 2005; 17(2): 24-27)

INTRODUCTIONAmalgam has been used for 150 years and

about 200 million amalgams are inserted each year in the United States and Europe, although periodically, concern arises about the mercury toxicity. (1,2)

As vapors mercury is odorless and colorless and has a high vapor pressure, these combinations make Hg a potentially serious inhalation hazard if not managed properly. (3) 4,5). *

Exposure to Hg in dental clinic has been recognized as a potential health hazard to patient and dental personnel for many years. (6) The dental office personnel are at greater risk to mercury vapor and therefore mercury vapor and therefore mercury toxicity. (1) The sources of Hg hazard in dental clinic include: � Some Hg vapor released from stored materials. � Small losses from capsules during tituration � Spillage during manipulation for cavity restorations � Some vapor exposure to dentist, assistant and patient during removal, placement, finishing and/or polishing of dental amalgam. � Contamination of cotton rolls. � Collection of debris via vacuum suction into plumbing system and sewage system. � Collection of remnants in jar for recycling (1) Assistant lecturer, Conservative Dentistry, College of

Dentistry, University of Baghdad.

� Hg that is trapped in small cracks between floor tiles and/or in carpet fibers. � Hg vaporization from contaminated instruments placed in sterilizer. (5,7)

Exposure to Hg can occur either through direct skin contact with Hg or Hg-containing compounds or through the inhalation of Hg vapor (7). The inhalation of Hg vapor is the primary route of exposure. (8)

Furthermore, Ferracane et al investigated exposure to elemental Hg vapor from Hg spills in the dental office. They concluded that Hg remained in vapor form for only limited periods, because of its density and affinity for surfaces, and that a single accidental Hg spill probably would not be the only significant source of Hg in dental clinic. (9)

Mercury combines readily to form amalgam with several metals such as gold, sliver, and copper, tin and zinc. (1) Johnson in 1967 reported that a mixture of tin powder and 18.5% mercury is completely amalgamated within two minute. This observation led to the idea that tin in the metal backing for dental x-ray film is an excellent material for removing mercury that has been spilled.(10)

The aim of this study was to evaluate the removal of mercury spills from different surfaces in dental clinic with tin in the metal backing for x-ray film.

Restorative dentistry 24


MATERIALS AND METHODS This study was done in the author's private

dental clinic. Mercury spills were simulated by placing 90 drops of Hg-each one of 0.2g (Mercure, Septodent, France)-on 9 different surfaces in the clinic.

According to the types of surfaces, the drops were divided into 3 groups. Each group had been subdivided into 3 subgroups each one contained 10 drops. Group I (protective surfaces) Subgroup 1 (dental mask) Subgroup 2 (gloves) Subgroup 3 (dental apron) Group II (dental instrument and equipment)

Subgroup 1 (metals, for example the metal tray of the sterilizer)

Subgroup 2 (the dental chair unit) Subgroup 3 (the wet surface, for

example the vacum suction tank of the sucker).

Group III (other clinical surfaces) Subgroup 1 (working bench) Subgroup 2 (the floor) Subgroup 3 (the carpet) The interaction of mercury and tin in the

metal backing for x-ray film was studied by using 45 sheets of metal backing for dental x-ray film, each one (0.8 g) divided into two pieces, each piece (0.4 g) was bent (in 45obend) to facilitate its application and removal, then it was held in one hand (Figure 1) while a digital timer was held in the other hand. The time interval between the application of tin and adsorption of mercury was recorded in seconds. (Figure 2)

The data obtained was subjected to analysis of variance (ANOVA) test and least significant difference (LSD) test.

RESULTS

All the Hg spills were adsorbed to the metal backing for x-ray film except those placed in the crevis of the carpet, so they were disregarded and replaced with another spills placed on the superficial surface of the carpet.

The mean values and standard deviations are presented in table 1 and figure3.

It is clearly obvious that the adsorption of Hg to the metal backing for x-ray film was faster when placed on dental gloves, while it was slower when placed on the wet surface.

Table 1: the means values and standard

deviation for the time of adsorption (of Hg to the metal backing for x-ray film) in

seconds.

Figure 1: Application of metal backing for

x-ray film on Hg spill placed on the superficial surface of the carpet

The statistical analysis of the data using ANOVA test indicated very highly significant difference at P< 0.01 level. The source of differences was investigated using LSD test. The statistical analysis of the data using LSD test showed: � There were no significant differences between: - All subgroups of group I (protective

surfaces). - Group II subgroup 2 (dental chair) vs.

Group III subgroup 2 (floor). - Group II subgroup I (metal surfaces) vs.

Group III subgroup 2 (floor) - Group III subgroup 2 (floor) vs. Group III subgroup 3 (superficial surface of the carpet) � There were statistical significant differences (LSD 0.5=8.559) between: - Group II subgroup 1 (metal surfaces) vs.

Group II subgroup 2 (dental chair) - Group III subgroup I (working bench) vs.

Group III subgroup 2 (floor). - Group II subgroup 1 (metal surfaces) vs.

All subgroups of group I.

Mean values + standard deviation Subgroup

Group I Group II Group III

1 9 + 1.64 40.1+ 4.8 24.5 +4.8

2 7.1 + 2.8 25 + 4.4 34.9 + 4.3

3 12.8+2.8 90 + 20.98 35.8 + 4.9



- Group II subgroup 2 (dental chair) vs. All subgroups of group I.

- All subgroups of group I vs. All subgroup of Group III.

- Group II subgroup 2 (dental chair) vs. group III subgroup 2 (floor)

- Group II subgroup 1 (metal surfaces) vs. group III subgroup 1 (working bench).

� There were highly significant differences (LSD 0.05 = 25.161) between: - Group II subgroup I (metal surfaces) vs. All

subgroup I. � There were very highly significant differences (LSD 0.01=33.338) between. - Group II subgroup 3 (wet surfaces) vs. All the other subgroups. DISCUSSION

Exposure to Hg in dental clinic has been recognized as a potential health hazard to patient and dental personnel for many years. (5) Ferracane et al concluded that concluded that Hg remained in vapor for only limited period, because of its density and affinity for surfaces. (9) Grayower et al prescribed the metal backing for x-ray film as an excellent material for removing Hg spills. (11)

In this study, the interaction of tin in the metal backing for x-ray film with Hg spills on different surfaces of dental clinic had been investigated. The results showed a clear difference in time of interaction between Hg spills and the tin in the metal backing for dental x-ray film. These findings attributed to the differences in surfaces. Every surface has a surface energy differs from the other. The spreading of Hg to any surface is a result of balance between the interfacial energies. The difference in spreading of Hg spills resulted in differences in the surface area in contact with the metal backing for x-ray film. This mechanical contact required to rupture the oxide layer that covers the metal backing for x-ray film. This oxide layer prevents the reaction of tin with Hg. Group I (protective surfaces) the Hg spills showed spreading to these surfaces, therefore a large surface area of Hg spills were in contact with the metal backing for x-ray film and resulted in the faster interaction. Group II (dental) instrument and equipment). The Hg spills showed less spreading to these surfaces. In group II subgroup3 (wet surfaces)

the water affect the mechanical contact between the Hg spills and the metal backing for x-ray film, thus resulted in the slowest interaction (90.3 + 20.981 sec.) Group III (other clinical surfaces), the Hg spills spreading was less than in group I and a slower interactions were recorded. Furthermore, the interaction of Hg spills with tin in the metal backing for x-ray film was faster than in group II subgroup 3 (wet surface) since there was no water to affect the mechanical contact between the Hg spills and the metal backing for x-ray film. This mechanical contact was absent in group III subgroup 3 (the crevis of the carpet) therefore the Hg spills didn't adsorb to the metal backing for x-ray film. Clinical Implication - Dental protective surfaces (gloves, dental mask and dental apron) are very effective in preventing occupational hazard with Hg, since Hg showed affinity to these surfaces, but they should be changed or decontaminated frequently. - It is better to dry a wet surface before being decontaminated. - It is better to avoid carpeting in the dental clinical.

Figure 2: Adsorption of Hg spill to the metal backing for x-ray film.

Figure 3: Bar chart shows the differences in means between groups and subgroups

0

2 0

4 0

6 0

8 0

1 0 0

1 2 3 4 5 6 7 8 9

1سلسلة

Tim

e in

seco

nds



REFERENCES 1. Craig RG, Marcus L. Restorative dental materials, 10

th ed.St. Louis: Mosby 1997; Ch9:209-243. 2. Cotton FA, Wilkinson G. Advanced inorganic

Chemistry, 4th ed. John Wiley & Sons, 1980; Ch. 15, 19: 493-501, 589-616.

3. Market JR. Dental amalgam and mercury. J Am Dent Assoc 1991; 122: 34.

4. Eames WB, Gaspar JD, Mohler HC. The mercury enigma in dentistry. J Am Dent Assoc, 1976; 92: 1199-203.

5. Sturdevant CM, Roberson TM, Heymann HO, Sturdevent JR. The art and science of operative dentistry, 3rd ed. St. Louis: Mosby 1995; Ch 6: 206-87.

6. ADA council on scientific Affairs. Dental amalgam: UP date on safety concerns. J Am Dent Assoc 1998; 129 (5): 494-503.

7. Langan DC, Fan PL, Hoos AA. The use of mercury in dentistry. Critical review of the recent literature. J Am Dent Assoc, 1987; 115 (12): 867-80.

8. Abraham JE. The effect of dental amalgam restoration on blood mercury levels. J Dent Res 1984; 63:71.

9. Ferracane JL, Engle JH, Okabe J, Mitchem JC. Reduction in operative mercury level. Am J Dent 1994; 7(2):103-7.

10. Grajower R, Mann J, Lewistein I. Mercury contamination removed with tin foil. Operative Dentistry 1984; 9: 101-4.

11. Mitchell DA, Mitchell L. Oxford Hand book of clinical dentistry 2nd ed. Oxford University press 1997; Ch 16: 712-738.

12. Johnson LB. Comparative rates of amalgam formation from tin, silver, and dental alloy powder. Journal of Dent Res 1967; 46: 753.


J College Dentistry Vol. 17(2) 2005 Strength, Hardness…

Strength, hardness, corrosion evaluation and computer-aided designing of cobalt–-chromium molybdenum

maxillary major connectors: part II Nadira A Hatim B.D.S., M.Sc. (1)

Ahmed A Al–Ali B.D.S., M.Sc. (1)

ABSTRACT Background: Computers have been applied for information processing in medicine and dentistry. This study was to design a special computer program that helps the dentist to select, and design a proper maxillary major connector made of different types of materials with minimum dimensions and adequate mechanical properties. Materials and methods: A special computer program was performed to select suitable dimensions of maxillary major connectors. The computer program was performed according to two principles related to transverse strength and distortion of 48 specimens of maxillary major connector of two different dimensions (Width and thickness) and materials (cobalt–chromium molybdenum in addition to other type) were prepared and tested in part I. Results: The formulated program (Run) showed a correlation results with the manual tests through linear curves analysis of load-deflection of transverse strength, and the proportional limits of each design of major connectors in relation to their width, length, and thickness. Conclusion: This program is applicable to all types and materials of major connectors, and the major connector should be with the minimum dimensions possible but compatible with the rigidity. Keywords: Strength, deformation major connectors, computer program. (J Coll Dentistry 2005; 17(2): 28-32)

INTRODUCTION

The objectives of RPD design have been well established. They include the restoration of function, enhancement of esthetic, and most importantly, the preservation of the remaining teeth and periodontal structures (1, 2).

The dentist is the only one who can make the proper decision involved in the treatment plan and design of a RPD. The technician can not decide what is biologically acceptable for a patient (3, 4)

Computers have been applied for information processing in medicine and dentistry (5- 7). Dental materials research already has capitalized on the capability to test materials on the computer versus by in vitro or in vivo methods (8, 9).

Lindquist et al. proved the effectiveness of computer–based removable partial denture design stimulators in a traditional removable partial denture design course for second–year dental students. (10)

The aim of this study was to design and perform a special computer program that helps the dentist to select, and design a proper maxillary major connector made of different types of materials with minimum dimensions (width and thickness), and adequate mechanical properties (transverse strength, proportional limit of metal), and correlate the results of computer with manual tests. (1) Assistant Professor, Department of Prosthodontics, College

of dentistry, University of Mosul.

MATERIALS AND METHODS

Forty eight cast single palatal strap major connectors (8 mm, and 4mm) antero-posterior width (at the midline), maximum thickness [22–gauge (0.6 mm)], and minimum thickness [24–gauge (0.4 mm)](11) of two Co–Cr–Mo dental casting alloys (Remanium, Dentaurum, Germany; and Biosil, Degussa, Germany) and two different casting techniques (induction and torch melting) were prepared as in Part I.

The transverse strength test of major connector is a part of ANSI/ADA specification No. 12 for denture base resins.(12) According to Ben–Ur et al forces in multiple of 5N were added, and the degree of distortion was measured as in part I. (13)

Computer program was designed to select suitable dimensions of maxillary major connectors according to the number of missing teeth, length of the saddle area, width of the dental arch and materials (Co-Cr-Mo, Ni-Cr, Type IV gold alloy, white gold, and commercially pure titanium) to be used. The computer program was based on two concepts:

The three points bending rule (12): 3 x load x length Stress= ----------------------------------------- 4 x width x (thickness)2

Proportional limit: The amount of stress that the major connector will be exposed to during mastication would be calculated to relate it to the proportional limit of the material used. It is clear that when the width and/or thickness of the major connector decreased, the rigidity of



the connector would be decreased, and the amount of stress induced inside the connector for a given load would be increased. In this program, dimensions would be decreased gradually and the stress induced would be calculated for every exchange in dimensions until reaching dimensions at which the stress induced during mastication is just below the proportional limit.

The result, thus, would be a major connector with minimum dimensions but it is still rigid and would not be deformed permanently during function. The input data would be the number of missing teeth, the width of the arch and the length of the saddle area.

Load was estimated to be 20 N on each missing tooth (14). The program was written by QUIC BASIC language and can be translated to any other language.

S : stress induced

N : missing teeth number

W : dental arch widthL : saddle length

T : major connector thickness

M : proprtional limitCo- Cr-Mo : 710 MPa Ni-Cr : 690 MPa Type IV gold alloy : 493 MPa White gold : 462 MPa Commercially pure titanium : 480 MPa

Ti-6Al-4V alloys : 825MPa Computer Program: 10 REM DETERMINE MAJOR CONNECTOR DIMENSIONS 20 INPUT N, W, L, M 30 T=0.5 40 S=30*N*W/ (((L-1)*(T^2)) + ((T+0.5) ^2)) 50 IF S>= M THEN 110 60 L=L-1 70 S=30*N*W/ (((L-1)*(T^2)) + ((T+0.5) ^2)) 80 IF S< M THEN 60 90 PRINT “WIDTH OF CONNECTOR IS:”L+1 “THICKNESS OF CONNECTOR IS:” T 100 GOTO 130 110 T=T+0.1 120 GOTO 40 130 END

Data were analyzed statistically using histogram analysis of transverse strength interaction between product, casting technique,

width, and thickness, of major connector. Application of computer program analysis by liner curves. RESULTS

Mean of transverse strength for product type, casting technique, width, and thickness from part I were analyzed and shown in Table (1) and figure (1-3).

A computer program was formulated to calculate the amount of deformation occurs for each applied load to compare the results with those obtained by the engineering test equipment. The program was based on a rule presented by Craig (1997) (12)

Load x Length ³ Deformation =

4 x Elastic Modulus x Width x Thickness³

Linear curves characterized each load-

deflection diagram were obtained where the slopes represented the stiffness of the major connectors and the termination of the curves represented the proportional limits (Figures 4-9). DISCUSSION

Computer program based on the results of transverse strength test shown in Tables (1), figures (1-3). It is evident how the width and thickness of the major connector play an essential role in its rigidity and even a slight change in width or thickness affects the rigidity. At the same time, it is obvious that the major connector or the RPD should be as simple as possible and covers as small area as possible and does not change natural contour inside the oral cavity by increasing the thickness.

As a result (Figure 4, 5, 6, and 7) of the mechanical test of transverse strength and (Figure 8,9) of program application of the major connector should be with the minimum dimensions possible but compatible with the rigidity, which is a major requirement of the major connector, and this is the goal of this program.(5,14)

This program is applicable to all types of maxillary major connectors except the U-shaped and antero-posterior major connectors.

From both the patient’s standpoint, and mechanical standpoint, the U-shaped major connector is the least desirable of maxillary



major connectors. It should never be used arbitrarily. When a large inoperable palatal torus exists that extend beyond the junction of soft and hard palate and occasionally when several anterior teeth are to be replaced, the U-shaped design may have to be used (11).

0102030405060708090

Remanium Biosil

4mm width 8mm width

T

The posterior palatal strap with an increased width has comparable rigidity and may be a reasonable alternative to the anteroposterior bar (14).

Thus, if we exclude these two designs, the program would be applicable to almost all clinical cases. So, because many dentists and technicians design major connectors with random dimensions, and this is not acceptable neither mechanically nor biologically, this program may be a good tool to help them to choose the proper dimensions (width and thickness) and a preferable materials of major connector for their designs.

Figure 2: Effect of interaction between product and width on transverse strength of

major connector

01 02 03 04 05 06 07 08 09 0

R em anium B io s il

0 .4 m m T hic knes s 0 .6 m m T hic knes s

Tran

sver

seIt should be mentioned that the idea of this

program and its formula is exclusively belong to the author and his supervisor, and this program is part of an ongoing work and can be considered a good basis for further development.

Figure 3: Effect of interaction between

product and thickness on transverse strength of major connector

Table 1: Mean and standard deviation of

product, technique, width, and thickness for transverse strength test.

Mean (N/in)

Standard Deviation

Remanium 61.5000 35.1879 Product Biosil 51.2500 26.3443

Induction 59.4444 31.8148 Technique Torch 54.4444 31.9956 4 38.7500 16.2354 Width

(mm ) 8 71.5000 33.6859 0.4(24-gauge) 29.3750 12.0066 Thickness

( mm)

Figure 4: Computer program application of load deflection diagram for Remanium

product 0.6(22-gauge) 79.0000 24.2970

Ind uc tio n T o rc h

0

10

20

30

40

50

60

70

Tran

ser

se

R emanium Bio s il

Figure 1: Effect of interaction between product and casting technique on transverse

strength of major connector

Figure 5: Computer program application of load deflection diagram for Biosil product



Figure 6: Load deflection diagram for

Remanium product, induction technique

Figure 8: Load deflection diagram for Remanium product, torch technique.

Figure 7: Load deflection diagram for Biosil

product, induction technique Figure 9: Load deflection diagram for Biosil

product, torch technique..

REFE1- Grant AA, Johnson W. An introduction to removable

chill Livingstone, 1986; pp

5-

7-

M.Sc. Thesis College of Dentistry University of Mosul.

8-

9-

RENCES denture prosthesis. Chur106-10,124-6.

2- Sadig WM, Idowu AT. Removable partial denture design: A study of a selected population in Saudi Arabia. J Contemporary Dent Practice 2002; 3(4):1-10.

3- Marris AL, Bahannan HM, Casullo DP. The dental specialties in general practice. W.D. Saunders Company, Philadelphia.1983; p 537.

4- Hatim NA, Al-Jarah RA, Al-Qaddo. Examination, diagnostic chart, and computer aided diagnosis of partially edentulous patients. Al-Rafid DJ 2001; 2: 93-103. Lechner SK, Lechner KM, Thomas GA. Evaluation of a computer-aided program in removable partial denture framework designing. J Prosthodont 1999; 8(2):100-5.

6- Oliveira AE, De Almedia SM, Paganini GA, Neto FH, Poscolo FN. A comparative study of two digital radiographic storage phosphor system. Braz Dent J 2000; 11(2):111-6. Jawad IA. Determination of occlusal plane in completely edentulous patients by computerized cephalometric method. A comparative study.2003;

Sertgoz A. Element analysis study of the effect of superstructure material on stress distribution in an

implant supported fixed prosthesis. Int J Prosthodont 1997; 10(1): 19-27. Al-Izzi TA, Ibrahim IK. Measurement of /s/closest speaking space by computer analysis. Iraq J Oral Dent Science 2003; 2 (1): 23-30

10- Lindquist TJ, Clancy JM, Johnson LA, Wiebelt FJ. Effectiveness of computer–aided removable partial denture design. J Prosthet Dent 1997; 6(2): 122-7.

11- McGivney GP, Castleberry DJ. McCracken’s Removable Partial Prosthodontics. 9th Ed. The CV Mosby Co, St Louis. 1995; Pp: 22-62, 367-402.

12- Craig RG. Restorative Dental Materials. 10th Ed. The CV Mosby Co, St Louis. 1997; Pp: 73-74, 86-90, 449-51.

13- Ben–Ur Z, Matalon S, Aviv I, Cardsh HS. Rigidity of major connectors when subjected to bending and torsion forces. J Prosthet Dent 1989; 62: 557-562.

14- Eto M, Wakabayashi N, Ohama T. Finite element analysis of deflection in major connectors for maxillary RPDs. Int J Prosthodont 2002; 15: 433-438.


J College Dentistry Vol. 17(2) 2005 Quantitative analysis of ….

Quantitative analysis of trace elements in saliva of oral cancer patients from Iraq

Natheer H. Al-Rawi, B.D.S, M.Sc, Ph.D (1)

Nazar G. A. Talabani, B.D.S, PhD (2)

ABSTRACT Background: Trace elements like iron, zinc, magnesium, cobalt and manganese are some of these elements involved in antioxidant defense mechanism. Many authors observed direct association between trace elements deficiency and the cancer mortality. The study was conducted to measure levels of Zinc (Zn), Copper (Cu), Iron (Fe), Manganese (Mn), Cobalt (Co), Nickel (Ni), Chromium (Cr), Cadmium (Cd), and Magnesium (Mg) in saliva of 50 patients with histologically proved squamous cell carcinoma. Patient and Method: Unstimulated (resting) saliva was collected from oral cancer patients one day before surgical excision of the tumor and one day after surgery using plastic polyethylene tubes. The collected saliva was cold centrifuged at 2500 rpm for 10 minutes at 0-5°C.The centrifuged supernatants were stored frozen at (-20°C) until time of analysis using Atomic Absorption Spectrophotometer. Results: Saliva levels of Zn, Mn, Co and Ni were significantly higher in preoperative saliva of oral cancer patients when compared to the normal control. On the other hand, a highly significant reduction in the levels of Cu, Fe and Mg was observed in preoperative saliva of oral cancer patients. However, no significant changes were seen in saliva trace element levels when preoperative values were compared with postoperative values of same patients. Conclusion: Saliva may be employed alone for trace elements measurements or it can be used supplementary to serum test for confirmation of any finding. However, saliva has the advantage of easy collection without trauma to the patients. Keywords: Trace elements, saliva, oral cancer. (J Coll Dentistry 2005;17(2):32-35)

INTRODUCTION

Saliva is a glandular secretion that constantly bathes the teeth and oral mucosa. It is formed by secretion of 3 paired major salivary glands (parotid, submandibular and sublingual) together with minor salivary glands. Most molecules found in blood and urine are found in saliva but at lower concentration (1). Therefore, saliva has been used to monitor levels of various materials like nitrite levels in patients with GIT cancer

(2), endogenous materials as antibodies (e.g.,IgA) in nasopharyngeal carcinoma (3), immunoglobulins in lymphomas (4). DNA has also been studied in the cellular content of saliva (5,6). Trace elements are recognized as versatile anticarcinogenic agents. Several biological mechanisms have been proposed to explain how trace elements could reduce the incidence of a number of different cancers. Koyama in 1996 have proposed the mechanisms involved which include: the antioxidant potential of trace element dependent enzyme system; induction of metallothionien, effect on immune response, DNA repair system, alteration of carcinogen metabolism and apoptosis of the initiated cells. (7)

(1) Assistant professor, Department of Oral Diagnosis,

College of Dentistry, Baghdad University

(2) Professor, Dean of College of Dentistry, Baghdad University.

Many authors observed direct association between trace elements deficiency and the cancer mortality (8-10).Abdula et.al. in 1978 reported a decrease in blood Zn and Cu in the sera of patients with head and neck tumors. (11) Vyas et.al. in 1982 reported an elevation in the serum Zn andCo levels of different malignancies. (12) An elevation in serum Cu levels in oral cancer patients receiving radiotherapy and/or chemotherapy has been observed by Sassidharam et.al.(13) .An attempt has been made to assess serum Cu and Zn levels in premalignant and malignant lesions of the oral cavity was done by Varghess et.al

(14) .They found a significant reduction in serum Cu and Zn levels in both oral submucous fibrosis and oral cancer ,whereas the Cu/Zn ratio was found to be elevated in oral submucous fibrosis and depressed in oral cancer.

In the present investigation, the levels of trace elements in saliva of oral cancer patients are studied. PATIENTS AND METHODS Patients:

Saliva levels of Zn, Cu, Fe, Co, Ni, Cr, Cd,Mn andMg were measured in 50 patients with oral squamous cell carcinoma one day prior to surgical excision of the tumor and one

Oral Pathology, Oral Medicine, Dental Radiology 32


day after surgery. Fifty age and sex matched healthy individuals were used as control. Saliva collection

Unstimulated (resting) saliva was collected after the patient rinsed out his mouth with water. The first mouthful of saliva is collected into small plastic polyethylene tube. The collection period was 20 minutes and the sampling time was always between 9-11 A.M. The collected saliva was cold centrifuged at 2500 rpm for 10 minutes at 0-5ºC. The centrifuged supernatants were stored frozen at (-20ºC) until time of analysis. Instruments

Perkin-Elmer (USA) Atomic Absorption Spectrophotometer model 305B fitted with Nitrous oxide acetylene burner head. Hollow cathode lamps were used as radiation emission source for Zn, Cu, Fe, Ni, Co, Cd, Cr, Mn and Mg. Absorption was measured in a Fuel-rich flame to obtain maximum sensitivity. RESULTS

Data recovered from saliva of oral cancer patients were compared with that of control

group (Table 1) and preoperative data was compared with postoperative data (Table2).

Saliva levels of Zn, Co, Ni, and Mn were significantly higher in preoperative saliva of oral cancer patients when compared to the control, whereas saliva levels of Fe, Cu, and Mg were significantly reduced (Table 2 and Figure 1). Pre andpost operative saliva levels of all trace elements assessed showed no significant difference except for saliva Cd levels which showed a significant increase in its levels postoperatively when compared to the levels measured preoperatively (Table 1). Moreover, Cu/Zn ratio was lower in preoperative saliva of oral cancer patients when compared with that calculated in saliva of normal control. However, postoperative saliva Cu/Zn ratio has recovered and showed a non-significant difference from that of the control (Table 3).

Applying paired t-test, a significant (p<0.05) increase in Cu/Zn ratio was noticed when comparing preoperative ratio with post operative ratio in saliva of oral cancer patients.(Table2).

Table 1: Mean concentration of trace elements in preoperative saliva of oral cancer patients and

saliva of normal subjects. Trace

elements Preoperative saliva Mean ±SD (ppm)

Normal saliva Mean ±SD (ppm)

P value

Zn 0.31± 0.05 0.19±0.04 <0.05 Cu 0.13± 0.09 0.23±0.1 <0.01 Fe 0.14± 0.03 0.31±0.07 <0.001 Co 0.15± 0.01 0.007±0.002 <0.001 Ni 0.17± 0.09 0.02±0.01 <0.001 Cr 0.03± 0.02 0.016±0.008 >0.05 Cd 0.01± 0.05 0.000 <0.001 Mn 0.05± 0.03 0.006± 0.003 <0.01 Mg 4.06± 1.06 9.46±2.07 <0.01 Cu/Zn 0.6± 0. 5 1.25±0.63 <0.05

Table 2: Mean concentration of trace elements in preoperative and postoperative saliva of oral

cancer patients (paired t-test). Trace elements Preoperative saliva

Mean ±SD (ppm) Postoperative saliva

Mean ±SD (ppm) P value

Zn 0.38± 0.28 0.16±0.2 >0.05 Cu 0.16± 0.06 0.097±0.06 >0.05 Fe 0.15± 0.07 0.19±0.03 >0.05 Co 0.16± 0.05 0.12±0.03 >0.05 Ni 0.19± 0.1 0.13±0.04 >0.05 Cr 0.03± 0.01 0.03± 0.01 >0.05 Cd 0.01± 0.001 0.03± 0.01 <0.05 Mn 0.06± 0.03 0.08± 0. 03 >0.05 Mg 4.08± 1.49 5.5±0.41 <0.05 Cu/Zn 0.6± 0. 5 1.2±0.6 <0.05



00.050.10.150.20.250.30.350.4

Zn Cu Fe Co Ni Cr Cd Mn

preoppostop

Figure 1: Mean concentration of trace elements in preoperative and postoperative saliva of oral

cancer patients

Table 3: Mean concentration of trace elements in postoperative saliva of oral cancer patients and saliva of normal subjects.

Trace elements Postoperative saliva

Mean ±SD (ppm) Normal saliva

Mean ±SD (ppm) P value

Zn 0.16± 0.29 0.19±0.04 <0.01 Cu 0.097± 0.06 0.23±0.1 <0.01 Fe 0.19± 0.03 0.31±0.07 <0.001 Co 0.12± 0.03 0.007±0.002 <0.001 Ni 0.13± 0.04 0.02±0.01 <0.001 Cr 0.03± 0.01 0.016±0.008 <0.05 Cd 0.03± 0.02 0.000 <0.001 Mn 0.08± 0.03 0.006± 0.003 <0.001 Mg 5.5± 0.4 9.46±2.07 <0.001 Cu/Zn 1.93± 1.6 1.25±0.63 <0.05

DISCUSSION

Saliva which can be easily collected may reflect a profile of trace elements of serum in both normal and cancer patients as well as other systemic conditions. The reduction in salivary Mg, Cu andFe contents in oral cancer patients may be explained on the basis that tumor cells and tissue have increased metabolic requirement of Mg which result in an increased uptake from adjacent structure such as glandular secretion, this suggestion may be proved true since a slight recovery of salivary Mg content was seen after surgical removal of tumor tissue. The higher levels of Mg, Cu andFe in saliva of oral cancer patients may be due to sequestration of these trace elements from cancer tissue to oral cavity, which is bathed by saliva. The increase in salivary Mn levels could reflect the activity of Mn against progression of carcinogenic process, since Mn is considered as an

anticarcinogenic element which is required for the activity of several enzymes such as Mn-SOD which have a role in the protection of mitochondria against oxidative damage (15).The changes in salivary Cu,Zn and Cu/Zn ratio in oral cancer patients in the present study are conspicuously similar to that reported in serum of patients with different types of cancers. Elevation of serum Cu andZn in colorectal cancer patients have been reported by Gupta, et.al (16) who suggested that serum Cu,Zn andCu/Zn ratio can have a value in estimation of the extent of the carcinoma and determination of their prognosis.

Results of the present study are comparable to some extent with a study of Jayadeep et.al (17) who measured serum levels of Cu/Zn ratio and Fe in patients with oral leukoplakia and oral squamous cell carcinoma. They found that Cu levels are significantly increased in leukoplakia and squamous cell



carcinoma. These authors also found that Cu/Zn ratio is significantly high in oral cancer and leukoplakia patients, whereas the present study revealed that Cu/Zn ratio in saliva is lower in oral cancer patients before surgical treatment.

From the results of the present investigation it can be concluded that the study of trace elements in the saliva may be used as a monitor for healthy and cancer patients. Saliva may be employed alone for trace elements measurements or it can be used supplementary to serum test for confirmation of any finding. However, saliva has the advantage of easy collection without trauma to the patients. REFERENCES 1. Slavkin H C. Protecting the mouth against microbial

infections. JADA 1998; 129: 1138-43. 2. Tenova J. The biochemistry of Nitrates,

Nitrosamines and other potential carcinogen in human saliva. J.Oral Pathol 1986; 15: 303-307.

3. Yao Q Y, Row M, Morgan A J, et al. Salivary IgA antibodies to the Epstein Barr virus glycoprotein gp340: Incidence and potential for virus neutralization. Int J Cancer 1991; 48: 45-50.

4. Meurman J H, Laine P, Kienanen S, et al. Five-year follow-up of saliva in-patients treated for lymphoma. Oral Surg Oral Pathol Oral Radiol Endod 1997; 83: 447-452.

5. Greenberg M S, Dubin G, Stewart J C, et al. Relationship of oral disease to the presence of CMV DNA in the saliva of AIDS patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79: 175-179.

6. Frides A , Coquous B. PCR DNA typing of stamps evaluation of DNA extraction. Forensic Sci Int 1996; 78: 103-110.

7. Koyama H. Trace elements: Mechanistic aspects of anticarcinogenic action. Nippon Rinshow 1996; 54 (1): 52-58.

8. Lalle S B, Singh B, Gulati K, et al. Role of nutrition in toxic injury. Ind J Exp Biol 1999; 37(2): 109-116.

9. Ames B N. Micronutrients prevent cancer and delay aging. Toxicol Let 1999; 28: 102-103.

10. Prasad A S, Beck F W, Doerr T D, et al. Nutritional and zinc status of head and neck cancer patients: an interpretive review. J Am Coll Nutr 1999; 17: 409-418.

11. Abdulla M, Biorkund A, Mathur A, et al. Zinc and copper levels in whole blood and plasma from patients with squamous cell carcinoma of head and neck. The role of zinc in experimental human oral cavity. 1978 University of Lund Publication.

12. Vyas R K, Gupta A P, Aeron A K. Serum Copper, Zinc, Magnesium and Calcium level in various human disease. Ind J Med Res 1982; 76: 301-304.

13. Sassidharan V K, Streekumar P, Vasudevan D M. Serum copper levels in-patients with carcinoma of oral cavity. Ind Med Gaz 1983; 47: 259-260.

14. Varghese I, Sugathan C K, Balasubramoniyan G,et al . Serum copper and zinc levels in premalignant and malignant lesions of the oral cavity. Oncology 1987; 44: 224-227.

15. De Rosa G, Keen CI, Hurley L E. Regulation of superoxide dismutase activity by dietary manganese. J Nutr 1980; 110: 795-804.

16. Gupta S K, Shulka V K, Vadya M P, et al. Serum and tissue trace elements in colorectal cancer. J Surg Oncol 1993; 52: 172-175.

17. Jayadeep A, Raveendran Pillai K, Kannan S, et al. Serum levels of copper, zinc, iron and ceruloplasmin in oral leukoplakia and squamous cell carcinoma. J Exp Clin Cancer Res 1997; 16: 295-300.


J College Dentistry Vol. 17(2) 2005 Clinical effect of low…

Clinical effect of low level laser therapy on healing of recurrent aphthous ulcer and oral ulceration in Behcet’s

disease Muhannad A. Kashmoola B.D.S., M.Sc., Ph.D (1)

Hadeel Salman B.D.S., M.Sc. (2) Mukaram M. Al-Waez M.B.Ch.B., Ph.D. (3)

ABSTRACT Background: As the exact etiology of recurrent aphthous ulcer (RAU) remains unknown, therapeutic measures are challenging and difficult. Low level laser therapy use in based on the concept that certain doses of specific wavelength can turn on or off certain cellular components or functions as well as aid in healing and reducing pain and swelling of oral lesions. The aim of this study was to evaluate the clinical effect of low energy Gallium-Arsenide semiconductor diode laser, 904 nm, on the healing process of recurrent aphthous ulceration and oral ulceration in Behcet’s disease. Patients and Methods: This study was performed on 47 patients, age range 12-58 years, with RAU lesions irradiated by laser into two doses (in alternative day), and divided into Control group: RAU patients without any treatment. Group one: RAU in Behcet’s disease irradiated with 1.5 Joule laser. Group two: RAU only, irradiated with 1.5 Joule laser. The results obtained account for duration of lesions, size measurement, pain symptoms, and presence of erythema in three visits. Results: It was shown that no difference in the healing process of RAU and oral ulcer in Behcet’s disease when compared with the control group after low level laser therapy, however when the lesion is less than 24 hours old, it was healed faster than control group. In addition to that, pain symptoms disappear soon after laser therapy, or it regains in low intensity. In RAU, healing process was reduced to a couple of days in initial stage of ulcer, however, a non significant clinical difference was observed on healing process of RAU and oral ulceration in Behcet’s disease after LLLT in comparison with non treated RAU lesions. There was no statistical significant difference on healing process of RAU and oral ulceration in Behcet’s disease after LLLT. Pain disappears soon after LLLT and this is temporary which recur in the next visit but in milder form. Conclusion: Dose and other parameters at which low level laser therapy (LLLT) is implemented influence effectiveness of the therapy Keywords: Aphthous, ulcer, Behcet, laser (J Coll Dentistry 2005; 17(2) 36-40)

INTRODUCTION Aphthous ulcers are among the most

common oral lesions in general population with a frequency of up to 20% and recurrence rates as high as 50%, with higher prevalence in high socio-economic classes. The ulcers, which usually occur on non keratinized oral mucosa, can cause considerable pain and may interfere with eating, speaking and swallowing. Clinically the lesions are confined to the oral mucosa and begin with prodromal burning any time from 2 to 48 hours before an ulcer appears. During this initial period a localized area of erythema develops. Within hours, small white papules form, ulcerates, and gradually enlarges over the next 48 to 72 hours. (1) Recurrent aphthous ulcer (RAU) is classified on the basis of ulcer size and number as minor, major and herpitiform. The cause of RAU is idiopathic in most patients. (1) Assistant professor, Department of Oral Diagnosis, College

of Dentistry, Baghdad University (2) Assistant lecturer, Department of Oral Diagnosis, College

of Dentistry, Baghdad University (3) Professor, Department of Dermatology, College of

Dentistry, Baghdad University

The most likely precipitating factors are local trauma and stress; other associated factors include nutritional deficiencies, food allergies, genetic predisposition, immune disorders, the use of certain medications, HIV infection and systemic diseases. (1,2,3) One of the systemic disease is Behcet′s disease, which is a complex, chronic, multisystem disease characterized by oral and genital aphthae, pustular vasculitis, cutaneous lesions and ocular, gastrointestinal and vascular manifestation. Virtually all patients with Behcet′s disease suffer recurrent aphthous ulceration which is one of the first-occurring major manifestations of Behcet′s disease and shows the highest mean recurrence rate and the longest mean duration period. (4,5)

The primary goals of therapy of RAU are relief of pain, reduction of ulcer duration and restoration of normal function. Current treatments are palliative and focused on pain reduction and accelerate healing process. (3,6) These factors necessitate the research of new methods of treatment without the use of



medicines. One of the most effective methods is physical therapy using a low intensity laser radiation. Dentists have been administering low level laser therapy (LLLT) to their patients as an aid in healing, reducing pain and swelling, and controlling oral infections for at least the past three decades. The research shows that LLLT works, but out of the thousands of studies that exist using LLLT, few represented good evidence-based research. It is virtually impossible to hurt a treatment site using LLLT, with the worst case scenario being that nothing happens after treatment.(7,8)

The oral aphthous ulceration is one of these mucous membrane diseases was treated by LLLT and many attempt was done to show the efficacy of certain dose of soft laser on the healing process. (9-11)

MATERIALS AND METHODS Materials: laser apparatus, which is GaAs infrared diode laser (optodent) with handpiece diode cap carrying the optic fiber beam for treatment of specific points of the oral cavity. The specifications of this device are listed in table 1.

Table 1: The specification of Optodent laser device:

Subjects: Forty seven patients were collected from the Behcet′s disease clinic at Baghdad teaching hospital and from private dental clinics at period (December 2003 -July 2004), only 35 gave analyzable data. All patients were informed about the nature of this treatment and their agreement was taken before laser irradiation. The patients were requested to refrain from the use of any medicaments throughout the trial.

Control group: similar in respect to age, sex, and ethnic with other groups. They were 12 patients with RAU only and should not have other systemic disease in which RAU is a part of its findings, and should not take any treatment or medications during the period of study.

The study sample consists of:The first group: included 12 patients of

Behcet′s disease and have typical RAU lesions. These patients fulfilled the ISG (international study group) criteria for diagnosis of Behcet′s disease. They were irradiated with continuos mode laser with energy 1.5 J (time: 5 min)

The second group: included 11 patients suffering from RAU only, they were otherwise healthy. They irradiated by continuous mode laser with energy 1.5 J (time: 5 min)

In each visit patients were examined clinically to evaluate healing process, duration and size of ulcers, presence of erythema around the lesions. Pain recorded as prescribed by patient himself. The recurrence rate of aphthosis at the same site after laser treatment was negligible. The irradiated groups were given two doses for each lesion in alternative day. The optic fiber end of laser device applied directly perpendicular to the ulcerative lesion in a manner does not traumatized the area (figure 1).

Data were collected, tabulated and statistically analyzed using Student’s T test, Z proportion test, ANOVA test ad Chi-Square. Non significance was considered when P> 0.05, significant, P≤0.05 and highly and significant P<0.01.

Figure 1: The end of the optic fiber of laser

device applied to ulcerative lesion. RESULTS Clinical observations:The Control Group:

The healing process was observed regarding to duration of ulcer, size (in millimeters), presence of pain, and presence of erythema in three session and this data is in table 2.The Study Groups :1) Group one: twelve Behcet’s disease patients with 20 RAU lesions were treated by

Type of laser Ga-As

Laser diode peak power 20 W. Laser diode average power 8 mW. Average power (in optic fiber) 5 mW. Wavelength 904 nm. Impulse width 200 nsec. Impulse frequency 3000 Hertz



1.5 J of laser, the mean duration of these lesions after two doses of laser irradiation was 5 ± 3.16 days, in two lesions (with less than 24 hours duration), signs and symptoms disappeared when irradiated by 1.5 J LLLT. The mean size of ulcer slightly reduced in second visit after one dose of laser irradiation but it is increased again in third visit after two doses of laser.

The pain sensation, about 17 lesions (85% of cases) experience pain relief soon after laser irradiation but this is temporary relief and pain regain but in low intensity in next visit (60%). The presence of erythema around the ulcerative lesion was decreased in second visit after one dose of laser irradiation (40%) and still the same percentage in third visit after second dose of laser irradiation.

2) Group two: twenty one RAU in 11 patients were irradiated by 1.5 J of laser. The mean duration of lesion after two doses of laser irradiation was 3.75± 3.89 days. The mean size of ulcer has been reduced. Five

lesions with duration less than 24 hours showed no signs and symptoms in second visit after irradiation by 1.5 J LLLT (fig. 2 a,b), while ulcerative lesions with duration more than 24 hours did not show any clinical changes. The pain sensation is disappearing soon after laser irradiation in 15 lesion (71.4% of cases) also this is a temporary relief and pain regain in low intensity in next visit (33.3%). The presence of erythema around the ulcer was decreased from 95.2% in first visit to 25% after two doses of laser irradiation.

Statistical analysis among different groups (tables 3) did not show any significant differences in duration and size in different groups (control, RAU in Behcet’s disease with 1.5 J laser irradiation, and RAU with 1.5 J laser irradiation) for each visit (first, second, and third) also there is no significant relation between the presence of pain and erythema in different groups in each visit except in pain in third visit.

Table 2: Statistical analysis of control group (RAU with out treatment) according to duration, size, pain and erythema.

Duration (days)

Size (mm) pain erythema

positive negative positive negative Visit Mean SD Mean SD No.% No.% No.% No.%

1st 5.58 5.28 3.08 2.64 11 91.70%

1 8.30%

10 83.30%

2 16.70%

2nd 6.67 6.18 2.92 2.39 6 50.00%

6 50.00%

7 58.30%

5 41.70%

3rd 5.83 3.12 1.67 1.03 0 0.00%

6 100.0%

1 16.6%

5 83.4%

p. value(1st & 2nd visit) NS NS p.value(2nd &3rd visit) NS HS p.value(1st & 3rd visit) HS NS

HS S

p.value(1st & 2nd visit) HS NS p.value(2nd &3rd visit) NS HS p.value(1st & 3rd visit) NS S

0.001 HS 0.003 HS

Table 3: Statistical analysis among different groups according to duration, size, pain and

erythema in third visit.

Duration (days) Size (mm) pain Erythema positive negative positive negative

Groups Mean SD Mean SD N % N % N % N % Control 5.83 3.13 1.76 1.03 0 0.0 6 100 1 20.0 5 80. Group-1 5.0 3.10 3.5 2.7 3 60.0 2 40.0 2 40.0 3 60.0 Group-2 3.75 3.89 1.85 1.56 2 16.7 10 83.3 3 25.0 9 75. P.value

Significance NS NS S NS



Figure 2a: Two lesions of RAU in lower lip of 12 years old male patient, with duration less

than 24 hours and size 1 mm for each.

Figure 2b: Same patient shows complete healing of RAU after two days of 1.5 Joule of

LLLT.

DISCUSSION

In present study, LLLT (Ga-As diode laser at 904 nm wavelength, continuos mode) was used, in treatment of RAU depending on its biomodulation effect (biostimulation or bioinhibition) which has been used clinically for pain reduction and wound healing (8,12-16).

The low energy laser stimulate DNA-RNA-protein system and rise mitotic activity of cell (17,18). This occur through modification of cellular homeostasis of the mitochondria promoting a cascade of events in the respiratory chain of cytochromes, cytochrome oxidase and flavin dehydrogenase that permit absorption of light (13,19), that lead to increase in mitochondrial content of ATP, transmembrane potential and pH and changes in ultrastructure of organelles. These changes in mitochondria promote cell division (12,20). This results in a rapid and more epithelialization and regeneration of mucous membrane in the area of the lesion (20,21).

Generally, the results showed that the mean duration of ulcer between different groups has no significant differences in all visits. This explain that laser radiation at dose 1.5 J in single dose or couple dose did not significantly affected the normal time of healing of RAU, same finding was reported by Howell et al (1988) who used He-Ne LLLT to treat RAU (9).

The variation in size and duration showed no significant differences between groups since laser therapy does not induce re-epithelialization and this agree with the findings of Mass et al,1993 (22), and disagree with Abd El-Sattar and Saudi, 2002 (10) who

stated a reduction in lesion size and duration after LLLT.

Pain sensation is the most important symptom in RAU and oral ulceration in Behcet’s disease patients. There was disappearance in pain sensation soon after laser irradiation in high percentage of lesions in two study groups, this mean LLLT can reduce the pain temporarily for few hours and the pain reappear but in mild intensity in some patients. This reduction in pain was also observed by Abd El-Sattar and Saudi (10).

The analgesic effect of laser irradiation have been explained by many studies as the restoration of the sodium pump necessary to maintain the negative resting potential of neuronal membranes (13,23). During inflammation, the normal resting potential of nerve fiber is decreased leading to hypersensitivity (13). LLLT inhibits a range of nociceptive signals arising from peripheral nerves including neuronal discharges elicited by chemical irritation of inflammation (13,24) because the laser light can increase the activity of the ATP-dependant Na-K pump and in this case laser increases the potential difference across the cell membrane moving the resting potential further from the firing threshold, thus, decreasing nerve endings sensitivity (23,25).

Erythema occurs due to inflammatory reaction and highly vascularization of the lesions (1,26). The clinical observation of erythematus halo around the ulcerative lesion was decreased in all cases of study groups. This is indicating a decrease in the inflammatory reaction in the ulcerative area. In other words, the inflammatory cell infiltration was less prominent (27, 28). But comparing these



two study groups with control group, the result shows no significant differences between them. The interpretation of controversial results in LLLT it was concluded that dose and other parameters at which LLLT is implemented influence effectiveness of the therapy (12, 14, 16,

29). However, the complexity of wound healing and vast biochemical mediators and cellular factors that modulate the process makes it unscientific to compare results when different lasers are used in the experiments along with varied tissue molecules like mucosa, different animal models, and different culture media.

REFERENCES

1. Greenberg M. Ulcerative, vesicular and bullous

lesions. Ch. 4. In Burket’s Oral Medicine, diagnosis and treatment. 10th. Edition, edit by Greenberg, M. and Glick M.; 2003; p. 50-84.

2. Scully C, Porter S. Recurrent aphthous stomatitis current concept, of aetiology, pathogenesis and management. J Oral Pathol Med 1989; 18: 21-27.

3. Barrons R. Treatment strategies for recurrent oral aphthous ulcers. Am J Health-Syst Pharm 2001; 58: 41-53.

4. Ghate J, Jorizzo J. Behcet’s disease and complex aphthosis. J Am Acad Dermatol 1999; 40: 1-18.

5. Ahn H, Kim M, Choi J, et al. A study on the effect of local factors on oral ulcers observed in Behcet’s disease. 9th international conference, on Behcet’s disease proceeding of 8th and 9th international conference on Behcet’s disease. 2001; p.286.

6. Kutcher M, Ludlow J, Samuelson A, et al. Evaluation of a bioadhesive device for the management of aphthous ulcers. J Am Dent Assoc 2001; 132: 368-76.

7. Korytnyy D. Experemintal invesigation of biological effect of Helium-Cadmium laser radiation. All USSR conf. on the use of lasers in medicine. Abstract book, Krasnoyarsk 1983; p. 189 (in Russian).

8. Myers T. The future of lasers in dentistry. Dent Clinics of North Amer 2000; 44: 971-80.

9. Howell R, Cohen D, Powell G, et al. The use of low energy laser therapy to treat aphthous ulcers. J Am Dent Assoc 1988; 119: 16-18.

10. Abd El-Sattar E, Saudi H. Comparative evaluation of low level laser therapy versus jogel in the treatment of RAU: a clinical and digital image analysis study. Official Journal of the Egypt Dent Assoc 2002; 48: 2227.

11. Convissar R. Laser palliation of oral manifestation of human immunodificiency virus infection. J Am Dent Assoc 2002; 133(5): 591-98.

12. Basford J. Laser therapy: scientific basis and clinical role. Orthopedics 1993; 16: 541-47.

13. Abt A. Biostimulation and photodynamic therapy. Ch. 17. In Laser in Dentistry. edit by Misrendino L.

and Pick R. Quintessence Publishing Co 1995; Inc., p. 247-57.

14. Catone G, Halusic J. Photobiology of laser in oral and maxillofacial surgery. Ch. 2, in Laser Application in Oral and Maxillofacial Surgery. First edition, Saunders company, Pensylvania. 1997; P.29- 43.

15. Karu T, Pyatibrate L.; Kalendo G. Photobiological modulation of cell attachment via cytochrome C oxidase. Photochem Photibiol Sci 2004; 3: 211-216.

16. Reddy G. Photobiological basis and clinical role of low intensity lasers in biology and medicine. J Clin Laser Med Surg 2004; 22(2): 141-50.

17. Pereira A, Edurado Cde P, Matson E, et al. Effect of low power laser irradiation on cell growth and procollagen synthesis of cultured fibroblasts. Lasers Surg Med 2002; 31 (4): 263-67.

18. Kreisler M, Christoffer A, et al. Effect of low level Ga-Al-As laser irradiation on the proliferation rate of human periodontal ligament fibroblasts. J Clin Periodontol 2003; 30(4): 353-58.

19. Smith K. The photobiological basis of low level laser radiation therapy. Laser Therapy 1991; 3: 19-24.

20. Prokhonchukov A, Pavlov A. Laser reflex diagnosis of periodontal diseases. Abstract Conf. (clinical and experimental use of lasers), Mosco 1987; p. 190-191.

21. Haas A, Isseroff R, Wheeland R, et al. Low energy He-Ne laser irradiation increase the motility of cultured human keratinocytes. J Invest Dermatol 1990; 94: 822-26.

22. Masse J, Landry R, Rochette C, et al. Effectiveness of soft laser treatment in periodontal surgery. Int Dent J 1993; 43: (2): 121-7.

23. Fangioni, Grosso, Vallino, et al. [Trattamento delle nevralgie trigeminali con laser di bassa potenza. Min Med 1984; P. 23-36] (OPTODENT).

24. Sato T, Kawatani M, Takeshige C, et al. Ga-Al-As laser irradiation inhibits neuronal activity associated with inflammation. Acupunct Electrotherm Res 1994; 19: 141-51.

25. Baxter D, Bell A, Allen J, et al. Low level laser therapy. Current clinical practice in Northern Ireland Physiotherapy 1994; 77: 171-8.

26. Sun A, Chla J, Chang Y, et al. Levamisole and chines medical herbs can modulate the serum interleukin-6 level in patients with RAU. J Oral Pathol Med 2003; 32: 206-14.

27. AL-Safi K. Effect of single and multiple laser radiation on wound healing in rats. M.Sc. thesis, College of Dentistry, Baghdad University 1991.

28. Latfullin I, Kovyazina S, Safiullina A. The immune status in patients with parodontal diseases under local irradiation by a He-Ne laser. Proc. Intern. Conf. (urgent problems of laser medicine and operative endoscopy), Moscow-Vidnoye. 1994; P.439-41.

29. Pick R. The use of laser for treatment of gingival disease. Oral and Maxillofac Surg Clinics of North Amer1997; 9: 1-19.


J College Dentistry Vol. 17(2) 2005 The value of fine …

The value of fine needle aspiration cytology in the diagnosis of oral and jaw lesions in patients with plasma cell dyscrasias

Bashar H. Abdullah, M.Sc., Ph. D.(1)

ABSTRACT Background: Fine needle aspiration cytology (FNAC) has been found to be very useful for the diagnosis of lesions as multiple myeloma (MM) and plasmacytomas in different parts of the body. The usefulness of such procedure has not yet been verified in the oral and maxillofacial region. This study was conducted to verify the value of FNAC in the diagnosis of oral and maxillofacial lesions in patients with plasma cell dyscrasias. Patients and methods: After clinical and radiological examination, FNAC was done by the use of 10 cc syringes with 22-23 gauge needles on 11 patients with lesions affecting the maxillofacial region. The smears stained with Leishman’s stain, to be examined microscopically. Results: Twenty eight patients were examined throughout 1.5 years period, 11 had soft tissue/or bone lesions affecting the maxillofacial region. 9 patients with MM and 2 had plasmacytoma. Of 9 patients with MM, the mandible was involved in 5 patients, 3 lesions affected the maxilla, and while in one patient the maxilla and mandible were both affected. Soft tissue lesions were seen in 6 patients. The results of FNAC showed that all lesions were due to involvement with myeloma cell infiltrates, with one exception of 2 osteolytic lesions which were due to odontogenic infection. Conclusion: FNAC is a very useful and safe procedure to diagnose different types of lesions affecting the oral cavity in patients with plasma cell dyscriasis. Keywords: Multiple myeloma, plasmacytoma, fine needle aspiration cytology. (J Coll Dentistry 2005; 17(2):41-44) INTRODUCTION

The plasma cell dyscrasias are a group of B cell neoplasms that have in common the expansion of a single clone of immunoglobulin-secreting cells and a resultant increase in serum level of a single homogenous immunoglobulin or its fragments. The homogenous immunoglobulin identified in the blood is often referred to as a component of the plasma dyscrasias are multiple myeloma (MM) and the localized plasmacytoma, other variants are the lymphoplasmacytic lymphoma, heavy-chain-disease, primary or immunocytic-associated amyloidosis and the monoclonal gammopathy of undetermined significance. Collectively, these disorders account for about 15% of deaths from malignant white cell disease, they are most common in middle-aged and elderly persons (1).

MM is characterized by the neoplastic proliferation of a single clone of bone marrow derived plasma cells. MM develops mainly multifocal endosteal lesions and rarely soft tissue masses. (1) Assistant Professor, Department of Oral Dagnosis, College of


Plasma cells growing within the bone marrow replace the normal haemtopoietic tissue and consequently expansion together with the release of different cytokines, including IL6 and IL1 by cells of tumor, or non-tumor origin may lead to the characteristic production of destructive lesions. Osteolytic bone lesions are usually the main cause of symptoms, namely pain, tenderness and numbness. Bone destruction may also cause hypercalcaemia and pathological fractures. Lesions are most common seen in vertebrae, ribs, skull and pelvis. In 70-90% of the cases, the jaw lesions seen as multiple sharply but not corticated (punched out) areas of radiolucency (2). Extramedullary plasmamcytoma (EMP) is a soft tissue malignant neoplasm composed of a monoclonal proliferation of plasma cells. The neoplastic cells display monocytic cytoplasmic immunoglobulin expression and absence of immature B cell antigen (3).

EMP may be primary or secondary to underlying MM. Both MM and EMP are not uncommonly manifested in the jaw bones. The clinical features of such involvement include osteolytic lesions, soft tissue masses, pain, parasthesia and amyloidosis (4,5,6). Although the incisional biopsy is the main stay for the diagnosis of bone or soft tissue lesions, many studies proved that FNAC is a



simple reproductive and reproducible and an accurate diagnostic procedure (7,8,9).

The value of this procedure as a diagnostic tool to distinguish different types of lesions that could affect the maxillofacial region has not been verified. Accordingly, clinical radiological and cytological examination was conducted in this study. PATIENTS AND METHODS

Eleven patients, 9 with MM and 2 with EMP in whom bone and/or soft tissue lesions were present in the maxillofacial region, were selected out of 28 known cases of MM, that were admitted to Baghdad Teaching Hospital, one and a half year period from 2000-Jun till Dec- 2001. The diagnosis of MM based on peripheral blood and bone marrow examination, urine and serum examination for the presence of Bence Johns proteins and serum protein electrophoresis.

Oral and maxillofacial region examination includes clinical and radiological examination, by OPG, oblique lateral and PA views. Any bony or soft tissue lesions were examined cytologically by the use of FNA to determine whether the lesion is infiltrated by myeloma cells or due to any other local condition which is not related to MM.

FNAC was done by the use of 10 cc disposable syringe, with 23-24 gauge needles. 2-4 smears were aspirated from each lesion. The smears were stained with Leishman’s stain. From cytomorphological point of view, the cellular elements in the bone marrow smears which were done as a routine diagnostic procedure were compared with oral smears. RESULTS

According to the criteria used for the diagnosis of the type of plasma cell dyscrasia, 9 patients had MM, while 2 had EMP. According to gender 4 were males, and 7 were females, with age range from 41-76 years with mean age of 58 year. Among the 9 patients with MM, the mandible was involved in 5 patients, while the maxilla in 3. In one patient both the maxilla and the mandible were involved with osteolytic lesion. Plasmacytoma was only seen in the mandible in two patients. Regarding the mode of presentation of the lesion, a maxillary palatal

mass was the only presenting feature of MM in one patient, in another 4 patients, the bone lesions were discovered on clinical and radiological examination and were not noticed by the patients. In the other 4 patients, the osteolytic lesions as well as the soft tissue lesions were part of the complaints. Apart from the lesions due to myeloma cell infiltrate, parasthesia of the lower lip was seen in 4 patients including the 2 patients with EMP. Resorption of the root of the teeth was a prominent feature being seen in 6 patients with bony lesions. The clinical features are summarized in this table (1). Table 1: The results of FNAC (bone and soft

tissue lesions) Clinical feature Site No. of cases

Maxilla 4 1. Osteolytic bone lesions Mandible 7 (2 EMP)

Maxilla 4 2. Soft tissue lesions Mandible 2 3. Parasthesia Lower lip 4 (2 EMP)

Maxillar 3 4. Root resorption Mandible 5 (2 EMP)

The total number of lesions seen in the 11 patients was 17, since more than one lesion was present in some patients, cytopathological examination of the aspirates taken from the soft tissue masses revealed myeloma cell infiltrate in all the cases. While aspirates from the osteolytic bone lesions showed also infiltrate of myeloma cell except 2 cases, in whom only neutrophils were seen due to odontohemic infection (periapical abscess). Morphologically, the myeloma cells seen in the smears were of 3 types: mature which are plasma cell like; blastic type (plasmablast) and an intermediate type between these 2 extremities.

This variation in the type of cells was similar to that seen in the bone marrow aspirates. Another cytomorpholgicall features noticed include binucleation, bizzar cells and even mitotic figures.

The technique of FNAC was proved to be safe, simple and reliable to diagnose different types of lesions in patients with plasma cell dyscrasias.



DISCUSSION REFERENCES The occurrence of oral and maxillofacial

lesions in patients with plasma cell dyscraisias was proved to be not uncommon complication in this study. Such complication could include soft tissue tumors, osteolytic bone lesions, parasthesia, pain, infection, resorption and mobility of the teeth and lastly amyloidosis. Apart from the last complication, all the other mentioned were observed in this study.

1- Kumar V, Cotran RC, Robbins S L. White cell disorder – Multiple myeloma and related plasma cell dyscrisias. Robbins Basic Pathology 2002; Saunders-Philadelphia. P. 428.

2- Andrikopoulous SA, Piperi E, Paikos S. Oral and maxillofacial manifestations of malignant haemopoitic and lymphoreticular disorders – Part IIB. Haema 2003; 6(1), 48-53.

3- Gnepp DR. Diagnostic surgical pathology of the head and neck.. Non squamous pathology of the larynx, hypopharynx and trachea- Extramedullary plasmacytoma 2001; W.B. Saunders Company. Philadelphia. 286-287. Osteolytic lesions of the mandible is

assumed to be more common than the maxilla in MM presumably due to the higher content of marrow in the former that the later (10). However, in this study, the affection of the mandible and maxilla were comparable, with simultaneous involvement of the skull in 4 patients.

4- Shibata M, Kodonai I, Doi R, et al. Multiple myeloma presenting symptoms in the oral and maxillofacial region. Yonago Acta Medica. 2003; 46: 77-81.

5- Lae ME, Vencio EF, Inwards CY, et al. Myeloma of the jaw bones: a clinico-pathologic study of 33 cases. Head and Neck 2003; May. 25(5): 373-81.

6- Millesi W, Enislidis G, Lindner A, et al.. Solitary plasmacytoma of the mandible – a combined approach for treatment and reconstruction. Int J Oral Maxillofac Surg 1997; Aug. 26(4): 295-8.

This study showed that both soft tissue tumors and bone lesions can be the presenting feature of MM or EMP, or can be seen during or throughout the course of the disease. Since the maxillofacial region is a common site for the occurrence of a vast number of lesions, it is essential to distinguish between the different cases of lesions which can be clinically and radiologically similar.

7- Mukunyadzi P, Bardalas RH, Wilson CS, et al. Soft tissue masses in patients with multiple myeloma: a fin needle aspiration study of 30 patients with flowcytometry and clinical correlation. Cancer 2001; Aug. 25; 93(4): 257-62.

8- Fernardez-Flores A, Fortez J, Smucler A, et al. Involvement of the liver by multiple myeloma nodular lesions: a case diagnosed by fine needle aspiration and immunocytochemistry. Diagn Cytopathol 2003; Nov. 29(5): 280-2. Biopsy is the orthodox method for the

diagnosis carrying with it all the risks of infection, bleeding and delayed healing. One alternative procedure in the use of FNAC, which is proved to be, useful, accurate and cost effective procedure in the diagnosis of different oral lesions due to varieties of pathological conditions (11,12). In MM FNC has been proved to be useful not as a diagnostic procedure only, but as a prognostic tool, by determining the grade of myeloma cell cytomorphologically, into low, intermediate and high grade myeloma (7). In this study, FNAC has been proved to be very effective diagnostic procedure to distinguish the cause of the lesion.

9- Pinto RG, Mandreker S, Vernekar JA. Multiple myeloma presenting as a subcutaneous nodule on the chest wall: diagnosis by fine needle aspiration. Acta Cytol 1997; Jul.Aug. 211(4): 1233-4.

10- Lee SH, Huang JJ, Pau WL, Chan CP. Gingival mass as the primary manifestation of multiple myeloma. Oral Surg Oral Med Oral Pathol. 1996; 82: 75-9.

11- Bardales RH, Baker SJ, Mukunyadzi P. Fine needle aspiration cytology findings in 21 cases of non-partotid lesions of the head. Diag Cytopathol 2000; Apr. 22(4): 211.

12- Chhieng DC, Cangiarella JF, Cohn JM. Fine needle aspiration cytology of lymphoproliferative lesions involving the major salivary glands. Am J Clin Pathol 2000; Apr. 113 (4): 563-71.

The value of FNAC was proved in different

body organs in MM, but studies concerning the maxillofacial lesions, is very scarce if ever existed. According to the results of this study, it is highly recommended to use FNAC to diagnose soft tissue and bone lesions in patients with plasma cell dyscrasias instead of taking a biopsy to avoid the possible complication and risk of the later and to win the advantages of the former.



1

3

2

4

Figure A: A patient with MM, (1)Sublingual mass (2) and (3) FNA smears showing sheets of myeloma cells (x 400 x1000 respectively). (4) X-ray showing osteolytic lesion in the body of the

mandible.

1

3 4

2

Figure B: A patient with MM, (1)Skull X-ray showing multiple osteolytic lesions (2) Palatal mass (3) and (4) FNA smears showing sheets of myeloma cells with a mitotic figure (x1000).

1

2

Figure C: A patient with solitary plasmacytoma, (1)FNA smear showing many myeloma cells some of them are binucleated (x 400) (2) OPG showing well demarcated radioluecency in the body of the

mandible with root resorption.


J College Dentistry Vol. 17(2) 2005 Evaluation of the efficacy …

Evaluation of the efficacy of alum suspension in treatment of recurrent ulcerative ulceration.

Tagreed S. ALtaei B.Sc., M.Sc.(1)

Raja H. AI-Jubouri B.D.S., M.Sc.(2) ABSTRACT Background: Recurrent aphthous ulceration or recurrent aphthous stomatitis is the most common oral mucosal disease known to human beings. Despite much clinical and research attention, the causes remain poorly understood, the ulcers are not preventable, and treatment is symptomatic. The most common presentation is minor recurrent aphthous stomatitis: recurrent, round, clearly defined, small, painful ulcers that heal in 10 to 14 days without scarring. Major recurrent aphthous ulcerative lesions are larger (greater than 5 mm), can last for 6 weeks or longer, and frequently scar. The third variety of recurrent aphthous stomatitis is herpetiform ulcers, which present as multiple small clusters of pinpoint lesions that can coalesce to form large irregular ulcers and last 7 to 10 days. Diagnosis of all varieties is usually made after clinical examination. Alum Potassium aluminum sulfate, or ammonium aluminum sulfate, used especially as an emetic, an astringent, and a styptic. Patients and Method: A sample of fifty two patients were included in this study. 28 female, 24 male, ages range 20-40 years. They all participated in a randomized double-blind placebo controlled study. Patients with RAU were separated in to 5 groups, and these were treated with 1, 3, 5, 7 % of alum suspension, and placebo, applied topically four times daily, for five days treatment. Patients response to treatment was determined by; clinical evaluation of subjective treatment response, duration of lesion healing. Results: Statistical analysis of the effect on healing time of the three concentrations of the drug (3, 5, 7) had a significant reduction in the time required for complete healing of the ulcer compared with placebo group. Conclusions: Alum shortened the duration of healing on RAU with lack of any side effects. Keywords: Alum RAU, (J Coll Dentistry 2005; 17(2):45-48) INTRODUCTION

Recurrent aphthous ulceration (RAU) is acute painful recurring mouth ulcers usually involving non keratinized oral mucosa. (1) It is the most common oral mucosal disease affecting humans and has been reported as affecting 20-25 % of the general population at any time. (2,3)

The cause of RAU is incompletely understood but appears to involve immune system dysfunction. (4) Analysis of the peripheral T lymphocytes in patients with aphthae shows a decreased ratio of T-helper (CD4+) cells to T-suppressor / cytotoxic (CD8+) cells. Evidence of the destruction of the oral mucosa mediated by these lymphocytes is strong, but the initiating cause is elusive. (3)

The causative factors of RAU are unknown but are probably multifactor, with precipitating systemic, local, microbial, and genetic factors all being implicated as follows:

Allergies, genetic predisposition, hemato-logical abnormalities, hormonal influences, infectious agents, nutritional imbalances, trauma, stress, smoking cessation. (2- 5)

(1) Assistant professor, Department of Basic Sciences, College of

Dentistry. University of Baghdad. (2) Assistant professor, Department of Oral Diagnosis, College of

Dentistry. University of Baghdad.

Therapy for RAU includes; Topical antiseptic (Chlorhexidine gluconate mouth wash), topical analgesics (Benzydamine hydrochloride mouth wash), topical corticosteroids (Hydrocortisone, Triamcinolone, Betamethasone, Beclom-ethasone), topical antibiotic (Chlortetracycline mouth wash). The systemic therapy is Immunomodulators (Azathioprine, Colchicine, Cyclosporin, Thalidomide, and miscellaneous; (Cimetidine, Carbinoxolone, 5 amino-salicylic acid, Pentoxyphylline, low energy laser, Livamisole). (2,5-7)

The clinical features of RAU may be classified as minor, major, or herpitiform. Minor aphthous ulcers are the most common type, with prevalence in the general population of 5-25% and clinically manifesting as small shallow ulcers (<5 mm diameter). Lasting approximately 7-10 days and recurring 2-3 times a year. Major ulcers are larger and deeper (>10mm) can last up to 6 weeks, and may lead to scarring. Herpitiform ulcers are the least commons, characterized by multiple recurrent crops of small painful ulcers of 1-3 mm in diameter and distributed through out the oral cavity. (8)

Alum; potash alum, potassium aluminum sulphate KAL (SO4)2.12H2O. Its colorless, transparent, odorless, crystalline masses or granular powder with a sweetish astringent



taste. When heated it melts and at about 200º loses its water of crystallization with the formation of the anhydrous salt. It is soluble as 1 part in 7.5 parts of water, 1 in 0.3 of boiling water, and 1 in 3 of glycerol. A 10% solution in water has a pH of 3 to 3.5. A 6.35% solution is iso-osmotic with serum. (9)

Alum employed in the treatment of lead colic and as an emetic in the treatment of poisoning. A 1% to 4% solution is used as mouthwash or gargle in stomatitis and pharyngitis. Alum is either as a solid or as a solution may be used as touching with crystal of alum may treat a haemostatic for superficial abrasions, cuts and ulcers on the lips. (10)

Alum may be used as 0.5% irrigation in the treatment of leucorrhoea and it was used for the treatment of herpes simplex labialis. (11)

The aim of this study is to assess the effect of alum suspension on healing of RAU. PATIENTS AND METHODS

Fifty-two patients were included in our study, 28 females, 24 males; age range 20to 40 years. All patients had at least monthly episodes of oral lesions and most patients had continuous involvement. All oral and/or topical corticosteroids and antibiotics used as therapy for aphthous stomatitis were discontinued and avoided during the study. A detailed history was taken for each patient particular attention was given to the frequency onset, duration and the associated degree of pain.

Clinical Examination Clinical examination of RAU was classified

according to the size as minor aphthae which were defined as those ulcers less than 5 mm in diameter (<5 mm in diameter) and major aphthae as those greater than 10mm (>5-10mm in diameter).

Each patient was randomly assigned 1, 3, 5, 7% suspension, at the early lesion four times daily for 3 consecutive days, then the patient reexamined at third day for determination of the response of treatment as follows; duration of lesions, patients self-evaluation of pain, size of lesions. RESULTS

The age distribution of the 52 patients participated in the study shows non-significant difference between males and females and the most affected age group was the early twenties (78%) This is presented in figure (1). In regard to the site distribution of RAU, it seems that females had more ulcers on the tongue and less lesions on the cheek than males. This is presented in figure (2 and 3).

The difference in the effect of the different concentration of drug on the healing time was non significant for 1% concentration and placebo, while significant for 3, 5, 7% concentration of alum suspension (Table 1).

The P value for the 5 different groups compared to placebo was significant in the ulcer size, pain, and healing (Table 2).

Pain disappeared after treatment with alum from the first day of treatment.

Figure 1: The age distribution in the (52) patients entering the study.

19

22

41

5 4

9

0 1 1 0 1 1

24

28

52

0

10

20

30

40

50

60

No.

20-24 25-29 30-34 35-40 Total

MaleFemaleTotal



4 5

9

1

11 12 11

5

16

7 8

15

86

14

31

35

66

0

10

20

30

40

50

60

70

No.

Sulcus tongue Cheek Upper lip Lower Lip Total

MaleFemaleTotal

Figure 2: The site distribution of RAU in relation to sex variation.

Table 1: The difference in the effect of the different conc.of drug on the healing with days

(alum concentration)

Groups No. of days No. of days % P-value Sig %

1% *6 12 4 25 0.124 NS3% 18 36 0 0 0.042 S**

5% 16 32 0 0 0.039 S 7% 10 20 0 0 0.032 S Placebo 0 0 12 75 0.127 NS

* 05 No nifican<0.05 S ifican

Table 2: The p-va ups with control

P-value Sig

P>0. n sig t **P ign t

l oue for different gr

Ulcer size 0.012 S*

Pain 0.002 S Healing 0.007 S

*P<0.05 ant DISCUSSION

anagement of RAU reflect ild and self-limiting, and

that

ine, or benzydamine can be effective. Also, mixtures of lidocaine, diphenhydramine, and Kaopectate may provide some relief. Other therapies that have been reported include hydrogen peroxide, phenol, silver nitrate, topical antimicrobials, antivirals, and antiseptic mouthwashes. These treatments are generally not very effective. The mainstay of treatment of RAU is topical steroid application. Triamcinolone 0.1% in a cream, paste or an aqueous base is the most commonly used. (12)

In this study alum show good healing for RAU and it’s significant, alum a colorless mixed salt provides a natural antibacterial action, contains no alcohol. It’s slightly

Signific

Goals in the mthat it is generally m

, currently, there is no treatment widely believed to be curative. Therefore, treatments that reduce pain and maintain function during attacks, or that reduce the severity and frequency of recurrent attacks, are considered successful. Treatments used for this generally benign disease should not be associated with more morbidity than the disease itself. Treatment options are those that either provides palliation or those that truly alter the course of the disease. Palliative medications are generally applied topically and are available over the counter. Preparations of benzocaine,

diclon



antiseptic, probably due to bacteriostasis through liberation of acid on hydrolysis. (9)

Astringent alum is locally applied protein precipitants, which have such low cell penetrability that the action is essentially limited to the cell surface and the interstitial spaces. The permeability of the cell membrane is reduced but cells remain viable.

The alum action is accompanied by contraction and wrinkling of the tissue and by blanching. The cement substance of the capillary endothelium is hardened, so that pathological trans-capillary movement of plas

of muc

the recurrent aph

mg

pathology oral

E. Oral and pany,

systemic therapy for recurrent

5- O

11- Hurt WC. Text Dent. J. 1971, Jan; 89 (1): 21-2.

ma protein is inhibited and local edema, inflammation and exudation are thereby reduced. (13, 14)

Mucous or other secretions may also be reduced, so that the affected area becomes drier. Therefore, alum reduce inflammation

ous membranes, promote healing. Also have the ability to interact with fatty acids librated or produced by action of bacteria on lipids and by an action suppressing bacterial growth, partly because of a decrease in pH.

By this mechanisms alum treat thous stomatitis. Our suggestion is to assess the effect of

other concentrations of alum and study the pharmacological evaluation, and study the effect of alum on other oral diseases.

REFERENCES 1- Greenberg MS. The efficacy and safety of 50

penicillin G potassium troches for recurrent aphthous ulcers. Oral surgery oral medicine oral radiology and endodontics 2003; 96: 6, 685-94.

2- Tyldesley’s oral medicine 5th Ed Anne field and Lesley longman. Oxford university press. 2003, chapter 5 oral ulceration.

3- Brad W, Douglas D, Carl M and Jerry Maxillofacial pathology by W.B. Saunders Com1995; chapter 9.

4- Macphil L. Topical and aphthous stomatitis. Semin Cutan Med Surg 1998; Dec.; 16 (4): 301-7. lson JA, Sol silverman, JR. Double-blind study of livamisole therapy in RAU. Journal of oral pathology 1978; 7: 393-9.

6- Revuz A. Crossover study of thalidomide vs. placebo in sever recurrent aphthous stomatitis. Arch Dermatol 1990; 126.

7- Edward A, Graykowski, Albert Kingman. Double-blind trial of tetracycline in recurrent aphthous ulceration. Journal of oral pathology 1978; 7: 376-82.

8- Ship JA, Chavez EM, Doeir PA, Henson BS, Sarmadi M. Recurrent aphthous stomatitis. Quintessence Int 2000; 31 (2): 95-112.

9- Gennaro AR. Astringents: Remington’s pharmaceutical science. Mack pub Co. Easton, Pennsylvania, 17 ed; 1985: 777.

10- Griffith: Martindale extrapharmacopea; 1989: 29.

12- Murray, N, Ulcerative Lesions of the Oral Cavity. American Academy of Otolaryngology Head and Neck Surgery Foundation, Inc. 2000.

13- Marriam- Webster Medical Dictionary, 2002. 14- WordNet R 1.6, 1997 Princeton University.


J College Dentistry Vol. 17(2) 2005 The interrelation of medical ..

The interrelation of medical history and temporomandibular joint disorders (TMD) in Iraqi

patients Wajnaa F. Qassim B. D. S. , M. Sc. (1)

ABSTRACT Background: Patients with a temporomandibular joint disorder generally are not subjected to an extensive examination of the entire body, but certain observations which are related mainly to diseases of the musculoskeletal system and nervous system should be taken into consideration. This study is to clear the relation of systemic medical status with temporomandibular disorders progression and vise versa. Materials and Method: this study was applied on 58 patients, 30 females and 28 males. The mean age was 35 years (range 19-63) years. All patients were complaining from temporomandibular disorder. Results: were recorded that most of temporomandibular disorder patients were clinically normal (48.4%), whereas patients subjected to stress form (34.3%) and only (17.3%) had different medical problems. The total male to female ratio nearly equal 1:1 with predominant age for both sexes was (20-29) years. Conclusion: temporomandibular joint was more prone to be affected by local factors, especially the stress relieving habit, than the systemic factors, but this will not preclude more comprehensive and sophisticated diagnostic process, to identify more hidden systemic causes of stress. Keywords: Temporomandibular Joint Disorders, etiology, risk factors (J Coll Dentistry 2005;17(2):49-52)

INTRODUCTION

Proper diagnosis is the key to successful therapy and the key to proper diagnosis is a thorough and accurate history and physical examination. The history should involve determining symptoms the patient has experienced that may or may not be linked to the present illness. Symptoms of stress, anxiety and depression which often are associated with psychosomatic disorders, also should be accented.(1)

The patient with a temporomandibular joint disorder (TMD) generally is not subjected to an extensive examination of the entire body, but certain observations which related mainly to diseases of the musculoskeletal system and nervous system should be taken into consideration.(2)Arthritis and connective tissue diseases are usually established from a detailed history and careful clinical examination. They are the most frequent systemic diseases that may involve temporomandibular joint (TMJ) as a form of polyarthritis or polyarthralgia.(3)Recently, Alstergren and Kopp,(4) found a frequently detectable level of prostaglandin E2 in synovial fluid of patients with TMJ inflammatory disorders that is related to TMJ allodynia. Al-Mobeerik,(5) demonstrated that TMJ was involved in early stages of rheumatoid arthritis whereas

(1) Assistant professor, Department of Oral Diagnosis, College

of Dentistry, Baghdad University

Winocur found a weak significant correlation

between the generalized joint laxity and temporomandibular joint hypermobility.(6) On the other hand, Fryzek showed no significant or large increase in risk of connective tissue diseases after finger and hand joint implants or TMJ implants in Danish. (7) It was obvious that environment play a similar role to that of genetics in development of temporomandibular disorder (TMD). Henry identified the presence of bacterial DNA in TMJ, which serves the pathognomic mechanism of TMJ inflammation. (8) He suggested that the internal derangement of the TMJ may occur as a result of a sexually acquired infection, after his isolation of two bacteria from the urogenital tract in the TMJ. Consequently, he found an increase in the frequency of serum antibodies to Chlamydia trachomatis in patients with internal derangement of the TMJ.(9)

This study was applied to focus on the relation ship between TMJ disorder and systemic diseases and to elucidate if there was a potential systemic effect which may accelerate or progress the TMJ disorder; also to determine the frequency of systemically compromised patients among Iraqi TMJ patients.

MATERIALS AND METHOD

This study was based on 58 patients (30 female and 28 male) with a mean age of 35 years and range (19-63). They were attended the oral medicine clinic in Dental College



Hospital of Baghdad University for treatment of temporomandibular disorders.

The TMJ examination chart was used to register the personal data, the general past history, that includes medical, past hospitalization, surgical, allergy, medication, psychological, occupational, social and family back ground, and the specific history related to the presenting complaint (onset + course). The medical history was reviewed for all body systems using medical history questionnaire (10). All patients underwent a standardized clinical examination of TMJ(1) which precede in an order, starting with the general body examination, the examination of the face followed by examination of the TMJ*, the muscles of mastication and associated cervical musculature, the dentition and other oral tissues, and finally, the remaining structures of the head and neck. *TMJ functions evaluation was involved: • TMJ pain and Joint sounds. • Maximum and comfortable inter

incisal distance. • Palpation of masticatory muscles. • Synchrony or clear deviation. • Chronic sublaxation. RESULTS

It is evident, in this study, that female was slightly more affected by TMD than male in the clinical sample and the highly affected patients are those in their 3rd decade of life, table –1.

The majority of TMJ patients (48.4%) in this study, had no signs or symptoms of any systemic diseases and they were appear clinically normal, this was confirmed statistically (P<0.01). The stress still form the highest frequency (34.3%) as a positive medical back ground of TMJ patients, (4.6%) of patients had different types of allergy, and (3.1%) associated with hypertension, table –2.

This distribution is coincident with that for the predominant age (20-29) years, represented in percentages of (61.3%) for clinically normal patients, (54.6%) for patients under stress and only (9%) with medical problems, (table –3). This table also reveals that the highest percentage of medically compromised patients is (27.3%) at the age group (50-59) years whom simultaneously show the lowest percentage of normal medical history (3.2%). The single affected joint showed high frequency in both patients with normal and compromised history.

While patients suffering from stress showed equal frequency of unilateral and bilateral TMJ involvement, table –4.

Table 1: Sample distribution according to patient’s age and gender.

Age groups Males Females Total10-19 - 1 1 20-29 16 15 31 30-39 2 3 5 40-49 5 6 11 50-59 2 3 5 60-69 3 2 5 total 28 30 58

Sum = 2031, Mean = 35.01, Standard deviation = 13.82

Table 2: Sample distribution and percentage

according to patients medical status Medical History No. of

patients Percentage

Normal 31 48.4 Cardiac dysrhythmia 1 1.6 Hypertension 2 3.1 Hypotension 1 1.6 Diabetes mellitus 1 1.6 Anemia 1 1.6 Allergy 3 4.6 Rheumatoid arthritis 1 1.6 Asthma 1 1.6 Stress 22 34.3 Total 64* 100.0

*6 Patients have combined positive history

Table 3: Distribution and percentage of patient’s medical status according to age

group Normal medical

history Medicallypatients

StressfulpatientsAge

groupsn. % n. % n. %

10-19 1 3.2 - - - - 20-29 19 61.3 1 9 12 54.630-39 2 6.5 2 18.2 1 4.5 40-49 5 16.1 3 27.3 4 18.250-59 1 3.2 3 27.3 4 18.260-69 3 9.7 2 18.2 1 4.5 Total 31 100.0 11 100.0 22 100.0

Chi-square =15.1 , d.f. =10 , p < 0.01 n= number of patients.

%= percentage.



Table 4: Unilateral and bilateral involvement of TMJ in relation to patient’s medical status

Medical status T

otal

no

. of

patie

nts

Patie

nts w

ith

unila

tera

l T

MJ

prob

lem

Perc

enta

ge

Patie

nts w

ith

bila

tera

l TM

J pr

oble

m

Perc

enta

ge

Normal 31 19 52.8 12 46.2Compromised status 9* 6 16.7 3 11.5

Stress 22 11 30.5 11 42.3Total 62 36 100.0 26 100.0Chi-square = 0.9 , d.f. = 2 , p < 0.01

*4 Patients have combined medical history.

DISCUSSION Historically, most TMD management has

been based on belief systems and testimonials according to the clinician’s favorite theory of causation. The common premise became that optimum health was dependent on very specific and precise morphologic criteria.(11)In the past, TMD have been identified as disturbances of function without consideration to the structure alterations that, according to biological laws, normally occur in association with dysfunction. Subsequently, Solberg discussed in his paper a realistic perspection, that TMJ problem was not merely a state of dysfunction but also involved organic changes.(12)

A morphologic variation without evidence of tissue pathology was actually be a developmental adaptation to any combination of intrinsic and extrinsic factors with the resulting functional equilibrium being the most physiologic relationship for that particular individual.(11)

Because TMDs are diverse and often multifactorial from an etiologic stand point, and with the knowledge that most signs and symptoms will not progress to more serious or long – term debilitating conditions(13), management requires a paradigm shift for most dentists to a biopsychosocial medical model. The mind –set change requires a shift from a singular approach, in which cause and effect is uncertain, variable and convoluted. In this study most of the patients gave a normal medical history, that print in mind that TMD is local problem associated with local disturbances rather than concomitant medical problem, a percentage of patients subjected to emotional stress was high for the total sample,

making sure that stress was represent the major causative factor for TMD, which agree with the results of Steed and Wexler.(14)

The ratio of patients with positive psychological history to medically compromised patients is 2:1.

Among the presented medical status, allergy represents the highest percentage (4.6%) that gives an idea about immunological back ground of TMJ problem in such patients.

The percentage of unilateral TMJ involvement (58.1%) is more than the bilateral involvement. This verify the local cause on the general or systemic cause which presumably be affected equally bilaterally.

Worthwhile to be mentioned here the systemic disease was well established in the age of (50-59) years whereas it didn’t well identified yet, the age before. On the other hand signs and symptoms of TMD increase with age, particularly during adolescence, until menopause, therefore TMDs that originate and reach the highest percentage during age (20-29) years, may be revert to the natural history of the disease itself, which agree with the results of Warren and Fried.(15)

The evolutionary process appears to be moving in the direction of a more comprehensive orofacial pain diagnostic process which based on elimination of the etiologic, contributing, and perpetuating factors that are responsible for the disease and localized dysfunction of the joint. However, causal therapy is not feasible, because the etiology and pathogenesis of TMJ degenerative diseases are not fully determined.(16)

REFERENCES 1. Sarnat B G, Laskin DM. The temporomadibular joint:

A biological basis for clinical practice, 4th ed. W. B. saunders company. 1992.

2. Springer PS, Greenberg MS. Temporomandibular Disorders. In: Burket L. W.: Oral medicine diagnosis and treatment, 9thed. J. B. Lippincott Company, Philadelphia, 1994.p.301-324.

3. Nuki G, Ralston SH, Luqmani R. Diseases of the connective tissues, joints and bones. In: Davidson: Principles and Practice of Medicine, 18th ed. Churchill Livngstone, 1999; p.801-876.

4. Alstergren P, Kopp S. Prostaglandin E2 in temporomandibular joint synovial fluid and its relation to pain and inflammatory disorders. J Oral Maxillofac Surg 2000; Feb;58(2):180-6; discussion 186-8.

5. Al-Mobeerik A et al. Experimental induction of rheumatoid arthritis in the temporomandibular joint of the guinea pig: A clinical and radiographic study.



Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84 (2).

6. Winocur E. Generalized joint laxity and its relation with oral habits and termporomadibular disorders in adolescent girls. J Oral Rehabil 2000; Jul; 27(7): 614-22.

7. Fryzek JP et al. Connective tissue disease and other related rheumatic conditions among patients with finger and hand and temporomandibular joint prostheses in Denmark. J Rheumatol 2000; Jun; 27(6): 1434-6.

8. Henry CH et al. Reactive arthritis: preliminary microbiologic analysis of the human temporomandibular joint. J Oral Maxillo-Facial Surg 2000; Oct; 58(10): 1137 -42.

9. Henry CH, Pitta MC, Wolford LM. Frequency of chlamydial antibodies in patients with internal derangement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2001; Mar;91(3):287-92.

10. Little J W, Falace DA, Miller GS, Khodus NL. Health questionnaire in use at the University of Kentucky College of Dentistry. In: Dental

management of the medically compromised patient, 5th ed. Mosby 1997.p.80-81.

11. McNeill C. History and evolution of TMD concepts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83 (1) 51-60.

12. Solberg WK. Temporomandibular disorders: clinical significance of TMJ changes. British dental journal 1986; 5: 231-6.

13. Boering G, Stegenga B, de Bont LGM. Clinical signs of TMJ osteoarthrosis and internal derangement 30-years after non – surgical treatment. J Orofacial Pain 1994; 8, 18-24.

14. Steed PA, Wexler G B. Temporomandibular disorders -traumatic etiology versus nontraumatic etiology: a clinical and methodological inquiry into symptomatology and treatment outcomes. Cranio 2001; Jul;19(3):188-94.

15. Warren MP, Fried JL. Temporomandibular disorders and hormones in women. Cells Tissues Organs 2001; 169 (3):187-92.

16. De Bont et al. Epidemiology and natural progression of articular temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83(1): 72-76.


J College Dentistry Vol. 17(2) 2005 Histological changes …

Histological changes in tongue of rabbits with iron deficiency state

Ban Abd – Al Ghani, B.D.S., M.Sc.(1)

ABSTRACT Background: Many oral symptoms can be contributed to iron deficient state. The present study was designed to show the effect of iron deficiency in histological feature of tongue. Materials and methods: Fifteen rabbits were used, 9 of them were given carrot only for duration of 2 months, they represent experimental group. Six of fifteen of rabbits were given normal food with all nutrient and vitamin supplement, for 2 months duration too, they represent the control group. Results: The result shows histological changes in tongue including atrophy and depapillation of experimental group. Conclusion: Iron element is important in epithelization of tongue and to keep tongue healthy. Keywords: Iron deficiency, tongue. (J Coll Dentistry 2005; 17(2):53-55)

INTRODUCTION

Iron deficiency represents a public health recognized throughout the world. It can trigger a wide range of mucocutaneous alteration resulted to a pathological condition. (1)

Many oral symptoms can be contributed to iron deficient state. Patients with iron deficiency complain of sore tongue especially when eating hot or spicy foods. On clinical examination they may not reveal any obvious abnormality although in long standing cases mucosal atrophy is apparent 2, smooth tongue, (3) swelling of the tongue with papillary atrophy and surface ulcerations are also possible in most deficiency states. (4) In severe cases of iron deficiency a carcinogenic states can be reported. (5)


Fifteen albino male rabbits had been used in this study. Six of them were given normal food as contain all the nutrients and vitamins, they represented the control group. While the other nine rabbits were given only carrot, they represented the experimental group. Serum iron level were estimated at beginning of study (day 0) and after 2 months.

Tongue biopsies were taken from control group and experimental group after 2 months for histological evaluation by using hematoxlin and eosin stain and observed under light microscope. (6)

(1) Assistant professor, Department of Oral Diagnosis, College of

Dentistry, University of Baghdad

RESULTS

The present result shows that serum iron level for both control and experimental group at day 0 is within normal range (80–85 μg/dl). After 2 months of the study serum iron level for control group shows to be within its normal range (75–80 μg/dl). While serum iron level of experimental group shows to be low, range (45–50 μg/dl), which represents an iron deficient state. Histological features of the tongue of control group rabbits show normal papillae, filiform and fungiform (fig 1 and 2). The papillae are covered with keratinized epithelium (fig 3). Histological features of the tongue of experimental group of rabbits (rabbits with iron deficiency) show depapillated tongue, smooth and atrophy of filiform and fungiform papillae (fig 4 and 5). Fig. 6 shows high magnification of papillae of experimental rabbit. The papillae lack keratinization and with laceration of the epithelium. DISCUSSION

The normal histological feature of the tongue shows numerous fine pointed cone shaped papillae named as filiform papillae while other form as a mushroom – shaped, round papillae called fungiform papillae. These papillae are keratinized epithelium structures containing a core of a connective tissue. The connective tissue contains blood vessels which gives nourishment to epithelia cell. (6)

In the present study, nutritional iron deficiency caused decrease in production of normal red blood cells which led to decrease in



nourishment to epithelium through connective tissue and at same time it will reduce oxygen supply that affect the metabolic activity of the epithelial cell, these changes caused atrophy to the papillae.

This finding agrees with the findings of Cawson, (7) Huber et. al., (4) Enwald et. al. (8) and Moher et. al. (9) who reported atrophy in the tongue due to iron deficiency state. Reduction in tissue oxygen supply will made the tissue liable to infection and that explains the presence of laceration in the tongue. This result coincides with results of William et. al. (10)

REFERENCES 1- Sato S. Iron deficiency: Structural and microchemical

changes in hair, nails and skin. Semin Dermatol 1991; 10 (4): 313-9.

2- Lamey PJ, Lewis MAO. The tongue: infection and mucosal atrophy. Dental update 1985; 12 (7): 429-436.

3- Geerlings SE, Statius V EPS. Sever deglutition disorders and iron deficiency, Plummer Vinson syndrome. Ned Tijdschr Geneeskd 1991; 135(45): 2136-7.

4- Huber MA, Hall EH. Glossodynia in patients with nutritional deficiencies. Ear nose throat J 1989; 68(10): 771-5.

5- Maresky LS, de Waal J, Pretorius S, Van Zyle AW, Wolfardt P. Epidemiology of oral precancer and cancer J Dent Ass Suppl 1989;1: 18 – 20.

6- Tencate's A, Nanci, A. Text book of oral histology, development, structure. Sixth edition. Mosby, St. Louis, Missouri 2003;p: 65-70.

7- Cawson RA. Systemic diseases in relation to dentistry, essentials of dental surgery. Oral pathology J 1987; 30: 393- 412.

8- Enwald CV, Drinka PJ, Swortz C, Langer EH, Vorks Sk. Iron status in atrophic glossitis: a pilot study. Wis Med J 1993;92 (10): 570 – 3.

9- Maher R, Aga P, Johnson NW, Sankaranrayanan R, Warnakulasuriya S. Evaluation of multiple micronutrient supplementation in the management of oral submucous fibrosis. Nutr Cancer 1997;27 (1): 41-7.

10- William G, Shafer, Maynard K, Hine and Barnet M. Levy. Diseases of the blood and blood forming organs. A text book of oral pathology. 4th ed. WB Saunders Com. 1983;719-59.

Figure 1: Normal histological feature of

Figure 2: High magnification of papillae

rabbit tongue showing filiform and d E X40). fungiform papillae (H an

of normal tongue (H and E X100)

Figure 3: Filiform papillae of normal tongue coverd with keratinized

epithelium (H and E )X400). Figure 4: Depapillated tongue of

rabbit with iron deficiency anemia (H and E X40)




Figure 5: High magnification of fig.4 (H and E X100)

Figure 6: Papillae of experimental rabbit (iron deficiency anemia )shows lack of keratinization with laceration

In the epithelium (H and E X400).

J College Dentistry Vol. 17(2) 2005 Densitometric evaluation of …

Densitometric evaluation of E-speed film with three different developing solutions.

Mouna Al Safi B.D.S., M.Sc.(1)

Ruqayya S. AL Qizweeny B.D.S., M.Sc.(2)

Jamal A. Abid Al –Rhida B.D.S., M.Sc.(3) ABSTRACT Background: In order to determine the influence of different solutions on the quality of the radiograph, the purpose of this study is to have a comparison between solutions to see the best one produce radiographs of highly diagnostic ability. Material and method: An aluminum step wedge was radiograph with E-Speed periapical films of the films were developed in three different processing solutions at standardized conditions according to manufacture’s instructions data concerning film density, contrast, fog and speed film. Each film solution combination was compiled in attempted to evaluate optimal film –solution combination. Results: In present study better contrast and less film fog obtained with technique C solution, for film speed, higher speed values indicate lower exposure time to patient. Conclusion: The rapid processing solution deteriorated faster and need less processing time than conventional solutions Keywords: Film-Speed, Contrast, Density. (J Coll Dentistry 2005; 17(1) 56-58).

INTRODUCTION

Rapid processing techniques for dental radio graphics have been an important adjunct in helping to resolve urgent diagnostic problems encountered in endodontic therapy and surgical energies (1,2,5). These techniques have reduced the time interval for developing and fixing of films from 13 minutes to 60 seconds. However some of question remains regarding the diagnostic quality of such films compared with that of conventionally processed films. MATERIALS AND METHODS

Thirty periapical X-Ray films type E-Speed intra oral dental film and examined by the same operator in order to eliminate the possibility of existence of any variation in technique between different operators. Exposure was made using an Aluminum step wedge used for determination the quality of dental films with the three different processing solutions. The step-wedge with 1mm. X-ray machine type general electric 1000, the step-wedge with 1 mm difference in each step made of commercially pure Aluminum. Exposure Factors were fixed at following: 65Kvp.10 mA, 1.5 second exposure time,

(1) Assistant professor, Department of Radiology, College of

Dentistry, University of Baghdad. (2) Assistant lecturer, Department of Radiology, College of

Dentistry, University of Baghdad. (3) Lecturer, Department of Radiology, College of Dentistry,


8 inches tube film distance 2.7 millimeters aluminum half value layer, and 2.5 millimeters aluminium filtration. Manual processor was made with the following solution: Processing solution A: Type read MSDA data distributed by DT&T. the 10 films were developed at 22c0 for 15 sec., rinsed, and fixed at room temperature for four minutes. Processing solution B: rapid Schell, replenished type AGFA, the 10 films were developed at 22 C0 for 15 seconds, rinsed, and fixed at room temperature for four minutes. Processing solutions C. Rapid Kodak replenished. The 10 films were developed at 22 C0 for 15 sec. , rinsed and fixed at room temperature for four minutes. The films were mounted separately for each solution and examined by five dental radiologists in radiology department in college of dentistry at university of Baghdad, using viewer with magnifying lens X10. The reading was kept for each examiner and repeated after 2 weeks for calibration; only one examiner was excluded from the study because of wide range between the two readings. RESULTS

The radiographs were ranked on a scale of one to three in ascending order of quality. Radiographies with the best diagnostic quality had an assigned weight of three and those with the least diagnostic quality had assigned weight of one.



The remaining position was assigned two between groups. The frequency of each rank was multiplied by assigned weight of that rank to produce a composite score. (Table 1).

So that statistically significant differences among the groups could be determined, a frequency distribution of each method was constructed and an analysis of variance performed. The magnitude of F value confirmed the existence of significant group differences (Table 2).

Although no significant differences was found between films processed by techniques A and B, there was significant differences between A and C, that final rank of diagnostic quality of the films processed by the C technique much better than B and A technique. (Table 3) DISCUSSION

Processing of the same type of films in different processing solutions materials will produce radiographs of different quality (1) with regard to density, contrast, fog and speed, the higher contrast value and lower the fog the better quality of the radio graph. In present study better contrast obtained with technique C solution higher than those obtained with other solutions. Fog (2,11,14) maybe due to the base density or to the various chemical reaction that the solution undergoes during the developing process.

Contrast was defined as the difference in density between step-wedges of 5 and 10 mm aluminum. Greatest contrast obtained with technique C solutions, then with technique B and lower values obtained with technique A solutions. (4- 6, 11).

Film speed was defined by standards as reciprocal of the exposure to direct X- Ray or Gamma radiation that required to produce a net image density of 1.0 ( that is, a density greater by 1.0 than that of the unexposed film). Higher speed values indicate that the X-Ray examination can be carried out with a lower exposure to the patient, without determined to the quality of the image.

According to this study, speed values obtained with the technique C solutions were significantly higher than those obtained with other solutions evaluated (4, 7, 9, 13, 15 ).

Table 1: Number of evaluators (4 radiologists who ranked the diagnostic

quality of radiographies by 3 rapid processing techniques)

Rapid Processing Technique

First (list) Second Third

(Best) Composite

rank

A 0 9 22 156 B 0 21 9 80 C 35 20 3 35

Table 2: Analysis of Varaince

Source of Variation

Degrees of

Freedom

Sum of Squares

Mean Squares F

Between groups 4 276.34 69.09 159.45

Within groups 170 73.66 0.43 -

Total 174 350.00 - - Significant at 0.01 level of significance.

Table 3: Comparison of groups of

radiographic films 30 films per groups .processed with fife techniques.

Techniques Mean Standard deviation T value

A B

4.11 1.00

0.62 0.00 29.19

A C

4.46 1.00

0.84 0.00 24.00

B C

4.46 4.11

0.84 0.62 1.91

REFERENCES 1. Brown R, Hadley JN, Chambers DW. An evaluation

of Ekta speed plus film versus Ultra speed film for endodontic working length determination. J Endod 1998; 24:131-2.

2. Grsch WJ, Matteson SR, Mckee MN. An evaluation of Kodak Ekta speed periapical film for use in endodontics. J Endod 1983; 9: 283-8.

3. Ingle JI, Beveridge EO, Clarindn E. Rapid processing of Endodontic Working Roenteroyram. Oral Surg Oral Med & Oral Path 1965; 19:101-7

4. Fryholm, A. Kodak extraspeed. A new dental x-ray film. Dentomaxillofac Radiol 1983; 12: 47.

5. Fredricksen NC. In Goaz PW, White SC, eds. Oral Radiology-Stlous: Mosby,: 1994. 58-9.

6. Horton PS, Sippy FH, Kohout FJ, Nelsoin JF, Kennle GC. A clinical comparison of speed group D and E dental x-ray film. Oral Surg 1984; 9 (4):104-5.

7. Kaffe I, Littner MM, XKuspet ME. Densitometric evaluation of intra oral x-ray films: Ekta speed versus ultra speed. Oral Surg 1984; 57 (2): 338.

8. Kitagawa H, Farman AG, Wakan M, et al. Objective and subjective assessments of Kodak Ekta speed and Ultra speed Plus films. Oral Surg Oral Med Oral Pathol 1995; 36 (1):61-7.



9. Kodak x-ray films used in dentistry technical information bulletin 1989; No. T10891.October .

13. Price C. Sensitometric evaluation of a new E-speed dental radiograph film. Dento maxillofac Radi 1995; 24 (5): 30-6. 10. Kogon SL, Stephens RG, Reid JA, Donnar A. Ekta

speed and a Screen/ film system compared with Ultra speed in the interpretation of early proximal caries. J Canad Dent Assoc 1988; 50: 397-8.

14. Skogon R,Stephens, J R, Mac Donald J. The effects of processing variables on the contrast of type D and type E dental film dentomaxillofac Radiol 1985; 14 (4):65-8 11. Olson AK, Goerig AXC, Cavakio RE, Luciano J. The

ability of the radiograph to determine the location of the apical foramen. Int Endo J 1991; 24:28-35.

15. 15-Thvnthy KH, Weinbery R. Sensitometric comparison of dental films of Groups D and E. Oral Surg 1984; 54 (4) : 250. 12. Powell- Culmgford AW, Pill Ford TR. The use of

Ekta speed film for rout canal length determination. Int Endod J 1993; 268-72.


J College Dentistry Vol. 17(2) 2005 The histochemical effects…

The histochemical effects of the administration of hydrocortisone sodium succinate upon the periodontium of

albino rats' experimental study Asmaa S. Al-Douri, M.Sc. Ph.D.(1)

ABSTRACT Background: The effects of the administration of cortisone upon numerous body tissues have been described; changes in the periodontal tissue of developing albino rats (newborn) histochemically have not been described. A study was therefore, under taken to investigate the effect of administration of cortisone upon the periodontal ligament tissues. Materials and methods: Experimental animals (new born rats, their age 10, 19, 25 days old) were treated by cortisone, saggital sections were stained by alcian blue and H&E stains. Results: It was shown that the hydrocortisone sodium succinate affect that periodontal tissue development and this drug inhibit and delay the synthesise of GAGs (glycosaminoglycans) till aged 25 post natal (p.n.). Conclusion: The periodontal membrane in the treated groups is affected (delay in the GAGs synthesis) by the hydrocortisone sodium succinate drug administration. Keywords: Hydrocortisone, periodontal ligament, alcian blue. (J Coll Dentistry 2005; 17(2):59-63) INTRODUCTION

Corticosteroids is produced by the adrenal cortex, and are divided into natural and synthetic cortical steroids, hydrocortisone sodium succinate (cortisol) is predominant natural gluco corticold in human. (1)

It is indicated for the treatment of rheumatic disorders, asthma, collagen disease, dermatological disease, heamatologic disorders. The adverse reactions include fluid and electrolyte disturbances, musclo skeletal disorders, metabolic imbalance, endocrine irregularities and long term cortiosoteroids use may be associated with more serious sequal including osteoporosis, growth suppression, possible congenital malformations (2,3,4). The osseous changes consisting of reduction in chondrogenesis and osteogenesis in the proximal epiphyseal cartilage, reduction in numbers of large vacuolated cartilage cells, reduction in number of osteoblast, irregular bony trabeculae and wider marrow sinusoids were described in experimental animals. (5) histomorphological changes (histological abnormalities) in the periodontal ligament Periodontal ligament. of developing tissue that treated by cortisone have been described by many authors6,7. However, there is no previous report remark alternate in their histochemical changes so this study was done to know the effect of hydrocortisone sodium succinate on Periodontal ligament development histochemically (by using alcian blue stain). (1) Lecturer, Department of Oral Diagnosis, College of Dentistry,


MATERIALS AND METHODS Thirty pregnant rats were randomly divided

into two main groups: the control (A) and the treated groups (B). A. The control groups

This group consisted of 15 pregnant rats, each one was given 1ml distilled water by i.m. (intramuscular) injection daily from (12 to 18) day of pregnancy. After delivery of the pregnant rats, 4 newborn rats were selected randomly to be sacrificed at 10, 19 and 25 days old. B. The treated group

This group consisted of 15 pregnant rats, each rat given a dose of 50 mg/ml hydrocortisone succinate by i.m injection, in lateral left thigh once daily from 12 to 18 day of pregnancy, hydrocortisone succinate was suspended in normal saline to obtain concentration of 100mg/2ml, and 1ml of volume was given i.m each time. After delivery of the treated pregnant rats by cortisone, roughly 4 new born rats were selected to be sacrificed at 10,19 and 25 days old (table 1).

Table 1: The number of newborn rats in

the experimental design days old Groups 10 19 25

Control group 20 20 20 Treated group 20 20 20

The General Histological Preparation.

The head was separated and cut saggitally into 2 halves; both sides were used in the control and experimental groups. After fixation,



decalcification, dehydration, clearing and embedding, mid saggital section of the specimens were cut at 5 microns by Reichert Jung microtome, one of each sections is stained with Harris Hematoxylin and eosin (H & E) and the other is stained by alcian blue (see below). All the sections were examined by Olympus light microscope. The special stain (Alcian blue) histochemistry.

The cationic dyes (special stain is alcian – blue prepared at pH1 and pH 2.5 pathalo cyanine dyes) are derivative of copper phthalocyanin and appear as a blue pigment of high physical and chemical stability,8 it is used in this study. First concentration, alcian blue pH 2.5

1% alcian blue solution was used for staining of weakly acidic mucopolysaccharides. It was prepared from mixing Alcina blue 8 GX I.g with glacialacetic acid 3% 100ml then filtered; it remains stable 2–4 weeks. Second concentration, alcian blue pH 1 1% alcian blue solution was used for more selective staining of strongly acidic sulfated mucosubstances. It is as well consisted from mixing

Alcian blue 8Gx 1.g was used with hydrochloric acid 0.1n. (1% HCl) 100mL and then filtered before use. Beside that a counter stain (Kernechtrot solution) was used. The slides were washed in running water (1min) and dehydrated, cleared and mounted (9,10).

RESULTS Gross observations

The cortisone treated animals appeared less active and smaller than the control at the time of sacrifice, while the gingiva of both groups showed marginal inflammation associated with local irritation from food particles.

The destruction of the inter dental papilla appeared to be more sever in cortisone treated animals Microscopic Observation.

The interdental bone between the molars teeth was lined on one aspect by a thin layer of osteoid with adjacent osteoblast (Fig 1and 3). Along the other aspect, the bony border was smooth in some areas and irregularly in others. The multinuclear osteoclast was seen in concavities along the surface at the gingival cryst of the bone, a small section of osteoid was seen, and the periodontal membrane was

densely collagenous with well formed fibroblasts.

While in the cortisone treated animals the interdental septa were reduced in height, the margins of the septa stained deeply and presented a minutely granular border, there was no appreciable evidence of osteoblast or osteoblastic activity, in a few isolated areas, shrunken, deeply staining osteoblasts were seen partially surrounded by faintly staining osteoid. The appositional lines were less clearly marked and in some instance were unusually irregular, the periodontal membrane was edematous, the fibroblasts were markedly reduced in number and shrunken in appearance, and the collagen fibers were reduced in amount, wavy and fibrin like and separated by the edema. (Fig.2 and 4)

In the bifurcation area of the molars, a broad peripheral zone of newly formed bone was seen adjacent to the periodontal membrane, demarcated from the under lying bone by deeply staining appositional line , osteoblasts were aligned along the periphery, separated from each other by collagenous fibers embedded in the bone. The periodontal membrane consisted of densely arranged fibers with numerous well formed cells. (Fig. 5). While The bone was outlined by a deeply staining irregularly indented border with the exception of a small area of new bone formation and a few poorly staining osteoblasts at the crest, of the treated animals. There was no evidence of peripheral bone apposition, the periodontal membrane was edematous, and the fibroblast were markedly reduced in number and shrunken in appearance. The collagen fibers were reduced in amount wavy and fibrin like and separated by edema. (Fig. 6). The cementum was thin and acellular in the gingival half of the roots and bulbous and cellular in the apical region of the control animal, While the cementum of treated molar teeth appeared thinned and devoid of newly formed cementoid (Fig 5,6). Glycosaminoglycans (Hyaluronic acid, chondroitin sulphated and heparin sulphate) Histochemistry. The reaction in general was stronger at PH 2.5 than PH 1, indicating the presence of both sulfated and non sulfated (Carboxylated) glycos aminoglycans. For hyaluronic acid and sialic acid as revealed by alcian blue PH2.5:

In the control groups the reaction was strong at 10 p.n, weaker at 19, 25 p.n Fig (7). While, In the treated groups, The reaction was



stronger than the control in the treated groups (19 p.n, 25p.n) Fig (8), while for chondroitin sulphate and heparin sulphate as revealed by alcian Blue (PHI). In the control group, there was strong reaction at 10 Pn, but it becomes weak at 19, 25Pn Fig (9). While, in the treated groups there was intense reaction at 19, 25Pn Fig. 10. DISCUSSION

The treated group gives obvious histological and histochemical abnormalities in their developing periodontal ligament, indicating alteration in normal developmental processes. It is well established that cortisol, cross the placenta (11). All the body compartments of fetus are affected by cortisone reaching them via fetal blood carrying it from their treated mothers.

Hydrocortisone inhibits protein and glycoprotein synthesis, decreases amount of proliferating cells, accelerates their differentiation and thus delay the development process, this was reported by Mazhuga et al.(12)

It should be noted that bone and periosteum in other area of the skeletal system presented changes (4) similar to those in the alveolar bone and periodontal membrane.

This inter relationship is consistent with the often repeated observation in experimental animals that the alveolar bone and periodontal membrane reflect the condition of the remainder of the skeletal system in systemically induced osseous disturbances (13).

In the periodontal membrane of cortisone injected animals the alterations in the fibroblast and collagen fibers are comparable to those described in connective tissues of other experimental animals, and human beings subjected to systemic administration of cortisone (14,15). The periodontal membrane at age 10 Pn is intensely stained by alcian blue so this indicate the presence of proteoglycan (GAG) in that membrane but when developing continues the staining become less or removed indicating the very little amount of proteoglycan in that membrane (16). In well developed P.d ligament structure (at 19, 25Pn) the presence of GAGs in 10p.n during P.d. ligament development have shown close association of these proteins with different stages of cell differentiation (Mast cells, fibroblast cells) and/ or in cell secretion in the ground substance. In the treated groups the

weak reaction at 10 Pn indicating that hydrocortisone drug inhibits the synthesis of GAGs. But when time pass and the new born rat become older at 19 p.n and 25p.n the effect of this drug is reduced and the P.d. ligament become normal in its content with GAGs (Chondroitin sulphate, heparinsulphate, hyaluronic acid) so there is delay in the formation of proteoglycan content at P.d. ligament because the reactivity is still until the age of 25 p.n is under the effect of the drug. REFERENCES 1- Gray CR, David SL. Pharmocology Board Review

series 3rd edition: Williams and Wilkins. Baltimore Maryland. 1998; 21201-436.

2- Sprague RG, Power M. Mason H; et al. Adrnocorticotrophic hormones. ACTH Arch Int Med. 1950; 85, 199.

3- Cave A, Arlett P, Lee E. Inhaled and nasal corticosteroids: factors affecting the risk of systemic adverse effects. Pharmacol Ther 1999; 83 (3): 153 – 79.

4- Buchman Al. Side effect of corticosteroid therapy. J. Clin. Gastroenterol 2001; 33(4): 289 -94.

5- Bocks H, Simpson MD, et al. The Effect of adrenocorticotrophic hormone (ACTH) on the osseus system in normal rats. Endocrinology 1944; 34:305,

6- Glickman I, Stone I, Chawila T et al. The effect of systemic administration of cortisone on the periodontal white mouse J Periodont 1953; 24-161

7- William A, Kusek JC, Steubaer EA. Effects of cortisone preparations on human teeth. J Dent Res 1968; 18.

8- Linda VL Manual of histochemistry Raven press New York USA 1986; 203 – 4,

9- Waldrop FS, Puchtler H. alcian blue stain. Staintechnol. 1977; 52: 237 -42.

10- Al- Salihi AR. Muscle histochemistry diagnostic and laboratory manual, Nahrain University, Baghdad. Iraq. 2000.

11- Klimcke HG, Christenson RK. Porcin fetal and maternal adrenocortico tropic hormone and cortic osteroid concentrations during gestation and their relation to fetal size. Biol Reprod 1997; 57(1): 99 – 106.

12- Mazhuga PM, Kabakks et al. Reproduction and differentiation tissue of grouping rat teeth in response to ponathyroid hormone oral hydrocortisone. Arch A Nat Histol Embriol 1987; 92(5): 57 -62.

13- Glickman L. The experimental basis from the bone factor concept in periodontal disease J Periodont 1949; 20:7,

14- Zoger S. Observation on the influence of cortisone on tissue response injury. Biol Med 1952; 25: 202.

15- Jackson LD, Blygenis D, Ndrov RA et al. Comparative efficacy and safety of inhaled corticosteroied. In asthma. Can J Clin Pharmacol 1999; 6(1): 926 -37.

16- Bhasker SN. Orbans oral histology and embryology 1994; 12th edition Mosby. Co. Year book, USA.



Figure 1: Control group, a mesiodistal section through the mandibular molar area showing

molar roots (m.r) and alveolar bone (a.b) (H & E x 40).

Figure 2: Experimental group; a section through the mandibular molar area showing molar root

(mr) and alveolar bone (a.b) (H & E x 60).

Figure 3: Control group, magnifical view of

interdental septum and periodontal membranes (p.m) shown in fig 1. There are

osteoblasts and osteoclast in regular sence. (H & E x 250).

Figure 4: Experimental groups, magnifical view of inter dental septum and periodontal membrane

shown in fig. 2. Note irregularly sence of osteoblasts and osteoid. The fibroblast of periodontal

membrane are reduced in number and the collagen fibers appear fibrin like and fragmented (H & E x

250).

Figure 5: Control group, detailed section of

bifurcation area (b.a) of the molar shown in fig 1. note the broad peripheral zone of recently formed bone which is demarcated from the

underlying bone by a deeply staining appositional line and normal thin cementum (H

& E x 250).

Figure 6: Treated group – Detailed study of

bifurcation area (b.a) of the molar shown in fig. 2. A side from a small area of osteoid at the crest, there is no apposition of newly formed

bone. In stead the margin of the bone is formed by a thin deeply staining irregularly indented line. Note the very thin cementum (H & E x

250).



Figure 7: Saggital section of molar tooth at 19 p.n in the control group stained with alcian blue

pH2.5. Note: The reaction is weaker at periodontal ligament area

Figure 8: Saggital section of molar tooth at 19 p.n in the treated group stained with alcian blue

pH2.5. Note: The reaction is more intense at

periodontal ligament area


J College Dentistry Vol. 17(2) 2005 Periodontal status during…

Periodontal status during pregnancy Bacima G. Ali, B.D.S., M.Sc. (1)

ABSTRACT Background: The purpose of the present research was to determine the prevalence and severity of gingival inflammation at different periods of gestation and the prevalence of pregnancy tumor, since the hormonal changes have been implicated complicating factors for periodontal disease. Method: Fifty women were examined; seventeen women from first trimester, twenty at second trimester and thirteenth at third trimester. Results: It was revealed that a high prevalence of periodontal disease increased with advanced stages of pregnancy. The percentage of pregnancy tumor was 6% from the total sample and only in 2nd and 3rd trimester groups. Conclusion: Local treatment in a preventive oral hygiene program from early pregnancy is very important to prevent further progression of any inflammation. Key words: Pregnancy tumor, prevalence, periodontal disease, pregnancy. (J Coll Dentistry 2005; 17(2):64-68) INTRODUCTION

From the clinical studies, it has been noticed that changes take place in the condition of gingiva and periodontium during the period of gestation (1). It was found that the severity of the inflammation would be exacerbated during the 2nd month of pregnancy reaching a peak at the 8th month (2). Gingivitis in pregnancy is characterized by a fire red color of the marginal gingiva and interdental papilla, edema and higher tendency for bleeding (3).

There are conflicting suggestions about the exact cause of the inflammation or the changes that take place during gestation (4). The ovarian hormones (progesterone and 17B- estradiol) have been found to alter the micro- environmental of oral bacteria (5). Other studies correlate the environmental inflammation to the plasminogen activator inhibitor type 2 (PAI- 2) or the modu1lation of progesterone of Interlukien- 6 (IL- 6) production by gingival fibroblast (6).

The aims of the present research were to: 1- Determine the prevalence and severity of

gingival inflammation at different period of gestation.

2- Determine the prevalence of pregnancy tumor at different period of gestation.

3- Determine the prevalence of gingival recession.

(1) Lecturer, Department of Periodontology, College of Dentistry,

University of Baghdad

MATERIALS AND METHODS Sample selection:

Fifty women were included in the study from the attendance to Al- Zuwia Maternity and Childhood health care center. The sample was divided according to the trimesters into 3 subgroups: Group 1: includes 17 women at 1st trimester. Group 2: includes 20 women at 2nd trimester. Group 3: includes 13 women at 3rd trimester.

A questionnaire was taken from all pregnant women including their names, ages, medical health smoking and brushing their teeth. Oral examination:

The examination was done in a dental clinic at Al- Zuwia Health Center using periodontal probe and dental mirror. The examination was done during the periodic visit of the pregnant women to the center as a part of the maternity and child had health care program available for the pregnant women. All the teeth were examined, and the3rd molars were excluded. The clinical parameters used for assessment of periodontal health are the followings: Plaque index system (Pl. I.): According to the criteria of plaque index of Silness and Loe, 1964 (7). Gingival index (G.I.): According to the criteria of gingival index by Loe and Silness, 1963 (1). Probing pocket depth (P.P.D.): Measured in millimeters by periodontal probe (type William) from the gingival margin to the most apical extent of the probe. For statistical analysis we divided the PPD into 2 scores:

Oral and Maxillofacial surgery and Periodontology 64


Score 0: when the PPD equal but not exceed 4mm.

Score 1: when the PPD > 4mm. Gingival recession: Measured in millimeters by periodontal probe from the cemento-enamel junction (CEJ) to the gingival margin according to the classification of Miller, 1985 (7). For statistical analysis, we coded score 0 for the absence of the recession and score 1 for the presence of recession. Presence of pregnancy tumor: The percentage differences in the presence of pregnancy tumor as detected clinically by oral examination among the three subgroups. RESULTS

Table 1 shows the distribution of the sample according to the trimester of the pregnant women and number of the examined sites

Table 2 reveals that the total means of Pl.I. for all subgroups was 1.76 + 0.73 and the highest mean was in the 2nd trimester subgroup (1.95 + 0.66) followed by the 3rd trimester subgroup (1.73 + 0.49), while the lowest mean score was found in the 1st trimester subgroup (1.57 + 0.93).

For the purpose of comparison between these three subgroups, ANOVA test was used which reveal a non-significant difference between different subgroups (P> 0.05).

As shown in table 3, the total mean score of GI in pregnancy groups was 1.52 ± 0.6. The prevalence of gingivitis was 100%. Using the ANOVA test for the comparison between the subgroups showed a significant difference between 1st and 2nd trimester subgroups. (P< 0.01) with a mean difference (0.80) and a highly significant difference was between 1st and 3rd trimester subgroups (P< 0.01) and the mean difference was 0.85, while a non significant difference was found between 2nd and 3rd trimester subgroups (Fig. 1).

Table 4 showed the prevalence of gingival recession according to the tooth type. The results showed that 16% of the total sample had gingival recession and that the affected teeth are upper and lower incisors and canines. Regarding the tooth surface, it appears that facial surface was more affected than the gingival or palatal surfaces (Fig. 2).

As shown in table 5, there are two scores for measuring probing pocket depth. Score 0 demonstrated a depth gingival sulcus that equals but does not exceed 4mm, while score 1 demonstrated a pockets > 4mm. The results showed that 40% of the pregnant women had score 0, while it was 58% for score 1.

Within the pregnancy groups, the 1st trimester subgroup exhibited score 1 in 27% while it was 65% in the 2nd trimester and 62% in the 3rd trimester subgroups. On other hand it appeared that the number of sites exhibited score 0 from the total site number were 66 sites (1.4%) out of 4880 site and 87 sites out of 4880 site for score 1 (1.8%) and this number in terms of percentage equal to 1.4% and 1.8% respectively.

The site distribution according to each group are shown in figure 3, which reveals that score 0 present in 27 sites in 1st group and 27, and 12 sites in 2nd and 3rd groups respectively, while score 1 was present in 14 sites in 1st subgroup and in 40 and 33 sites in 2nd and 3rd groups respectively.

Results showed that the prevalence of malignancy tumor was 6% among all subgroups. We did not found any women exhibiting this tumor at the 1st trimester, and 4% of the women exhibited pregnancy tumor at 2nd trimester and 2% at 3rd trimester. All the pregnant women who had this lesion had a negative behavior for brushing when we asked them for daily brushing (Fig. 4). The most affected areas with pregnancy tumor in the oral cavity area were the interdental area at upper and lower premolars.

From the results it appears that 8% of the whole number of pregnant women under study was smokers and that 74% brush their teeth and 26% not brush their teeth (Table. 6). Regarding the systemic disease and after examining the record files of each pregnant woman, it appeared that only 5 examined women had a systemic disease. Three of them had diabetic mellitus, one with asthma and the other with hypertension. DISCUSSION

The prevalence of plaque was 100% among all subgroups with non-significant differences, this result could be attributed to total oral health negligence and the insufficient motivation in plaque control that the patient must received in



their oral health care program which must be submitted to the pregnant women during their periodic recalls in the center. Although the sample was drawn from all area of high socio-economic standards, but as we see that most of the attendance were the servants and farmers wives who works at this area. This finding is in agreement to the findings of Salameh, 2000 (2)

and Kornman and Loeschel, 1980 (8), but disagrees with Suliaman, 1995 (9) who reveal an increasing level of plaque during pregnancy a great difference had been found between 1st and 2nd trimester and this could be attributed to the differences in the sample size.

The present study showed an increase prevalence of gingival inflammation during pregnancy with a significant difference between 1st and 2nd and 1st and 3rd trimester and this in agreement with the results of Hugoson, 1970 (10)

and Guttmiller, 2001 (4). Our study demonstrated a higher prevalence

of presence of pockets in the entire three subgroups, the highest being in the 2nd and 3rd trimesters subgroups and this because of extended period of the inflammation in addition to that inflammation with associated gingival swelling causes increase in the depth of the sulcus. This finding is in agreement to that of Loe and Silness, 1963 (1).

The presence of some of the pregnant women under study have gingival enlargement or what’s called pregnancy tumor agreed with the finding of Raber-Durlacher, 1991 (11).

The presenting of this tumor like gingival enlargement is an inflammatory response to local irritation and is modified by the patient’s condition and this explained it’s presence during the 2nd and 3rd trimester due to longtime exposure of the tooth to local irritation with absence of continuous cleaning as it’s shown in the result that 74% of the total sample not brush their teeth from those inflammation appear more obvious with increase severity of inflammation and prevalence of pregnancy tumor. These findings agreed with other findings of and Kornman and Loesche, 1980 (8) and Vittek et al., 1982 (12) .

In conclusion we can say that the local treatment in a preventive oral hygiene program from early pregnancy is very important to prevent further progression of any inflammation.

Pregnancy tumors need only to be removed when they are disturbing or bleeding otherwise it will regress post-partum.

Table 1: Distribution of the sample by

trimester and sites

Table 2: Mean of plaque index score and standard deviation with significance

comparison among three groups.

Table 3: Mean and standard deviation of GI score for three subgroups

Trimester Mean G.I. S.D. 1st/ n=17 0.98 0.52 2nd/ n=20 1.79 0.49 3rd/ n=13 1.52 0.32 Total/n=50 1.52 0.60

Table 4: Percentage distribution of gingival recession according to the trimester and tooth

type.

1st trimester

2nd trimester

3rd trimester Total

N= 17 N= 20 N= 13 50

Sites 1572 2016 1292 4880

Trimester subgroup Mean Pl.I + S.D. Sig.

1st/ n=17 1.57 0.93 2nd/ n=20 1.95 0.66 3rd/ n=13 1.73 0.49 Total/ n=50 1.76 0.73

ANOVA d.f.= 1.22

N.S.

Trimester % recession Tooth type

1st/ n=17 6 incisor/ canine 2nd/ n=20 6 incisor/ canine 3rd/ n=13 4 incisor/ canine Total/ n=50 16



Table 5: Percentage distribution of pockets among all subgroups.

1st 2nd 3rd

Score N % N % N % Total %

Absent 9 53 7 35 5 38 42 Present 8 47 13 65 8 62 58

Total number 17 20 13 50

Table 6: Percentage subject with smoking and tooth brushing

Smoking Brushing

Yes % No % Yes % No % 8 92 74 26

0 0.2 0.4 0.6 0.8

1 1.2 1.4 1.6 1.8

2

1st trimester 2nd trimester 3rd trimester total trimeste

mean SD

mean and SD

r

Figure 1: Comparison of significance among different subgroups for gingival index.

0

2

4

6

8

10

12

14

16

1 2

Tooth surface

Perc

enta

ge

facial surface Lingual surface

Figure 2: Distribution of gingival recession according to tooth surface.



0

5

10

15

20

25

30

35

40

45

50

score 0 score 1

Pocket score

Perc

enta

ge Series1Series2Series3

1st

2nd

3rd

Figure 3: Distribution of pockets according to the numbers of sites for each score.

0

1

2

3

4

5

6

percentage

trim

este

r

1st 2nd 3rd

Figure 4: Percentage distribution of pregnancy tumor. REFERENCES

1. Loe H, Silness J. Periodontal disease in pregnancy, 1. Prevalence and severity. Acta Ondont. Scand 1963; 21: 533.

2. Salameh RM. The periodontal status during pregnancy and intake of contraceptive. Thesis, College of Dentistry, University of Baghdad 2000.

3. Raber-Durlacher JE, Leene W, Palmer-Bouva. Experimental gingivitis during pregnancy and post-Partum: Immunohitochemical asepects. J Periodont 1993, 64: 211.

4. Guthmiller JM, Hassebroek - Johnson JR, Weening DR. Periodontal disease in pregnancy complicated by type 1 diabetes Mellitus, J Periodont 2001;2: 1485- 90.

5. Yasuko M, Yoshinori T. Oral health status related subgingival bacterial flora and sex hormones in saliva during pregnancy. Bull Tokyo Dent Coll 1994; 35: 139.

6. Lapp CA. Thomas ME, Lewis JB. Modulation by progesterone of interleukin- 6 production by gingival fibroblast. J Periodont 1995; 66: 279.

7. Miller PD. A Classification of marginal tissue recession. International J Periodontics and Restorative Dentistry 1985; 5 (2): 9-13.

8. Kornman KS, Loesche WJ. The subgingival microflora during pregnancy. J Periodont Res 1980; 5: 111-22

9. Suliaman AW. Oral health status and cariogenic microflora during pregnancy. Thesis, College of Dentistry, University of Baghdad 1995.

10. Hugoson A. Gingival inflammation and female sex hormones, J Periodont Res 1970; Suppl. 5.

11. Raber- Durlacher JE, Zeijlemaker W, Meinsz AA. CD4 to CD8 ratio and in vitro lymphoproliferative responses during experimental gingivitis in pregnancy and post-partum. J Periodont 1991;62: 663.

12. Vittek J, Hernandez MR, Wenk EJ, Rappaport SC, Southren AL. Specific estrogen receptors in human gingiva, J of Clinical Endocrinology and Metabolism 1982; 54: 608-12.


J College Dentistry Vol. 17(2) 2005 Periodontal condition and…

Periodontal condition and attachment loss among patients with spinal cord injuries in comparison with a non -

injured patients. Maha S. Al-Rubaie B.D.S., M.Sc. (1) ABSTRACT Background: Spinal cord injury is a serious condition that produces life-long disabilities The purpose of this investigation was to determine periodontal condition and attachment loss of patients with spinal cord injury in comparison with non injured patients and to investigate the cause and age of spinal cord injury, tooth mortality tooth brushing of the injured patients. Methods: A total of 53 patients with spinal cord injuries and 53 control patients of the age groups 20-40 years and 41-60 years were examined in this study. Periodontal condition and attachment loss were assessed using PDI of Ramfjord .The data was analyzed by student-T test and correlation coefficient(r). Results: The results revealed a high prevalence of periodontal disease in both injured and control groups (100 %) but the severity of periodontal disease was higher in injured patients. Non – significant differences in the mean periodontal disease index (PDI) and the mean attachment loss (AL) were found for both injured and control groups. Conclusion: The results indicate a high prevalence of periodontal disease in both injured and control groups but the severity of periodontal condition and attachment loss was higher in injured patients. Key words: Periodontal condition, spinal cord injuries (J Coll Dentistry 2005; 17(2):69-73)

INTRODUCTION Spinal cord injury (SCI) is a serious

condition that produces life-long disabilities (1)

and it is most commonly caused by traumatic injuries, mainly road traffic accidents or sports injuries .Rarely, it may be due to infections, haemorrhage, transverse myelitis, tumours or follow spinal surgery (2).It can lead to tissue destruction, vascular damage and rupture of the nerve fibers within the cord leading to severe pain (3). Data indicates that neuropathic pain post spinal cord injury reduces quality of life including mood and physical andsocial functioning ( 4 ).

The sudden onset and severity of disability can lead to a severe emotional reaction which influences the individual s ability to adjust to the dramatic changes in life –style, choice and dependence for personal needs (2).

The site and severity of the lesion governs the type of disability. Cervical lesions are more seriously disabling, with a gradual potential for increased function the lower the injury .The effect is paralysis and loss of sensation in the areas receiving their nervous supply at, or below the injured area. Paraplegia refers to injury below the cervical vertebrae resulting in paralysis of lower extremities .Tetraplegia (quadriplegia) refers to injury in the cervical region resulting in paralysis of all limbs and the trunk to varying degrees(2).

(1) Assistant professor, Department of Periodontology, College of Dentistry, University of Baghdad.

With incomplete transaction of the spinal cord, limited function and sensation may return .With lower cervical injury; some arm movements may be possible although hands may be weak, lacking powerand dexterity (2). In recent years, a growing concern of the community and governments for the handicapped has been achieved .Dentistry has paralleled medicine in this concern so that the handicapped patients have at least an equal share of dental services as the normal non disabled persons (5 ) .

Many studies have been done by Iraqi researchers regarding the medical condition of spinal cord injured patients (6-8) , but to our knowledge, periodontal condition and attachment loss in patients with SCI have not been evaluated yet in comparison to non injured control.

The purpose of the present study was to identify the occurrence of handicap situations in individuals with SCI and to investigate the periodontal condition and attachment loss in comparison to non injured patients.


The spinal cord injured patients that have been examined in this study were resident in the National Spinal Injuries Centre in Baghdad. The total number of patients in this centre was 65. Only 53 patients were examined and the other 12 patients either refused to participate in this study or they were severely



ill that is impossible to examine them. Information regarding name, age, sex were registered from each patient prior to oral examination. Oral examination was performed in this centre under natural day light and the patients were examined while sitting in a wheel chair or in their beds.

The sample is composed also of 53 controls who attended the periodontics department in order to compare their periodontal condition and attachment loss with the spinal cord injured patients.

The instruments used in this study included plane mouth mirrors, Williams Periodontal probes, and dental explorers. The prevalence and severity of periodontal disease and attachment loss were assessed using periodontal disease index of Ramfjord 1959 (9).

The criteria of this index include the following: 0 = healthy. 1= mild to moderate inflammatory changes not

extending around the tooth. 2 = mild to moderate inflammatory changes

extending all around the tooth. 3 = severe gingivitis (swelling, marked

redness, bleeding, ulceration). 4 = 3mm apical extension of the crevice from

C.E.J. 5 = 3 – 6mm apical extension of the crevice

from C.E.J. 6 = over 6 mm apical extension of the crevice

from C.E.J. All surfaces of the six Ramfjord teeth were

examined. If an index tooth was missing , the nearest distal tooth was substituted for examination and the patient will be examined if he had at least 5 of 6 Ramfjord teeth present. Attachment loss was assessed by using Williams periodontal probe and it is represented by scores 4 , 5 and 6 of the PDI of Ramfjord.

This is done as follows: 1. If the gingival margin is on the enamel, we

measure the distance in mm from free gingival margin to the C.E.J. and then measure the distance from free gingival margin to the bottom of the sulcus or pocket. The attachment loss was obtained by subtracting the first measurement from the second one.

2. If the gingival margin is on the cementum (gingival recession), we measure the distance from C.E.J. to the bottom of the

sulcus or the pocket and attachment loss was obtained from this measurement.

The presence of dental calculus also was assessed using the calculus index of Ramfjord ( 10 ) which include the following criteria :- 0 = absence of calculus. 1= supra gingival calculus extending not more

than 1mm below the free gingival margin

2= moderate amount of supra and sub gingival calculus or sub gingival calculus alone

3= an abundance of supra and sub gingival calculus.

Student T – test and correlation coefficient (r) were used where indicated. Level of significance was 0.01. RESULTS

The distribution of the sample by age and sex is shown in table (1). The sample is composed of 53 patients with spinal cord injury, 45 males (84.9 %) and 8 females (15.1 %). The control group is composed of 53 patients, 40 males (75.5 %) and 13 females (24.5 %) at the age groups 20–40 years and 41-60 years.

Table (2) shows the mean periodontal disease index and the mean calculus index (Cal I) for the injured patients and control by age and sex. The mean PDI for the total sample was 2.41 + 1.0, while the mean Cal I was 1.42 + 0.8. There was a weak correlation (0.4) between PDI scores and Cal I scores.

The mean of PDI of the control group was 2.44 + 0.9. It was slightly higher than the mean PDI of the injured patients and this difference was found non significant p > 0.01.

Table (3) shows the severity of periodontal disease expressed as percentage distribution of the sample according to the highest PDI scores, The highest percentage of the injured patients ( 41.5 % ) has score 3 as the highest score , followed by score 2 ( 32.07 % ) and the lowest percentage of patients had score 1 ( 1.8 % ) while 28.3 % of the control group had score 2 as the highest score followed by score 3 ( 26.4 %) and the lowest percentage was for score 6 which was zero which mean none of the control patients had score 6 as the highest PDI score .From this table we can see that neither the injured patients nor the control group had healthy periodontium ( score 0 ) which mean the prevalence of periodontal disease assessed with PDI for the total sample was 100 % .



Regarding attachment loss, table (4) showed the mean values and S.D. of attachment loss of the injured patients and control group which were 4.32 + 0.5 and 4.13 + 0.2 respectively. This difference was found non significant statistically.

The mean value of attachment loss of injured patients at the age group 20 – 40 years was found 4.08 + 0.2, while for the age group 41 – 60 years was found 4.58 + 0.7 and this difference was found non significant . DISCUSSION

Most studies of dental diseases prevalence in handicapped groups found high prevalence of periodontal disease. The current investigation has confirmed a high prevalence of periodontal disease among injured patients which agree with other studies ( 11 , 12 ) and can be explained by difficulties in maintaining adequate oral hygiene , but it must be emphasized that statistically significant difference between injured patients and control group have not been demonstrated and this agrees with other studies ( 13 , 14 ) .

However, the severity of periodontal disease is much higher in injured patients than normal patients as we noticed in table (3). 41.5 % of the injured patients had severe gingivitis while 26.4 % of the control group had severe gingivitis. None of the control group had score 6 of the PDI while 3.7 % of the injured patients had this score which is severe loss of attachment. This could be explained by many factors:- 1. In general, poor oral hygiene which is a

wide spread condition among individuals in this community.

2. Development of emotional problems and depression because the life style of those injured patients is so different from that of normal persons and this result in behaviour problems when dental treatment is attempted ( 15 ) .

3. It was found that lymphocytes – mediated immunity are impaired in patients with spinal cord injury because of malfunctioning neuronal regulation of immune and bone marrow function ( 16 ) .

Regarding attachment loss, a non-significant difference was found in this study when compared the mean value of attachment loss between the injured and control patients

and it increased with increasing age in both groups and this is consistent with other studies (17, 18, 19). Finally, it is the responsibility of the dental profession to ensure that the necessary care is provided for chronically sick patients and must emphasize on regular dental care to reinforce dental health education and provide preventive care and treat any dental disease in its early stage before the problems occur ( 15 ). Also the medical profession must ensure that appropriate psychological care is available within spinal cord injury rehabilitation settings so that many individuals will successfully achieve various social roles despite the presence of disabilities (20,21). REFERENCES 1- Taoka Y, Okajima K. Role of Leukocytes in spinal

cord injury in rats. J Neuro trauma 2000; March 17 (3): 219 – 29.

2- Griffiths J, Boyle S. A color guide to Holistic oral care,A practical approach . Chapter 10, physical disability and sensory impairment 1993; 144-5.

3- Nurmikko TJ. Mechanisms of central pain. Clin J Pain 2000; June 16 ( 2 suppl ) 21 – 5.

4- Haythorn thwaite JA, Benrud-Larson LM. Psychological aspects of neuropathic pain. Clin J Pain 2000; 16 ( 2 suppl ) : 101-5.

5- Swallow J N, Swallow BG. Dentistry for physically handicapped children in the international year of the child. Int Dent J 1980; 30: 1.

6- Khalid O, Al-Jubori. Late onset complication of spinal cord injury. MSc. Thesis in community medicine; Univ of Baghdad; 1996.

7- Alrubeye SG, Kedar Al-Chalaby , Abd Al-Zahra K, Basim. M. The effect of abdominal corset and posture on pulmonary function tests in spinal cord injured patients. A research discussed in the second scientific conference of collage of medicine, University of Baghdad; 1996.

8- Kedar , Al Chalaby. Functional electrical stimulation of spinal cord injured neural prosthesis. A research discussed in the first scientific meeting for rheumatic diseases and medical rehabilitation; 1995.

9- Ramfjord SP. Indices for prevalence and incidence of Periodontal disease. J Periodontol 1959; 30: 51–9.

10- Ramfjord SP. The periodontal Index (PDI) J Periodontol 1967; 38: 602.

11- Abbas DK, Al-Safi F, Mahmmoud FH, Al-Salihi AH. Caries prevalence and periodontal treatment need in a group of Iraqi Handicapped. Iraqi Dent J 1990;!5: 113-116.

12- Al-Ganabi B S. Oral health status and treatment needs among groups of handicapped children and adolescents in Baghdad – Iraq. Thesis, Baghdad University; 1995 .

13- Tiefel DJ, Truelove EL, Persson RS, Chin MM, Mandel LS. A comparison of oral health in spinal cord injury and other disability groups. Spec Care Dentist 1993; Nov.-Dec: 13 (6):229-Related articles, Links 35.



Table 1: Distribution of the sample by age and sex.

Male Female Total Age (Years ) No. % No. % No. % 20 – 40 38 90.4 4 9.5 42 79.2 41 – 60 7 63.6 4 36.3 11 20.8

Spinal cord injured patients

Total 45 84.9 8 15.1 53 100 20 – 40 29 76.3 9 23.6 38 71.7 41 – 60 11 73.3 4 26.6 15 28.3

Control group

Total 40 75.5 13 24.5 53 100

Table 2: Periodontal disease index and calculus index ( mean and standard deviation ) for the injured patients by age and sex .

Injured Patients / PDI

Injured Patients / Cal I Control / PDI Age

(Years ) Sex No. Mean + S.D. Mean + SD No. Mean + SD

M 38 2.27 + 29 1.34 + 0.7 29 2 + 0.8 F 4 1.37 + 9 1.05 + 0.8 9 2.21 + 0.7 20 – 40

TOTAL 42 2.19 + 38 1.31 + 0.7 38 2.05 + 0.7 M 7 3.47 + 11 1.78 + 0.8 11 3.47 + 0.9 F 4 2.92 + 4 2 + 0.7 4 3.3 + 0.2 41 – 60

TOTAL 11 3.27 + 15 1.86 + 0.8 15 3.41 + 0.7 M 45 2.46 + 40 1.41 + 0.8 40 2.4 + 1.0 F 8 2.15 + 13 1.52 + 0.9 13 2.6 + 0.8 Total

Sample TOTAL 53 2.41 + 53 1.42 + 0.8 53 2.44 + 0.9

Correlation coefficient ( r ) = 0.4 Weak correlation between PDI scores and Cal I scores Mean PDI of injured patients and mean PDI of Control group non significant P> 0.01, t = 0.163

Table 3: Severity of periodontal disease expressed as percentage of patients distributed according to the highest PDI scores by age and sex .

Highest PDI scores 1 2 3 4 5 6 Age

(Years) Sex No. 0 No % No % No % No % No % No % M 38 0 0 0 11 28.9 19 50 6 15 1 2.6 0 0 F 4 0 1 25 2 50 1 25 0 0 0 0 0 0 20 – 40

TOTAL 42 0 1 2.4 13 30.9 20 47 6 14 1 2.3 0 0 M 7 0 0 0 3 42.8 1 14 1 14 2 28.5 1 14 F 4 0 0 0 1 25 1 25 1 25 0 0 1 25 41 – 60

TOTAL 11 0 0 0 4 36.3 2 18 2 18 2 18 2 18 M 45 0 0 0 14 31.1 20 44 7 15 3 6.6 1 2.2 F 8 0 1 12.5 3 37.5 2 25 1 12 0 0 1 12.5

Spinal cord

Injured patients

Total

Sample TOTAL 53 0 1 1.8 17 32.0 22 41.5 8 15 3 5.6 2 3.7 M 29 0 2 6.8 9 31 11 38 5 17.2 2 6.8 0 0 F 9 0 0 0 4 44.4 3 33.3 1 11.1 1 11.1 0 0 20 – 40

TOTAL 38 0 2 5.2 13 34.2 14 36.8 6 15.7 3 7.8 0 0 M 11 0 0 0 1 9 0 0 6 54.5 4 36.3 0 0 F 4 0 0 0 1 25 0 0 1 25 2 50 0 0 41 – 60

TOTAL 15 0 0 0 2 13.3 0 0 7 46.6 6 40 0 0 M 40 0 2 5 10 25 11 27.5 11 27.5 6 15 0 0 F 13 0 0 0 5 38.4 3 23 2 15.3 3 23 0 0

Control group

Total Sample TOTAL 53 0 2 3.7 15 28.3 14 26.4 13 24.5 9 17 0 0



Table 4: Attachment loss ( means and SD ) among spinal cord injured patients and control group by age and sex .

AL Age (Years ) Sex No.No. Mean + SD

M 38 7 4.08 + 0.2 F 4 0 0 20 – 40

TOTAL 42 7 4.08 + 0.2 M 7 4 4.75 + 0.8 F 4 2 4.25 + 0.3 41 – 60

TOTAL 11 6 4.58 + 0.7 M 45 11 4.33 + 0.6 F 8 2 4.25 + 0.3

Injured patients age difference N.S.

t =1.661.

Total SampleTOTAL 53 13 4.32 + 0.5

M 29 7 4.05 + 0.09 F 9 2 4.1 + 0.1 20 – 40

TOTAL 38 9 4.06 + 0.1 M 11 10 4.18 + 0.3 F 4 3 4.16 + 0.1 41 – 60

TOTAL 15 13 4.17 + 0.3 M 40 17 4.12 + 0.2 F 13 5 4.14 + 0.1

Control Group

Total SampleTOTAL 53 22 4.13 + 0.2

14- Brown JP. The efficacy and economy of comprehensive dental care for handicapped children. Int Dent J 1980; 30 No.1 , 14 – 24 .

15- Hobson P. The treatment of medically handicapped children. Int Dent J 1980; 30 No. 1, 6 – 13.

16- Iversen PO, Hjeltnes N, Holm B, Flatebo T, Strom – Gundersen I, Ronning W, Stanghelle J, Benestad HB. Depressed immunity and impaired proliferation of hematopoietic progenitor cells in patients with complete spinal cord injury. Blood 2000; 15; 96 (6) : 2081 – 3.

17- Jackson LB, Richard CO, Harald L. Evaluating periodontal status of US employed adults. J Am Dent Assoc 1990; 121: 226 – 32.

18- Albandar JM, Kingman A. Gingival recession, gingival bleeding and dental calculus in adults 30 years of age and

older in the United States 1988- 1994. J Periodontol 1999; 70:30 – 43.

19- Anthony LN, Theodore RH, Harald L, Age A, Hans B. The natural history of periodontal disease in man. Risk factors for progression of attachment loss in individuals receiving no oral health care. J Periodontol 2001; 72 : 1006 – 15 .

20- Waters RL, Sie IH, Adkins RH. Rehabilitation of the patient with a spinal cord injury. Ortho P Clin. North Am 1995; Jan. 26 (1) : 117 – 22 .

21- Kennedy P, Rogers BA. Anxiety and depression after spinal cord injury: a longitudinal analysis. Arch Phys Med Rehabil 2000; 81 (7): 932–7.


J College Dentistry Vol. 17(2) 2005 The relationship between…

The relationship between restoration and furcation involvement in molar teeth

Wassan Al-Zaidi BDS, M.Sc.(1)

ABSTRACT Background: The reason of restoring a defect in a tooth is to preserve the tooth and its surrounding structures. This study aims to examine the correlation between the presence of a crown (CR) or a proximal restoration (RE) and furcation involvement (FI) on molar teeth. Material &method: Data was collected from 238 periodontal patients (130 male and 108 female) who had restored and non-restored molars present both with and without (FI). A majority of the restoration that were present in these patients had been placed for at least five years prior to the study. First and second molars were examined clinically using the following criteria : CR, RE, FI, MO (mobility). Results: Females showed higher percentage of crown placement & Cl.II restorations than males results were 29.7%, 73.2%& 10%, 40% respectively.while percentage of furcation involvement &tooth mobility were higher in male and the results were 52.4%, 17.7% & 31. 9%, 16.7% respectively Conclusion: The results of this study indicated that molars with CR or RE had a significantly higher percentage of FI but no greater mobility when compared to molars without restorations (CR or RE). Keywords: Molar, furcation. (J Coll Dentistry 2005; 17(2) :74-76)

INTRODUCTION Molars in comparison with other teeth are

more vulnerable to periodontal attachment loss and more prone to extraction(1,2). Prognosis is particularly affected when periodontal disease involves the bifurcation or trifurcation area of multi-rooted teeth, with their greater susceptibility to periodontal break down and their high risk to furcation involvement. Surprisingly, few researches were done to examine relationships between the presence of a crown (CR) or a proximal restoration (RE) and furcation involvement (FI).

Therefore, the aims of this study were to determine the impact of (CR) and/or (RE) on (FI) in molar teeth, to evaluate the influence of tooth mobility (MO) and endodontic treatment (EN) on furcation involvement (FI)(3).


Two hundred and thirty eight periodontal patients with FI and without FI, and with and without restoration were selected from University of Baghdad, College of Dentistry, Department of Periodontics. The majority of the selected patients had restorations 1present for at least five years prior to the study. Most of the restorations were supragingival in position. The clinical examination conducted on the molars included the assessment of the following criteria according to Hom Lay Wang et al :

(1) Lecturer, Department of Periodontology, College of


1. CR : absence or presence of a crown

type restoration. 2. RE : absence or presence of a

restoration involving the proximal surface.

3. EN : absence or presence of endodontic treatment.

4. FI : absence or presence of furcation involvement with exposure of (1/3) or more of the width of the furcation.

5. MO : no mobility or mobility present of greater than (0.5mm) movement in the buccolingual direction.

The data was collected by the use of the Michigan periodontal probe, dental mirror and dental probe / explorer. RESULTS

The overall findings in this study are listed in table (1). From the 238 examined patients, only 45 had crown placement while CL II restorations were present in 131 patients. Furcation involvement was found in 102 patients, whereas 57 patients had endodontic treatment, and finally mobility was present in 50 patients only.

Regarding sex variations, data revealed higher percentage of crown placement and class II restoration in female group (29.7% & 73.2%) in comaprison to male group (10% & 40%).

Percentage of furcation involvement and mobility were higher in male group (52.4% & 17.7%) respectively in comparison with female group (31.4 & 16.7%) respectively. Table (2)


J College Dentistry Vol. 17(2) 2005 The relationship between… shows molars with CR or RE had a significantly (p<0.032) higher presence of FI than molars without restorations especially molars with (CL II) restorations.

Data analysis indicated that the relationship between the restoration status of the molars and MO was not significant, while that of EN was significant but with small sample size. A significant difference frequency of FI was found between molars with and without restoration for both maxillary and mandibular arches (Table 3).

DISCUSSION

The results of this study indicate that molars with CR or RE have a higher prevalence of FI than non-restored molars. This is in agreement with previous reports (3,4,5), who reported that periodontal lesions associated with furcations respond differently to periodontal treatment than similar lesions adjacent to other tooth surfaces. Restored molars were shown to be more likely to be involved in the furcation, unless the FI occurred prior to placement of the restoration. There are factors involved with the restoration that contribute to periodontal break down, and these factors could be associated with the restorative process it self as the location of the restoration margin, the contact relationship,

trauma from occlusion, plaque retentive factors, and personal oral hygiene(3).

The difference in the prevalence of restorative treatment between female and male group may be due to the fact that females are usually more concerned about their appearance than males.

Results demonstrated that FI was more prevalent in maxillary than in mandibnlar molars which is in agreement with other findings(3,6). Mobility was found to be a significant factor for attachment loss in a single previous study(7). However, no correlation between MO and FI was found and this may be due to the fact that molars with both MO and FI were more likely to be extracted and lost. This is in agreement with Wang et al(3).

Since practice dictates protected cusp type restoration for endodontically treated molars, the finding that EN was a significant factor for RE or CR (3).

The clinical data obtained in the study suggest that periodontitis in the furcations is associated with several factors including restorations. Controlled longitudinal studies examining such factors as occlusion, inflammation, location of gingival margin of restorations, and contact relationship could determine how restorations contribute to periodontal break in furcation sites.

Table 1: Distribution of CR, RE, MO, FI & EN on both sexes.

Variables Female No. 108 Presence (%)

Male No. 130 Presence (%)

Total No. 238 Presence (%)

Crown placement 32 (29.7) 13 (10) 45 (18.9) Class II restoration 79 (73.2) 52 (40) 131 (55.1) Mobility 18 (16.7) 23 (17.7) 50 (21.1) Furcation involvement 34 (31.4) 68 (52.4) 102 (42.9) Endodontic treatment 34 (31.5) 32 (24.6) 57 (23.9)

Table 2: The relationship between restoration and FI, MO or EN.

Furcation involvement Mobility Endodontic involvement Groups

Presence %

Presence %

Presence % No crown placement or class II restoration (n=44) 38.11 19.77 9.84

Class II restoration (n=131) 68.15 15.09 2.48 Crown placement (n=45) 56.47 24.11 22.35 Chi-square Ρ value 0.03 * 0.37 0.03 *


J College Dentistry Vol. 17(2) 2005 The relationship between…

Table 3: Frequency distribution for teeth with and without crown placement or class II restoration.

Furcation involvement Mobility Maxillary arch Presence % Presence%

No crown placement or class II restoration (n=24) 52.34 17.65 Class II restoration (n=64) 51.77 13.13 Crown placement (n=24) 71.64 16.46 Chi-square Ρ value 0.039* 0.342 Mandibular arch No crown placement or class II restoration (n=20) 25.01 16.90 Class II restoration (n=67) 53.67 13.05 Crown placement (n=21) 64.82 16.23 Chi-square Ρ value 0.038* 0.097

* Statistically significant at Ρ <0.05 level

REFERENCES 1- Ramfjord SP, Knowles JW, Morrison EC, et.al.

Results of periodontal therapy related to tooth type. J Periodontol 1980; 51::270-3.

2- Pihlstrom B L, Oliphant TH, McHugh RB. Molar and nonmolar teeth compared over (6-12) years following two methods of periodontal therapy. J Periodontol 1984; 55:499-504.

3- Hom Lay Wang, Burgett FG, Yu Shyr. The relationship between restoration and furcation involvement molar teeth. J Periodontol 1993; 64: 302-5.

4- Chen JT, Burch JG, Beck FM, Horton JE. Periodontal attachement loss associated with proximal tooth restoration. J Prosth Dent 1987; 57: 416-20.

5- Kalkwarf KL, Kaldahl WB, Patil KD. Evaluation of furcation region response to periodontol therapy. J Periodontol 1988; 59:794-804.

6- Ross IF, Thompson RH. Furcation involvement in maxillary and mandibular molars. J Periodontol 1980; 51:450-4.

7- Wang HL, Zahn M, Burgett F, Greenwell H. The effect of furcation involvement on attachment loss. J Dent Res 1991; 70 (Spec. Issue): 282 (Abstr.).

8- Keszthely IG, Szabo I. Influence of class II amalgam fillings on attachment loss. J Clin Periodontol 1984; 11:81-6.

9- Silness J. Periodontal conditions in patients treated with dental bridges. J Periodontol Res 1970; 5:219-24.

10- McFall WT. Tooth loss in 100 treated patients with periodontal disease a long term study. J Periodontol 1982; 53:539-49.

11- Hirschfeld L, Wasserman B. Along-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978; 69:225-37.

12- Andergg CP. The treatment of Cl III maxillary furcation using a resin ionomer. Case report. J Periodontol 1998; 69:948-50.

13- Fowler E, Lawrence GB. Failure of resin Ionomers in the retention of multi-rooted teeth with class III furcation involvement, Case Report. J Periodontol 2001; 72, 8:1081-91.


J College Dentistry Vol. 17(2) 2005 Gingival fluid status….

Gingival fluid status in improperly restored and non restored teeth

Hala A.Al-Jubory B.D.S, M.Sc. ABSTRACT Background: Gingival crevicular fluid is a characteristic feature of inflammatory periodontal diseases. The aim of the present study is to assess the gingival fluid flow level in restored and non restored teeth. Methods: A total of 434 sites in 30 dental students were evaluated in this study. The participants ranged in age from (20-23y.) teeth selected for measurement were from the maxillary right second premolar to the maxillary left second premolar. The tested sites were divided into two groups of the first group (206 sites) is the experimental group with restoration and the second group (228 sites) is the control with no restoration .Student T-test was used where indicated , the level of significance was 0.001 . Results: The results demonstrated very high significant difference between the two groups. Conclusion: The results indicate that gingival crevicular fluid in addition to other clinical Parameters were greater in restored teeth with overhang fillings than non restored teeth with a highly significant difference. Keywords: Gingival fluid, restored teeth. (J Coll Dentistry 2005; 17(2) :77-79) INTRODUCTION Overhanging margins contribute to periodontal disease by providing ideal location for the accumulation of plaque & changing the ecologic balance of the gingival sulcus area to one that favor the growth of disease associated organisms(Gram –ve anaerobic species) at the expense of health associated organisms(Gram +ve facultative species) (1) a key objective in restorative dentistry is the reproduction of missing natural tooth contours. The procedures and properties of the materials used in this undertaking make preservation of the dento- epithelial junction a difficult task.(2). Excessive crown contour is unfavorable to periodontium health. The more the teeth are excessively contoured, the more they impair periodontium. (3) Clinical assessment of gingival inflammation depends on evaluation of changes in color, surface characteristics, texture, contour, consistency & bleeding tendency, these determinations are subjective & therefore susceptible to examiner variability. The flow of gingival fluid begins few days before other clinical signs of inflammation are evident since , clinical features are always preceded by histological changes within the gingival tissue(4) . The amount of gingival crevicular fluid is greater When inflammation is present, it means there is a positive relation between the flow of gingival fluid & the severity of inflammation which in turn may increase with overhang placement of restoration.(5)

(1)Lecturer, Department of Periodontology, College of

Dentistry, University of Baghdad

The aim of the present investigation is to compare the amount of gingival fluid flow from sulci nearby restored teeth with those nearby non restored teeth. MATERIAL AND METHODS

A total of 434 sites in 30 dental students were evaluated in this study, their age ranged from (20-23 years) and they were in a good general health and had no history of periodontal surgery in the evaluated areas, teeth selected for measurement were from the maxillary right second premolar to the maxillary left second premolar, the tested sites were divided into two groups of (206) and (228) the first group is the experimental group and the second group is the control according to the presence or absence of a subgingival restoration, each participant was examined for the number of teeth with overhang restorations to be recorded as the experimental group, other sites with no restorations were recorded as the control group. In each group the clinical parameters measured were:- 1- Gingival crevicular Fluid (GCF):-

This measurement was performed before taking the plaque index and gingival index readings to avoid any stimulation of sulcular fluid flow, the estimation was done by intracrevicular method of Brill (1962) (4) this technique was usually preceded by isolation of the area with cotton rolls and drying with air syringe then a standardized paper point size (30) was placed gently in each sulcus until resistance was met , each paper point was left in place for 3 minutes, then removed by a



tweezers and stained with 0.2%- 2% alcoholic solution of ninhydrin, this staining was used for recording the wet area of the paper point since the staining makes the column more visible to be measured by a vernia to the nearest millimeter. (6) The reaction of ninhydrin is specific for alfa-amino groups and gives a blue or purple color. 2- Plaque index (PLI)

This parameter was estimated on a scale of 0-3 according to Silness and Loe (1964) (7)

3- Gingival Index (GI) This parameter was estimated on a scale of 0-3 according to Loe and Silness (1963) (8)

Results of the present study were analyzed by the following statistical methods:- 1- Descriptive statistic which include a- Arithmetic mean(X) b- Standard deviation (S.D.) 2- Inferential statistics

This had been carried out by using student's "t" test to detect the comparative significance among the two groups.

RESULTS The mean values of gingival crevicular

fluid and gingival index in the first group which represent teeth containing subgingival overhanged restoration in comparison with the other group which represent normal teeth without any restorations are presented in table (1).

It indicates that the highest values of gingival fluid flow were obtained in areas with the most sever gingivitis, and the least amount of similar flow was obtained from the healthy areas that express the lowest scores of gingivitis. The difference was statistically significant (P<0.001).

Mean values for (PLI) scores were as well significantly more in the first group than in the second group that's indicate more plaque accumulation adjacent to badly made subgingival restorations than teeth have no restorations, table (1).

Table 1: The mean value of GCF, PLI, GI,

of teeth with overhang restorations and non restored teeth

P Group (2) Group (1) Sig.df t S.D. Mean S.D. Mean

Paramters

VHS0.00123.02 0.49 2.32 0.50 3.42 GCF VHS0.00113.39 0.58 0.85 0.64 1.64 PLI VHS0.00113.17 0.60 0.80 0.59 1.55 GI

P< 0.001 very high significant difference

DISCUSSION

The increase difference in gingival scores between teeth with subgingival restorations and non restored teeth in the present study was expected since that overhanging restorations of any material produce more inflammation and periodontal destruction than similar restorations exhibiting a close- fitting marginal adaptation, several studies concerning the correlation between the degree of gingival inflammation and the intensity of gingival fluid flow have noted a greater amount of crevicular fluid from patients with extensive restorations compared to clinically healthy non restored teeth (9,10,11) these studies agree with the results of the present study, Measurement of gingival fluid flow from the gingival pocket was suggested by Brill (12, 13) he also discussed the influence of capillary circulation on the flow of this fluid which appear to be dilated as it represents the first indication of inflammatory changes within the gingival tissues(9,12)

The correlation between gingival fluid measurement with macroscopic and microscopic characteristics of gingival tissue was further studied in 1976 (5) there is an increase in gingival fluid flow with increasing gingival index scores, the present study shows an agreement with these previous results, also it substantiates earlier reports demonstrating significant increase in inflammation associated with the presence of subgingival placement of restorations (14)

Stetler and Bissada in 1987 observed that teeth with subgingival restorations and narrow zones of attached gingiva showed statistically significant higher gingival scores than teeth having sub marginal restorations with wide zones of attached gingival with subsequent increase and decrease in gingival fluid flow related to gingival index scores further studies are needed which correlate the zone of attached gingiva with the rate of gingival crevicular fluid from gingiva adjacent to subgingivally placed restorations (15) .

REFERENCE 1. Lang NP, Kiel RA, Anderhalden K. Clinical

and microbiological effect of subgingival restorations with overhanging or clinically perfect margin. J Clin Periodontal 1983; 10:563.



9. Brill N, Bjorn H. Passage of fluid into human gingival pocket. Acta Odontol Scand 1959; 17: 11.

2. Jameson M, Lee. Comparison of the volume of crevicular fluid from restored and non restored teeth. J Prosth Dent 1979; 41:209-14

10. Waehaug J. Periodontology and partial prosthesis. Int Dent J 1968; 18: 101.

3. Zhoughua- Kou- Qiang- Yi- Xue- Za- Zhi. Effects of change of crown contour on health of gingiva, “Special Dental Dept. - Peking University School of Stomatology, Beijing, China. 2001; Nov; 36(6): 440- 2

11. Burch J. Periodontal considerations in operative dentistry. J Prosth Dent 1975; 34: 156.

12. Brill N. Effect of chewing on flow of tissue fluid into human gingival pockets. Acta Odontol Scand 1959a; 17:277-84.

4. Carranz's Clinical Periodontology. Newman, Takei, & Carranza. 9th edition; 2002.

5. Daneshmand H, Wade BA. Correlation between gingival fluid measurements and macroscopic and microscopic characteristics of gingival tissue. J Periodont Res 1976; 11:35-46.

13. Brill N. Influence of capillary permeability on flow of tissue into gingival pockets. Acta Odontol Scand 1959b; 17: 23-33.

14. Brill N, Krasse B. Effect of mechanical stimulation on flow of tissue fluid through gingival pocket epithelium. Acta Odontol Scand 1959; 17:115-30.

6. Brill N. The gingival pocket fluid studies of its occurrence, composition and effects. Acta Odontol Scand 1962; 20 Suppl: 32.

15. Stetler KJ, Bissada NF. Significant of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations. J Periodont. 1987; Oct. : 696- 70

7. Silness J, Loe H. Periodontal disease in pregnancy II Correlation between aral hygiene and periodontal condition. Acta Odontal Scand 1964; 22: 121-35.

.8. Loe H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta Odontol Scand 1963; 21: 533-51.


J College Dentistry Vol. 17(2) 2005 Gingival health status…

Soft tissue impingement and lip form in Iraqi teenagers

Akram F. Al-Huwaizi, B.D.S., M.Sc., Ph.D. (1)

Wael S. Al-Alousi, B.D.S., M.Sc. (2)

Ausama A. Al-Mulla, B.D.S., Dr.D.Sc. (3)

ABSTRACT Background: Soft tissue impingement and lip form have often been overlooked in previous epidemiological surveys. Materials and Methods: About seven thousand 13 year olds with no history of orthodontic treatment were selected from six governorates (Baghdad the capital, Ninevah, Basrah, Diyala, Anbar and Najaf). An intra-oral clinical examination was used to assess traumatic overbite causing soft tissue impingement and the lip form of each student. Results: Soft tissue impingement was found in 2.7% (2.5% palatally and 0.2% labially). Normal lip form was found in 80.7%, contracting lip form in 14.7% and lip trap in 4.6% of the sample. All the previous were non-significantly related to gender and residency. Conclusion: Iraqi children present a much m re favorable lip form than Western children. oKeywords: Soft tissue, impingement, lip form (J Coll Dentistry 2005; 17(2):80-83)

INTRODUCTION

Deep traumatic overbite may lead to gingival recession, looseness of the teeth and periodontal problems (1). This trauma commonly happens on the palatal soft tissue in class II division 1 malocclusion and can happen both on the palate and the labial gingiva of the mandibular incisors in class II division 2 malocclusion Some studies dealing with soft tissue impingement as a result of deep traumatic overbite are summarized in table 1.

The concept of the effect of soft tissues on the occlusal development is by no means new. Desirabode in 1847 described the lips as one of the factors controlling incisors positions (2). The lip form has been assessed by various methods of which are: 1- Clinical: More than one method for clinical

lip assessment were described: a) Assessment of the vertical form of the lips

classifying them into competent and incompetent (4-6). Jones and Oliver (6) defined lips as competent, potentially competent and incompetent lips.

b) Foster and Day (4) classified lip form into normal, contracting and lip trap.

c) Haynes (7) classified the lower lip position into five types and each type was correlated with an overjet range.

d) Direct anthropometric measurement consisting of measuring certain landmarks on the subject’s skin (8).

(1) Assistant Professor at the Department of Orthodontics, College of Dentistry, University of Baghdad.

(2) Professor and Chairmen of the Department of Orthodontics, College of Dentistry, University of Baghdad.

(3) Professor at the Department of Pedodontics and Prevention, College of Dentistry, University of Baghdad.

2- Electromyography to record perioral

muscular activity during rest and function. 3- Intraoral sensors cemented directly on the

teeth to measure the pressure exerted by lips.

4- Cephalometric measurements to assess lip profile including Schwarz, Ricketts, Steiner’s and Holdaway’s lip analyses (9).

The results of some studies on lip form are listed in table 2.


The sample included a total of 7176 intermediate school students 13 years of age. These students were taken from 6 governorates (cities and environs) in Iraq selected to cover the whole country geographically (Baghdad the capital, Ninevah, Basrah, Diyala, Anbar and Najaf) according to a multi-stage stratified sampling technique. Details of the geographic distribution and sampling technique are given in Al-Huwaizi (10).

After excluding the invalid case sheets and isolating the students with some sort of orthodontic treatment, the number of casesheets which entered the statistical analysis dropped to 6957 (11-12). Soft tissue impingement

The sole assessment of the soft tissue was made in the region of the occlusion of the four maxillary and four mandibular incisors. A record was made of any occlusal palatal impingement due to the mandibular incisors, or any mandibular labial impingement due to the maxillary incisors (13). Lip form

The lips were categorized according to Foster and Day (4) as:

Orthodontics, Pedodontics and Preventive Dentistry 80


1. Normal: Lips meet in front of the maxillary incisors in the relaxed posture without circumoral contraction.

2. Contracting: Lips which because of their shape or size, can only meet in front of the maxillary incisors with contraction of the circumoral musculature.

3. Lip trap: The lower lip rests or contracts completely or partly behind the maxillary incisors (Fig. 1).

Statistical analysis Chi square test was used to assess the

association between soft tissue impingement and lip form on one side and gender, urban and rural, and governorates on the other side.

P levels of more than 5% were regarded as statistically insignificant

Figure 1: Patient in rest position showing

lower lip resting behind the maxillary incisors

Table 1: Reported prevalences of tissue impingement (traumatic overbite).

Sample Results Author Country Size Age Labial Palatal

Kelly et al. (21) American WhiteAmerican Blacks 6-11 4.6%

1.2%

Kelly & Harvey (20) American WhiteAmerican Blacks 12-17 1.0%

0.3% Cons et al. (18) America 1337 15-18 0.2% 6.7%

Kinaan (19) Iraq England

250236 11-12 1.2%

6.3% Farah (22) Iraq 101 9-10 1%

Hill (14) Scotland 765 9

12 15

3% 3%

2.7%

Abdulla (15) Iraq 200200200

13 15 17

0% 0.5%0%

3.5% 4%

5.5%

Batayine (16) Jordan 200200200

13 15 17

1% 1%

0.5%

2.5% 3% 4%

Al-Dailami (17) Yemen 400400

10-1213-15

0% 0.75%

3% 2.5%

Table 2: Reported prevalences of lip form.

Sample Lip form Author Country Size Age Normal Contracting Trap

Foster & Day (4) England 1000 11-12 63.2 14.8 22

Abdulla (15) Iraq 200200200

13 15 17

74.5 72.5 81

21.5 26.5 18.5

4 1

0.5

Batayine (16) Jordan 200200200

13 15 17

76 73.5 80

21 25 19

3 1.5 1

Al-Dailami (17) Yemen 400400

10-1213-15

71.25 71.75

26.5 26

2.25 2.25



RESULTS AND DISCUSSION Soft tissue impingement

Of the sample 2.5% had palatal soft tissue impingement, 0.2% had labial soft tissue impingement (Table 3). The prevalence of palatal soft tissue impingement was similar to that found by others (14-17), but it was much less than that found by Cons et al. (18) on Americans and Kinaan (19) on English children and much higher than that of Kelly and Harvey (20) and Kinaan (19) on Iraqi children (Table 1). These differences may be attributed to differences in defining soft tissue impingement and the subjectivity in deciding it during examination.

The distribution of soft tissue impingement by traumatic overbite in the six examined governorates was statistically insignificant both palatally (X2=1.539, d.f.=5, NS) and labially (X2=3.434, d.f.=5, NS) as shown in table 3.

Considering gender difference, soft tissue impingement was statistically insignificantly distributed between both genders and between urbans and rurals both palatally and labially (Table 4 and 5). Lip form

Of the sample, 80.7% had a normal lip form, 14.7% had a contracting lip form and 4.6% had lip trap (Table 6). The prevalence of contracting lips was very similar to the one of Foster and Day (4) but smaller than those of others (15-17). On the hand, the prevalence of lip trap was very similar to that of Abdulla (15) and higher than

those of Batayine (16) and Al-Dailami (17) but remarkably smaller than that of Foster and Day (4) as shown in table 2.

The reason for this noticeable difference from the findings of Foster and Day (4) is the much higher prevalence of class II malocclusion in this English sample than that found in the present sample.

Contracting lips were highest in Diyala (19.9%) and lowest in Najaf (12.9%). Lip trap was also highest in Diyala (5.4%) and lowest in Najaf (3.5%). The distribution of lip form in the six examined governorates was statistically significant (X2=34.389, d.f.=10, p<0.001) as shown in table 6. This is in coincidence with the previous finding that Diyala showed the highest overjet and Najaf showed the least overjet value (23).

Considering gender, lip form was statistically insignificantly distributed between both genders for the urbans (X2=1.202, d.f.=2, NS), rurals (X2=2.297, d.f.=2, NS) and total sample (X2=0.113, d.f.=2, NS) as shown in table 7. This came in agreement with the findings of Al-Dailami (17).

Lip form was also statistically insignificantly distributed between urbans and rurals for the males (X2=0.559, d.f.=2, NS), females (X2=3.517, d.f.=2, NS) and total sample (X2=0.694, d.f.=2, NS) as shown in table 7.

Table 3: Distribution (%) of the soft tissue impingement according to type by governorate.

Type Baghdad N=1995

NinevahN=991

BasrahN=989

DiyalaN=994

AnbarN=995

NajafN=993

Total N=6957

Palatal 2.6 2.4 2.1 2.3 2.6 2.9 2.5 Labial 0.2 0.2 0.1 0.1 0.2 0.4 0.2

Table 4: Distribution (%) of the soft tissue impingement according to type by residency and

gender.

Urban Rural Total Type Male

N=1739 Female N=1744

Total N=3483

Male N=1738

FemaleN=1736

Total N=3474

Male N=3477

Female N=3480

Total N=6957

Palatal 2.6 2.2 2.4 2.8 2.4 2.6 2.7 2.3 2.5 Labial 0.2 0.2 0.2 0.2 0.1 0.2 0.2 0.1 0.2

Table 5: Chi square tests between both genders and residencies (urban and rural) for soft tissue

impingement.

Gender difference Residency difference Location Chi square Urban Rural Total Male Female Total

X2 0.451 0.408 1.008 0.010 0.018 0.061 Palatal p level NS NS NS NS NS NS

X2 0.000 0.166 0.310 0.125 0.000 0.000 Labial p level NS NS NS NS NS NS



Table 6: Distribution (%) of lip form according to type by governorate.

Type Baghdad N=1995

NinevahN=991

BasrahN=989

DiyalaN=994

AnbarN=995

NajafN=993

Total N=6957

Normal 81.3 82.3 81.8 74.6 79.9 83.6 80.7 Contract 14.2 13.0 13.5 19.9 15.2 12.9 14.7 Trap 4.5 4.6 4.7 5.4 4.9 3.5 4.6 Total 100 100 100 100 100 100 100

Table 7: Distribution (%) of lip form according to type by residency and gender.

Urban Rural Total Type Male

N=1739Female N=1744 N=3483

Total Male N=1738

Female N=1736

Total N=3474

Male N=3477

Female N=3480

Total N=6957

Normal 80.4 81.2 80.8 81.1 80.1 80.6 80.8 80.6 80.7 Contract 14.8 14.8 14.8 14.7 14.6 14.6 14.7 14.7 14.7 Trap 4.8 4.0 4.4 4.3 5.4 4.8 4.5 4.7 4.6 Total 100 100 100 100 100 100 100 100 100

REFERENCES 1- Bergerson EO. A longitudinal study of anterior vertical

overbite from 8-20 years of age. Angle Orthod 1988; 58: 237-55.

2- Luffingham JK. The lower lip and the maxillary central incisors. Eur J Orthod 1982; 4: 263-8.

3- Walther DP. Walther’s Orthodontic notes. 1st ed. Wright PSG, Bristol 1960.

4- Foster TD, Day AJW. A survey of malocclusion and the need for orthodontic treatment in Shropshire school population. Brit J Orthod 1974; 1(3): 73-8.

5- Ingervall B, Elliason GB. Relationship between lip strength and lip function in posture and chewing. Eur J Orthod 1982; 4: 45-53.

6- Jones ML, Oliver RG. Walther and Houston’s Orthodontic notes. 5th ed. Wright PSG, Bristol 1994.

7- Haynes S. The lower lip position and incisor overjet. Brit J Orthod 1975; 2(4): 201-5.

8- Farkas LG, Katic MJ, Hreczko TA, Deutsch C, Munro IR. Anthropometric proportions in the upper lip-lower lip-chin area of the lower face in young white adults. Am J Orthod Dentofac Orthop 1984; 86(1): 52-60.

9- Rakosi T. An atlas and manual of cephalometric radiography. Wolfe Med Publ Ltd; 1982.

10- Al-Huwaizi AF. Occlusal features, perception of occlusion, orthodontic treatment need and demand among 13 year old Iraqi students (A national cross-sectional epidemiological study). Ph.D. Thesis, College of Dentistry, University of Baghdad, Iraq 2002.

11- Al-Huwaizi AF, Al-Alousi WS, Al-Mulla AA. Orthodontic treatment demand in Iraqi 13 year olds - A national survey. J Coll Dent 2002; 13:134-9.

12- Al-Huwaizi AF, Al-Mulla AA, Al-Alousi WS. Method of a national survey on malocclusion. J Coll Dent 2002; 13: 12-23.

13- Baume LJ, Horowitz HS, Summers CJ, Backer Dirks O, Carlos JP, Cohen LK. A method for measuring occlusal traits developed by the FDI commission on classification and statistics for oral conditions. Int Dent J 1973; 23: 530-7.

14- Hill PA. The prevalence and severity of malocclusion and the need for orthodontic treatment in 9-, 12-, and 15-year-old Glasgow schoolchildren. Br J Orthod 1992; 19(2): 87-96.

15- Abdulla NM. Occlusal features and perception: a sample of 13-17 years old adolescents. Master Thesis, College of Dentistry, University of Baghdad, Iraq 1996.

16- Batayine FAM. Occlusal features and perception of occlusion of Jordanian adolescents: a comparative study with an Iraqi sample. Master Thesis, College of Dentistry, University of Baghdad, Iraq 1997.

17- Al-Dailami MMY. Occlusal features in a sample of Yemeni students aged (10-15) years. Master Thesis, College of Dentistry, University of Baghdad, Iraq 2000.

18- Cons NC, Mruthyunjaya YC, Pollard ST. Distribution of occlusal traits in a sample of 1337 children aged 15-18 residing in upstate New York. Int Dent J 1978; 28(2): 154-64.

19- Kinaan BK. Overjet and overbite distribution and correlation: a comparative epidemiological English-Iraqi study. Brit J Orthod 1986; 13: 79-86.

20- Kelly JE, Harvey CR. An assessment of the occlusion of the teeth in youths 12-17 years. Washington DC: National Center for Health Statistics. DHEW publication no. (HRA) 1977; 77-1644 (Vital and health statistics; 11(162)).

21- Kelly JE, Sanchez M, van Kirk LE. An assessment of the occlusion of the teeth of children 6-11 years. Washington DC: National Center for Health Statistics. DHEW publication no. (HRA) 1973; 74-1612 (Vital and health statistics; 11(130): 1-49).

22- Farah ME. The orthodontic examination of children aged 9 and 10 years from Baghdad, Iraq: a clinical and radiographic study. Master Thesis, College of Dentistry, University of Baghdad, Iraq 1988.

23- Al-Huwaizi AF, Al-Mulla AA, Al-Alousi WS. The overjet of Iraqi 13 year olds (a national survey). J Oral Dent Sc 2004; 3(1): 40-6.



Gingival health status among 3-5 years old children in Al-Edwania village, Baghdad

Wesal A. Al-Obaidi, B.D.S., M.Sc.(1)

ABSTRACT Background: Periodontal disease is one of the most widespread diseases in Iraq therefore this study was conducted to assess the periodontal condition. Materials and methods: A sample of 91 children living in AL-Edwania village was examined using plaque and gingival indices. Results: It showed a high prevalence of gingival inflammation, gingival inflammation increased with age, and females had a significantly higher gingival index mean than males. The mild type of gingivitis was found to be the highest score. Higher gingival and plaque index means in posterior segment were demonstrated than that in anterior segment. Conclusion: The most common type of gingivitis was the mild. The GI and PlI were increased with age and higher among females. Keywords: Gingivitis, children, Al-Edwania village. (J Coll Dentistry 2005; 17(2):84-86) INTRODUCTION

Periodontal disease is one of the most widespread diseases, all nations and regions in the world have this disease (1). Epidemiological studies on prevalence and severity of periodontal disease in Iraq are concentrated mostly on adults (2, 3, 4) while a few studies have been conducted concerning the gingival health condition of children specially in rural areas (5,

6), therefore, this study was designed to estimate the oral hygiene and gingival inflammation among children in AL-Edwania village which is situated 30km west Baghdad city, to obtain a baseline data aids for comparison with other studies. MATERIALS AND METHODS

The sample size of the study was composed of 91 children whose ages ranged between 3-5 years. The sample was selected randomly fro1m different areas of AL-Edwania village. Sharp sickle-shaped caries explorers (No.00) and plane mouth mirrors (No.4) with natural light were used for oral examination. Oral hygiene was assessed using the plaque index, (7) while gingival condition was assessed using the criteria of gingival index system. (8) Index teeth of Ramfjord (9) were examined to represent the whole dentition. Only fully erupted teeth were scored, if the index tooth was partially erupted or missing, the segment

(1) Assistant professor, Department of Pedodontics and

Preventive Dentistry, College of Dentistry, Baghdad University.

would be excluded. For statistical analysis, student T-test was used. RESULTS

Distribution of the sample according to age and sex is shown in Table (1). The total sample consisted of (91) children, (49) males and (42) females. Table (2) shows that although girls had a higher mean PI than boys, it was not significant. The total means PI was found to be (1.16). The PI and GI scores were increased with age (Tables 2, 3). Table (3) revealed that girls had a significantly higher mean GI than boys for the total sample. PI and GI for anterior teeth were found to be significantly lower than that for posterior teeth (P<0.05) (Table 4). Table (5) demonstrated that (91.3%) of the children were with gingival inflammation, where as (8.7%) of them were with healthy gingiva. The highest percentage of affected children was found to be with mild gingivitis.

DISCUSSION

This study showed that PI mean and GI mean were high, this finding is in agreement with Sadki's study (5) and in disagreement with AL-Obaidi's study, (10) which may be attributed to type of the geographical location (whether it was urban or rural), that rural people had higher scores than those in other areas. (3, 11) Although different indices were used, the comparison with other studies showed that gingival inflammation increased with age, this finding is in accordance with many previous



studies. (5,6,10) This study indicated a high prevalence of gingival inflammation, this comes in accordance with other studies, (3, 6, 12) and it may be attributed to the poor oral hygiene, and that there was a strong correlation between the prevalence and severity of periodontal disease and oral hygiene and it was documented, (3, 7) this study revealed that GI was significantly higher in posterior than in anterior segment, this finding was in accordance with many studies. (5, 12)

Females had a significantly higher GI mean than males; this finding was in disagreement with many studies (3, 5, 10) and in agreement with EL-Samarrai's study. (12) The data showed that the mild type of gingival inflammation had the highest percentage among children, this was in agreement with other studies (10, 13) and in disagreement with AL-Sayyab's study (3) and it may be due to the fact that the commonest type of gingivitis in early childhood is the mild one and that the severity increases with age.

Table 1:Distribution of children according to age and sex. Male Female Both Age

No. % No. % No. % 3 11 12.09 12 13.18 23 25.27 4 20 21.98 11 12.09 31 34.07 5 18 19.78 19 20.88 37 40.66

All Ages 49 53.85 42 46.15 91 100.00

Table 2: Plaque index and standard deviation of the mean by age and sex. Boys Girls Both Age

No. Mean ±S.D No. mean ±S.D No. mean ±S.D 3 11 0.76 0.50 12 0.93 0.42 23 0.85 0.46 4 20 1.05 0.42 11 1.20 0.42 31 1.10 0.42 5 18 1.31 0.48 19 1.48 0.77 37 1.39 0.64

All Ages 49 1.08 0.50 42 1.25 0.63 91 1.16 0.57

Table 3: Gingival index and standard deviation of the mean by age and sex Boys Girls Both Age

No. Mean ±S.D No. Mean ±S.D No. Mean ±S.D 3 11 0.64 0.31 12 0.58 0.45 23 0.52 0.39 4 20 0.54 0.37 11 0.84* 0.32 31 0.65 0.38 5 18 0.94 0.79 19 1.22 0.85 37 1.08 0.82

All Ages 59 0.67 0.58 42 0.94** 0.68 91 0.73 0.56 *t=2.19, P<0.05, d.f=29

** t=2.10, p<0.05, d.f=89 Table 4: Plaque index and gingival index of anterior and posterior segments.

PlI GI Age Sex No. Ant

Mean±SD Post

Mean±SD Ant

Mean±SD Post

Mean±SD M 11 0.77±0.48 0.74±0.53 0.41±0.37 0.53±0.30 F 12 0.83±0.39 0.98±0.46 0.46±0.40 0.64±0.49 3

Both 23 0.80±0.43 0.86±0.50 0.44±0.38 0.59±0.40 M 20 0.96±0.41 1.13±0.39 0.47±0.49 0.60±0.44 F 11 1.05±0.49 1.23±0.46 0.65±0.37 0.91±0.36 4

Both 31 0.99±0.43 1.16±0.41 0.53±0.45 0.71±0.44 M 18 1.06±0.59 1.39±0.50 0.78±0.83 1.01±0.80 F 19 1.32±0.83 1.53±0.76 1.03±0.92 1.27±0.87 5

Both 37 1.19±0.72 1.46±0.64 0.91±0.87 1.14±0.84 M 49 0.95±0.50 1.13±0.52 0.57±0.63 0.73±0.61 F 42 1.11±0.67 1.29±0.65 0.77±0.71 1.00±0.71 All ages

Both 91 1.02±0.58 1.21±0.59* 0.66±0.67 0.86±0.67**

*t=2.18, P<0.05, d.f=180 **t=2.01, p<0.05, d.f=180



Table 5: Distribution of children in relation to severity of gingival inflammation by sex.

Scores Male No. %

Female No. %

Both No. %

0 4 8.1 4 9.5 8 8.7 0.1-1 38 77.6 26 61.9 64 70.3 1.1-2 6 12.3 10 23.8 16 17.6 2.1-3 1 2 2 4.8 3 3.4

REFERENCES 1- WHO. Epidemiology, etiology and prevention of

periodontal disease. Technical Report Series; 1978, No. 621. WHO Geneva, Switzerland.

2- Ghali R. Oral health status and treatment needs among students of Baghdad University. (Thesis) ; 1989.

3- AL-Sayyab M. Oral health status among 15-year-old school children in central region of Iraq. (Thesis) ; 1989.

4- Rawenduzy K. Pattern of periodontal breakdown among a selected adult population living in rural areas in the southern part of Iraq. (Thesis) ; 1992.

5- Sadki M, AL-Azawi L. Gingival health status among children and teenagers in Badran village, Baghdad. Iraqi Dent J 1997; 20: 139-44.

6- AL-Sayyab M. Periodontal treatment needs among Iraqi children living in two Iraqi villages, Sheha and Albu Etha. J College of Dentistry 1995; Accepted for publication.

7- Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odont Scand 1964; 22: 121-35.

8- Löe H, Silness J. Periodontal disease in pregnancy. Acta Odont Scand 1963; 21: 533-51.

9- Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Periodontol 1959; 30: 51-9.

10- AL-Obaidi W. Oral health status in relation to nutritional status among kindergarten children in Baghdad, Iraq. (Thesis) ; 1995.

11- AL-Alousi W, Legler D, Janison H. Methods for a survey of oral health of secondary school students in Iraq. Iraqi J Dent Res 1981; 2: 33.

12- EL-Samarrai S. Oral health status and treatment needs among preschool children in Baghdad, Iraq. (Thesis) ; 1989.

13- Stamm JW. Epidemiology of gingivitis. J Clin Periodontol 1986; 13: 360-6.


J College Dentistry Vol. 17(2) 2005 The effect of oral…

The effect of oral respiration on the dental occlusion in patients with respiratory tract allergies

Sundus M. Bezzo B.D.S.; M.Sc.(1)

ABSTRACT: Background: Malocclusion is one of the main problems concerning the oral cavity. This study examined the possible effect of mouth breathing habits in patients with respiratory tract allergies on the dental occlusion. Materials and methods: The study was conducted on 150 patients having allergic rhinitis, asthma or both ranging in age from 5-19 years. A group of 150 healthy individuals matched with gender and age to the study group was used as a control group. The total sample was questioned about their mode of breathing then their occlusion was examined clinically. Results: Significantly higher percentages of mouth breathers were found among the study group (P<0.05). Similarly CLII and CLIII dental occlusion, displaced teeth as well as crowding affected significantly greater percentages of allergic patients in comparison to the control group. Conclusion: Mouth breathing habits in patients with respiratory tract allergies may have an additive role in the development of some undesirable malocclusions. Keywords: Allergic rhinitis, asthma, malocclusion. (J Coll Dentistry 2005; 17(2) 87 -92) INTRODUCTION

Allergic respiratory disorders are significantly connected in their history, etiology, pathology and treatment measures. They are highly prevalent conditions that have significant social implication (1)

Allergic rhinitis is a term used to describe disorders of the nasal mucosa which are caused by inhaled allergens that indicates an inflammatory reaction with associated symptoms of nasal discharge or obstruction, sneezing, rhinorrhea, pain and anosmia (2). Similarly asthma is a chronic inflammatory disorder of the airways, characterized by reversible airflow obstruction causing cough, chest tightness and shortness of breath (3).

The effect of mouth breathing on dento-facial development is controversial; some considered it as the primary factor in the etiology of malocclusion and other facial abnormalities (4). Others found that mouth breathing is unrelated to the type of occlusion (5,6), while others suggested that it is may be the additive factor in the development of undesirable malocclusion particularly around the prepubertal timing of growth during the period of transitional dentition (7).

Marks, in 1965, found that persistent oral habits are frequent in children with perennial allergic rhinitis.

(1) Lecturer, Department of Paedodontic and Preventive Dentistry; College of Dentistry, University of Baghdad.

He concluded that mouth breathing in the infant and children should be regarded as an allergic manifestation and that efficient allergy management can forestall this major contributor to the progressive effects of dento-facial deformities (8).Respiratory allergy is considered one of the exciting factors that causes mouth breathing due to impairment of nasal breathing (9,10,11).

Many authors who found that mouth breathing as a result of allergy affects the dento-facial features leading to paranasal depression and overriding maxillary incisors (12,13), retroclined lower incisors (10,14), high arched narrow palate “constricted maxillary arch” (12,13,14), and posterior cross-bites in children having asthma (15) or allergic rhinitis with an increased upper anterior and total anterior facial height as well as greater overjets (16). Others found inconclusive evidence linking malocclusion and mouth breathing in patients having respiratory tract allergies (5,17).

This study was conducted to see the effect of persistent or intermittent oral respiration on the developing dentition in patients with respiratory tract allergies in Baghdad city to point out if this group has any special orthodontic needs. MATERIALS AND METHODS

The sample included 150 patient with an age range 5-19 years, diagnosed as having (allergic rhinitis &/ or asthma) attending the Allergy Institute in Baghdad as the study group. The control group consisted of an equal number of healthy individuals selected



randomly from primary and secondary schools in Baghdad city and matched concerning age and gender to the study group.

Information about the medical condition of the patients in the study group concerning type of allergy and the time and duration of disease onset were taken from their medical record.

Mouth breathing habit was established by patient observation and parent’s corroboration as being the predominant mode of breathing (15). Then the occlusion was examined including: 1- The antero-posterior occlusion: A/ for the permanent dentition, Angle

classification according to the first molar relation (18). If not applicable the canine relation was recorded (19). In case of primary dentition, the intermaxillary relation was regestered (20). If the above methods were not applicable, the incisal relationship was recorded according to the British standard classification (21).

B/ Overjet: using a vernier with depth gauge, the overjet was recorded to the 0.1 mm and if the four upper incisors occluded lingually to the four lower incisors, the overjet was registered as reversed (22).

2- Vertical occlusion: the overbite was measured using the vernier to the complete 0.1mm. It was recorded according to Nilner and Lassing (20).

3- Transverse occlusion: subjects were recorded as having anterior crossbite if 1, 2 or 3 incisors occlude lingual to mandibular incisors (23). Posterior crossbite was recorded as unilateral or bilateral if the maxillary teeth occluded lingually to those of the corresponding mandibular teeth (22,24).

The above three relations were recorded when the dental arches were in centric occlusion.

4- Intra-arch discrepancies: 1) A modified instrument from Vankirk and Pennell (1959) and Bjork et al. (1964) was used to record: A/ rotation as present if one or more fully

erupted teeth are rotated mesially as as or distally more than 15˚ (22).

B/ displacement if one or more fully erupted teeth was displaced bodily more than 1mm, buccally or lingually from the ideal arch line (25).

2) Spacing and crowding were assessed for the maxillary and mandibular dentitions separately and recorded as if a shortage or

an excess of 2mm or more was recorded in one of the six segments of both upper and lower arches (22,24). Data were statistically analyzed using Chi-

square test to compare percentages. RESULTS

The types of dentitions found in the sample of an age range “5-19” years included primary, mixed and permanent dentition. 88 males formed 58.7% of the study group and the rest 62 (41.3%) were females and those figures were matched when selecting their healthy controls (Table- 1).

Of the total experimental group, 103 (68.7%) were asthmatic and only 13 (8.7%) had allergic rhinitis. Allergy affected about half of the allergic patients (50.6%) for 5 years or more (Figure- 1).

More significant mouth breathing habits mostly during the disease episodes were recorded among allergic patients (P<0.05) as shown in Figure- 2. When comparing the antero-posterior occlusion between the two groups, more allergic patients had Cl II and Cl III malocclusion than the healthy controls and the difference between the two groups was significant at P<0.05 (Table- 2).

Some of the measured occlusal traits were not recordable due to the uncompleted eruption of teeth or were doubtful in few individuals; therefore, these cases were excluded from the statistical analyses for that specific occlusal trait. Table- 3 reveals non-significant differences between the two groups in overjet, overbite. Higher percentages of patients with respiratory tract allergies had anterior cross-bite (6.8%) as well as posterior cross-bite (9.5%) compared to the controls (2.7%) and (4.4%) respectively, yet these differences didn’t reach the level of statistical significance (Table- 3).

As shown in table- 4, rotation of teeth showed a non-significant difference between the two groups studied. But significantly higher percentages of allergic patients were affected by tooth displacement than their healthy controls. As well as, crowding of teeth affected 61 allergic patients and 43 healthy controls, this difference was statistically significant (P<0.05). While spacing was recorded in 39 allergic patients only compared to 44 healthy individuals, which was non-significant statistically.



Table 1: Sample Distribution According to Age and Gender Cases Controls Age / Years Gender

NO. % NO. % M 19 12.67 19 12.67 F 16 10.67 16 10.67 5 - 9 T 35 23.33 35 23.33 M 49 32.67 49 32.67 F 21 14.00 21 14.00 10-14 T 70 46.67 70 46.67 M 20 13.33 20 13.33 F 25 16.67 25 16.67 15 -19 T 45 30.00 45 30.00 M 88 58.67 88 58.67 F 62 41.33 62 41.33 TOTAL T 150 100.00 150 100.00

4.66

%

0.67

%

0.67

%

28%

5.33

% 10%

21.3

3%

2%

6% 14.6

7%

0.67

% 6%<1 Year 1- 4 Years 5-9 Years 10+ Years

ASTHMA RHINITIS BOTH

Figure 1: Type and Duration of the Allergic Disorder

9.33%66%

67.33%22%

23.33%12%

Never

Occasional

Always

CASES CONTROLS

Figure 2: Mouth Breathing Habits



Table 2: Antero-Posterior Relationship

Controls Cases P- Value % No. % No.

Antero-Posterior relationship

80.67 121 74 111 CL I 14.67 22 19.33 29 CL II 4.67 7 6.67 10 CL III P<0.01

100 150 100 150 Total

Table 3:Distribution of Antero-posterior, Vertical and Transverse occlusions among the Two Groups

Cases Controls Malocclusion Trait No. % No. %

P-Value

1/ Overjet Reverse (<0) 2 1.52 3 2.31 Normal (0-4) 96 72.73 92 70.77 Increased (5-8) 32 24.24 33 25.38 Excessively Increased (9+) 2 1.52 2 1.54 Total 132 100 130 100

N.S.

2/ Overbite Openbite (<0) 1 0.76 0 0 Normal (0-4) 94 71.76 90 69.23 Deep Bite (5+) 36 27.48 40 30.77 Total 131 100 130 100

N.S.

3/ Crossbite A) Anterior Negative 136 93.15 140 97.22 Positive 10 6.85 4 2.78 Total 146 100 144 100

N.S.

B) Posterior Negative 134 90.54 138 94.52 Positive Unilateral 10 6.76 6 4.11 Positive Bilateral 4 2.70 2 1.37 Total 148 100 146 100 Positive 50 33.33 46 30.67 Total 150 100 150 100 Positive 61 40.67 43 28.67 Total 150 100 150 100

N.S.

DISCUSSION

Patients with respiratory tract allergy showed a significant higher tendency for occasional and persistent mouth-breathing habits compared to their healthy controls, which could be referred to their allergic disorder that necessitate oral respiration due to nasal blockage in allergic rhinitis or shortness of breath in asthma that are essential clinical manifestations of these disorders. This result matched the previous findings of Marks (1965) (8), Hannuksela (1981) (10) and Venetikidou

(1993) (15). The disorder was diagnosed 5 years ago or even more in about 50% of the total allergic patients when this research was conducted, meaning that these mouth breathing habits affected most of the study group in the prepubertal growth period which can explain the significant higher percentage of CL II dental relation than their controls that agrees with Meslen et al. (1987) (26). But it disagrees with others findings such as Miller (1949) (5).

Deference in overjet and overbite between the two groups were statistically non-significant which is similar to Hannuksela



(1981) (10) and Venetikidou (1993) (15) findings, yet it disagree with Bresolin et al. (1983) (16), who reported an increased overjets in patients

with allergic rhinitis and Meslen et al. (1987) who found a higher frequency of openbite in mouth breathers (26).

Table 4: Distribution of Intra-arch Discrepancies among the Two Groups

Cases Controls Malocclusion Trait No. % No. %

P- Value

4/ Rotation of Teeth Negative 53 35.33 59 39.33 Positive 97 64.67 91 60.67 Total 150 100 150 100

N.S.

5/ Displacement of Teeth Negative 100 66.67 104 69.33 Positive 50 33.33 46 30.67 Total 150 100 150 100

P<0.05

6/ Crowding of Teeth Negative 89 59.33 107 71.33 Positive 61 40.67 43 28.67 Total 150 100 150 100

P<0.01

7/ Spacing of Teeth Negative 111 74 106 70.67 Positive 39 26 44 29.33 Total 150 100 150 100

N.S.

Higher percentages of anterior and posterior crossbite “especially unilateral posterior crossbite” affected the study group individuals compared to their healthy controls although it didn’t reach the level of statistical significance. That can be attributed to the mouth breathing habits, which leads to constriction in the maxillary arch during the growth period resulting in crossbite. This agrees with authors reporting a crossbite or a tendency towards such in patients with respiratory allergy (15,16). On the contrary, Miller in 1949 couldn’t find any differences between allergic and non-allergic patients included in his study concerning posterior crossbite (5) .

As for rotation and displacement of teeth, the slight differences between the two groups studied were of statistical significance concerning the displaced teeth only. This might be due to the morphological changes occurring in the arch dimensions in addition to the positional and functional alterations affecting the oral soft tissues “tongue and lips” as a result of mouth breathing habits in these patients.

When comparing crowding and spacing of teeth between allergic patients and their healthy controls, highly significant higher percentages

of allergic patients were affected by crowding compared to the controls. This finding agrees with Balyeat and Bowen (1934) (9). Again this could be explained by the possible narrowing occurring in the maxillary arch due to oral respiration in patients with respiratory tract allergy. Similarly, Miller (1949) (5), reported a slightly higher percentages of crowding in allergic patients in comparison to non-allergic individuals, yet the differences didn’t reach the level of statistical significance in his study.

An early diagnosis and proper medical treatment of patients with respiratory tract allergy can prevent any possible adverse effect on the growing face and the developing occlusion especially in prepubertal period during the transitional dentition. Patients with respiratory tract allergy included in this study were following a hyposensitization program to raise their immune system tolerance to the specific allergens they are allergic to. This resulted in reducing the frequency and severity of their allergic attacks, eventually it can be concluded that the frequency of mouth breathing habits “especially those reporting occasional oral respiration during the disease episodes only” is reduced after a while following starting this type of treatment in most of them. This might explain the slight



differences in some malocclusion traits examined.

It is also essential to take in consideration that other factors such as hereditary factors has an important role on the developing occlusion which was not included in the present study.

In conclusion, the prevalence of mouth breathing habits is greater in patients with respiratory tract allergy compared to healthy individuals included in this study due to the nature of their allergic disorder and this could be an additive factor in the development of undesirable malocclusion in these patients. REFERENCES

1. Busse WW, Goldstein R, Rachelefsky GS, Rotrosen D. Managed care and upper respiratory diseases: A focus on allergy and asthma. Clinician 1997; 15 (2).

2. Zeiger RS, Schatz M. Rhinitis. In Internal Medicine. Editor-in-chief Stein JH, 5th ed. chapter 187. Mosby company, USA. 1998; p. 1180-5.

3. Crompton GK, Haslett C, Chilvers ER. Diseases of the respiratory system. In DAVIDSON’S principles and practice of medicine. Edited by Haslett C, Chilvers ER, Hunter JAA, Boon NA, 18th ed. chapter 4. Churchill livingstone, London. 1999; p. 303-82.

4. Tarvonen P, Koski K. Craniofacial of 7-year-old children with enlarged adenoids. Am J Orthod 1987; 91: 300-4.

5. Miller HI. The relation of long-continued respiratory allergy to occlusion. Am J Orthod 1949; 35:780-9.

6. O’Ryan FS, Ghallagher DM, LaBnac JP, Epker BN. The relation between nasorespiratory and dentofacial morphology: A review. Amer J Orthod 1982; 82(5): 403-10.

7. Subtelny JD. Oral respiration: facial mal-development and corrective dentofacial orthopedics. Angle Orthod 1980; 50: 147-64.

8. Marks MB. Allergy in relation to orofacial dental deformities in children: A review. J Allergy 1965; 36:293-302.

9. Balyeat RM, Bowen R. Facial and dental deformities due to perennial nasal allergy. Int J Orthodontia 1934; 20: 445-60.

10. Hannuksela A. The effect of moderate and severe atopy on the facial skeleton. Eur J Orthod 1981; 3(3): 187-94.

11. Zhu JF, Hidalgo HA, Holmgreen WC, Redding SW,

Hu J, Henry RJ. Dental management of children with asthma. Pediatric Dentistry 1996; 18 (5): 363-70.

12. Cohen MB. Orthodontic problems associated with allergy. Angle Orthod 1937; 7(3): 150-4.

13. Fuchs AM. Allergy related to dental practice. Dental Outlook 1939; 26: 10-13.

14. Straub WJ. Frequency of allergy in orthodontic patients. J Am Dent A 1944; 31: 334-42.

15. Venetikidou A. Incidence of malocclusion in asthmatic children. J Clin Ped Dent 1993; 17(2): 89-94.

16. Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S. Mouth breathing in allergic children. It’s relationship to dento facial development. Am J Orthod 1983; 83: 334-40.

17. Chobot R, Merrill EF. Bone scorings in normal and allergic children. J Allergy 1937; 8: 588-90.

18. Angle EH. Classification of malocclusion. Dent Cosmos 1899; 41: 248-64.

19. Foster TD. A textbook of orthodontics. 2nd ed. Blackwell Scientific Publications, Oxford. 1982.

20. Nilner M, Lassing S. Prevalence of functional disturbances and diseases of the stomatognathic system in 7-14 years olds. Swed Dent J 1981; 5: 173-87.

21. Mills JR. Principles and practice of orthodontics. Churchill Livingstone. 1987.

22. Bjork A, Krebs A, Solow B. A method for epidemiological registration of malocclusion. Acta Odontol Scand 1964; 22: 27-41.

23. Egermark-Eriksson I, Carlsson GE, Ingervall B. Prevalence of mandibular dysfunction and oro-facial parafunction in 7-, 11- and 15- year- old Swedish children. Eur J Orthod 1981; 3(3): 163-72.

24. Federation Dentaire Internationale. A method of measuring occlusal traits developed by FDI commission on classification and statistics for oral conditions, working group 2 on dento-facial anomalies. Int Dent J 1973; 23(3): 530-7.

25. Van Kirk LE, Pennell EH. Assessment of malocclusion in population groups. Am J Orthod 1959; 45(10): 752-8.

26. Meslen B, Attina L, Santuari M, Attina A. Relationships between swallowing pattern mode of respiration, and development of malocclusion. Angle Ortho d 1987; 57 (2): 113-20.


J College Dentistry Vol. 17(2) 2005 Evaluation of the….

Evaluation of the complications due to delayed management of trauma to anterior teeth.

Lubab J. Mohammed B.D.S., M.Sc.(1)

ABSTRACT: Background: Trauma to anterior teeth is a serious problem in young aged patients. This study was done to evaluate the complications that occur if treatment to the traumatized anterior teeth (primary or permanent) was delayed. Materials and Methods: Patients who came to the Department of Pedodontics and Preventive Dentistry at the college of dentistry / Baghdad seeking treatment of traumatized anterior teeth for esthetic or symptomatic reason were studied. Dental and medical history was taken, and the injured teeth were examined clinically and radiographically. Results: Most of the patients were late in seeking treatment month or more. Trauma which involves enamel and dentin was seen in (51) cases and pulp necrosis was seen in (43.1%) of these cases. Enamel and dentine fracture with pulp exposure (36 cases) showed a very high frequency of pulp necrosis (72.2%). External and internal root resorption were seen in only (13) cases of the (153) teeth examined. Conclusion: There is a need to educate the parents and the public about the seriousness of dental trauma and urge them to seek dental treatment as soon as possible. In addition a thorough clinical and radiographic examination is essential to identify the complications of dental trauma and treat them. Keywords: Injured teeth, pulp necrosis, (J Coll Dentistry 2005; 17(2) 93-96)

INTRODUCTION

Oral and dental trauma is common in infants, preschool and school aged children (1). Approximately 50% of children will sustain traumatic dental injury during childhood (2). Injuries to the mouth may include teeth that are: - Knocked out, fractured, forced out of position, pushed up, or loosened. Root fracture and dental bone fracture can also occur (3). Many traumatized teeth can be restored to form and function with prompt, appropriate dental care, however a number will inevitably develop complications, such as pulp necrosis, pulp canal obliteration, root resorption, and loss of marginal attachment(4). It is not known how lack of treatment or delayed management will affect the long term prognosis of trauma.

This study was an attempt to determine the effect of delayed management of traumatized primary and permanent teeth, with the aid of clinical and radiographic examination. MATERIALS AND METHODS

Seventy eight patients reported to the Department of Pedodontics and Preventive Dentistry at the College of Dentistry/ Baghdad University, during a one year period (2003-2004), with injured teeth.

(1) Assistant lecturer, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad

They were examined clinically for the presence of discoloration of the crown, tenderness to percussion, and signs of swelling or a sinus tract, as well as reaction to cold.

Periapical radiographs of the traumatized teeth were taken using the standard periapical bisecting angle technique. All radiographs were read under standardized conditions using an x – ray viewer and magnification. The assessment included periapical pathology, root resorption and root fracture

RESULTS

The sample consisted of 78 children aged between 2-13 years. Male patients represented 65.4% and female patients 34.6%. The causes of dental trauma in relation to age and gender are shown in Table (1). Fall represented the most common cause of trauma 69.2% for all age groups followed by other causes like car accidents and hitting a hard object 12.8%. The age group that showed the highest number of dental trauma was 8–10 years in which 37 children were affected Table (1).

The maxillary permanent central incisors were the most frequently injured teeth 66% followed by the maxillary permanent lateral incisors 11.1%, while the mandibular permanent central and lateral incisors were less involved. On the other hand the maxillary deciduous central incisors represented 7.2% of the teeth affected. This is all shown in Table (2).



Most of the patients had a treatment delay exceeding 1 month Table (3). In addition, the number of patients who seek treatment for esthetic reasons was equal to those who seek treatment due to symptoms

Enamel-dentin fracture (Cl.2) was found to be the most common type of dental trauma, and in 43.1% of the cases it ended with pulp necrosis Table (4). Enamel-dentin fracture with pulp exposure represented the second common type of dental trauma and showed a frequency of 72.2% pulp necrosis Table (4). The same table shows that, root resorption complication was seen in only 13 teeth of the 153 teeth involved in this study.

DISCUSSION

Traumatic dental injury is a common accident during childhood. Because time of injury is one of the most critical factors determining clinical outcome and maximizing prognosis, all dental injuries should be considered true emergencies. As far as it is known, there was no previous research in Iraq that studied the importance of this factor, and the present study is an attempt to evaluate the effect of delayed management on the long term prognosis of trauma.

Table 1: Etiology of dental trauma according to age and gender

Fall Sports Fight Other Age Group (year)

Gender No.No. % No. % No. % No. %

M 2 2 100 0 0 0 0 0 0 F 0 0 0 0 0 0 0 0 0 2-4

Both 2 2 100 0 0 0 0 0 0 M 1 1 100 0 0 0 0 0 0 F 5 4 80 0 0 1 20 0 0 5-7

Both 6 5 83.3 0 0 1 16.7 0 0 M 25 17 68 0 0 4 16 4 16 F 12 9 75 1 3.8 0 0 2 16.7 8-10

Both 37 26 70.3 1 2.7 4 10.8 6 16.2 M 23 14 60.9 6 26.1 0 0 3 13 F 10 7 70 0 0 2 20 1 10 11-13

Both 33 21 63.6 6 18.2 2 6.1 1 3 M 51 34 66.7 6 11.8 4 7.8 7 13.7 F 27 20 74.1 1 3.7 3 11.1 3 11.1 Total

Both 78 54 69.2 7 8.9 7 8.9 10 12.8

Table 2: Location of traumatized teeth

Teeth Maxilla % Mandible % Total % Permanent central incisor 101 66 12 7.8 113 73.8 Permanent lateral incisor 17 11.1 5 3.3 22 14.4 Primary central incisor 11 7.2 0 0 11 7.2 Primary lateral incisor 4 2.6 0 0 4 2.6 Primary canine 2 1.3 0 0 2 1.3 Primary first molar 1 0.7 0 0 1 0.7 Total 136 88.9 17 11.1 153 100



Table 3: Reported time since injury and reasons for seeking treatment

Reason for seeking treatmentEsthetic Symptoms

Reported times since injury

Male Female Male FemaleTotal

0-1week 7 2 8 9 26 2-4weeks 2 0 0 0 2 1-6months 4 3 9 3 19 7-12months 1 0 1 0 2 1-4years 9 7 3 2 21 5-10years 3 1 4 0 8 Total 26 13 25 14 78

Table 4: Frequency of pulp necrosis and root resorption in relationship of type of dental injury

Pulp condition Resorption Type of dental injury No. of teethNecrosis % Internal % External %

enamel only 14 3 21.4 0 0 1 7.1 enamel+dentin 51 22 43.1 2 3.9 3 5.8 enamel+ dentin +pulp 36 26 72.2 3 8.3 4 11.1 enamel +dentin+cementum 0 0 0 0 0 0 0 root fracture 2 1 50 0 0 0 0 concussion 5 4 80 0 0 0 0 luxation 25 6 24 0 0 0 0 intrusion 6 0 0 0 0 0 0 extrusion 3 0 0 0 0 0 0 avulsion 11 - - - - - -

Seventy eight children were examined in

this study with different age groups ranged 2-13 years old. Most of cases were in 8-10 and 11-13 years old individuals. This may be due to the vigorous play characteristic of this age group. The study showed that male children were more affected by dental injury than females. This result was in agreement with previous studies (6,

7, 8). The difference between the two sexes could be explained by the fact that males tend to be more active and are more likely to participate in sports and contact games (9).

The cause of most dental injuries among the examined cases was a fall. This finding was similar to other investigators (6,10). Regarding the location of traumatized teeth, the maxillary permanent central incisor and to a lesser extent, the maxillary primary central incisors were the most frequently injured teeth. This result was in agreement with other studies (4, 7, 8, 11). This finding may be due to several causes like protrusion of upper incisors, minimal lip coverage and increased overjet.

This study showed that enamel-dentin fracture Cl (2) was the most common type of fracture 51 cases, followed by enamel-dentin fracture with pulp exposure 36 cases. This result agreed with Al-Nazhan et al. (6). But it

disagreed with other studies like Al-Obaidi and Al-Mashhadani (7), and Al-Obaidi and Al-Geburi(8), who showed that simple enamel fracture Cl (1) was the most common type of fracture. The reason behind this difference is that the investigators in those studies had gone to certain schools and villages and examined all children there, while in this study we have examined only the children who came to the dental hospital seeking treatment because of esthetic or symptomatic reasons like pain and swelling, and Cl (1) fracture is usually not associated with such conditions. The study also concluded that enamel fracture Cl(1) normally represented a minimal risk to pulp tissue, where only 3 of 14 teeth represented showed necrosis with a percentage of 21.4%. These results were in agreement with other studies (6, 12). On the other hand Cl (2) fracture which involves enamel and dentin showed a higher frequency of pulp necrosis 43.1%. In addition 2 teeth (3.9%) showed internal resorption and 3 (5.8%) showed external root resorption. This result agreed with Al-Nazhan et al.(6). The high frequency of pulp necrosis could be explained by the fact that dentin exposure allows the entry of bacteria into the dental tubules, as well as



chemical or thermal irritation of the pulp canal (3).

In case of teeth with pulp exposure Cl(3) the percentage of pulp necrosis was very high (72.2%). The cases of pulp exposure require immediate care and treatment, and eventually lead to pulp necrosis from bacterial infection if not treated (2, 3). Since most of the patients in the present study had a delay management exceeding 1 month this explains the very high percentage of pulp necrosis. Further more, internal root resorption was seen in three teeth and external root resorption in four teeth. This may be related to the necrosis of pulp tissue and the long standing periapical pathosis that was observed radio graphically in some of the cases (6).

Root fracture Cl 5 was seen only in two cases, and pulp necrosis has been found to occur in 50 % of the cases. This result agreed with other studies (6,13).

Pulp necrosis following concussion injuries was found in 80% of the cases. A severe blow to the tooth without crown fracture often results in pulp autolysis and necrosis, since all the energy of the blow is absorbed by the tooth and its supporting tissue rather than being paring partly dissipated as the crown fractures(3). In luxation injuries, pulp necrosis was seen in 24% of the cases. This lower percentage of pulp necrosis may due to the early management of this type of trauma. Luxation injury is usually associated with tooth mobility, a sign that could urge the parents to seek immediate dental treatment for their children.

This study also found that the most common type of injury affecting the primary teeth was luxation, or displacement (Intrusion, extrusion, avulsion). This may be related to the elasticity and resiliency of the alveolar bone surrounding the primary teeth favoring dislocation rather than fracture (1,3) In addition, the study should that time elapsed since these dental injuries was not exceeding one week. Luxation and displacement injuries are usually associated with sever signs and symptoms; therefore the child's parents come to the dental clinical as soon as possible asking for treatment.

Treatment of traumatized anterior teeth is often delayed, because parents cannot ascertain the seriousness of the injury or are unsure where to seek treatment, and this usually leads to high frequency of pulp necrosis. A trauma awareness educational program should be developed to provide information to parents on how to handle an oral emergency in their child and to encourage them and the public to seek immediate treatment. In addition, a thorough clinical and radiographic examination is essential to identify complications of trauma which require treatment. REFERENCES 1- Nowak AJ, Slayton RI. Trauma to primary teeth:

Setting a steady management course for the office. Contemp Ped Arch 2002; 11:99-110.

2- Fountain SB, Camp JH. Traumatic injuries. In: Cohen S, Burns RC. Pathways of the pulp. 6th ed. St. Louis: Mosby; 1994.

3- Mcdonald RE, Avery DR. Dentistry for the child and adolescent. 6th Ed. St. Louis : Mosby ; 1994; P. 525-7.

4- Blinkhorn FA, Mackie IC. The value of radiographs in the assessment of previously traumatized anterior teeth. Europ J Ped Dent 2000; 1(4):157-60.

5- Garcia-Godoy F. A classification for traumatic injuries to primary and permanent teeth. J Pedodon 1981; 5: 295-7.

6- Al-Nazhan S, Andreasen JO, Al-Bawardi S, and Al-Rouq S. Evaluation of the effect of delayed management of traumatized permanent teeth. J Endodon 1995; 21(7):391-3.

7- Al-Obaidi W A, Al-Mashhadani AT. Traumatic dental injury and treatment needs among 5-30 years old in Sheha Village, Baghdad. Iraqi Dent J 2002; 29:299-304.

8- Al-Obaidi W A, Al-Geburi IK. Pattern of traumatic injuries in a sample from Al-Buetha Village, Baghdad. Iraqi Dent J 2002; 30:207-14.

9- Ranalli DN. Sports dentistry. Dent Clin North Am 1991; 35:609-26.

10- Andreasen J. Challanges in clinical dental traumatology. Endo Dent Traumatol 1985; 1:45-55.

11- El-Sammarai S. Oral health status and treatment needs among preschool children in Baghdad. Master thesis 1989. University of Baghdad- Iraqi.

12- Ravan J. Follow up study of permanent incisors with enamel fracture as a result of acute trauma. Scand J Dent Res 1981; 89:213-7.

13- Andreasen F, Andreasen J, Bayer T. Prognosis of root-fractured perment incisors-predication of healing modalities Endo Dent Traumatol 1989; 5:11-22.


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Congratulations Promotion to higher academic positions:

To the Assistant Professorship - Dr. Bashar Hamad - Dr. Tagrid S. Altaei

To the Lecturer rank

- Dr. Iman Ibrahem

Acknowledgement The journal of college of dentistry appreciates all the efforts of Assistant

Professor Dr. Akram Faisal Al-Huwaizi in editing the journal to the present form.

vol 17 no. 2

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