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Scientific Journal Published by the College of Dentistry – University of Baghdad

Vol. 24 No. Special Issue 1 2012

ISSN ISSN 1680-0087

A quarterly peer reviewed published scientific journal of the College of Dentistry, University of Baghdad.

Editor in chief: Prof. Dr. Nabil Abdulfatah Hatoor, M.Sc Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD International Members

National Members Prof. Dr. Khulood Al-Safi MSc, PhD

Prof. J. L. Gutmann D.D.S., Ph.D.(USA)

Prof. Dr. Adel Farhan MSc

Prof. Dr. M. Goldberg PhD (France)

Prof. Dr. Zainab Al-Dahan MSc Prof. Dr.Abbas Sabri M.Sc., PhD Prof. Dr.Wasan Hamdi M.Sc, PhD Assist. Prof. Dr. Fakhri Al-Qaisy M.Sc Assist. Prof. Dr. Sabah Nema M.Sc., PhD Prof. Dr. Nidhal Hussain MSc Assist. Prof. Dr. Sahar Shaker MSc Assist. Prof. Dr. Ghassan Abdulhameed MSc Board of editorial consultants: 1- Prof. Dr. Majida Al-Hashimi MSc

5- Prof. Dr. Shatha Saleem MSc

Assist. Prof. Dr. Akram Al-Huwaizi MSc, 6- Assist. Prof. Dr. Maha Shukri MSc PhD

3- Prof. Dr. Mohammad Al-Qaisi MSc

7- Assist. Prof. Dr. Abbas Fadhil PhD

4- Prof. Dr. Raja Hadi MSc, PhD

8- Lecturer Dr. Jamal Abid MSc

Secretarial committee: 1- Lecturer Dr. Mohammad Nahidh 2- Lecturer Yassir AbdulKadum 3- Assist. Lecturer Ahmed Fadhil 4- Assist. Lecturer Ayad M. Al-Obaidi For consultation, please contact: Website: www.codental.uobaghdad.edu.iq E-mail: [email protected] Telephone: (+9641)4169375 Fax: (+9641)4140738

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Contents i

Editor and Editorial Board

ii

Contents

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Instructions for the Authors Restorative Dentistry

1

Evidence for feasibility of aluminum potassium sulfate (alum) solution as a root canal irrigant. Bestoon M. Faraj

6

Microleakage of class II packable resin composite lined with flowable composite and resin modified glass ionomer cement: An in vitro study. Haitham J. AL-Azzawi, Nagham A. AL-Hyali, Firas J. M. Al-Dabbagh

11

A comparison between the arbitrary and kinematic intercondylar distances of full mouth rehabilitation patients (An in-vivo study). Ma'an R. Zakaria, Hussain F. Al-Huwaizi, Widad A. Alnakkash

18

A clinical comparison between maxillary and mandibular posterior teeth using local anesthesia and normal saline by the periodontal ligament injection (An in vivo study). Majidah K.W. AL-Hashimi, Raad S. Al-Doori

24

Comparative study of wettability of different lining, tissue conditioning and denture base materials (invitro study). Mostafa S. M. Al-Shaikhli, Amir H.M. Khamas

31

Evaluation of different techniques used in non surgical endodontic retreatment for teeth with different obturation techniques (An in-vitro study). Nsar Muhyaddin Aziz, Dara Hamarashed Saeed

36

The effect of addition of calcium hypochlorite disinfectant on some physical and mechanical properties of dental stone. Shorouq M. Abass, Ibrahim K. Ibrahim

44

Comparison the tensile strength of heat cure and visible light cure acrylic resin denture base. Zahraa N. Al- Wahab, Bassam A. Hanna, Shakwaan K. Kadir

Oral Diagnosis

48

Evaluation of the effect of Nigella sativa oil and powder on healing process, histologically and radiographically (An experimental study on rabbit). Hani Sh. Mohammed, Athraa Y. Al-Hijazi

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53

Evaluation of topical versus systemic medications in the treatment of neuropathic orofacial pain A prospective study. Ihsan A. Kumail

60

Assessment of cadmium levels in Blood, hair, saliva and teeth in a sample of Iraqi workers and detection of dental findings. Raja H. Al-Jubouri, Ammar Issa Bashbosh

65 70

Changes in oral flora of newly edentulous patients, before and after complete dentures insertion. Saeed Abdul Latteef Abdul-Kareem Topical treatment of herpes simplex lesion by lavender cream. Tagreed Altaei, Shaheen Ali Ahmed

Oral and Maxillofacial Surgery and Periodontology

77 80 85

The prevalence of overhanging m a r g i n s in posterior filling restorations and periodontal consequences. Alaa'Omran , Abdul Karim Abed Ali Biochemical analysis and periodontal health status in type 1 and type 2 diabetes (Comparative study) Salah Mahdi Ibrahim, Leka'a M. Ibrahim The correlation between hemoglobin level and generalized moderate chronic periodontitis. Suzan Ali

Orthodontics, Pedodontic, and Preventive Dentistry

89

Oral hygiene and gingival condition among epileptic patients 5-15 year-old (A comparative study) Azhar A. Hussien, Athraa M. AL-Weheb

94

The reliability of bisecting interpupillary perpendicular line, facial and dental laterality and coincidence in adult normal occlusion Iraqi sample (A photographic, cross sectional study). Dina A. Hassan, Nidhal H. Ghaib

99

Dental arches dimensions, forms and the relation to facial types in a sample of Iraqi adults with skeletal and dental class I normal occlusion. Haider M.A. Ahmed, Fakhri A. Ali

108

The relationship between the dental caries and the blood glucose level among type II non insulin dependent diabetic patients. Hawraa Khalid Aziz

115

Dental knowledge and behavior among technical medical institute students in Baghdad governorate Jinan Mohammed Rashad

120

A new calibration procedure for expectation of arch length. Mustafa M. Al-Khatieeb, Layth M. K. Nissan, Mushriq F. Al-Janabi

127

Oral health status among children Downs syndrome in Sumawa city, Iraq. Raya R. Al-Dafaai

131

Effects of Pimpinella Anisum extract on salivary counts of Streptococci and Mutans Streptococci in comparison to Chlorhexidine in vivo. Sabreen S. Abd Al- Muhsen, Wesal A. Al-Qbaidi

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135

The characteristics of profile facial types and its relation with mandibular rotation in a sample of Iraqi adults with different skeletal relations. Sara M. Al-Mashhadany, Nagham M.J. Al- Mothaffar

140

Dental calculus in relation to idiopathic calcium renal stone. Shaimaa Kh. Yaser, Mohammed S. AlCasey

146

Psychological impact of dental aesthetics for Kurdish young adults seeking orthodontic treatment. Trefa M. Ali Mahmood, Fadil A. Kareem

Basic Sciences

153

Antibacterial efficiency of salvia officinalis extracts and their effect on growth, adherence and acid production of oral Mutans Streptococci. Hadi A. Hmeem Al-Lamy, Abbas S. Al-Mizraqchi

158

Relationship between Herpes simplex Virus Type-1 and Candida albicans in Pregnant Women with Aphthous Stomatitis in the oral cavity. Mohammad T. Abdul Hussin, Sana A. AL-Shaikhly

164

Study the role of proinflammatory and anti- inflammatory cytokines in Iraqi chronic periodontitis patients. Zahraa F. Shaker, Batool H.Hashem

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Instruction for the Authors The Journal of the College of Dentistry accepts manuscripts that address all topics related to dentistry. Manuscripts should be prepared in the following manner: Typescript. Type the manuscript on A4 white paper, with page setup of 2.5 cm margins. 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, MATERIALS AND METHODS, RESULTS and REFERENCES. 3) Font size 12 Bold and italic for the names and addresses of the authors ex. Ahmed G. Husam 4) Font size 11 for the legends of the tables and figures. 5) Font size 10.5 for the text in the manuscript. 6) Font size 10 for the text inside the tables. 7) Font size 9 for the references at the end of the manuscript. Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand corner. Title of the manuscript: The title should be written with a capital letter for the first word as (Effect of the retention and stability….etc). 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. The abstract should be written by the font Century Gothic size 8. Text. The body of the manuscript should be divided into sections preceded by the appropriate major headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES) which are written in bold and capital. Minor headings should be typed in bold and subheadings should be not bold but underlined. 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 at the end of the manuscript : Book 1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9th ed. St. Louis: CV Mosby; 1985. p.312-23. Journal article 4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9. Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g. Table 1). The tables should be done with a width of no more than 8 cm. Figures and illustrations. All figures must have a title placed below the figure. Identify figures with Arabic numbers (e.g. Figure 1). The figures should be done with a width of no more than 8 cm. The article should not exceed 7 pages. The author should submit three copies of the article (one original and two copies) and a (CD) containing the article.

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J Bagh College Dentistry

Vol. 24(special issue 1), 2012

Evidence for feasibility

Evidence for feasibility of aluminum potassium sulfate (alum) solution as a root canal irrigant Bestoon M. Faraj B.D.S. H.D.D. M.Sc. PhD. (1)

ABSTRACT Background: The purpose of this study was to evaluate, in vitro, the antimicrobial activity and cleaning efficiency of the aluminum potassium sulfate (alum) solution. Materials and methods: The antibacterial action of alum solution (1 mg /mL, at pH 3.6) against bacterial isolates found in infected root canals, including facultative anaerobic microorganisms (Escherichia coli , Staphylococcus aureus and Klebsiella sp.), and aerobic species (Pseudomonus aerogenosa ) ,using agar well diffusion test. The investigation of the debridement and smear layer removing efficiency, on the cervical, middle and apical thirds of root canals of freshly extracted human single-rooted teeth were done by a scanning electron microscopy study. Results: Alum solution were able to demonstrate antibacterial activity against all the bacteria tested, and produced inhibitions zones of 27, 25, 24 and 22 mm against Staphylococcus aureus, Pseudomonus aerogenosa ,Escherichia coli, and Klebsiella sp. respectively. Alum solution was effective in removing the debris and smear layer. Removal of the smear layer and other debris was more effective in the coronal and middle third than in the apical third. Conclusion: The findings of this study suggested that alum solution has potential for use as an endodontic irrigant, during chemomechanical root canal preparation. Key words: antimicrobial, chemomechanical debridement, smear layer removing activity. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):1-5).

which is used as an astringent and antisepsis in various food preparation processes such as pickling and fermentation and as a flocculants for water purification among other things. (13) Moreover the FDAs over the –Counter Advisory Panel has recommended alum as category I active ingredient in mouthwashes. (14) Potassium aluminum sulfate (Alum) in concentrations of 10% and 100% is used in mechanico- chemical gingival displacement. (15, 16) The purpose of this study was to evaluate, in vitro, the aluminum potassium sulfate (alum) solution, in respect to their antibacterial action against common bacterial isolates found in infected root canals, including facultative anaerobic microorganisms (Staphylococcus aureus, Escherichia coli and klebsiella sp), and aerobic bacteria (Pseudomonas aeruginosa), using agar well diffusion test , and to investigate their debridement and smear layer removing efficiency from the prepared root canals on freshly extracted human teeth, by a scanning electron microscopy study.

INTRODUCTION It is known that removal of vital and necrotic remnants of pulp tissues, microorganisms, and microbial toxins from the root canal system is essential for endodontic success. (1, 2) Although this might be achieved through chemomechanical debridement. (3) An uninstrumented area with organic and inorganic debris still present and it is impossible to shape and clean the root canal completely. (4, 5) Therefore, irrigation is an essential part of root canal debridement because it allows for cleaning beyond what might be achieved by root canal instrumentation alone. (6, 7) During mechanical root canal instrumentation, formation of a smear layer occurs which consists primarily of fine inorganic particles, along with some organic material from necrotic and/or viable pulp tissue, odontoblastic processes, bacteria and blood cells. (8, 9) Despite controversy over maintaining the smear layer, it has been shown that the smear layer itself may contain bacteria and protect the bacteria within the dentinal tubules. The smear layer has also been shown to hinder the penetration of intracanal disinfectants and sealers into dentinal tubules and can potentially compromise the seal of the root canal filling. (10, 11) Natural products have been used for centuries in treating human diseases and they contain components of therapeutic value. Natural products are environmentally safer, easily available, and cheap. (12) Alum (Aluminum potassium sulfate), the crystallized double sulphates with the formula KAl(SO4)2.12H2O, are generally odourless, colourless crystalline solids that turn white in air,

MATERIALS AND METHODS This study received approval from the ethics committee of the University of Sulaimani, Sulaimani, Iraq. Preparation of alum solutions Seven hundred grams of alum material were purchased from the local botanical market of Sulaimani, and were identified in the College of Science, Department of Chemistry, Sulaimani University. Crystals of alum KAl(SO4)2·12(H2O).dissolved completely in hot (distilled) water at 92Co, to obtain a final concentration of 1 gm /mL, at pH 3.6

(1) Lecturer,Conservative Department, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani.

Restorative Dentistrty

1



the root canals were filled with the tested endodontic irrigants through the pulp chamber using 3 ml disposable syringes and 30-gauge needles, which were placed to approximately 3–4 mm from the working length without binding as described by Monika and Izabel. (20) Each time the files were substituted, the canals were thoroughly rinsed with alum solution, aspirated and refilled with a new quantity of this solution. After final irrigation with 5.0 ml of distilled water to terminate the action and eliminate any precipitates from the irrigants according to methodology described by Manuele et al. (21) The root canals were carefully dried with paper points. Then, by using a diamond disk mounted on a lowspeed handpiece, with a constant water spray, longitudinal and transversal grooves, which did not penetrate into the canal, were prepared along the buccal and lingual surfaces of each root. Afterwards, the roots were carefully fractured with the aid of a chisel and a surgical mallet. The cervical, middle and apical thirds were divided, thereby providing three sections from each portion. The roots were mounted on stubs, put in a vacuum chamber, sputter coated with goldpalladium ~35 nm thick with a sputter coater for SEM evaluation. After that an observation with a scanning electron microscope is given. Specimen grading Randomly assessment in each third of each half-root at a magnification of 1000x was done. One photomicrograph for each specimen was taken to visualize the coronal, middle, and apical portion of the root canal system. The areas examined for each sample were standardized using parameters similar to those proposed by AL-Hadlaq et al. (22), and Soares et al. (23) with some modifications. A total of 36 images were analyzed by a calibrated, blinded evaluator using the following scoring system : Score 1, clean surface with very little to no debris, presenting open dentinal tubules throughout the canal wall (figure 1A); Score 2, clean surface with some scattered debris and/or thin homogenous smear layer with some open or partially open dentinal tubules (figure 1B); Score 3, mostly unclean surface containing debris and smear layer with few visible open or partially open dentinal tubules (figure 1C); Score 4, unclean surface with large amount of debris and smear layer with no visible dentinal tubules (figure 1D).

Bacterial samples The bacterial isolates used in this experiment were obtained from the College of Science (Department of Biology), University of Sulaimani. These bacteria were: Staphylococcus aureus, Klebsiella sp., Psedomonus aerogenosa and Escherichia coli. All the isolates were collected from infected root canals and cultivated in suitable culture medium; Staphylococcus aureus in Muller-Hinton agar and the other isolates were cultivated in Mackoncky agar. Evaluation of antibacterial activity of the alum solution Agar well diffusion method was used to evaluate, in vitro, the antibacterial effect of the alum against the common bacterial isolates found in infected root canals, by means of agar-well diffusion assay. (17, 18) Fifteen milliliters of the molten agar (45 °C) were poured into sterile petri dishes (Ø 90 mm).50 μl from each bacterial isolate (Cell suspensions containing 108 CFU/ml cells), were taken separately and evenly spread onto the surface of the agar plates of MuellerHinton agar using a micropipette as described by Bauer et al. (19) Wells (6mm diameter, and 4mm height) were bored using a sterile cork borer. Different concentrations of the test solution were placed into the wells and the plates were incubated aerobically and under CO2 incubation at 37°C for 24 h. After 24 hours of incubation, the plates were removed from the incubator and are examined for the inhibition zone around each well (if present), by using the ruler (minimum calibration: 1mm). Scanning electron microscopy study The goal of this part of the study is to assess by mean of scanning electron microscopy, the debridement and smear layer removing ability of alum solution tested as an irrigants, on the cervical, middle and apical thirds of root canals of human extracted teeth.Six freshly extracted human single-rooted teeth with straight roots, mature apex and less than 5 degree curvature, were selected for this part of the study. The crown of each tooth was removed at the cemento-enamel junction using a diamond disk. The working length of each canal was determined by placing and moving a #15 K file apically in the canal until it exited from the apical foramen. Root canals were manually instrumented according to a step-back type of instrumentation using sequential K-type files up to size #40. First,



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A B C D Figure 1: (A) This sample received a score of 1. It shows most of the dentinal tubules are open with a clean surface and very little debris. (B) This sample received a score of 2. It shows a clean surface with very little debris, a thin homogenous smear layer, and some partially open dentinal tubules. (C) This sample received a score of 3. It shows a mostly unclean surface containing debris and smear layer and few open dentinal tubules. (D) This received a score of 4. It shows an unclean surface with large amounts of debris and smear layer with no open dentinal tubules.

RESULTS mm against Staphylococcus aureus, Pseudomonus aerogenosa ,Eschericia coli, and Klebsiella sp. respectively. The results revealed that the wider inhibition zone was seen against Staphylococcus aureus, and the least inhibition zone was against Klebsiella sp.

Agar well diffusion assay The mean diameters of the zones of bacterial inhibition for the tested solution against the bacterial isolates are shown in Table 1. Alum solution were able to demonstrate antibacterial activity against all the bacteria tested, and produced inhibitions zones of 27, 25, 24 and 22

Table 1: The mean diameters of the zones of bacterial inhibition for the tested solution against the bacterial isolates Inhibition zones (in mm) produced by test solution Mean 27 25 24 22

Bacterial isolates Staphylococcus aureus Pseudomonus aerogenosa Eschericia coli. Klebsiella sp

the coronal and middle level than the apical level. (figure. 2)

Scanning electron microscopy study The data is summarized in Table 2. The tested solution removed debris and smear layer better at

Table 2: The effect of alum solution on the debris and smear layer at the three locations in the root canals Score 1 Score 2 Score 3 Score 4 Coronal third 9 3 Middle third 7 3 2 Apical third 3 4 3 2

A B C D Figure 2: Representative SEM photomicrographs of samples attributed to different root thirds: A) Score 1-coronal third, B) Score 2-Apical third, C) Score 3-Middle third, D) Score-4 Apical third.


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DISSCUSION

CONCLUSIONS

A biocompatible irrigant with antimicrobial activity and which removes smear layer along with necrotic and organic debris is desirable, as long as predictable and complete bacterial elimination does not appear to be possible, either with traditional hand instrumentation or with newer rotary NiTi – systems. With the latter at least 35 per cent of root canal surfaces still remain uninstrumented. (24) This study is the first to report the feasibility of alum as an endodontic irrigant, based on the most important requirements of an ideal root canal irrigant, which are antimicrobial activity, debridement and smear layer removing activity. Two facultative anaerobic bacterial isolates were tested (S. aureus and E. coli), which are best representing endodontic infections and were good models to be tested for antibacterial sensitivity, because these are present in all phases of the development of an infection in root canals. (25, 26) Another two bacterial isolates (Pseudomonas aeruginosa and Kiebsiella sp.) also tested; they have been isolated in open necrotic root canal system and after contamination of the root canal during the treatment. In this study, no attempt was made to test all associated organisms, because endodontic infections are polymicrobial, the antimicrobial sensitivity testing of all associated organisms is difficult and produce a great deal of confusing data, also no absolute correlation has been made between any specific microbial species or combination of species with clinical signs and symptoms. (27, 28) Analysis of the dentinal walls of all the specimens demonstrated that cleaning have been more effective on the coronal and middle thirds than on the apical third. It is possible that the size of the canals in these thirds, allowed better circulation and action of the irrigating solution, making the complete removal of the smear layer and debris more possible. These results are in agreement with those of various authors who have observed an effective cleaning action on these thirds even when different volumes of solutions and times of irrigation were employed. (29, 30) Based on the results of this investigation, it seems that alum is an effective solution for the removal of the smear layer when used as a final rinse. It does not significantly change the structure of the dentinal tubules. Studies are in progress to determine the efficacy of alum as a root canal irrigant with and without NaOCl for removing the smear layer and completely disinfecting the root canal system.

Based on the results of this study, it seems that alum solutions have acceptable antimicrobial effect on tested bacterial isolates, however this finding is promising and warrants further laboratory experiments on different types of bacteria, including strict anaerobic and species has been significantly found to persist after treatment procedures. The degree of cleanliness obtained with alum solution (concerning debris and smear layer), was highly satisfactory, however the cleaning effect was more pronounced in the coronal and middle thirds than in the apical parts of the root canals. Finally, other properties beyond antimicrobial and debridement activity must also be investigated before the final choice of an irrigant solution for clinical use, such as tissue dissolution capacity, and acceptable biologic compatibility.


REFERENCES 1. 1.Waltimo T, Trope M, Haapasalo M, Orstavik D. Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing. J Endod 2005; 31: 863-6. 2. Siqueira JF Jr, Roˆcas IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008; 34:291–301. 3. European Society of Endodontology. Consensus report of the European Society of Endodontology on quality guidelines for endodontic treatment. Int Endod J 1994; 27:115–24. 4. 4.Ferreira RB, Alfredo E, Porto de Arruda M, Silva Sousa YT, Sousa-Neto MD . Histological analysis of the cleaning capacity of nickel-titanium rotary instrumentation with ultrasonic irrigation in root canals. Aust Endod J 2004; 30:56–8. 5. Gutarts R, Nusstein J, Reader A, Beck M . In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod 2005;31:166–70. 6. Svec TA, Harrison JW. Chemomechanical removal of pulpal and dentinal debris with sodium hypochlorite and hydrogen peroxide vs normal saline solution. J Endod 1977; 3:49–53. 7. Gulabivala K, Patel B, Evans G, Ng YL. Effects of mechanical and chemical procedures on root canal surfaces. Endodontic Topics 2005; 10:103–22. 8. Heard F, Walton RE. Scanning electron microscope study comparing four root canal preparation techniques in small curved canals. Int Endod J 1997; 30:323–31. 9. Peters OA, Barbakow F. Effect of irrigation on debris and smear layer walls prepared by two rotary techniques. A scanning electromicroscopic study. J Endod 2000; 26:6–10. 10. Torabinejad M, Handysides R, Khademi A, Bakland LK.. Clinical implications of the smear layer in endodontics: a review. Oral Surg Oral Med Oral Path Oral Radiol Endo 2002; 94:658–66. 11. Shahravan A, Haghdoost AA, Adl A, Rahimi H, and Shadifar F . Effect of smear layer on sealing ability of

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canal obturation: a systematic review and metaanalysis. J Endodon 2007; 33: 96–105. Osuala FI, Ibidapo obe MT, Okoh HI, Aina OO, Igbasi UT, Nshiogu ME .Evaluation of the efficacy and safety of Potassium Aluminium Tetraoxosuiphate in the treatment of tuberculosis. European J of Biol Sci 2009; 1:10-14. Clark, J.D .North Carolina popular beliefs and superstitions. North Carolina Folklore 1970; 18:1-66. Olmez A,Can H,Ayhan H ,Olur H . Effect of an alumcontaining mouthrinse in children for plaque and salivary levels of selected oral microflora. J Clin Pediatr Dent 1998; 22:335-41. Woody R D, Millar A, Staffanou R S. Review of the pH of hemostatic agents used in tissue displacement. J Prosthet Dent 1993; 70: 191-92. Dimashkieh M R, Morgano S M. A procedure for making fixed prosthodontic impressions with the use of preformed crown shells. J Prosthet Dent 1995; 73: 95-6. NCCLS. Performance Standards for Antimicrobial Disc Suspectibility Tests. Approved Standard NCCLS Publication 1993; M2- A5, Villanova, PA, USA. Yogish K V , Maheep B , Kanika S .In vitro evaluation of antibacterial activity of an herbal dentifrice against Streptococcus mutans and Lactobacillus acidophilus. Indian J Dent Res 2008; 19(1). Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol 1966; 45: 493– 96. Monika C, Izabel C .A scanning electron microscopic evaluation of different root canal irrigation regimens. Braz Oral Res 2006; 20:235-40. Manuele M, Emiliano A, Adriano C, Loredana C, Luigi C . A Comparative study of smear layer


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removal and erosion in apical intraradicular dentine with three irrigating solutions: A scanning electron microscopy evaluation. J Endod 2009; 35:900–3. Al-Hadlaq SM, Al-Turaiki SA, Al-Sulami U, Saad AY .Efficacy of a new brush-covered irrigation needle in removing root canal debris: a scanning electron microscopic study. J Endod 2006;32: 1181-4. Soares F, Varella CH, Pileggi R .Impact of Er,Cr:YSGG laser therapy on the cleanliness of the root canal walls of primary teeth. J Endod 2008; 34: 474-7. Peters OA, Sch¨onenberger K, Laib A. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J 2001; 34:221-30. Sundqvist G. Associations between microbial species in dental root canal infections. Oral Microbiol Immunol 1992; 7:257-62. Luciana MS, Rivail AS, Sandra RF, Marina RH. Antimicrobial activity of different concentrations of NaOCl and Chlorhexidine using a contact test. Braz Dent J 2003; 14: 99-102. Sundqvist G, Johansson E, Sjogren U . Prevalence of black-pigmented Bacteroides species in root canal infections. J Endod 1989; 1: 13–19. 28.Wasfy M, McMahon K, Minah G, Falkler W. Microbiological evaluation of periapical infections in Egypt. Oral Microbiol Immunol 1992; 7:100–5. Torabinejad M, Khademi A, Babagoli J, Cho Y, Johson WB, Bozhilov K, Kim J, Shabahang S . A new solution for the removal of the smear layer. J Endod 2003; 29:170-5. Teixeira CS, Felippe MCS, Felipp WT. The effect of application time of EDTA and Naocl on intra canal smear layer removal: an SEM analysis. Int Endod J 2005; 38: 285-90.



Microleakage of class II

Microleakage of class II packable resin composite lined with flowable composite and resin modified glass ionomer cement: An in vitro study Dr. Haitham J. AL-Azzawi, B.D.S., M.Sc. (1) Dr. Nagham A. AL-Hyali, B.D.S., M.Sc. (2) Dr. Firas J. M. Al-Dabbagh, B.D.S., M.Sc. (2)

ABSTRACT

Background: Packable composites most commonly used as posterior restorative materials, however, disadvantages like polymerization shrinkage limited their use, so the aim of this an in vitro study was to investigate the microleakage of posterior packable composite(Filtek™ P-60) using different liner materials; flowable resin composite(Filtek™ Flow) and resin modified glass ionomer cement (Vitrebond TM 7150) using open sandwich technique at the proximal box of class II preparation located above the cemento-enamel junction (CEJ)in enamel. Materials and Methods: Twenty four recently extracted human upper premolars were prepared with standardized Class- II cavities as follows; Occlusal Outline Form: 2mm in bucco-lingual width and 1.5 mm in depth measured from occlusal fissure to pulpal floor. Proximal Boxes: The depth of the proximal box from the proximal cavo-surface margin to the axial wall was 2mm, so as the bucco-lingual width (2mm). The proximal box margin located 1 mm coronal to the CEJ (in enamel). The teeth were assigned into 3 groups (n=8): Group-I (control): acid etching (H H3PO4) + bonding agent (Adoper Single Bond 2 Adhesive) + posterior packable composite (Filtek™ P-60), Group-II (RMGIC): acid etching + resin modified glass ionomer cement (Vitrebond TM 7150) + posterior packable composite; Group-III (Flowable): acid etching + bonding agent + flowable composite (Filtek™ Flow) + posterior packable composite. The teeth were immersed in distilled water at 37ºC for 24 h., then thermocycled (1000X, 5°-55°C, 30 sec. dwell time) and immersed in 1% methylene blue solution for 24 h., after that the teeth were sectioned longitudinally in mesiodistal direction and dye penetration in millimeters were measured in each cavity by using stereomicroscope. Data obtained were analyzed using ANOVA and LSD tests at 0.05 significance level. Results: The microleakage of posterior packable composite (group-I) significantly (P0.05) in enamel microleakage in respect to dye penetration were detected between the two liners used (group-II and group-III), with the association flowable composite Filtek flow (group-III) showing the best results. Conclusion: The use of flowable composite (Filtek™ Flow) and resin modified glass ionomer(Vitrebond TM 7150) in the open sandwich technique decrease the microleakage of posterior packable composite(Filtek™ P-60) with margin located in enamel surface and better results with flowable composite. Keywords: Flowable, microleakage, RMGIC and packable composite. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):610).

INTRODUCTION

Packable composites are indicated for stress bearing posterior restorations with improved handling properties. (1-4) Packable composites use amalgam techniques for placement and produce acceptable interproximal contacts and because of the high depth of cure and low polymerization shrinkage of packable composites, a bulk–filling technique may be possible.(1) Clinicians are concerned with poor adaptations of the material to tooth structure when placing posterior restorations. A materials ability to seal cavity preparations can be influenced by its composition, plastic deformation flow, coefficient of thermal expansion, modulus of elasticity and the mechanical stresses caused by cavity preparation and shape.(2) Composite resins have an initial polymerization shrinkage ranging from 1.675.68%. This shrinkage leads to the pulling of the

Composite restorations have become a popular alternative to amalgam restorations in posterior teeth. Increase patient’s demand for better esthetic, possibility of mercury toxicity from amalgam and improvements in composite materials has significantly contributed the popularity of these materials. However posterior composite restorations have many clinical problems including: severe leakage, secondary caries, loss of anatomic form and high rate of wear. To overcome these short comings, Packable composites have been introduced to the dental market.(1) The increased viscosity of these materials permits for greater packability with less slumping characteristics and lower polymerization shrinkage as compared to conventional universal composites. (1)Professor, Conservative Department, College of Dentistry, Baghdad University. (2)Assistant Lecturer, Conservative Department, College of Dentistry, Baghdad University.

Restorative Dentistry

6




unprepared tooth surface using dispensing tips for application. Then the gel was removed with water spray for 10 sec. (7)

resin material from the walls of the preparations and results in a gap between the restoration and the tooth structure and causes microleakage. (3) Another factor affecting microleakage directly is the difference between the co-efficient of thermal expansion of the resin and the tooth structure. Temperature change also causes varying volumetric changes in the resin and tooth structure leading to marginal leakage. (4) However concerns related to the ability of these stiffer materials to adequately adapt to internal areas and cavosurface margins have been raised. To offset this problem, materials with low viscosity and better adapt to the cavity used under packable composites. (1) So, the purpose of this an in vitro study was to evaluate the microleakage of posterior packable resin composite restorations with and without liner using open sandwich technique at the proximal box of class II preparation located above the cemento-enamel junction (in enamel).

Bonding Immediately after blotting excess water, two coats with fully saturated brush tip of Adoper Single Bond 2 Adhesive ( see Table-1 for composition and manufacture ) was applied onto the etched tooth surface for 15 sec. with gentle

Table 1: Materials used in the study: composition and manufacturers. Material

Type

Filtek™ P-60 Posterior Restorative

Packable composite

Filtek™ Flow

Flowable composite

VitrebondTM 7150

Resin modified glass ionomer cement

MATERIALS AND METHODS Twenty four caries-free recently extracted human upper premolars were selected for this study. The teeth were cleaned and stored in normal saline until sample preparation. (5, 6) Sample Preparation The teeth were sealed with a composite resin (Swiss Tec Composite, Coltene Whale dent) at the root apices and each tooth embedded in acrylic mould to hold the tooth during cavity preparation, restorative and testing procedures. (5) Cavity Preparation In each tooth, standardized Class II cavities prepared as follow: • Occlusal Outline Form: 2 mm in buccolingual width and 1.5 mm in depth measured from occlusal fissure to pulpal floor. • Proximal Boxes: The depth of the proximal box from the proximal cavo-surface margin to the axial wall was 2 mm, so as the bucco-lingual width (2mm). The proximal box margin located 1 mm coronal to the CEJ (in enamel).(5) The cavity preparations were prepared by using high-speed hand piece with water spray and #1090 diamond fissure bur (Diatech Dental AG, Heerbrugg, Switzerland). The teeth were divided into three groups of 8 cavities each.

Adoper single bond 2 adhesive

Super etch gel

Total Etching

Manufacturer

3M ESPE, St. Paul, MN, USA



HEMA, ethanol, water, bis-GMA, functional copolymer of polyacrylic and polyitaconic acids


37% Phosphoric acid etchant gel

SDI, Australia

agitation, then gently air dried for 5 sec. to evaporate solvents and light cured for 10 sec., according to manufacturer's instruction.(5) Sample grouping Group- I (control): The cavities were filled with packable posterior composite (Filtek™ P-60, see Table-1 for composition and manufacture) only without lining according to manufacturer instructions. (1)

Restorative Procedure Etching Enamel and dentin were etched with Super etch gel ( 37% phosphoric acid, see Table-1 for composition and manufacture) for 15 sec., etching gel was applied to all of the prepared cavity wall approximately 0.5 mm beyond Restorative Dentistry

Water/ethanol solvent based adhesive

Composition Resins: BisGMA, UDMA and Bis-EMA Fillers: Zirconia/ silica - 61% by volume. The particle size range (0.01 – 3.5 µm) ResinsBis–GMA ,TEGDMA and Bis - EMA FillersZirconia/ silica - 47% by volume. The particle size range (0.01 to 6.0 µm) Powder: ionleachable fluoroaluminosilicate glass powder Liquid: modified polyacrylic acid With pendent methacrylate group, HEMA, water and photo-initiator

7



Group-II (RMGIC): Resin modified glass ionomer cement ( VitrebondTM7150, see Table-1 for composition and manufacture) was placed in 0.5 mm thick layer in axial wall and gingival margin using open sandwich technique and light cured for 20 sec.(7) Group-III (Flowable):- Flowable composite (Filtek™ Flow, see Table-1 for composition and manufacture) was applied in 0.5 mm increment depth in axial wall and gingival margin using open sandwich technique and light cured for 20 sec.(2) Filling The matrix band was adjusted in the matrix retainer Ivory no. 8, then the retainer and the band were seated around the tooth which was held in the acrylic mold.(5) The cavities were filled with packable composite as a restorative material in bulk technique by using the plastic instrument and light cured for 20 sec. to restore the cavities. All materials were polymerized using a halogen light curing unit (Dentsply, United Electronic Co.). Finishing procedure was performed with a fine diamond bur (Diatech Dental AG, Heerbrugg, Switzerland), then polished with a graded series of Sof-Lex discs (3M ESPE, St. Paul, MN, USA). Care was taken to avoid polishing the cervical margin. (7) Testing procedure All teeth were stored in distilled water at 37ºC for 24 hours using incubator (JRAD, China), then thermocycled for 1000 cycles, with baths held between 5˚C and 55˚C, a dwell time of 30 sec. The teeth were previously sealed with a composite resin at the root apices, and two coats of nail varnish were applied on the tooth within 1mm of the restoration margins.(5) The teeth were then immersed in a 1 % methylene blue solution (Gain land Chemical Company, UK) for 24 hours at room temperature. Subsequently they rinsed with tap water and dried at room temperature (7). All specimens were sectioned longitudinally in mesiodistal using a water-cooled; slow-speed diamond saw ISO 524 (Top Dent, Swiss Made). The lengths of the dye penetration in millimeters were examined with a stereomicroscope (40X magnifications, Hamilton, BioVision 320). (5) Statistical analysis was performed with SPSS software package (version 19.0). Analysis of Variance test (ANOVA) and least significant difference (LSD) were performed to test for any significant difference between the groups in microleakage values. The mean difference is significant at the 0.05 level.



RESULTS The mean and standard deviation of microleakage values are presented in (Table- 2) and (Figure- 1). The data showed that there is statistically significant difference (p0.05) between group-II and III in microleakage reduction (Table- 4).

MICROLEAKAGE OF PACKABLE COMPOSITE

0.7875 0.6375

0.55

3

2

0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

1

Figure 1: Graphical presentation of microleakage values of all groups of the study.

DISCUSSION Packable composites most commonly used as posterior restorative materials, however, disadvantages like polymerization shrinkage, high co-efficient of thermal expansion and increased wear, limited their use. Further research led to improvements in wear resistance and strength but the problem of polymerization shrinkage remained. Polymerization shrinkage resulted due to the contraction of the resin during curing and is in the range of 1.67-5.68%. This polymerization shrinkage results in the formation of a marginal gap which can ultimately lead to increased microleakage, (8) so various techniques and modifications in the material were proposed to overcome and minimize polymerization shrinkage and microleakage. These included changes in filler content, use of expanding resin matrices and modifications in curing techniques like soft curing, ramped curing and delayed curing.(9) They observed that when the material is 8



group in this study showed that using of flowable composite as liner under packable composite significantly reduced microleakage more than RMGIC, this result due to low filler loading of flowable composite (47% by volume) that enhanced flow and reduced elastic modulus. These two characteristics reduce microleakage by increasing adaptation and forming an elastic stress-absorbing layer (8) These results in agreement with studies by, Leevailoj et al.(1), Peutzfeldt and Asmussen (8) and Stefanski and van Dijken (12) . The reduction in microleakage values by using two types of liners, measured when the margin of class II cavity located at enamel surface. Enamel has homogeneous structure, hydrophobic character and strong adhesion achieved with its inorganic tissue. (13) In the future, further clinical studies and researches needed to compare between these two liners at margin located in dentin surface.

in more rigid state, most of the polymerization cannot be observed and is transmitted to the adhesive interface. Here, the contraction stress can become responsible for opening marginal gap. It has been proposed that an “elastic” layer at the restoration base be incorporated to act as a stress absorber, not only of the functional loads but also of the internal tensions induced by composite polymerization. (8, 10) In our study, the concept of using various liners as stress absorbing cushions to minimize polymerization shrinkage was proposed; two types of materials (resin modified glass ionomer cement and flowable composites) were experimented as stress absorbing liners. The use of GIC as lining material in conventional sandwich restoration reduces considerably the bulk resin composite used, thus the amount of polymerization shrinkage of the composite resin is decreased and the marginal adaptation may be improved. A further advantage of the sandwich technique is the fluoride-release property of GICs, which is considered to have some inhibitory effect on caries formation and progression around the restoration. The sandwich restorations using RMGIC showed significantly less dye penetration than control group (packable composite without lining), this result in agreement with the results of Chuang et al.(6) and Donly et al.(11). RMGIC obtained by adding a resin, usually the water-soluble polymerizable 2-hydroxyethyl methacrylate (HEMA), to the liquid and its bonding process to tooth structure takes place by micromechanical retention, like in resin composites. The setting reaction of RMGIC follows two distinct mechanisms: resin polymerization and acid-base reaction. The better sealing produced by RMGIC is a result of the formation of resin tags into the dentinal tubules allied to the ion exchange process present in the interface between dentin and RMGIC, this assumption stands to be the reason for the superior performance of the RMGIC. In addition, the presence of HEMA in the RMGIC is responsible for the increased bond strengths to resin composite and prevent dye penetration through the interface of these materials, as demonstrated by the results of the present study. The shrinkage stresses of resin composites during polymerization create forces that compete with the adhesive bond, and this may disrupt the bond to cavity walls, which is one of the main causes of marginal failure and, subsequent, microleakage. The main rationale behind the use of flowable composites is the formation of an elastic layer that may compensate for the polymerization shrinkage stresses.(5) The third Restorative Dentistry


CONCLUSIONS Under the conditions of this an in vitro study: • None of groups tested were able to totally prevented microleakage at enamel margin. • Microleakage of packable composite significantly decreases by using of RMGIC and flowable composite as lining. • Microleakage of flowable composite with margin located at enamel surface less than resin modified glass ionomer in open sandwich technique.

•

There were no significant differences between two liners tested in term of microleakage.

REFERENCES 1.

2.

3.

4.

5.

6.

9

Leevailoj C, Cochran MA, Matis BA, Moore BK, Platt JA. Microleakage of posterior packable resin composites with and without flowable liners. Oper Dent. 2001; 26 (3): 302-7. Neme AL, Maxson BB, Pink FE, Aksu MN. Microleakage of Class II packable resin composites lined with flowables: an in vitro study. Oper Dent. 2002; 27 (6): 600-5. Tung FF, Hsieh WW, Estafan D. In vitro microleakage study of a condensable and flowable composite resin. General Dent. 2000; 48 (6): 711-5. Tung FF, Estafan D, Scheren W. Microleakage of a condensable resin composite: an in vitro investigation. Quintessence Int. 2000; 31: 430-34. Sensi LG, Marson FC, monteiro S J. Flowable Composites as Filled Adhesives, A Microleakage Study. J Cont Dent Prac. 2004; 5(4): 1-5. Chuang SF, Jin YT, Lin TS, Chang CH, GarciaGodoy F. Effects of lining material on microleakage and internal voids of class II resin-


7.

8.

9.

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11.

12.

13.


based composite restorations. American J Dent. 2003; 16 (2): 84-90. Bona A, Pinzetta C, Rosa V. Effect of acid etching of glass ionomer cement surface on the microleakage of sandwich restorations. J appl oral sci. 2007; 15(3): 230-4. Peutzfeldt A, Asmussen E. Composite restorations: Influence of flowable and self curing resin composite linings on microleakage in vitro. Oper Dent. 2002; 27: 569-575. Goracci G., Mori G. and de’ Martinis L.C. Curing light intensity and marginal leakage of resin composite restorations. Quintessence Int. 1996; 27: 355-362. Beznos C. Microleakage at the cervical margin of composite Class II cavities with different restorative techniques. Oper Dent. 2001; 26: 60-69. Donly ZR, Segura A, Donly KJ. In Vitro Microleakage of Two Glass Ionomer Cements. IADR/ AADR/ CADR 85th General Session and Exhibition (March 21-24, 2007); Seq#71 (Internet site:http://iadr.confex.com/iadr/2007orleans/techpro gram/abstract_88957.htm. Date of access: 01/11/2011). Stefanski S, van Dijken JWV. Clinical performance of a nanofilled resin composite with and without an intermediary layer of flowable composite: a 2-year evaluation. Clin Oral Invest. 2012; 16(1):147–153. (IVSL) Loguercio AD, Bauer JR, Reis A. Microleakage in class II composite resin restorations: total bonding and open sandwich technique. J Adhes Dent. 2002; 4(2): 137-44.


Table 2: Descriptive Analysis: Mean, Standard deviation of microleakage values of the groups. Groups Group-I (Control) Group-II (RMGIC) Group-III (Flowable)

N

Means

SD

Min.

Max.

8

0.78

0.124

0.6

1

8

0.63

0.106

0.5

0.8

8

0.55

0.119

0.4

0.7

Table 3: One Way- ANOVA Test for all groups

Between Groups Within Groups Total

Sum of Squares

D.f

Mean Squares

0.231

2

0.115

0.287

21

0.014

0.518

F

PValue

Sig.

8.43

0.002

S

23 S: significant

Table 4: LSD test compare between the groups in microleakage values (mm) Groups I vs. II I vs. III II vs. III

Pvalue 0.018 0.001 0.150

Level of significant S S NS

NS: non- significant, S: significant


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A comparison between

A comparison between the arbitrary and kinematic intercondylar distances of full mouth rehabilitation patients (An in-vivo study) Ma'an R. Zakaria, B.D.S., M.S., Ph.D. (1) Hussain F. Al-Huwaizi, B.D.S., M.Sc., Ph.D. (1) Widad A. Alnakkash, B.D.S., M.Sc. (2)

ABSTRACT Background: The intercondylar distance can change the radius of movement and affect the arcs traveled by the cusps during lateral mandibular excursions in the horizontal plane. The aim of this study was to record and compare the intercondylar distances of male and female patients requiring full mouth rehabilitation by using arbitrary and kinematic face-bows. Materials and methods: Interfacial widths of fifty asymptomatic male and female full mouth rehabilitation patients were recovered from arbitrary and kinematic face-bows. Intercondylar distances were recorded and statistically compared. Results: Results indicated that arbitrary and kinematic intercondylar distances of male patients were significantly greater than females indicating asymmetry in locating the condylar axes of rotation in both sexes. Conclusion: The majority of intercondylar distances of patients were more than 110 mm indicating that an articulator with an adjustable intercondylar distance would be more anatomically correct for the treatment of full mouth rehabilitation cases. Key words: Arbitrary, Kinematic, Intercondylar distance. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):11-17).

The importance of the ICD has been stressed by Mahan et al. (4) in that both the immediate and progressive side shifts were sensitive to recording point location of mandibular hinge axis where positions forward and above the true hinge axis created the greatest variations. Their study showed that it would be difficult to compare condylar movements across subjects if recording points were different which necessitate locating the terminal hinge axis with kinematic face-bows. The mediolateral location of the centers of rotation (i.e. the intercondylar distance) can also change the radius of movement and affect the arcs traveled by the cusps during lateral mandibular excursions in the horizontal plane. If the intercondylar width is accurately measured and duplicated on the articulator and if the casts are mounted accurately, the arc of movement of the articulator will approximate that of the mandible. Accurate location and size of morphologic features on the occlusal surface of the restoration are more easily achieved (3). Slight errors appear in the arcs of movement of the cusps between the articulator and the mandible when the ICD of the articulator is less than or greater than that of the mandible. Errors of similar magnitude occur when the casts on the articulator are moved closer to the condyles or farther from them. However, when the casts are mounted on a small hinge articulator, the error produced on the nonworking side is of a much greater magnitude. In this situation, there is an increased likelihood

INTRODUCTION The intercondylar distance (ICD) is "the distance between the rational centers of each condyle" (1). Within the confines of each condyle there is an area defined as "the rotation center" which is an imaginary geometric point through which the three axes of rotation trisect at right angles to each other when the condyles are in their most distal, unstrained, retruded positions in their respective fossae: the horizontal, vertical and sagittal axes of the mandible and condyles. During 3-dimensional movements of the jaw, the condyles rotate around and linearly translate along these axes thus the name hinge axis, or terminal hinge axis (2). The terminal hinge axis is a fixed anatomic and geometric reference axis that can be relocated repeatedly by mechanical methods. This point is stable in a healthy, physiologically functioning adult joint and can be used as a reference point with accuracy for mounting casts or measuring jaw movement. Although the condyles in most people do not function from the terminal hinge position, it is biologically considered a physiologic position when there is an absence of both premature occlusal tooth contacts during mandibular closure and dysfunction in the stomatognathic system (3).

1. Professor, Department of Conservative Dentistry, College of Dentistry, University of Baghdad. 2. Professor, Department of Prosthetic Dentistry, College of Dentistry, University of Baghdad.


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of producing a nonworking occlusal interference in the restoration (5). When the ICD of the articulator is greater than that of the mandible, the paths of movement on the articulator will slightly be distal to the paths traced in the mouth. The cusp paths traveled on the articulator will be distal to those in the mouth when the casts are moved close to the condyles on the articulator. On the small hinge articulator, there is a major discrepancy between the nonworking cusp path and that in the mouth (5). An important relationship between the path of lower teeth and the ICD exists; if anterior guidance is determined and fabricated from articular settings, differences in ICD would result in significantly enough difference in the path of the lower incisal edges to affect the lingual contours of the upper anterior teeth (2). It has been reported that the "Pantronic" electronic pantograph (Denar Corp., USA) records mandibular movements and computes the articulator settings but it does not determine the ICD hence it approximates it from the interfacial width at the condyles. An average distance of 12.5 mm was calculated to be subtracted from each side to determine the ICD (6). To confirm that, Mandilaris et al. (7) recorded 45 patients' articulator ICDs that had been set from a "mechanical pantograph" and they were compared with the Pantronic's approximation. The mechanical pantograph recordings were transferred to a Denar D-5A fully adjustable articulator with a telescoping mounting axis positioned between them. This instrument indicates the transfer of the ICD as it directly subtracts 12.5 mm x 2 from the subject's interfacial width. The mean ICD for the subjects was 113.2 mm and a statistically significant difference was found between the mean ICDs of men and women. Their conclusion was that an asymmetry in the location of the condylar axes of rotation should be expected in most patients (7). The relationship between the ICD and the interdental widths of the upper and lower canines and first molars were clinically studied to aid in denture teeth positioning. Results indicated that ICD measurements can be used for setting up canines and first molars in complete dentures since ICD remains fairly static throughout life unlike setting teeth according to anatomical landmarks which are few and far from posterior teeth and are subject to the unusual constraint of soft tissue anatomical landmarks which may change as a result of resorption or ageing (8). It has been concluded that the ratio of occlusal vertical dimension (OVD) to intercondylar width could be helpful in determining the OVD for Restorative Dentistry


patients receiving multiple fixed restorations on natural teeth or fixed full arch prosthesis on implants where the OVD determination is essential for achieving better esthetics and function (9). The aim of this study was to record and compare the intercondylar distances of male and female patients requiring full mouth rehabilitation by using arbitrary and kinematic face-bows.

MATERIALS AND METHODS Fifty asymptomatic adult patients (25 females and 25 males) aged 30 to 65 years who required extensive occlusal rehabilitation treatment (patients with either generalized loss of incisal and occlusal morphology due to attrition and faceting of teeth, extensive defective restorations, or multiple missing teeth, associated with moderate or severe OVD collapse) participated in this study. Full mouth rehabilitation patients were recruited from patients seeking fixed prosthodontic work at the Department of Conservative Dentistry, College of Dentistry, University of Baghdad. The criteria for patients' selection concentrated on the status of being healthy with no oral pathology or history of TMJ pain or dysfunction. Full series of periapical xrays and a panoramic radiograph were taken for each patient. Arbitrary mandibular hinge axis location was achieved by placing the index finger tip over the TMJ area and asking the patient to open wide so that when the condyle translated forward, the finger tip dropped into the depression where the condyle was. The patient was asked to close and as the condyle translated back; its position was located by the finger tip. The procedure was repeated to feel the condyle rotation and locate the axis within an average of 2 mm or less since the axis generally occurs near the center of the depression felt by the finger tip. When that point was located, it was marked as a dot by an indelible pencil (2). A measurement method was applied by placing a ruler on an imaginary line running from the patient's superior border of the tragus of the ear to the outer canthus of the eye. The arbitrary axis was marked on the skin at eleven mm anterior to the tragus (10). Arbitrary face-bow record was performed using the Hanau face-bow (Fascia-Bow 132-2SM, Teledyne-Hanau Co., NY, USA). A piece of softened modeling wax was placed on the bite fork and pressed against the upper teeth and held in position by the patient's thumbs. The face-bow was attached to the bite fork with its bow parallel to the patient's eyes and its axis locator rods were set to touch the skin marks on both sides at the same setting. The set screw was tightened to lock 12




the bite fork into the correct relation with the facebow (Fig.1). The face-bow assembly was removed and the distance between the tips of its two axis locator rods was measured by an electronic caliper (Prokit's Industries Co., Ltd, Taiwan) to verify the interfacial distance (Fig. 2).

Figure 3. Marking the terminal hinge axis at the tip of the stylus of the kinematic facebow. The kinematic face-bow assembly was detached from the universal clutch which was taken out of the patient's mouth and the interfacial width (IFW) was measured by the electronic caliper (Fig.4).

Figure 1. Arbitrary face-bow registration.

Figure 2. Measuring the IFW scored by the arbitrary face-bow using the electronic caliper.

Figure 4. Measuring the IFW scored by the Kinematic face-bow. Intercondylar distance was then determined by the graduated scale on the TMJ fully adjustable articulator (TMJ Instrument Co., Inc., USA) after subtracting 12.5 mm from the measured readings on both sides (i.e. 25 mm)(6). The 12.5 mm is the distance between the center of condyle ball and tip of condyle pin. The condyle posts were locked at the determined final measurements (Fig.5).

Terminal mandibular hinge axis location was performed using the TMJ kinematic face-bow (TMJ Instrument Co., Inc., USA) following the manufacturer's instructions. Adjustments were made by the micro-adjustment screws of the kinematic face-bow to allow for superior/inferior adjustments of the side arms until the stylus didn't translate when the mandible was arced indicating the pure rotational axis of the condyle thus locating the terminal hinge axis of the mandible. The procedure was performed on each side of the patient. When the axis locator pin of the stylus achieved a pure rotational movement, its pin point location was marked on the hinge axis flags' graph paper grids on both sides. The hinge axis flags were removed, styli moved out to mark its tip with graphite pencil and with holding the supported mandible in terminal hinge position, and each stylus was moved toward the skin to mark it (Fig. 3).

Figure 5. Face-bow styli engaged into condyle pin holes of the TMJ articulator.

RESULTS Descriptive statistics of the arbitrary interfacial width (AIFW) and the arbitrary intercondylar distance (AICD) are shown in Table 1 and Fig.6. ANOVA test results revealed a highly significant difference between the tested groups (Table 2).


13



Table 1: Descriptive statistics of (AIFW) & (AICD) of females & males (in mm). Groups AIFW, F AICD, F AIFW, M AICD, M Total

Mean 135.09 110.58 145.59 120.67 127.98

S.D. 9.666 9.294 6.033 5.917 15.555

Min. 115.0 90.0 135.4 110.4 90.0


Table 5: ANOVA test results of (KICD). KICD Groups Between Groups Within Groups Total

Max. 153.1 128.1 159.3 134.3 159.3

Sum of Squares

df

Mean Square

F

Sig.

1355.53

1

1355.53

24.276

HS

2680.25

48

55.839

4035.79

49

Student's t-test results of the KIFW and the KICD scored also highly significant differences between males and females (Table 6).

Table 6: Group Statistics (Student's t-test) results of (KIFW) & (KICD). Group

Mean (mm)

S.D

F M F M

131.4 141.8 106.4 116.9

8.78 5.87 8.78 5.87

KIFW

Figure 6: Means of (AIFW) & (AICD) of females & males (in mm).

KICD

Table 2: ANOVA test results of (AIFW) & (AICD). AIFW & AICD Groups Between Groups Within Groups Total

Sum of Squares

df

Mean Square

F

Sig.

17926.5

3

5975.5

95.14

HS

6029.5

96

62.8

23956.0

99

S.D. 8.786 5.870 8.786 5.871

Min 112.23 131.41 87.23 106.41

Sig.

-4.92

0.000

HS

-4.92

0.000

HS

Table 7: Student's t-test results of (AICD) & (KICD). Groups AICD, F

vs. KICD, F AICD, M

vs.

Table 3: Descriptive statistics of (KIFW) & (KICD) of females & males (in mm). Mean 131.48 141.89 106.48 116.90

P value

Investigating the source of the difference via the Student's t-test revealed no significant differences between the females' arbitrary intercondylar distance (AICD) and kinematic intercondylar distance (KICD) (P>0.05). On the contrary, significant differences were evident when comparing the AICD of male patients to their KICD (P0.05), (Fig. 7&Table, 8).

Table 4: ANOVA test results of (KIFW). KIFW Groups Between Groups Within Groups Total

Sum of Squares

df

Mean Square

F

Sig.

1354.49

1

1354.4

24.25

HS

2680.11

48

55.83

4034.60

49

Figure 7: Difference between (AICD) & (KICD) mean values of females & males (in mm). Restorative Dentistry

14



were more than 110 mm, a finding that coincided with Laurell et al. (12) conclusions that an articulator with a variable ICD would be more anatomically correct. Those findings were based on their results that the ICD measurements of 50 human dried skulls at the lateral poles were 123 mm as a maximum which were close to our females' KICD maximum range of 122.90 mm. Also, our mean KICD value of both sexes was 111.6964 mm which strongly corroborates Laurell et al. (12) mean ICD value of 111.40 mm. It has been concluded that varying the patient's ICD to match that of the articulator produced a significant change in the anterior horizontal table tracing, i.e. the Gothic arch tracing, which explains why patients' greater ICDs simulation cannot be precisely duplicated in articulators with fixed ICDs (13). In this study, the mean KICD of both male and female patients (111.6964 mm) was close to that recorded by Mandilaris et al. (7) (113.2 mm) who also found statistically significant differences between the male and female patients which was attributed to asymmetry in the location of the condylar axes of rotation in most patients. Dawson (2) stated that "the width of human faces is surprisingly consistent and very few patients will have an intercondylar distance that varies more than 10 mm from the average 110 mm." In our study, the maximum mean of AICD of males was 120.676 mm which agreed with Dawson's statement. Tradowsy (14) found that the mean KICD was 108.0 mm for men and 102.0 mm for women, a difference reported to be significant. Based on the data gathered, Tradowsy concluded that a semiadjustable articulator with a fixed average ICD of 110 mm is better suited for men than for women while an articulator with a lowerlimit of 96 mm ICD such as the Denar D-5A fully adjustable type (Denar Corp., USA) won't be adjustable for 20% of women and 5% of men having a smaller ICD. An adjustment range of 80 to 130 mm was suggested since it would miss only one woman in 10,000 at the lower limit (with an ICD smaller than 80 mm), and one man in 10,000 at the upper limit (with an ICD larger than 130 mm). Since the TMJ fully adjustable articulator used in our study possesses an ICD ranging between 80 to 160 mm, therefore, it can be considered adjustable for most cases. Our results concerning the KICD were different in the mean value of both sexes (111.6964 mm) from that of dos Santos and Ash(15) (102.0 mm). On the other hand, the AICD mean values scored by the Hanau arbitrary face-

Table 8: ANOVA test results of the difference between the (AICD) & (KICD) mean values. Diff. of AICD & KICD Groups Between Groups Within Groups Total

Sum of Squares

df

Mean Square

F

0.027

1

0.027

0.041

31.668

48

0.660

31.695

49

Sig.

NS

Concerning the AIFW and AICD, KIFW and KICD, all male patients' mean values were greater than those of the females. Total means of the AICD (115.6282 mm) were more than the KICD (111.6964 mm) with a difference of 3.9318 mm (Table 9).

Table 9: Total means of (AIFW & KIFW) & (AICD & KICD). Measured distances (mm) AIFW AICD KIFW KICD

Female

Male

Total mean

135.0964 110.5804 131.4896 106.4896

145.5960 120.6760 141.8992 116.9032

140.3462 115.6282 136.6944 111.6964

DISCUSSION In this study, estimation of the AICD and KICD for each patient was performed following Clayton and Beard (6) who, by applying the Pantronic pantograph, had tested the average distance between the vertical condylar axes of rotation and the surface of the skin at the condylar region and found it to be 12.5 mm which was recommended by the Denar Corp., USA. This finding was accurate for 60% of their study patients. The authors recommended subtracting 12.5 mm x 2 from the subject's interfacial width to determine his ICD. The results of our study revealed that the arbitrary and kinematic interfacial widths of the male patients were greater than the females, a difference which was highly significant. Such finding may be attributed to the large craniofacial skeleton measurements of the males compared with the females. The intercondylar distance (ICD) of the Hanau H-2 semiadjustable articulator is fixed at 110 mm and patient simulation with an ICD greater that 110 mm couldn't be precisely duplicated (11). On the other hand, the TMJ articulator is provided with an adjustable ICD of a range up to 160 mm which was suitable with most of the measured ICDs in our study since the majority Restorative Dentistry


15



bow (115.6282 mm) were close to that of dos Santos and Ash (114.667 mm). Comparing our results to those of Biserka et al. (16) the means of the KICD of both male and female patients were greatly different. Our mean KICD of both sexes was 111.6964 mm compared to 126.0 mm of Biserka et al. study who referred their highest scores, compared to other studies, to the larger craniofacial skeleton of the Croatian subjects. On the other hand, our findings concerning the significant differences which lied between the KICDs of the male and female patients coincided with those of Biserka et al. results. In a study designed by Keshvad et al. (8) to investigate the relationship between ICW and interdental widths of the upper and lower canines and first molars to aid in denture teeth positioning, the mean of the KICD of the female and male subjects was 104.0 mm and 117.9 mm respectively which was close to that of our study (106.4896 mm for females & 116.9032 mm for males). The group means of the KICD of both sexes in our study (111.696 mm) was also close to that of Keshvad et al. study (112.19 mm). Also, in our study, the female patients had a significantly shorter KICD than the males which agreed with Keshvad et al. findings. In our study, the mean of the AICD of males (120.6760 mm) was significantly higher than that of Keshvad et al. study (108.0 mm) (8). Also, the mean of AICD of both sexes in our study (115.6282 mm) was significantly higher than that estimated by Keshvad et al. (110.54 mm) which could be attributed to the ear piece face-bow used in their study. It has been reported that any dentist might expect a range of +1.2 mm error in using this instrument/articulator combination (17). The ear piece face-bow has an ear plug which fits into the external auditory meatus to orient the facebow as the posterior reference and since the ear piece face-bow is not oriented to the arbitrary hinge axis points as in case of fascia face-bow, thus during its transfer to the articulator, the ear plug won't be seated on the condylar pins of the articulator but on the auditory pins which have the same dimensional relation to the axis of the articulator as existing between the hinge axis and the external auditory meatus (10). Our results agreed with Price et al. (18) findings in that the use of an arbitrary hinge axis compared with the terminal hinge axis as the posterior reference point will produce statistically different articulator settings and therefore, for best results, the terminal hinge axis should be selected as the

posterior reference point and located with a kinematic terminal hinge axis locator since the mouth rehabilitation requires organized approach to regain the lost function, comfort and esthetics of the patient (19).

CONCLUSIONS From the observations made in this study, the following conclusions were formulated: 1. Arbitrary and kinematic intercondylar distances of male patients were significantly greater than females indicating asymmetry in locating the condylar axes of rotation in both sexes. 2. Careful location of the terminal hinge axis as the posterior reference point instead of depending upon an arbitrary marking is recommended to avoid potential sources of error in mounting casts on the adjustable articulator thus preventing statistically different articulator settings which could critically affect the occlusion of the final fixed restorations. 3. The majority of intercondylar distances of patients were more than 110 mm indicating that an articulator with an adjustable intercondylar distance would be more anatomically correct for the treatment of full mouth rehabilitation cases.

REFERENCES 1. Glossary of Prosthodontic Terms, 8th ed. J Prosthet Dent 2005; 94(1):10-92. 2. Dawson PE. Evaluation, diagnosis and treatment of occlusal problems. 2nd ed., St. Louis, Mosby Co., 1989, pp.238-60. 3. Keshvad A, Winstanley RB. Comparison of the replicability of routinely used centric relation registration techniques. J Prosthodont 2003; 12:90-101. 4. Mahan, PE, Lundeen HC, Lupkiewicz SM, Fujimoto J, Ariet M, Gibbs CH. Reproducibility of border movements, Part 2: Sensitivity to condylar recording point location. J Prosthet Dent 1980; 43(1):94-9. 5. Hobo S, Shillingburg HT, Whitsett LD. Articulator selection for restorative dentistry. J Prosthet Dent 1976; 36:35-43. 6. Clayton JA, Beard CC. An electronic computerized pantographic reproducibility index for diagnosis of temporomandibular joint dysfunction. J Prosthet Dent 1986; 55(4):500-5. 7. Mandilaris CB, Beard CC, Clayton JA. Comparison of the intercondylar distance and the interfacial width as used with the electronic pantograph. J Prosthet Dent 1992; 67(3):331-34. 8. Keshvad A, Winstanley RB, Hooshmand T. Intercondylar width as a guide to setting up complete denture teeth. J Oral Rehabil 2000; 27(3):217-26. 9. El-Ebbadi TM. Utilizing the intercondylar width in determining the occlusal vertical dimension. A Master

Degree thesis, Department of Prosthetic Dentistry, College of Dentistry, University of Baghdad, 2007.



10. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics, 4th ed, St Louis, The CV Mosby Co, 2006, pp.31-33.

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11. Engelmeier RL, Belles DM, Starcke EN. The history of articulators:The contributions of Rudolph L.Hanau and his company-Part I. J Prosthodont 2010; 19(5):409-18. 12. Laurell KA, Whitacre JL, Stieg M. A comparison of various angles of the mandible with the condylar long axis. J Prosthet Dent 1987; 57(3): 369-74. 13. Schulte JK, Wang SH, Evdman AG, Anderson GC. Working condylar movement and its effect on posterior occlusal morphology. J Prosthet Dent 1985;54(1):118-21. 14. Tradowsy M. Sex difference in intercondylar distance. J Prosthet Dent 1990; 63(3):301-2. 15. dos Santos J, Ash MM. A comparison of the equivalence of jaw and articulator movements. J Prosthet Dent 1988; 59(1):36-41.



16. Biserka L, Berislav T, Jadranka K, Dragutin K, Tonci S, Zoran A. Intercondylar distances of the human temporomandibular joint. Coll Antropol 2006; 30(1):3741. 17. Choi DG, Bowley JF, Marx DB, Lee S. Reliability of an ear-bow arbitrary face-bow transfer instrument. J Prosthet Dent 1999; 82(2):150-56. 18. Price RB, Gerow JD, Ramier WC. Potential errors when using a computerized pantograph. J Prosthet Dent 1989; 62(2):155-60. 19. Prithviraj D, Gupta A, Saravanakumar M. Organized approach for the rehabilitation of a mutilated dentition using integration of fixed and removable prosthodontics. J Indian Prosthod Soc 2007; 7(4):203-6.

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A clinical comparison

A clinical comparison between maxillary and mandibular posterior teeth using local anesthesia and normal saline by the periodontal ligament injection (An in vivo study) Majidah K.W. AL-Hashimi, B.D.S., M.S. (1) Raad S. Al-Doori, B.D.S., M.Sc. (2)

ABSTRACT Background: Local anesthesia is the primary method used in dentistry to control patients’ pain. However, even in the presence of adequate soft tissue anesthesia, there may be incomplete pulpal anesthesia. This is particularly true in the mandible where obtaining profound pulpal anesthesia may be difficult. The periodontal ligament injection has received much attention in the dental literatures. lntraligamentary anesthesia has been advocated as a primary and a supplemental injection technique. The purpose of this study is to evaluate, with electrical pulp tester, the anesthetic efficacy of the periodontal ligament injection using 2% Lidocaine with 1:80000 epinephrine and normal saline in forty volunteers. The success rate was defined as no patient’s response to the maximum output of an electrical pulp tester. Also pain rating during initial needle penetration and injection of solution were compared. Material and method: Forty adult volunteers participated in this study. The subjects were divided into four groups (10 subjects each): Group Ia: each subject received a periodontal ligament injection in mandibular first premolar and first molar right or left side with Lidocaine injection and pulp tested each minute by EPT and Ethyl chloride. Group 1b: each subject received a periodontal ligament injection in mandibular first premolar and first molar right or left side with normal saline injection and pulp tested each minute by EPT and Ethyl chloride. Group IIa: each subject received a periodontal ligament injection in maxillary first premolar and first molar right or left side with Lidocaine injection and pulp tested each minute by EPT and Ethyl chloride. Group IIb: each subject received a periodontal ligament injection in maxillary first premolar and first molar right or left side with normal saline injection and pulp tested each minute by EPT and Ethyl chloride. Results: The results showed that the duration of profound pulpal anesthesia, using 2% Lidocaine with 1:80000 epinephrine, was 10 minutes and injection of anesthetic solution and normal saline in clinically healthy teeth were only mildly discomforting. The periodontal ligament injection using normal saline was not effective in producing anesthesia. A conclusion was drawn from the study that the periodontal ligament injection can be used effectively, as a primary injection technique, to anesthetize mandibular posterior teeth especially the first molars. Key words: Pain, PDL, local anesthesia. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):18-23).

occurs within the alveolar bone, which provides pulpal anesthesia of one or more adjacent teeth and surrounding periodontium. Attaining local anesthesia for the treatment of teeth diagnosed with irreversible pulpitis ("hot" tooth) can be a big challenge (4). Supplementary injected anesthesia is particularly suited for providing effective pain control of teeth diagnosed with irreversible pulpitis (5). It was concluded that when the inferior alveolar nerve block failed to provide profound pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis, the intraligamentary injection was successful approximately 56% of the time (6). The PDL injection and the IO injection are effective anesthetic techniques for managing nerve block failures and for providing localized anesthesia in the mandible (7). A great advantage of this injection is its ability to achieved nearly instantaneous anesthesia of one or two teeth in the mandibular arch without use of the mandibular block technique. PDL injection is used primarily when conventional anesthesia is not fully effective, when dentists require only a short duration of anesthesia, and when a patient wants to avoid the

INTRODUCTION Painful treatment has been shown to be important in the etiology of dental fear. People, who were hurt while receiving dental care, are more likely to avoid dental treatment (1). Local anesthesia is the primary method used in dentistry to control patient’s 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 (2). Several methods of providing local anesthesia are available. These include the periodontal ligament injection (PDL) or intraligamentary injection, the intraseptal injection, intraosseous anesthesia, and the intrapulpal injection. The PDL or the bone-tooth fibrous joint is an intricate and a dynamic system with a cross-talk between several mineralized and soft tissue (3). The PDL injection technique is fundamentally intraosseous injection. A small amount of anesthetic solution is deposited adjacent to the tooth to be anesthetized, and considerable diffusion of the anesthetic solution (1) Professor, Department of Conservative Dentistry, College of Dentistry, University of Baghdad. (2)Assistant lecturer, College of Dentistry, University of Sulaimani.


18



Group IIa: each subject received a PDL injection in maxillary first premolar and first molar right or left side with 2% Lidocaine injection and pulp tested each minute by EPT and Ethyl chloride. Group IIb: each subject received a PDL injection in maxillary first premolar and first molar right or left side with normal saline injection and pulp tested each minute by EPT and Ethyl chloride. The saline cartridges were prepared in the following manner: Empty anesthetic cartridges and plungers were washed for 5 minutes with soap and water using a nylon brush. All cartridges and plungers were then rinsed twice with distilled water for 1 minute and autoclaved for 50 minutes. Each cartridge was filled with 1.8 mL of sterile saline and the plungers were replaced. PDL injections were given using ligament syringe with 30-gauge ultra short needle. The needle was inserted through the mesial and distal gingival sulcus of (maxillary and mandibular first premolars) and through the mesial, distal and palatal or lingual gingival sulcus of (maxillary and mandibular first molar) to a point of maximum penetration. The bevel of the needle was directed toward the crestal bone surface, at 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 20 seconds, this procedure delivered 0.1 ml of the tested solution, (Figure 1).

lip and tongue numbness associated with mandibular block injections (8). The use of this technique in the maxillary arch is possible but less frequent, except in the incisal area, where supraperiosteal injection can be painful (9). Successful use of the PDL injection technique depends on generating a considerable amount of pressure during the use of a fine short needle to engage the entrance to the PDL of individual teeth. The ligmaject syringe possesses the advantages of a measured (0.2 ml) delivery of solution with each trigger pull, with a protective shield around the anesthetic cartridge to protect against accidental glass breakage. Unlike supraperiosteal (infiltration) or block anesthetic techniques, there is little or no sensations of soft-tissue anesthesia of the nearby mucosa, lip, chin, and so forth (10). The aim of this study was to compare the effect of PDL injection in producing pulpal anesthesia, using 2% Lidocaine with 1:80000 Epinephrinc and Saline, in human maxillary and mandibular posterior teeth by using electrical pulp tester and ethyl chloride (cold application).

MATERIAL AND METHODS Forty adult volunteers, 23 Males and 17 Females, participated in this study. The age of subjects ranged from 18-25 years with average age of 22 years. All subjects were in good health and were not taking any medications, which might alter their pain perception. No subject had contraindications or sensitivities to a PDL injection with any of the solutions tested. The subjects had maxillary and mandibular first premolars and first molars free of caries, deep restorations, and had no exposed dentine. Any tooth exhibited mobility, more than 0.5 mm in any direction, was excluded. All subjects had mandibular first Premolar and first molar or maxillary first premolar and first molar, left or right sound and not inflamed. Each tooth was pulp tested by electrical pulp tester and ethyl chloride before and after anesthesia, or normal saline injections to verify a base line data of vitality. The subjects were divided into four groups (10 subjects each):Group Ia: each subject received a PDL injection in mandibular first premolar and first molar right or left side with 2% Lidocaine injection and pulp tested each minute by EPT and Ethyl chloride. Group Ib: each subject received a PDL injection in mandibular first premolar and first molar right or left side with normal saline injection and pulp tested each minute by EPT and Ethyl chloride.


A clinical comparison

Figure 1: Injection technique. The pain rating of the initial needle penetration and injection of solution were obtained and it was as follows: score zero (no pain), score one (mild pain “pain which was recognizable but not discomforting”), score two (moderate pain “pain which was discomforting, but bearable”), score three (severe pain “pain which caused considerable discomfort and was difficult to bear”), all injections were given by the principle investigator, another operator recorded the scores of pain rating and of the EPT. Each tooth was isolated and dried with air for 10 seconds. A small quantity of Sanino tooth paste was applied at the tip of the EPT probe and the probe tip was placed on the middle third of the buccal surface at experimental teeth. The EPT 19



used in this study was mains-operated unipolar constant- current generator. A spring-loaded micro switch was attached to the hand electrode and was operated by the subject to start and stop the current. A micro-ammeter measured the current flow and it was calibrated from 0 to 10 micro-amps. Two consecutive reading were obtained as base line vitality readings, and immediately after the completion of each injection, a stop watch timer was started. The depth of anesthesia was monitored by pulp testing the teeth and Ethyl chloride stimulation (the second reading of Ethyl chloride obtained at the minute of complete anesthesia). The experimental teeth were tested at postinjection times of 1, 2, 3, 4, 5, 6... until complete anesthesia obtained, which is the absence of the patient response at the maximum output of the pulp tester. At this minute the second reading of Ethyl chloride was obtained. The electrical pulp testing was repeated each minute until the effect of anesthesia was finished and the tooth returned to the normal status.

Table 3: Percentages of solution deposition pain ratings

Moderate 27.5% 37.5%

Groups U4 & U6 U4 & L4 U4 & L6 U6 & L4 U6 & L6 L4 & L6

Mild p-value 0.505 0.639 0.371 0.827 0.801 0.639

Moderate p-value 0.3 17 0.640 0.038 * 0.640 0.157 0.09 1

Severe

55 % 52.5 %

2.5% 2.5%

None pvalue 1.00 1.00 0.850 0.551 0.391 0.198 1.00 0.357

Mild pvalue 0.178 0.424 0.476 0.151 0.677 0.796 0.795 0.347

Moderate pvalue 0.34 0.227 0.396 0.561 0.641 0.726 0.515 1.00

Severe pvalue 1.00 0.391 1 .00 0.391 1.00 1.00 0.391 0.391

Tables 6, 7 and 8 show statistical comparisons of mean (anesthetic, normal saline, and the both together) onset time in minutes.

Table 6: Statistical comparisons of mean anesthetic onset time (minutes)

Severe 2.5% 5%

Groups U4.A U6.A U4.A L4.A U4.A L6.A U6.A L4.A U6.A L6.A L4.A L6.A

Severe p-value 1.00 1.00 0.391 1.00 1.00 1.00

* Significant difference at level P .05).

Sig. H.S.

Table 12: one way analysis of variance for consistency test

Sig. N.S N.S. H.S. H.S.

P 0.654

d.f. 4 45 49

Mean

A-B A-C A-D A-E

Between groups Within groups Total

d.f. 4 40 44

F 6.897

P 0.003

Sig. H.S.

Table 13: LSD for consistency test

Sig. N.S.

Test groups

Mean difference

P

Sig.

A-B A-C A-D A-E

-5.7778** -3.6667** -3.7778** -4.0000**

0.000 0.002 0.002 0.001

H.S. H.S. H.S. H.S.

** Mean difference is highly significant when P < .01

Table 14: one – way analysis of variance for dry compressive strength of dental stone

Table 8: one–way analysis of variance for the compatibility of dental stone with silicone impression materials d.f. 4 45 49

0.659 0.596 0.000 0.537

groups

Table 7: one–way analysis of variance for the compatibility of dental stone with alginate impression materials d.f. 4 45 49

0.5000 -0.6000 -6.4000** -0.7000

Test

** mean difference is highly significant when P < 0.01


A-B A-C A-D A-E

Table 11: LSD for the compatibility of dental stone with ZOE impression materials

Table 6: LSD for the reproduction of details Test groups A-B A-C A-D A-E

Sig.


Table 5: one-way analysis of variance for details reproduction d.f. 4 45 49

P

Sig.

** mean difference is highly significant when P < 0.01


Mean difference

Table 10: one–way analysis of variance for the compatibility of dental stone with ZOE impression materials

Table 4: LSD for setting expansion Test groups A-B A-C A-D

Test groups

** The mean difference is highly significant at the .01 level The mean difference is N.S when P > .05

Table 3: one -way analysis of variance for the setting expansion d.f.

The effect of addition

P 0.000


Sig. H.S.

41

d.f. 4 11 15

F 59.780

P 0.000

Sig. H.S.



Table 15: LSD for the data of dry compressive strength of dental stone Test groups

Mean difference

P

Sig.

A-B A-C A-D A-E

313.16367** 26.53833 95.54175** 79.61800**

0.000 0.266 0.001 0.005

H.S. N.S. H.S. H.S.


Table 21: LSD for the data of surface hardness of dental stone (after 7 days) Test groups A-B A-C A-D A-E

Mean difference 0.0635 -0.1632 -0.2298 -0.1964

P 0.834 0.591 0.452 0.519

Sig. N.S. N.S. N.S. N.S.

The mean difference is not significant when (P >

** The mean difference is highly significant at the .01 level (P < .01)The mean difference is not significant at the .05 level (P > .05).

.05).

Table 16: one–way analysis of variance for wet compressive strength data of dental stone Between groups Within groups Total

d.f. 4 10 14

F 715.812

P 0.000

Sig. H.S.

Table 17: LSD for the wet compressive strength of dental stone Test groups

Mean difference

P

Sig.

A-B A-C A-D A-E

103.4091** -143.1818** 2.6515 31.8182**

0.000 0.000 0.588 0.000

H.S. H.S. N.S. H.S.

Figure 1: Setting time of dental stone

Table 18: one way analysis for variance for hardness test (after 1 day) d.f. 4 20 24


F 5.608

P 0.003 P .05

Figure 3: Reproduction of details of dental stone

Table 20: one – way analysis of variance for the data of surface hardness test of the dental stone Between groups Within groups Total

d.f. 4 20 24

F 0.373

P 0.825

Sig. N.S.

Figure 4: The compatibility of dental stone with alginate


42



Figure 5: The compatibility of dental stone with silicone impression materials

Figure 9: Surface hardness of dental stone

Figure 6: The compatibility of dental stone with ZOE impression materials

Figure 7: Consistency of dental stone

Figure 8: Dry compressive strength of dental stone



43



Comparison the tensile

Comparison the tensile strength of heat cure and visible light cure acrylic resin denture base Zahraa N. Al- Wahab, B.D.S., M.Sc. (1) Bassam A. Hanna, B.D.S., M.Sc. (2) Shakwaan K. Kadir, B.D.S., M.Sc. PhD. (2)

ABSTRACT Background: Visible light cured acrylic resin denture materials are one of the developed polymeric acrylic denture base and are manufactured in the form of sheets and rapes, and also in powder and liquid system, they can be adapted for various dental uses and provides rapid service at low cost. This study aimed to compare the tensile strength of heat cured acrylic resin and visible light cured acrylic resin. Materials and Methods: Twenty samples of acrylic denture base materials were prepared, ten samples of heat cured acrylic denture base materials and ten samples of visible light cured acrylic denture base material. After curing of both groups, the materials were subjected to tensile strength test with the use of Instron universal testing machine. Results: The results of the present study showed a high significant difference comparing between the two groups; heat cured acrylic denture base material showed a high significant tensile strength than the visible light cured acrylic denture base material. Conclusion: heat cured acrylic denture base resin showed superiority in the tensile strength values than the visible light cured acrylic denture base material. Key words: heat cures acrylic, visible light cure acrylic, tensile strength. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):4447).

In 1984, visible light – cured base resins became available to profession and marketed under the trade name " triad " which was suitable for many prosthodontic applications , removable , fixed and maxilla facial prosthesis . (4) Since then the use of these materials has increased with new products being used for the relining and repair of dentures. (5,6,7) The light output of light curing units is designed to promote an intensity great enough to cure the deeper parts of the body of the resin, the conversion from soft to solid material relies on the ability of the light to access and initiate the curing in all parts of the restorative material , so high intensity light results in deep polymerization of the material to a depth of (6mm).the cure of visible light cure resin material is most effectively initiated by light in the wave length range 450-500 nm .( 8 ) Tensile strength is the resistance of the material to a tensile or stretching force (9 ). The elongation, in combination with ultimate strength is an indication of the toughness of the plastic .The larger the area under the stress; the tougher the material , while a material with less elongation will be brittle. (10). This study aimed to compare the tensile strength of heat cured acrylic resin and visible light cured acrylic resin.

INTRODUCTION The general upgrading of resin in dentistry regarding their physical and mechanical properties render the use of resin based restorative materials to rise exponentially, as dental clinician are always looking for the ideal restorative dental material, also dental community in its search for better, less expensive, easier to handle materials, is often quick to adapt a rising technology for new and different purposes.(1) The development and continued evolution of photo polymerizable dental materials represents a significant practical advance for dentistry. Photo polymerization had become an integral component in the practice of dentistry since the commercialization of this technology in the late 1960s. (2) Later, in 1980 the visible light activated system was introduced and dominates the world market and has proved its efficiency and acceptance through its rapid evolution. Initially, visible light curing materials were used to restore only anterior teeth and to seal pits and fissure. With time the use and application of these materials has been expanded with a large variety of materials including cavity liners , die materials , provisional crown and bridge materials , surgical cements , orthodontic resins and adhesive system with composite resins for posterior and anterior restorations , In 1983 , anew visible light cured resin technology was developed for use in removable prosthodontic .(3 )

MATERIALS AND METHODS Specimens grouping Twenty specimens were prepared, light cured acrylic denture base resin (Palatray, RXL, Germany) and heat cured acrylic denture base resin (Vertex Netherland) and divided into (10)

(1) Lecturer, Department of Dental Technologies, College of Health and Medical Technologies (2)Lecturer, Department of Conservative Dentistry, College of Dentistry, Sulaimaniya University


44



specimens for each of the following group : heat cured , and light cured acrylic resin .

the hydraulic press. The pressure was slowly applied to allow even flow of dough throughout the mould space. The pressure was released. The flask was opened and the over flowed material (flash), surrounding the mould space was removed with wax knife. A second trial closure was preformed; the stone surface was again coated with the separating media. The two halves of the flask were finally closed until an intimate contact had been established, and it was left under the press (1500 psi) for 5 minutes before clamping was done. Then the flask was placed in a flask clamp maintaining undisturbed pressure during ) processing.(12

Metal pattern preparation The metal pattern was constructed with dimensions of [65mm, 10mm, 2.5mm] length, width, depth, respectively according to ADA specification (11).

Curing and cooling Curing was carried out by placing the clamped flask in a thermostatically controlled water bath and processed by long curing cycle is established by heating at 74°C for 8 hours in water bath .after completing the curing process, the flask was allowed to cool slowly at room temperature for 30 minutes followed by complete cooling of the flask with tap water for 15 minutes before deflasking .The acrylic patterns were then removed from the stone mould.

Figure 1: materials used in the study

Preparation of test specimens of light cured acrylic denture base resin mold preparation Stone mold was prepared following the same method used for conventional denture base acrylic. Metal block was used with dimensions of (65mm X 10mm X 2.5mm) length, width, and depth according to the ADA specification (11). The metal is placed on a flat glass plate, separating medium is applied. Stone slurry was prepared by mixing correct water/powder ratio and it was poured onto the metal block. A second glass plate was placed over the stone mix , so the stone was sandwiched between the two glass plate .after setting of the stone .the glass plates were removed and metal block was removed , layer of separating medium was applied on the mould cavity and all set stone surface.

Figure 2: showing the metal pattern Mold preparation The lower portion of dental flask was filled with dental stone (Zeta, Italy) mixed according to manufacture instruction; metal block was coated with stone mix to avoid air trapping during insertion the metal block into the stone mix after coating with separating medium. When stone set, both the stone and metal patterns were coated with separating medium (Vertex, Netherland), the upper half of the flask was then placed on top of the lower portion and filled with stone. Stone was allowed to harden for 60 minutes before the flask was opened. The metal patterns were invested for each sample to be prepared. The flask was then opened and metal patterns were removed from the mould carefully.

Packing Light cured sheet was taken out of its light proof packing and positioned into the stone mold .the material was adapted well in the mold using finger pressure, excess material was removed by cutting with sharp wax knife and then the top surface of the stone mold was flattened with a glass plate.

Flasking Pink heat cured acrylic resin was mixed according to manufactures instructions (powder/liquid ratio is 3/1). The acrylic resin dough was packed in the mould which had been treated with separating medium. The two halves of the flask were closed together and placed under Restorative Dentistry


45




Where: TS = Tensile strength (N/m2) (then converted to MPa) F = force at failure (N) A= Area of cross section at failure (m2)

Curing The material was polymerized in the light curing unit (Engen, Germany) for 5 minutes according to manufactures instruction. Then the material was then removed from the mold, inverted and exposed to the light cured unite again immediately for additional (5minutes) to ensure complete polymerization, so the total time of curing is 10 minutes. (13)

RESULTS I-Descriptive statistics: Mean (M) and Standard Deviation (SD) are presented in Table 1. The hot cured acrylic showed higher tensile strength values than visible light activated acrylic.

Table 1: showing the mean, standard deviation for both group expressed in MPa Group Group 1 ( hot cured acrylic) Group 2 (visible light activated acrylic)

Mean 51.2

SD 0.341

16.7

0.636

Figure 3: Showing the light cure device Finishing and polishing All flashes of acrylic were removed with an acrylic bur to get a smooth surface. The acrylic bur should be used followed by (120) grain size sandpaper to remove any remaining small scratches with continuous water cooling. Polishing was accomplished by using bristle brush and pumice with Lathe polishing machine. A glossy surface was obtained with wool brush and polishing soap on dental Lathe using low speed (1500 rpm) and the specimens were continuously cooled with water to avoid overheating, which may lead to distortion of the specimens, then the final measurements of the specimens were obtained using the vernier. After finishing and polishing, the specimens were measured again to ensure exact measurement

Figure 5: Graphical representation of means by bar chart

II- Inferential statistics In Table -2, student t – test compared between tensile strength values of hot cured acrylic and visible light cured acrylic and this table revealed that there is a high significant difference when comparing between the two groups, and the hot cured acrylic produced higher tensile strength values than visible light cured acrylic.

Mechanical tensile strength test Test equipment and procedure The tensile strength was tested using Instron testing machine with grips suitable for holding the test specimens .Each specimen was set at across head speed of 0.5 mm/min. chart speed. The load cell was measured by a tensile load cell, with a maximum capacity of 200 kg. Each Specimen was loaded until fracture, and the load of fracture was recorded from the Instron graph reader in kilograms (kg) which were converted into Newton (N).

DISCUSSION

The values of tensile strength were calculated for each sample according to the following formula:TS = F/A

Visible light cured acrylic denture base material had been used in this study because it has many applications such as the fabrication of complete and partial dentures, relining material, transitional prosthesis, provisional splints, denture


Table 2: student t – test comparing between the two groups Group 1 (hot Group 2 (visible T– cured acrylic) light cured acrylic) value 51.2 16.7 27.41 HS highly significant at P – value < 0.01

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5. Havakawa I, Nagao M, Matstumoto T, Masuhara E. Properties of a new light polymerized relining material .Int J Prosth 1990 ;3:278-284 6. Mitrani R, Rubeenstein JE, Kois JC, Phillips KM. Alternative uses of a visible light –polymerized materials .J Prosth Dent 2001;85 :501-503. 7. Williamson DL, Boyer DB, Aquilino SA, Leary JM. Effect of polythelene fiber reinforcement on the strength of denture base resins polymerized by microwave energy .J Prosthet Dent 1994;72:835-8. 8. Noort RV. Introduction to dental materials .2th edition ,Hong Kong ,RDC com., 2002,Ch.2.3 9. Sakaguchi RL, Powers JM. Craig’s restorative dental materials. 13th ed. ELSEVIER MOSBY; 2012, p86. 10. Craig RG, Marcus L. Restorative dental materials .10th edition, saint Louis,Mosby Year Book,Inc.,1996.ch.19 11. ADA American Dental Association. specification no. for denture base polymer guide to Dental materials and devices,7th ed. ,Chicago Illinois 1975. 12. AL-Sheikhli AA. Evaluation of some properties of visible light cured acrylic denture base materials. A thesis submitted to the College of Dentistry, University of Baghdad in Partial Fulfillment of the requirement for the Degree of Master of Science in Prosthodontics .2005. 13. Rached RN, Power JM, Del-belcury AA. Repair strength of auto polymerizing, microwave and conventional heat –polymerized acrylic resins. J Prosthetic Dent 2004 ;92(1) :79-82. 14. Ogle RE, Sorensen SE, Lewis EA. A new visible light –cured resin system applied to removable prosthodontics .J Prosth Dent 1986 ;56(4): 497-506. 15. Gurbuz O, Unalan F, Dikbas I. Comparative study of the fatigue strength of five acrylic denture resins .J Mechan Behave Biomed Mater 2010 ;3(8) :636-639. 16. AL-Mulla MAS, Huggett R, Brooks SC, Murphy WM. Some physical and mechanical properties of a visible light –activated material. Dent Mater 1988;4:197-200. 17. Dar-Odeh NS, Harrison A, Abu-Hammad O. An evaluation of self –cured and visible light cured denture base materials when used as a denture base repair materials. J Oral Rehabel 1997 ;24:755-760. 18. Elian AA. Evaluation of transverse and Tensile strength of different Acrylic Denture base materials After Relining and Repair with a visible –light – polymerized material. A thesis submitted to the college of Dentistry , University of Baghdad in partial Fulfillment of the requirement for the Degree of Master of Science in Prosthodontics.2005

repairs and orthodontic appliances, record bases, special trays and obturators. (14) One of the mechanical properties of dental material is tensile strength. It had been chosen in this study because the material is much weaker in tension than in compression, which may contribute to failure of the material in service.(15) In the present study, two types of acrylic resin denture base were had been used: the traditional hot cured acrylic resin and the visible light cured acrylic resin denture base material, and the tensile strength of both materials was compared. The results of the present study showed a high significant difference when comparing between the two groups, since hot cured acrylic resin produced a high tensile strength values than the visible light cure acrylic resin. This is in agreement with (14,16) , who stated that the visible light cured acrylic resin material tends to be more brittle than heat cured acrylic resin. This is in agreement with Dar-Odeh et al (17) who explained this result due to the brittle nature of visible light cured acrylic resin denture base. Al-Sheikhli (12) explained such reduction in tensile strength of visible light cured acrylic resin denture base is due to their nature and composition, which consists of inorganic fillers, mainly silica incorporated in the matrix, impede interpenetrating polymer network, with less homogenicity, and giving brittle nature . These results have agreement with Elian (18) who found that this reduction is due to the composite nature of the visible light cured acrylic resin, it is completely different polymer from other acrylic resin, so this leads to such reduction in tensile strength. According to the knowledge of the authors, there are no previous studies disagree with the results of the present study.

CONCLUSION It can be concluded from this study that heat cured acrylic denture base resin showed superiority in the tensile strength values than the visible light cured acrylic denture base material.

REFERENCES 1. Rueggeberg FM. Form vulconite to vinyl,a history of resins in restorative dentistry. J Prosth. Dent 2002;87: 864-879. 2. Stansbury JW. Curing dental resins and composites by photopolymerization .J Esthet Dent 2000 ;12:300308. 3. Barateri LN. Esthetic, direct adhesive restoration on fractured anterior teeth 2nd edition, Quintesssence editor .Lt. 1998. 4. Andreopoulos AG, Polyzois GL, Demetrious PP. Repairs with visible light –curing denture base materials. Quint Int, 1991; 22:703-706.



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Evaluation of the effect

Evaluation of the effect of Nigella sativa oil and powder on healing process, histologically and radiographically (An experimental study on rabbit) Hani Sh. Mohammed, B.D.S., M.Sc. (1) Athraa Y. Al-Hijazi, B.D.S., MSc., Ph.D. (2)

ABSTRACT Back ground: Today’s world is increasingly seeking ways to replace the synthetic drugs with the therapeutic power of natural products to decrease the percentage of many side effect which result from conventional treatment; one of these products was Nigella sativa (NgS) which was used so extensively that it became known as the seed of blessing “Habbatul Barakah” due to its powerful healing qualities for many ailments. The aim of this study was to evaluate the therapeutic effect of Nigella sativa (powder and oil) on the healing process of extracted teeth sockets. Materials and Methods: The sample of our study consist of Forty eight rabbits to extract there upper two central incisors under general anesthesia. The left side filled once with Nigella sativa powder and once with Nigella sativa oil material, and the right side left for normal healing as a control group. The two sockets were sutured. The results were studied radiographically and histologically after 1,2,4,6 weeks postoperatively. The radiographic examination was performed by using parallel technique in a digital radiographic examination and histological examination was performed under light microscope for the section stained with heamatoxiline and eosin. Results: Radiographically we found that NgS powder showed more radiopacity with complete disappearance of lamina dura in 6 weeks duration compared with NgS oil and control groups, while histologically we found that the Nigella sativa (NgS) groups (powder and oil) illustrate an early apposition of osteoid tissue in 1st week duration with numerous osteoblast and osteocyte in comparision to control group.In six weeks duration well developed bone filled all the portions of the socket in treated socket with NS powder with obvious complete epithelization of socket surface Conclusion: Nigella sativa (powder or oil) seems to be bioactive materials that enhance differentiation and proliferation of progenitor cells to specialized bone formative cells, with no signs of inflammation. Keyword: Healing process, Nigella sativa. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):48-52).

INTRODUCTION Repair of bone tissue is a complex process involving a number of cellular functions directed towards the formation of a scaffold and mineralization of the defect followed by an eventual remodeling of the defect site to attain the original structure .(1) Today’s world is increasingly seeking ways to replace the synthetic drugs with the therapeutic power of natural products. Interest in medicinal plants has burgeoned due to increased efficiency of new plant-derived drugs and the growing interest in natural products. Because of the concerns about the side effects of conventional medicine, the use of natural products as an alternative to conventional treatment in healing and treatment of various diseases has been on the rise in the last few decades.(2) Many wonderful helping plants surfaced when the cultures of our world started to share trade and teach their herbal medicines to each other. One such plant was Nigella sativa commonly known as black seed.

This mild aromatic herb is indigenous to the Middle East where it has been used as a traditional remedy for over 2000 years. It was used so extensively that it became known as the seed of blessing "Habbatul Barakah" .(3) Its therapeutic use was initiated after the advent of Islam since Prophet Mohammed (peace and pray upon him) mentioned its therapeutic efficacy and potential of cure, when said that "there is cure for every disease in black seed except death".(4) Its chemical composition contains volatile and non-volatile oils in addition to many other active ingredients including proteins, alkaloids, coumarines, saponins, minerals, carbohydrates, phenolic compounds, steroidal compounds, and other ingredients .(5) Many studies have been conducted on the effect of Nagilla sativa seed extracts on varies body systems in vitro or in vivo. The pharmacological investigation of the seed extracts reveal abroad spectrum of activities including immuneopotentiation, antihistaminic, antidiabetic, antihypertensive, antinflammatory, antitumor,(6) antiparasitic, antibacterial, antifungal and antioxidant (7). In recent study, the black seed induced bone healing as manifested by faster bone trabeculae formation and mature bone formation (8) and as when a tooth is extracted, the healing process was done by two processes

1) Lecturer, department of Oral Histology & Biology, Ministry of Heath, Baghdad, Iraq. (2) Professor, department of Oral Histology & Biology, College of Dentistry, University of Baghdad.

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A.Osteogenesis B. Epithelization Therefore the present study was designed to: 1. Evaluate the effect of Nigella sativa (powder or oil) on healing process of the socket of extracted teeth. 2. Study the comparison effect of Nigella sativa (powder or oil) on healing process in different weeks.

MATERIALS AND METHODS The samples of the present study consist of Forty eight rabbits subjected to extract their upper two central incisors under general anesthesia. The left side filled once with Nigella sativa powder and once with Nigella sativa oil material, and the right side left for normal healing as a control group. The two sockets were sutured. The animals were grouped into: 1st group (24) rabbits, left socket of each rabbit filled by (0.068g) of Nigella sativa powder till 2/3 of socket length which had average length (2.3mm) after removal of blood clot by using blugger instrument. 2nd group (24) rabbits, left socket treated with Nigella sativa oil by using a piece of cotton impregnated in oil then inserted inside the socket till 2/3 of socket length after removal of blood clot and waiting for five minutes then removed it. The control group of (24) rabbits in which their sockets had been left for normal healing process without removal of blood clot after extraction process. Each group divided into four subgroups ( 5 in number); these subgroups are sacrified for each of four healing periods; 1week, 2weeks, 4weeks and 6weeks respectively and the socket examined radiographically and histologically . The radiographic examination was performed by using parallel technique in a digital radiographic examination and histological examination was performed under light microscope for the section stained with hematoxiline and eosin.

Figure1: Conventional radiographic view of sockets for rabbit’s anterior teeth of six weeks duration shows radio-opacity filled coronal, middle and apical portion of experimental (powder and oil) side (left) and the lamina dura shows to be disappear internally and externally partially disappeared, while in the control (right) side the radio-opacity extended to the middle portion and the lamina dura partially disappeared internally and externally Histologically The result showed active proliferation of cellular connective tissue with early deposition of osteoid tissue and presence of osteoblast cells (OB) in the coronal portion of the experimental socket treated with Nigella sativa powder and oil in 1st week in comparison to control (Figures 2,3)

RESULTS Radiographically. Nigella sativa NgS showed more radiopacity with complete disappearance of lamina dura in 6 weeks duration compared with control group (Figure 1)

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Figure 2: Coronal portion of extracted tooth socket of the rabbit (control) one week duration shows formation of granulation tissue H&E *200

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Figure 5: Coronal portion of rabbit left socket treated with (NgS) oil 6weeks duration shows mature bone trabiculae covered with connective tissue and epithelia (EPI) H&E *40.

Figure 3: Micrograph view for coronal portion of rabbit left socket treated with NgS, one week duration show active proliferation of osteoid tissue(OT) H&E * 100 At Six Weeks postoperatively Experimental group treated with NgS powder showed that mature bone filled all cervical regions and covered with epithelial layers (Figure 4). On other hand experimental group treated with NgS oil showed that mature bone trabeculae covered with connective tissue and incomplete epithelization; also remodeling process shows osteoclast (OCL) cells occupied howship’s lacunae (Figure 5). Histological findings for control showed that bone (lamellated and haversian) filled cervical portion with fibrous connective tissue lay over it and superficial layer of epithelial tissue (Figure 6)

Figure 6: Coronal portion of rabbit right socket 6weeks duration shows bone filled the cervical portion with fibrous connective tissue lay over it and superficial layer of epithelial tissue (Epi.T) H&E *40.

DISCUSSION The results of the present study showed early detection of osteoid formation in 1st week and bone trabeculae formation in 2nd, 4th and 6th weeks in sockets treated with NgS (powder and oil). Active cell proliferation (osteoblast, osteocyte and even Osteoclast) was illustrated too in these sockets in comparison to control one; it was indicated that NgS acts as bioactive and bioinductive materials that enhance bone formation. This could be attributed to presence of the following components: 1. Protein and amino acids: Nigella sativa seed had 22.6 % - 26.7 % protein and amino acid, Glutamic acid(Gla,), Arginine(R) and Aspartic acid(D) were the

Figure 4: Coronal portion of rabbit left socket treated with (NgS) powder 6 weeks duration shows mature bone filled all cervical region and covered with epithelial layers (EPI) H&E *40.

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main amino acids present (9) in addition to other like glycine(G), leucine, etc (10) These mentioned amino acid play important role in the formation and function of the following ECM proteins: A. Osteocalcin: also known as bone Gla protein is one of the most abundant non collagenous proteins (NCPs) in bone (comprising up to 20 % of the NCPs) (11). It has 49 amino acid residues containing three glutamate (Gla) residues, which are critical for the ability of osteocalcin to bind calcium (12). It’s binding to HA through orientation of the Gla residues with the Ca ions in the mineral lattice (11). It has been reported that osteocalcin involved in bone growth & repair (13). B. Bone Sialoprotein (Bsp): comprises 15 % of the total non collagenous protein (NCP) in bone (11). C. Osteopontin: One of the important NCPs that includes in bone formation (12). Bone sialoprotien and osteopontin are belived to Vitamin * Thiamine (B1) * Pyridoxine (B6) Niacin Foliate Ascorbate (C) Retinol (A)

play roles in cell adhesion and binding of mineral because they contain Arg – Gly – Asp and poly acidic sequences (14). It was reported that it stimulates the adhesion of osteoblasts and,therefore, to improve the osseointegration process (15,16). These proteins and amino acid functionated a receptor specificity, binding affinity and signaling of cell responses (17). 2. Minerals: The induction of bone formation by the black seed oil extract seen in this study as manifested by faster bone formation could be attributed to the presence of calcium and phosphorous in the chemical composition of the black seed oil extract which are necessary for bone formation. 3. Vitamins Vitamins are low– molecular – mass organic compound that can’t be synthesized by humans or are synthesized in inadequate amounts for example:

Biochemical function Co-enzyme in phosphgluconate path way. Amino acid transamination Hydride-transfer reaction. Thymidylate synthase; purine biosynthesis. Prolyl and lysyl hydroxylases (collagen); dopamine hydroxylase. Form 11-Cis-retinal with rhodopsin.

It appears that Vitamins are important because they play a central role in metabolism. (18) NgS contain the a above mentioned vitamins so it possess nutritional value (19) and has been reported to possess a favorable effect on growth rate and health of human and animal (20). In histological study we found that the effect of Nigella sativa (NgS) powder more effective than oil in formation of bone inside the socket of extracted tooth because there is no any component of Nigella sativa will be lost such as in oil extract and the minerals present without any defect which help in faster bone formation, also the absorption of Nigella sativa oil require more time for complete absorption which applied by apiece of cotton for only 5 minutes and then removed. This could be attributed to the low percentage of volatile oils (0.4-0.45%) in the chemical composition of the cold-pressed oil as compared with the higher percentage of fixed oils (32-40%) including the unsaturated fatty acids (arachidonic, eicosadienoic, linoleic, linolenic, oleic and almitoleic acid) and the saturated fatty acids (palmitic, stearic and myristic acid, BetaOral Diagnosis


sitosterol, cycloeucalenol, cycloartenol, sterol esters and sterol glucosides). From the histological examination of the treated sockets with NgS (specially powder) showed early proliferation of epithelia covered the cervical portion of the socket, compared to control, this can be explained that NgS has inductive power to epithelial cells as if it has induction to connective tissue cells (mesenchymal cells). 4. Radiographic findings: Radiographic results of the present study showed radiopaque patches appeared in the middle (specifically) and apical portions of treated sockets with NgS (powder and oil) groups as it supported histological findings which showed trabeculae formation in these portions more than in coronal one and more than in control group. In 6th week duration NgS powder showed radiopacity filled whole socket (coronal, middle and apical portion) with disappearance of lamina dura, this related to apposition of mature bone filled the socket as it illustrated histologically, and that lamina dura landmark be obscured as the new 51



bone interdigited and coalesce with the original bone. This result is in agreement with others who found increase in bone formation and reported anabolic effects of NgS oil on bone loss radiographically (21).

18.

19.

REFERENCES 1. Oda T, Kinshita S Ueda M. Effect of cortical bone perforation on periosteal destruction. J Maxillofacial Surgery 2009; 67(7): 1478-85. 2. Sogut B, Celik I, Tuluce Y. The effect of diet supplemented with the Black cumin upon Immune potential and antioxidant marker enzymes and lipid peroxidation in broiler chicks. J Animal and Veterinary Advances 2008; 7(10): 1196-990. 3. Randhawa MA, Al-Ghamdi MS. A review of the pharmaco-therapeutic effects of Nigella sativa. Pakistan J Med Res 2002; 41(2). 4. Sahih Bukhari. 7; 71: 592. 5. El-Tahir KH, Bakeet D. The Black seed Nigella Sativa: Aplea for urgent clinical evaluation of its volatile oil. J T U Med Sc 2006; 1(1): 1-19. 6. Mbarek LA, Mouse HA, Elabbedi N, Bensalah M, Gamoyuh A, Aboufatima R et al. Anti-tumor properties of black seed (Nigella sativa) extracts. Brazil J Medical and Biological Research, 2007. 7. Abdulelah H, Zainal-Abidin B. In vivo anti-malarial test of Nigella sativa (black seed) different extracts. Ameri J Pharm & Toxicol 2007; 2: 46-50. 8. Majeed M. Assessment of the black seed oil extract as an intracanal medicament. A PhD thesis, Department of Conservative Dentistry, College of Dentistry. University of Baghdad, 2006. 9. Al–Jassir SM. Chemical compositionad microflora of black cumin (Nigella Sativa L.) seeds growing in Saudi Arabia. Food Chemistry 1992; 45(4): 239–42. 10. Gilani A, Jabeen Q, Ullahkhan M. A review of medicinal uses and pharmacological activities of Nigella sativa. Pakistan J Biological Sciences 2004; 7(4): 441-51. 11. Hing KA. Bone repair in the twenty–first century: biology, chemistry or engineering? Phil Trans R Soc Lond 2004; 362: 2821–50. 12. Stanford CM, Keller JC, Solursh M. Bone cell expression on titanium surfaces is altered by sterilization treatments. J Dent Res 1994; 73 (5): 1061–71. 13. Nagai M, Ota M. Pulsating electromagnetic field stimulates mRNA expression of bone morphogenetic protein–2 and–4. J Dent Res 1994; 73 (10): 1601–5. 14. Puleo DA, Nanci A. Understanding and controlling the bone –implant interface. Biomaterials 1999; 20: 231121. 15. Alt V, Bitschnau A, Osterling J, Sewing A, Meyer C, Kraus R, Meissners et al. The effect of combined gentamicin– hydroxyapatite coating for cementless joint prostheses on the reduction of infection rates in a rabbit infection prophylaxis model. Biomaterials 2006; 27: 4627-34. 16. Bernhardt R, Vanden Dolder J, Bierbaum S, Beutner R, Scharnweber D, Jansen J et al. Osteoconductive modifications of Ti – implants in a goat defect model; characterization of bone growth with SR mu CT and histology. Biomaterials 2005; 26: 2009–19. 17. Jonge LT, Leeuwwnburgh SC, Wolke JG, Jansen JA. Organic – inorganic surface modifications for titanium

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20.

21.

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implant surfaces. Pharmaceutical Research 2008; 25(10): 2357–69. Anyakora C, Afolami I, Ehianeta T, Anwnmere F. HPLC analysis of nicotinamide, pyridoxine, riboflavin and thiamin in some selected food products in Nigeria. African J Pharmacy and Pharmacology 2008; 2 (2): 29–36. Takruri HR, Dameh MA. Study of the nutritional value of black cumine seed. J Sci Food Agricul 1998; 76(3): 404-10. Abu–Dieyeh ZHM, Abu–Darwish MS. Effect of feeding powdered black cumine seeds (Nigella Sativa) on growth the performance of 4 – 8 week old Broilers. J Animal and Veterinary Advances 2008; 7(3): 286–90 Valizadeh N, Zakeri HR, Shafiee A, Sarkheil P, Heshmat R, Larijani B. The effect of Nigella sativa Extract on biochemical bone markers in osteopenic postmenopausal women. European J of Scientific Research 2009; 10(6): 570–80.



Evaluation of topical

Evaluation of topical versus systemic medications in the treatment of neuropathic orofacial pain A prospective study Ihsan A. Kumail, B.D.S., M.Sc., Ph.D. (1)

ABSTRACT Background: Neuropathic orofacial pain is a multifactorial condition and mainly treated by systemic anticonvulsant and antidepressant medications which result in unpleasant side effects and may contradict or interact with other medications especially in elderly. This study demonstrates preparation of alternative topical treatment and evaluation of its efficacy versus systemic treatment in respect to period taken for pain reduction and side effects. Sample and Method: A prospective study was conducted on systemically healthy 41 patients treated for neuropathic orofacial pain attended the Oral Medicine Clinic/ Dentistry College/ Mustansiria University and private clinic. Patients were divided into 2 groups of almost similar ages, genders and pain severities. Microemulsive gel was prepared to carry specific concentrations of active agents by transdermal permeative vehicle to the affected sites. The first group received topical medications only (n = 21), while the second group was treated with systemic medications only (n = 20). The intensity of pain was recorded for each on a Visual Analog Scale (from 0= no pain to 10= intolerable pain) at diagnosis, and at 4 successive weeks after initiation of treatment. Reduction in pain severity was considered only if it equals 30% or more. The two methods of treatment were evaluated according to the period required for 30% pain reduction and side effect(s) caused by each type of treatment. Results: After initiation of treatment, 81% of patients (no= 17) on topical treatment showed 30% reduction in neuropathic orofacial pain levels (which is considered a good response) within 2 weeks, the rest 4 patients (19%) reached 30% pain reduction within the third week. In systemic group, 50% of patients (no= 10) showed 30% pain reduction within 2 weeks, 4 patients (20%) showed 30% reduction in the third week and 6 patients (30%) of the same group did not experienced 30% pain reduction until the fourth week. Ten patients of systemic group experienced side effects, while patients on topical treatment did not complain of any side effect along term of treatment. Conclusion: Topical medication as a single treatment is more efficient in reduction of neuropathic orofacial pain within shorter period and no side effects than systemic medications. Younger patients (≤ 40 years) responded to treatment better than elderly in both groups. Key words: Neuropathic orofacial pain, systemic treatment, topical treatment. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):53-59).

INTRODUCTION

the nerve (the myelin sheath) (6), TN may be due to central pathology (e g multiple sclerosis in ages less than 50 years) or a part of the normal aging process, as blood vessels lengthen, rest and pulsate against a nerve which results in demeylination of the nerve and changes in sodium channels located at peripheral terminals of that cranial nerve, those channels lose their activity to close resulting in extremely sensitive area on the face (trigger zone) which will lead to severe shocking pain if exposed to a stimulus normally does not provoke pain (allodynia) (7), (facial and glossopharyngeal are not uncommon) (7). The treatment for neuropathic pain in most cases is pharmacological with medications that include antidepressants, analgesics, and antiepileptics, the efficacy of these medications varies from patient to another depending on a variety of factors such as pain location, age of the patient, and systemic diseases (8,9). Pharmacologic treatment is often accompanied with unpleasant side effects such as sedation and dizziness. Moreover, interaction with other medications may contradict the use of these medications or prevent their use in the medically compromised or elderly patients (9-11). Topical medications is an alternative method which has been reported by several authors to be clinically

Neuropathic orofacial pain is a chronic pain initiated or caused by a primary lesion or dysfunction in the nervous system (1). Etiologies of this pain vary from peripheral trauma to central nervous system pathologies (1,2). Peripheral pathology is due to two main causes: 1- Chronic peripheral nociceptor irritability, as a result of neuronal injury following trauma, dental needles, extractions, endodontic treatment, and dental implant insertion, this is called traumatic neuroma which is characterized by chronic facial pain with periods of exacerbations to sever form (2,3). 2Demyelination of afferent peripheral sensory nerves or vascular compression occurs subsequent to a release of local excitatory or inflammatory mediators which is called deafferentation pain and characterized by intermittent symptoms which may be referred to orbit, temporal region and back of the neck (4). In types discussed above, a painful stimulus will result in exaggerated response of pain (hyperalgesia) (5). And a central cause as trigeminal neuralgia (TN) which may be due to pressing of a blood vessel on the trigeminal nerve as it exits the brainstem, this compression causes the wearing away of the protective coating around (1) Lecturer, Department of Oral Diagnosis, College of Dentistry, Al-Mustansiria University

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by topical treatment only (n=21) and group B were given systemic treatment only (n=20). The systemic medications prescribed were medications commonly used to treat neuropathic pain conditions: anticonvulsants which are carbamazepine (Novartis) (200 mg) and gabapentin (Park Davis) (100 mg) one tablet of each per day for neuralgic pain (trigeminal neuralgia associated with trigger zone whether this zone provokes pain as mild or sever) (18, 19), or tricyclic antidepressant which is amitryptyline tab 25 mg (Novartis) and baclofen tab 25 mg (Novartis) daily for patients without trigger area which could be either deafferentation pain or traumatic neuroma (20). Studies stated that combination of medications above results in synergism between those two medications which leads to higher response and reduced adverse effects (19, 21, 22). In order to apply topical medications, there should be a vehicle that penetrates cutaneous tissue to carry active agents to the affected site, this vehicle must contain oil/ water microemulsion system (23). (Preparation of topical medication gel was under supervision and control of specialist pharmacist*). The vehicle was represented by 5 gm sodium carboxymethyl cellulose (NACMC), this amount of vehicle was added to 20 gm glycerin (oil phase) and 2 ml Di methyl sulphoxide liquid (water phase) (24). After mixing 5 gm NACMC with 20 gm glycerin in a graded glass containe, 50 ml of distilled water heated to 70 C° was added to the mixture with vigorous stirring for 15 minutes, then the 2 ml of Dimethyl sulphoxide was added, the result is clear transdermal gel of 77 gm (25, 26). A sum of 20 gm row material of active agents which are Amitriptylin (Novartis), Baclofen (Novartis), Cabamazepin (Novartis) and Gabapentin (Park Davis) (5 gm of each) was added, and then 3 ml of distilled water was added to complete 100 gm (13,27-29). Each patient of topical group was given a plastic container of 100 gm of the mixture and asked to apply 4 times daily to the painful area (13, 15, 29). All previous trials of topical treatment to neuropathic pain contained anaesthetic (lidocaine gel 1%) and NSAID (ketoprofen 4%) (12-15,23,24). In this study neither analgesic nor anaesthetic agent was used, so that to clarify the specific mechanism of medications used to reduce pain faraway from anaesthesia or analgesia which are considered as non specific pain reducers. Pain level was recorded at the first visit on a 10 cm visual analogue scale (VAS) (0= no pain – 10 intolerable pain) for each patient, and after start of treatment, all patients have been followed weekly until 30% reduction of pain was obtained and the

useful for neuropathic pain with minimal or no systemic effect, but studies targeting orofacial region were few (12-14). Topical medications need transdermal compounds which should be designed to transport active agents harmlessly through the skin as an alternative to oral or parenteral administration (15). This article described a new preparation of transdermal permeating gel containing active medications for topical use and a prospective comparison between results of topical versus systemic treatment for 41 patients with neuropathic orofacial pain and evaluation of the outcome of each method in respect to period of pain reduction and side effect(s).

PATIENTS AND METHOD A prospective study with informed consent was conducted from December 2009- October 2011 on systemically healthy 41 patients (21 males and 20 females with ages ranging from 3363 years) suffering from neuropathic orofacial pain conditions of durations ranged from 3 months- 2 years, they admitted Oral Medicine Clinic/ Dentistry College/ Mustansiria University and private clinic. A thorough medical and dental history was taken with a precise description of pain, careful intra and extra oral examination was performed and medications taken were recorded for each patient. Radiographic views (OPG and PA) were taken for each patient to exclude any intra or extra osseous lesion. A precise intra and extra oral examinations had been carefully performed for all patients to detect any possible cause of facial pain. The diagnosis was done based on the history provided by the patient and the International Association for the Study of Pain guidelines which stated that neuropathic orofacial pain is a chronic pain lasts more than 3 months expressed as hyperexcitation to painful stimulus or to shocking pain at a trigger zone which is provoked by a stimulus that normally does not cause pain (allodynia), both correlate to abnormality in branches of V2 and /or V3 but does not correlate to any detectable local, referred or systemic disease (1, 2, 16). Patients who had a diagnosis of neuropathic orofacial pain along with TMJ dysfunction or psychologic conditions were excluded from the study. Diagnosis of TMD was performed according to Research Diagnostic Criteria of temporomandibular disorders (RDC) (17). Patients were divided into 2 groups, each group almost showed similarity in age (group A 33- 63 years mean= 46.2, group B 34- 60 years mean= 48.5), gender (A: 12 males and 9 females, B: 9 males and 11 females) and pain description (as shown in tables 1 & 2). Group A were treated Oral Diagnosis


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period taken for this amount of reduction as well as the side effect(s) experienced by the patient were recorded for each. In other word, 30% reduction of pain was chosen to represent the time for onset of action of the medication; accordingly, a fair evaluation for the efficiency of treatment method will be the shorter treatment period to obtain 30% pain reduction with minimal side effects.

RESULTS Results showed that all patients were not complaining of brain lesion or multiple sclerosis (they did not suffer from any associated disorder that may give hint about such diseases). Radiographic views did not clarify any intra or extra bonny lesion. There was similarity in mean of ages between the two groups (A: 46.2 & B: 48.5 years), gender (A: 12 males and 9 females, B: 9 males and 11 females) and severity of pain (A: 6.4 & B: 6) (tables 1 & 2). In patients with unilateral facial or intraoral trigger zone, diagnosis was trigeminal neuralgia, they were 9 patients, 4 in group A (mean age 58 years) and 5 in group B (mean age 54.8 years) (table 3). Deafferntation (demyelination of afferent nerve terminals) or traumatic neuroma was the diagnosis of patients without trigger zone and they were 32 patients (table 3), 17 in group A (mean age 43.5 years) and 15 in group B (mean age 46.6 years) (table 3). Although pain relief felt by the patients was based on their subjective feeling and was not standardized, but the most important finding of this study is that 81% of patients (no= 17) on topical treatment showed 30% reduction in neuropathic orofacial pain levels (which is considered a good response) within 2 weeks, the rest 4 patients (19%) who suffered from trigeminal neuralgia reached 30% pain reduction within the third week (table 1, 4 and figure 1). In systemic group, 10 patients (50%) showed 30% pain reduction within 2 weeks, 4 patients (20%) showed 30% reduction in the third week and 6 patients (30%) (5 of them with trigeminal neuralgia) did not experience 30% pain reduction until the fourth week (as shown in figure 1 and table 2 and 4). No patient (0%) of topical treatment group experienced any side effect along the period of treatment (2- 3 weeks), while side effects (nausea, dry mouth, dizziness, drowsiness, headache and heart burn) were experienced by patients of systemic group as follows: 2 patients at the 1st week, increased to 4 at the 2nd week, increased to 8 at the 3rd week and became 10 patients (50%), at the last week of treatment, as shown in (figure 2, table 5) . All patients with trigeminal neuralgia Oral Diagnosis 55


(who received Carbamazepin and Gabapentin) in systemic group (no= 5) experienced side effects (table 5, figure 2). Results also showed that patients in both groups whose ages ≤ 40 years (8 in group A and 6 in group B) with no trigger area showed 30% pain reduction within 2 weeks except one in the systemic group whose 30% pain reduction was obtained in the third week after initiation of treatment, besides, they did not experienced any side effect along treatment period except 5 of 15 patients from group B (table 5).

DISCUSSION In younger patients, the main cause of orofacial pain was either deafferntation of nerves or traumatic neuroma rather than trigeminal neuralgia which mainly seen in more than 50 years old patients, otherwise, there may be central pathology (e g multiple sclerosis, brain tumor) (1,2,4,5), and this may explain the good and quick response of those patients to both types of treatments (8,14), moreover, the severity of their complain was less than older patients. Side effects have been gradually experienced by 10 subjects in systemic group with time, 5 of them who received Carbamazepin and Gabapentin and the rest 5 received the other combined systemic medication. This was expected and mentioned in the leaflet of each medication. Side effects were not sever because of low doses of drugs combination strategies used and the short period of treatment (3- 4 weeks) which may explain the limited adverse drug reaction or drug tolerance (8,11,14,1821). While topical medications did not result in side effects because their action is local rather than systemic (13). Patients with TN in both groups took more time for 30% pain reduction. This may be due to that the main pathology was not at the site of pain, it was at the root of the 5th cranial nerve but experienced at a site that is faraway from exact pathology, so stabilization of abnormally opened Na+ channels at the nerve terminals needed more time to return them back to normal closure (4,7). Moreover, those patients were older in age which may delay the response (9), also they presented with longer pain duration and higher intensity than others which needed more time for considerable reduction. Amitriptylin is an antidepressant that induces analgesia centrally by modulation of gammaamino-butyric acid (GABA) and serotonin systems and peripherally by blocking Potassium, Calcium and Na+ channels of peripheral nerves and thus resulting in pain relief especially in traumatic neuroma or demyelination of afferent nerves (hyperalgesia) (20-22). Baclofen is skeletal



muscle relaxant, but it is capable of inhibiting both monosynaptic and polysynaptic reflexes at the spinal level, possibly by depolarization of afferent terminals (8), also, Baclofen is an analog of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) (10, 11). Combination and low doses of both medications may result in synergistic effect and reduced side effects (19, 21, 22). Anticonvulsant medications (Carbamazepin and Gabapentin) act centrally by blocking GABA receptors, thus suppressing paroxysmal discharges and reducing neuronal hyperexcitability (10,11,14,30) and peripherally by stabilizing the inactivated Na+ channels that remain opened at a terminal branch of damaged or compressed (demyelinated) cranial nerve and result in closing of those channels and subsequent reduction in their excitability (18,30), so they were used in this study to treat neuralgias with trigger zone (allodynia). Combination of low doses of both medications was favored for synergistic effect and reduced side effects (19,21,22). Neuropathic orofacial pain signaling involves complex mechanisms. Peripheral hyperactivity or opened Na+ channels of afferent nerves is an important contributor to this pain. These conditions can benefit from application of topical medications which contain combination of active agents targeting different pain mechanisms. Local amitriptylin blocks Na+ (13,20,28), local baclofen acts by depolarization of afferent nerves (6,13), local carbamazepin and gabapentin stabilize the inactivated Na+ channels (which remained opened) in neuralgia and make them active for closure again (13,15,27). This may explain the superiority of topical treatment in achieving 30% reduction of pain in shorter period whether the cause was deafferentation, traumatic neuroma or neuralgia. Glycerin was used as well known bioadhesive in dermatologic practice (27). Dimethyl sulphoxide was used as penetration enhancer, it acts by denaturing intercellular proteins of skin, changing the β- sheet of intercellular keratin of skin and finally it acts on intercellular lipid domain and distorts the packing geometry of the barrier lipid, thus reducing the barrier properties of stratum corneum of the skin (31), resulting in enhancement of permeation without damaging skin cells (26). The NACMC represents the oil phase of the microemulsion gel, it is widely used in topical applications because of its high ability to fuse with active medication powders and its low molecular weight which enables it to pass through intercellular spaces of skin, thus it acts as a vehicle which carries active agents to the affected area without damaging skin cells (26, 29). Oral Diagnosis


CONCLUSION The effective ingredients concentrations of topical medication 5% Carbamazepin, 5% Gabapentin, 5% Amitriptylin and 5% Baclofen in anhydrous gel is more efficient in reduction of neuropathic orofacial pain than combined systemic medications in respect to shorter onset of action and no adverse effects. This study can serve as a basis for further prospective studies and trials on this issue.

REFERENCES 1. International Association for the Study of Pain, H. Merskey and N. Bogduk, IPT, Classification of Chronic Pain IASP Task Force on Taxonomy, (2nd ed.), IASP Press, Seattle (WA) 1994; pp. 209–214. 2. Turk D. Strategies for classifying chronic orofacial pain patients. Anesth Prog 1990; 37:155–60. 3. Gregg J.M., Neuropathic complications of mandibular implant surgery: review and case presentations. Ann R Australas Coll Dent Surg,2000;15: pp. 176–180. 4. Vickers E.R. and Cousins M.J., Neuropathic orofacial pain, part 1—prevalence and pathophysiology. Aust Endod J 2000; 26 1 : pp. 19–26. 5. Cutrer FM, Moskowitz MA. Headaches and other head pain. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 421 6. Fromm GH, Terrence CF, Chattha AS. Baclofen in the topical treatment of trigeminal neuralgia: double-blind study and long - term follow up. Ann Neurol 1984; 15: 240 - 4. 7. Watson C.P., Management issues of neuropathic trigeminal pain from a medical perspective. J Orofac Pain, 2004; 18 4 pp. 366–373. 8. Lewis M.A, Sankar V., De Laat A. and Benoliel R., Management of neuropathic orofacial pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, Suppl 2007; 103S32 e1-24. 9. Feinberg S.D, Prescribing analgesics. Geriatrics, 2000; 55 11 pp. 44–62. 10. Collins S.D. and. Chessell I.P, Emerging therapies for neuropathic pain. Expert Opin Emerg Drugs, 2005; 10 1 pp. 95–108. 11. Colombo B., Annovazzi P.O. and Comi G., Medications for neuropathic pain: current trends. Neurol Sci, 2006; 27 Suppl 2 pp. S183–S189. 12. McCleane G., Topical analgesics. Med Clin North Am, 2007; 91 1 pp. 125–139. 13. Padilla M., Clark G.T and Merrill R.L., Topical medications for orofacial neuropathic pain: a review. J Am Dent Assoc, 2000; 131 2 pp. 184–195. 14. Lund J.P., R. Dubner and B.J. Sessle, Orofacial pain: from basic science to clinical management, Quintessence, Chicago 2001; LG. 15. Priano L., Gasco M.R. and Mauro A., Transdermal treatment options for neurological disorders: impact on the elderly. Drugs Aging, 2006; 23 5 pp. 357–375. 16. Giamberardino M.A., Pain: an updated review refresher course syllabus, IASP Press, Seattle (WA) (2002). 17. Look JO, John MT, Tai F, Huggins KH, Lenton PA, Truelove EL, Ohrbach R, Anderson GC, Schiffman EL. Research diagnostic criteria for

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18.

19.

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21. 22.

23. 24.


temporomandibular disorders: Reliability of Axis I diagnoses and selected clinical measures. J Orofac Pain. 2010;24(1):25–34 Jensen T.S., Anticonvulsants in neuropathic pain: rationale and clinical evidence. Eur J Pain, 2002; 6 Suppl A pp. 61–68. Gilron I. and Max M.B., Combination pharmacotherapy for neuropathic pain: current evidence and future directions. Expert Rev Neurother, 2005; 5 6 pp. 823–830. Pancrazio; Kamatchi, GL; Roscoe, AK; Lynch C, "Inhibition of neuronal Na+ channels by antidepressant drugs". The Journal of pharmacology and experimental therapeutics 3rd 1998;284 (1): 208– 14. Jackson K.C, Pharmacotherapy for neuropathic pain. Pain Pract, 2006; 6 1 pp. 27–33. Jones M. Chronic neuropathic pain: Pharmacological interventions in the new millennium- A theory of efficacy. IJPC 2000;4(1):6-15. Berti JJ. Lipsky JJ. Transcutaneous drug delivery: A practical review Myo Clin Proc 1995;70(6):581-586. Csoka I, Csanyie E, Zapantis G et al. In vivo and in vitro percutaneous absorption of topical dosage forms Case studies. J Pharm 2005; 291(-2):11-19.


25. Ansel HC, Allen LV, Popovich NG .Pharmaceutical Dosage Form of Drug Delivery System 8th ed, Leo and Febiger, Philadelphia, USA 2005;415-425. 26. William A. Chemical modulation of topical and transdermal permeation: Transdermal and Topical Drug Delivery 1st ed, Pharmaceutical press, London, UK, 2003;4:86-90 27. Posner R., Liposomes. J Drugs Dermatol, 2002; 1 2 pp. 161–164 28. Lynch M.E., Clark A.J. and Sawynok J., A pilot study examining topical amitriptyline, ketamine, and a combination of both in the treatment of neuropathic pain. Clin J Pain, 2003; 19 5 pp. 323–328. 29. Zabka, M. Muller, R H. Hilderband, Microemulsions – Modern Dosage Forms in Pharmaceutical and Technological aspects and perspectives. Bratislava, Slovak Academic Press 2001, p. 161- 176. 30. Granger, P. et al. Modulation of the gammaaminobutyric acid type A receptor by the antiepileptic drugs. Mol. Pharmacol. 1995; 47, 1189–1196. 31. Anigbogu ANC, William AC, Barry BW, Edward HGM. Fourier transforms Raman Spectroscopy of interaction between the penetration enhancer Dimethyl sulphoxide and human stratum corneum. Int J Pharm 1995;12 5:265-282.

Table 1: shows degree of pain at diagnosis of group A, the period taken by treatment to obtain 30% pain reduction and side effects of treatment

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Table 2: shows degree of pain at diagnosis of group B, the period taken by treatment to obtain 30% pain reduction and side effects of treatment

Table 3: shows the distribution of patients in both groups in respect to diagnosis and ages with mean VAS Diagnosis Deafferntation & TRN TN Total

Topical Treatment 17 4 21

Mean VAS 5.94 8.25 6.4

Mean Age 43.5 58 46.2

Systemic Am+ Bac 15

Mean VAS 5.46

Mean age 46.6

Systemic Car+ Gab

Mean VAS

Mean Age

5 7.6 54.8 20 (Systemic) Mean VAS= 6 Mean age= 48.5 *Am=Amitriptylin , Bac=Baclofen, Car=Carbamazapin, Gab=Gabapentin, TRN=traumatic neuroma, TN=trigeminal neuralgia

Table 4: shows number of patients showed 30% pain reduction in both groups during treatment period

Group Topical ( no= 21) Systemic (no= 20)

Oral Diagnosis

No of patients showed 30% pain reduction during period of treatment 1st week 2nd week 3rd week 4th week 1 16 4 0 10 4 6

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Table 5: shows the time needed for both treatment methods in reducing 30% of pain symptoms Side effects of Treatment Topical treatment Systemic treatment period (no= 21) (no= 20) 1st week 0 2 (Car+ Gab) 2nd week 0 2(Car+ Gab) 3rd week 0 1(Car+ Gab)+ 3 (Am+Bac) 4th week 0 2 (Am+Bac) Total 0 10 *Car= Carbemazepin, Gab= Gabapentin, Am= Amitriptylin, Bac= Baclofen

Mean of pain records on VAS

Figure 1: Efficiency of topical and systemic treatments in reducing 30% of pain and the time taken for this reduction. Numbers above columns represent number of patients still need to treatment

No. of patients experienced side effects

Figure 2: shows side effects experienced by patients in both groups along treatment period

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Assessment of cadmium

Assessment of cadmium levels in Blood, hair, saliva and teeth in a sample of Iraqi workers and detection of dental findings Raja H. Al-Jubouri, B.D.S., MS.c., Ph.D. (1) Ammar Issa Bashbosh, B.D.S., MS.c. (2)

ABSTRACT Background: Cadmium considered one of the heavy metals, by time can be accumulate in plants, animals and humans. This study aimed to using some biomarkers (blood, hair, saliva and teeth), that can be easily obtained and processed for measuring the cadmium concentration in human body and assessment of DMF/t which may result from accumulation of cadmium. Subjects, Materials and methods: This study had been done between April – October of 2010 at Al-kufa Cement Factory in Najaf , the numbers of exposed subjects were 55 and control subjects were 44, blood, hair ,saliva and teeth were taken as biomarkers then DMF/t were calculated. After processing of these biomarkers (blood, hair, saliva and teeth) cadmium analyzed by using atomic absorption spectrophotometer device (AAS). Results: The study reported that blood ,hair ,saliva and teeth are good biomarker for measuring the concentration of cadmium in addition to effect of some factors like smoking habit , residency, age and in accumulation of that heavy metal in addition to increasing of the numbers of decayed and missing teeth with increasing of cadmium but without increasing in numbers of the filling teeth. Also there was significant difference in cadmium concentration between exposed and control people Conclusions: This study reported that there was significant increased in cadmium concentration among exposed subject if compared with control subject. Also indicated that factors like smoking habit, residency and age could led to increasing the cadmium concentration. In addition to increased the numbers of decay and missing teeth when the cadmium concentration was increased in these biomarkers. Keywords: Cadimum, saliva, blood, hair teeth. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):60-64).

INTRODUCTION

two groups, the first group consist of 55 cadmium exposed subjects (43 males, 12 females) at Alkufa cement factory in Najaf providence and this regarded to study group, the second group consist of 44 from out of that factory (29 males, 15 female). All the subjects answered a questionnaire regarding their name, gender, age, type of working, residency, smoking habit and systemic disease. Oral examination Oral examination, was done using sterile mirror and probe& dental chair light, oral finding limited to DMFt (8), the study compared decay, missing and filling teeth of subjects separately with each biomarkers. Saliva collection and measurement procedure 5ml mixed un-stimulated saliva was collected in polypropylene vials by direct collection. The samples that contaminated with food , blood or nasal discharge were discarded. The mixed saliva was then frozen and stored in a freezer at 20˚C. Prior to sample preparation, the saliva samples were defrosted and allowed to equilibrate to room temperature then 20 ml of 2% nitric acid (HNO3) was added. This solution was filtered with Whatman no. 42 filter paper into a volumetric flask and diluted to a final volume of 100mL with DDW (9).

“Heavy Metals” are chemicals with a specific gravity that is at least 5 times the specific gravity of water. Specific gravity of water is 1 at 4. (39o F). (1). Many human biomarkers can reflect cadmium deposition in it's content like (blood, urine, saliva, human milk, sweat, hair and nail, and teeth) which can easily obtain from participants than some vital tissues as kidney or liver or bones, blood is useful biological indicator of recent cadmium exposure (2), hair useful for long period of cadmium exposure (3,4,5), teeth, also good bioindicator and stable record of environmental exposure and incorporate the metal into dental tissue at the time of exposure (6). Dental findings which may appear after long duration of environmental exposure to cadmium is dental decay (7).

SUBJECTS, MATERIALS AND METHODS: A prospective study has been done between (April – October 2010). The sample consist of 99 subjects, with age ranged between (18- 62 years) of both sexes (72 males, 27 females), divided into (1) Professor Oral medicine, College of dentistry, Baghdad University. (2) Specialist in Ministry of health.

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being digested completely with acids. And stored in plastic tube for time of analysis (11). Analysis of samples The heavy metal concentration in the final digest solution was determined by AA-6300 in laboratory at kufa University, Cd was determined at 228.8nm, and at a slit width of 0.5 nm for metal. (12, 13). The hollow cathode lamps for Cd was operated at 8mA. A minimum of three replicates was employed in each case. The calibration curve Cd was prepared using calibration standards prepared by several dilutions of a stock solution (1000µg/g) with deionized water. Recovery experiments were carried out by adding measured volumes of aqueous standard solutions of Cd metal to measured volumes of a solution containing the tooth or hair dissolved in the acid mixture. Statistical analysis: Statistical analysis has been done by using software technique (SPSS) programmed (version 13)

The 100 ml solution was then stored in a plastic container until analysis with an AAS . Blood, collection and measurement procedure Five milliliters of blood from vein putted in EDTA tube after labeling the tube with information alcoholic pen then put it in ice box Preparation of samples for analysis 1- Shaking 5 cc of blood specimen on an electrical shaker for 1 hours. 2- Mixing the specimen with nitric acid and diluted with Titron X-100 (sigma). 3- The specimen left for 1 hour to ensure that all cells and protein have dissolved and precipitated. 4- Centrifugation 4500 r.p.m. 5- Taking the supernatant by using micropipettes with disposable tips and put it in a dry, sterilized plastic plain tube for cadmium examination with AAS. Teeth collection and measurement procedure. The teeth were collected from the exposed subjects after checking the subject's dental status in the health center of Al-kufa cement factory. Extracted teeth from control subjects was collected all that teeth were label in dry containers for 2-3 days. All the vials in which the teeth were collected were cleaned with detergents and (DDW) and then immersed in 10% HNO3 overnight and washed several times with DDW and finally rinsed with deionizer water. Teeth were stored in refrigerators at 4°C until the time of analysis. Preparation of samples for analysis Each tooth was cleaned with a 3% solution of H2O2 or sodium hypochlorite to remove organic material, and washed several times with DDW and demonized water. The tooth was placed in an oven at 50°C to dry and be weighed, then it was dissolved in an a liquor of 3 ml of ultrapure 70% HNO3 and 1.0 ml of 70% perchloric acid (HCIO4). Each mixture was poured in 50-ml beaker and evaporated until nearly dry. After that the digest was rinsed with 1% HNO3, and made up to 10mL, and returned to the vial (10). Hair collection and measurements procedure Hair samples were cut at the scalp at 6 different locations on the head.. The total amount of hair collected from each individual and then analyzed ranged from 0.1to 0.5g. Hair samples were rinsed with alcohol followed by triple rinsing with water and then a repeated rinsing with alcohol. Washed hair was dried at 105oC. Dried samples were weighed and then mineralized using a mixture of concentrated nitric and perchloric acids (mixed at a ratio of 5:1)until

Oral Diagnosis

Assessment of cadmium

RESULTS Distribution of exposed and control group as shown in table (1). Mean concentration of cadmium in human biomarkers related to the gender between two groups as shown in table (2). DMF/t related to the gender between two groups and among the study group as shown in table (3). Mean concentration of cadmium in human biomarkers related to the smoking habit as shown in table (4). Mean concentration of cadmium in human biomarkers related to the residency as shown in table (5). Mean concentration of cadmium in human biomarkers related to the age as shown in table (6).

DISCUSSION Despite the mean concentration of cadmium in males were higher than in females, but there was no a statistical significant difference between the two genders in the study group (P>0.05), this result agreed with (14). In this study mean concentration of cadmium in hair among males were higher than females despite that ,there was no a statistical significant difference (P>0.05), this result agreed with (11). Blood considered important biomarker because it can reach to all tissues and renewed continuously and have large quantity in the body, .In this study the mean concentration of cadmium in blood among males were higher than females 61



women in some biomarkers (blood, hair and teeth) this is in agreement with (7).

but there was no a statistical significant difference (P>0.05), and this result agreed with (15). Saliva has been taken as a biomarker for cadmium analysis. In this study, the mean concentration of cadmium in saliva among males were higher than females, but without a statistical significant difference (P>0.05), this result agreed with (16), but disagreed with (17). Smoking is very important source for cadmium accumulation in human body. The mean concentration of cadmium in human teeth among smoking subjects were significantly higher than non-smoking subjects (p 0.05) ,this result agreed with other study results (17), which indicated that geographic area had no influence on cadmium increase . On the other aspect the study found a statistical significant difference (p