18-2

Scientific Journal Published by the
Vol. 18 No.2 2006

College of Dentistry University of Baghdad
ISSN
ISSN
1680-0087

i

A quarterly peer reviewed and published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Nazar G. Al-Talabani PhD
Vice Editor in chief: 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. Anwar Al-Saeed MSc
Assist. Prof. Dr. Balkees Taha Garib MSc,PhD
Assist. Prof. Dr. Natheer Al-Rawi MSc,PhD
Assistant professor Dr. Abbas Faisal Al-Huwaizi MSc,PhD

Board of editorial consultants:
1- Prof. Dr. Haitham Al-Azzawi MSc
2- Prof.Dr. Salem El-Samarai PhD
3- Prof. Dr. Waleed Al-Hashemi MSc
4- Prof. Dr. Ausama Al-Mulla PhD
5- Prof. Dr. Ahlam Hamed MSc
6- Prof. Dr. Khalid Kezer FDSRCS
7- Prof. Dr. Zainab Al-Dahan MSc, PhD
8- Assist. Prof. Dr. Latifa Al-Mendalawi, MSc.
9- Assist. Prof. Dr. Lamia Al-Azzawi MSc, PhD
10-Assist.Prof.Akram F. Al-Huwaizi MSc, PhD
11- Assist. Prof. Dr. Bashar Hamed MSc, PhD
12- Assist. Prof. Dr. Lekka Mahmood MSc
13- Assist. Prof. Dr. Asma Tahsin MSc

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Administrative secretary: Hadeel Abdul Wahab.
For consultation, please contact:
Website: www.baghdentistry.com
E-mail: dentalcoll@yahoo.com, info@baghdentistry.com
Telephone: (+9641)4169375, Fax: (+9641)4140738

ii
Contents
i
Editor and Editorial Board
ii
Contents
iv
Instructions for the Authors
v
Pioneers
Restorative Dentistry
The effect of prepared denture cleansers on some physical properties of stained acrylic resin denture base
material cured by two different techniques. Salem A.L. Salem, Aseel M.A. Al-Khafaji. 1

A comparison of inferior alveolar nerve block and periodontal ligament injections during endodontic treatment
of human mandibular first premolars. Majida K. Al-Hashimi, Waleed I. Ali.
9
An evaluation of the effects of different polishing agents on the surface roughness of porcelain. Maan R.
Zakaria. Rawaa H. Al-Hadithy.

15
Percentage of undercut areas in edentulous patients. Ghayda'a H. Al-Izzi, Sabah S. Al-Habib
22
An assessment of the effect of using different post systems on the fracture resistance of endodontically treated
teeth. Lamis A. Al-Taie, Aladin Al-Rubayi 25
Evaluation of interfacial bond strength of repaired composite resins. Ali M. Abdul Kareem
32

Oral Pathology,Oral Medicine, and Dental Radiology
The prevalence of oral developmental disturbances and dental alignment anomalies in females of secondary
schools in Thamar city (14-21years). Balkees T. Garib 35
Orthopantomographic assessment of mandibular asymmetry as an aid in diagnosis of tempromandibular
problems. Asmaa T. Uthman, Natheer H. Al-Rawi. 40
Detection of acid fast bacilli in the saliva of patients having pulmonary tuberculosis. Gassan Yassen, Jamal
Noori. 43
Burning mouth syndrome: an analysis of 130 patients. Shanaz M. Gaphor.
47

iii

Oral and Maxillofacial Surgery and Periodontology

Gutta-percha as retrograde filling in endodontic surgery without apicectomy (A clinical and radiographical
study with new technique). Anwar A. Al-Saeed.
52

Comparison of conventional periodontal therapy versus scaling and root planing with subgingival minocycline
gel 2%. Kholood A. Al Safi
57

The effect of aspirin on the periodontal parameter bleeding on probing. Maha Abdul Aziz
63

Blood groups and hypertension. Nasreen A.R. Wafi
68

Relations between dental plaque, gingivitis & dental caries among 21-50 years dental patients. Vian M. Al-Jaf
71

Drainage of submandibular abscess by using local anesthetic block technique of transverse cervical
cutaneous nerve of the neck. Anwar A. Al-Saeed

75

Orthodontics, Pedodontic, and Preventive Dentistry

Treatment of clinically evident skeletal mandibular asymmetry. Nidhal H. Ghaib, Ali F. Al-Zubaidee, Zina
Z. Al-Azawi.
83

Salivary calcium, potassium and oral health status among smokers and non-smokers (a comparative study).
Wesal A. Al-Obaidi.
89

Prevalence, severity and pattern of dental fluorosis among a group of children in Dahmar Yemen. Wesal
A. Al-Obaidi
92

Local anesthetic quality in pedodontic department, College of Dentistry/ University of Baghdad. Abeer
M.Zwain. 96

Some societies of dental specialities

iv

Instruction for the Authors

The quarterly published J ournal 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 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 J C, Zarb GA, Bolender CL. Bouchers prosthodontic treatment for edentulous patients.
9
th
ed. St. Louis: CV Mosby; 1985. p.312-23.
Journal article
4. J ones ER, Smith IM, Doe J Q. 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 authors name and the figures 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.

v

Pioneers

In Memory of Prof. Suad Al-Ani

It is with sorrow that the college of dentistry, university of Baghdad lost
one of its pioneers. She is Professor Suad Al-Ani. She was specialized in
oral pathology since 1965. She was a supervisor of many postgraduate
students in the department of oral diagnosis and a co-supervisor in other
departments.

Date of Birth: 1/7/1937
Bachelor in Dentistry: 30/6/1961
Master degree in oral pathology: In Boston, USA, 12/7/1965
Assistant lecturer: 7/10/1965
Lecturer: 9/7/1970
Assistant professor: 15/8/1973
Head of the department of oral diagnosis: 1/9/1980
Professor: 10/12/1994

J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of prepared
The effect of prepared denture cleansers on some physical
properties of stained acrylic resin denture base material
cured by two different techniques

Salem A.L. Salem, B.D.S., Ph.D.
(1)

Aseel M.A. Al-Khafaji, B.D.S., M.Sc.
(1)

ABSTRACT
Background: The debris in the denture cause many problem to the patient and the use of the denture cleanser is the
solution for this problem but this denture cleanser may affect the properties of the denture. The aim of our study was
to observe the effect of prepared denture cleansers on some physical properties (water sorption, water solubility and
color stability) of the acrylic resin after their immersion in the tea solution and also to compare the effect of those
denture cleansers on heat and microwave cure acrylic resin.
Materials and methods: Heat curing and Microwave acrylic denture was prepared and immersed in four types of
denture Cleansers after their staining with tea then the water sorption, water solubility and color stability of acrylic
resin was measured .
Results: There were no changes in the stained acrylic properties when the samples were immersed in the prepared
denture cleansers and in the alkaline peroxide cleanser compared to that immersed in the distilled water.
Furthermore no significant differences were observed between microwave and water bath cured specimens in
respect to color stability, sorption and solubility of the testing groups.
Conclusions: The prepared denture cleanser solutions are good and satisfactory cleanser materials for the acrylic
resin denture base cured by two different techniques.
Key words: Acrylic, denture cleanser, water sorption, water solubility. (J Bagh Coll Dentistry 2006; 18(2) 1-8)

INTRODUCTION
1

Acrylic plastic has been the most widely
used and accepted among all denture base
materials and it was estimated that they
represent 95% of the plastics in prosthodontics
(1, 2)
.
The unclear denture may have undesirable
effect on patient's health and ability to
successful wear of the denture
(3)
. If a patient's
denture becomes unsanitary, the consequences
may be bad breath, poor esthetic, denture
stomatitis and angular cheilitis
(4)
.
The efficient cleansing of the fitting surface
of the denture is a key factor in the maintenance
of healthy oral mucosa and important for the
long term success of removable prosthodontics
treatment
(5,6)
.
Denture cleansers are a popular method
used by denture wearers for cleaning
(7)
. There
are wide varieties of denture cleansers used to
remove soft food and hard deposits of calculus
and stains on denture base and teeth; the most
common of them used immersion technique and
marketed as powder, tablets or liquid. In spite
of the large variety of these cleansers and their
different mode of action each had its
advantages and disadvantages.

(1) Professor, Department of Prosthodontics, College of
Dentistry, University of Baghdad.
(2) Assistant lecturer, Department of Prosthodontics, College of

Cleansers and cleaning methods used may
have harmful effect on the plastic or metal
component of the denture
(8)
. Knowledge of
constituents of denture cleansers, their
efficiency, adverse effect and safety would aid
in dispensing appropriate information to the
patient
(9)
, so the dentist must be able to
recommend a denture cleanser that is effective,
non deleterious to denture material and safe for
patient use
(10,11,3)
.
This study evaluated the effects of prepared
denture cleanser solution (4% Oxalic acid,
4%tartaric acid and 4%citric acid) in addition to
alkaline peroxide solution on the water sorption
,water solubility and color stability of stained
acrylic resin material that cured by two curing
method.

MATERIALS AND METHODS
A disc of (501 mm in diameter and
0.50.1mm in thickens) were constructed from
Heat cured acrylic resin (major base 2\italy) and
Microwave acrylic denture base resin
(AcronTM MCGC 2AB) to measure water
sorption , water solubility and color stability
;the preparation of the acrylic samples was
conducted according to the ADA specification.
Sample grouping
The specimen grouping was classified as
follows:
Restorative Dentistry 1
Group 1: Specimens immersed in 4% citric
acid denture cleanser solution.
Group 2: Specimens immersed in 4% tartaric
Group 3: Specimens immersed in 4% oxalic
Group 4: Specimens immersed in alkaline
peroxide denture cleanser solution.
Group 5: Specimen immersed in distilled water
(control group).
Preparation of the solutions
1. Tea solution: 4 grams of dry tea boiled in 500
ml of distilled water for 4 minutes, and allowed
to cool at room temperature, and then the
solution was decanted from tea leaves
(12)
.
2. Alkaline peroxide solution: It's prepared
according to the manufacturers instructions {1
tablet of alkaline peroxide added to 150 ml of
warm distilled water (500C)}.
3. The experimental denture cleanser solutions:
a fresh denture cleanser solutions was prepared
by dissolving each of the oxalic acid, tartaric
acid and citric acid in the isopropyl alcohol (the
isopropyl alcohol was chosen as solvent to the
acid powder due to its antiseptic effect)
(13)
as
followed:
4 gm of acid powder +100 ml. alcohol 4%
W/V of acid isopropyl denture cleanser solution
Then, prior to the use each prepared denture
cleanser solutions were diluted with an
equivalent volume of distilled water as follow:-
50 ml. of + 50 ml. of prepared 100 ml. of
distilled water. denture cleanser solutions. fresh diluted
denture cleanser solutions.

Water sorption and water solubility test
The specimens' preparation and testing
procedure were done according to the ADA
specification No.12 for denture base resin
(9)
.
The no. of the specimens used in this study
were 50 specimens for the two curing methods
(25 specimens from the water bath curing
method and 25 from the microwave energy)) (5
samples for each group). The specimens were
dried in a desiccator containing freshly dried
silica gel. The desiccator was stored in an
incubator at a 37
0
C 2
0
C for 24 hours. After 24
hour, the specimens were removed to a similar
desiccator at room temperature for one hour
then weighed with a digital balance on a
precision of 0.1mg. This cycle was repeated
until a constant mass "conditioned mass" was
reached (The weight loss at each disc was not
more than 0.5mg in 24 hours period).
Then the discs of group (1,2,3,4) were
immersed in fresh tea solution for 24 hours.
Afterwards, they were immersed in the denture
cleansing solution for another 24 hours, while
the discs of group 5 were immersed in distilled
water at 370C20C for 48 hours.
For all groups after which time the discs
were removed from the solutions with tweezers
wiped by a clean dry hand towel until free from
moisture, waved in the air for 15 seconds and
weighed one minute after removal from the
solutions this mass was consider as mass after
immersion .
After that to obtain the value of solubility
test, the discs were reconditioned to a constant
mass in the desiccator at 370C 20C as done
previously for sorption test and considered as
the reconditioned mass.
The values for sorption were calculated for
each disc from the following equation and the
final value should be rounded to the nearest 0.1
mg/cm2:
Sorption (mg/cm2) =mass after immersion
(mg)-condition mass (mg)/ Surface area (cm2)
The soluble matter lost during immersion
was determined to the nearest 0.01 mg/cm2 for
each disk as follows:
Solubility (mg/cm2) =condition mass (mg)
- reconditioned mass (mg)/ Surface area (cm2)

Color stability test:
The number of the specimens used in this
study was 50 specimens for the two curing
methods (25 specimens from the water bath
curing method and 25 from the microwave
energy)) (5 samples for each group). The color
stability test was measured by two methods
a. Objective method (Spectroscopic
study).
b. Subjective method (visual
examination).
We used a spectrophotometer device to
measure the light absorption of each specimen
at two wavelengths at 400 and 500.For all
groups the light absorption for each disc was
measured before immersion of the discs in the
solutions.
The discs of groups 1,2,3,4 were immersed
first in the fresh tea solution then they were
immersed in the denture cleansing solution
while for the control group (group 5) the discs
were immersed just in the distilled water. After
the completion of immersion of the discs of all
the groups the light absorption of the discs were
measured as done before the immersion
The ANOVA test of solubility
demonstrated no significant difference between
the investigating material (F =2.229, P =0.102,
for water bath) and (F =0.177, P =0.948, for
microwave). The results of the (t-test) show that
there is no significant difference found between
the microwave and water bath curing method
for all tested groups as shown in Table and
Figure 2.
procedure by using a spectrophotometer at the
same two wave length and the difference
between the two readings were calculated.
The visual examination of staining removal
was assessed by ten independent observers
(dentist). Each observer read the samples after
their removal from the solutions. The samples
were evaluated visually for staining removal by
comparing the tested samples with the control
group by placing the specimens on a white
background and they were graded for the
amount of staining on a scale of (No, slight,
mild, moderate, sever).
For the color stability test the mean and
standard deviation of the amount of absorption
difference before and after immersion in the
denture cleanser solution as well as in distilled
water are presented in Table and Figure 3. In the statistical analysis we used
Descriptive statistics (Arithmetic mean,
Standard deviation, Statistical tables) and
Inferential statistics (ttest, one way analysis of
variance test (ANOVA) and Multiple
comparison tests utilizing the least significant
differences (LSD) }.
The ANOVA test revealed a highly
significant difference between groups that cured
by the microwave curing method for both
wavelength 400 nm (F =9.572, P =0.000) and
at 500nm (F =21.739, p =0.00) while for the
samples that cured by the water bath method
there is no significant difference between the
groups at 500nm (F =2.803, P =0.054) but at
400nm there is a significant difference between
the groups (F = 3.352, P = 0.030). Table 4
represent the results of the LSD test of the color
stability.

RESULTS
The mean and the standard deviation of
sorption test for the experimental and the
control groups that cured by the conventional
water bath and microwave are listed in Table
and Figure 1.
There is no significant difference for all
groups at the two wave length when compared
between the two curing methods except the
tartaric acid which showed a highly significant
difference (P<0.01) at 400nm and a significant
difference (P<0.05) at (500nm) by applying t
test (Table 4, and Figure 3).
The sorption value for all the groups are
nearly similar in both curing method they were
all within the ADA specification limit. No.12
for denture base polymers (the uptake should
not be more than 0.8mg/cm
2
).
One way analysis of variance test
(ANOVA) demonstrated a no significant
difference in the sorption between the 5 groups
in both curing method (F =0.117, P =0.975 for
water bath) and (F = 0.077, P = 0.988 for
microwave) (P >0.05).
The result of visual examination of staining
removal of all groups for both curing methods
show no difference in the color when compared
with the control group as shown in Table 5.

The (t-test) show there is no significant
difference between the microwave and water
bath method for each group as shown in Table
and Figure 1.

Similar methods of statistical analysis used
for sorption test were applied to the results of
solubility test. The mean and standard deviation
of solubility for both curing method are
presented in Table and Figure 2.

The solubility value for both curing
methods was complied with the ADA
specification limit (The loss in weight should
not be more than 0.04 mg/cm2).

Figure 1: Histogram of sorption test


Table 1:Descriptive statistics and t-test of sorption test (mg/cm
2
)
Water bath Microwave
Materials
Mean S.D. Mean S.D.
P value Sig.
Citric acid 0.8 0.069 0.8 0.068 0.993 N.S.
Tartaric acid 0.8 0.053 0.8 0.063 0.845 N.S.
Oxalic acid 0.8 0.086 0.8 0.075 0.803 N.S.
Alkaline peroxide 0.8 0.029 0.8 0.041 0.961 N.S.
Distilled water 0.8 0.010 0.8 0.031 0.909 N.S.

Table 2:Descriptive statistics and t-test of solubility test (mg/cm
2
)
Water bath Microwave
Materials
Mean S.D. Mean S.D.
P value Sig.
Citric acid 0.004 0.004 0.046 0.04 0.140 N.S.
Tartaric acid 0.005 0.002 0.044 0.01 0.052 N.S.
Oxalic acid 0.006 0.006 0.044 0.02 0.285 N.S.
Alkaline peroxide 0.013 0.006 0.024 0.01 0.108 N.S.
Distilled water 0.010 0.005 0.044 0.03 0.298 N.S.

Figure 2: Histogram of solubility test

Table 3: Descriptive statistics and t-test of color stability test(nm)
400 nm 500 nm
Water bath Microwave Water bath Microwave
Materials
Mean S.D. Mean S.D.
Pvalue Sig.
Mean S.D. Mean S.D.
P value Sig
Citric acid - 0.262 0.32 - 0.486 0.24 0.275 N.S. - 0.261 0.32 0565 0.05 0.10 N.S
Tartaric acid - 0.191 0.13 - 0.420 0.12 0.006 H.S. - 0.195 0.15 0.406 0.14 0.01 S.
Oxalic acid - 0.113 0.16 - 0.332 0.10 0.076 N.S. - 0.126 0.17 0.330 0.10 0.11 N.S
Alkaline peroxide 0.178 0.29 - 0.024 0.15 0.161 N.S. 0.145 0.30 .018 0.18 0.32 N.S
Distilled water 0.081 0.14 - 0.065 0.02 0.060 N.S. 0.067 0.14 0.056 0.03 0.08 N.S

Table 4: Mutiple comparison test (LSD) of color stability test (Spectroscopic studies)
400 nm 500 nm
Water bath Microwave Water bath Microwave
Materials
Mean
D.F.
P
value
Sig.
Mean
D.F.
P
value
Sig.
Mean
D.F.
P
value
Sig.
Mean
D.F.
P
value
Sig.
Distilled Water +
citric acid
0.344 0.02 S. 0.421 0.00 H.S 0.329 0.036 S. 0.509 0.00 H.S.
Distilled Water +
tartaric acid
0.273 0.07 N.S. 0.355 0.00 H.S 0.262 0.089 N.S. 0.350 0.00 H.S.
Distilled Water +
oxalic acid
0.195 0.18 N.S. 0.267 0.01 S 0.193 0.202 N.S. 0.274 0.001 H.S.
Distilled Water +
alkaline peroxide
-
0.096
0.50 N.S.
-
0.040
0.67 N.S - 0.077 0.602 N.S.
-
0.074
0.327 N.S.
Citric acid + Tartaric
acid
-
0.071
0.62 N.S.
-
0.066
0.49 N.S - 0.066 0.654 N.S.
-
0.159
0.044 S.
Citric acid + oxalic
acid
-
0.148
0.31 N.S.
-
0.153
0.12 N.S. - 0.135 0.366 N.S.
-
0.235
0.005 H.S.
Citric acid + alkaline
peroxide
-
0.441
0.00 H.S.
-
0.461
0.00 H.S
-
0.407*
0.012 S.
-
0.584
0.00 H.S.
tartaric acid + oxalic
acid
-
0.077
0.59 N.S.
-
0.087
0.37 N.S - 0.068 0.644 N.S.
-
0.076
0.316 N.S.
tartaric acid +
alkaline peroxide
-
0.369
0.01 S.
-
0.395
0.00 H.S - 0.340 0.031 S.
-
0.424
0.00 H.S.
Oxalic acid + alkaline
peroxide
-
0.292
0.05 N.S.
-
0.308
0.00 H.S - 0.271 0.079 N.S.
-
0.348
0.0 H.S.

Table 5: Visual examination of acrylic resin specimens
Degree of staining
Materials Water bath Microwave
Citric acid 0.42 (NO) 0.38 (NO)
tartaric acid 0.40 (NO) 0.08 (NO)
Oxalic acid 0.24 (NO) 0.14 (NO)
alkaline peroxide 0.30 (NO) 0.12 (NO)
Scale of staining {NO Slight Mild Moderate Severe}
NO=0; Slight=1; Mild=2; Moderate=3; Severe=4

Figure 3: Histogram of color stability (Spectroscopic studies)


HOOC COOH

A
HOOC CH COOH
CH

OH OH
HOOC
CH
2
COOH
C

CH
2
COOH
C
B
OH

Figure 4: The chemical formula of the denture cleanser solutions powder {A. The oxalic acid.
The Tartaric acid C. The citric acid}
(38)

DISCUSSION
Sorption of the material represents the
amount of water absorption on the surface and
into the body of the material, the sorption of
poly methyl methacrylate (PMMA) is
facilitated by its polarity and the mechanism
primary responsible for ingress of water is
diffusion
(14)
; whereas solubility represents the
mass of the soluble materials from polymer.
The only soluble materials present in the
denture base resins are initiator, plasticizers and
free monomer
(1,15,16)
. The rate at which the
materials absorbed water or lost soluble
components varied considerably with the type
of material, the amount of the plasticizer or
filler content and the solution in which they
were immersed
(17)
.
In the present study the sorption and
solubility were measured according to ADA
specification no.12
(9)
. The result of immersion
of acrylic resin in the denture cleanser as well
as in the distilled water complied with ADA
requirement; the results of sorption and
solubility tests showed that there was no
statistically difference between the two curing
methods (water bath and microwave energy).
Similar conclusion was reported by others
authors
(18-21)
while Al Doori and al Haydary
disagreed with them where they found that the
microwave group samples showed a lower
sorption than the water bath group samples.
(22,
23)
The water molecules has affinity more than
that of the chemical solution molecules to enter
and get out from the acrylic resin (the water
molecules has simple and small structure
compared to the complex structure of the
denture cleanser solutions), this might be the
cause of the low solubility value of the water
bath acrylic resin samples was lower when
immersed in chemical solutions than when
immersed in distilled water.
A change in appearance indicates reduction
of the long term quality of a denture
(24)
; several
denture base resins have been introduced that
provide easier and faster processing, although
these materials have adequate mechanical
properties the color stability also of interest.
For both curing methods there was no color
change observed visually after immersion of the
acrylic samples in the denture cleanser
solutions and in the distilled water this may be
due to that human eyes are not sensitive like the
apparatus used in our study.
The result of the spectrophotometer study
showed that for all tested groups except the
samples that immersed in tartaric acid there was
no significant difference among the tested
groups between the two curing methods this
result agree with those done by an earlier
studies
(18, 25-27)
who found that acrylic resin
whether cured by microwave or by water bath
methods showed adequate color stability when
acrylic resin processed according to the
manufacturers instructions, while May et al.
found that there was a significant color
difference between the two curing method.
(28)

The tartaric acid had greater effect on the
color of the acrylic resin this might be due to
that the tartaric acid have 4 active groups in
their structure that are available to molecular
interacted with the acrylic polymer by
formation of hydrogen bonds while the citric
acid have 3 active groups ; the oxalic acid have
2 active groups and water molecules have only
one active group in their structure; this could be
used to explain the reason of that the
microwave and water bath acrylic resin when
immersed in the prepared cleanser solutions
have significant color differences compared
with that immersed in the distilled water
(Figure 4).
The statistical analysis for both curing
method show a significant differences among
the tested groups regarding the color stability
test; the presence of the residual monomer
could be one of the possible reason that may be
used to explain the color changes
(25, 28, 29)
, while
Gross and Moser showed that the surface
porosity resulting from a dissolution of slight
soluble component of the material which cause
the color changes
(30)
. On the other hand other
authors saw that the high immersed temperature
might be sufficient to cause decomposition of
the resin leading to discoloration; or the
oxidation of the un reacted c=c double bonds
produced colored peroxide product
(30- 33)

Although the spectrophotometer study
showed a statically significant difference
among the tested groups for both curing
methods but the color difference was often
clinically insignificant because many reporters
demonstrated that when the value of color
difference was less than (1) it mean that the
color difference was clinically insignificant
.(34-
37)
.

REFERENCES
1. Craig RG, Powers J M. Restorative dental
materials.11 th edition. St. louis:mosby. 2002.
2. Craig RG, O'Brien WJ , Powers J M. Dental materials,
properties and manipulation. 6th ed. St. Louis. The
C.V. Mosby Co. 1996; 242-62.
3. Polyzois GL, Zissis AJ , Yannikakis SA. The effect of
glutaraidehyde and microwave disinfection on some
properties of acrylic denture resin. Int J Prosthodont
1995; 8 (2):150-4.
4. Suzuki T, Mizumi M, Furuya J , Okamoto Y,
Rosenthal SF. Influence of ozone on oxidation of
dental alloys. Int J Prosthodont 1999; 12(2): 179-83.
5. Budtz J rgensen EB. Materials and method for
cleaning dentures. J Prosthet Dent 1979; 42(6): 619-
23.
6. Sindel DW, Billy EJ , Richards MW, Rains TC, Shan-
Hua LI. Dissolution of cost aluminum in different
cleansers. Int J Prosthodont 1994; 7(3): 280-4.
7. Sheen SR, Harrison A. Assessment of plaque
prevention an dentures using an experimental
cleanser. J Prosthet Dent 2000; 84(6): 594-601.
8. Dills SS, Olshan AM, Goldner S., Brogdon C.
Comparison on the microbial capability of an
abrasive paste and chemical soak denture cleansers. J
Prosthet Dent 1988; 60:467.
9. ADA. American national standers institute/American
dental association specification No. 12 for denture
base polymer". Chicago: council on dental material
and devices. 1999.
10. Neill DJ . A study of materials and methods employed
in cleaning dentures. Br Dent J 1968; 124(3):107-15.
11. Backenstose WM, Wells J G. Side effects of
immersion. Type cleaners on the metal components
of dentures. J Prosthet Dent 1977; 37(6):615-21.
12. Scotti R, Mascellani SC, Foruiti F. The in vitro color
stability of acrylic resins for provisional restorations.
Int J Prosthodont 1997; 10(2):164-8.
13. Hatim NA, Salem AS, Khayat IK. Evaluating the
effect of new denture cleansers on the surface
roughness of acrylic resin denture base material (An
in vitro study). Al-Rafidain Dent J 2003; 3 (1):31-8.
14. Anusavice KJ . Philips science of dental materials
"10th ed. Philadelphia, WB Saunders Co. 1996.
15. Phillips RW. Skinners Science of dental materials"
7th ed. Saunders Company, Philadelphia. 1973.
16. Miettinen VM, Vallitlu PK. Water sorption and
solubility of glass fiber-reinforced denture
polymethylmethacrylate resin. J Prosthet Dent 1997;
76:531-4.
17. Kazanji MNM, Walkinson AC. Soft lining
maerials:their absorption of, and solubility in
artificial saliva. Br Dent J 1988; 165:91-4.
18. Reitz PV, Sanders J L, Levin B. The curing of denture
acrylic resins by microwave energy, physical
properties. Quintessence Int 1985; 8: 547-51.
19. Truong VT, Thomasz FGV. Comparison of denture
acrylic resins cured by boiling water and microwave
energy. Aust Dent J 1988; 33(31): 201-4.
20. Ilbay SG, Guvener S, Al-Kumru HN. Processing
dentures using a microwave technique. J Oral Rehabil
1994; 21:103-9.
21. Hafidh MMJ . A study on the effect of the chemical
disinfectants on acrylic resin cured by two different
techniques". M.Sc. Thesis, University of Baghdad,
collage of dentistry. 1995.
22. Al-Doori DJ I. Polymerization of poly methyl
methacrylate denture base materials by microwave
energy" M.Sc.D. Thesis University of Wales College
of Medicine. 1987.
23. Al-Haydary ASA. The use of microwave energy in
polymerization of radio opaque denture base
polymer". M.Sc. Thesis, University of Baghdad,
collage of dentistry. 1992.
24. Sazb G, Valderhaug J , Ruyter IE. Some properties
of a denture acrylic coating. Acta Odontol Scand
1985; 43:249-56.
25. Austen AM, Basker RM. Residual monomer in
denture bases the effect of varying short curing
cycles. Br Dent J 1982; 153:424.
26. May KB, Razzoog ME, Koran A, Robinson E.
Denture base resins: Comparison study of color
stability. J Prosthet Dent 1992; 68:78-82.
27. Subhi MD. The effect of disinfectant solutions on
some properties of acrylic dental base material".
M.Sc. Thesis, University of Baghdad, college of
dentistry. 1999.
28. May KB, Shotweell J R, Koran A. Color stability:
Denture base resin processed with the microwave
method. J Prosthet Dent 1996; 76:581-9.
29. Keng SB, Cruickshanks-Boys DW, Davies EH.
Processing factors affecting the clarity of a rapid
curing clear acrylic resin". J Oral Rehabil 1979;
6:327-35.
30. Gross MD, Moser J B. A colorimetric study of coffee
and tea staining of four composite resins. J Oral
Rehabil 1977; 4:311-22.
31. Brown RL, Argentor H. Diminishing discoloration in
methacrylate accelerator systems. J Am Dent Assoc
1967; 75:918.
32. Lee HT, Orlowski J , Kobashigawa A. Handbook of
dental composites, Lee pharmaceuticals, south EI
Monte, Cal, 1973.
33. Ferracane J L, Moser J B, Greener EH. Ultraviolet
light-induced yellowing of dental restorative resins. J
Prosthet Dent 1985; 54:483-7.
34. Kuehni RG, Marcus RT. An experimental in visual
scaling of small color differences". Color Res Appl
1979; 4:83-91.
35. Ma TS, J ohnson GH, Gordon GE. Effects of
chemical disinfectants on the surface characteristic
and color or denture resin. J Prosthet Dent 1997;
77(2): 197-204.
36. Douglas RD, Brewer J D. Acceptability of shade
differences in metal ceramic crowns. J Prosthet Dent
1998; 79:254-60.
37. Buchalla W, Attin T, Hilgers RD, Hellwing E. The
effect of water storage and light exposure on the
color and translucency of a hybrid and a microfilled
composite. J Prosthet Dent 2002; 87:264-70.
38. Poylan PJ . Elements of Chemistry, Allyn and Bacon,
united states of American.1965

J Bagh Coll Dentistry Vol. 18(2), 2006 A comparison of inferior
A comparison of inferior alveolar nerve block and
periodontal ligament injections during endodontic
treatment of human mandibular first premolars

Majida K. Al-Hashimi, B.D.S., M.S.
(1)

Waleed I. Ali, B.D.S., M.Sc.
(2)

ABSTRACT
Background: Profound pulpal anesthesia for root canal treatment is difficult to achieve in mandibular posterior teeth.
Several authors emphasized on the effects of periodontal ligament injection as a primary or supplementary
technique. The aim of this study was to compare the efficacy of periodontal ligament injection and inferior alveolar
nerve block injection in providing profound pulpal anesthesia for endodontic treatment of human mandibular first
premolars; and to compare the discomfort associated with each injection in regard to initial needle insertion and
injection of solution.
Materials and Methods: Periodontal ligament injection was used as a primary injection technique to anesthetize 30
sound, healthy mandibular first premolars and it was compared to the pulpal anesthesia of the other 30 mandibular
first premolars on the other side of the same patient, which were anesthetized using the inferior alveolar nerve block
injection.
Results: The results showed no statistically significant differences between the two injection techniques.
Conclusion: The periodontal ligament injection can be used effectively to anesthetize mandibular first premolars, as
a primary technique, during root canal therapy procedure. Pain associated with insertion of needle and injection of
solution for both injection techniques was acceptable.
Key words: Periodontal ligament, inferior alveolar, anesthesia. (J Bagh Coll Dentistry 2006; 18(2) 9-14)

INTRODUCTION
1

Local anesthesia is the primary method
used in dentistry to control pain. However, even
in the presence of an adequate soft tissue
anesthesia after the standard injection by block
or infiltration, there may be incomplete pulpal
anesthesia.
(1)

One of the techniques that have been used
with success is the periodontal ligament
injection (PDL).
(2)
The intercellular fluid of the
gingival apparatus and the hydrostatic pressure
of the ligmaject syringe the syringe for
periodontal ligament injection, allows for a
safer, more efficient means of local
anesthesia.
(3)

PDL injection is an effective technique for
anesthetizing mandibular first premolars.
(4)
It
was found that the success rate of profound
pulpal anesthesia to be highest in molars and
premolars and lowest in mandibular lateral
incisors.
(5)
It has been reported that the PDL
injection is an effective primary technique in
anesthetizing mandibular first premolars using
2% lidocaine with 1:100,000 epinephrine.
(6)

Edwards and Head
(7)
showed that PDL injection
with lidocaine was effective in providing

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

adequate anesthesia, which was statistically
more effective than were epinephrine or saline
solutions. Zakaria
(8)
stated that PDL injection
showed a success rate of 73.33% which was
lower than that scored by the IAN block
technique but no statistically significant
differences were detected between them.
Selection of an injection technique should be
based on some factors that include the ability to
determine the technique respective anatomical
landmarks, the presence of accessory
innervations, or trismus.
(9)
Al-Doori and Al-
Hashimi
(10)
reported that 2% lidocaine with
1:80,000 epinephrine produces significantly
higher rates of successful pulpal anesthesia than
saline, especially in lower first molars.

All patients selected for this study (17
females and 13 males), aged between 18-25
years and were healthy with no allergic reaction
to the used dental local anesthetic. They had
bilateral lower first premolars that were
clinically free of caries, filling, and periodontal
disease, and were indicated for extraction for
orthodontic reasons.
Sixty lower first premolars from thirty
subjects were used. In group A, 30 teeth on the
right side received the PDL injections, and in
group B, 30 teeth on the left side received the
IAN block. All teeth in the two groups were
electrically pulp tested before the
administration of the local anesthesia to
measure the response threshold. In addition, all
the teeth were electrically pulp tested after the
administration of the local anesthesia to verify
the success of anesthesia. Then access cavity
was prepared and the pulp was extirpated on
each tooth in both groups.
Two parameters were used to define
success of local anesthesia: The first was no
subject response to the maximum output of the
electrical pulp tester. The second was a rating
scale as that designed by Eriksen et al
(11)
, which
measures pain during pulpectomy procedures
and was divided into score zero
(adequate)pulpectomy could be performed
without pain, score one (partial) pulpectomy
could be performed with tolerable discomfort,
score two (unacceptable) pulpectomy could
not be performed due to intolerable pain.
Pain rating of initial needle penetration and
injection of solution were compared for each
technique, using the scale designed by White et
al(5) being score zero (no pain), score one (mild
pain), score two (moderate pain), score three
(severe pain).
Electrical pulp tester technique.
A small quantity of toothpaste was applied
at the tip of the EPT (Analytic Technology
Corp., U.S.A.) probe and the probe tip was
placed on the middle third of the buccal surface
of the experimental tooth and the mesial, and
distal teeth to it. Two consecutive readings
were obtained as base line vitality readings,
similar to that used by Dreven et al.
(12)

Periodontal ligament injection technique
Periodontal ligament injections were given
using Ligmaject syringe (Ligmaject, Germany)
with 30-gauge ultrashort needles (length 12
mm, Morita, J apan). The needle was inserted
through the mesial gingival sulcus to a point of
maximum penetration. The bevel of the needle
was directed away from the tooth surface and
toward the crestal bone surface, at
approximately 30-degree angle to the long axis
of the tooth. The trigger of the syringe was
pulled firmly until backpressure was achieved
and this pressure was sustained for
approximately 20 seconds. This procedure
delivered 0.2 ml of the anesthetic solution (2%
lidocaine with 1:100,000 epinephrine local
anesthesia cartridges of 1.7 ml (3M ESPE,
Germany)) for each injection. If no
backpressure was achieved, the needle was
repositioned and the injection was repeated.
The injection was then repeated on the distal
surface of the tooth. This technique was
identical to that described by Schleder et al.
(6)

lnferior alveolar nerve block technique
The technique used to block the inferior
alveolar nerve is the direct approach described
by J astac et al
(13)
, in which the needle was
advanced along a straight line to a point where
the tip lies just over the mandibular foramen.
The posterior ramus was grasped by the non-
dominant hand of the operator with the thumb
placed in the mouth to retract the cheek and the
underlying loose connective tissue and fat pad
laterally. Properly positioned, the thumb was
parallel to the mandibular occlusal plane and in
the greatest concavity of the coronoid notch.
After drying the area with gauze, a 27- gauge
long disposable dental needles (length 30
mm, Morita, J apan) was inserted at a height
approximating an imaginary line running
through the bisected thumbnail, and the needle
was at least 1 cm. above the mandibular
occlusal plane. With the syringe (Asculap,
England) and needle axis oriented from the
opposing lower premolars, the needle was
advanced gently through the mucosa and the
underlying soft tissues within the
pterygomandibular space till it contacted the
bone at a depth of 2 to 2.5 cm. Then the needle
was withdrawn slightly, aspiration was
performed and if negative, 1.7 ml of anesthetic
solution was injected at a rate of 2 ml/mm using
a stop watch.
Technique of pulpectomy
Access cavities were prepared on 60
premolars using carbide round bur no. 4
(Komet, Germany) in a contra-angle hand piece
(W&H, Austria). Entrance was gained through
the middle of the central groove of mandibular
first premolars and the bur was kept parallel to
the long axis of the buccolingual extension.
Finishing of the cavity walls was completed
with round-end tapered fissure bur (Komet,
Germany).
(14)
A barbed broach (Komet,
Germany) was passed to a point just short of the
apex and rotated clockwise to engage the
fibrous tissue of the pulp, then was slowly
withdrawn. The data was analyzed using the
Chi-square test and Student t-test.

RESULTS
Pain rating during initial needle penetration
The summary of numbers and percentages
of needle penetration pain rating are presented
in Table I and Figure 1. Two of the 30 (6.66%)
periodontal ligament injection caused no pain,
and 2 of the 30 (6.66%) PDL injection caused
severe pain, while 18 of 30 (60%) PDL
injection caused mild pain and 8 of 30 PDL
injections (26.66%) caused moderate pain. For
the IAN block, 2 of 30 (6.66%) injection caused
severe pain and 6 of 30 injection (20%) caused
no pain and 18 of 30(60%) caused mild pain
and 4 of 30 (13.33%) caused moderate pain.
Statistical analysis using the chi-square test
showed no significant difference between the
two injections regarding pain of initial needle
penetration.

Table 1: Pain rating during initial needle penetration.
Score 0 Score 1 Score 2 Score 3 P value
PDL 2/30 (6.66%) 18/30(60%) 8/30(26.66%) 2/30(6.66%)
IANB 6/30(20%) 18/30(60%) 4/30(13.33%) 2/30(6.66%)
P > 0.05 NS
Chi-square = 5.3332, NS: Not significant.

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Score 0 Scor e 1 Scor e 2 Scor e 3
PDL
IANB

Figure 1: Pain rating percentages during initial needle penetration.

Pain rating during injection of solution
Table II and Figure 2 show the summary of
numbers and percentages of pain rating during
injection of solution for both techniques. Ten of
30 (33.33%) PDL injections showed no pain
during injection of solution, while 17 of 30
(56.66%) PDL injection caused mild pain and
only 3 of 30 (10%) injections caused moderate
pain, with no severe pain. For the IAN block,
15 of 30 (50%) showed no pain during injection
of solution and 13 of 30 (43 .33%) caused mild
pain and only 2 of 30 (6.66%) caused moderate
pain, with no severe pain. No statistical
significant differences were revealed between
the two injections regarding pain during
injection of solution.
Table 2: Pain ratings during injection of solution.

Score 0 Score 1 Score 2 Score 3 P value
PDL 10(33.33%) 17 (56.66%) 3 (10%) 0 (0%)
IANB 15 (50%) 13 (43.33%) 2 (6.66%) 0 (0%)
P > 0.05 NS
Chi-square = 1.7333, NS: Not significant.

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Scor e 0 Score 1 Scor e 2 Score 3
PDL
IANB

Figure 2: Pain rating percentages during injection of anesthetic solution.
Pain rating during pulpectomy procedure
Table III and Figure 3 show the summary
of numbers and percentages of pain rating
during pulpectomy procedure. Twenty-five of
30 (83.33%) PDL injection showed no pain
during pulpectomy, and 3 of 30 (10%)
injections showed partial response during
pulpectomy and only 2 of the 30 (6.66%) PDL
injection caused severe pain during
pulpectomy. For the IAN block, 23 of the 30
(76.66%) injection caused no pain during the
pulpectomy, while 4 of 30 (13.33%) injections
caused partial response and only 3 of the 30
(10%) injection caused severe response during
pulpectomy. Also no significant differences
existed between the two injection techniques
regarding pain during pulpectomy procedure.

Table 3: Pain ratings during pulpectomy procedure.
Score 0 Score 1 Score 2 P value
PDL 25/30(83.33%) 3/30(10%) 2/30(6.66%)
IANB 23/30(76.66%) 4/30(13.33%) 3/30(10%)
P >0.05 NS
Chi-square = 0.7666, NS : Not significant.

0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Scor e 0 Scor e 1 Scor e 2
PDL
IANB

Figure 3: Pain rating percentages during pulpectomy procedure.

The success rates for both injections was
defined as no response to the maximum output
of EPT and no patients response at pulpectomy
and accordingly the success rate for PDL
injection was 80.33%, and the success rate for
IAN block was 76.66%. If the partial response
(score two) at pulpectomy was regarded
acceptable and was included in the success rates
for both injections, then the success rate for
PDL injection was 90.33%, and for IAN block
was 90%. Statistical analysis using Student t-
test showed no significant difference between
the two injection techniques regarding success
rates (P >0.05), (Tables IV and V).

Table 4: The mean and standard deviation (SD) of EPT readings for both groups before and
after the administration of local anesthesia.

Before PDL After PDL Before IANB After IANB
Mean 32.6667 76.1034 32.6333 74.6897
SD 4.2535 8.9815 4.0214 9.8093

Table 5: Student t-test results of EPT readings.

t-test df P
PDL 0.189 28 0.851 (NS)
IANB 1.013 28 0.320 (NS)
df: degree of freedom, P : Probability values, NS : Not significant.
DISCUSSION
It has been found that for healthy teeth an
80/80 EPT reading with no patients response
was an indicator of profound pulpal anesthesia.
A lower reading than the maximum output but
higher than the baseline indicated unsuccessful
pulpal anesthesia for pulp extirpation. This
agrees with Dreven et al.
(12)

The results of the present study showed that
pain rating of initial needle penetration for the
PDL injection was 86.66% of mild to moderate
type with more mild (60%) and the pain of
injection of solution was 90% of no pain to
mild pain with more mild pain. These findings
agree with White et al
(5)
and Schleder et al.
(6)

On the other hand, for the IAN block, the pain
rating of initial needle penetration was 80% of
no pain to mild pain with more mild pain (60%)
and the pain of injection of solution was
93.33% of no pain to mild pain, which agree
with Whal et al.
(15)
Malamed
(2)
found that 70%
of the patients preferred the PDL injection to
the standard injection. Montagnese et al
(16)
reported that 40% of the patients found the
standard injection painful (moderate to severe).
Also Vreeland et al
(17)
reported that 33-40% of
the subjects had moderate to severe discomfort
during deposition of solution.
Several factors may explain the results of
this study regarding the above criteria. First, no
topical anesthetic was used. Second, pain
perception can be modified by psychological,
social, and situational factors. Fear and anxiety
may lower the pain threshold. Fear of the IAN
block may be due to the injection site or the
long needle penetration and fear of the PDL
injection may be due to the gun-like appearance
of the syringe. Third, pain on injection of the
anesthetic solution could be due to the low pH
of the solution, which may cause burning
sensation. Fourth, pain threshold and tolerance
of each patient may vary and the results should
be considered as subjective evaluation of local
anesthesia techniques.
(11)

The success rate for the PDL injection was
83 .33%, which was lower than the success rate
achieved by Malamed (88.52%)
(2)
and Schleder
et al (86.7%)
(6)
and higher than the success rate
achieved by Moore et al (78.9%)
(4)
and White et
al (63.2%).
(5)
It seems that the most important
factor in the success of the PDL injection is
injection of the local anesthetic under strong
backpressure. Smith and Walton
(18)
explained
that, when the PDL injection was given under
strong backpressure, there was spread of the
injected material throughout the periodontal
ligament, periapical tissues, medullary bone,
and pulps of injected and adjacent teeth.
Conversely, they found that when the PDL
injection was given under little pressure, there
was no spread or penetration of the injected
material apically into the previously mentioned
tissues.
The success rate for IAN block achieved in
the present study was 76.66% which was higher
than the success rate achieved by Vreeland et al
(63.3%)
(17)
and Kennedy et al (50%)
(19)
, but
lower than that achieved by Malamed
(82.05%).
(2)
Although Vreeland et al used
sound teeth in their study, their lower success
rate, when compared to the present study, may
be due to their usage of different teeth
(mandibular molars and incisors) and different
concentrations of local anesthetic agents and
vasoconstrictors. On the other hand the higher
success rate achieved by Malamed may be
because of that the majority of patients had
simple procedures that actually did not cause
pain. Inflammation plays a major role, which
may be the cause of the lower success rate
achieved in Kennedy et al study,
(19)
but was
excluded from the present study as healthy
mandibular premolars were used.
Anatomical variation and accessory
innervations were also found to play a role in
the failure of block injection. The mylohyoid
nerve has been shown to enter the mandible
through a foramen between the premolars on
the lingual aspect supplying the molars and
premolars. The auriculotemporal nerve
penetrates the retromolar region, the condyler
area or near the insertions of the muscles of
mastication. These nerves could ramify through
the cancellous bone and eventually establish
one or more obvious junctions with the main
trunk of the inferior alveolar nerve.
(20)
Based
on the results of this study it was concluded that
the periodontal ligament injection can be used
effectively to anesthetize mandibular first
premolars, as a primary technique, during root
canal therapy procedure. Pain associated with
insertion of needle and injection of solution for
both injection techniques was acceptable.

REFERENCES
1. Cohen HP, Spangberg LS. Endodontic anesthesia in
mandibular molars: a clinical study. J Endod 1993;
19: 370-3.
2. Malamed SF. The periodontal ligament injection: an
alternative to inferior a1aveolar nerve block. Oral
surg Oral path Oral med 1982; 53: 117-121.
3. Khedari AJ . Alternative to mandibular block
injection through intraligamental anesthesia. Quintess
Int 1982; 2: 231-7.
4. Moore KD, Reader A, Meyers MJ . Beck M, Weaver
J . A comparison of the periodontal ligament
injection using 2% lidocaine with 1:100,000
epinephrine and saline in human mandibular
premolars. Anesth Prog 1987; 34: 181-6.
5. White J J , Reader A, Beck M, Meyers J . The
periodontal ligament injection: a comparison of the
efficacy in human maxillary and mandibular teeth. J
Endod 1988; 14: 508-14.
6. Schleder J R, Reader A, Beck M, Meyers J . The
periodontal ligament injection: a comparison of 2%
lidocaine, 3% mepivacaine, and 1:100,000
epinephrine to 2% lidocaine with 1:100,000
epinephrine in human mandibular premolars. J Endod
1988; 14: 397-404.
7. Edwards RW, Head TW. A clinical trial of
intraligamentary anesthesia. J Dent Res 1989; 68:
1210-4.
8. Zakaria MR. A Clinical evaluation of the periodontal
ligament injection as a primary technique in
preparing mandibular molar abutment teeth for
crowns and bridges among Iraqi patients. J of College
of Dent 1998; 2: 171-83
9. J acobs S, Haas DA, Meechan JG, May S. Injection
pain: comparison of three mandibular block
techniques and modulation by nitrous oxide: oxygen.
J Amer Dent Assoc 2003; 134: 86976.
10. Al-Doori RS, Al-Hashimi MK. A clinical comparison
between maxillary and mandibular posterior teeth
using local anesthesia and normal saline by
periodontal ligament injection. Master thesis. College
of Dentistry. University of Baghdad. 2005.

11. Eriksen HM, Aamdal H, Kerekes K. Periodontal
ligament anesthesia. A clinical evaluation. Endod
Dent Traumatol 1986; 2: 267-269.
12. Dreven LJ , Reader A, Beck M, Meyers J , Weavers J .
An evaluation of an electrical pulp tester as a
measure of anesthesia in human vital teeth. J Endod
1987; 13: 233-8.
13. J astak J G, Yagiela J A, Donaldson D. Local
anesthesia of the oral cavity, 1st ed. 1995,
Philadelphia, W.B.Saunders, p. 23, 61, 87.
14. Ingle J I, Bakland LK. Endodontics, 4th ed. 1994,
Philadelphia, Lea and Febiger; p. 215.
15. Wahl MJ , Overton D, Howell J , Siegel E, Schmitt
MM, Muldoon M. Pain on injection of prilocaine
plain vs. lidocaine with epinephrine: a prospective
double-blind study. J Amer Dent Assoc 2001; 132:
1396-401.
16. Montagnese LA, Reader A, Melfi R. A comparative
study of the Gow-Gates technique and a standard
technique for mandibular anesthesia. J Endod 1984;
10: 158-63.
17. Vreeland DL, Reader A, Beck M, Meyers J , Weavers
J . An evaluation of volumes and concentrations of
lidocaine in human inferior alveolar nerve block. J
Endod 1989; 15: 6-12.
18. Smith NG, Walton RE. Periodontal ligament
injection: distribution of the injected solution. Oral
Surg 1983; 55: 232-7.
19. Kennedy S, Reader A, Nusstein, J , Beck M, Weaver
J . The significance of needle deflection in success of
the inferior alveolar nerve block in patients with
irreversible pulpitis. J Endod 2003; 29: 630-3.
20. Chapnick L. Nerve supply to the mandibular
dentition a review. J Can Dent Assoc 1980; 7: 446-8.

J Bagh Coll Dentistry Vol. 18(2), 2006 An evaluation of the

An evaluation of the effects of different polishing agents on
the surface roughness of porcelain

Maan R. Zakaria B.D.S., M.Sc.
(1)

Rawaa H. Al-Hadithy B.D.S., M.Sc.
(2)

ABSTRACT
Background: Rough porcelain surface due to faulty glazing technique or occlusal adjustment can cause grinding of
opposing structure and tissue irritation. The aim of this study was to evaluate the effects of different polishing agents
on the surface roughness of adjusted porcelain in comparison to applied glaze.
Methods and Materials: Thirty five porcelain specimens resembling flat-back facing (metal porcelain buttons) were
fabricated according to the manufacturers instructions. The specimens were randomly divided into five groups
according to the type of surface treatment tested. Each group consisted of seven specimens and the groups were
distributed as follows: Group I: Applied glazed; Group II: Polished porcelain using dental pumice; Group III: Polished
porcelain using Dentalloy polishing paste; Group IV: Polished porcelain using Dentaurum universal polishing paste
and Group V: Polished porcelain using Al203 paste. The surface roughness evaluation of the specimens was carried
out by a surface roughness analyzer device (profilometer).
Results: Statistical analysis showed no significance between porcelain samples polished by Dentaurum universal
polishing paste and those subjected to applied glaze. Both techniques provided better smoothness than the rest
polishing procedures.
Conclusion: Final polishing of rough porcelain surface by Dentaurum universal polishing paste can be considered as
an alternative to reglazing adjusted surfaces of porcelain restorations regarding the technique sensitivity and time
consuming related to the latter procedure.
Key words: Polishing agents, porcelain, surface roughness. (J Bagh Coll Dentistry 2006; 18(2) 15-21)

INTRODUCTION
Porcelain has been available as a
restorative material for over 150 years. Its an
ideal material for replacement of lost tooth
tissue because of its esthetic quality, low
thermal and electrical conductivity, and its
resistance to degradation in the oral
environment
(1)
.
Dental porcelain combines esthetic with
excellent biocompatibility and remains an
important restorative material
(2)
. Prevention of
severe tissue irritation and plaque
accumulation around unglazed porcelain seems
to require that porcelain restorations be highly
glazed before placement in the mouth
(3)
.
Faulty technique during the laboratory
procedure or some other manipulation in the
dental office after fabrication of porcelain can
result in a porcelain surface which might well
cause irritation and unfavorable tissue reaction.
Therefore, porcelain used as a restorative
material should be well glazed
(4)
.

(1) Professor, Advanced fixed prosthodontics, Department of
Conservative Dentistry, College of Dentistry, University of
Baghdad.
(2) Assistant lecturer, Department of Conservative Dentistry,
College of Dentistry, Al-Mustansiriya University.

For many years, standard clinical and
laboratory techniques indicated that adjusted
porcelain surface should be reglazed to restore
the surface finish; however, reglazing is not
always convenient or possible. Many agents
for polishing porcelain have been evaluated
(5,6)
.
The surface finishing of polished and glazed
porcelain have been compared
(7,8)
.
Investigations have shown that there are
advantages to polishing the porcelain surface
after adjustment as opposed to glazing
(9,10)
.
Different researches have been conducted
concentrating on different methods of
polishing porcelain using variable polishing
agents
(11,12)
. Many of those works have shown
that polishing adjusted porcelain surface gave
better surface topography when compared to
autoglazed surfaces. Polishing of adjusted
porcelain with a polishing paste was reported
to produce surface smoothness better than auto
glaze
(13)
.

MATERIALS AND METHOD
Thirty five porcelain specimens
resembling flat-back facing of Vita ceramic
were fabricated according to the manufactures
instructions as follows:
A sheet of modeling base plate wax (2 mm in
thickness) was punched with copper ring (10

mm in diameter). Then five points were
measured for uniform thickness of 2mm using
wax caliper device (Aesculpa, Germany). Each
seven samples were sprued together in one
casting ring no. 9 (Dentaurum, Germany). The
sprue former (wax wire) was 1.7 mm in
diameter attached to running bar of 3.2 mm so
that the samples could be located at
approximately 4 mm from the open end of the
ring which was lined with a single layer of
asbestos-free ring liner after wetting it with
water and adapting it to the inner surface of the
ring. Surface tension reducing agent (Lubrofil,
Dentaurum, Germany) was applied carefully to
the pattern and left to dry for 5 minutes. Then
the phosphate-bonded investment (Rema Exact,
Dentaurum, Germany) was mixed according to
the manufacturers instructions using vacuum
auto mixing machine (Bego, Germany) to
minimize the chance for air bubbles which
could be attached to the pattern and
compromise the result
(14)
.
A brush was used to apply the investment
material gently to the wax patterns, and then
the remaining investment was poured into the
ring carefully using an electrical vibrator
(Degussa, Germany).
Following the wax burn-out, the casting
procedure was performed in a manual- driver
broken arm centrifugal casting machine
(Degussa, Germany) with the same casting
pressure which was achieved by turning the
casting arm for four turns before locking it in
position with its pin
(15)
.
The type of alloy used in the casting was
nickel chromium alloy (Heraenium NA,
Heraeus Kulzer, Germany), which was melted
using a gas-oxygen torch (Perko D-7140,
Germany). The mold was not removed
from the burn out furnace until the alloy
was melted and ready to cast. After
completion of casting, each ring was
immersed in water as soon as the red glow
of the button disappeared
(16)
.
The castings were divested and any
residual surface investment was removed by
sandblasting (Krupp, Germany) using (250 m)
aluminum oxide abrasive. The sprues were cut
using red cut off wheels (Moores Co. Inc, USA)
mounted on straight hand piece. Metal
finishing was done by using stone bur (Major,
Italy) and carborandom discs (USA).
The castings were then cleaned with
ultrasonic cleaning device (Quayel Dental,
England) using distilled water for five minutes
and the thickness of each metal button was
standardized using the metal caliper device
(Aesculap, Germany) and rechecked by a
micrometer at five points of each surface to be
(2 mm).
Oxidizing the castings was performed at
950
o
C for 5 min according to the manufacturer
instructions in a computerized porcelain
furnace (Programat P10, Ivoclar, Vivadent,
England). Sandblasting was performed
according to the manufactures instructions to
decrease the amount of the oxide layer using
A1
2
O
3
powder (250 um) for 5 seconds under
pressure of 5 bars. The distance between the
button and nozzle was standardized at five
cm
(17)
.
Opaque porcelain (Vita 95, VitaZahnfabrik,
Germany) was applied according to the
manufacturers instructions by using a bristle
dental brush. All metal buttons were coated
with two layers of opaque porcelain. The first
opaque layer was dried and fired at 940C, the
holding time was one minute, at reduced
pressure (760 mm. Hg). The second opaque
layer (creamy layer) was condensed on the
sample by vibrating the locking tweezers with
the serrated portion of a porcelain carving
instrument. Excess moisture was removed by
blotting with a clean dry tissue paper, then was
fired at 930C, with a holding time of one
minute at reduced pressure (760 mmHg).
After the opaque layers were completed,
dentin and enamel layers were applied by
using bristle dental brush and baked together at
920C with a holding time for one minute (760
mm Hg) in the porcelain furnace (under
vacuum). After complete porcelain build up,
the surface of porcelain was brought to a fine
finish prior to glazing or polishing by using
diamond finishing disc
(18)
.
The final thickness of each specimen
(porcelain +metal) was (4.0 mm 0.5) and
was standardized using a micrometer at 5 point
readings for each sample as in Figure 1.


Figure 1: Standardization of porcelain
thickness using micrometer.

Profilometric readings were carried to
standardize the surface topography of all
samples before surface glazing and polishing.
Group I samples were subjected to applied
glaze (Universal Glasur Glaze, Ivoclar,
Vivadent, England) by bristle dental brush
technique and then subjected to a temperature
of 900C at a holding time of one minute
without vacuum.
The samples were randomly divided into
five groups according to the type of finishing
and polishing. Each group consisted of seven
specimens. The groups were as follows:
Group I: Samples subjected to applied glaze.
Group II: Samples polished with sand paper
disc, porcelain rubber wheel, rubber cup,
dental pumice.
Group III: Samples polished with sand paper
Dentalloy polishing paste.
Group IV: Samples polished with sand paper
Dentaurum Universal paste.
Group V: Samples polished with sand paper
Aluminum Oxide paste (Al
2
O
3
).
In order to construct a base for each metal-
porcelain disc to be fixed to the lower member
of the surveyor, an acrylic block was
constructed for each disc as follows:
A square-shaped sheet of wax 3x3 cm with
2 mm in thickness was placed on a cement
glass slab with a circular punch at the middle
made with a copper ring of 10 mm in diameter.
Each metal-porcelain disc in the five
groups was placed in the perforation in such a
way that the porcelain surface was directed
toward the cement glass slab. A plastic ring
(20 mm in diameter, 25 mm in height), opened
from both ends was lubricated with a
separating medium and centered over the
square shaped sheet of wax and a cold-cure
acrylic resin was mixed in a mixing jar with
powder to liquid ratio of (1.3:1) and poured in
the plastic ring to embed the disc in it leaving
the porcelain part of the disc outside the
acrylic.
Standardization of porcelain polishing was
controlled using a straight hand piece (W&H,
Austria) mounted on a surveyor (Cendrex
Metauxy SA250, Bienne, Swiss) carrying
sand paper disc (J elenko Mfg Co., USA),
rubber wheels (Fine cut, Dedeco, USA) and
rubber cups (Shoefu dental Mfg Co., J apan) at
90 angle to the porcelain surface.
Each sample was attached by its acrylic
base to the lower member of the surveyor to
prevent sample movement. The arm of the
surveyor was moved in estimated continuous
circular movement (7 cycles per 10 seconds) to
polish each sample. The hand piece was fixed
in position just touching the sample and the
speed was fixed at 35,000 r.p.m by the use of
control switch for manual operation as in
Figure 2. The time was also fixed to 10
seconds using a stop watch (Orient, J apan)
(13)
.
The use of the hand piece permitted good
control for finishing and polishing small
samples. A lathe was not used for polishing to
avoid problems if the specimen was
accidentally caught in the polishing wheel and
spunn off
(14)
.
Each type of smoothing and polishing bur
(sand paper disc, rubber wheel, rubber cup)
was used for seven samples then discarded.

Figure 2: Polishing porcelain using rubber
wheel.

Final polishing of group II samples was
done using slurry of flour of pumice (20 m,
Iraq) and distilled water. The ratio of powder
to liquid mixing was 1.5:1. Group III samples
were polished using Dentalloy polishing paste
(Iraq-Factory for Dental Materials &
appliances, Baghdad, Iraq), Figure 3.


Figure 3: Materials used for polishing group
(III), sand paper discs, rubber wheels,
rubber cups, Dentalloy polishing paste.

Group IV samples were finally polished
using universal polishing paste (Tiger
Starshine, Dentaurum, Germany), Figure 4.

Figure 4: Materials used for polishing group
(IV) sand paper discs, rubber wheels,
rubber cups, Dentaurum universal polishing
paste.
Group V samples were finally polished
using slurry of A1
2
O
3
(30 um) (Batch no.
31166, Germany) and distilled water (1.5:1
ratio). The samples, after polishing, were
cleaned with distilled water for 5 minutes then
dried before profilometric testing.
A surface roughness analyzer device
(Hommel, Germany) was used to verify the
surface topography of the glazed and polished
samples. Profilometric parameter (Ra) was
selected for this study, Figure 5.

Figure 5: Surface roughness testing of
polished porcelain.

For each specimen, three readings were
recorded, the first reading in a vertical line, the
second in a horizontal line and the third in a
radial line (slope line), and the mean value was
calculated. The results were recorded and
analyzed statistically using a one-way Analysis
of Variance (ANOVA), Least Significant
Difference (LSD) and Student t-test.

RESULTS
The roughness mean values (Ra) of
applied glazed, dental pumice, Dentalloy
polishing paste, Dentaurum universal polishing
paste and aluminum oxide before and after
surface treatment (S.T.) are shown in Table I
and Figure 6.

Table 1: Roughness mean values (Ra) in m
of the tested groups, before and after (S.T.).

Applied
glazed
Group
I
Dental
pumice
Group
II
Dentalloy
paste
Group
III
Dentaurum
paste
Group IV
Aluminum
oxide
Group V
Before
S.T.
0.93143 0.92857 0.920 0.91571 0.92286
After
S.T.
0.71571 0.79286 0.74286 0.72571 0.840
0
0.2
0.4
0.6
0.8
1
Mean Ra (m)
Group
I
Group
III
Group
V
Before
After
Figure 6: Histogram showing the means of
differences in (Ra) values of the five groups
(before and after S.T.).

In general, the highest mean score of Ra
values after polishing were recorded in group
V (Aluminum oxide) which represented the
roughest surface followed by group II (dental
pumice) then group III (Dentalloy polishing
paste) then group IV (Dentaurum universal
polishing paste). Group I (applied glaze)
showed the lowest mean score of Ra values
and thus the smoothest surface of porcelain
Statistical analysis of the data using one-
way Analysis of variance (ANOVA) revealed
non significant statistical difference at level (P
>0.05) between the five groups before S.T. as

shown in Table 4. On the other hand,
(ANOVA) test revealed very high statistical
significant difference at level (P < 0.001)
between the five groups after surface treatment,
Table 5.
Least significant difference test (LSD) of
the data of the groups (after S.T.) revealed
non-significant differences between group I
and group IV while the rest of groups showed
different significant levels as shown in Table 6.
In addition, very high significant
differences were present between the treated
and untreated samples of each group using the
Student t-test.

DISCUSSION
In this study, surface roughness evaluation
of polished porcelain using different agents
was carried out to verify the best polishing
system locally available as a substitute for the
applied glaze technique.
The glazed samples of group I scored
smoothness of very high significant values
than groups II, III and V; a finding that
concurred with Campbell
(15)
and Patterson et
al
(16)
results. On the other hand, no
significance occurred between the glazed
group and the polished porcelain using
Dentaurum paste (group IV); a finding that
disagreed with the results of Scurria and
Powers
(17)
who reported that feldspathic
porcelain could be polished smoother than
glazed and also disagreed with Ward et al
(18)

and Kawai et al
(19)
results.

Table 4: One-way (ANOVA) test of the five groups (before S.T.).
ANOVA Sum of squares d.f Mean of squares F value Sig.
Between Groups 0.001131 4 0.000283
Within Groups 0.0 13286 30 0.000443
Total 0.014417 34
0.64N.S 0.639
d.f.: degree of freedom
N.S.: Non Significant

Table 5: One-way (ANOVA) test of the five groups (after S.T.).
ANOVA Sum of squares d.f Mean of squares F value Sig.
Between Groups 0.07596 4 0.01899
Within Groups 0.005029 30 0.000168
Total 0.080989 34
113.29 V.H.S. 0.001
d.f.: degree of freedom
V.H.S.: Very High Significant difference

Table 6: L.S.D test.
Comparison groups Difference between groups L.S.D 0.05 L.S.D 0.01 L.S.D 0.001 Sig.
Group I vs. Group II 0.07715 ***
Group I vs. Group III 0.02715 ***
Group I vs. Group IV 0.010 N.S.
Group I vs. Group V 0.12429 ***
Group II vs. Group III 0.05 ***
Group II vs. Group IV 0.13285 ***
Group II vs. Group V 0.04714 ***
Group III vs. Group IV 0.01715 *
Group III vs. Group V 0.09714 ***
Group IV vs. Group V 0.11429
0.014

0.019

0.025

***
* = Significant difference, ** = High Significant difference, ***Very High Significant difference
N.S : Non Significant
Natural glaze (autoglaze) was not tested in
the present study since it has been shown to
cause generalized pitted porcelain surface that
was attributed to incomplete flow and
coalescence of the superficial layer which
would impact a desired stain texture to the
porcelain surface
(20)
.
As a result, natural glazing would be
recommended for porcelain restorations that do
not require additional stains otherwise applied
glaze is preferred. The glazed retention was
found to be far from guaranteed and once an
interruption of the glaze occurs, deleterious
effects of abrasion would start
(21)
. It has also

been found that the glaze could be lost after a
relatively short period of intraoral function
corresponding to two days after final
cementation of the porcelain restoration
(22)
.
Polishing porcelain using dental pumice
caused significantly very high levels of
decreased smoothness in comparison to the
applied glaze group, a finding that disagreed
with Grieve et al
(23)
results. Also pumice
significantly caused inferior smoothness than
polishing with Dentalloy and Dentaurum
pastes respectively. The Iraqi-made Dentalloy
polishing paste, which was introduced to the
market in 2002, produced significantly less
smooth porcelain texture than both applied
glaze and Dentaurum paste.
On the other side, Dentaurum polishing
paste resulted in non-significant porcelain
surface characteristics compared to the applied
glaze samples. This good polishing
performance could be related to the fine
particle size of the abrasive content which
could fill the tiny scratches present in the
adjusted porcelain surface thus providing a
smooth surface rather than cutting grooves
especially when a high speed polishing pattern
was required by the solidity of the porcelain
surface.
Polishing surface with Al
2
O
3
-water paste
produced the roughest surfaces among the
treated samples of the other groups, which was
not consistent with Klausner et al
(24)
results
who showed no significant difference between
using levigated alumina and glazing. Scurria
and Powers
(17)
also concluded that Al
2
O
3

pastes were equivalent to polishing pastes and
gels. Still it was evident in the present study,
that polished samples of all groups exhibited
very high significant difference in smoothness
than the unpolished ones, which stresses the
importance of glazing or polishing adjusted
porcelain surfaces than keeping them rough.
The disparity present in researches
findings concerning porcelain texture
following either glazing or polishing might be
attributed to the different polishing agents and
the different porcelain systems tested. While
dental porcelains have been modified to a state
of near perfection, they still acquire a number
of decided flaws due to the inhomogeneous
distribution of crystals in the glassy matrix
(25)
.
Opinions vary as which method would provide
the smoothest surface while maintaining the
structural requirements of ceramic restorations,
and it seems that the optimal ceramic finish
will remain as an unsolved equation for dental
ceramists for the time being and the nearest
future.

REFERENCES
1. Leopold H, Charles B, Gerald T. Polish versus auto
glazed porcelain surface. J Prosthet Dent 1982; 47 (2):
157-62.
2. Oram DA, Davies EH, Boyd CH. Fracture of ceramic
and metalloceramic cylinders. J Prosthet Dent 1984;
52(2): 221-30.
3. Podshadley AG, Harrison JD. Rat connective tissue
response to pontic materials. J Prosthet Dent 1966; 16:
110-8.
4. Clayton J A, Green E. Roughness of pontic materials
and dental plaque. J Prosthet Dent 1970; 23 (2): 407-
11.
5. Newitter DA, Schlissel ER, Wolff MS. An evaluation
of adjustment and post adjustment finishing techniques
on the surface of porcelain-bonded-to-metal crowns. J
Prosthet Dent 1982; 48: 388-95.
6. Goldstein GR, Barnnard BR, Penugonda B.
Profilometer, SEM, and visual assessment of porcelain
polishing methods. J Prosthet Dent 1991; 65: 627-34.
7. Sulik WD, Plekavitch EJ . Surface finishing of dental
porcelain. J Prosthet Dent 1981; 46: 217-21.
8. Raimondo RL, Richardson JT, Weidner B. Polished
versus autoglazed dental porcelain. J Prosthet Dent
1990; 64: 553-7.
9. Brewer J D, Garlapo DA, Chipps EA, Tedesco LA.
Clinical discrimination between autoglazed and
polished porcelain surfaces. J Prosthet Dent 1990; 64:
631-4.
10. J acobi R, Shillingburg HT, Dancanson M. A
comparison of the abrasiveness of six ceramic surfaces
and gold. J Prosthet Dent 1991; 66: 303-9.
11. Barghi N, King CJ , Draughn RA. A study of
porcelain surfaces as utilized in fixed prosthodontics. J
Prosthet Dent 1975; 34: 314-9.
12. Kiyoshi A, Dhuru V, Cariapa V, Ziebert G. Effect of
various polishing agents on dental porcelain surfaces. J
Dent Res 1995; 74: 425, Abstract No. 194.
13. Zakaria MR, Al-Naami MM. Profilometric study of
the surface characteristics of porcelain using different
glazing and polishing techniques. J College of Dent
2002; 11: 163-6.
14. Lombardas P, Carbunaru A, McAlarney ME,
Toothaker RW. Dimensional accuracy of castings
produced with ringless and metal ring investment
systems. J Prosthet Dent 2000; 84: 27-31.
15. Campbell SD. A comparative strength study of metal
ceramic and all-porcelain esthetic materials. Modulus
of rupture. J Prosthet Dent 1989; 62: 476-9.
16. Patterson CJ W, McLundie AC, Stirrups DR, Taylor
WG. Polishing of porcelain by using a refinishing kit. J
17. Scurria MS, Powers J M. Surface roughness of two
polished ceramic materials. J Prosthet Dent 1994; 71:
174-7.
18. Ward MT, Tale WH , Powers J M. Surface roughness
of opalescent porcelains after polishing. Oper Dent
1995; 20: 106-10.
19. Kawai K, Urano M, Ebisu S. Effect of surface
roughness of porcelain on adhesion of bacteria and
their synthesizing glucans. J Prosthet Dent 2000; 83:
664-7.

20. Cook PA, Griswold WH, Post AC. The effect of
superficial colorant and glaze on the surface texture of
vacuum-fired porcelain. J Prosthet Dent 1984; 51: 476-
84.
21. Leinfelder KF. Will ceramic restorations be
challenged in the future? J Am Dent Assoc 2001; 132:
46-7.
22. J agger DC, Harrison A. An in vitro investigation into
the wear effects of unglazed, glazed and polished
porcelain on human enamel. J Prosthet Dent 1994; 72:
320-3.

23. Grieve AR, J effert IW, Sharma SJ . An evaluation of
three methods of polishing porcelain by comparison of
surface topography with the original glaze. Restorative
Dent 1991; 7: 34-6.
24. Klausner LH, Cartwright CB, Charbeneau GT:
Polished versus autoglazed porcelain surfaces. J
Prosthet Dent 1982; 47: 157-62.
25. Oh WS, Delong R, Anusavice, KJ . Factors affecting
enamel and ceramic wear: A literature review. J

J Bagh Coll Dentistry Vol. 18(2), 2006 Percentage of undercut
Percentage of undercut areas in edentulous patients

Ghayda'a H. Al-Izzi B.D.S, M.Sc.
(1)

Sabah S. Al-Habib B.D.S, M.Sc.
(2)

ABSTRACT
Background: Bony undercuts are usually present in both maxillary and mandibular jaws (anteriorly and posteriorly)
unilateral or bilateral. Their location is affected by bone resorption and aging process.
Materials and methods: This study was conducted on a sixty male and female patients attending the fifth class clinic
in college of dentistry / Baghdad University. Their ages ranged from 30 -80 years with no systemic diseases.
Results: In the maxillary jaw the percentage of undercut in male anteriorly was 57%, while posteriorly was21%. In the
mandibular jaw anteriorly was 24%; posteriorly was 43%. In the female subject the percentage of undercut was in
maxillary jaw anteriorly 23%; posteriorly was 6%, in mandibular jaw anteriorly was 4%, posteriorly was 15%.
Conclusion: There was a highly significant difference in the prevalence of undercuts between males and females, in
the maxillary posterior region and mandibular anterior areas. A significant difference was also found between males
and females in the maxillary anterior region and mandibular poster area.
Key words: Maxillary undercut, mandibular undercut. (J Bagh Coll Dentistry 2006; 18(2) 22-24)

INTRODUCTION
1

One can not speak about complete or partial
dentures and maxillofacial prosthesis without
mentioning to the basal seat underneath which
provides supports and retention for these
prosthesis.
The most important part of the basal seat is
the undercut, which can be defined as the
portion of the surface of an object that is below
the height of contour in relationship to the path
of placement.
(11)

Undercut effect function and health of
underling tissues. Many systemic and local
factors may affect the presence and amount of
these undercut. There location varies, they
could be seen anteriorly, posteriorly, unit or
bilaterally in single or both jaws.
J aw bones are the mandible which looks
like horse shoe and the maxilla form the
maxillary jaw
(8)
. J aw bone is a living tissue
with a collagenous protein matrix that has been
impregrated with mineral salt, especially
phosphates and calcium, also it is cellular and
well vascularized
(12)
.
The residual alveolar bone is that bone of
the alveolar process which remains after teeth
are lost and full with new bone later on. This
alveolar process becomes the residual ridge
which is the foundation of the denture.
(4)

Results from some studies said that
approximately 50% of the population become
edentulous by the age of 60 years
(3)
, so the
alveolar bone become under different forces
which lead to remodeling of the bone and this
continue until the forces are balanced and

(1) Assistant lecturer, Department of Prosthodontics, College of
Dentistry, Baghdad University.
(2) Assistant lecturer, Technical College, Baghdad University.
equilibrium returns
(9)
. This remodeling
determined by the timing and sequence of tooth
loss, prosthesis wear and facial morphology
(7)
.
The differential pattern of remodeling and
resorption between maxilla and mandible lead
to pseudo-class III relationship
(7)
.
There are different factors act on ridge
resorption observed on different patients like
anatomic, metabolic, functional and prosthetic
(1)
. Investigators agree that individual difference
in the rate of resorption of the ridge very great
underling metabolic, hormonal and nutritional
causes account for these differences
(2)
.
Residual alveolar ridge undercuts are rarely
excised as a routine part of improving a
patient's denture foundation. Dentists utilized
the undercut for extra stability
(5, 6)
.
The aim of this study was to find the
percentage of those undercuts in both jaws and
find the relation between their location in male
and female by intra oral examination, visual
and palpation examination.

MATERIALS AND METHOD
A sample was selected of 60 patients male
and female from the clinic of dentistry college,
Baghdad University. All patients have no
systemic diseases and never received any
surgical correction on both jaws and the age
range between 3080 years old.
Each patient was examined for presence of
undercut areas by visual examination first by
using dental mirror, second by palpation (Index
Finger). The order of examination was
maxillary anterior, maxillary bilateral posterior,
mandibular anterior then mandibular bilateral
posterior areas. The examinations were
confirmed by examination of the final cast of
22 Restorative Dentistry
each patient. Data were collected on a data
sheet (Figure 3). Statistical analysis was done
by using Chisquare and presented as
histograms.

RESULTS
Figure 1 shows the total number of females
having anterior and posterior (mandibular and
maxillary) undercut areas. Figure 2 represents
the total number of males having anterior and
posterior (mandibular and maxillary) undercut
areas.
Table 1 shows the percentage and number
of males having undercut areas in maxillary and
mandibular jaw posteriorly and anteriorly.
Table 2 gives us an idea about the percentage
and number of females having undercut areas in
maxillary and mandibular jaw posteriorly and
anteriorly.
Table 3 explains a comparison between
males and females having undercuts in
mandibular and maxillary jaws both posteriorly
and anteriorly.

Table 1: No. and percentage of males (maxillary and mandibular)
Maxillary Mandibular
Male
Ant. N % Post. No % Ant. No % Post. No %
30-39 1 1.7 1 4.76 2 8.33 0 0
40-49 7 12.3 1 4.76 3 12.5 4 9.3
50-59 11 19.3 6 28.57 8 33.3 13 30.2
60-69 20 35.1 3 14.28 5 20.8 13 30.2
70-80 18 31.6 10 47.61 6 25 13 30.2
Total 57 21 100 24 100 43 100

Table 2: Number and percentage of females (maxillary and mandibular)
Male
Ant. No. % Post. No. % Ant. No. % Post. No. %
30-39 0 0 0 0 0 0 0 0
40-49 0 0 0 0 0 0 0 0
50-59 9 39.13 2 3.33 2 50 3 20
60-69 10 43.48 2 33.33 0 0 8 53.33
70-80 4 17.39 2 33.33 2 50 4 26.67
Total 23 100 6 100 4 100 15 100

Table 3: Chi- square between male and female
Maxillary Chi square P value Sig. Mandibular Chi-Square P-value Sig.
Anterior 3.071 0.042 S 4.265 0 HS
Posterior 4.922 0 HS 3.282 0.012 Sig

Figure 1: Total female of anterior and posterior areas (Maxillary & Mandibular)


Figure 2: Total male of anterior and posterior areas (maxillary & mandibular)

DISCUSSION
It was evident that there was high
percentage of undercuts in the maxillary
anterior and mandibular posterior areas (Table
1). This might be due to the pattern of
resorption occurring as a normal process of
aging and also due to the extraction of teeth.
The same finding appeared in females that
the highest percentage was in the maxillary
anterior area. This is might be due to the same
reason above, but the big difference in the
percentage might be due to the anatomical
variation between male and female in size of
jaws and consequently in the amount of
resorption. Also the high percentage of males in
the presence of anterior undercuts might be due
to ignorance of males to esthetic and oral
hygiene steps (brushing, flossing, periodic
checkup) which leads to early loss of teeth and
subsequent bone resorption. The highly
significant difference between males and
females found in table 3 between posterior
maxillary and anterior mandibular areas, and
significant difference between anterior
mandibular and posterior maxillary areas might
be explained on the basis of hormonal factors
affecting the resorption amount in females and
also to the anatomical differences between both
genders regarding to the size of jaws and to the
force of muscles of mastication which may lead
to more resorption in males when edentulous
jaws used for mastication of food.

REFERENCES
1. Atwood DA. Some clinical factors related to rate of
resorption of residual ridges. J Prosthet Dent 1962;
12: 441-50.
2. Ellaworth K. Changes caused by mandibular
removable partial denture apposing a maxillary
complete denture. J Prosthet Dent 1972; 27: 140-50.
3. Enlow DH. Alveolar bone: Review of literature. In
lang BR, Kelsey CC (eds): International
prosthodontic workshop. Ann Arbor M. The
university of Michigan school of Dentistry; 1973.
4. Hickey J C, Zarb GA, Bolender CL. Boucher's.
prosthodontic treatment for edentulous patients. 8th
ed. St. louis:CV Mosby; 1980.P.3.
ed. St. louis:CV Mosby; 1980. P.24.
ed. St.louis:CV Mosby; 1980. P. 105.
7. Mercier P, Lafontant R. Residual alveolar ridge
atrophy, classification and influence of facial
morphology. J Prosthet Dent 1979; 41: 90-100.
8. Richard S, Snell. Clinical anatomy. 5th ed. 1995. P
687-8.
9. Scott RF. Oral and maxillofacial trauma in geriatric
patient. In Fonseca RJ , Walker RV (eds): oral and
maxillofacial trauma, vol 2. Philadelphia, WB
Saunders; 1991. pp 754-80.
10. Tallagren A. The effect of denture wearing on facial
morphology: A seven year longitudinal study. Acta
Odont Scand 1967; 25: 563.
11. The Glossary of prosthodontic terms. J Prosthetic
Dent 7th ed. 1999; 81: 105.
12. Ganong W F. Review of medical physiology.10th
edition. Los Altos: California; 1981; P.309.

J Bagh Coll Dentistry Vol. 18(2), 2006 An assessment of the
An assessment of the effect of using different post systems
on the fracture resistance of endodontically treated teeth.

Lamis A. Al-Taie, B.D.S, M.Sc.
(1)

Aladin Al-Rubayi, B.D.S, Ph.D
(2)

ABSTRCT
Backgroud: Different post systems are available in the market but the prognosis of teeth by which they are restored
has been questioned. This in vitro study evaluated and compared the fracture resistance of endodontically treated
teeth restored with four post systems.
Materials and Methods: Forty intact human mandibular second premolars were selected for this study. These samples
were endodontically treated, and randomly divided into 5 groups of eight each. Group I: the control group (without
posts), group II: restored with prefabricated carbon fiber posts (C-post), group III: restored with prefabricated parallel-
sided titanium posts (Radix-anker posts), group IV: restored with cast post and cores, and group V: restored with glass
fiber posts (Postec), then the samples were tested to failure with an obliquely applied compressive load at 45
o
C,
using a Zwick testing machine with a crosshead speed of 5 mm/ min. until failure.
Results: Failure load results were obtained for all test specimens. The means and standard deviations for each group
were as follows: group 1 (control group): 113.875 4.19Kg; group 2: 89.875 4.16 Kg; group 3: 84 4.28 Kg; group 4: 82
5.58 Kg; and group 5: 80 5.21 Kg.
Conclusions: The specimens restored with carbon fiber posts and composite cores showed significantly greater
resistance to root fracture than those restored with the other three systems tested. There was a little difference in the
fracture mode between the different treatment modalities, and teeth without post and core foundations tested
significantly stronger than the other comparison groups.
Key words: Fracture resistance, metal posts, fiber reinforced posts. (J Bagh Coll Dentistry 2006; 18(2)25-31)

INTRODUCTION
Endodontically treated teeth with defective
coronal aspects very often need to be restored
with a post and core as foundation for the final
restoration.
(1)
In the last decades, cast posts
were most commonly used because of their
favorable physical properties and
biocompatibility. Unfortunately, several
disadvantages associated with conventional cast
post and core were found such as loss of
retention of the post, potential for post and root
fractures and risk of corrosion.
(2)
The difference
between modulus of elasticity of dentin and
post material is a source of stress for the root
structure.
(3)
Until recently, all available
prefabricated posts consisted of metal alloys
that cause a final heterogeneous combination
with the dentin, the metallic post, cement
(usually zinc phosphate), and the core
material.The major disadvantage of these
techniques is that the stresses can be
concentrated in uncontrolled areas that are
sometimes very vital to the root.

(1) Assistant lecturer, Department of conservative Dentistry,
College of Dentistry, University of Baghdad
(2) Professor, retired.
Furthermore, there is no adhesion between
the zinc phosphate cement and the root
structure or any of the restorative materials with
which it is used.
(4)
Technology has produced
rigid non-metallic composite posts that are
strengthened by various kinds of fibers (carbon
fiber, carbon-quartz, quartz, glass, and silicon)
and can be formed in various configurations to
make maximum use of its properties.
Experimental studies done by King and
Setchel
(5)
, and Isidor et al.
(6)
confirmed the
value of such material and adhesive techniques
to obtain a tooth-post-core monoblock instead
of an assemblage of heterogeneous materials,
which provides the most predictable post-
endodontic treatment modality.
The aim of this study was to evaluate the
fracture resistance and mode of failure of the
endodontically treated teeth restored with
different post systems.

Forty sound recently extracted lower second
premolars of comparable sizes and shapes, were
selected for experimentation.
All teeth were cleaned from soft tissue
debris and stored in physiologic saline solution
at room temperature from the time of extraction
to the time of testing. The samples were
randomly divided into 5 groups of 8 teeth each:
Group I (control group): consisted of
endodontically treated teeth without posts.
Group II: consisted of endodontically treated
teeth restored using carbon fiber posts
(composi posts).
Group III: consisted of endodontically treated
teeth restored using parallel-sided titanium
threaded posts (Radix anker posts).
Group IV: consisted of endodontically treated
teeth restored using nonprecious cast post-
cores.
Group V: consisted of endodontically treated
teeth restored using glass fiber posts
(postec).
These samples were endodontically
obturated with gutta- percha root canal filling
material (DiaDent, Korea), and then the coronal
portions of teeth in Group II, III, IV, and V
were removed at a level 1mm coronal to the
cemento-enamel junction with a diamond disk
(Komet, Germany) and full water spray coolant.
The coronal portions of teeth in group I (control
group), were removed in the same way ending
with (19 mm) tooth portion lengths.
The gutta-percha was removed from the root
canals of teeth in group II, III, IV, and V with
peeso drills (Dentsply, Switzerland), to a depth
of 10 mm measured from the coronal end of the
root. Then the post spaces were prepared in all
groups with the special preparation drills of
each system.
The carbon fiber posts (Composipost -No.2
0610122-, RTD, France) were used in group II,
post no.2 was selected. The special drill of the
system was used to prepare the post spaces
under full water irrigation. Radix-Anker
Standard posts (titanium parallel sided threaded
posts) (Dentsply, Switzerland) were used in
group III. Post no.3 was selected. The seating
for the Radix-Anker Standard head was drilled
with the root facer No.3. Precision drilling was
performed manually with the spiral bur No.3
and mandrel.
Glass fiber posts (Postec FRC -No.2 0123-,
Ivoclar-Vivadent, Liechtenstein) were placed in
group V, post No.2 was selected (the system
was designed to have a tapered form; the degree
of taper gradually decreased to 1.00 mm
diameter at the apical end).
The special drill of the system was used
to prepare the post spaces under full water
irrigation, while custom cast post and cores
were made for group IV, in this group post
space preparation was done using pesso drill
No.2 (Preci-Line, Post set) under full water
irrigation.
The wax patterns were invested with a
phosphate bonded investment material (Speedy,
Italy). Then the casting was performed using a
lost wax technique and nickel-chromium alloy
(CB Blando 72, Hatakeyama dental Mfg. Co.,
J apan).(figure 1c).
For group I (control group), the coronal
gutta-percha was removed to a depth of 5 mm
then filled with composite resin.After that,all
teeth were embedded in individual blocks of
acrylic resin.
All posts were first tried inside the canals
without cement to the full prepared length, then
cemented using Panavia F dual cure adhesive
resin cement (Kurary Co. LTD, Osaka,
J apan).(Figure 1 a,b,d).
Following the manufacturers directions, one
drop of alloy primer bottle was applied
homogenously on the surface of posts in group
III and IV, and allowed to set for 60 seconds.
One drop of each ED Primer (A and B) was
dispended on a mixing dish, then applied
homogeneously on dentin in the post space as
well as on the surface of the posts (in group II
and V) and allowed to set for 60 seconds, then
carefully dried with a faint air jet.
According to manufacturers instructions
equal parts of Panavia F paste A and B were
dispended on a paper mixing pad and were
gently mixed using a plastic spatula for about
20 seconds until a creamy consistency with a
uniform color mix was obtained.
The mixed cement was inserted into the
prepared canal with a lentulo spiral (Produits
Dentaires S.A., Vevey, Switzerland), and the
post was uniformly coated with cement and
fully seated into the canal to the prepared
length.Oxyguard II was applied homogeneously
at the margin (which is an oxygen inhibition
gel), it initiates curing mechanism of the
Panavia F resin cement.
In group II, III, and V composite cores were
constructed using Tetric composite resin
(Vivadent, Ets/ Liechtenstein).(Figure 1)a,b,d).
Then, for all samples, crown preparations
were done with a diamond chamfer bur
(medium grain size particles, Meisinger,
Germany) to standardized dimensions (6 mm
height, 5.5 mm bucco-lingually, and 4 mm
mesio-distally) and total axial taper of 5 degrees
with a 1 mm gingival chamfer finishing line on
a sound tooth structure.
Wax patterns were constructed directly
on the core samples using type II blue inlay
wax after the application of the separating agent
on the samples, then the wax patterns were
invested with the phosphate bonded investment
material , then casting was performed using a
lost wax technique and nickle-chromium alloy
(CB Blando 72, Hatakeyama dental Mfg. Co.,
J apan). Cementation procedure of the cast
crowns was done using Panavia F dual cure
adhesive resin cement, then the samples were
subjected to 100 thermal cycles between 5
o
C
and 55
o
C, keeping the samples for 30 seconds
at each temperature bath.
The samples were placed in a fixture
attached to a universal testing machine (Zwick
testing machine, Germany). A continuously
increasing compressive force was applied to the
facial cusp in the axio-occlusal line angle at 45
degrees to the long axis of the tooth at a
crosshead speed of 5 mm/min. until failure
(Figure 2). The fracture loads were determined,
and the mode of fracture was recorded and
classified as favorable (restorable), or
catastrophic (non-restorable).
One-way ANOVA test was used to
determine the significance of failure loads
among the tested groups.

a b
c d
Figure 2: Specimen positioned at 45
o
in the
mounting apparatus fixed in the universal
testing machine.
Figure 1: Specimens after cementation: a. C-post, b.
Radix Anker post, c. Cast post, d. Glass fiber post.

RESULTS
The data of the load failure of all tested
specimens is shown in Table 1.
Statistical analysis of data by using the
analysis of variance ANOVA revealed that
there was a statistically highly significant
difference (P<0.000) between the mean forces
among the five groups as shown in Table 2.
Further investigation using LSD (Least
Significant Difference) test showed that there
was a statistically highly significant difference
between group I (control group), and the other
experimental groups, also between group II
(carbon fiber post) and group V (glass fiber
post).
There was no significant difference in the
mean failure load between groups III, IV, and V
(Table 3).
The mode of failure in all teeth tested were
oblique and horizontal radicular fractures, the
majority of fractures involved the buccal crown
margin and extended to the cervical third of the
lingual root surfaces.
There was no significant difference in the
fracture mode between groups, catastrophic
fractures were observed in titanium parallel
sided posts (Radix anker post) (Table 4 and
Diagram 1).

Table 1: The data of failure loads (in Kg) for all test specimens with the mean and standard
deviation of each group.

Table 2: Analysis of variance (ANOVA) test for the five groups.

Sum
of
squares
Degree
of
freedom
Mean
square
F

valu
e
Sig. P
value
Between
groups
6098.150 4 1524.538
HS
0.000
Within groups 779.750 35 22.279
Total 6877.900 39
68.431

Table 3: Least significant difference LSD test to compare the mean failure loads between groups.
Control
Carbon fiber
post (C-post)
Radix anker
post
Cast post
Glass fiber
post

Table 4: The number of restorable and catastrophic fracture patterns for the five groups.
Restorable
Fractures
Catastrophic
Fractures
Group I (Control) 6 2
Group II (Carbon fiber posts) 5 3
Group III (Radix Anker posts) 4 4
Group IV (Cast post and cores) 6 2
Group V (Glass fiber posts) 5 3

Group
I
Group II Group III
Group
IV
Group V
Sample
No.
Control
Carbon fiber post (C-
post)
Radix anker
post
Cast post
Glass fiber
post
1 120 97 90 90 90
2 118 95 90 88 84
3 115 90 86 85 82
4 115 90 84 85 80
5 115 88 82 82 78
6 110 87 80 80 76
7 110 87 80 75 75
8 108 85 80 75 75
Mean 113.875 89.875 84 82.5 80
S.D 4.19 4.16 4.28 5.58 5.21
0.000
HS
0.000
HS

0.000
HS

HS

0.000

0.018
S
0.004

0.000

S

HS
0.529

0.099
NS

NS
NS

0.297
HS: highly significant, S: significant, NS: non significant

Figure 3: Bar chart shows the mean failure loads (in Kg) for the five groups.

.

Diagram 1: Failure modes and distribution

DISCUSSION
Under the conditions of this study, the
results showed that the endodontically treated
teeth without posts (Group I) recorded the
highest mean failure load than the other groups
(endodontically treated teeth with post and
core).This indicates that the bulk of the
remaining tooth structure, rather than the post,
provides the strength and resistance to fracture
for the endodontically treated tooth.
This finding is in agreement with that
obtained by Lovdahl and Nicholls
(7)
; Sidoli et
al.
(8)
; and Dean et al.
(9)
. The results of this
study demonstrated the higher mean failure load
of Group II (carbon fiber posts) compared with
Group III (Radix anker posts), Group IV (cast
post and cores), and Group V (glass fiber
posts).There are four possible explanations for
the observed differences in the fracture
resistance between teeth in Group II and the
other groups;
-Their module of elasticity, which at 21 Gpa
resembles that of natural dentin, seems to have
a positive effect on their biomechanical
characteristics and eliminates the stresses that
are often formed at the interfaces of different
materials such as (dentin and fiber post).
-The carbon fibers can actually reduce the
stress by changing their orientation inside the
post to correspond to that of the applied force,
and it appeared able to distribute the applied
forces evenly along the length of the post, as it
was previously explained by King and Setchel
(5)
; and Assif et al..
(10)

-The transfer of forces from the post to the
tooth undoubtedly depends on whether the post
is bonded or not. The resin bonding of the fiber
posts seems to distribute the applied forces
more or less equally over the entire bonded
interface, as well as increasing the strength of
the restored tooth. This was previously proved
by Mendoza et al.
(11)
and Asmussen et al..
(12)

- The design of the C-post that was used in
this study has particular advantages:
1. Beveling of the edges and the apex to
reduce concentration of stresses in these areas.
113.88
0
20
40
60
80
100
120
F
a
i
l
u
r
e

l
o
a
d
s

i
n

K
g
89.88
84
82.5
80
Control Carbon
fiber post
(C-post)
Radix anker
post
Cast post Glass fiber
post
2. Relatively narrow diameter of the lower
portion of the post to reduce the amount of
tooth structure that must be removed.
Cast and metallic posts transfer more stress
to the root, predisposing to root fracture when
compared to carbon fiber/ epoxy post
(8,9,13)
.
The statistically significant difference in
fracture resistance of teeth in Group II over that
of Group III, is in agreement with the finding of
Isidor et al.
(6)
and Isidor and Brondum
(14)
, but
disagrees with the result of Dean et al.
(9)
who
found that there was no statistically significant
differences in fracture resistance of teeth
restored with C-post, and those restored with
prefabricated parallel sided posts.
The statistically significant difference in
fracture resistance of teeth in Group II over that
of Group IV, is consistent with the finding of
Isidor et al.
(6)
and Isidor and Brondum
(14)
, but
inconsistent with the result of Martinez-Insua et
al.
(13)
who found a statistically higher fracture
thresholds which were recorded for the cast
post and core group in comparison to carbon
fiber post group. In their study the post-hole for
the cast post was prepared to the same shape as
prefabricated carbon fiber post using the same
peeso drill of the Composipost system which
may explain the disagreement.
Although the new double taper system of the
glass fiber posts was designed for the purpose
of close canal adaptation with minimal tooth
structure removal, the obvious problem that
associated the use of tapered post design was
the wedge- like action which was responsible
for the increased stress concentration at the
apical end resulting in root fracture. This post
design may have accounted for the significant
difference in fracture resistance of teeth in
Group II over that of Group V.
In the present study, the results showed that
although the mean failure load of Group III was
higher than that of Group IV, it was statistically
not significant. The different post geometries
were responsible for the observed difference.
Tapered cast posts have been blamed for a
wedging effect and lower failure loads
(8)
.This
finding is in agreement with that of Sidoli et al.
(8)
; Assif et al.
(10)
; and Akkayan &Caniklioglu
(15)
, but disagrees with the finding of Tjan and
Whang
(16)
and Assif et al..
(17)
All of them
observed that the threaded parallel-sided posts
exhibited higher failure rate as a result of root
fracture.
Although roots in Group III exhibited higher
mean failure load than Group V, it was also
statistically not significant. This finding
disagrees with the finding of Akkayan and
Gulmez
(18)
who found that teeth restored with
titanium posts exhibited lower mean resistance
to fracture than those restored with glass fiber
posts. The possible explanation for this finding
is that the titanium posts used in their study had
a tapered design while the glass fiber post used
had parallel-sided and serrated designs, which
in fact agrees with the results of this study.
The pattern and location of root fractures
were studied and there was a little difference in
the fracture mode between groups.The
descriptive evaluation of teeth in these groups
revealed that the majority of fractures were
extended obliquely from the buccal crown
margins to the cervical third of the lingual root
surfaces.The possible explanation of such
finding is that when the force applied obliquely,
the greatest compressive and tensile stresses
were predicted to occur at the lingual
(compression) or facial (tension) root surface on
the coronal third of the root. This is consistent
with the finding of Assif et al.
(17)
; Hunter et
al.
(19)
and Holmes et al..
(20)

The greatest number of catastrophic
fractures was recorded in Group III (teeth
restored with prefabricated parallel-sided
titanium posts). This is due to the fact that one
potential disadvantage of parallel-sided post
system is the weakening of the apical part of the
root during post space preparation accompanied
with the high Young's modulus of titanium
posts which makes the system stiff and unable
to absorb stresses. This would imply that the
overall strength of the system is related to the
ability of remaining tooth structure to resist
fracture.

REFERENCES
1. Gutman J L. The dentin-root complex: Anatomic and
biologic considerations in restoring endodontically
treated teeth. J Prosthet Dent 1992; 67:458-67.
2. Trabert KC, Cooney J P. The endodontically treated
tooth. Restorative concepts and techniques. Dent
Clin North Am 1984; 28: 923-51.
3. Lin LM, Langeland K. Vertical root fracture. J
Endod 1982; 8: 558-621.
4. Fredriksson M, Astback J , Pamenius M, Arvidson
K. A retrospective study of 236 patients with teeth
restored by carbon fiber reinforced epoxy resin
posts. J Prosthet Dent 1998; 80: 151-7.
5. King PA, Setchell DI. An in vitro evaluation of a
prototype CFRC prefabricated post developed for
the restoration of pulpless teeth. J Oral Rehabil
1990; 17: 599-609.
6. Isidor F, Odman P, Brondum K. Intermittent loading
of teeth restored using prefabricated carbon fiber
posts. Int J Prosthodont 1996; 9: 131-6.
7. Lovdahl PE, Nicholls J I. Pin-retained amalgam
cores versus cast gold dowel cores. J Prosthet Dent
1977; 38: 507-14.
8. Sidoli GE, King PA, Setchell DJ . An in vitro
evaluation of a carbon fiber-based post and core
system. J Prosthet Dent 1997; 78: 5-9.
9. Dean J P, J eansonne BG, Sarkar NK. In vitro
evaluation of a carbon fiber post. J Endod 1998; 24:
807-10.
10. Assif D, Bitenski A, Pilo R, Oren E. Effect of post
design on resistance to fracture of endodontically
treated teeth with complete crowns. J Prosthet Dent
1993; 69: 36-40.
11. Mendoza DB, Eakle WS, Kahl EA, Ho R. Root
reinforcement with a resin-bonded preformed post. J
12. Asmussen E, Peutzfeldt A, Heitmann I. Stiffness,
elastic limit, and strength of newer types of
endodontic posts. J Dent 1999; 27: 275-8.
13. Martinez-Insua A, Silva LD, Rilo B, Santana U.
Comparison of the fracture resistances of pulpless
teeth restored with a cast post and core or carbon-
fiber post with a composite core. J Prosthet Dent
1998; 80: 527-32.

14. Isidor F, Brondum K. Intermittent loading of teeth
with tapered, individually cast or prefabricated,
parallel-sided posts. Int J Prosthodont 1992; 5:257-
61.
15. Akkayan B, Caniklioglu B. Resistance to fracture of
crowned teeth restored with different post systems.
Eur J Prosthodont Restor Dent 1998; 6: 13-8.
16. Tjan AHL, Whang SB. Resistance to root fracture of
dowel channels with various thicknesses of buccal
dentin walls. J Prosthet Dent 1985; 53: 496-500.
17. Assif D, Oren E, Marshak BL, Aviv I. Photo-elastic
analysis of stress transfer by endodontically treated
teeth to the supporting structures using different
restorative techniques. J Prosthet Dent 1989; 61:
535-43.
18. Akkayan B, Glmez T. Resistance to fracture of
endodontically treated teeth restored with different
post systems. J Prosthet Dent 2002; 87: 431-7.
19. Hunter AJ , Feiglin B, Williams J F. Effects of post
placement on endodontically treated teeth. J Prosthet
Dent 1989; 62: 166-72.
20. Holmes DC, Diaz-Arnold AM, Leary J M. Influence
of post dimension on stress distribution in dentin. J
J Bagh Coll Dentistry Vol. 18(2), 2006 Evaluation of interfacial

Evaluation of interfacial bond strength of repaired
composite resins

Ali M. Abdul Kareem B.D.S, Ph.D.
(1)

ABSTRACT
Background: Repair of composite restorationsis a choice if absence of caries is guaranteed. The purpose of this study
was to evaluate the interfacial shear bond strength of the immediately repaired composite specimens.
Materials and methods: Sixty specimens from 2 types of composite were made in a special mold and polymerized
with light. Three methods of surface treatment of the initial layer were done prior to the application of the repair layer
including the use of matrix strip or not and abrasion. The specimens were subjected to shear force from the testing
machine and mean for each group was calculated.
Results: The nonair inhibited specimens showed the highest values of shear bond strength (mean =13.1 Mpa) which
was significantly different from the bur abraded specimens (p<0.05), but insignificant from the air inhibited specimens
(p>0.05) for both types of composite.
Conclusion: The absence of air inhibited layer by using matrix strip increase the interfacial bond strength of the
immediately repaired composite with inferior interfacial bonding for the bur abrasion method.
Keywords: Composite, bond strength, repair. (J Bagh Coll Dentistry 2006; 18(2) 32-34)

INTRODUCTION
A freshly placed composite restoration is
considered sometime unacceptable, because of
color difference, incorrect contour and over
finishing
(1)
. Therefore, there are two solutions,
either to repair or replace the filling. Repair
option is preferred to reduce pulp injury and
cost.
(2)

The most important thing in the repair
procedure is the development of good bond
strength in the interface between the old and
new layers
(3)
. It has been found that the
interfacial bond strength of the repaired
restoration for various composite resins is
affected by age of the initial layer, the condition
of surface in the initial layer, the curing
medium, contamination of the surface of the
initial layer by saliva, the use of bonding agent
(4,5)
and similarity of the two composites
(6,7)
.
The aim of this study was to measure the
interfacial bond strengths of immediately
repaired composite resins after different surface
treatments of the initial layer.

Two types of commercially available
composite resins were used in this study:
Degufill mineral (Degussa Dental; Germany,
hybrid composite) and Helioprogress
(Vivadent; Liechtenstein, microfilled
composite).

(1) Lecturer, Department of Conservative Dentistry, College of
Sixty specimens were made by creating
special mold (6mm in diameter and 8mm
length).
Then the materials were polymerized by
light curing device (Coltolux 50 ColtenFrance)
for 40 seconds. The samples were divided into
3 groups for each type of composite and treated
as follows:
Group I: Air-inhibited specimens. The
composite material was placed in 6 mm
diameter, 8 mm high gelatin capsules and
placed on the top of the initial layer and cured
for 80 seconds.
Group II: Non-air inhibited specimens;
0.05mm thick matrix strip is used to cover the
surface of the cured layer prior to the placement
of the capsule and its polymerization.
Group III: Abraded specimens; in this
group, no strip was used. The surface of the
cured layer was abraded with carbide bur prior
to the placement of capsule and light curing.
In all the three groups, the capsules were
dissolved after polymerization and all excess
material was removed carefully from the
bonded site. All specimens were stored in
normal saline for 4 weeks at 37
o
C. The samples
were subjected to shear loading until failure
using shear punch test
(8)
with Zwick (Model
1454, Germany) testing machine (Figure 1).
After fixation of specimens on special plate,
a stainless steel chisel-shaped rod is directed
toward the interface between the two layers,
allowing the repair layer to be sheared from the
initial layer in a displacement speed of
5mm/min. The shear bond strength was
calculated by dividing the force by the surface
area, and expressed in Mega Pascal (Mpa).

RESULTS
After calculating the shear bond strength, the
mean and standard deviation for each group
were recorded (Table 1). The result data
showed that the specimens showed different
resistance to failure under loading as shown in
figure 2.
ANOVA test was done, and showed that
there is a high significant difference between
the three methods of treatment (P=0.000), while
there is no significant difference (P>0.05)
between the 2 types of composite used.
In Group II in which there is no air-inhibited
layer on the initial layer because of the
placement of strip, the means of shear bond
strength for both types of composite were
higher than those in the group I, but the
difference is statistically insignificant (p>0.05)
according to T-test.
Figure 1: The Zwick testing machine.
In Group III in which the initial layer was
abraded prior to the placement of repair layer,
the specimens had the lowest mean of bond
strength in both types (7.8, 6.7 Mpa) which
were significantly different from the mean
values for the Group I and II (P<0.05) by t
tests.

Table 1: Mean and standard deviation values of the interfacial shear bond strength for the
immediately repaired composite specimens (Mpa)
Composite
type
Helio progress Degufill mineral
Group Group I Group II Group III Group I Group II GroupIII
Mean 11.2 13.1 6.7 11.4 12.3 7.8
SD 3.3 4.2 2.1 2.9 3.2 1.6

Figure 2: Bar chart showing the difference between the groups

DISCUSSION
The immediate repair of composite resin
restoration for minor correction is more
preferable to replacement, to reduce pulp
damage, cost of the replacement material and
time.
For immediate repair, several methods can
be used like: direct application of the repair
layer, application of acid etch and bonding
agent on the initial layer and abrasion of the
initial layer
(9)
.
In this study, the effects of air-inhibited
layer formation and abrasion of the surface
layer were investigated. The result data showed
that, the interfacial shear bond strengths for the
non air and air-inhibited surface state of the
initial layer were significantly indifferent, while
these values were significantly different from
the values of the Group III in which the
surfaces were abraded. For specimen made of
either types of composite, the absence of air-
inhibited layer on the surface of initial layer led
to increase in the interfacial shear bond strength
and this agreed with (Croll 1990
(10)
, Armstrong
et al 2001
(11)
and disagreed with (Li and others
1995
(12)
and Eliades et al 1989
(13)
who
suggested that the formations of a thin viscous
layer comprising unreacted methaycrylate
groups on the cured layer during
polymerization (because of inhibition by
oxygen) will enhance the bonding between the
initial and repair layer through the formation of
covalent bond, secondary bonds and
mechanical interlocking
(14)
.
The present results supported the results of
(Puckett et al 1991)
(15)
, who found that the
oxygen inhibited film between adjacent
composite layers reduced interfacial bond
strength. This was argued to in adequate
bonding, which is related to topical reduction of
the initiator concentration arising form co-
polymerization of the inhibited film with the
repair composite.
In group III, abrasion of the initial layer
prior to the placement of the repair layer
produced weaker bonds. The abraded surface
consisted of exposed inorganic filler particles
and exposed prepolymerized resin particles.
Bonding to either of these particles is less
favourable compared to a resin rich layer (un-
abraded surface) because of the decreased
ability for primary bonding to methacrylate
groups
(16)
.

REFERENCES
1. Deligeory V, Major I, Wilson NA. An overview of
reasons for the placement and replacement of
restorations. Prime Dent Care 2001; 8: 5-11.
2. Bruke FJ , Wilson NH, Cheung SW. Influence of patient
factors on age of restoration at failure and reasons for
their replacement. J Dent 2001; 29: 317-29.
3. Pounder B, Greogery WA. Bond strengths of repaired
composite resins Oper Dent 1987; 12: 127 31.
4. Hickel R, Manhart J . Longevity of restorations in
posterior teeth and reasons for failure. J Adhes Dent
2001; 3: 45 64.
5. Swift EJ , Close BC, Boyer DB. Effect of Silane
coupling agent on composite repair strengths. Am J
Dent 1994; 7: 200 2.
6. Kao EC, Pryor HG, J ohnston WM. Strengths of
composites repaired by Laminating with dissimilar
composites .J Prosth Dent 1988; 60:328-33.
7. Miranda FJ , Dun Canson MG, Dilts WE. Interfacial
bonding strength of repaired composite systems. J
Prosthet Dent 1984; 51:29-32.
8. Nomoto R, Carrick TE, McCabe J . Suitability of shear
punch test for dental restorative materials. J Dent
Mater 2001; 17: 412 21.
9. Opdam NJ . Repair and replacement of composite. Ned
Taandh eelkd 2001; 108: 90 3.
10. Croll TP. Repair of Class I composite resin
restorations. Quint Int 1990; 21: 6958.
11. Armstrong S, Keller J C, Boyer DB. Mode of failure in
the resin bonded joint as determined by strengthbased
and fracture based mechanical testing. Dent Mater
2001; 17: 20110.
12. Li J , Liu Y, Sundostromf WM. Oxygen layer and
bonding in dental composite. J Dent Research 1995;
74:493.
13. Eliades GC, Capto AA. The strength of layering
technique in visible light cured composite. J Prosthet
Dent 1989; 61: 318.
14. Vankerckhoven H, Lam Brechts P, Vanherle G. Un
reacted methacrylate groups on the surfaces of
composite resins; J Dent Res 1982; 61; 7915.
15. Puckett AD, Holder R, OHara J W. Strength of
posterior composite repairs using different composite
bonding agent combinations. Oper Dent 1991;
19:13640.
16. Boyer DB, Chan KC, Tormey DL. Build up and repair
of light cured composites: bond strength J Prosthet
Dent 1984; 43:1241 4.

J Bagh Coll Dentistry Vol. 18(2), 2006 The prevalence of oral

The prevalence of oral developmental disturbances and
dental alignment anomalies in females of secondary
schools in Thamar city (14-21years)
Balkees T. Garib Ph.D.
(1)

ABSTRACT
Background: Abnormalities of the oral and dental tissue are detected frequently during routine dental examination.
and the prevalence of these anomalies is varying among different population.
Materials and methods: A thousand young aged females (14-21 years) were collected randomly from secondary
school in Thamar city- Yamen. Full oral examination was carried for the prevalence of any oral-dental anomalies.
Results: Flourosis enamel hypoplasia is the predominant dental anomaly 10.2%. The second problem was the retained
deciduous teeth 4.1% and the non erupted permanent dentition 3.9%, while malposed alignment accounts 12.8%.
Soft tissue showed fissure and geographical tongue in n2.6% and 2% respectively. Other anomalies present in minimal
percentages.
Discussion: Esthetic problem are predominant in young females of Thamar city including both changes in enamel
tooth structure (Flourosis) and mal alignment (crowding, spacing and malposed tooth). An obvious disturbance in
shedding is present (4%) which may relate for further dental mal alignment.
Key words: Developmental anomalies, flourosis, dental mal alignment. (J Bagh Coll Dentistry 2006; 18(2) 35-39)

INTRODUCTION
The development of oral tissues may be
subjected to several genetic and environmental
factors resulting in certain anomalies. Some
dental anomalies manifest themselves more
frequently in deciduous teeth; however, they
generally are more frequent in the permanent
dentition
(1)
.
Literature review indicates that different
prevalence of various oral anomalies is
reported in different populations
(2-6)
.Thamar,
is one of the mountainous cities in Yemen. The
majority of the inhabitants are depending in
their nutrition on the local cultural plants
which are irrigated from fountains that contain
a high concentration of different minerals.
In this study we selected young aged
females to study the most common oral-dental
anomalies at permanent dentition. Females
were selected between ages 14-21 years to
exclude the mixed dentition and to avoid the
effect of Khat chewing, since females are not
allowed to chew Khat before marriage.

This study was conducted in Thamar city
in Yemen after getting the approval from the
administration of the Al-Wihda secondary
school for girls. It includes 1000 randomly
selected females with age range between 14-21
years who represent most of the families
resident in this city.

(1) Assistant Professor, Department Oral Diagnosis, College of
Dentistry, Baghdad University
Oral examination for dentition and soft
tissue was carried out in the school using plane
mouth mirror and sharp probe under the sun
light. Any anomaly was recorded carefully by
the author. No further investigation was done.
Personal information including the age,
habitation, habits, medical history..etc were as
well recorded for each female. Any Yemeni
females who were not born and living in
Thamar city were excluded.

RESULTS
Oro-dental anomalies represent 402 cases
(incidence 40%) out of 1000 young females.
There were 346 cases related to the teeth (218
teeth development, 128 teeth alignment) and
56 cases observed in oral soft tissue.
Teeth anomalies
Disturbances in structures:
Enamel anomalies represent 115 (11.5%)
cases out of the total 1000. The incidence of
flourosis constitute was 10.2%. They range
from sever to mild conditions that involve
several or whole dentition. Local enamel
hypoplasia was seen in 2 cases (involve the
mandibular right 2nd premolar and central).
Enamel hypocalcification was reported in 8
cases; 4 of them were generalized and 3
limited to the anterior teeth. Hutchinson's teeth
enamel hypoplasia was seen in one case. Lastly
amelogenesis imperfecta was seen in 2 cases
only (Table 1, 2).
Disturbances in size
Macrodontia (large teeth) were recorded in
2 cases (involve the lateral incisors and 1st
premolar both in mandibular right side). On the
Oral Pathology, Oral Medicine, Dental Radiology 35

other hand, microdontia (small teeth) were
more common, they included 18 (1.8%) cases,
predominantly seen in maxillary lateral
incisors 14 cases (4 cases were bilaterally, 8
cases on left side and 2 were on right side).
However 4 cases were observed in mandibular
arch (2 anterior lateral incisors bilaterally and
2 involve the 1st and 2nd left premolars)
(Table 2).
Disturbances in shape
Talon cusp involving the mandibular left
central incisor was observed in one case
(0.1%).
Disturbances in number
This is either increase or decrease in the
number of existing permanent teeth. It
collectively accounts to 41 cases (4.1%). A
supernumerary tooth was seen in 2 cases
(0.2%) at the left maxillary lateral incisor area,
while decrease number of teeth due to
unerupted or missing permanent teeth with loss
of primary teeth was seen in 6 cases maxillary
permanent canines on both sides
simultaneously and one case in mandibular left
2nd premolar. On the other hand, clinically
missing permanent teeth with lost primary
teeth was seen predominantly of lateral
incisors in maxillary jaw (29 cases), and only 3
cases occurred in mandibular incisors teeth
(Table 3).
Disturbances in eruption
This condition also accounts to 41 cases.
Retained deciduous teeth were seen
predominantly in maxillary deciduous canines
(21 cases), and frequently at both sides
simultaneously 11 cases (one case was
associated with microdontia). The retention of
most deciduous dentition was seen in 2 cases at
age of 15-16 years. Few other teeth was
recorded in other sites see table 4. Other cases
(11) had both the successors and precursors at
the same time and again predominantly in
maxillary canines (10). On the other hand, only
one case was seen in the left maxillary lateral
incisor which was malposed.
Disturbances in teeth alignment; spacing,
crowding, and single malposed tooth.
Spacing of anterior teeth was only seen in
maxillary jaw (9 cases) beside 3 cases showed
diastema while crowding of anterior teeth
occurred frequently in mandibular arch (31 vs
7). Nevertheless, other cases showed crowding
in both maxillary and mandibular anterior
regions simultaneously or even in the whole
arches (9 and 11 cases respectively) (Table 5).
Single malposed tooth alignment was seen
predominantly in canines (26 females, 45
teeth). Only in one case all the 4 canines were
malposed, while in 7 females it simultaneously
occurs in one arch bilaterally (2 maxillary and
5 mandibular). In general there was no
difference between left and right sides and
most of the maxillary canines located labially.
On the other hand, in the mandibular jaw they
either located labialy or rotated. Other
malposed single teeth include lingual
positioned premolar and rotated laterals (4
maxillary and 2 mandibular). There were 2
cases cross bite lateral and central incisors left
side (Table 6).
Oral soft tissue disturbances
It constitutes of 56 cases (incidence
5.6%).The most common developmental
anomaly was geographical tongue (20 cases); 4
of them were associated with symptoms. There
were 26 cases of fissured tongue which was
considered as age changes and large tongue
was seen in 4 cases only. Other minority soft
tissue developmental anomalies are illustrated
in table 1.
Table 1: The incidence of oral anomalies in 1000 young females (14-21y) in Thamar
Types of oral tissue disturbances No. %
Structure 115 11.5
Size 20 2
Shape 1 0.1
Number 41 4.1
Eruption 41 4.1
Teeth
Alignment 128 12.8
Large 4 0.4
Fissured 26 2.6 Tongue
Geographical 20 2
Lip (Pit commesures) 3 0.3
Palate (Torus) 2 0.2
Soft tissue
Gingival hyperplasia 1 0.1
Total 402 40.2

Table 2: Teeth anomalies reported in 1000 secondary school females

Development disturbances in teeth No. %
Structure
Flourosis 102 10.2
E hypoplasia 2 0.2
E hypocalcification 8 0.8
Amelogenesis imperfecta 2 0.2
Hutchinson teeth 1 0.1
Size
Small 18 1.8
Large 2 0.2
Shape
Talon casp 1 0.1
Number
Supernumerary tooth 2 0.2
Non erupted permanent teeth 39 3.9
Retained deciduous teeth 41 4.1
Alignment
Malposed 52 5.2
Spacing 25 2.5
Crowding 51 5.1

Table 3: Non erupted permanent teeth

Tooth No. %
3I3

6 15.4
I5 1 2.56
2I2

10 25.6
2I2 2 5.13
I2

3 7.69
2I

16 41
1I 1 2.56
Total 39 100

Table 4: Retained deciduous teeth with or without permanent successors

without permanent successors with permanent successors
tooth No. % tooth No. %
c I c

11 36.7 3cIc3

4 36.4
cI 4 13.3 3cI

4 36.4
Ic 6 20 Ic3 2 18.2
Ib 2 6.67 Ib2 1 9
cI 1 3.33
Icde 3 10
Ie 1 3.33
Most of the teeth 2 6.67
Total 30 100
Total 11 100


Table 5: The disturbances in dental alignment; crowding and spacing

Table 6: The disturbances in dental alignment; Malposed teeth

DISCUSSION
It is well accepted that the study of
developmental anomalies of tooth number, size
and morphology should be studied as a group
rather than as an isolate. This study covers a
broad range of developmental anomalies and
morphologic variants that may occur in the oral
cavity of females living in Thamar.
One of the visible developmental enamel
defects that is related to environmental
alteration during secretion or maturation of
enamel matrix is enamel hypoplasia. In Thamar
city enamel hypoplasia is a predominant defect
(11.5%) and mainly related to fluoride intake
(flourosis) (10.2%) due to the high
concentration of minerals in drinking water
from fountains. This is unlike findings reported
from countries with low fluoridation as Iraq
(7,8)

and seems to be better than other fountain cities
like Taiz, Yemen. The situation considered as a
true esthetic problem for females. The trend of
using purified mineral waters in sealed bottles
is growing nowadays in several families.
The second frequent developmental
anomaly was the disturbances in the time
sequence of deciduous teeth shedding (retained)
and delayed permanent teeth eruption (8%).
Retained deciduous teeth beyond their usual
shedding schedule are usually out of function
and had been reported to occur frequently in the
maxillary lateral incisors
(9)
. Nevertheless,
young females in Thamar showed that
deciduous canines were the most frequent
retained teeth, whether they were alone or
associated with their permanent precursors (32
cases out of 41). On the other hand, delayed
permanent teeth eruption may be attributed
mainly to systemic factors including;
nutritional, genetic and endocrinal deficiencies
rather than local factors ( since there was no
clinical evidence of blockage of eruption
pathway, no radiographical images were taken).
We reported 29 missing maxillary lateral
incisors (partial hypodontia) and only 5
mandibular lateral incisors. The prevalence in
the permanent mandibular central and lateral
incisor region is low, ranging from 0.23%-
0.08% respectively. This is compared with an
overall incidence of hypodontia of 3.49%.
However, significant racial variation occurs
(6,10)
.
The small percentage of local microdontia
of maxillary lateral incisors is similar to that
crowding spacing
Regions
No. % No. %
Maxillary ant. 0 0 9 36
Mandibular ant. 31 60.8 7 28
U &L ant. 9 17.6 3 12
Both arches 11 21.6 2 8
Post region 54I 0 0 1 4
Diastema 3 12
Total 51 100 25 100
Teeth Position
No. No.
Labial 11 11
Left
Palatal 2 0
Labial 9 9
Right
Palatal 3 0
Canines
Total 25 20
Cross bite 2 0
Incisors
Rotated 2 2
Premolar Lingual 0 1

reported in Al-Radwanyia Iraqi village
(8)
. The
smaxillary nummarary tooth is considered as a
minor dental anomaly in this study. Talon casp
that occur on central incisor is associated with
clinical problems including unsight dental
appearance indicated that central tubercle is
more frequent and occlusal interference.
Ooshim et al in permanent dentition
(5)
we
reported only one case out of 1000 young
females. There was no case of dens invaginatus
reported here, which is unlike other report
(11)

Malalignment of teeth (predominantly
malposed canine 45% and anterior teeth
spacing %)occur nearly equal in maxillary and
mandibular jaws, while crowding of teeth
(51%) predominantly seen in anterior
mandibular teeth. This indicates to identify the
predisposing factors for such disturbances and
plan to prevent consequent complication related
to the situation.
The only obvious soft tissue anomaly was
seen in the tongue and it represents 5% of all
oral-dental conditions. It predominates with
fissure and geographical tongue. The
geographical tongue is of unknown etiology
that may relate to fissure tongue. Its prevalence
is approximately 1% of the population. This
condition occurs over a wide age range. In this
study it accounts 2% of young females while
the females express fissured tongue in 2.6%
with 4 cases complain from symptoms. Most
studies have shown that the prevalence of
fissured tongue range from 2-5% of the over all
population
(12)
, and consider it as relatively
common condition that attributed to aging, local
environmental factors beside hereditary.

REFERENCES
1. Soams J V, Southan J C. Disorders of development of
the teeth, In: Oral pathology, 3rd ed. Oxford 1998,p
33-7.
2. Friend GW, Harris EF, Mincer HH, et al. Oral
anomalies in the neonate by race and gender in an
urban setting. Pediatr Dent 1990; 12, 157-61.
3. Al-Nori AH. Developmental anomalies of teeth and
oral soft tissue among 143-15 yrs old school children
in Baghdad city. Thesis, College of Dentistry,
University of Baghdad 1990.
4. Sedano HO, Garza MLG, Franco CMG et al. Clinical
orodental abnormalities in Mexican children. Oral
Surg 1989; 68, 300-11.
5. Ooshima T, IshidaR, Mishima et al. The prevalence
of developmental anomalies of teeth and their
association with tooth size in primary and permanent
dentition of 1650 J apanese children. Int J Paediatr
Dent 1996; 6, 87-94.
6. Kirzioglu Z, Koseler Sentut T, Ozay Erturk MS,
Karayilmaz H. Clinical features of hypodontia and
associated dental anomalies, a retrospective study.
Oral disease 2005; 11, 399.
7. Al-Alousi W, Kadhim AM. Fluoride content of
drinking water in Iraq. Iraqi Dent J 1983; 10, 8-14.
8. Sarkis SA. Dental anomalies in Al-Radwaniya Iraqi
village. Iraqi Dent J 2003; 33, 83-90.
9. Bhashar SN, Orban's oral histology and
emberyology. 12th ed Mosby Co. 1999.
10. Cameron J , Sampson WJ . Hypodontia of the
permanent dentition. Aust Dent J 1996; 41, 1-5.
11. KannanSK, Bharadwaj TP, Urraj G. Dens in dente
(dens invaginatus). Report of two unilateral and one
bilateral case. Indian J Dent Res 2003; 14, 125-9.
12. Neville BW, Damm DD, Allen CM, Bouquot J E. Oral
and maxillofacial pathology. 2nd ed. Sannders Co.
2002.

J Bagh Coll Dentistry Vol. 18(2), 2006 Orthopantomographi c assessment
Orthopantomographic assessment of mandibular
asymmetry as an aid in diagnosis of tempromandibular
problems

Asmaa T. Uthman B.D.S., M.Sc.
(1)

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

ABSTRACT
Background: Dental rotational panoramic radiographs can be used to diagnose vertical asymmetries between the
right (R) and left (L) mandibular condyle and/ or ramus. The aim of this study was to study the effect of dentition on
condylar asymmetry which is the early risk of developing tempromandibular problems.
Materials & Methods: A total sample of 70 Iraqi patients (30 dentate & 40 edentulous) were selected in this study. All
were exposed with a Siemens OPG-5. The outline of the condyle & the ascending ramus of both sides were traced
using acetate paper. The difference in vertical height between the two sides is expressed by an asymmetry index
which is calculated with the formula (R-L)/ (R+L) X 100%.
Results: A statistically significant difference was found between dentate & edentulous patients regarding condylar
height symmetry.
Conclusion: More than 6% differences measured on OPG-5 indicated condylar asymmetry.
Keywords: condylar asymmetry, TMJ , OPG (J Bagh Coll Dentistry 2006; 18(2) 40-42)

INTRODUCTION
1

The increased clinical detection of the high
prevalence of craniomandibular disorders has
increased the demand for early
tempromandibular joint diagnosis
(1)
. The
procedure should include bilateral examination
of the stomatognathic system. As the
orthopantomaogram (OPG) provides such
information, it may be justified as a routine tool
for screening. The reliability of the vertical
dimension images of the two condyles and their
rami in the OPG has been described by
Habets,et.al in 1987
(2)
.
The lateral parts of the condylar outline in
the image are the medial areas of the condyle.
Two hypotheses have been generated to explain
mandibular asymmetries; the first one is that
observed asymmetries are due to fluctuating
morphological asymmetry
(3)
. The second is a
functional and mechanical one. The chewing
forces from the mandible to the cranium during
mastication suggest the magnitude of joint
loading overtime to be related to condylar size
(4)
. Stressing on the second hypothesis, two
groups of patients were selected in this study:
Dentate & edentulous group, to examine the
effect of dentition on condylar asymmetry.

Two groups of Iraqi patients of both
genders attended Dental College / Baghdad
University were selected. Dentate group

(1) Assistant Professor, Department of Oral Diagnosis, College of
consisted of 30 dentate patients (15 men & 15
women). The Edentulous group consisted of 40
edentulous patients (20 men & 20 women). The
mean age of both groups is between 40-70
years. All were exposed with a Siemens OPG-
5
(Siemens Corporation, Dental Division,

Iselin, New J ersy). The outline of the condyle
and the ascending ramus of both sides were
traced on acetate paper. On the tracing paper a
line was drawn between the most lateral point
(C) of the condylar image and the ascending
ramus image (R) (figure 1). To this line"the
ramus tangent (I)" a perpendicular line (P) was
drawn from the most superior point of the
condylar image. The vertical distance from this
line on the ramus tangent" to the most lateral
point of the condyle (C) projected on the ramus
tangent was measured. This distance was
called the condylar height (CH). The distance
between (C&R) was called the ramus height
(RH) and measured.

Figure 1: Diagrammatic presentation of the
lines & points
To express the symmetry between the
condyles and the rami on the OPG image the
following formula [(R-L)/(R+L)X 100% was
used. This calculation allows individual
difference in size and provides a value for (a)
asymmetry of each individual. The result of this
ratio- formula gives a range from 0% (complete
symmetry) to 100% (asymmetry). According to
the study by Habits, et.al
(2)
a 6% difference
between condylar vertical size in an OPG is
acceptable with respect to a 1 centimeter
change in head position. Differences between
groups (Dentate & Edentulous) and subgroups
(condyle, ramus, men & women) regarding
symmetry {(R-L)/(R+L) X100%} were
calculated with a student's t-test as level of
significance P<0.05 was chosen.

RESULTS
The measured mean differences between
the two sides expressed in millimeter for
dentate and edentulous groups are summarized
in table 1. These differences were bigger in
edentulous males than in dentate males
regarding the condylar height.
The only statistically significant differences
were found for the condylar height between
dentate and edentulous group of both genders,
also there was a statistically significant gender
difference among edentulous group only
regarding condylar height expressed as a mean
differences between the two sides (table 1).
A statistical gender difference between
dentate and edentulous group was seen
regarding condylar height symmetry [(R-
L)/(R+L) X100%.
Non statistical difference between genders
or between the two groups regarding the mean
difference and symmetry for ramus height was
seen (table1). Table 2 shows all calculations
made after dividing the material into subgroups:
(<3 asymmetry, 3-6% asymmetry and> 6%
asymmetry).
Generally, for ramus height, dentate group
tend to be more symmetrical than edentulous
group. Non statistical difference between two
groups regarding condylar height symmetries,
while a statistical gender difference for dentate
group at 3-6% asymmetry and a statistical
gender difference for edentulous group at both
3-6% and >6% asymmetries.

DISCUSSION
The dentate group with an age ranging from
40-70 years are considered in this study, since
skeletal growth rate has been completed & has
no influence
(4)
.
In the edentulous group, the subjects were
selected so that they had a complete edentulous
ridge for at least 5-11 months. The subjects
selected having no history of any lower
complete denture wearing, since condylar angle
may be influenced by wearing dentures
(5)
.
According to the results of Uthman in 1996
(6)
, she concluded a good validity for the
reference points used. The head position did not
contribute to the variation in the measurements,
but the type of panoramic machine has some
influence.

Table 1: The measured mean differences between the two sides expressed in mm.(S.D) for
dentate & edentulous group

Significance t-value Dentate Edentulous Condylar Height
0.03
*
1.95 1.53 0.7 2.61 2.01 Males
0.002
**
-3.12 1.39 1.21 0.91 0.94 Females
-0.42 -2.95 T-value
0.33 0.003
**
Significance
Significance t-value Dentate Edentulous Ramus Height
0.08 1.43 2.41 1.86 1.55 1.33 Males
0.4 -0.21 1.94 1.54 2.121.21 Females
-0.84 1.23 T-value
0.203 Significance 0.11

* Significant at 0.05 level ** significant at 0.01 level

Table 2: The calculated symmetry of the ramus & condylar heights expressed in percentages
according to the formula [(Right-Left) / (Right + Left) X100%]
Sig. dentate
vs. edentulous
t-value No. Edentulous Sig
males
vs
females
No. Dentate Condylar Height
Males
1 0 <3%
N.S 0.44 4 5.330.14 S
*

S
*
2 5.4 0.2 3-6%
N.S 0.4 15 22.459.9 S
*
13 24.64 16.7 >6%
Females
4 0 5 0 <3%
N.S 1.65 4 3.451.9 S
*
S
*
3 4.7831.39 3-6%
N.S 0.66 12 15.656.7 S
*
6 18.528.7 >6%
Sig. dentate vs. edentulous t-value No. Edentulous No. Ramus Height
Males
N.S 0.4 17 1.290.96 15 1.160.86 <3%
3 3.980.5 3-6%
>6%
Females
N.S -0.21 16 0.90.75 14 1.530.84 <3%
4 3.450.27 3-6%
>6%

The values in table 1 indicate that the used
methods are suitable in the discrimination of
panoramic radiographically projected
mandibular asymmetries. The differences
between the two groups of patients regarding
condylar height asymmetry are remarkable and
seem to be of clinical use in the radiographic
diagnosis.
The border value of 3% asymmetry
between the right and left sides was based
purely upon the maximum 6% difference
between the two sides which is due to technical
errors
(1)
.
A difference between the left and the right
condyle of more than 6% difference measured
on the OPG indicated condylar asymmetry
which is higher in edentulous than dentate
group which could provide a basis for the first
distinction of the risk of developing cranio-
mandibular disorders.

REFERENCES
1. Hansson LG, Hansson T, Petersson A. A
comparison between clinical & radiologic findings
2. in 259 tempromandibular patients. J Prosthet Dent
1983, 50; 89.
3. Habets LMH, Bezuur J N, Hasson TL. The

4. orthopantomogram, an aid in diagnosis of TMJ
problem 1. The factor of vertical magnitude. J Oral
Rehab 1987; 14; 475-80.
5. Costa RL. Asymmetry of the mandibular condyle in
Haida Indians. Am J Physical Anthropology 1986;
70; 119.
6. Mongini FG, Preti G, Calderale PM & Barberi G.
Experimental strain analysis on the mandibular
condyle under various conditions. Acta Orthopedica
Belgica 1981;46,601.
7. Sato K, Mitani H. Relationship between late
adolescent growth of mandible and maturity
indicators mandibular third molar, hand bones,
body height in J apanese boys (abstract).Nippon-
Kyosei-Shika-Gakkai-Zasssh 1990;49(2):140-146.
8. Uthman AT. Registration of gonial angle, ramus
height & mandibular body length among different
age groups of Iraqi sample. A cross sectional
panoramic radiographic study. M.Sc. Thesis,
University of Baghdad, College of Dentistry,1996.

J Bagh Coll Dentistry Vol. 18(2), 2006 Detection of acid
Detection of acid fast bacilli in the saliva of patients having
pulmonary tuberculosis

Gassan Yassen B.D.S., M.Sc
(1)

Jamal Noori B.D.S., M.Sc.
(2)

ABSTRACT
Background: Tuberculosis is a serious disease caused by bacteria called Mycobacterium tuberculosis. The disease is
readily detected by demonstration of the bacteria in a clinical specimen. The purpose of this study was to determine
the density of acid fast bacilli in the mixed and parotid saliva samples and to compare them with the sputum, in
addition, to find out the efficacy of the saliva samples in the diagnosis of pulmonary tuberculosis.
Subject and Methods: A sample of 25 patients of both sexes, Age ranged from 17-70 participated in this study,
Unstimulated mixed saliva and the parotid saliva was collected for direct .smear of acid fast bacilli by Ziehl-Nelson
acid fast stain. Five samples were inoculated on Lowenstein J ensen media and storen brink media to determine the
presence of the bacilli in the samples.
Results: Concerning the mycobacterium tuberculosis, about 60% of unstimulated mixed saliva revealed positive acid
fast bacilli, while all samples of parotid saliva showed negative acid fast bacilli. There was no significant relationship
between the duration of signs and symptoms of disease and the detection of mycobacterium tuberculosis in the
collected specimens. The density of mycobacterium tuberculosis in the mixed saliva mainly was scanty which mean
it was not more than 2-9 bacilli in at least 100 fields. This confirms the fact that the body fluids commonly contain only
small number of mycobacterium tuberculosis. The five samples of saliva which were inoculated on Lowenstein
J ensen media and stonebrink media showed positive cultures.
Conclusion: Mixed saliva was less efficient than sputum by direct smear of sputum.
Keywords: Mycobacterium tuberculosis, saliva. (J Bagh Coll Dentistry 2006; 18(2) 43-46)

INTRODUCTION
Tuberculosis is a serious disease caused
by bacteria called Mvcobacterium
tuberculosis. The disease usually affects the
lungs but other organs may also be affected.
(1)

The variable nature of its manifestation, as
well as its ability to involve almost every
organ system, either singly or multiply,
makes it essential that the possibility of extra
pulmonary tuberculosis be included in the
differential diagnosis of any infectious
process in the body.
(2,3)

The disease is considered a worldwide
problem. Almost one-third of the world's
population is infected with TB, although a
healthy immune system can prevent active
disease.
(4)

The disease is readily detected by skin
test, chest x-ray, or by demonstration of M.
tuberculosis bacteria in a clinical specimen.
There are two distinct stages of TB:
1. TB infected individuals are those
who are tuberculin test positive, but do not
have the

(1) Private practice.
(2) Assistant professor, department of Oral Diagnosis, College
of Dentistry, University of Baghdad.

bacteria in their saliva and are without
clinical symptoms.
1

2. TB diseased persons have M. tuberculosis
bacteria in their saliva and are symptomatic
for the disease.
(5)

Since the disease is infectious in nature,
the clinical signs and symptoms of
tuberculosis are common to many other
diseases which are:
. Loss of weight.
. Loss of energy.
. Poor appetite.
. Fever and wet cough.
TB is transmitted through the air from
exposure to germs in the saliva of infected
person from their lungs.
(1,6)
There are two
kinds of active TB :
Primary TB: Occurs soon after a person is
first exposed to TB. Reactivation TB: occurs
in people who were previously exposed to TB
if their immune system is weakened, TB can
breakout of the tubercles and cause active
disease. Most of the cases of TB in people
with HIV disease are due to reactivation of a
previous TB infection.
(7, 8)

TB may be of concern to the dentist from
at least three standpoints:

First: It is an infectious disease and as such
is communicable in its active state. The dentist is
in a high-risk population and may contract the
disease from a patient or patients may contract
the disease from the dentist who might have an
active case.
Second: On rare occasions tuberculosis
lesion may be found in the oral cavity; thus the
dentist must be alert to include tuberculosis in
the differential diagnosis of oral lesions.
Third: The dentist may be the first person to
discover that a patient has Tuberculosis.
(1)

The treatment usually consists of
combination of drugs. Generally, TB drugs are
taken daily for 5 to 12 months. It is important
that the exact
Medication plan should be decided by
qualified health care providers. If left untreated,
an individual with TB disease can become
severely ill and also transmit the disease to
others. Untreated, TB disease can be fatal.
(9)

The purpose of this study was finding out
the density of acid fast bacilli in the mixed and
parotid saliva samples and to compare them with
the sputum, in addition, to determine the
efficacy of the saliva samples in the diagnosis of
pulmonary tuberculosis.

SUBJECTS AND METHODS
A total of 25 subjects who were diagnosed
as having pulmonary tuberculosis participated
in this study. Their age ranged between 17-65
years.
The subjects were not having systemic
disease other than tuberculosis. Those patients
were collected from Chest and Respiratory
Disease Institute, TB Lab Reference. The
patients were having duration of the disease
between 2-12 months. The samples of the saliva
were collected from the patients under
standardized condition (between 10-12 a.m., at
least 2hrs after eating and oral hygiene
procedure). The mixed saliva samples were
taken from the floor of the mouth, while parotid
saliva was taken after localization of the orifice
of the parotid salivary gland duct. The area was
dried with a piece of cotton, and then the gland
milked gently with the finger. The milked saliva
was collected with blunt instrument and
distributed on a glass slide for a direct smear.
The slides were then processed and stained
with Ziehl Nelson acid fast stain and examined
under oil immersion (1000x) for the presence of
acid fast bacilli. Culture of mycobacterium was
done by digestion-decontamination method to
confirm the presence of the micro-organism.
Statistical analysis was done with the
assessment of the values at the P>0.05 levels.

RESULTS
The results of mixed saliva showed
microorganisms in 15 patients. However, 10
patients showed negative results (absence of
microorganisms) in the samples collected. The
microorganisms could not be isolated from the
parotid saliva of the total number (25 patients
with pulmonary tuberculosis) so the results
considered negative. However the
microorganisms were isolated from the sputum
of the whole number of the patients, as shown
in table 1.

Table 1: The presence of mycobacterium
tuberculosis in different specimens.

Sample positive negative Total
Mixed saliva 15 10 25
Parotid
saliva
0 25 25
Sputum 25 0 25

In the specimens examined, the presence of
2-9 bacilli in 100 fields was considered scanty
positive) which were observed in saliva
samples, while in the sputum, samples the
microorganisms were scanty to sever; as shown
in figure 1.

Figure 1: Scanty Mycobacterium TB in a
specimen.

The duration of signs and symptoms of the
total TB patients ranged between 1-12 months.
In order to, compare the duration of signs and
symptoms with the results of direct smear of
saliva we divided the duration into four groups.
The highest percentage of positive acid fast
bacilli found in patients with 1-3 months
duration of the disease, while the lowest
percentage was found in 7-9 months.
There was no significant relationship
between the duration of signs and symptoms of
the disease and the presence of microorganisms
(Table 2).

Table 2: The duration of the disease and
presence of microorganisms in the
stimulated mixed saliva.
Duration positive negative Total
1-3 12 5 17
4-6 2 2 4
7-9 0 1 1
10-12 1 2 3

DISCUSSION
In this part of study about 25 patients
having pulmonary tuberculosis were diagnosed
by direct smear of sputum for acid fast bacilli.
By using mixed saliva from those patients with
pulmonary tuberculosis, about 15 (60%)
revealed the presence of mycobacterium
tuberculosis in the saliva. This confirms the fact
of presence of mycobacterium tuberculosis in
the saliva of patient having pulmonary
tuberculosis.
(10)

We did not identify mycobacterium
tuberculosis in the parotid saliva because the
microorganism which was identified in the
mixed saliva was not present in the saliva
primarily but it results from contact of the oral
tissue with infected sputum. Up to our
knowledge we did not find any study performed
on the saliva as a sample for diagnosis
pulmonary tuberculosis to compare our finding
with these studies, so we did our comparison
between the sensitivity of saliva and the
sensitivity of sputum.
In our study the sensitivity of direct smear
of saliva for acid fast bacilli is equal to 60% of
the sensitivity of sputum. The sensitivity of
direct smear of sputum for the microorganism
ranged from 22-80%.
(11, 12)

The density of mycobacterium tuberculosis
in the mixed saliva mainly is scanty which
mean it was not more than bacilli in at least 100
fields
(2-9)
. This confirms the fact that the body
fluid commonly contains only small number of
mycobacterium tuberculosis.
(10)
Therefore, the
mixed saliva was less efficient than sputum
because by direct smear of sputum the quantity
of the bacilli observed on the smear could be
provided which serve in the demonstration of
the severity of disease.
To overcome this shortage, we had to
concentrate the sample of saliva by using,
cytocentrifugation, or sequential layering of
several drops of uncenterfuged fluid, on-slide,
or polycarbonate membrane.
(10,13)

Cultivation
To explain the ability of using saliva as
sample for culture, five samples of mixed saliva
selected randomly to be inoculated on the
Lowenstein J ensen media and stone brink
media. All samples revealed positive culture.
This means that the mycobacterium
tuberculosis which was recovered well by
Lowenstein J ensen media and mycobacterium
bovis which was recovered by stone brink
media were present in the saliva.
(14)
So we can
conclude that the sample of saliva can be
inoculated on different media and we can use it
if the sputum is unavailable.
Therefore, we can summarize the difference
between sample of saliva and sputum as shown
in Table3.

Table 3: Comparison between the saliva and sputum
Saliva Sputum
Always available Sometimes not available
Less efficient than sputum because is like other
body fluids commonly contain only small numbers
of mycobacteria
More efficient than the body fluid
Can be concentrated to maximize the yield of
mycobacterium before inoculation on media and
direct smear
Also can be concentrated to maximize the yield of
mycobacterium before inoculation on media and
direct smear
Can be inoculated to liquid and solid media Can be inoculated to liquid and solid media
The sample which revealed positive is always
scanty so we cannot graduate the severity of disease
The sample which revealed positive may be scanty
or moderate or severe so we can measure the
severity of disease

RFERENCES
1. J ames W, Little D, Falace A. Pulmonary disease in:
Dermal management of Medically Compromise
Patients. Mosby Company. 5 th ed., 1997; 251-9.
2. Valdaso lP, Perez A, Albarracin A. Tuberculosis
arthritis, Report of a case with multiple joint
involvement and periarticular involvement and
periarticular tuberculosis abscess. J Rheumatol 1990;
17; 399-401.
3. Mathew R, George F. Extrapulmonary tuberculosis
experience of a community hospital and review of
literature. American J Medicine 1985; 79: 467-77.
4. Mehta J B, Burt A, Harvill L, Mathews K.
Epidemiology of extra-pulmonary tuberculosis. Chest
1991; 99:1134-8.
5. Lvfalcolm A, Lynch. Diseases of the respiratory
system in;Burket's of oral .Medicine diagnosis and
treatment. 4 th ed., J B Lippincot Company,
Philadelphia, 1994; 435-48.
6. Lucas SB. Histopathology of tuberculosis in; Clinical
tuberculosis, 2nd ed. Chapmann and Hall medical,
1998; 113-27.
7. Hang M, Gong J H, Lyer DV, J ones BE, Modlin RL,
Barnes PF. T cell cytokineresponses in persons with
tuberculosis and HW infection. J Clin Investig 1994;
94: 2435-42.
8. J eanne M, Wallace MD, Andrew L, Deutch MD,
J ames H, Harrell MD, Kenneth M, Moser MD.
Bronchoscopy and transbronchial biopsy in
evaluation of patient with suspected active
tuberculosis. Am J Medicine 1981; 70:1189-94.
9. Sharba J A. Tuberculosis in 1990s: Therapeutic
challenge. Chest 1995; 108:585-625.
10. Beverly G, Metchock F, Ritchard J R. Mycobacterium
In: Manual of clinical microbiology, 7 th ed ASM
press Washington DC 1998; 399-437.
11. Lipsky BJ , Gats FC, Tenover J J . Factors affecting the
clinical value of microscopy for acid fast bacilli. Rev
Infect Dis 1984; 6:214-22.
12. Murray PR, Elmore K., The acid fast stain A specific
and predictive test for mycobactrium disease. Ann
Inter Med 1980; 92:512-13.
13. Saceanu C N, Pfeiffer, Miclean T. Evaluation of
sputum smear concentrated by cytocentrifugation for
detection of acid fast bacilli, J Clin J Micro 1993;
31:2371-3.
14. Zaher F, Mark J. Methods and medium for culture of
tubercle bacilli. Tubercle 1997; 58: 143-5.

J Bagh Coll Dentistry Vol. 18(2), 2006 Burning mouth syndrome

Burning mouth syndrome: an analysis of 130 patients
Shanaz M. Gaphor B.D.S., M.Sc, Ph.D.
(1)

ABSTRACT
Background: Burning mouth syndrome (BMS) of the oral mucosa is relatively common complaints of dental patients.
The aim of this study was to determine the possible causes of (BMS).
Materials and methods: A sample of 130 patients (91 women and 39 men) was thoroughly studied.
Results: Females were more commonly affected than males and particularly those aged over 50 years. The tongue
and palate were the most frequently affected sites. Psychogenesis was found to be the most frequent cause,
followed by geographic tongue and candidiasis.
Conclusion: Burning mouth syndrome is a multifactorial condition generally affecting women much more than men.
Keywords: BMS, local and systemic causes. (J Bagh Coll Dentistry 2006; 18(2) 47-51)

INTRODUCTION
Burning mouth syndrome (BMS) is a
multifactorial condition that generally affects
women much more than men. The age group
affected is usually over 50 years of age, and
clinical examination reveals no mucosal
abnormality
(1,2)
. A patient with a burning
mouth often presents a diagnostic and
therapeutic problem. Clinicians frequently
consider the burning symptom to be
psychologically induced
(3,4)
. Many
precipitation factors are recognized and most
patients with BMS respond to treatment
(5, 6)
.
These include hematological disorders
(7,1)
,
vitamin B complex deficiencies
(8)
, candidal
infection
(2, 3)
, reduced salivary gland function
(9)
, climacteric and undiagnosed diabetes
(7,10)
,
erosive lichen planus and geographic tongue.
(3,6)
Additional factors such as depression,
anxiety, cancerphobia were also evaluated
(11,12)
.
The purposes of the investigation are (1) to
demonstrate any one or more specific diseases
that may lead to stomatopyrosis, (2) to
determine, if possible, the relative frequency of
each disease as the cause of oral burning, (3) to
demonstrate that the burning mouth is
frequently caused by multiple etiologic factors,
and (4) to describe a diagnostic protocol which
will assure, in most cases, identification of the
cause or causes of oral burning.

MATERIAL AND METHODS
A total of 130 patients (91 women and 39
men, mean age was 48 years) with BMS was
seen in the Oral Diagnosis (Oral Medicine)
Department, College of Dentistry, University of

(1) Assistant Professor, Department of Oral Diagnosis, College of
Baghdad from October 2000 to J une 2001.
Each patient in this study had (1) a thorough
clinical examination, (2) a complete review of
past medical history, including drug history,
and (3) a detailed history of duration of the
condition burning symptom, site affected, and
pattern of burning. The relation of the condition
to wearing dentures and orthodontic appliance
was established. Patients were asked directly
about cancerphobia, depression and anxiety.
Appropriate, laboratory procedures were
performed; these included culturing for fungi,
complete blood count, fasting blood glucose
determination, and biopsy and neurologic and
psychiatric examinations were performed. The
clinical examination, medical history, history of
symptoms, and laboratory results were
assembled for each patient. The appropriate
diagnosis was made from data gathered by the
above methods.

RESULTS
Table 1 shows the number of patients in
each age group. All age groups were found to
be affected with a peak from 41-60 years of age
(50.7%). Table 2 shows the distribution among
examined patients. Female (70%) were more
commonly affected than males (30%). Figure 1
shows the site of the oral mucosa affected by
the burning sensation. Tongue (69.2%) seems
to represent the most common site of
involvement followed by palate (30.7%). Table
3 shows the causes of burning mouth sensation
among examined patients. Psychogenesis
(28.4%) was found to be the most frequent
cause followed by geographic tongue (21.5) and
oral candidiasis (15.3%).


Table 1: Distribution of patients among the
age group.
Age group No. of patients %
0-20 6 4.6
21-40 38 29.2
41-60 66 50.7
61-80 20 15.3

Table 2: Gender distribution among 130
patients.
Gender No. of patients %
Males 39 30
Females 91 70

Table 3: Causes of the burning mouth or
tongue.
Local Patients No. %
Geographic tongue 28 21.5
Errosive lichen planus 10 7.6
Oral candidiasis 20 15.3
Trauma 8 6.1
Systemic
Anemia 9 6.9
Hyperglycemia 8 6.1
Idiopathic
Psychologenesis 37 28.4
Multiple causes 10 7.6

Local Causes
Geographic Tongue
There were 28 patients (21.5%) 20 females
and 8 males whose burning was restricted to the
tongue, where the typical patterns of geographic
tongue were located. Their ages ranged from 8
to 60, with an average of 32.25 years. Ten
patients described themselves as being
nervous, stressful person. Cultures for
fungi obtained from 8 patients were negative.

Site of burning sensation
Figure 1: Histogram showing the site of
burning as reported by patients.
Erosive lichen planus
Ten patients (7.6%) 6 females and 4 males
who were complaining from burning mouth.
Clinically, oral lesions appear as lacy white
configurations (wickhams striae) with erosions
and ulceration. Six of 10 patients complained of
a burning buccal mucosa, 3 had a burning
tongue and 2 had a burning gingiva. The
diagnosis was confirmed by biopsies for 5
cases. Their ages ranged from 33-65, with
average of 49 years.
Oral Candidiasis
Candidiasis is a group of burning mouths
consisted of 20 patients (15.3%) 14 females and
6 males. The oral lesions were of the typical red
and /or white monilial types. Their ages ranged
from 23-75 years with an average age of 57.2
years. All had positive candida albicans
cultures, 8 responded dramatically to topical
antifungus therapy. Precipitating factors
included complete maxillary denture (14),
angular chelitis (3), steroid therapy (2) and
general debilitation (1).
Trauma
There were 8 patients (6.1%) 5 females and
3 males; the burning mouth was diagnosed as
being traumatic in origin. These patients ranged
in age from 21-65 years, with an average age of
(48) years. Three of the 8 patients complained
of burning cheeks, 3 had a burning tongue, 2
had a burning of lips and one each had a
burning maxillary, mandibular area and
gingiva. Three of the 8 patients had traumatic

ulcers due to chronic irritation by orthodontic
appliance and five of the 8 patients had denture
irritation (ill fitted denture). All laboratory
studies were negative. The blood glucose and
blood count were normal.

Systemic causes
Iron deficiency anemia
There were 9 patients with burning mouth
who had iron deficiency anemia (6.9%) seven
females and 2 males. Six of (9) patients were
with distinct atrophy of the dorsal portion of
tongue. These patients ranged in age from 33-
65, with an average age of 47.2 years. There
complete blood count, hemoglobin and serum
iron concentration were decreased and serum
iron binding capacity was increased. The blood
glucose was normal and fungal cultures were
negative. With appropriate antianemia therapy,
the patient shows dramatic improvement of
burning mouth.
Hyperglycemia
There were 8 patients (6.1%) 5 females and
3 males who were complaining from burning
mouth and found accompanying fasting blood
glucose concentrations. Four of these had an
abnormal glucose tolerance test result. These
patients ranged in age from 28-56, with an
average of 46.3 years.
Five of 8 patients had a burning tongue, 3
had a burning lips and buccal mucosa.
Adequate control of diabetes was achieved and
contributed to complete resolution of oral
symptoms. The complete blood count was
normal and fungal cultures were negative.

Idiopathic
Psychogenesis
In 37 patients (28.4%) 28 females and 9
males, the burning mouth was diagnosed as
being psychogenic in origin. These patients
ranged in age from 25 to 75 years, with an
average of 52.2 years.
Clinical oral examination showed no
abnormality. Twenty five of the 37 patients
complained of a burning tongue, 6 had a
burning palate, 6 had a burning (lip)s, and one
had a burning oral mucosa, alveolar ridge, and
mouth. Medical history revealed that 4 had
hypertension, 3 had had peptic ulcers, 1 had
esophageal reflux, 5 patients suffered from
family problems, 2 had dry mouth and 4 were
heavy smokers. Cancerphobia was an important
factor in 20 patients; reassurance alone was
often successful in alleviating the burning
sensation.

Multiple causes
Ten patients had multiple coexistent causes
(7.6%). Four of these (2 of each gender, with an
average age of 29 years) had psychogenesis and
geographic tongue as the multiple causes of
their stomatopyrosis. They had a completely
negative laboratory work-up. They had
extremely adverse social circumstances. Many
areas burned intraorally, including a solitary
patch of geographic tongue located on the
dorsum. Four of these (3 females- one male
with an average age of 60.2 years) had
psychogenesis and candidiasis as a cause. They
were treated with antidepressant medication and
demonstrable xerostomia which was most likely
induced by the medications. All had positive
candida albicans cultures and showed marked
rapid improvement with topical antifungal
therapy.
Two patients (52 years old woman and 57
years old man) had geographic tongue, angular
chelitis, inflamed gingiva and palate. A
complete blood count and blood glucose
determination were normal, but fungal cultures
were positive.

DISCUSSION
This study illustrates the multifactorial
origins of the burning mouth syndrome and the
results support findings of preponderance in
women, particularly those aged over 50. It is
imperative, however, to establish that patients
are truly suffering from the syndrome,
particularly that they have a normal mucosa on
examination. Careful and thorough clinical and
laboratory investigations are necessary if one is
to identify the etiologic factors and administer
appropriate therapy.
In considering the etiological factors;
errosive lichen planus and multiple causes each
accounted for 7.6% of the cases, hyperglycemia
and trauma each accounted for 6.1% of the
cases, iron deficiency anemia 6.9%, oral
candidiasis 15.3%, geographic tongue 21.5%
and psychogenic factors 28.4%.
The findings indicate that geographic
tongue was found to be the sole cause in 28
patients (21.5%) and played a contributory role
in 6 others (4.6%). Several patients complained
of sensitivity to hot and /or spicy foods at the
affected sites. As in the psychogenic group,
females were more often affected than males.

Other clinicians mentioned the association of
geographic tongue with stress, tension and
worry characteristics noted in this group of
patients
(13,14)
. Erosive lichen planus was the
cause of oral burning in 10 patients (7.6%).
Other clinicians mentioned the association of
erosive lichen planus with burning sensation
(14)
.
The findings also indicate that candidiasis
was the sole cause of burning in 20 patients
(15.3%) and a contributing cause in 6 patients
(4.6%) thus; candidial infections played an
etiologic role in 19.9% of the burning mouths.
Problems with dentures are important in the
syndrome; its clinically helpful if patients find
that removal of the denture alleviates their
symptoms. Oral candida infections are
opportunistic and the underlying cause was
easy to determine in each patient
(15)
. Candidial
diagnosis was further corroborated in 8 patients
by rapid improvement with topical antifungus
therapy.
Trauma was the cause of oral burning in 8
patients (6.1%). Trauma includes dental or
denture irritation. Other clinicians mentioned
the association of trauma with burning
sensation
(16,17)
. Dental or denture irritation
diagnosed easily and successfully treated of
many such cases by the primary-care clinician
without the need for referral to a specialist.
It is generally accepted that undiagnosed
iron- deficiency anemia and diabetes mellitus
may cause burning mouth. In this study only 9
of the 130 patients (6.9%) the burning was
explained by the presence of iron-deficiency
anemia, and 8 of the 130 patients (6.1) in which
diabetes was found to be the cause. Various
reasons are put forward to support the
suggestion that diabetes is a likely cause of a
burning sensation in the mouth
(18)
. First, insulin
increases the rates of glycogen, lipid and
protein synthesis and it maintains a balance
between anabolic and catabolic processes. It
would see possible that lack of insulin would
encourage the catabolic process within the oral
mucosa, making the tissue less resistance to
normal wear and tear. Secondly, xerostomia is a
common symptom of diabetes. Thirdly,
candidal infections are relatively common in
diabetic patients.
Psychogenic factors are often implicated as
being etiologic in the burning mouth
(19-21)
and,
indeed it constituted the most frequent cause of
burning in 37 patients (28.4%) and a
contributing cause in 8 additional cases (6.1%)
so it was the major factor in oral burning. It is
important to note that diagnosis of a
psychogenically induced disease was
established in all cases after all other local and
systemic disease possibilities had been
excluded by a negative clinical picture, negative
laboratory findings, and positive historical data
regarding emotional factors.
In clinical practice three main factors are
important: anxiety, depression and
cancerphobia. For the patients who are
cancerophobic the presence of unremitting oral
symptoms leads them to believe either that they
already have cancer or that they are about to
develop it. Repeated reassurance and direct
questioning of their fears are important, and
occasionally we have restored to antidepressant
treatment to break the vicious cycle. Some
anxious patients readily become depressed,
particularly if there is some additional adverse
social circumstance such as bereavement. Other
patients had histories of diseases often related
to/or associated with stress, peptic ulcer and
esophageal reflux which causing an irritation of
the oral mucosa with consequent development
of a burning sensation.
It is of diagnostic interest that most
psychologically induced burning occurred in
women in the post menopausal age group. In
this study, 28 of 37 (75.6%) patients were
female and 20 of 28 (71.4%) were more than 50
years old. These features have been recognized
by other authors whom symptoms of oestrogen
deficiency occur
(14,17)
. The tongue is the most
frequent sites of oral burning. The pain could
often be aggravated with hot and/or spicy
foods.
The pathogenesis of those burning mouth
patients in whom multiple etiologic factors
were established was of considerable interest.
This was particularly true for those 4 in the
psychogenic-candidial group. It was especially
notable that all 4 had histories of a psychiatric
disorder (depression) followed by
antidepressant medication and that each
subsequently developed xerostomia which was
soon followed by candidiasis.
The following diagnostic protocol is
suggested when a patient presents with a
complaint of burning mouth. It should
include but is not limited to the following.
1. Complete mouth examination: A
thorough clinical examination is performed as is
done for every new patient, but with special
emphasis on detecting lesions of the oral soft

tissues which might be associated with the
anemias, diabetes, candidiasis, geographic
tongue, malnutrition, errosive lichen planus,
local irritation and trauma.
2. History: A thorough history should be
taken with particular emphasis on psychiatric
disorders, systemic diseases (unassociated with
or associated with psychogenic factors, such as
peptic ulcer and esophageal reflux), and
administration of medications, trauma events,
and personal or social problems which might
cause anxiety, worry, fear, stress and depression.
3. Laboratory investigations: Laboratory
studies are mandatory for all patients with
burning mouth. Routine tests should include a
complete blood count, blood glucose
defermenation, cultures for candida albicans and
biopsy should be performed.

REFERENCES
1- Main DMG, Basker RM. Patients complaining of
burning mouth. Br Dent J 1983; 154: 206-11.
2- Lamey PJ , Lamd AB. Lip component of burning
mouth syndrome. Oral Surg Oral Med Oral Pathol
1994; 78: 590-3.
3- Zegarelli DJ . Burning mouth: an analysis of 57
patients. Oral Surg Oral Med Oral Pathol 1984; 58:
34-8.
4- Rojo L, Silvestre FJ , Bagan J V, Vicente TD, Valencia
MD. Prevalence of psychopathology in burning mouth
syndrome. Oral Surg Oral Med Oral Pathol 1994; 78:
312-6.
5- Domb GH, Chole RA. The burning mouth and tongue.
Ear Nose Throat J 1981; 60: 310-4.
6- Lamey PJ , Lamb AB. Prospective study of etiological
factors in burning mouth syndrome. Br Med J 1988;
296: 1243-6.
7- Basker RM, Sturdee DW, Davenport J C. Patients
with burning mouths. Br Dent J 1978; 145: 9-16.
8- Lamey PJ , Hammond A, Allam BF, McIntosh WB.
Vitamin status of patients with burning mouth
syndrome and the response to replacement therapy. Br
Dent J 1986; 160: 81-4.
9- Glick D, Ben-Aryeh H, Gutman D, Szargel R.
Relation between idiopathic glossodynia and salivary
flow rate and content. Int J Oral Surg 1976; 5: 161-5.
10- Ferguson MM, Carter J , Boyle P, Hart DMck,
Lindsay R. Oral complaints related to climateric
symptoms in Oophorectomized women. J R Soc Med
1981; 74: 492-8.
11- Browning S, Hislop S, Scully C, Shirlaw P. The
association between burning mouth syndrome and
psychosocial disorders. Oral Surg Oral Med Oral
Pathol 1987; 64: 171-4.
12- Rojo L, Silvestre FJ , Bagan J V, De Vicente T.
Psychiatric morbidity in burning mouth syndrome:
Psychiatric interview versus depression and anxiety
scales. Oral Surg Oral Med Oral Pathol 1992; 75: 308-
11.
13- Banoczy J , Szabol, Csiba A. Migratory glossitis.
Oral Surg 1975; 39: 113-21.
14- Lynch MA, Brightman VJ , Greenberg MS. Burket's
Oral Medicine. Diagnosis and Treatment.9
th
ed. J .B.
Lippincott Company Philadelphia; 1994.p 258-9.
15- Holmberg K. Oral mycoses and antifungal agents.
Swed Dent J 1980; 4: 53-61.
16- Ali A, Bates J F, Reynolds AJ et al. The burning
mouth sensation related to the wearing of acrylic
denture. An investigation. Br Dent J 1986; 161: 444.
17- Grushka M. Clinical features of burning mouth
syndrome. Oral Surg Oral Med Oral Pathol 1987; 63:
30.
18- Hatch CL. Glossodynia as an oral manifestation of
diabetes mellitus. Ear Nose Throat J 1989; 68: 782.
19- Koblenzer CS. Psychosomatic concepts in
dermatology. Arch Dermatol 1983; 119: 501-12.
20- Hughes AM, Hunter S, Still D, et al. Psychatric
disorders in dental clinic. Br Dent J 1989; 166; 16.
21- Mott AE, Grushka M, Sessle BJ . Diagnosis and
management of taste disorders and burning mouth
syndrome. In:D'Ambrosio J A, Fotos PG.Topics in
oral diagnosis II. Dent Clin North Am 1993; 33: 37.

J Bagh Coll Dentistry Vol. 18(2), 2006 Gutta-percha

Gutta-percha as retrograde filling in endodontic surgery
without apicectomy (A clinical and radiographical study
with new technique)

Anwar A. Al-Saeed, B.D.S., M.Sc.
(1)

ABSTRACT
Background: Many materials are being used as retrograde filling materials. This study was to evaluate the effect of
Gutta-percha as retrograde filling in endodontic surgery by using ultrasonic device in comparison to the use of Zinc
free Amalgam.
Patients and Methods: Fifty-seven patients of average age ranging from 18-34 years of old, 32 were males, while 25
were females of different socioeconomic status. All the cases had chronic periapical lesions that were exposed to
endodontic surgery with the use of Gutta-percha as retrograde filling by the use of ultrasonic device. Clinical and
radiographic evaluation was used as criteria for detection of the state of healing process for 1 year follow-up.
Results: All the cases 57 (100%) showed a complete healing without any recurrence of periapical lesions. The current
study shows that 42 (73%) of cases had faster and much better healing process in maxillary anterior region than that
of the mandibular anterior region 15 (26.3%). Healing process was significantly and clearly better than in those
patients with short duration of the pathological lesions, in comparison to the long duration lesions. The study
registered that healing process was significantly better in males than in females. No rejections were detected from
the use of Gutta-percha as retrograde filling materials in comparison retrospectively to the use of Zinc free Amalgam.
Conclusion: No allergic reactions or rejections were reported from the use of Gutta-percha as reported from the use
of amalgam. There was absence of contraction or microleakage of microorganisms in case of Gutta-percha while
this has been reported in the use of amalgam and other materials. No remnant particles have been observed
clinically or even radiographically in the use of Gutta-percha while these commonly occur and clearly observed in
case of amalgam.
Key words: Endodontic surgery, gutta-percha, ultrasonic technique. (J Bagh Coll Dentistry 2006;18(2) 52-56)

INTRODUCTION
Retrograde filling of the root canal during
endodontic surgery is a successful method that
when orthograde filling to the root canal can
not approach coronally, in addition to that this
technique has been done to close and seal the
apical foramen, and to arrest the spread of
microorganisms or their toxins from/and to the
surrounding tissues
(1-3)
.
There are certain factors that play an
important rule in the successful results of this
procedure and these factors are the followings:
1. The experience and skills of the dental
surgeon
(4)
.
2. The material that has been used as
retrograde filling
(5)
.
3. The method of the approach to the
apical area
(6,7)
.
4. The severity of the condition (duration,
stage, the presence of internal and
external root resorption).

(1) Assistant professor, Department of Oral and Maxillo-
Facial Surgery, College of Dentistry, University of
Baghdad.
5. The age, gender, and the oral hygiene of
the patient.
6. The site of the operation.
Usually, most of the dental surgeons
suggest to use amalgam as retrograde filling in
the past and till now
(8,9)
, but most of failures
from the use of amalgam in this procedure are
the followings: -
1. Contraction defects between the dentin wall
and the amalgam filling
(5)
.
2. Microleakage occurs because of initial
contraction and even the non gamma II
amalgam shows such microleakage
(10)
.
3. Allergic or toxic reaction to mercury (oral
galvanism)
(10)
.
The need for retrograde filling materials
other than amalgam seems to be obvious, so
many processing and materials have been tried
such as; Tin posts
(11)
, Methyl-2-cyano-acrylate
(12),
and Cavit
(13)
. On the other hand, in 1969, a
glass-ionomer cement was used
(14-16)
, but many
authors found that the glass-ionomer cement has
a slight cytotoxic effect on cell cultures
(17,18)
,
while Kloetzer and Langeland
(19)
, reported that
mild to severe changes of pulp tissue in
connection with application of glass-ionomer
cement
(19)
.

Oral and Maxillofacial Surgery and Periodontology 52

Fifty seven patients were selected for this
study. All the cases were indicated for
endodontic surgery with retrograde filling and
not for orthograde procedure. The average age
of the patients used ranged from 18-34 years of
old, 32 were a males, while 25 were females of
different socio-economic status (Table 1). All
the patients were healthy, without any history
of any systemic diseases. Only the anterior
teeth and premolars were used in the current
study of both jaws.

All the cases were exposed to endodontic
surgery with the use of Gutta-percha as
retrograde filling and with the use of sealer, for
the adherence of the Gutta-percha against the
walls of the canal. Intra-canal instrumentation
was done directly from the apical foramen of all
cases by using ultrasonic device, as shown in
Figure 1. Irrigation of the canal was performed
by the use of normal saline associated with the
device, and the paper points dried the canals
(20)
.
The application of Gutta-percha was done
according to the size that fitted to the root canal
and apical area just closed the apical 1/3, which
was enough to seal the apical foramen with good
condensation by heated plugger. Follow-up
examination from the time of operation up to 1
year by clinical and radiographic examination
(21-
24)
.
Figure 1;A. Ultrasonic device B. Ultrasonic probe for retrograde preparation

C. Preparation for retrograde filling by ultrasonic probe device

eported that all the cases that
we
the healing process of
ora
of the mandibular anterior region as presented in
rly much better in those
pat

RESULTS
This study r
re exposed to endodontic surgery with the
use of Gutta-percha as retrograde filling
showed complete healing without any
recurrence of the periapical lesions, as seen in
Table 2, and Figure 2.
Table 2 shows that
l tissues and particularly the alveolar bone
were observed clearly from the 3
rd
week post-
operative and completed at the period of 1-2
months. In addition to that 42 (73.7%) of cases
showed better and faster healing process in
maxillary anterior region than 15(26.3%) cases
Table 3. On the other hand, the study does not
report any rejection or complication from the use
of Gutta-percha as retrograde filling like toxicity
or allergic reaction.
Table 4 shows that the healing process was
significant and clea
ients with short duration of the pathological
lesions in comparison with those patients who
had long duration lesions. The current study also
reported that the healing process appear to be
significantly much better in males than females,
as recorded in Table 5.

Table 1: The number, age gender, and duration of pathological lesions.
Gender
No
Fem les
s . of patients Average age years Duration of pathological lesion
ales Ma
57 18-34 25 32 6months-5 years

Table 2: The healing process and the duration of follow-up
Follow-up post-operation
No. o
1M-2M 2M- during 1 year
f patients
3M 3M-6M Recurrence
57 (100%) 3 1 6 (63%) 9 (33.3%) 2 (3.6%)

Table 3: The healing process according to the site of the jaws.
No. of patients Healing process
Maxillary anterior lar anterior region region Mandibu
42 (73.7%) 15 (26.3%)
Fem %) Fem ) ale 12 (21.1 ale 13 (22.8%
57 (100%)
Male 30 (52.6%) Male 2 (3.5%)

Table 4: Healing process according to the gender of the patient.
No. of patients Duration of pathological lesion Duration of healing
57(100%)
rs
30(5 ths

6Months-1year
1-2 years
2-3 years
3-5 1/5 yea
2.6%) within 1-2Mon
6(10.5%)within 1-2Months
19(33.3%)within 2-3Months
2(3.6%)within3-6Months

Table 5: Healing process according to the gender of the patient.
No. of patients Healing process post-operation
1-2 Month onths s 2-3 Months 3-6 M
57 (100%)
Fe
)
Fem ) Fe ) male 4 (7%)
Male 32(56.1%
ale 19 (33.3%
Male 0 (0%)
male 2 (3.6%
Male 0 (0%)

Figure 2-A: Immediately after operation B-Complete healing process of Gutta-
of Gutta-percha as retrograde filling -Percha as retrograde within 2 month

Figure 3: Periapical radiograph shows a clear remnant particles of Amalgam in the surrounding
alveolar bone when used as retrograde filling.
DISCUSSION
Gutta-percha is an efficient and safe
material to be used as a retrograde filling when
compared with other materials, particularly the
amalgam for the following reasons: -
1. It is biocompatible and it is used for many
years as a conventional root canal filling
without any rejection observed from the
patient, particularly when it is used in a
correct manner
(1,21,22)
.
2. Gutta-percha is the only material that can
be used in every tooth in maxillary and
mandibular jaw without any complications
and difficulties
(4)
.
3. It is the only flexiblematerial that can be
used for the straight and curved root canal
(25,26)
.
4. Gutta-percha does not precipitate remnant
particles in the surgical field as seen with
the use of amalgam
(4)
.
5. Sealing of the apical area by the use of
Gutta-percha gives a better barrier to
prevent a microleakage from
microorganisms rather than amalgam, and
other materials
(8,10)
.
6. It is easy to manipulate and apply.
7. It is non toxic as other materials
(5,10)
.
In addition to the previous points the skills
and the experience of the dental surgeon for
approaching the apical foramen and accessing
the instrumentation of the canal, stay a very
important factor for giving the successful
results beside the advantages of the material.

(6,7,27,28)

Some dental surgeons believed that the use
of Gutta-percha sometimes shows
complications when it is used as a
conventional root canal filling particularly
when there is over extension. On the other
hand, the use of Gutta-percha as a retrograde
filling, the filling seal the root canal and the
apex so no excess of the material will leave
outside the root canal, and this procedure is
different from over extension of the Gutta-
percha, because here it act as foreign body that
cause a cellular reaction and aggregation of
inflammatory cells (antigen-antibody reaction)
around the apical surface which lead to recurrent
infection and failure of the procedure, so there is
no relationship between the two conditions.
In the comparison between the results from
the use of Gutta-percha as retrograde filling with
amalgam, the study found according to the
follow-up of both cases and from other
literatures that most of amalgam cases failed and
the patient came with recurrent lesion, which is
not due to the lesion itself but from the use of
amalgam material which may end with the tooth
lost
(5,8-10)
.
Radiographic findings of previous literatures
shows clearly remnant of amalgam particles
inside and around the surgical field and alveolar
bone, which can not be observed during the
operation, even when there is a dry field and
with the use of isolated material (like bone wax).
Even with the use of small curved amalgam
carrier, the particles of amalgam are very fine
and heavy weight which can not be removed by
irrigation particularly when it settles down inside
the cancellous of alveolar bone, and most of
dental surgeons leave these particles inside the
bone, because it is very difficult to localize and
remove. These small particles act as antigen or
foreign body inside the surgical region, which
lead to toxicity reaction (Figure 3).
Therefore, trying to remove of these particles
after operation, needs another surgical
interference and more alveolar bone removal
randomly to involve these particles, because
these particles can not be localized correctly
even by the use of radiographs. Therefore, the
procedure will change from the conservative
manner to destructive manner.
On the other hand, the comparison of these
problems with the use of Gutta-percha according
to the results from the current study found that
no remnant of Gutta-percha particles are

detected outside in the surgical field
(4)
and the
entire pathological lesion would disappear.
Perhaps, there is small piece of Gutta-percha
outside the root canal such as in case of over-
extension. Trying to remove is much easier for
detection of the excess and approach surgically
with conservative manner and give better
prognosis rather than in case of excess of
amalgam which may end with bad prognosis.
From the previous literatures, other
disadvantages from the use of amalgam as
retrograde filling, and these are: -
1. Contraction defects between the dentin wall
and amalgam filling
(5)
.
2. Micro-leakage of microorganisms
commonly occurs
(5,8,10)
.
3. Allergic reaction to mercury (oral
galvanism)
(5,10)
.
4. Cytotoxic reaction on cell cultures similar to
the reaction observes in the use of glass-
ionomer cement
(14,15,19,24)
.
Histologically, Zetterquist in 1987 found
that the use of both amalgam and glass-
ionomer cement as retrograde filling caused
vascular granulation tissues containing
lymphocyte, plasma cells, and polymorph
nucleated leukocytes observed around these
materials. Phagocytizing polynuclear giant
cells were focally sited in the granulation
tissue that seen
(5,21)
.
In this study, the healing process of all
cases was successful without any signs or
symptoms of complications or recurrent
lesions were reported during the follow-up of
all cases.

REFERENCES
1. Dahlen G, Beergen G. Endotoxic activity in teeth
with necrotic pulps. J Dent Res 1980; 59: 1033-40.
2. Malooley J J R, Patterson. Response of periapical
pathosis to endodontic treatment in monkeys. Oral
Surg 1979; 47: 545-54.
3. Moller AJ R, Hyden G. Influence on periapical tissues
of indogenous oral bacteria and necrotic tissue in
monkeys. Scand J Dent Res 1981; 89: 475-84.
4. Robert K, Flath DDS. Retrograde instrumentation
and the abturation with new Devices. J Endod 1987;
13: (11): 546-9.
5. ZetterQuist G, Anneroth, Nordenram. Glass-ionomer
cement as retrograde filling material. Int J Oral
Maxillofac Surg 1987; 16: 459-64.
6. Langeland K, Liaokek. Work-Saving devices in
endodontics. Efficacy of sonic and ultrasonic
techniques. J Endod 1985; 11: 499-510.
7. Marlin J , Krakow. Clinical use of injections molded
thermoplaticized Gutta-percha for obturation of the
root canal system: a preliminary report. J Endod
1981; 7: 277-81.
8. Feldman G, Nyborg H. Tissue reactions to root canal
filling materials. Odontal Revy 1962; 13: 1-14. (Cited
by ZetterQuist in Int J Oral Maxillofac Surg 1987; 16:
459-64).
9. Feldman G, Nyborg H. Tissue reactions to root canal
filling materials. Odontal Revy 1964; 15: 33-40 (Cited
by Zetterquist in Int J Oral Maxillofac 1987; 16: 459-
64).
10. Boyer DB, Torney DL. Microleakage of higher copper
amalgams. J Dent Res 1979; 58A: 394 (abstract. No.
1213).
11. Vees A. Ergebinsse der chirugischen Wur-
Zellbehandlung DasDtsch Z. 1966; 20: 35-8 (Cited by
Zetterquist in Int J Oral Maxillofac 1987; 16: 459-64).
12. Nordenram A. Biobond for retrograde root filling in
apicectomy. Scand J Res 1970; 78: 251-5.
13. Finne K, NorD PG, Person G. Retrograde filling with
amalgam and cavit. Oral Surg 1977; 43: 621-7.
14. Hank CT, Anderson M, Craig RG. Toxicity tests with
cultured cells of live dental cements. J Dent Res 1980;
59: 376.
15. Kawahara H, Imanishi Y, Oshima H. Biological
evaluation on glass-ionomer cement. J Dent Res 1979;
58: 1080-6.
16. Kent BE, Wilson AD. The properties of the glass-
ionomer cement. BDJ 1973; 135: 322-6.
17. Mealcan J W, Wilson AD. The clinical development of
the glass-ionomer cement. Aust Dent J 1977; 2: 31-36,
120-7, 190-5.
18. Wilson AD, Kent RE. A new translucent cement for
dentistry. The glass-ionomer cement for dentistry. BDJ
1972; 132: 133-5.
19. Kent BE, Langeland K. Tierexperimeutelle prulug von
materialien und Metoden der Krnoenund
Brunckenprosthetic. Scch Weiz-Msehri Zahnheilk
1973; 83: 163-244. (Cited by ZetteroQuist in Int J Oral
Maxillofac Surg 1987; 16: 459-64).
20. Rud J , Andereasen J O, Moller. Radiographic criteria
for the assessment of healing after endodontic surgery.
Int Oral Surg Int J Oral 1972; 1: 195-214.
21. Andreasen J O, Rud J . Correlation between histology
and radiograph in the assessment of healing after
endodontic surgery. Int J Oral Surg 1972; 161-73.
22. Olav Molven et al. Observer strategy and the
radiographic classification of healing after endodontic
Surgery. Int J Oral Mazxillofac Surg 1987; 16: 432-9.
23. Rud J , Andreasen J O, Moller. A follow-up study of
1000 cases treated by endodontic surg. Int J Oral Surg
1972; 1: 215-28.
24. Mener O, DominQuez VF. Tissue response to a glass-
ionomer used as endodontic cement. A preliminary
study in dogs. Oral Surg 1983; 56: 198-205.
25. Chenail BL, Teplistsky BE. Endodontics in curved root
canals. J Endod 1985; 11: 369-74.
26. Schneider SW. A comparison of canal preparations in
straight and curved roots canals. Oral Surg 1971; 82:
271-5.
27. Eldeeb ME. The sealing ability of injection-modeled
thermoplasticized Gutta-percha. J Endod 1980;11: 84-6.
28. Harrison J W, Todd MJ . The effect of root resection on
the scaling property of root canal obstructions. Oral
Surg 1980; 50: 204-72.

J Bagh Coll Dentistry Vol. 18(2), 2006 Comparison of conventional
Comparison of conventional periodontal therapy versus
scaling and root planing with subgingival
minocycline gel 2%
Kholood A. Al Safi B.D.S., M.Sc.
(1)
ABSTRACT
Background: Alternative regimens using subgingival minocycline plus scaling and root planing (SRP/ M) significantly
improved clinical attachment (CAL) and reduced probing depth (PD) compared with SRP alone. The purpose of this
study was to evaluate clinical and radiographic outcomes in 2 periodontitis cohorts, one receiving conventional
periodontal therapy and the other receiving scaling and root planing with multiple doses of subgingival minocycline
Materials and Method: Moderate to advanced chronic periodontitis patients were concurrently treated with
either:(1) scaling and root planing with 4 subgingival doses of minocycline in all 5mm pockets over a 6 month
period (SRP/M) n = 25 patients or (2) conventional therapy 6 month period (SRP n = 25 patients). Clinical and
radiographic measurements including (PD), CAL, BOP and interproximal bone height (BH), were analyzed at baseline
and 1 year.
Results: Baseline clinical and radiographic data were similar between SRP/M and SRP patients. PD showed greater
mean improvement in SRP/M (1.1 0.1 versus 0.5 0.1 mm P=0.02) with 25% of subject of SRP/ M gaining 2mm
compared to 4.2% in SRP. The mean loss in bone height and percent subjects losing bone height were less in SRP/M
(2.9 0.6 mm) than SRP (3.7 0.7mm) while cross sectional SRP/M data between CAL and BH or PD and CAL were
highly correlated, changes over 1 year were not correlated among any of these parameters.
Conclusion: Scaling and root planing and subgingival minocycline in experimental sites resulted in more PD reduction
and less frequent bone height loss than conventional periodontal treatment alone.
Keywords: Root planing, minocycline. (J Bagh Coll Dentistry 2006; 18(2) 57-62)

INTRODUCTION
The management of periodontal disease
includes many treatment modalities such as
conventional therapies consisting of surgery
and/or non surgical methods. In any case, the
purpose of periodontal treatment is to arrest
progressive tissue destruction and to prevent
further attachment loss. Undoubtedly to
successfully treat periodontitis we have to find
more effective technique surgical as well as non
surgical
(1-3)
.
Antimicrobial therapy has become an
accepted part in periodontal treatment
(4)
. Use of
subgingival antimicrobial medications
including tetracycline, has been shown to
improve probing depths (PD) and clinical
attachments levels (CAL).
(5,6).
This is
presumably due to decreases in gingival
inflammation by modulating the inflammatory
response and suppressing the pathogenic
microbiota. The use of these medications may
improve the clinical outcome of therapy.
(7).
The fact that periodontal tissues can be
infected by specific anaerobes and that these
bacteria are present in some sites with recurrent
or persistent disease even after mechanical
treatment methods so that it requires a special
treatment concept, a combination of mechanical
treatment modalities with antibiotics therapy
had been suggested
(8-10).

(1) Assist professor, Department of Periodontology, College of
Clinical studies have demonstrated that
minocycline has a beneficial effect on various
parameters of chronic and acute inflammatory
periodontal disease Due to the antibacterial and
anticollagenolytic properties of tetracyclines,
use of minocycline in conjunction with scaling
and root planing (SRP +M) may further slow
the rate of bone loss
(10,11).
In a randomized, double blind comparative
study subgingival administrated minocycline in
patients with adult periodontitis revealed that it
was a safe and efficient adjunct to scaling and
root planing
(13)
. It also led to significant
adjunctive improvement after subgingival
instrumentation in both clinical and
microbiological variables over a 3 to 15 months
period
(12,13)
. In vitro studies have also
suggested that minocycline may be more
effective than the other tetracycline on various
microbiological components of dental plaque
(14,15).
In recent years, numerous studies have
demonstrated improvement in clinical
periodontal parameters after additional
treatment with metronidazole and tetracycline
in cases of sever periodontitis
(7,16,17).
It has
become clear that scaling and root planing are
essential in initial periodontal therapy to reduce
inflammation via the removal of plaque,
calculus and endotoxins from the root surfaces
of all teeth. Therefore, the purpose of this study
was to assess the comparison of conventional
periodontal treatment versus scaling and root
planing (SRP) with subgingival minocycline
gel.

Patients selection and assignment to
treatment groups
Subjects presenting to the department of
Periodontology College of Dentistry, University
of Baghdad were selected after a periodontal
screening examination by a periodontist. The
selected patients were given an oral explanation
of the clinical trial. A total of 50 patients with
moderate to advanced chronic periodontitis
were selected for these studies (28 females and
22 males, 35-65 years of age) met the following
criteria:
1. At least 2 molar or premolar teeth with
5mm interproximal pockets,
2. Did not have specific systemic diseases.
3. Had not recently taken medication.
4. No scaling and root planing within the past 6
months.
5. Not pregnant or lactating. Once subjects were
selected for participation, they were assigned
to their respective treatment groups.
The subjects were randomly divided into 2
groups. The test group, n=25; in those patients,
all 5 pockets were scaled and root planed
(SRP) using ultrasonic and hand curettes, then a
dose of minocycline gel 2% is injected
subgingivally. After baseline, no additional
instrumentation was performed for 1 year.
Control group, n=25, those patients
received concurrent conventional therapy
consisting of scaling, plaque debridement and
root planing without minocycline application.
Both groups received oral hygiene instructions
as necessary.
Delivery of minocycline
After baseline clinical measurements,
scaling and root planing, the minocycline gel
2% was delivered into each 5 pockets in
every study subjected. Prior to delivering the
minocycline gel into pocket, the site was dried
and cleansed of blood, debris and saliva then
application of a subgingivally-administrated gel
formulation containing 2% minocycline
hydrochloride delivered with a specially
designed disposable applicator versus a vehicle
control immediately after root planing, and after
1 month, 3 months and 6 months according to
study protocol. After baseline appointment and
over the course of 1 years investigation, study
subject included in the data analysis did not
receive any prophylaxis, root planing or drug
therapy which could affect the plaque
microorganisms.
Clinical and radiographic measurements
The clinical parameters that were recorded
at baseline and 1 year including probing pocket
depth (PPD), bleeding on probing (BOP) and
clinical attachment level, (CAL). In addition
four posterior vertical bitewing radiographs
were taken at baseline and 1- year following up
measurement were made by a masked evaluator
from CEJ to alveolar bone height (BH).
Statistical Analysis
Data obtained in the present study were
presented as a mean value and standard error.
The comparison of clinical outcomes between
control group and test group was done by the
MannWhitney Utest, changes in PPD and BH
within groups were evaluated using paired t
test and between groups changes were tested
using analysis of variance and chi-square
analysis. Correlation coefficients were
calculated among clinical and radiographic
changes. The statistical computation was
performed using a statistical soft ware program.

RESULTS
The baseline clinical data indicated that test
group SRP/M and control group SRP were
similar according to interproximal probing
depths of experimental sites (Table 1), as
expected with the matching strategy in the
study design. SRP/M had 12 premolar/38 molar
sites and SRP had 10 premolars/40 molars.
Bleeding upon probing was reduced over
the period of investigation, both protocols
reduced percent of patients bleeding on
probing, but no statistical differences were
found after 1 year (SRP/M =81%; SRP=72%).
Changes in PD and BH over 1 year are
summarized in Table 2. During one year, an
improved PD and CAL were noticeable. The
mean PD was reduced from 5.0 0.5 mm to 4.5
0.4mm in control group, and from 5.0 0.5
mm to 3.9 0.4mm in the test group. Probing
depths were improved more than 1 mm on
average for SRP/M which was significantly
different than the SRP group. Both groups
showed a significant reduction in PD between
baseline and one year visits (P<0.0001 for both
groups). Twenty five percent (25%) of SRP/M
patients had an experimental site which was
improved by 2.0mm compared to only 4.2%
for SRP. In fact 8.3% of SRP patients had a site
which lost 2.0mm probing depths, while
SRP/M patients had no such sites.
During the period of study, the mean CAL
was reduced from 7.7 0.6mm to 5.7 0.2 mm
in the control group, and from 7.70.6mm to
4.70.2mm in the test group. Both groups
showed a significant CAL gain between the
baseline and one year visits (P=0.01 for the
control group and p =0.001 for the test group).
The mean gain of CAL was 2.0 0.3mm in
control group and 3.0 0.3mm in the test one,
and this difference was statistically significant
(P=0.03 and P<0.05) according to the Mann
Whitney Utest.
Average bone height losses appeared to
parallel probing gain in that SRP/M had about
twice the PD gain and almost about one of the
BH losses of the SRP group over the 1 year
period (Table 2). There was a statistical
significant difference between groups for BH.
Baseline PD versus CAL and BH versus
CAL, as well as 1 year PD versus CAL and BH
versus CAL, were significantly correlated in the
SRP/M, with r values >0.61. Baseline BH also
was correlated with 1 year CAL (r=0.72,
P=0.001), and baseline CAL was correlated
with 1 year BH (r=0.81, P=0.0001) in the
SRP/M. PD was not significantly correlated to
BH at any time in either group. Although there
is cross sectional connections, no significant
correlations could be found in either group
when changes across the 1 year period were
compared (Table 3). The highest correlation
coefficient occurred between clinical
attachment level and bone height changes
measured in SRP/M group (r=0.45; P=0.09).

DISCUSSION
It is widely recognized that scaling /root
planing constitutes the basis of periodontal
therapy. Clinical research has documented
however, that conventional mechanical therapy
often leaves behind significant numbers of
pathogenic periodontal bacteria. Scaling and
root planing may fail to eliminate these bacteria
because of their location within the gingival
tissue or because their location in tooth
structures makes them inaccessible to
periodontal instruments.
This investigation demonstrated that local
delivery of a minocycline periodontal
formulation directly into the gingival crevice
following root planing results in a greater
reduction of periodontal pocket depth than root
planing alone. Other investigators have also
examined the effect of the antibiotics delivered
into the gingival crevice on the subgingival
plaque microbial flora. Our results are
consistent with the findings of Goodson et al in
1985, Addy et al in 1988, Deasy et al in 1989,
and Minabe et al in 1989
(18-21)
, in that all of
these investigators demonstrated the
antibacterial effectiveness of local delivery
antimicrobial agents including tetracycline and
metronidazole as well as minocycline.
All clinical and radiographic outcomes
were numerically better in test group if
compared with control group (Table 2). The
SRP/M group in our study had a mean decrease
in PD of 1.1mm while the SRP was 0.5mm for
5mm pockets (Tables 1 and 2).Other studies
have shown PD reduction with SRP and
subgingival chemotherapeutics but most of
these studies were less 12 months in length
(15,22-
24)
.
The SRP/M data was comparable to the
study of Garrett et al in 2000
(15)
who did
scaling and root planing combined with
subgingival medication in which SRP/M
participated showed a mean 1.31mm reduction
in PD for all pockets (5 to 9 mm) while our
results demonstrated an overall 1.10mm PD
reduction. The SRP group outcome was
comparable to the study of Drisko et al in 1995
(26)
, who reported a 0.36 mm PD decrease with
prophylaxis alone while in our study PD
reduction in this group was 0.50 Other studies
of SRP alone during initial therapy of moderate
pockets have shown PD reduction around 1mm
after 1 year
(26-30).
The mean difference in PD changed
between the 2 groups in this study was
statistically significant (Table 2). The amount
may appear to be less than clinically significant.
However, no further instrumentation after
baseline was performed in the SRP/M group
and no chemotherapeutic treatment was given
after the 6 months appointment. In addition,
none of the patients had sites which increased
in PD in the SRP/M group over 1 year study,
(8.3% of SRP subjects had sites which
increased, while 25% of subjects had at least
one site which improved in PD 2mm (P=0.02).
In the present investigation the local
subgingival delivery of minocycline
antimicrobial agent aids in the reduction of
periodontal pocket depth and therefore, can
help the clinician to achieve a more favorable
therapeutic result when used as an adjunct to a
root planing when compared to that observed
with root planing alone, this is agreed with
many studies.
(4,5,16,31).
Little information is available
radiographically comparing changes in bone
height for various local chemotherapeutics.
J effcoat et al. showed no bone loss with the
chlorhexidine chip in combination with SRP,
while 25% of the sites showed some gain in the
9 months study
(24)
.No thresholds to determine
real change were described, but mean changes
in bone height were within =0.1mm .Our study
had a predetermined threshold of 0.5mm
based on three standard deviations of replicate
measurements to provide 99% confidence of
real change. The test group (SRP/M) and
control group (SRP) in this study showed a
minimal incidence of subjects with bone gain
0.5mm (4%) and no statistically significant
difference between groups. Bone loss of
0.5mm occurred in more of the SRP subjects
(17.0% SRP, 11.9% SRP/M) but differences
were not significant. A comparable 15% of
participants receiving SRP alone lost bone in
the J effcoat study
(24)
.
It is thought that chemotherapeutics work
by modulating the inflammatory response
and/or by suppressing or eradicating the
pathogenic microbiota which should result in
maintenance of bone height
(32)
. Even if
additional bone height was not gained, a
treatment which reduces the progression of
bone loss is a step toward effective periodontal
maintenance
(33).
The mean clinical attachment gain of the
test group receiving the non surgical SRP and
local minocycline therapy improved
significantly over that of the control group
receiving only conventional therapy SRP (Table
2). On the other hand Zucchelli
(34)
,
administrated a slow releasing dental gel
containing metronidazole benzoate (25%) and
they found no statistically significant difference
between test group receiving the local
antimicrobial therapy and control group given
systemic antibiotics. Although some studies
concerning the local delivery of antimicrobial
therapy, they had no effect of clinical
significance on bone regeneration or on soft
tissue attachment
(3,35,36).
Cross-sectional correlations were found
between PD versus CAL and BH versus CAL
in the SRP.M group but not between PD versus
BH in either group. In additions, BH at baseline
was correlated with CAL at 1 year and vice
versa. These findings suggest that CAL and BH
may parallel each other, but especially BH is
not related to the common clinical measurement
of PD.
Changes in PD and CAL are subject to
changes of inflammation where an increase in
soft tissue integrity due to decreased
inflammation may decrease probe penetration
(37,38).
Bone height measurements would not be
expected to be affected by such inflammatory
changes and appear to be an efficient measure
to compliment PD and CAL in long-term
analysis of subgingival antimicrobials
(10).
In general, it seems reasonable to conclude
that minocycline delivered subgingival as an
adjunct to scaling and root planing resulted in
more PD reduction and slower BH loss than
conventional therapy alone. The data from
local-delivery controlled release antimicrobial
studies in general, and this study in particular,
suggest that further understanding is needed
relative to the effects observed in no treatment
groups and the impact of supragingival plaque
control on the long term outcomes of this type
of therapy.

Table 1: Base line clinical and radiographic data
Group Age Gender PD CAL
Interproximal bone
height
BOP
Test (SRP/M) 53.5 0.5 M=11 F=14 5.0 0.5 7.70.6 4.5 0.4 56.20.5
Control (SRP) 55.12.5 M=12 F=13 5.0 0.5 7.70.6 4.0 0.4 57.50.5
P value
0.23
NS
0.72
NS
0.50
NS
0.11
NS


Table 2: Change in clinical and radiographic data over 1 year
Groups
PD
reduction
% subjects with sites
changing 2.0mm
PD
CAL
gain
Interproximal
bone height
% subject with sites
changing 0.5mm
BH
BOP
Test
(SRP/M)
1.1 0.1
+ 25.0
*
0.0
3.0
0.3
2.9 0.6
+4.5
-11.9
32.40.5
Control
(SRP)
0.5 0.1
+4.2
-3.3
2.0
0.3
3.70.7
+4.1.
- 17.0
33.00.5
P value
0.07
S

0.035
S
0.08
S

0.13
NS

Higher incidence of subject with PD improvement in SRP/M (P=0.020)

Table 3: Correlations among clinical and radiographic changes
Comparison SRP/M SPR
PD vs CAL -0.18, P=0.61 0.08, P=0.92
PD vs BH -0.12, P=0.72 0.03, p=0.81
CAL vs BH 0.40, P=0.11 0.10, P=0.64

PD= interproximal probing depth; CAL= interproximal clinical attachment level; BH= interproximal bone height.

REFERENCES
1- Saxen L, Asikaninen S, Kanervo A, Kari K,
J ousimiesh. The long term efficacy of systemic
Doxycycline medication in the treatment of
localized juvenile periodontitis. Arch Oral Bio 1990;
35: 227- 9.
2- Killoy WJ . The use of locally delivered
chlorhexidine in the treatment of periodontitis.
Clinical results. J Clin Periodontal 1998; 25: 953- 8.
3- Van Steenberrghe D, Bercy P, Kohl J . Subgingival
monocycline hydrochloride ointment in moderate to
sever chronic adult periodontitis a randomized,
double blind vehicle controlled, multicenter study. J
Clin Periodontal 1993; 64: 637- 44.
4- Meinberg A, Barnes M, Dumming G, Reingardt A.
Comparison of conventional periodontal
maintenance versus scaling and root planing with
subgingival minocycline. J Clin Periodontal 2002;
73: 163- 72.
5- Van Steenberrghe D, Rosling B, Soder P. A 15
month evaluation of the effect of repeated
subgingival minocycline in chronic adult
periodontitis. J Clin Periodontal 1999; 70: 657- 67.
6- J anson H, Brathall G, Saderhalm G. Clinical
outcome observed in subjects with recurrent
periodontal disease following local treatment with
25% Metronidazole. J Clin Periodontal 2003; 74:
372- 7.
7- Greenstein C. The role of Metronidazole in the
treatment of periodontal disease. J Periodontal 1993;
64: 1- 15.
8- Gusberti FA, Syed SA, Lang NP. Combined
antibiotic (Metronidazole) and mechanical
treatments effect on the Subgingival bacteria flora of
sites with recurrent periodontal disease. J Clin
Periodontal 1998; 15: 353- 9.
9- Mangnusson I, Marks PG, Clark WB. Clinical
microbiological & immunological characteristics of
subjects with refractory periodontal disease. J Clin
Periodontal 1991; 18: 291- 9.
10- Khattab Razan. Clinical response of early onset
periodontitis to periodontal therapy supported by
adjunct tetracycline and Metronidazole. Long term
follow up. J ournal of the Arab Board of Medical
Specializations (J ABMS) 2001; 3: 80- 90.
11- Ti- Sun K, Burklin T, Schacher B, Kruger P, Malthijs
T, Renbbli H, Fiehn W, Frckholz P. Pharmacokinetic
profile of a locally administrated Doxycycline gel in
crevicular fluids, blood, and saliva. J Periodontal
2002; 73: 313- 9.
12- Ciancio SG, Slots J , Reynolds HS, Zambon J J ,
Mckenna J D. The effect of short term administration
of minocycline HCL on gingival inflammation and
Subgingival microflora. J Periodontal 1982; 53: 557-
61.
13- Omori N, Kobayashi H, Tsutsui T. Quantitative
comparison of cytocidal effects of tetracyclines and
fluoroquinolones on human periodontal ligament
fibroblasts. J Periodontal Res 1999; 34: 290- 5.
14- Novak MJ , Stamatelakys C, Adair SM. Resolution of
early lesions of juvenile periodontitis with tetracycline
therapy alone. Long- term observations of 4 cases. J
15- Garrett S, Adams S, Bagle G. The effect of locally
delivered controlled release Doxycycline or scaling
and root planing on periodontal maintenance patients
over 9 months. J Clin Periodontal 2000; 71: 22- 30.
16- Okuda K, Wolf L, Oliver R, Osborn J , Stolitenberg J ,
Berenuter L, Anderson P, Foster N, Haridie D, Hara
K. Minocycline slow release formulation effect on
Subgingival bacteria. J Clin Periodontal 1992; 63: 73-
9.
17- Eickholz P, Kim TS, Burklin T. Non surgical
periodontal therapy with adjunctive topical
Doxycycline. A double blind randomized controlled
multicenter study. J Clin Periodontal 2002; 29: 108-
17.
18- Goodson J M, Offenbacher S, Farr DH, Hogan PE.
Periodontal disease treatment by local drug delivery.
J Clin Periodontal 1985; 56: 262- 72.
19- Addy M, Hassan H, Moran J , Wade W, New combe
R. Use of antimicrobial containing acrylic strips in
the treatment of chronic periodontal disease. A three
month follows up study. J Periodontal 1988; 59:
557- 64.
20- Deasy PB, Collins AE, MacCarthy DJ , Russell RJ .
Use of strips containing tetracycline hydrochloride
or Metronidazole for the treatment of advanced
periodontal disease. J Pharm Pharmacol 1989; 41:
694- 9.
21- Minabe M, Takeucgi K, Tamura T, Hori T,
Umemoto T. Sibgingival administration of
tetracycline on a collagen film. J Periodontal 1989;
60: 552- 6.
22- Newmann MG, Korman KS, Doherty FM. A six
months multicenter evaluation of adjunctive
tetracycline fiber therapy used in conjunction with
scaling and root planing in maintenance patients.
Clinical results. J Periodontal 1994; 65: 685- 91.
23- Caton J , Ciancio S, Bileden T. Treatment with
subantimicrobial dose Doxycycline improves the
efficacy of scaling and root planing in patients with
adult periodontitis. J Clin Periodontal 2002; 71: 521-
32.
24- J effcoat MK, Palcains KG, Weather TW, Reese M,
Gerus NC, Flashner M. Use of a biodegradable
chlorhexidine chip in the treatment of adult
periodontitis. Clinical and radiographic findings. J
25- Kinane D, Radvar M. A six month comparison of
three periodontal local antimicrobial therapies in
persistent periodontal pockets. J Clin Periodontal
1999; 70: 1- 7.
26- Drisko C, Cobb C, Killey J . Evaluation of
periodontal treatment using controlled release
tetracycline fibers. Clinical response. J Clin
Periodontal 1995; 66: 692- 9.
27- Claffy N, Loos B, Gantes B, Martin M, Heins P,
Egelberg J . The relative effects of therapy and
periodontal disease on loss of probing attachment
after root debridement. J Clin Periodontal 1988; 15:
163- 9.
28- Kaldhal WB, Kalkwarf KL, Patil KD. A review of
longitudinal studies that compared periodontal
therapies. J Periodontal 1993; 64: 243-53.

29- Kaldhal WB, Kalkwarf KL, Patil KD, Movar MP,
Dyer J K. Long term evaluation of periodontal
therapy incidence of sites breaking down. J
Periodontal 1996; 67: 93- 102.
30- Meinberg T, Canarsky A, McClenahan A, Poulsen D,
Marx D, Reinhardt R. Outcomes associated with
supporative periodontal therapy in smokers and non
smokers. J Dent Hygiene 2001; 75: 15- 24.
31- Minabe M, Takeuchi K, Kumada H, Umemoto. The
effect of root conditioning with minocycline HCL in
removing endotoxin from the roots of periodontally
involved teeth. J Clin Periodontal 1994; 81: 387- 92.
32- Yoshinari N, Tohya T, Kawase H, Matsuoka M,
Nakane M, Kawachi M, Mitani A, Koide M, Inagaki
K, Fukuda M, Noguch T. Effect of repeated local
minocycline administration on periodontal healing
following guided tissue regeneration. J Clin
Periodontal 2001; 72: 284- 95.
33- J ames J , Brayton, Oing Yang, Robin J , Nakkula, J ohn
D, Walters. An in vitro model ciprofloxacin and
minocycline transparent by oral epithelial cell. J Clin
Periodontal 2002; 73: 1- 1.
34- Zucchelli G, Sforza NM, Clauser C, Cesari C, Sonetis
M. Topical and systemic antimicrobial therapy in
guided tissue regeneration. J Clin Periodontal 1999;
70: 239- 47.
35- Goulding MJ , Sandhal KO, Nowadly CA, Zambon J J ,
Chrislersson LA. Release of minocycline after
Subgingival deposition by use of a resorbable
polymer. J Periodontal 1991; 62: 84- 5.
36- Williams RC, Paquette DW, Offenbacher S.
Treatment of periodontitis by local administration on
minocycline microspheres. A controlled trial. J Clin
Periodontal 2001; 72: 1535- 44.
37- Fowler C, Garrett S, Criggar M, Egelberg S.
Histologic probe position in treated and untreated
human periodontal tissue. J Clin Periodontal 1982; 9:
373- 85.
38- Kaldhal WB, Kalkwarf KL, Patil KD, Movar MP.
Responses of four teeth and site groupings to
periodontal therapy. J Clin Periodontal 1990; 61: 173-
9.

J Bagh Coll Dentistry Vol. 18(2), 2006 The effect of aspirin on the
The effect of aspirin on the periodontal parameter
bleeding on probing

Maha Abdul Aziz B.D.S., M.Sc.
(1)

ABSTRACT
Background: The absence or presence of bleeding on probing (BOP) is a sign of periodontal health or disease,
but the presence of BOP is not an accurate predictor of disease progression. Aspirin is increasingly used in the
prevention of cerebrovascular and cardiovascular diseases and is a non-disease factor that may modify
bleeding indices given its antithrombolytic activity. The objective of this double-blind placebo-controlled
randomized clinical trial was to study the effect of short-term daily aspirin ingestion on the clinical parameter
BOP.
Materials and methods: A total of 60 subjects were randomly assigned to oral administration to one of three
arms: placebo (group 1), 100mg aspirin (group 2) , 300mg aspirin (group 3). Before (visit 1 V1) and after 7 days
(visit 2 V2) exposure to the respective regimens, clinical parameters were measured on all teeth, included
plaque index (PLI), probing depth (PD) and BOP.
Results: The primary measure of interest was BOP so, the results of this study indicate that the group treated with
300mg aspirin demonstrated a statistically significant increase from base line in percent of BOP compared to the
placebo group and 100mg aspirin group.
Conclusion: Failure to consider the effects of aspirin on BOP could impair proper diagnosis and treatment
planning for clinicians and introduce a significant confounding variable in research situations.
Key words: Aspirin, bleeding on probing, clinical trial. (J Bagh Coll Dentistry 2006; 18(2) 63-67)

INTRODUCTION
1

Aspirin has been recommended by the
American Heart Association as a therapeutic
agent for cardiovascular disease
(1)
. In addition,
it is commonly used to treat inflammatory joint
diseases
(2)
.
Aspirin is a non-steroidal anti-inflammatory
drug (NSAID)
(3)
. It is absorbed from the
duodenum and metabolically, it binds
irreversibly with cyclooxygenase and inhibits
the release of thromboxanes, which is
responsible for platelet aggregation for a period
of 7 to 10 days
(4-6)
. This change could increase
the chances of bleeding and bleeding on probing
for that period of time
(2)
.
Bleeding indices are used to measure
disease prevalence and treatment effectiveness
in clinical trials and monitor disease progression

(7)
. Thus failure to consider aspirin intake during
a routine clinical dental examination could
produce various false positive readings, which
could result in an inaccurate patient diagnosis
(2)
.
While several studies have examined the
anti-inflammatory effects of (NSAIDs) on
gingivitis and periodontitis
(8-11)
, some have
attempted to specifically examine the effect of
aspirin on BOP in patients with a clinically
healthy periodontium. Their results
demonstrated that aspirin intake of 325 mg daily
for 7 days moderately and significantly
increased the appearance of BOP
(12)
.

(1) Lecturer, Department of Periodontology, College of Dentistry,
University of Baghdad.
In another study done by Royzman et al.
2004
(2)
reported that 7 days aspirin use in doses
of 81mg and 325mg will significantly increase
the percentage of BOP sites in a population with
gingivitis.

The sample consisted of 60 subjects (30
males & 30 females), age range of 25-30 years.
At the beginning, all the participants signed
informed consent forms prior to entering the
study then they were screened through
evaluation of medical and dental histories.
Exclusion criteria were any known
contraindication to aspirin intake, compromising
systemic medical conditions, any form of
ongoing tobacco use, pregnancy or lactation,
any condition requiring antibiotic premedication
for the prevention of sub acute bacterial
endocarditis, a history of systemic or topical use
of any type of (NSAIDs) within 2 weeks prior to
study entry, or requiring the use of any type of
(NSAIDs) during the study period. Finally, any
one found to have single or more PPD of 4mm
, those with a previous diagnosis of chronic
periodontitis and received periodontal treatment
other than a routine prophylaxis within 12
months prior to entering the study.
At day zero, baseline measurements (V1) of
clinical parameters were recorded on all teeth
except third molars, then subjects were
randomized to one of the regimens (placebo,
100mg aspirin or 300mg aspirin) and were
63 Oral and Maxillofacial Surgery and Periodontology
provided with seven tablets with the instructions
to consume one each day, for 7 consecutive
days. Both the subjects and the investigator
were blinded to the content of the tablets. After
7 days from exposure to placebo or aspirin
regimens subjects were re-examined for
outcome measurements (V2) of clinical
parameters. The clinical examinations were
conducted using graduated Williams periodontal
probes and mouth mirrors.
Clinical Assessments:
1- PLI: Plaque index system in scale from (0-
3)
(13)

2- PD: The distance from gingival margin to the
most apical extent of the probe to the nearest
millimeter was recorded.
3- BOP: Absence or presence of bleeding on
probing.
(12)

RESULTS
In this study, the sample consisted of 60
subjects (30 males & 30 females) each group
divided into 3 groups, 20 in each, according to
the type of regimen they received (Table 1).
It is clear from Table 2 that the means of PLI
in V1 are nearly similar at each gender group
and the highest means of PLI at males, females
and totally found in group 2. The results were
1.98, 1.84 and 1.91 respectively. At V2 means
of PLI were slightly decreased but non
significant differences were observed by
comparing each type of regimen at V1 with V2
at each gender group (Table 5). Again the
highest means of PLI at males, females and
totally registered in group 2, the results were
1.909, 1.79 and 1.849 respectively. Generally,
females showed lower means of PLI than males
at V1 and V2 (Table 2).
It is obvious from Table 3 that means of PD
at V1 are nearly similar at each gender group
and the highest means of PD at males and totally
found in group 2, while at females presented in
group 3, the results were 2.43, 2.185 and 1.95
respectively. At V2 means of PD were slightly
decreased, although, when each type of regimen
at V1 was compared with V2 at each gender
group and totally a non significant difference
were recorded (Table 5).
In V2 the highest means of PD at males,
females and totally found in group 2, the results
were 2.10, 1.90 and 2.0 respectively. However
females demonstrated lower means of PD than
males (Table 3).
Results from Table 4 and Figure 1 revealed
that the percentages of BOP in V1 are nearly
similar in each gender group and the highest
percentage of BOP in males was found in group
1, the result was 22.86%, but at females and
totally recorded in group 3, the results were
21.60% and 21.96% respectively.
Placebo group registered slight increase in
percentages of BOP at V2 but non significant
differences were noted by comparing V1 with
V2 at each group. The same results were
recorded in respect to group 2 (Table 5),
however at V2 higher increase in percentages of
BOP than that registered in placebo group were
observed, at males, females and totally, the
results were 24.11%, 22.143% and 23.13%
respectively (Table 4).
On the contrary, a significant difference was
noted in group 3 by comparing V1 with V2 at
each gender group (Table 5). Additionally, at
V2 this group demonstrated the highest increase
in percentages of BOP at males, females and
totally, the results were 27.86%, 27.15% and
27.5% respectively. Finally, females recorded
lower percentages of BOP than males at each
visit (Table 4).

DISCUSSION
By evaluating the effects of treatments on
plaque, it is interesting to point out that the three
groups experienced a non significant decrease in
means of PLI from baseline visit. The
explanation of this situation could be attributed
to the fact that the subjects may be slightly
practiced better oral hygiene measures when
they were invited to participate in the study.
The other secondary measure of interest was
PD. All groups showed a non significant
decrease in means of PD by comparing V1 with
V2, this finding agree with Schroder et al in
2002
(12)
, and it is not in accordance with
Royzman et al in 2004
(2)
in which they reported
that treatment with both aspirin regimens
significantly decrease means of PD.
Reduction in means of PD could be attributed
to the anti-inflammatory effects of aspirin
(3,6,14)

and could also be due to the Hawthorne effects,
were subjects altered their regular practices due
to their participation in a study.
Not surprisingly there is a positive
relationship between PLI and BOP. This
positive association at V1 is supported by an
overwhelming amount of evidence, which
suggests that microbial plaque near the cervical
region of teeth causes gingivitis
(15,16)
. In contrast
to the above, at V2 reduction in means of PLI
were registered, in spite of that the group treated
with 300mg aspirin demonstrated a statistically
significant increase in percentages of BOP.
However, the subjects in group 1 and group 2
showed a non significant increase in percentages
of sites exhibiting BOP. These findings tend to
support the results of Schroder et al in 2002
(12)
,
while Royzman et al.
(2)
reported a significant
increase in percentages of BOP at both aspirin
regimens groups. Anti-thrombolytic effects of
aspirin
(17-19)
could explain the increase in
percentages of BOP among groups treated with
aspirin. However, this dose-dependent effect
was somewhat surprising in that several studies
indicated that due to aspirin's irreversible
acetylation of cyclooxygenase enzyme. The
effect of low dose aspirin is cumulative and over
time is expected to have anti-thrombolytic
activity equivalent to higher doses
(17,20)
. More
recent study indicated that 100mg aspirin
significantly reduced platelet aggregation after 4
hours of drug intake and the thromboxane 2
level, was significantly reduced after 7 days of
the initial drug uptake, however, this study
registered that low doses of aspirin may not
achieve an equivalent effect to higher doses
within a 1 week period
(21)
.
Generally, females showed lower PLI, PD
and BOP than males at V1 and V2, and these
results corroborate with previous
(2,12,12)

studies
(22)
, who describes females as having
better oral hygiene, less gingival bleeding and
less subgingival calculus compared to males.
These findings can be explained by the fact that
females are more concerned about their
appearance especially from esthetic point of
view thus they practiced a better oral hygiene
regimens than males.
Finally, meaningful comparisons between
studies are not easy since investigators do not
use standard criteria, methodologies can be
different and also the interpretation of the data,
hence one has to be cautious in this respect, so,
in the previously mentioned studies
(2,12)
they
use 81mg and 325mg aspirin regimens and the
clinical parameters assessed using an automated
pressure-sensitive probe. In spite of these
differences, the findings of this investigation
tend to slightly confirm the results of these
studies.

Table 1: Number and percentage of study population according to treatment regimen by gender.

Placebo Aspirin 100 mg/daily Aspirin 300mg/daily
Gender
No. % No. % No. %
Male 10 50.0 10 50.0 10 50.0
Female 10 50.0 10 50.0 10 50.0
Total 20 100 20 100 20 100

Table 2: Distribution of mean plaque index according to treatment regimen by gender (visit 1&
visit 2).

Male Female Total
Visit 1
Mean SD Mean SD Mean SD
Placebo 1.90 0.32 1.71 0.27 1.81 0.29
100mg 1.98 0.35 1.84 0.29 1.91 0.31
300mg 1.88 0.32 1.77 0.28 1.83 0.29
Visit 2 Mean SD Mean SD Mean SD
Placebo 1.86 0.32 1.66 0.28 1.76 0.28
100 mg 1.91 0.32 1.79 0.30 1.85 0.29
300 mg 1.81 0.31 1.72 0.29 1.77 0.28


Table 3: Distribution of mean probing depth according to treatment regimen by gender (visit 1&
visit 2).
Male Female Total
Visit 1
Placebo 2.21 0.353 1.901 0.304 2.055 0.328
100mg 2.43 0.388 1.940 0.310 2.185 0.349
300mg 1.98 0.316 1.950 0.312 1.965 0.314
Visit 2 Mean SD Mean SD Mean SD
Placebo 1.97 0.315 1.870 0.317 1.920 0.307
100 mg 2.10 0.336 1.90 0.323 2.000 0.320
300 mg 1.95 0.312 1.880 0.319 1.915 0.306

Table 4: Number and percentage of bleeding on probing according to treatment regimen by
gender (visit 1 & visit 2).
Male Female Total
Visit 1
No. % No. % No. %
Placebo 0 432 77.14 446 79.64 878 78.39
1 128 22.86 114 20.36 242 21.61
100 mg 0 438 78.21 448 80.00 886 79.11
1 122 21.79 112 20.00 234 20.89
300 mg 0 435 77.68 439 78.39 874 78.04
1 125 22.32 121 21.60 246 21.96
Visit 2 No. % No. % No. %
Placebo 0 430 76.79 443 79.107 873 77.95
1 130 23.21 117 20.893 247 22.05
100 mg 0 425 75.89 436 77.857 861 76.88
1 135 24.11 124 22.143 259 23.13
300 mg 0 404 72.14 408 72.850 812 72.50
1 156 27.86 152 27.150 308 27.50

Table 5: Comparison of clinical periodontal parameters between visit 1 & visit 2 according to
treatment regimen by gender.
Male Female Total
PLI
P-value Sig P-value Sig P-value Sig
Placebo 0.682 NS 0.556 NS 0.722 NS
100 mg 0.744 NS 0.799 NS 0.683 NS
300 mg 0.788 NS 0.882 NS 0.703 NS
PD P-value Sig P-value Sig P-value Sig
Placebo 0.092 NS 0.752 NS 0.096 NS
100 mg 0.674 NS 0.922 NS 0.962 NS
300 mg 0.982 NS 0.481 NS 0.892 NS
BOP P-value Sig P-value Sig P-value Sig
Placebo 0.887 NS 0.825 NS 0.798 NS
100 mg 0.356 NS 0.373 NS 0.202 NS
300 mg 0.033 S 0.031 S 0.002 S
*P<0.05 significant, **P>0.05 Non significant
78.39
21.61
79.11
20.89
78.04
21.96
77.95
22.05
76.88
23.13
72.5
27.5
0
10
20
30
40
50
60
70
80
%
Visit1 Visit 2
Placebo 0
Placebo 1
100 mg 0
100 mg 1
300 mg 0
300 mg 1

Figure 1: Percentage of total bleeding on probing (visit 1 and visit 2).

The findings of this study lend credence to
the notion that BOP may be related to an
inadequate function of platelets in patients
taking aspirin. Thus aspirin intake is an
important factor to consider in clinical trials as
an inclusion / exclusion criterion, in addition,
failure of clinicians to take into account aspirin
use in patients undergoing periodontal
treatment could lead to false-positive results,
which would lead to an improper diagnosis,
treatment choice, and assessment of disease
activity and progression because aspirin could
significantly alter the sensitivity and specificity
if one outcome being measured is BOP.

REFERENCES
1- Hennekens CH, Dykan ML, Fuster V. Aspirin as a
therapeutic agent in cardiovascular disease; a
statement for health care professionals from the
American Heart Association. Circulation 1997; 96:
2751-3.
2- Royzman D, Recio L, Rachel LB, Joseph F, Goodson
M, Howell H, Nadeem K. The effect of aspirin intake
on bleeding on probing in patients with gingivitis. J
Periodontol 2004; 75: 679-84.
3- Laurence DR, Bennett PN. Inflammation and non-
steroidal anti-inflammatory drugs: Arthritis. In:
clinical pharmacology, sixthed. Churchill livingstone,
Edinburgh, London & New York. 1987; 279-99.
4- Brown BA. Hematology: Principles and procedures,
6th ed. Lea & Febiger, Philadelphia, 1993, p.268.
5- Liesner RJ, Machin SJ. ABC of clinical haematology.
Platelet disorders. Br Med J 1997; 314: 809-12.
6- Craig CR, Stitzel RE. Modern Pharmecology with
Clinical Applications. Philadelphia: Lippincott,
Williams & Wilkins; 1997; 456-61.
7- Newburn E. Indices to measure gingival bleeding. J
Periodontol 1996; 67: 555-61.
8- Heasman PA, Seymour RA, Kelly PJ. The effect of
systemically administered flurbiprofen as an adjunct
to tooth brushing on the resolution of experimental
gingivitis. J Clin Periodontol 1997; 21: 166-70.
9- Jeffcoat MK, Haigh S, Buchanan W, Doyle MJ,
Meresdith MP, Nelson SL, Goodale MB, Wehmeyer
KR. Comparison of topical ketorolac, systemic
flurbiprofen, and placebo for the inhibition to bone
loss in adult periodontitis. J Periodontol 1995; 66:
329-38.
10- Lawrence HP, Paquette DW, Smith PC, Maynor G,
Wilder R, Mann GL, Binder T, Troullose E, Annett
M, Friedman M, Offenbacher S. Pharmacokinetic and
safety evaluation of ketoprofen gels in subjects with a
dult periodontitis. J Dent Res 1998; 77(11): 1904-12.
11- Al-Waheed ZA. The periodontal status of patients
under NSAIDs therapy. A clinical study. A thesis
presented to the University of Baghdad for the degree
of Master of Science in periodontics 1999.
12- Schrodi J, Recio L, Fiorellini J, Howell H, Goodson
M, Karimbux N. The effect of aspirin on the
periodontal parameter bleeding on probing. J
Periodontol 2002; 73: 871-6.
13- Silness J, Loe H. Periodontal disease in pregnancy.
Correlation between oral hygiene and periodontal
condition. Acta Odontol Scand 1964; 22: 121-35.
14- Flemming TF, Rumetsch M, Laiber B. Efficacy of
systemically administered acetylsalicylic acid plus
scaling on periodontal health and elastase-alpha -1-
proteinase inhibitor in gingival crevicular fluid. J Clin
Periodontol 1996; 23: 153-9.
15- Loe H, Theilade E, Jensen SB. Experimental
gingivitis in man. J Periodontol 1965; 36: 177-87.
16- Page R, Schroeder HE. Pathogenesis of inflammatory
periodontal disease. A summary of current work. Lab
Invest 1976; 33: 235-49.
17- Patrono C, Ciabatton G, Patrignan P et al. Clinical
pharmacology of platelet cyclooxygenase inhibition.
Circulation 1985; 72: 1177-84.
18- Mealey BL. Periodontal implications. Medically
compromised patients. Ann Periodontol 1996; 1: 256.
19- Carranza FA, Newman MG, Takei HH. Clinical
periodontology. 9th edition, Philadelphia, W.B.
Saunders company 2002; 544.
20- Patrignani P, Filabozzi P, Patrono C. Selective
cumulative inhibition of platelet thromboxane
production by low-dose aspirin in healthy subjects. J
Clin Invest 1982; 69: 1366-72.
21- Bode-Broger SM, Boger RH, Shubert M, Frolich JC.
Effects of very low dose and enteric coated
acetylsalicylic acid on prostacyclin and thromboxane
formation on bleeding time in healthy subjects. Eur J
Clin Pharm 1998; 54: 707-14.
22- 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.
J Bagh Coll Dentistry Vol. 18(2), 2006 Blood groups

Blood groups and hypertension

Nasreen A.R. Wafi MB.ChB, MSc
(1)

ABSTRACT
Background: Essential hypertension is very common worldwide & it has many harmful effects. The aim of our study
was to find whether any relation between blood groups and essential hypertension exists.
Materials and methods: 439 hypertensive patients were chosen from the hypertensive clinic in Sulaimanyia , 288
females & 151 males. Their age ranging between 40- 76 years (mean 58). The blood group of these patients was
determined. At the same time a control group of 439 non hypertensive persons were chosen in whom the blood
groups were determined.
Results: A close relation between blood group O and hypertension where 51.2% of hypertensive patients were group
O, while 23.5% were group A, 19.8% were group B and 5.2% were group AB. This close relation between hypertension
and blood group O was found almost equally in both female & in male patients.
Conclusion: Group O people in Sulaimanyia are more prone to have essential hypertension than other blood groups.
Keywords: Essential hypertension, Blood groups. (J Bagh Coll Dentistry 2006; 18(2) 68-70)

INTRODUCTION
Since the discovery of the ABO blood
groups by Landsteiner in 1900, scientists were
interested in finding a relation between these
groups and different pathologies. The first
relation that was found was the relation
between gastric cancer and blood group A
(1)
.
The second relation was the relation between
peptic ulcer and blood group O
(2)
.
After that different studies were carried out to
establish other relations as for example the
relation of group A with pancreatic cancer
(3)
,
breast cancer
(4)
, upper urinary tract cancer
(5)

ovarian cancer
(6)
and bladder cancer
(7)
. The
relation between blood groups and pulmonary
function was studied
(8)
, that with asthma
(9)
.
The relation between these groups and
psychological disorders
(10)
, urinary tract
infections
(11)
& cardiovascular diseases
(12)
are
documented.
Thus the ABO system may be considered a
predisposing factor in some pathology
especially if environmental & heredity factors
were added.

Essential hypertensive patients were chosen
from the hypertensive unit in Sulaimanyia.
Blood group were determined by the slide
method using the anti-A & anti-B sera (Sera
clone, Biotest).
Blood groups of 439 normal people were
determined at the same time to see the normal
distribution of blood groups in Sulaimanyia
from the period 1/11/2003- 1/3/2004

(1) College of Medicine, University of Sulaimanyia

For statistical analysis, the Chi square was
used to estimate the significance of the results.

RESULTS
As shown in table 1, the percentage
distribution of essential hypertension was
highest in group O people. Group O is the most
frequent blood group as mentioned in text
books, but in Sulaimanyia the distribution of
group A was as equal as that of group O.
Normally there is no gender difference in the
distribution of blood groups as they are
genetically determined & are carried with the
autosomal chromosomes. The distribution of
blood groups in male & in female hypertensive
were determined as shown in table (2) to see
whether any difference exist.

DISCUSSION
Essential hypertension is by far the most
common form of hypertension. It is the subject
of great concern because of its high prevalence
among the population and because of the great
risk it can cause to different systems in the
body. It can be the cause of a heart attack or can
lead to hypertensive encephalopathy,
hypertensive nephropathy & hypertensive
retinopathy. It affects both genders about
equally
(12)
. The main incidence falls between
the ages of forty and sixty. It accounts for about
20% of all deaths over the age of fifty. Like
other forms of cardiovascular diseases it is a
mixture of genetic and environmental
influences. Heredity is important and the
disease tends to run in families
(12)
.


Table 1: Distribution of blood groups in hypertensive & in controls (using the Chi square there
was a highly significant difference between both groups . The P-value was less than 0.01)

Blood Group Hypertension % Control %
A 103 23.5% 148 33.7%
B 87 19.8% 99 22.5%
AB 23 5.2% 36 8.2%
O 226 51.5% 156 35.5%
TOTAL 439 439

Table 2: Distribution of blood groups in female & in male hypertensives (Using the Chi square
there was no significant difference between the two groups)
% Female hypertensives % Male hypertensives Blood Group
23% 68 23.6% 35 A
17.8% 60 20.8% 27 B
5.2% 15 5.2% 8 AB
53.6% 145 50.3% 81 O
288 151 TOTAL

Studies have been carried out to show the
relation between blood groups and
cardiovascular pathologies. Most of these
studies pointed to a possible relation between
blood group A and cardiovascular diseases
(13-
20)
. Wincap studied the relation between blood
groups and platelet function
(21)
, while Robinson
studied the relation between blood groups and
venous thromboembolism
(22)
. Wong studied the
relation of blood groups and cholesterol level in
Japanese people
(23)
. He pointed to the possible
relation with blood group A, while Malatani
(24)

did not find this relation.
One study was done on hypertension
(25)
,
but it concluded that no relation existed
between blood groups & hypertension.
Our study showed a significant relation
between blood group O & essential
hypertension as shown in table 1. Essential
hypertension makes about 95% of total cases of
hypertension
(12)
. Probably the relation of group
A to cardiovascular diseases that was found in
western & in Japanese communities (as
mentioned in the previous references) is not
found in our community.

REFERENCES
1- Aird L, Bentall H. Relationship between cancer of
stomach & ABO blood groups. BMJ 1953; 1: 799-801.
2- Aird L, Bentall H, Mehigan JA. Blood groups in
relation to peptic ulceration & carcinoma of colon,
rectum, breast & bronchus. BMJ 1954; 2: 321-5.
3- Aird L, Bentall H. ABO Blood groups & cancer of
oesophagus, cancer of pancreas & pituitary adenoma.
BMJ 1960; 1: 1163-6.
4- Anderson DE, Haas C. Blood type A & familial breast
cancer. Cancer 1984; 54: 1845-9.
5- Kvist E. Relationship between blood groups & tumors
of the upper urinary tract. Scan J Urol Nephrol 1988;
22: 289-91.
6- Zhan G. Influence factors in etiology of epithelial
ovarian cancer. Chunig Hua Fu Chan Ko Tsa Chih
1997; 31(6): 357-60.
7- Nakatas P. Epidemiologic studies of risk factors for
bladder cancer. ACTA Urologica japonica 1995;
41(12): 969-77.
8- Kauffmann F, Frette C, Pham QT. Association of blood
group-related antigens to FEVI, wheezing & asthma.
Am J Respir Crit care Med 1996; 153(1): 76-82.
9- Mozalevskii AF, Polymorphic blood system in children
with bronchial asthma. Tsitol Genet 1985; May-Jun;
19(3): 220-5.
10- Rinieris P, Rabavilas A, Lykouras E. Neurosis & ABO
blood types. Neuropsychobiology 1983; 9(1): 16-8.
11- Voigtmann B, Burchardt U. ABO blood groups in
patients with nephropathies. Z Gesamte Inn Med 1991;
46 (5): 156-9.
12- Davidsons text book of medicine ,18
th
ed,Chap.3;216-
23.
13- Ismagilov MF, Petrova SE. ABO blood group system
and vegetative-vascular orders in children. Zh
nevropatol Psikhiatr 1981; 81(10):1487-8.
14- Meshalkin EN, Okuneva GN. ABO and Rh blood
groups in cardiovascular pathology. Kardiologiia 1981;
21 (4): 46-50.
15- Erikssen J, Thaulow E. ABO blood groups and
coronary heart disease (CHD). A study in subjects with
severe & latent CHD. Thromb Hemostat 1980; 18; 43
(2): 137-140.
16- Galeazzi L, Gualandri V. ABO blood-group
phenotypes & pathogenesis of cardiovascular
diseases.Congenital,rheumatic & coronary heart disease
& arterial hypertension. G Ital Cardiol 1975; 5(5): 744-
51.

17- Allan TM. ABO blood groups age & work in ischemic
heart disease. Atherosclerosis 1975; 21(3): 459-61.
18- Whncup PH, Cook DG. ABO blood group &
ischemic heart disease in British men. BMJ 1990; 30:
300(6741): 1679-82.
19- Rosenberg L, Miller DR. Myocardial infarction in
women under 50 years of age. JAMA 1983; 25:
250(20): 2801-6.
20- Platt D, Muhlberg W, Kiehl L. ABO blood group
system, age, gender, risk factors & cardiac function.
Arch Gerontol Geriatr 1985; 4 (3): 241-9.
21- Sweeney JD, Labuzetta JW. Platelet function & ABO
blood group. Am J Pathol 1989; 91(1): 79-81.
22- Robinson WM, Roisenberg I. Venous
thromboembolism & ABO blood groups in a Brazilian
population. Hum Genet 1980; 55(1): 129-131.
23- Wong FL, Kodama K, Sasaki H. Longitudinal study of
the association between ABO phenotype & total serum
cholesterol level in Japanese cohort. Genet Epidemiol
1992; 9(6): 405-18.
24- Malatani TS, Katowah RA. Gall bladder disease &
ABO blood groups. Afr J Med Sci 1997; Sep-Dec;
26(3-4): 141-3.
25- Gillum RF. Pressure & Obesity in adolescent. J Nati
Med Assoc 1991; 83 (8): 682-8.

J Bagh Coll Dentistry Vol. 18(1), 2006 Relations between
Relations between dental plaque, gingivitis & dental caries
among 21-50 years dental patients

Vian M. Al-Jaf B.D.S., M.Sc.
(1)

ABSTRACT
Background: The reason for this study was to find the relation between dental plaque, gingivitis and dental caries.
Materials and methods: The study was conducted among 52 patients attending department of periodontics,
college of dentistry, Arbil, age (21-50) years grouped into 3 age groups. The plaque index (PI), gingival index (GI),
calculus index simplified (Cal-SI) and dental caries from the DMFS were used.
Results: Positive correlation between PI and GI (r =0.48) & weak positive correlation between PI and Cal-SI (r =0.33).
But negative correlation was found between PI and DMFS (r =-0.059). No significant differences were found for each
of plaque, calculus and gingival indices between different age groups (P >0.05). The study showed higher mean
number of DMFS in the age group (31-40) years with no significant differences between age groups and gender.
Conclusion: Gingivitis is plaque associated disease but dental caries is not.
Key words: Plaque, gingivitis, dental caries. (J Bagh Coll Dentistry 2006; 18(1) 71-74)

INTRODUCTION1
Both gingivitis and dental caries are plaque
related diseases; the presence of plaque has
been established as being a precondition for
gingivitis, with the presence of strong
association between plaque, calculus and
periodontal disease
(1)
.
Carious lesions may be considered as local
plaque retentive sites and may be regarded as
etiologic factors in periodontal diseases.
However, little is known about the relationship
between the presence of such lesions and
progression of periodontal diseases
(2)
.
Numerous investigators have attempted to
determine the relation between the occurrence
of periodontal diseases and dental caries. Many
controversies were published with no clear cut
positive or negative relationships have been
established; although a positive correlation
between them claiming that both diseases are
caused by the same dental plaque
(1- 3)
.
Some authors suggested an inverse relation
between gingivitis & dental caries
(4,5)
and on
the other hand no correlation had been found by
Skier and Mandel
(6)
.
The present study was conducted to find the
relation between plaque, gingivitis & dental
caries.

Fifty two adult patients (24 females and 28
males) were examined with an age range
between 21-50 years attending department of

(1) Assistant lecturer, Department of Periodontics, College of
Dentistry, University Of Salahaddin, Erbil

periodontics, college of dentistry, Arbil, during
February and March, 2005.The patients were
divided into three age groups as follows: Group
1: 21-30 years, Group 2: 31-40 years, and
Group 3: 41-50 years.
Every patient was examined generally to
exclude any systemic disease. A complete
dental examination was performed and the
following indices were recorded: Plaque index
(7)
, gingival index
(8)
, simplified calculus index
(9)
and dental caries from Decay, Missing, and
Filling Surfaces (DMFS)
(10)
, clinical
examination of surfaces was conducted using
mirror &dental explorer.
After a complete examination was
performed, All patients then received complete
treatment including scaling, polishing and root
planning with instructions about the most
scientific method of tooth brushing and the use
of dental floss with brief explanation of its
effectiveness in reducing of inter proximal
plaque accumulation, to overcome any
periodontal problems in the future.

RESULTS
All results were subjected to statistical
analysis using t-test and Pearson correlation.
The distribution of patients examined according
to their age and gender are represented in figure
1. The highest percentage was for group 1 and
was decreased in the older age groups.
Regarding the mean number of plaque,
gingival and calculus indices are shown in table
1 and for the total sample, plaque and gingivitis
were of moderate type while calculus of mild
type only. No significant differences were
found for each of plaque, calculus and gingival
indices between different age groups and
gender (P>0.05). Pearson correlation between
plaque and gingival indices was positive (figure
2) since the correlation coefficient (r=0.48),
while Pearson correlation between plaque and
calculus was weak positive since the correlation
coefficient (r=0.33) (figure 3).
The mean number of DMFS is shown in
table 2; for total male & female it was higher in
age group 2 and lowest in younger age group
(group 1), with no significant differences
between age groups and gender. The correlation
coefficient between PI and DMFS or caries
experience (r= -0.059) means negative
correlation between them. The correlation
between PI and DMFS is represented
graphically in figure 4.
There are highly significant differences in
relation to plaque and DMFS between the three
age groups.

0
10
20
30
40
50
60
70
No. % No. %
Female Male
V
a
l
u
e
s
Age groups 21-30
Age groups 31-40
Age groups 41-50

Figure 1: Distribution of patients according to their age and gender.

Table 1: Mean and standard deviation of plaque, gingival, and calculus indices, by age groups
and gender.

0
0.5
1
1.5
2
2.5
3
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Pati ents
V
a
l
u
e
s
plI
GI

Figure 2: Correlation between mean plaque and gingival indices.

Pl GI Cal-SI
Age groups in Years Gender
M 1.31 0.57 1.24 0.61 0.86 0.55
F 1.11 0.44 1.52 0.41 0.91 0.46 G 1-21-30
T 1.23 0.52 1.36 0.55 0.88 0.51
M 1.21 0.30 1.40 0.36 0.70 0.49
F 1.27 0.24 1.47 0.49 1.23 0.82 G 2 -31-40
T 1.27 0.26 1.45 0.42 1.05 0.73
M 1.60 0.31 1.82 0.24 1.32 0.48
F 0.80 0.00 0.80 0.00 0.80 0.00 G 3-41-50
T 1.49 0.41 1.67 0.44 1.24 0.48
M 1.35 0.47 1.40 0.54 0.92 0.55
F 1.19 0.36 1.47 0.44 1.08 0.65 Total
T 1.28 0.43 1.43 0.49 0.99 0.60
Table 2: Mean and deviation of DMFS by age groups and gender.
DMFS
Age groups in Years Gender
Mean SD
M 11.60 7.46
F 12.55 6.28 21-30
T 12.00 6.87
M 27.00 15.25
F 28.33 20.47 31-40
T 27.84 18.28
M 23.00 11.88
F 36.00 0.00 41-50
T 24.86 11.91
M 17.89 12.49
F 21.42 17.01 Total
T 19.52 14.71
0
0.5
1
1.5
2
2.5
3
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Pati ents
V
a
l
u
e
s
plI
calI

Figure 3: Correlation between mean plaque and calculus indices.
0
10
20
30
40
50
60
70
80
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Pati ents
V
a
l
u
e
s
plI
DMFS

Figure 4: Correlation between mean plaque and DMFS.

DISCUSSION
The results of the present study shows
positive correlation between plaque and
gingival indices and this agrees fairly well with
El-Samarrai 1992
(11,12)
. Others found high
significant and strong positive correlation
between plaque & gingivitis
(13-15)
. Plaque
accumulation results in gingivitis because
plaque is composed mainly of bacteria, in the
presence of bacterial challenge, numerous
acquired and innate risk factors may influence
the initiation and progression of periodontal
disease
(16)
. The plaque index in this study
measured the severity in or near the gingival
sulcus only, but recent data indicate that
periodontal pathogens reside in other sites
intraorally such as tongue , mucosa, saliva and
tonsils other than gingival sulcus and
periodontal pockets and translocations might
occur between these ecologic niches as well as
between individuals
(17, 18)
. The effect of plaque
is pointed out that the bacterial masses which
accumulate at or in the gingival sulcus possess
an array of antigens and possibly polyclonal
activators capable of triggering sequences of
host-mediated events that have been postulated
as mechanisms of tissue destruction
(19)
. The
moderate type of plaque results usually in
moderate gingival inflammation that is to say a
direct correlation between the amount of
bacterial plaque and the severity of gingival
inflammation
20 ( )
.
Calculus is of grade one only or of mild
type because calculus formation is influenced
by saliva content
(21)
. Low severity of calculus
comes in accordance with Hugoson et al
(22)

who indicate a low severity of calculus among
younger age groups in Sweden.
This study showed negative correlation
between plaque and caries experience by tooth
surfaces and this come in agreement with other
studies
(23, 24)
that support the hypothesis that
plaque and dental caries are negatively
associated. Plaque composed mainly of
microorganisms about 109 organisms are
present in 10 mg of plaque and the initiation of
caries lesions requires the presence of
cariogenic microorganisms, fermentable
carbohydrates and susceptible tooth, for a
significant time and the most efficient
cariogenic organisms are Streptococcus mutans
(25)
.
Acid production is the major output of
metabolic activity for a number of bacterial
plaques and any interference with this process
may restrict the growth of Streptococcus
mutans, and zinc in saliva was proved to
depress acid production from glucose by these
organisms
(26)
. A negative association between
dental caries and salivary concentration of zinc,
potassium and magnesium was observed by
Ibrahim
(27)
. Buffer capacity of saliva may result
in this negative correlation in addition to the
effect of some minerals
(28)
. It may be
concluded that clinical data collected in the
dental clinic and statistical analysis of the data
confirm that positive correlation exists between
plaque and gingival index measurements, weak
positive correlation between plaque and
calculus index measurements, negative
correlation between plaque and caries
experience distributed by tooth surfaces.

REFERENCES
1. Loe H, Theilade E, J ensen S. Experimental gingivitis
in men. J Periodontol 1965; 36:177-87.
2. Axelsson P, Lindhe J . Effect of controlled oral
hygiene procedures on caries & periodontal disease
in adults. J Clin Periodontol 1987; 5: 133.
3. Fermin A, Carranza, Michael G, Newman. Clinical
Periodontology. 8th edition. 1996; 79.
4. Greene J S. Periodontal disease in India: report of an
epiodemiological study. J Dent Res 1960; 39: 302
5. Ramfjord SP. the periodontal status of boys 11-17
years old in Bomby, India. J Periodontol 1961;
32:237.
6. Skier J , Mandel ID. Comparative periodontal status
of caries resistant versus susceptible adults. J
Periodontol 1980; 51: 614.
7. Silness J , Loe H. Periodontal disease in pregnancy II.
Acta Odontol Scand 1964; 24: 74759.
8. Loe H, Silness J. Periodontal disease in Pregnancy I.
Acta Odontol Scand 1963; 21: 53351.
9. Green J C, Vermilion J . The simplified oral Hygiene
Index. J ADA 1964; 68: 7-13.
10. World Health Organization. Oral Health surveys;
Basic Methods. 3rd ed. Geneva, WHO. 1987
11. El-Samarrai S. Relations between Dental Plaque,
gingivitis & dental caries among children attending
clinic of prevention, college of dentistry. Iraqi Dental
J 1992; 7.
12. March P. Microbial ecology of dental plaque & its
significance in health & disease. Adv Dent Res 1995;
8(2): 263 -71.
13. Miklos M, Breuer, Roberta S, Cosgrove. The relation
between gingivitis & plaque levels. J Periodontol
1989; April: 1725.
14. Al-Sayyab MA. Oral Health Status among fifteen
years old school children in the central region of Iraq.
M.Sc. Thesis. College of dentistry, University of
Baghdad. 1989
15. El-Sammarrai S. Major & trace elements contents of
perminant teeth & saliva, among a group of
adolescent, in relation to dental caries , gingivitis, &
mutans streotococci. Ph.D. thesis, college of
Dentistry, University of Baghdad. 2001
16. Mcleod D. A practical approach to the diagnosis and
treatment of periodontal disease. J ADA 2000; 131:
483.
17. Greenstein G, Lmster I. Bacterial transmission in
periodontal disease: a critrical review. J Periodontol
1997; 68: 421-31.
18. Quirynen M, Desoete M, Dierickxk Van Steenbrghe.
The intra oral translocation of periodontal pathogens
jeopardizes the outcome of Pd therapy. A review of
Literature. J Clin Periodontol 2001; 28: 499-507.
19. J an Lindhe. Clinical periodontology & Implant
Dentistry. 3rd edition. Munksgard. 1998
20. Eley BM, Manson J D. Text book of Periodontics;
2004. 5th edition, P 39.
21. Norman J E, McGurk M. Color Atlas & Text of
salivary glands. Mosby. Wolf London; 1995; 42-5.
22. Hugoson A, Koch G, Bergendal T. Oral Health of
individual aged 3-80 years in J onkoping Sweden, in
1973 & 1983. Swed Dent J 1986; 10: 175.
23. Green J S. Periodontal disease in India : report of an
epidemiological study . J Dent Res 1960; 39: 302.
24. Liisi A, Sewon, J uija H, Parvinen, Tauno VH
Sinisalo, Markku A, Larmas, Pentti J ., Alanen.
Dental status of adults with & without periodontitis. J
Periodontol 1988; Sept: 595-98.
25. Soames J V, Southern J C. Textbook of oral pathology,
3rd edition. 1998; p.24.
26. Harrap GJ , Best J S, Sexton GA. Human Oral
retention of Zinc from mouth washes containing zinc
salts & its relevance to dental plaque control. Arch
Oral Biol 1984; 29: 87-91.
27. Ibrahim R. Relation between saliva zinc
concentration & dental caries experience in dental
students. College of Dentistry, university of Baghdad.
1993
28. Ashley F, Wilson R, Woods A. An initial evaluation
of two caries prediction kits. J Dent Res 1983; 2 :17

J Bagh Coll Dentistry Vol. 18(2), 2006 Drainage of

Drainage of submandibular abscess by using local
anesthetic block technique of transverse cervical
cutaneous nerve of the neck

Anwar A.Al-Hussain Al-Saeed, B.D.S., M.Sc.
(1)

ABSTRACT

Background: The purpose of the current study was to create a painless drainage of submandibular abscess by using
local anesthetic block technique of transverse cervical cutaneous nerve of the neck.
Patients and Methods: Ninety-seven patients attending College of Dentistry /University of Baghdad, and Private
Clinic in the period between (J anuary 2002-October 2004) were selected. The average age of the patients was
ranged between 14-63 years from different socioeconomic status. Sixty-one were females, and thirty-six were males.
All the patients were complaining of submandibular abscesses with severe pain huge swelling of different duration,
and of several odontogenic etiologies. Clinical and radiographic examination was evaluated depending mainly on
orthopantomography due to the presence of severe trismus. The patients were divided into two groups. The control
groups (48 patients) who were treated by ordinary technique, by using topical ethyl chloride, incision, drainage,
insertion of corrugated drain with suturing, covered by heavy dose of antibiotics according to the sensitivities of the
patients. While the study group (49 patients) who were treated by using local anesthetic block technique of
transverse cervical cutaneous nerve at the lateral side of the neck at the level of thyroid cartilage (Adams` apple).
Measurement records of pain severity were registered during incision, drainage, and insertion of corrugated drain
with suturing. Also other measurements were recorded for the state of consciousness of the patients during their
treatments.
Results: The study reported that 46 (96%) cases of the control group had severe pain during incision of the skin and
subcutaneous layer over submandibular abscess in comparison to 0 (0%) case of the study group which showed no
pain. The control group showed 48 (100%) cases having severe pain during drainage of submandibular abscess in
comparison to 31(63%) cases of the study group, which shows no pain. Also 47 (96%) cases of the study group shows
no pain by using local anesthetic block technique of transverse cervical cutaneous nerve in comparison to 48
(100%) cases which have severe pain. The study reported that 17 (35.4%) cases of control group showed fainting
during drainage of submandibular abscess in comparison to only 5(10.4%) cases of the study group. No signs and
symptoms of hematoma, ecchymosis, or parasthesia was detected during the use of local anesthetic block
technique of transverse cervical cutaneous nerve.
Conclusions: Incision through skin, and subcutaneous layer over submandibular region to drain a chronic abscess
can be done safely without significant pain or spread infections as well as no significant pain during insertion of
corrugated drain with suturing unlike the ordinary technique.
Key words: Submandibular abscess, Transverse Cervical Cutaneous Nerve. (J Bagh Coll Dentistry 2006;18(2) 75-82)

INTRODUCTION
Odontogenic infections are usually mild and
easily treated which may require the
administration of an antibiotic. Odontogenic
infections may be more complex and require an
incision and drainage, or they may be more
complicated, which require admistration the
patient to the hospital. Some infections that
occur in the oral cavity are preventable if the
surgeon uses appropriate antibiotic prophylaxis.
(1-5)
These infections may range from low-grade,
well-localized infections that require only
minimal treatment to severe, life threatening
fascial space infections.
(6-8)
Odontogenic
infections are caused by bacteria, which act as a
part of the normal oral flora.

(1) Assistant professor, Chairman of Department of Oral and
Maxillo-Facial Surgery, College of Dentistry, University of
Baghdad.

Those are primarily aerobic gram-positive
cocci, anaerobic gram-positive cocci, and
anaerobic gram-negative rods. When these
bacteria gain access to deeper underlying
tissues, through a necrotic dental pulp or
through a deeper periodontal pocket they cause
odontogenic infections.
(9-11)
Most odontogenic infections penetrate the
bone in such a way that they become vestibular
abscesses. On occasion they erode into fascial
spaces directly, and causing fascial space
infection
(12,13)
(Figure 1).
Fascia Spaces: They are fascia-lined areas that
can be eroded or distended by purulent exudate.
These are potential spaces that do not exist in
healthy people, but become filled during
infections.
(14)
Although, most infections of the
posterior mandibular teeth erodes into the
submandibular spaces if the infections erodes
through the medial aspect of the mandible just

inferior to the mylohyoid line. The mandibular
third molar is the most commonly involved
then follow by the second, and first molar.
(15)
The submandibular space: It lies between the
mylohyoid muscle and the overlying skin and
superficial fascia. The posterior boundary of
the submandibular space communicates with
the secondary spaces of the jaw posteriorly.
(16)

Infection of the inferior border of the mandible
may extend medially to the digastric muscle,
and posteriorly to the hyoid bone. When
bilateral submandibular, sublingual, and
submental spaces become involved with an
infection it is known as Ludwigs angina.
(17)

This infection is a rapidly spreading
cellulitis that commonly spreads posteriorly to
the secondary spaces of the mandible. Severe
swelling is almost always seen with elevation
and displacement of the tongue, with tense hard
induration of the submandibular region superior
to the hyoid bone.
(18)
The patients have
trismus, drooling of saliva, and difficulty with
swallowing and sometimes breathing. The
patient often experiences severe anxiety
concerning the inability to swallow and
maintain an airway. This infection may
progress with alarming speed and thus may
produce upper airway obstruction that often
leads to death.
(19,20)

Cutaneous Nerves:
Cervical Plexus: At the mid point of the
posterior margin of the sternocleidomastoid
muscle, the superficial branches from the
cervical plexus diverge into
(21)
:- Figure(2)
1. Ascending branches.
2. Transverse branches.
3. Descending branches.
1. Ascending Branches: Include the
followings:
a. Lesser occipital nerve (C2, C3).
b. Greater auricular nerve (C2, C3).
Lesser occipital nerve: The smaller one, which
ascends along the posterior margin of the
sternocleidomastoid muscle to the mastoid
process. It divides into auricular, mastoid, and
occipital terminal branches. These are sensory
branches, which supply the skin of the three
areas indicated by their names.
(20,21)

Greater auricular nerve: Crosses at a point
superficial to the sternocleidomastoid muscle
and passes toward the angle of the mandible,
dividing into; mastoid, auricular, and facial
terminal branches.
2. Descending Branches: Includes; medial,
intermedial, and lateral supraclavicular nerves
(C3, C4), these are sensory nerves, supplying
the skin of the upper anterior chest wall, the
upper, and lateral areads of the shoulder. The
medial nerve sends fibers to the
sternoclavicular joint, and the lateral nerve
sends fibers to the acromioclavicular joint.
(20,21)
3. Transverse Cervical Branches: (C2, C3);
They pass transversely across the posterior
boarder of sternocleidomastoid muscle, at the
level of thyroid cartilage (Adams` apple), just
distally and laterally to the external jugular
vein, and divided into superior innervation of
the skin and subcutaneous tissue of the fronto-
lateral part of the neck.
(22)

PATIENTS AND METHODS
Patients: Ninety-seven patients were attending
College of Dentistry, and Private Clinic in the
period between (J anuary 2002-October 2004).
The average age of those patients were ranged
between 14-63 years of old of different
socioeconomic status, sixty one were females
with average age ranged from (14-47) years,
and thirty six were males of average age ranged
of 16-63 years (Table 1). The patients were
complaining of submandibular abscesses of
both sides of the lower jaw with severe pain,
huge swelling according to the stage of the
infections, different duration periods, and of
odontogenic etiology (Figure 4).
All the patients were sent for radiographic
examination (Figure 5), mostly dependant on
orthopantomography due the presence of severe
trismus. Examination of the patients was done
by clinical and radiographic examination to
determine the etiology, stage of the swelling,
extension of the swelling to the neck,
consistency of the swelling, and
lymphadenopathy (Table 3)
Methods: The patients were divided into two
groups: -
1.Control group: It consisted of 48 patients, 23
were females, and 25 were males. Those
patients were complaining from chronic
submandibular abscesses that originated from
different infected teeth involving the lower jaw
as shown in Table 2. The treatment of
submandibular abscesses was done by ordinary
technique through using topical ethyl chloride
on the fluctuant region of the skin in
submandibular region. The incision was done
one finger below the inferior boarder of the
mandible by using blade (No; 11) for about 4-5
mm in length, deep enough to involve the

subcutaneous layer and fascia, then complete
the opening sinus forceps were used passed
deeply through the platysma muscle until reach
the submandibular space, through anterior,
posterior , and inferior direction to the inner
surface of the mandible to create enough poring
of pus discharge , then completed by insertion
of a corrugated drain in the incised region.
During the treatment we determine the degree
of the pain, and associated factors that enhance
the pain during incision, drainage, and insertion
of the drain.
2.Study group: It consists of 49 patients, 28
were females and 21 were males. Those
patients were suffered from submandibular
abscesses of various infected teeth of their
lower jaws, as shown in Table 2.
The treatments of chronic submandibular
abscesses were done by using local anesthetic
block technique for transverse cervical
cutaneous nerves far away from the infected
region. At the level of thyroid cartilage
(Adams` apple) in the midline of the neck, the
transverse cervical cutaneous nerve pass from
the posterior boarder of large
sternocleidomastoid muscle in the lateral side
of the neck. In this area the nerve seek curls
around the posterior boarder of this muscle as a
small trunk, to branch and fan out to innervate
the skin of the neck (Figure 3).
Before injection of local anesthesia the skin
region were disinfected by using habitant
(detergent agent) to prevent cross bacterial
infections (Figure 6). The local anesthetic
solution used with adrenaline concentration of
1:80.000, with the help of aspirating dental
syringe to avoid penetration of anesthetic
solution into the external jugular vein which
passes over the sternocleidomastoid muscle just
anteriorly, and laterally to the transverse
cervical cutaneous nerve. After trunk location
of this nerve the surgeon should be stand
behind the patient, and handling the dental
syringe horizontally at the same level of the
nerve trunk to pierce the skin and subcutaneous
region just to do a parallelism of the needle
puncture with the same direction of the nerve
transmission to avoid damage or tearing the
nerve sheath that lead to parasthesia. A quarter
quantity of local anesthetic solution will be
enough to anesthetize the nerve (Figure 7, 8).
After few minutes the skin and the
subcutaneous region in the lateral side of
submandibular region will be anesthetized, and
can be checked by asking the patient about the
numbness feeling around nerve distribution
areas. An incision was done by (No; 11) blade
just one finger below the inferior boarder of the
mandible at the fluctuant region (Figure 9-11).
Then explore the drainage opening by using
sinus forceps in different direction, and inserted
the corrugated drain with suturing. A heavy
dose antibiotics according to the patients
sensitivities were instructed like 500 mg IM
twice daily for three days, and heavy dose of
metronidazol (Flagyl) (500 mg orally) for
anaerobic microorganisms with the help of
analgesics.
The following records should be registered: -
Measurement Records of pain severity:
1. During incision.
2. During drainage.
3. During corrugated drain insertion
and suturing.
Measurement Records of the level of fainting
(Vasovagal attack):
1. Fainting with consciousness.
2. Fainting with unconsciousness.
3. No Fainting.

RESULTS
The study showed a highly significant
difference between the two groups during the
incision technique through the skin and
subcutaneous layer in the submandibular
region. It was reported that 46 (96%) cases
showed severe pain in comparison to 0 (0%)
case of the study group, while 47 (96%) cases
of the study group showed no pain records by
using local anesthetic block of transverse
cervical cutaneous nerve technique, as shown
in Table 5.
Table 6 showed a highly significant
difference between the two techniques during
drainage of submandibular abscess. The control
group shows 48 (100%) cases with severe pain
in comparison to 16 (33%) cases that showed
severe pain, while, 31 (63%) cases had no pain
by the use of local anesthetic block of
transverse cervical cutaneous nerve technique.
A significant difference was found
regarding pain between two techniques during
suturing of the corrugated drain. 48 (100%)
cases of the control group showed severe pain
in comparison to 0 (0%) case of the study
group that showed 47 (96%) cases have no pain
by using of local anesthetic block of transverse
cervical cutaneous nerve technique, as shown
in Table 7.

The study reported that 17 (35.4%) cases of
the control group showed fainting of the patient
during drainage of submandibular abscess, 5
(10.4%) cases from these develope loss of
consciousness, in comparison to 0(0%) case of
the study group that showed all patients were
not vasovagal attack by the use of local
anesthetic block of transverse cervical
cutaneous nerve technique as shown in Table 8.
No significant differences of complications
were observed in both groups during their
follow up. Also no signs, and symptoms of any
parasthesia or numbness feeling were detected
following the used of local anesthetic block
technique of transverse cervical cutaneous
nerve in those of study group. However, no
hematoma or ecchymosis was detected over the
skin of the lateral side of the neck.
.
Table 1: The number of the patients, gender, average age and location of submandibular
abscess in the lower jaw
Patient No. Gender
Average Age
(Years)
Left side Mandible Right Mandible
Male 25(42%) 18-63
Control group (48)
Female 23(48%) 14-42
20(42%) 28(58%)
Male 21(43%) 14-51
Study group (49)
Female 28(57%) 17-47
27(55%) 22(45%)
Total 97 14-63 47(48%) 50(52%)
Chi-square = 1.947 p-value = 0.377 Non significant

Table 2 Submandibular abscess according to the teeth involvement
Patient No. Left Mandible Right Mandible
1
st
Molar 2
nd
Molar 3
rd
Molar 1
st
Molar 2
nd
Molar
3
rd

Molar
2 (4.2%) 5 (10.4%) 13 (27%) 0 (0%) 3 (6.3%) 25(52.1%)
Control group (48)
20 (42%) 28 (58%)
1 (2%) 10(20.4) 16(32.6) 0 (0%) 1 (2%) 21 (43%)
Study group (49)
27 (55%) 22 (45%)
Chi-square =7.682 p-value = 0.0103 significant

Table 3: Signs and symptoms of submandibular abscess
Patien
t No.
Redness Fluctuant Pain
Palpable
Lymph node
fever
SL
M Sev Yes No
SL
M Sev Yes No Yes No Contr
ol
group
(48)
1
(2%
)
5
(10.4
%)
42
(88%
)
48
(100%
)
0
(0%)
8
(16.7
%)
13
(27%)
27
(56.3
%)
33
(69%
)
15
(31.3
%)
37
(77%)
11
(23%)
Study
group
(49)
0
(0%
)
10
(20.4)
39
(80%
)
36
(73.5
%)
3
(6.2%
)
8
(16.3
%)

11
(22.4)
%
30
(61.2
%)
39
(80%
)
12
(24.5
%)
34
(69.4
%)
15
(30.6
%)
SL: Slight M: Moderate Sev : Severe

Table 4: Spread of infections to other fascial spaces
Patient No. Sub massetric spaces Buccal spaces Ptrygomandibular spaces
Control group (48) 2(4%) 1(2%) 7(14.6%)
Study group (49) 1(2%) 0(0%) 3(6%)

Table 5: The characteristic features of pain during incision of the submandibular abscess in
both groups
Severity of Pain
Patient No.
Slight Moderate Severe
No pain
Control group (48) 0(0%) 2(4%) 46(96%) 0(0%)
Study group (49) 0(0%) 2(4%) 0(0%) 47(96%)


Table 6: The characteristic features of pain during drainage of the submandibular abscess in
both groups
Severity of Pain
Patient No.
No pain
Control group (48) 0(0%) 0(0%) 48(100%) 0(0%)
Study group (49) 0(0%) 2(4%) 16(33%) 31(63%)
Chi-square = 1.967 p= 0.373 Non significant

Table 7: The characteristic features of pain during suturing of the corrugated drain within the
skin
Severity of Pain
Patient No.
No pain
Control group (48) 0(0%) 0(0%) 48(100%) 0(0%)
Study group (49) 0(0%) 2(4%) 0(0%) 47(96%)

Table 8: Incidence of vasovagal attack (fainting) occuring during the treatment of
submandibular abscess in both groups
Fainting
Patient No.
Conscious Unconscious
No Fainting
12(25%) 5(10.4%)
Control group (48)
17(35.4%)
31(64.6%)
0(0%) 0(0%)
Study group (49)
0(0%)
49(100%)

DISCUSSION
The use of the ordinary technique for
drainage of submandibular abscesses may be
more painful and more aggressive for the
patients whom they tend to refuse the treatment
and they prefer to use a heavy dose of
antibiotics in spite of drainage of abscesses
which may lead to Antibioma. Some of the
inefficient surgeon may act as a main cause of
this problem for the patient.
The feeling of pain during incision
technique in the skin and subcutaneous layer in
the control group was due to non-anesthetized
region in the submandibular area, also drainage
by sinus forceps, and suturing of corrugated
drain may develop pain, and these are due to
contraindication to use local anesthesia in the
skin of the developed abscesses which may
cause flare up of infections to the more serious
facial spaces particularly retropharyngeal
spaces which may eventually lead to death, and
these were in agreement with Peterson
(11,19)
,
and David Wray
(6)
.
The study reported a significant difference
between the two techniques during drainage of
submandibular abscesses, which showed 47
(96%) cases with no pain by the use of local
anesthetic block of transverse cervical
cutaneous nerve at the lateral side of the neck,
which becomes more comfortable for the
patient than the ordinary way. This was due to
anesthetized skin and subcutaneous layer in the
region of submandibular area and anterior part
of the neck, which supply by terminal branches
of the transverse cervical plexus that give the
sensory innervations of the lateral side of the
neck. This is in agreement with Hamilton
(22)
,
and Roycel Montgomery
(20)
.


Figure 1A: Facial swelling in the B;Chronic Submandibular abscess
Right side of 49 years adult female

Figure 2A: Cervical plexus Figure 3: Transverse Cervical
Cutaneous nerve.

Figure 4: Impacted lower 3
rd
molar Figure 5: Digital panoramic
is one of causes of submandibular radiographs shows lower second
abscess molar with chronic abscess


Figure 6: Use habitant at the site of Figure 7: Site of block injection of
T.C.C.N. injection T.C.C.N at level of thyroid cartilage

Figure 8: Site of injection from other Figure 9: Site of incision and
side of view drainage of submandibular abscess

Figure 10: Site of drainage from other Figure 11: After one week from
Side of view drainage & treatment


The current study shows that no signs and
symptoms of complications in the study group
like parasthesia or hematoma of the skin, and
these were due to correct localization of block
technique injection of the anesthesia, no nerve
damage will developed, and no damage to the
external jugular vein were detected due to the
use of aspirating dental syringe, and these were
in agreement with Roycel Montgomery
(20)
.
6. David Wray, David Stenhouse, David Lee et al.
textbook of General and Oral Surgery 2003; p:
263-70.
7. Field EA, Martin MV. Prophylactic antibiotics
for patients with artificial joints undergoing oral
and dental surgery: necessary or not. J Oral
Maxillofacial Surg 1991; 29 B: 341.
8. Haug RH, Picard U, Indreasano AT. Diagnosis
and treatment of the retropharyngeal abscess in
adults. J Oral Maxillofacial Surgery 1990; 28B:
34.
However, there were no signs and
symptoms of spreading infections by the use of
local anesthetic block technique of transverse
cervical cutaneous nerve, and these were due to
the fact that the injection site was too far from
the infections site (abscess), and no flare-up
were detected during the follow up, and these
are in agreement with Field et al.
(7)
, Lewis
(15)
,
and Petersson
(11)
.
9. Heimdahl A, Nord CE. Treatment of orofacial
infections of odontogenic origin, second. J Infect
Dis 1985; 46 (suppl): 101.
10. Killey and Kays. Outline of Oral Surgery, Part I.
Second edition 1987; p: 121-174.
11. Peterson LJ . Contemporary management of deep
infections of the neck. J Oral Maxillofac Surg
1993; 51: 226.
12. Maclan D, Preece PE. Lecture Notes on Clinical
Medicine and Surgery for Dental Students. Third
edition 1986; p: 9,284,292.
The development of vasovagal attack were
highly significant in the control group than the
study group, with only 5 (10.4%) cases
developed unconsciousness, and these were due
to severe pain during incision, drainage by
sinus forceps, and suturing of corrugated drain
in the control group, but the majority cases 31
(64.6%) were not developed vasovagal attack,
and these were due to anesthesia of the
drainage areas of the skin and subcutaneous
layer in the submandibular region, which is in
agreement with Roycel Montgomery
(20)
.
13. Labrioia J D, Mascaro J , Alpert B. The
microbiologic flora of orofacial abscesses. J Oral
Maxillofacial Surgery 1983; 41: 711.
14. Peterson L, Ellis E, Hupp J R, Tucker MR.
Contemporary Oral and Maxillofacial Surgery
forth edition 2003; P: 344-367.
15. Lewis MAO et al. A randomized trial of co-
amoxiclav (Augmentin) versus penicillin V in the
treatment of acute dentoalveolar abscess. Br Dent
J 1993; 175: 169.
16. Lewis MAO. Prevalence of penicillinresistant
bacteria in acute suppurative oral infection. J
Antimicrob Chemother 1995; 3513: 785.
17. Macrciani RD. Clinical consideration in head and
neck infections in. Principles of oral and
maxillofacial surgery 1992 Philadelphia, J B
Lippincott.
REFERENCES
18. Onderdonk AB. Use of an animal model system
for assessing the efficiency of antibiotics in
treating mixed infections, Infect Dis Clin Prac
1994; 3(suppl I): 528.
1. Barratt GE, Koopmann CF, Coulthand SW.
Retropharyngeal abscess: a ten years experience.
Laryngoscope 1984; 94: 455.
2. Beck HJ et al. Life threatening soft tissue
infections of the neck, Laryngoscope 1984; 94:
354.
19. Peterson LJ . Antibiotic prophylaxis against
wound infections in oral and maxillofacial
surgery, J Oral Maxillofac Surg 1990; 48: 617.
3. Conover MA, Kaban LB, Mulliken J B. Antibiotic
prophylaxis for major maxillocranial surgery. J
Oral Maxillofacial Surg 1985; 48: 865.
20. Roycel Montgomery. Head and Neck Anatomy.
1981; P: 28-30,98-99.
21. Sclar DA, Tartaglione TA, Fine MJ . Overview of
tissue related to medical compliance with
implications for out 336 patients management of
infectious diseases. Infect Agents Dis 1994; 3:
266.
4. Peterson LJ . Microbiology of head and neck
infections, Atlas oral Maxillofac Surg Clin North
Am 1991; 3: 247.
5. Quayle AA, Russell C, Hearn B. Isolated from
severe odontogenic soft tissue infections; their
sensitivities to cefotetan and seven other
antibiotics and implications for therapy and
prophylaxis. J Oral Maxillofac Surg 1987; 25B:
34.
22. Hamilton WJ . Textbox of Human Anatomy
Second edition. 1987; p: 627-8

J Bagh Coll Dentistry Vol. 18(2) 2006 Treatment of clinically
Treatment of clinically evident skeletal mandibular
asymmetry

Nidhal H. Ghaib B.D.S., M.Sc.
(1)

Ali F. Al-Zubaidee B.D.S., F.D.S.R.C.S., F.F.D.R.C.S.
(2)

Zina Z. Al-Azawi B.D.S., M.Sc.
(3)

ABSTRACT
Background: Orthodontists are frequently called upon to treat conditions in which there is asymmetry, either
dentally, skeletally, or dentoskeletally, between the patients' right and left sides. Such asymmetries exist in all
degrees of severity. It is well known that correction of dental and functional asymmetries can be accomplished
with orthodontic treatment only whereas skeletal asymmetries are considered to present difficult orthodontic
treatment problems and require orthopedic treatment and/ or surgical intervention. The aim of this study was to
assess the extent to which combined orthodontic and surgical treatment are applied to treat patients with
mandibular asymmetry.
Materials and methods: The sample of this study consisted of 33 patients with different skeletal clinically evident
mandibular asymmetry conditions. Comprehensive examination protocol was established for each patient and the
deformity of mandibular asymmetry had been classified according to Henderson (1985) and J ames (1990) into 6
different conditions. Then the treatment has been determined according to each individual case following the
policy of each of the operators in the different hospitals from which the sample had been collected.
Results: The treatment of mandibular asymmetry conditions was found to be mostly achieved by surgical
intervention with or without orthodontic treatment.
Conclusion: The importance of the teamwork for the treatment of the candidates for orthognathic surgery was
found to be realized by the operators in the different hospitals from which the sample had been collected but it
needs to be emphasized and reinforced to be a well-established policy for the treatment of such cases.
Keywords: Mandible, asymmetry, orthognathic surgery. (J Bagh Coll Dentistry 2006;18(2)83-88)

INTRODUCTION
1

It is well known that correction of dental
and functional asymmetries can be
accomplished with orthodontic treatment only
whereas skeletal asymmetries are considered to
present difficult orthodontic treatment problems
and require orthopedic treatment and/or
surgical intervention
(1- 4)
.
With the advent of orthognathic surgery,
the orthodontists role in diagnosis and
treatment planning of cases involving skeletal
disharmony has expanded greatly. Since
contemporary surgical procedures can alter the
bones relationship of the craniofacial complex,
it is important that the orthodontist accurately
assess the degree to which skeletal
disharmony contributes to a given malocclusion
before he/she formulates treatment objectives.
Thus, close cooperation between the
orthodontist and the oral and maxillofacial
surgeon is needed
(5, 6)
.

(1) Professor, Department of orthodontics, college of dentistry,
university of Baghdad.
(2) Professor, college of medicine, university of Nahrain.
(3) Assistant lecturer, Department of orthodontics, college of
dentistry, university of Baghdad.

MATERIALS & METHODS

From the information elicited from the
patient's history and clinical examination aided
by orthodontic and surgical records, the
diagnosis has been established for each of the
33 patient with skeletal clinically evident
mandibular asymmetry, and according to
Henderson (1985)
(7)
and J ames (1990)
(8)
, the
asymmetric mandibular condition for each
patient had been classified.
Then treatment has been determined
according to each individual case following the
policy of each of the operators in the different
hospitals from which the sample had been
collected as follows:
1. Orthodontic treatment.
2. Surgical treatment.
3. Combination treatment.

RESULTS
Table 1 shows counts and percentages for
each condition with the treatment method, for
the treatment method with each condition, and
for the total.
As the table shows that 20 patients out of
33 have been operated upon and only one
patient out of 33 had been followed up.
Orthodontic treatment alone constitutes 4.8%,
while surgical treatment alone constitutes
Orthodontics, Pedodontics and Preventive Dentistry 83
61.9%. Combination treatment on the other
hand, had been performed for 19.1% of the
patients: 4.8% with presurgical orthodontics
and 14.3% with postsurgical orthodontics. For
9.5% of the operated upon patients with
presurgical orthodontics, it was decided to
perform surgical intervention after the
completion of their orthodontic phase of
treatment. In only 4.8%, the treatment was
postponed and follow up was indicated. Table 2
shows the methods applied for treatment of
mandibular asymmetry and it is quite obvious
that the females 12 patients were more willing
to seek treatment than the male 8 patients.

DISCUSSION
In this study, 20 patients out of 33 with
mandibular asymmetry have been operated
upon. As table 1 shows orthodontic treatment
alone had been performed for 4.8% of the
cases. This case was a mild form of HME and
orthodontic treatment alone in form of upper
and lower fixed appliances were satisfactory for
the patients needs.
Presurgical orthodontic treatment as a
preparatory phase prior to the surgical
intervention had been performed for 9.5% of
the patients. Those patients had severe
constricted maxilla with complete crossbite and
upper and lower dental crowding, so
presurgical orthodontics in the form of upper
and lower fixed appliances were indicated to
expand the upper arch and to remove dental
compensations and crowding before surgery,
which will be performed for those patients after
the completion of the orthodontic phase of
treatment.
Surgical intervention had been performed
for 61.9% of the patients without presurgical
orthodontic treatment but postsurgical
orthodontics might be performed later on for
those patients. The allowed research period
precludes the follow up of the patients to the
end of the treatment; however, this study found
that some of the patients would be encouraged
to continue their treatment with orthodontic
appliances after performing the surgical
intervention.
In 19.1% of the cases, combination of
orthodontic and surgical treatment had been
performed: 4.8% with presurgical orthodontics
and 14.3% with postsurgical orthodontics.
It is clear that surgical intervention had
been performed in approximately all the
patients. It is well known that skeletal
asymmetries are not corrected orthodontically
but rather surgery is employed because
orthodontic treatment may align the teeth, but it
will not straighten the face. Furthermore,
stability, periodontal health and facial balance
are optimized when dental midlines shifts that
result from skeletal deviation are treated with
surgical, rather than orthodontic, tooth
movement. Attempts to orthodontically correct
the bite when the etiology is skeletal can
produce buccal plate violation and gingival
recession
(2, 9, 10)
.
When table 2 is reviewed, it can be noticed
that a variety of surgical techniques for the
treatment of mandibular asymmetry had been
performed. In some cases, the surgical
procedure did not involve the mandible only,
but bimaxillary surgical correction has been
required. This was done in cases when the
mandibular asymmetry was just one component
of existing deformities that may present, or
when the occlusal plane was significantly
canted especially in cases with craniofacial
microsomia and early ankylosis; nevertheless
many patients were treated by mandibular
surgery only and the net result had been a high
degree of patient satisfaction.
Treatment of mandibular asymmetry by a
variety of surgical procedures have been
documented and established extensively in the
literature
(11-17)
. Nevertheless, to achieve the
morphological and functional requirements of
the treatment, mandibular asymmetry is best
managed by a team: the dentist, the
orthodontist, and the oral and maxillofacial
surgeon. However, in this study it was found
that the orthodontic treatment was to be
implicated mostly in cases with severe
malocclusion so presurgical orthodontics was
indicated to remove the dental compensations
and to align the teeth within each arch before
surgery.
In this study, 1 case out of 33 patients
presented with a history of late onset of HME
(the onset was after 20 years). Suspicion of
persistent active growth of the condyle on the
affected side made the treatment to be
postponed and the case was indicated for
follow up for 6 to 12 months to ensure
ceasation of the abnormal growth before
establishment of treatment; this was done in
order to prevent relapse, the most problematic
postoperative issue. The follow up is achieved
by taking history and full records (panoramic
radiograph, lateral and posteroanterior
cephalometric, upper and lower study models,
and photographs) for the patient, then after 6
months another history and records will be
made and compared with the first one.
In the literature
(8, 16, 18-22)
there is a
profound emphasis on what is considered as a
more definitive evaluation for the presence or
absence of abnormal condylar growth, this is
technetium 99 bones scanning. However this
method is not applied in the diagnosis of the
presence or absence of abnormal growth in
cases with mandibular asymmetry in the
hospitals from which the sample had been
collected because it is considered invasive
technique.
There is a great deal of literature referring
to condylectomy or high condylar shave for
treatment of CH; it was frequently used by
many authors
(7,17,23-27)
. Concerning this point,
the surgeons in the hospitals from which the
sample had been collected follow two treatment
options; the first one is to postpone surgery
until growth is complete, but the patient may
suffer during this period from functional,
esthetic and psychological problems. In this
study, this was indicated only for 1 case out of
33 patients as previously mentioned. The
second option is to perform condylectomy or
high condylar shave for the abnormally active
condyle combined with orthognathic surgery
for correction of the secondary deformity, if
present, at the same time as one-stage operation
or later on as two-stage operation. In this study,
this was not applied for any patient as all the
cases (except the case that discussed above)
were presented with the abnormal condylar
growth had been already settled down.
In this study, it is obvious that the treatment
plan in applying orthodontics and surgical
procedures for those patients with facial
asymmetry due to a growth disturbance in the
mandible depends to a great extent upon:
First: the nature of the deformity.
Second: the patient needs.
Third: clinical judgment and the experience of
the operator.
In addition, it is clear that the cooperation
between the orthodontist and the surgeon is
present but not to the optimal level, especially
in the hospitals that have not been provided
with orthodontists and orthodontic facilities.
Therefore, sometimes the surgeon was reluctant
to refer the patient for the orthodontic
consultation and treatment before and/or after
surgery. On the other hand, it is important for
the orthodontist also not to be reluctant to refer
such cases for the surgical consultation and
treatment for the reasons explained above.
Treatment of mandibular asymmetry by a
team needs not to be overemphasized and
therefore, it is important to reinforce this
cooperation and to provide each consultant
clinic of oral and maxillofacial surgery with
orthodontist to work hand by hand with the
surgeon in planning for the treatment of the
candidates for orthognathic surgery.

REFERENCES
1. Mulick J K. An investigation of craniofacial
asymmetry using the serial twin-study method, Am J
Orthod 1965; 51 (2): 112-29.
2. Cook J T. Asymmetry of the cranio-facial skeleton.
Br J Orthod 1980; 7: 33-8.
3. Yaillen DM. Case report: Correction of mandibular
asymmetric prognathism. Angle Orthod 1994; 2: 99-
104.
4. Sarver DM. Esthetic Orthodontics and Orthognathic
Surgery, St. Louis, Mosby Company, 1998.
5. Ellis E, J ohnson DG, Hayward J R. Use of the
orthognathic surgery simulating instrument in the
presurgical evaluation of facial asymmetry. J Oral
Maxillofac Surg 1984; 42: 805-11.
6. Forsberg CT, Burstone CJ , Hanley KJ . Diagnosis and
treatment planning of skeletal asymmetry with the
submental-vertical radiograph. Am J Orthod Dent of
Orthop 1984; 224-37.
7. Henderson D, Poswillo D. A Color Atlas and
Textbook of Orthognathic Surgery: The Surgery of
Facial Skeletal Deformity, London, Wolfe Medical
Publications Ltd, 1985.
8. J ames D. Growth Problems, In: Norman J E and
Bramley SP (eds.), Textbook and Color Atlas of the
Temporomandibular J ointDiseases-Disorders-
Surgery, England, Year Book Medical Publishers,
Inc., 1990.
9. Thompson J R. Asymmetry of the face. J Am Dent
Assoc 1943; 30 (1): 1859-71.
10. Arnett GW, Bergman RT. Facial Keys to orthodontic
diagnosis and treatment planning-Part II. Am J
Orthod Dent of Orthop 1993; 103: 395-411.
11. Gottlieb MD, Faust RA. Mandible fractures in
children, emedicine 2001. [Internet]
12. Hinds EC, Reid LC, Burch RJ . Classification and
management of mandibular asymmetry. Am J Surg
1960; 100: 825-34.
13. Mercier P. Mandibular asymmetry: Proposed
classification and an analysis of two cases. J Cand
Dent Ass 1969; 35 (3): 146-53. [French]
14. Erickson GE, Waite DE. Mandibular asymmetry. J
Am Dent Assoc 1974; 89: 1369-73.
15. Hall HD. Facial Asymmetry. In: Bell WH, Proffit
WR and White RP (eds.), Surgical Correction of
Dentofacial Deformities, Philadelphia, WB Saunders
Company, 1985.
16. Chen Y, Bendor-Samuel RL, Huang C.
Hemimandibular hyperplasia. Plast Recon Surg
1996; 97 (4): 730-7.
17. Secchi A, Vanarsdall R. Efficacy of high
condylectomy for management of condylar
hyperplasia. Am J Orthod Dent of Orthop 2002; 121:
136-51. [Abstract]
18. Rubenstein LK, Campbell RL. Aberrations of
development-Acquired unilateral condylar
hyperplasia and facial asymmetry: Report of case. J
Dent Child 1985; 114-20.
19. Zide BM. The Temporomandibular J oint, In:
McCarthy J G (ed.), Plastic Surgery, Vol. 2, The Face
(Part 1), Philadelphia, W.B. Saunders Company,
1990.
20. McCormick SU. Facial Asymmetry-The Diagnostic
Challenge, In: Assael LA (ed.): Atlas of the Oral and
Maxillofacial Surgery Clinics of North America,
Philadelphia, W.B. Saunders Company, 1996: 4 81).
21. Quinn PD. Color Atlas of Temporomandibular J oint
Surgery, St. Louis, Mosby, 1998.
22. Vittayakitpong P, Pripatananont P. Bone scintigraphy
in the diagnosis and treatment planning of condylar
hyperplasia. J Dent Assoc Thailand 2000; 50 (5):
407-14. [Abstract]
23. Bruce RA, Hayward J R. Condylar hyperplasia and
mandibular asymmetry: A review. J Oral Surg 1968;
26: 281-90.
24. Graziani M. Laterognathism, supraclusion, and facial
asymmetry from condylar hyperplasia. J Oral Surg
1972; 33 (6): 884-7.
25. Norderud RW, Ragab RR. Unilateral condylar
hyperplasia and the associated deformity of facial
asymmetry-Case report. Scand J Plast Reconstr Surg
1977; 11: 91-6.
26. Norman J E, Painter DM. Hyperplasia of the
mandibular condyle-A historical review of important
early cases with a presentation and analysis of twelve
patients. J Maxfac Surg 1980; 8: 161-75.
27. Carlson ER. Pathologic Facial Asymmetries, In:
Assael LA (ed.): Atlas of the Oral and Maxillofacial
Surgery Clinics of North America, Philadelphia,
W.B. Saunders Company, 1996: 4 (1).

Table 1: Cross tabulation of the conditions with the methods of treatment (descriptive
statistics).
Methods of Treatment
Ortho. / Surg.
CONDITION
Ortho.
Presurg.
Ortho.
Presurg. Postsurg.
Ortho. Ortho.
Surg. Follow up
Total

(1)
[25.0%]
{50.0%}
((4.8%))

(3)
[75.0%]
{23.1%}
((14.3%))

(4)
[100.0%]
{19.0%}
((19.0%))
Prognathism with
Anterior Open Bite
(AMP+)
Prognathism
without Anterior Open
Bite
(AMP-)

(1)
[33.3%]
{50.0%}
((4.8%))

(1)
[33.3%]
{33.3%}
((4.8%))
(1)
[33.3%]
{7.7%}
((4.8%))

(3)
[100.0%]
{14.3%}
((14.3%))
Hemimandibular
Elongation
(HME)
(1)
[14.3%]
{100.0%}
((4.8%))

(2)
[28.6%]
{66.7%}
((9.5%))
(3)
[42.9%]
{23.1%}
((14.3%))
(1)
[14.3%]
{100.0%}
((4.8%))
(7)
[100.0%]
{33.3%}
((33.3%))
E
N
L
A
R
G
E
M
E
N
T

Hemimandibular
Hyperplasia
(HMH)

(1)
[33.3%]
{100.0%}
((4.8%))

(2)
[66.7%]
{15.4%}
((9.5%))

(3)
[100.0%]
{14.3%}
((14.3%))
Unilateral TMJ Ankylosis
(UTMJA)

(2)
[100.0%]
{15.4%}
((9.5%))

(2)
[100.0%]
{9.5%}
((9.5%))

D
E
F
I
C
I
E
N
C
Y

Unilateral Craniofacial
Microsomia
(UCFM)

(2)
[100.0%]
{15.4%}
((9.5%))

(2)
[100.0%]
{9.5%}
((9.5%))
Total
(1)
[4.8%]
{100.0%}
((4.8%))
(2)
[9.5%]
{100.0%}
((9.5%))
(1)
[4.8%]
{100.0%}
((4.8%))
(3)
[14.3%]
{100.0%}
((14.3%))
(13)
[61.9%]
{100.0%}
((61.9%))
(1)
[4.8%]
{100.0%}
((4.8%))
(21)
[100.0%]
{100.0%}
((100.0%))
( ) count
[ ] % within condition
{ } % within methods of treatment
(( )) % of total

Table 2: Methods of treatment.

Case No Condition Gen./Age Surgical Procedure Orthodontic Procedure
3 HME F / 21 None
Upper and lower fixed
appliances.
5 UTMJ A F / 20
a. Anterior subapical maxillary osteotomy with
extraction of 4 4 (set-back & upward
movement).
b. Centralizing sliding genioplasty / Splint.
None

6

HME

F / 20

Body ostectomy with extraction of 4 / Splint.

Postsurgical upper & lower
fixed appliances.

7

HME

F / 19

Body ostectomy with extraction of 4 / Splint.

fixed appliances.

10

AMP
-

F / 31

Bilateral sagittal split osteotomy (set-back)/IMF.
fixed appliances.

11

UTMJ A

M / 16
a. Resection of ankylotic segment.
b. b. Ipsilateral coronoidotomy.
c. c. Early mobilazation & physiotherapy.

None

12

AMP
+

M / 22
a. Bilateral sagittal split osteotomy (set-back and
rotation).
b. Genioplasty (reduction & backward
movement).
c. Le fort 1 osteotomy (upward movement) with
bone graft /IMF.

None

13

HMH

F / 20

Lower border surgery.
Presurgical upper & lower
fixed appliances.

14

HME

F / 19
a. Maxillary bilateral posterior segmental
osteotomy with extraction of 4 4 (upward
movement).
b. Bilateral sagittal split osteotomy (set-back
& rotation) / IMF.

None
16 AMP
+
M / 21 Kle procedure / Splint. None
18 HME F / 19 Body ostectomy with extraction of 4 / IMF. None
19 AMP
-
F / 20 Body ostectomy with extraction of 4 / Splint. None

22

UCFM

F / 28
a. Le fort 1 osteotomy to correct canting.
b. Bilateral sagittal split osteotomy / IMF.

None

24

AMP
+

M / 16

None
Upper & lower fixed
appliances with extraction
of 4 4 & expansion for
4 4 upper arch.

26

AMP
-

M / 17

None
Upper & lower fixed
appliances with extraction
of 5 & expansion for
the upper arch.
27 AMP
+
M / 25 Body ostectomy with extraction of 4 / Splint. None
29 HMH F / 22 Lower border surgury. None

30

UCFM

F / 22
a. Le fort 1 osteotomy (to correct canting).
b. Unilateral sagittal split osteotomy
(Rt side), inverted L osteotomy (Lt side) with
bone graft / IMF.

None
31 HMH M / 27 Lower border resection. None

33

HME

M / 20
a. Le fort 1 osteotomy (upward movement) with
extraction of 4 4 & anterior segmental maxillary
osteotomy (set-back).
b.Genioplasty( reduction & forward movement).
c. Bilateral sagittal split osteotomy (set-back and
rotation) / IMF.

None


0
10
20
30
40
50
60
70
ortho. presurg. ortho. combination surg. follow up
Co n d i t i o n s

Figure 1: Percentage distribution of the methods of treatment through the mandibular
asymmetry conditions.

E
D C
B A
Figure 2: Condylar hyperplasia (Hemimandibular Elongation Rt side)
(A & C): Preoperative (B & D): Correction by body ostectomy on Rt side
(E): Postoperative orthodontic treatment.

J Bagh Coll Dentistry Vol. 18(2), 2006 Salivary calcium

Salivary calcium, potassium and oral health status among
smokers and non-smokers (a comparative study).

Wesal A. Al-Obaidi, B.D.S., M.Sc.
(1)

ABSTRACT
Background: Smoked tobacco contains various toxic substances which are primarily responsible for oral diseases. The aim of
this study was to estimate salivary electrolytes (calcium and potassium), salivary parameters (pH and flow rate) and oral
health status among smokers.
Materials and methods: A sample included 30 healthy subjects, 15 smokers and 15 non-smokers. Clinical examination of
dental caries and gingivitis and stimulated whole saliva were obtained.
Results: Dental caries experience and gingivitis were significantly higher among smokers than non-smokers. No significant
differences were found in mean pH and flow rate between the two groups (P>0.05). The mean salivary calcium (2.51.4
mg/100ml) and potassium (24.14.4 mmol/L) recorded were higher among smokers than non-smokers. Statistically, the
difference was significant regarding potassium only (P>0.05).
Conclusion: Smoking affects some salivary electrolytes. Dentists have an important role to play in preventing the harmful
effects of smoking in the mouth.
Keywords: Saliva, calcium, potassium, dental caries, gingivitis smokers. (J Bagh Coll Dentistry 2006; 18(2)89-91)

INTRODUCTION
Tobacco is derived from the species of the
plant of genus Nicotiana. Cigarettes contain
various toxic substances
(1)
which have been
shown to be secreted in salivary and gingival
crevicular fluids
(2)
. The role of tobacco in the
etiology of oral diseases has been studied
(3- 7)
.
Smoking appears to increase the susceptibility
to periodontal disease. Whether this is due to
differences in amount and quality of plaque or
to changes in defense mechanisms is still a
matter of debate
(8)
. Cigarette smoking is most
certainly associated with an increased caries
rate but that a cause and effect relationship is
still not proven
(2)
.
Iraqi investigations reported the effects of
smoking on salivary Streptococcus Mutans
(7)

and salivary Lactobacilli
(6)
with no information
regarding its effect on the salivary elements.
The aim of this study was to evaluate the effects
of smoking on salivary composition (calcium
and potassium), salivary parameters and oral
health.

Stimulated saliva secretion was collected
by chewing 0.5 gm paraffin wax for 4 minutes
from 31 healthy subjects.
The sample was subdivided into 15
smokers and 15 non-smokers matching in age
and gender.

(1) Assistant professor, Department of Pedodontic and Preventive
Dentistry, Dental College, University of Baghdad.

Immediately after collection, the salivary
pH was estimated by pH meter. The salivary
flow rate for each subject was calculated and
expressed by ml/1min. The collected saliva was
centrifuged at 3000 r.p.m. for 40 minutes. Then,
supernatant saliva was frozen at -20
o
C until
analysis. Atomic absorption spectrophotometer
was used for calcium analysis, and flame
photometer was used for potassium analysis.
Gingival inflammation was assessed using
Gingival Index
(9)
for each six Ramfjord Index
teeth. Dental caries was measured following
WHO criteria
(10)
. The oral examination was
done using dental explorer and mirrors.
Student's t-test was applied for statistical
analysis.

RESULTS
Table 1 reveals mean ages, caries
experience (DMFS) and Gingival Index in both
groups. Statistically, significant differences
were found in the mean DMFS and GI between
the two groups (P<0.005). Although, salivary
calcium was higher among smokers, but
statistically, the difference was not significant
(P>0.05). Salivary potassium was significantly
higher in the mean value among smokers than
non-smokers (Table 2). Table 3 demonstrates
non-significant differences in the mean pH and
flow rate between smokers and non-smokers
(P>0.05).



Table 1: Mean ages, caries severity and
gingival index among smokers and non-
smokers
No.
Age
MeanSD
DMFS
MeanSD
GI
MeanSD
Smokers 15
32.6
12.3
23.3
13.5*
1.17
0.2**
Non-smokers 15
32.8
11.3
14.7
10.2
0.98
0.3
* t = 1.98 P<0.05 d.f = 28
** t = 1.97 P<0.05 d.f = 28

Table 2: Salivary calcium and potassium
concentrations among smokers and non-
smokers
No.
Ca (mg/100ml)
Mean SD
K (mmol/L)
Mean SD
Smokers 15 2.5 1.4 24.1 4.4*
Non-smokers 15 2.2 0.9 21.3 2.8
* t = 2.08 P<0.05 d.f = 28

Table 3: Salivary pH and flow rate among
smokers and non-smokers
No.
pH
Mean SD
Flow Rate
Mean SD
Smokers 15 7.19 0.2 1.84 0.8
Non-smokers 15 7.20 0.3 1.80 0.9

DISCUSSION
A high caries severity was recorded in this
study which may be attributed to the over
estimation of missing component by the teeth
extracted due to the cause rather than caries
(1)
.
A significant difference was found between the
two groups regarding the caries experience
(DMFS). This result is in agreement with many
studies
(5-7)
. Increasing in dental caries may be
attributed to the change in the dietary habits
among smokers, like chewing gum
(11)
, eating
candies
(7)
and high sugar tea
(6)
. It was reported
that, mean Streptococcus Mutans counts were
higher among smokers than non-smokers
(7)
, as
well as, Lactobacilli
(6)
.
The present study revealed a significantly
higher mean GI among smokers than non-
smokers, which is in discordance with many
studies
(2, 12)
and in accordance with other
studies
(7, 13)
. This result could be due to the
poorer state of oral hygiene
(7)
and/or the
harmful effect of smoking on the gingiva as a
result of direct heat, irritating effect of tar and
other toxic materials
(1)
.
Although salivary calcium was higher
among smokers, statistically, no significant
difference was observed between the two
groups. This result is in disagreement with
other researches
(14,15)
. They revealed a
significant increase in salivary calcium among
smokers. Also, it is in disagreement with Kiss
et al results
(16)
. They noted a decrease in
skeletal bone density, a known side-effect of
smoking, may reflect an increased level of
salivary calcium which could be one of the
most important reasons for the worse
periodontitis of smokers. No significant
difference was observed in calcium
concentration, which is somehow, similar to
Laine et al study
(17)
. Their results showed that
salivary calcium was not affected by smoking
among the younger group (45) and
significantly higher among the older group. In
this study, about 90% of the smokers were
under the age of 45 years. Besides, a normal
serum calcium concentration was recorded in
osteoporosis in which smoking is considered to
be one of the risk factors
(18)
.
Potassium significantly increased in the
smoking group compared to the non-smoking
one. The same result was reported by Dogon et
al
(14)
. They revealed that the increase in
salivary potassium could not be due to the
increased potassium intake from cigarettes, but
more likely due to the pharmacological action
of the nicotine in the tobacco smoke. While,
Laine et al
(17)
demonstrated that salivary
potassium concentration varies according to the
age of the smokers. The result revealed that
salivary flow rate had no significant difference
between the two groups, which is in accordance
with other investigations
(6, 7, 12)
. Long-term use
of tobacco does not adversely affect the taste
receptors and hence, salivary secretion
(12)
.
Also, the clinical impact of the degenerative
changes among intense smokeless tobacco
appears to be minimal and cigarette smoking
typically causes a noticeable short-term
increase in salivary flow rates
(2)
.
Statistically, mean value of salivary pH was
found to be not significant between the two
groups. This result is in disagreement with Al-
Ward
(7)
and in agreement with Al-Weheb
(6)
.
This may be explained by the fact that there
was no reduction in the salivary flow rate
among smokers, leading to no increase in the
salivary hydrogen concentration.

REFERENCES
1. Peter S. Essentials of preventive and community
dentistry. 2
nd
ed. Sudhir Kumar Arya, Arya (Medi)
publishing house. New Delhi 2003; 127-240, 468-504.


2. Bouquot J, Schroeder K. Oral effect of tobacco
abuse. J Am Dent Inst Cont Educa 1992; 43: 3-17.
3. Sham A, Cheung L, Jin L, Corbet E. The effect
of tobacco use on oral health. Hong Kong Med J 2003;
Aug; 9(4): 271-7.
4. Calsina G, Ramon J, Echeverria J. Effect of
smoking on periodontal disease. J Clin Periodontol
2002; Aug; 29(8): 771-6.
5. Reibel J. Tobacco and oral diseases. Med Princ
Pract 2003; 12 supp 1: 22-32.
6. Al-Weheb A. Smoking and its relation to caries
experience and salivary Lactobacilli count. J Coll
Dentistry 2005; 17(1): 92-5.
7. Al-Ward F. Oral health status and salivary
mutans streptococci in smokers and non-smokers.
Master thesis submitted to the College of Dentistry,
Baghdad University, 2004.
8. Koch G, Moder T, Poulsen S, Rasmussen P.
PedodonticsA clinical approach, 1
st
ed. Munksgaard,
Copenhagen; 1994; 211-4.
9. Loe H, Silness J. Periodontal disease in
pregnancy. I. Acta Odontol Scand 1989; 21: 533-51.
10. WHO. Oral health survey. Basic methods. 4
th
ed.
Geneva, 1997.
11. Hirsch J, Livian G, Edward S, Noren J. Tobacco
habits among teenagers in the city of Goteborg, Sweden
and possible association with dental caries. Swedish
Dent J 1991; 15: 117-23.

12. Khan G, Mehmood R. Effects of long-term use
of tobacco on taste receptors and salivary secretion. J
Ayab Med Coll Abbottabad 2003; Oct-Dec; 15(4): 37-9.
13. Erdemir E, Duran I, Haliloglu S. Effects of
smoking on clinical parameters and the gingival
crevicular fluid levels of IL-6 and TNF-alpha in patients
with chronic periodontitis. J Clin Periodontol. 2004;
Feb; 31(2): 99-104.
14. Dogon I, Amdur B, Bell K. Observations on the
diurnal variation of some inorganic constituents of
human parotid saliva in smokers and non-smokers.
Archs Oral Biol 1971; 16: 95-105.
15. Zuabi O, Machtei E, Ben-Aryah H, Ardekin L.
The effect of smoking and periodontal treatment on
salivary composition in patients with established
periodontitis. J Periodontol 1999; Oct; 70(10): 1240-6.
16. Kiss E, Gorzo I, Sewon L. Salivary calcium in
relation to oral health of tobacco smokers. J Dent Res
2004; March; 13: 10-3.
17. Laine M, Sewon L, Karjalainen S, Helenius H.
Salivary variables in relation to tobacco smoking and
female sex steroid hormone-use in 30 to 59-year-old
women. Acta Odontologica Scand 2002; Aug; 60(4):
237-40.
18. Nizel A, Papas A. Nutrition in clinical Dentistry.
3
rd
ed. W.B. Saunders Company. Philadelphia. London;
1989; 144-66.

J Bagh College Dentistry Vol. 18(2), 2006 Prevalence, severity and
Prevalence, severity and pattern of dental fluorosis among
a group of children in DahmarYemen

Wesal A. Al-Obaidi, B.D.S., M.Sc.
(1)

ABSTRACT
Background: Dental fluorosis is an irreversible condition caused by excessive fluoride ingestion during the tooth
formation. The aim of the study was to estimate the prevalence, severity and pattern of dental fluorosis of the
primary and permanent dentitions.
Materials and Methods: A random sample of one hundred eighty children aged 6-12 years were examined by using
Deans Flourosis Index modified criteria.
Results: The prevalence of dental fluorosis was 77.8%. Permanent teeth fluorosis was higher than primary teeth
fluorosis which was relatively uncommon. Dental fluorosis was most frequently seen on the posterior teeth
(particularly the molars). 42.9% of the children had a moderate type of fluorosis. Dental fluorosis was more prevalent
among males than females. Both early and late forming teeth were affected by fluorosis. Upper teeth were more
affected than the lower teeth. There was a high degree of bilateral symmetry.
Conclusion: Dental fluorosis was prevalent in both primary and permanent dentitions; it was a moderate public
health problem. The high prevalence and severity of fluorosis emphasized the need to study the risk factors
determining dental fluorosis in Dahmar Village rather than water fluoridation.
Keywords: Dental fluorosis, children, Yemen. J Bagh Coll Dentistry 2006; 18(2)92-96)

INTRODUCTION
Dental fluorosis is a specific disturbance
of tooth formation caused by excessive
fluoride intake through a disorder of
ameloblasts during the period of teeth
calcification. It is a chronic effect of fluoride
toxicity on enamel
(1)
. The extent of subsurface
of enamel porosity depends on the
concentration of fluoride at developmental
time
(2)
. The parts of crowns of developing
permanent teeth are expected to be affected by
systemic disturbances, from birth to seven
years
(3)
, while primary teeth are protected
against systemic disturbances until birth
except for the severe one
(4)
.
A population which receives 1ppm of
fluoride
(3, 5, 6)
in drinking water, or less
(5, 7)

exhibits symptoms of mild dental fluorosis.
Varying amount of fluoride are found in many
food substances
(1)
. Once the crowns of the
teeth are formed, no further fluorosis can be
induced by additional intake of fluoride
(1, 8)
.
About 60-80% of dental fluorosis was found to
be an important problem because of its
unfavorable effects on an individual's
personality
(9)
. This study was conducted to
estimate the prevalence, severity and pattern of
dental fluorosis among a group of children in
Dahmar Yemen.

(1) Assistant professor, Department of Pedodontic and
Preventive Dentistry, College of Dentistry, University of
Baghdad.

A random sample of one hundred eighty
children aged 6-12 years, residing in Dahmar
was examined. Prevalence and severity of dental
fluorosis were assessed using Deans Flourosis
Index modified criteria.
(10)
. Each tooth present
in an individual's mouth was rated according to
the fluorosis index. The score assigned to an
individual is the one which corresponds to the
two most severely affected teeth in the mouth. If
the two teeth were not equally affected, the
classification given was that of the less involved
tooth. The severity of dental fluorosis as a
public health problem was determined using
Community Fluorosis Index by Dean,
(CFI =No.of individuals *statistical weights)
(10)

No. of individuals examined

RESULTS
Table 1 shows the high prevalence of dental
fluorosis (77.8%). Dental fluorosis among males
was higher than that among females. Figure 1
demonstrates the severity of dental fluorosis. It
was found that the moderate was the
predominant type, while the questionable and
very mild types were the lowest percent.
According to Dean Index, it was found that
Community Fluorosis Index (CFI) =1.97. The
percentage of teeth affected by fluorosis was
found to be 30.8% among the total sample.
Dental fluorosis was highly prevalent among
permanent (95.5%) than that among primary
dentition, besides, 54.8% of the total teeth
affected was prevalent in upper jaw (Figure 2).
Dental fluorosis in relation to types of
teeth was illustrated in Figure 3. Permanent
second molar was the predominant tooth that
was affected by fluorosis (66.7%), while the
permanent first premolar was the lowest type
that was affected (20.7%). Although the
primary second molar had the highest
prevalence of fluorosis among primary teeth, it
was still lower than that among permanent one.
Figure 4 shows the pattern of dental fluorosis in
relation to mouth quadrants, there was a high
bilateral similarity with the exception of
permanent first molars and canines.

Table 1: Prevalence of dental fluorosis by gender
Gender No.
Dental fluorosis
No. %
Males
Females
Both
150
30
180
120 80.0
20 66.7
140 77.8

0
5
10
15
20
25
30
35
40
45
50

1 2 3 4 5
%
p
e
r
s
o
n
Questionable Very Mild Mild Moderate Severe

Figure 1: Severity of dental fluorosis

0
20
40
60
80
100
120
1 2 3 4 5 6
%

Affected Healthy Upper Lower Primary Permanent

Figure 2: Percentages of teeth affected


0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7
0
10
20
30
40
50
60
70
80
2 3 4 5
%

8
0

7
0

6
0

5
0

4
0

1
E D C B A 1 2 3 4 5 6

Figure 3: Dental fluorosis in relation to types of teeth

Figure 4: Pattern of dental fluorosis in relation to the mouth quadrants

0
2
4
6
8
10
12
14
16
18
1 2 3 4 5 6 7 8 9 10 11 12
0
2
4
6
8
10
12
14
16
18
1 2 3 4 5 6 7 8 9 10 11 12
%
18

16

14

12

10

8

6

4

2

2

4

6

8

10

12

14

E D C B A 7 6 5 4 3 2 1 1 2 3 4 5 6 7 A B C D
DISCUSSION
The results showed high prevalence of
dental fluorosis which was in accordance with
many studies
(7, 11-13)
and in disagreement with
others
(14-16)
. The moderate form of dental
fluorosis was found to be the highest percent
among the other types. This result was in
agreement with other studies
(6, 13)
and in
contrast with many studies
(11, 14, 16, 17)
. The
controversy existing in the prevalence and
severity of dental fluorosis may be attributed to
the changing of the fluoride level in drinking
water. Analysis of drinking water by national
water and sanitation authority reported the
fluoride level in Dahmar was ranged (0.1-1.9
ppm)
(18)
. This wide range may be due to that
the most water resources came from wells. In
addition to water fluoridation, dietary habits
(tea and fish) which are the richest sources of
fluoride
(19)
may be behind the increased
prevalence of dental fluorosis
(20)
.
Females had a lower prevalence of dental
fluorosis than males. This result was in
agreement with previous studies
(7, 21)
and may
be due to the earlier tooth formation among
females about half a year than males
(3)
. The
second molars had the highest prevalence of
fluorosis among the permanent teeth which was
in agreement with previous investigations
(22,
23)
, while primary second molars were most
commonly affected among primary teeth, this
finding was in accordance with other researches
(14,24)
. These teeth have the longest
mineralization period
(3)
, so that the latest the
tooth was formed, the highest was the
prevalence of dental fluorosis.
Although the permanent lower incisors are
of a short mineralization time, they were also
affected by fluorosis which was almost of a
mild type. This result was somehow in
disagreement with Larsen et al studies
(22)
and
in agreement with Larsen et al studies
(23)
. It is
known that mineralization of primary crowns
starts at 3.5 months in utero and become fully
formed during the first year of life, while for
the permanent crowns, it starts from birth till 7
years of age
(3)
. This fact may explain the
higher prevalence of dental fluorosis among
permanent than that among primary teeth, and
the latter had a very low prevalence which was
in accordance with other studies
(14,24)
.
Moreover, primary teeth are protected
parentally, because of the slow diffusion of
fluoride through the placenta
(4)
, so it is mostly
a postnatal phenomenon
(14)
. Besides, fluoride
in the breast milk is less than half of that in
plasma
(1)
which is the main child food during
the first year of life.
In general, upper teeth were more affected
by fluorosis than the lower teeth, because that
the mandibular teeth develop earlier than the
maxillary teeth
(3)
. The dental fluorosis
prevalence showed a high degree of bilateral
symmetry which was in accordance with Manji
et al study
(12)
, with the exception of permanent
first molars and canines which may be
attributed to variation in eruption time and/or
missing teeth due to caries.
All children with primary teeth fluorosis
had permanent teeth fluorosis, and this result is
in agreement with Warren's study
(24)
who
concluded that "primary tooth fluorosis may be
related to the occurrence of fluorosis in the
permanent dentition". The occurrence of
fluorosis was more in the posterior than
anterior teeth, and this result was in accordance
with Kumar et al research.
(25)
They noted that
the longer maturation process of the posterior
teeth and the thicker enamel appear to be the
explanation for the higher occurrence in
posterior teeth. The Fluoride Community Index
was equal to 1.97; it meant that it was a
medium public health problem
(10)
, which was
in accordance with Ibrahim study
(7)
.

REFERENCES
1. Peter S. Essentials of preventive and community
dentistry. 2
nd
ed. Sudhir Kumar Arya, Arya (Medi)
publishing house. New Delhi 2003; 279-371.
2. Harris NO, Clark DC. Water fluoridation, In: Harris
NO and Christen AG, eds. Primary preventive
dentistry, 4
th
ed. Appleton and Lange, Stamford,
Connecticut 1995; 157-91.
3. Koch G, Moder T, Poulsen S, Rasmussen P.
PedodonticsA clinical approach, 1
st
ed.
Munksgaard, Copenhagen 1994; 42-64.
4. Andlaw RJ , Rock WP. A manual of pediatric
dentistry, 4
th
ed. Churchill, Livingstone. New York
1996; 141-8.
5. J ackson RD, Kelly SA, Katz BP, Hull J R, Stookey
GK. Dental fluorosis and caries prevalence in
children residing in communities with different
levels of fluoride in the water. J Public Health Dent
1995; spring; 55(2): 79-84.
6. McDonagh MS, Whiting PF, Wilson PM, Sutton AJ ,
Chestnutt I. Systemic review of water fluoridation.
BMJ 2000; 321: 855-59.
7. Ibrahim YE, Affan AA, Bjorvatn K. Prevalence of
dental fluorosis in Sudanese children from two
villages with 0.25 and 2,56 ppm fluoride in the
drinking water. Int J Paediatr Dent 1995; Dec; 5(4):
223-9.
8. Horowitz HS. Indices for measuring dental fluorosis.
J Public Health Dentistry 1986; 46(4): 179-83.
9. Welbury RR, Shaw L. A sample technique for
removal of mottling, opacities and pigmentation.
Dental Update 1990; 17: 161-3.
10. Dean HT, Arnold FA, Elvove E. Domestic water and
dental caries. Public Health Repo 1942; 57(32):
1155-79. Cited in: Nizel A, Papas A. Nutrition in
clinical dentistry, 3
rd
ed. W.B. Saunders company,
Philadelphia, London; 1989.
11. Skotowski MC, Hunt RJ , Levy SM. Risk factors for
dental fluorosis in pediatric dental patients. J Public
Health Dent 1995; 55(3): 154-9.
12. Manji F, Baelum V, Fejerslow O. Dental fluorosis in
an area of Kenya with 2ppm fluoride in drinking
water. J Dent Res 1986; May; 65(5): 659-62.
13. Irigoyen ME, Molina N, Luengas I. Prevalence and
severity of dental fluorosis in a Mexican community
with above-optimal fluoride concentration in
drinking water. Community Dent Oral Epidemiol
1995; 8; 23(4): 243-5.
14. Warren J J , Levy SM, Kanellis MJ . Prevalence of
dental fluorosis in the primary dentition. J Public
Health Dent 2001; spring; 61(2): 87-91.
15. Leverett D. Prevalence of dental fluorosis in
fluoridated and non-fluoridated communities a
preliminary investigation. J Public Health Dent 1986;
fall; 46(4): 184-7.
16. U.S. Department of health and human services,
Public health service. Review of fluoride: benefits
and risks. Report of the Ad Hoc subcommittee on
fluoride. Washington DC; February 1991.

17. Levy SM, Guha-Chowdhury N. Total fluoride intake
and implications for dietary fluoride
supplementation. J Public Health Dent 1999; 59:
211-23.
18. National water and sanitation authority. Analysis of
drinking water in Dahmar. 1990-2000.
19. Nizel A, Papas A. Nutrition in clinical dentistry, 3
rd

ed. W.B. Saunders company, Philadelphia, London;
1989: 167-95.
20. Lewis DW, Banting DW. Water fluoridation: current
effectiveness and dental fluorosis. Community Dent
Oral Epidemiol 1994; J un; 22(3): 153-8.
21. Al-J uboury HA. Prevalence of dental fluorosis in
Yemen (accepted for publication in Al-Mustansiria
Dent J 2005).
22. Larsen MJ , Kirkegaard E, Poulsen S. Patterns of
dental fluorosis in European country in relation to the
fluoride concentration of drinking water. J Dent Res
1987; J an; 66(1): 10-2.
23. Larsen MJ , Senderovitz F, Kirkegaard E, Poulsen S,
Fejerskov O. Dental fluorosis in the primary and
permanent dentition in fluoridated areas with
consumption of either powdered milk or natural cows
milk. J Dent Res 1988; May; 67(5): 822-5.
24. Warren J J , Kanellis MJ , Levy SM. Fluorosis of the
primary dentition: what does it mean for permanent
teeth? J Am Dent Assoc 1999; Mar; 130(3): 347-56.
25. Kumar J , Swango P, Haley V, Green E. Intrs-oral
distribution of dental fluorosis in Newbunrgh and
Kingston, New York. J Dent Res 2000; J ul; 79(7):
1508-13.

J Bagh Coll Dentistry Vol. 18(2), 2006 Local anesthetic quality
Local anesthetic quality in pedodontic department, College
of Dentistry/ University of Baghdad

Abeer M.Zwain B.D.S., M.Sc.
(1)

ABSTRACT
Background: Discomfort and pain usually is associated with dental work especially for young patients. Pain control
can be achieved by using local anesthesia. This study is designed to estimate the frequency of ineffective pain
control during treatment provided for children in pedodontic department in college of dentistry, university of
Baghdad.
Subjects and methods: 166 children, 82 males and 84 females 4.5-12 years old participated in this study. The level of
child anxiety was measured before giving the injection, quadrant treated and type of treatment also recorded. The
effectiveness of pain control had been rated by SEM (sound, eye, motor) scale during providing the dental
treatment.
Results: The local anesthesia was ineffective in 26.5% of the studied sample, while the others 73.5% undergone
treatment with no signs of pain. Anxious children showed more signs of pain experience during treatment than the
non anxious. Treatment in the mandibular jaw was associated with anesthetic failure more than that of the maxillary
jaw.
Conclusions: Ineffective pain control is relatively frequent in pedodontic department in College of Dentistry,
University of Baghdad and there is a need for using more methods for reducing anxiety like nitrous oxide sedation
(NO2) and computer controlled local anesthesia because of the close relation between anxiety and pain control.
Key words: Local anesthesia pain. (J Bagh Coll Dentistry 2006; 18(2)96-99)

INTRODUCTION
1

The most critical subject in the pedodontic
patient management during dental treatment is
controlling the pain. Painful dental treatment
will results in anxious person
(1)
that avoid
seeking dental treatment in the future and were
more likely to defer, cancel or not turn up for
dental appointments
(2, 3)
.
Local anesthesia is usually indicated when
operative as well as surgical work is to be
performed for adult as well as young children
patients
(4)
.
Little is known about the frequency of
ineffective local anesthesia in pedodontic
patients and its possible reasons, for the adult
it's suggested that the failure of the anesthesia is
common and its possible causes include
anatomical variation, inflammation, anxiety and
injection technique
(5-7)
. For pediatric dentistry,
a child age, gender
(8)
, anxiety
(9)
, initial dose of
anesthetic administration
(10,11)
, arch treated
(8)
,
the operative procedures performed
(12)
, and the
use of nitrous oxide
(13,14)
and oral premedication
(15)
all have been suggested to influence the
effectiveness of local anesthesia.
This study was carried out to add some
information on the effectiveness of pain control
in pedodontic department in college of
dentistry, university of Baghdad by testing the

(1) Assistant lecturer, Department of Pedodontic and Preventive
Dentistry, College of Dentistry, University of Baghdad

hypothesis that effective pain control could be
related to some factors like anxiety, type of
treatment, quadrant treated, and administration
technique.

SUBJECTS AND METHODS
One hundred and sixty child patients 82
males, 84 females. 4.5-12 years old in age were
participated in the present study; any patient
give history or clinical signs of infection or
swelling were excluded from the study. The
following information were recorded in a
simple check list for each patients: age in years,
sex, quadrants anesthetized, injection
techniques, initial dose (to the nearest quarter of
cartilage) of 2% lidocaine with 1:100,000
epinephrine, use of topical anesthesia in
combination of local anesthesia and type of
operative or surgical procedure performed.
Child's anxiety has been rated before the
initial injection into four categories according
to Frankle scale: "definitely positive",
"positive", "negative", "definitely negative",
children rated into the negative categories were
considered to be anxious
(16)
.
The anesthetic injection had been given by
the student under a supervision of senior
instructor and each patient treated by the
treatment demand while this the effectiveness
of pain control had been rated by SEM (sound,
eye, motor) scale
(12)
which consists of four
levels ranging from comfort to painful takes
into account sound, eyes and motor ( table 1).
RESULTS
The studied sample included 166 children
82 males, 84 females 4.5-12 years old in age.
Table 2 shows the effectiveness of local
anesthesia in different age groups of the studied
sample. No statistical differences was found
between different age groups when compared to
the total number of the sample (p=0.1245).
135 children were rated as not anxious
while 31 children rated as anxious children
from dental treatment. In 71 patients the
treatment was provided for the maxillary jaw
while 95 patients received treatment for the
mandibular jaw. Ninety nine patients received
restorative treatment, extraction or pulpotomies
were performed for 67 patients (table3).
Topical anesthesia in combination with
local anesthesia was given for 63 patients, no
significant relation was found between
effectiveness of local anesthesia and the use of
topical anesthesia.
Figure 1 show the effectiveness of local
anesthesia among the studied sample. Thirteen
females and 31 males were reported that the
local anesthesia was ineffective while 69
females and 53 males undergone the treatment
with no signs of pain, ineffective local
anesthesia was 26.5% of the total sample.
Associated variables that affect
successfulness of local anesthesia are seen in
table 3 and 4. A significant relation was found
between the level of child anxiety and
effectiveness of local anesthesia according to
SEM scale (P=0.034). The results show that
anxious children show more signs of pain
experience during dental treatment.
Although no significant relation was found
between pain experience and type of treatment
(P=0.093), but the percentage of ineffective
local anesthesia while the patients undergoing
restorative treatment is relatively low (9.04%)
when compared with that when the patient
undergone more aggressive treatment like
extraction or pulpotomy (17.5%). On the other
hand, a significant relation between
effectiveness of local anesthesia and quadrant
treated was found (P=0.023) so that treatment
in the mandibular jaw associated with pain
experience more than that in the maxillary jaws.
Table 4 shows the effectiveness of local
anesthesia compared with administration
technique. A significant relation was found
between the two (P=0.0238), the more
successful technique was buccal infiltration
anesthesia for restorative treatment in the
maxillary and mandibular anterior teeth, while
inferior dental nerve block for operative
treatment and inferior dental nerve block and
long buccal nerve anesthesia for extraction in
the mandibular jaw associated with high
percentage of ineffective pain control, no
significant difference was found between
infiltration local anesthesia in the mandibular
anterior teeth and that in the maxillary jaw .

DISCUSSION
This study is the first study that deals with
amount of pain associated with dental treatment
provided for children attending pedodontic
department in the College of Dentistry,
University of Baghdad. 26.5% of the studied
sample undergone the treatment suffered from
pain. This percentage varies from study to
study, it is ranged from 11.6 to 35
(12,17,18)
.
Females tend to be more suffering from pain
than the males. This may be due to the physical
and social nature of females that make them
more apprehensive.
Pain is a complex experience and it's highly
related to the experience of anxiety
(9)
, so that
anxious children before injection tends to show
more pain experience than non anxious
children, (P=0.034) as shown in table 3. This
result was confirmed with NAKAI and his
colleagues
(12)
. Although inhalation sedation
with nitrous oxide can provide effects of good
quality antianxiety sedation, amnesia in dental
treatment
(13,14)
. In addition, a recent method for
administration of local anesthesia is a computer
controlled local anesthesia in which the flow
rate of anesthetic solution is controlled by a
microprocessor instead of the pressure of
traditional syringe, so that the dentist can give a
painless injection that decrease stress and
anxiety of the patient
(19)
, but there are no
facilities provided in the pedodontic department
in the College of Dentistry, University of
Baghdad for these methods.
Type of treatment is considered to be one of
the variables that effect amount of pain control
during dental treatment
(12)
. No statistical
significance was found between amount of pain
associated with restorative treatment when
compared with that associated with extraction
or pulpotomy which is not confirmed with other
studies
(12,20)
.
The present study shows that anesthesia in
the mandibular jaw which is inferior dental
nerve block associated with high percentage of
failure as compared with infiltration technique.
Complex administration technique which needs
more experience and skill is the cause of this
finding so that the students must have more
knowledge about inferior dental nerve block
anesthetic technique.

REFERENCES
1. Locker D, Shapiro D, Liddell A. Negative experience
and their relationship to dental anxiety. Community
Dental Health 1996; 13:86-92.
2. Bedi R, Sutcliffe P, Donnan P, Barrett N,
McConnachie J . Dental caries experience and
prevalence of children afraid of dental treatment.
Community Dent Oral Epidemiol 1992; 20:368-71.
3. Poulton R, Thomson W, Brown R, Silva P. Dental
fear with and without blood injection fear:
implication for dental health and clinical practice.
Behavior Research and Therapy 1998; 36:591-7.
4. McDonald RE, Avery DR, Dean J A. Dentistry for the
child and adolescent 8th ed. Mosby-Yearbook;
2004:272.
5. Weinstein P, Milgram P, Kaufman E, Fiset L,
Ramsay D. Patient perceptions of failure to achieve
optimal local anesthesia. Gen Dent 1985; 33:218-20.
6. Brown RD. The failure of local anaesthesia in acute
inflammation. Br Dent J 1981; 151:47-51.
7. Rood J P, Patromichelakis S. Local anaesthetic
failures due to an increase in sensory nerve impulses
from inflammatory sensitization. J Dent 1992; 10:
201-6.
8. Liddle A, Locker D. Gender and age differences in
attitudes to dental pain and dental control.
Community Dent Oral Epidemiol 1997; 25: 314-8.
9. Litt MD. A model of pain and anxiety associated with
acute stressors: distress in dental procedures. Behave
Res Ther 1996; 34:459-76.
10. Vreeland DL, Reader A, Beck M, Meyers W, Weaver
J . An evaluation of volumes and concentrations of
lidocaine in human inferior alveolar nerve block. J
Endod 1989; 15: 6-12.
11. Aberg G, Sydnes G. Studies on the duration of local
anesthesia: effects of volume and concentration of
local anesthetic solution on the duration of dental
infiltration anesthesia. Int J Oral Surg 1978; 7:141-7.
12. Nakai Y, Milgrom P, Coldwell S, Ramsay D.
Effectiveness of local anesthesia in pediatric dental
practice. J ADA 2000; 131:1699-705.
13. Rodrigo MR. Use of inhalational and intravenous
sedation in dentistry. Int Dent J 1997; 47(1):32-8.
14. Sun Y. Inhalation sedation with nitrous oxide in
dental extraction. Zhonghua Kou-Qiaug-Yi-Xue
1998; 33(1): 24-6 (M.L.).
15. Henderson BN. Anxiolytic therapy: Oral and
intravenous sedation. Dental Clinics of North
America 1994; 38(4): 603-17.
16. Frankl SN, Shiere FR, Fogels HR. Should the parent
remain with the child in the dental operatory? J Dent
Child 1962; 29:150-63.
17. Kaufman E, Holan G, Goodman E, Eidelman E.
Evaluation of student's performance in obtaining
local anesthesia in children. Int J Paediatr Den 1991;
Dec; 1(3):147-50.
18. Kuster CG, Rakes G. Frequency of inadequate local
anesthesia in child patients. J Paediatr Dent 1987;
3:7-9.
19. Loomer PM, Perry DA. Computer-controlled
delivery versus syringe delivery of local anesthetic
injection. J ADA 2004; 135(3), 358-65.
20. Wilson TG, Primoshc RE, Melamed B, Courts FJ .
Clinical effectiveness of 1 and 2 percent lidocain in
young pediatric dental patients. Pediatr Dent 1990;
12:353-9 (M.L.).

Table 1: Ratings of a child's pain according to the SEM scale.
Comfort or pain level Observations of
possible
indications of
pain
1-comfort 2-mild discomfort 3-moderately painful 4- painful
Sound
No sounds
indicating pain
Nonspecific sounds;
possible indication of
pain
Specific verbal
complaints (such as
"OW"), raises voice
Verbal complaint
indicate intense pain
(such as screaming
sobbing)
Eye
No eye signs
of discomfort
Eyes wide, show of
concern, no tears
Watery eyes, eyes
flinching
Crying tears running
down face
Motor
Hands relaxed;
no apparent
body tension
Hands showing some
distress or tension;
grasping of chair owing
to discomfort, muscular
tension
Random movement of
arms or body without
aggressive intention of
physical contact,
grimacing, twitching
Movement of hands to
make aggressive
physical contact (such
as puching, pulling
head away)

Table 2: Effectiveness of local anesthesia in different age groups of the studied sample.
Ineffective L.A Effective L.A
Total No.
% No. % No.
Age groups/years
13 3 5 4.8 8 4-5
27 7.8 13 8.4 14 6-7
55 6 10 27.1 45 8-9
50 7.2 12 22.9 38 10-11
21 2.4 4 10.24 17 12
166 26.5 44 73.4 122 Total
P- Value = 0.1245

Table 3: Associated variables that affect successfulness of local anesthesia.
Effective
L.A

Ineffective
L.A

P-
value
Sig

No. % No. %
Total
No.

Anxious 7 4.22 24 14.5 31 Child anxiety Frankle
scale) Not anxious 115 69.3 20 12 135
0.034 S
Operative treatment 84 50.6 15 9.04 99
Type of Treatment Extraction or
pulpotomy
38 22.9 29 17.5 67
0.093 NS
Maxillary 59 35.5 12 7.23 71
Quadrant treated
Mandibular 64 38.6 31 18.7 95
0.023 S

Table 4: Effectiveness of local anesthesia compared with administration technique.
Effective Ineffective

Administration Technique
No. % No. %
Total
No.
Buccal infiltration anesthesia for restorative treatment 35 20.48 0 0 35
Buccal & palatal infiltration anesthesia for extraction 24 14.46 13 7.63 37
Inferior dental nerve block anesthesia only for restorative treatment in
the mandibular jaw
46 28.32 15 9.04 61
Inferior dental nerve block &long buccal nerve anesthesia for
extraction in the mandibular jaw
18 10.85 15 9.04 33
P- Value =0.0238

Effective 73.5

10

Some societies of dental specialities

Societies of Endodontics
1-American Association of Endodontists (AAE)
http://www.aae.org/
2-American Board of Endodontics (ABE)
http://www.aae.org/ABE1.html
3-American Endodontic Society (AES)
http://www.aesoc.com/
4-Australian Society of Endodontology (ASE)
http://www.ada.org.au/Societies/ASE/
5-British Endodontic Society (BES)
http://www.britishendodonticsociety.org/
6-Canadian Academy of Endodontics (CAE)
http://www.caendo.ca/
7-European Society of Endodontology (ESE)
http://www.e-s-e.org/
8-Hong Kong Endodontic Society (HKES)
http://www.hkes.org.hk/
9-Malaysian Endodontic Society (MES)
http://www.mda.org.my/mes/index.htm
10-Turkish Endodontics Society
http://www.turkishendodontics.org/

Societies of Forensic Odontology
1-British Association for Forensic Odontology (BAFO)
http://www.bafo.org.uk/

Societies of General Dentistry
1-Academy of General Dentistry (AGD)
http://www.agd.org/

Societies of Oral and Maxillofacial Surgery
1-Academy of Oral Surgery - Chalmers J . Lyons
http://www.cjlyons.org/
2-American Association of Oral and Maxillofacial Surgeons (AAOMS)
http://www.aaoms.org/
3-American Board of Oral and Maxillofacial Surgery (ABOMS)
http://www.aboms.org/
4-American College of Oral and Maxillofacial Surgeons (ACOMS)
http://www.acoms.org/
5-Association of Oral & Maxillofacial Surgeons of India (AOMSI)
http://www.aomsi.com/
6-Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS)
http://www.anzaoms.org/
7-British Association of Oral and Maxillofacial Surgeons (BAOMS)
http://www.baoms.org.uk/
8-Canadian Association of Oral and Maxillofacial Surgeons (CAOMS)
http://www.caoms.com/

10

9-Hellenic Association for Oral and Maxillofacial Surgery (HAOMS)
http://www.haoms.org/
10-International Association of Oral and Maxillofacial Surgeons (IAOMS)
http://www.iaoms.org/
11-Oral and Maxillofacial Surgery Foundation (OMSF)
http://www.omsfoundation.org/

Societies of Oral Diagnosis
1-American Academy of Oral and Maxillofacial Pathology (AAOMP)
http://www.aaomp.org/
2-American Academy of Oral and Maxillofacial Radiology (AAOMR)
http://www.aaomr.org/
3-American Academy of Oral Medicine (AAOM)
http://www.aaom.com/
4-American Board of Oral and Maxillofacial Pathology (ABOMP)
http://www.abomp.org/
5-American Board of Oral and Maxillofacial Radiology (ABOMR)
http://www.aaomr.org/
6-Australasian Society of Oral Medicine And Toxicology (ASOMAT)
http://www.asomat.org/
7-British Society for Oral Medicine (BSOM)
http://www.bsom.org.uk/
8-European Association for Oral Medicine (EAOM)
http://www.eastman.ucl.ac.uk/~eaom/
9-European Society for Oral Laser Applications (ESOLA)
http://www.esola.at/
10-Indian Academy of Oral Medicine and Radiology (IAOMR)
http://www.iaomr.tripod.com/index.htm
11-Organization for Teachers of Oral Diagnosis (OTOD)
http://www.otod.org/

Societies of Orthodontics
1- Academy of GP Orthodontics (AGpO)
http://www.academygportho.com/
2-Academy of Interdisciplinary Dentofacial Therapy (IDT)
http://www.dental-idt.com/
3-American Association of Orthodontists (AAO)
http://www.aaortho.org/
4-American Board of Orthodontics (ABO)
http://www.americanboardortho.com/
5-American Lingual Orthodontics Association (ALOA)
http://www.ormco.com/lingual/
6-American Orthodontic Society (AOS)
http://www.orthodontics.com/
7-Asian-Pacific Orthodontic Society (APOS)
http://www.ap-os.org/
8-Australian Orthodontic Institute (AOI)
http://www.austorthinst.org.au/
9-Australian Society of Orthodontists (ASO)
http://www.aso.org.au/
10-Association of Orthodontists - Singapore
http://www.aos.org.sg/

10

11-Association of Philippine Orthodontists (APO)
http://www.apo.com.ph/
12-British Lingual Orthodontic Society (BLOS)
http://www.blos.co.uk/
13-British Orthodontic Society (BOS)
http://www.bos.org.uk/
14-Canadian Association of Orthodontists (CAO)
http://www.cao-aco.org/
15-Charles H. Tweed International Foundation
http://www.tweedortho.com/
16-College of Diplomates of the American Board of Orthodontists (CDABO)
http://www.cdabo.org/
17-Egyptian Orthodontic Society (EOS)
http://www.egortho.org/
18-European Federation of Orthodontic Specialists Associations (EFOSA)
http://www.efosa.org/
19-European Federation of Orthodontics (FEO)
http://www.feo-online.org/
20-European Orthodontic Society (EOS)
http://www.eoseurope.org/
21-European Society for Lingual Orthodontics (ESLO)
http://www.eslo.de/
22-Greek Orthodontic Society
http://www.grortho.gr/
23-New Zealand Association of Orthodontists (NZAO)
http://www.orthodontists.org.nz/
24-Orthodontic National Group, The
http://www.orthodontic-ong.co.uk/
25-Orthodontic Society of Ireland (OSI)
http://www.orthodontics.ie/
26-South African Society of Orthodontists (SASO)
http://www.saso.co.za/
27-World Federation of Orthodontists (WFO)
http://www.wfo.org/

Societies of Osseointegration
1-European Association for Osseointegration (EAO)
http://www.eao.org/

Societies of Pediatric Dentistry
1-American Academy of Pediatric Dentistry (AAPD)
http://www.aapd.org/
2-American Board of Pediatric Dentistry (ABPD)
http://www.abpd.org/
3-Korean Academy of Pediatric Dentistry (KAPD)
http://www.kapd.org/

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Vol. 18 No.2 2006

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