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Romanian Journal of Oral Rehabilitation

Vol. 5, No. 3, July - September 2013

3

Romanian Journal

of Oral Rehabilitation


Editor in Chief

Norina Consuela Forna, Iaşi, Romania

Vice-Editor

Viorel Păun, Bucharest, Romania

Editorial Board

Corneliu Amariei, Constanţa, Romania

Vasile Astărăstoae, Iaşi, Romania

Sorin Andrian, Iaşi, Romania

Grigore Băciuţ, Cluj Napoca, Romania

Constantin Bălăceanu – Stolnici, Bucharest,

Romania

Marc Bolla, Nice, France

Dorin Bratu, Timişoara, Romania

Alexandru Bucur, Bucharest, Romania

Eugen Carasevici, Iaşi, Romania

Radu Septimiu Câmpean, Cluj Napoca,

Romania

Costin Cernescu, Bucharest, Romania

Yves Commissionat, Paris, France

Marysette Folliguet, Paris, France

Cristina Glavce, Bucharest, Romania

Emilian Hutu, Bucharest, Romania

Constantin Ionescu – Tîrgovişte, Bucharest,

Romania

General Secretary

Magda Ecaterina Antohe, Iaşi, Romania

Oana Ţănculescu, Iaşi, Romania

Senior Associate Editors

Pierre Lafforgue, Paris, France

Sami Sandhaus, Lausanne, Switzerland

Robert Sader, Frankfurt, Germany

Zhimon Jacobson, Boston, USA

Michel Jourde, Paris, France

Ion Lupan, Chişinău, Rep. of Moldavia

Veronica Mercuţ, Craiova, Romania

Patrick Missika, Paris, France

Ostin Costin Mungiu, Iaşi, Romania

Ady Palti, Kraichtal, Germany

Mihaela Păuna, Bucharest, Romania

Phillipe Pirnay, Paris, France

Constantin Popa, Bucharest, Romania

Sorin Popşor, Tg. Mureş, Romania

Dorin Ruse, Vancouver, Canada

Valeriu Rusu, Iaşi, Romania

Adrian Streinu-Cercel, Bucharest, Romania

Dragoş Stanciu, Bucharest, Romania

Mircea Suciu, Tg. Mureş, Romania

Alin Şerbănescu, Cluj Napoca, Romania

Monica Tatarciuc, Iaşi, Romania

Legislation Committee

Delia Barbu, Bucharest, Romania

DEMIURG Publishing House



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5

CONTENTS

FOREWORD

Editor in Chief Norina Forna

7

FROM THE ANNOUNCEMENT OF A FATAL PROGNOSIS TO THE RESPECT FOR

AUTONOMY

Philippe PIRNAY

9

INFLUENCE OF HYALURONIC ACID IN PERIODONTAL TISSUE

REGENERATION

Vera Radojkova Nikolovska, Mirjana Popovska, Ana Minovska, Bruno Nikolovski,

Biljana Kapusevska

12

EXPLORING THE ASSOCIATION OF CARIES EXPERIENCE WITH SOCIAL AND

BEHAVIOURAL FACTORS AMONG SCHOOLCHILDREN FROM IASI, ROMANIA

Dana Baciu, Ioan Danila, Carina Balcos

18

SALIVARY PERIODONTAL MARKER BACTERIA RELATED TO COMMUNITY

PERIODONTAL INDEX (CPI) IN NONSMOKERS VERSUS SMOKERS ROMANIAN

ADULTS

Cristina Nuca, Victoria Badea, Aureliana Caraiane

26

TREATMENT OF THE BACTERIAL CORNEAL ULCER

Claudia F. Costea, D. Petraru, A. Cărăuleanu

41

CLINICAL ASPECTS IN PROSTHETIC CONVENTIONAL REMOVABLE

TREATMENT FOR ELDERLY PATIENTS

Dan Nicolae Bosînceanu, Dana Budală, Norina Consuela Forna

46

CONVENTIONAL VERSUS LASER-ASSISTED THERAPY WITH AGGRESSIVE

PERIODONTITIS

Mirjana Popovska, Milco Ristoski, Aneta Atanasovska-Stojanovska, A. Minovska, V.

Radojkova-Nikolovska, Biljana Kapusevska, Kristina Mitic, Lindita Zendeli-Bedzeti,

Spiro Spasovski

52

STUDY ON THE Ph INFLUENCE ON SURFACE MICROHARDNESS OF SOME

REPAIR MATERIALS USED IN ENDODONTICS

Liana Aminov, Mihaela Salceanu, T.Hamburda, Anca Melian, Dana Cristiana Maxim,

Maria Vataman

60



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SURGICAL AND LASER TREATMENT CHIRURGICAL OF MAXILLARY

OSTEITES

Bonchis Iuliu Alexandru

68

FINITE ELEMENT ANALYSIS OF PERIODONTAL STRESSES IN FIXED

PROSTHODONTICS

Valeria Pendefunda, Arina Ciocan – Pendefunda, Nicoleta Ioanid, Alina Apostu,

Oana Ţănculescu

72

STUDY CONCERNING THE INFLUENCE OF THE FINISHING AND POLISHING

SYSTEMS ON THE SURFACE STATE OF VARIOUS TYPES OF COMPOSITE

RESINS

Simona Stoleriu, Gianina Iovan, Galina Pancu, Irina Nica, Sorin Andrian

78

TECHNOLOGICAL ASPECTS IN THE CONSTRUCTION OF PROSTHETIC

REHABILITATION WITHOUT METAL FRAMEWORK

Diana Diaconu, Monica Tatarciuc, Andrei Melinte, Anca Viţalariu

84

RESEARCHES REGARDING THE BEHAVIOUR OF ACRYLIC RESINS VERSUS

SILICONIC MATERIALS INVOLVED PROSTHETIC RECONSTITUTIONS

Doriana Forna, Mariana Cazacu, Magda –Ecaterina Antohe

91

SEM STUDY REGARDING DENTAL EROSION ON EXTRACTED TEETH

IMMERSED IN HYDROCHLORIC ACID

Cristina-Angela Ghiorghe, Claudiu Topoliceanu, Galina Pancu, Simona Stoleriu,

Gianina Iovan

100

ELECTRON MICROSCOPY VALIDATION OF ICDAS CODES 5 AND 6

FOR PROXIMAL CARIES

Elena – Cristina Marcov, Narcis Marcov

105

THE IMPACT OF KINETO-THERAPY AND OF THERAPEUTICALLY MASSAGES

TO IMPROVE LIFE QUALITY OF PATIENTS WITH SDSS

Laura Checheriţǎ, Nicoleta Ioanid, Cornelia Brezulianu, Liliana Foia,

Antonela Beldiman, Amelia Surdu

110

PARTICIPATION OF SUPERFICIAL MUSCULO-APONEUROTIC SYSTEM OF THE

FACE IN CORRECT DENTAL OCCLUSION

Marius V. Hinganu, Delia Hinganu, Laurian L. Frîncu

119

CLINICAL ANALYSIS OF A DIGITAL METHOD FOR RADIOGRAPHIC ROOT

CANAL LENGTH DETERMINATION

Narcis M. Marcov, Elena-Cristina G. Marcov

125



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Dear Colleagues,

Interdisciplinarity constitutes a key word with

profound implications in order to reach performance in

the medical practice as well as to materialize thee

integrative holistic vision of oral and general

rehabilitation. Failure to see the dental medicine as a self-

sufficient clinical entity constitutes the sine qua non

condition of a modern therapeutic approach that

governs the contemporary dental practice.

The interplay of various types of field anchored in the sphere of systemic

pathology on the therapeutic approaches in the field of dental medicine materializes

as pertinent starting points for the realization of bivalent studies destined to the holistic

approaches among various specialties of general medicine and oral therapies.

The fundamental disciplines have a fundamental role in tracing the main

mechanisms involved in various types of pathologies, basic aspects that lie at the basis

of the therapeutic decisional algorithm in the oral and general medical practice.

The thorough knowledge of the type of terrain shown by the patient with

dental lesions constitutes an essential trajectory that diminishes accidents and risks and

that should govern the current dental medical therapy.

To be continuously linked to what’s new constitutes an essential aspect

towards evolution on a professional level and the access to the latest science

discoveries in the medical field materializes in a viable starting point for bringing

excellence, avant-garde and the latest technology in the daily practice.

Editor in Chief,

Prof. Univ. Dr. NORINA FORNA

Dean, Faculty of Dental Medicine

University of Medicine and Pharmacy “Grigore T. Popa”, Iasi



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9

FROM THE ANNOUNCEMENT OF A FATAL PROGNOSIS TO THE

RESPECT FOR AUTONOMY

Philippe PIRNAY

President of Comité National Odontologique d'éthique (France)

Vice-President of Académie Nationale de Chirurgie Dentaire (France)

Oral health is closely related to the quality

of life. It is a determining factor of the

condition of general health based on the

principle of oms which defines health not as

the absence of a disease, but as “a general

physical and mental state of wellbeing”. The

study related to the quality of life is always

oriented towards a practical application for

the patient’s interest. But in order to do so,

we need to reflect on the meaning and value

we attach to life and on the way we would

like to die. Evidently, when we are young, in

full physical and mental health, the quality of

life seems to have little impact on our actions.

We perceive all its significance and value

when life gives birth to injuries, handicaps

and diseases. A tooth extraction at a young

patient becomes the image of old age

approaching.

Ethics, often divided between the principle

of reality and the aspiration towards truth and

justice, guides therefore the surgeon-dentist

towards a global approach in order to better

understand what the patient goes through,

feels and expects from his/her health and how

to preserve his dignity.

The surgeon-dentist’s personal conscience

and his professional responsibility are the

ones that should guide his actions and speech.

Because the patient (sick person) /practitioner

(surgeon-dentist or doctor) relationship

requires loyalty and respect. But it is by its

very nature imbalanced, between an

individual who has access to knowledge and

another, non-professional individual who

wants to be informed.

THE INFORMATION

That is why informing one’s patient is a

humanistic obligation which reveals a

minimal ethic behavior. The preference for

the most relevant and not the most plausible

information, the most adapted understanding

and not the vaguest one allows the patient to

condition his autonomous decision properly,

closest to all possibilities. It is in this open

field of communication and therapeutic

education that the practitioner should invest

ethically for a medical relationship superior to

that lived punctually and often solitary

outside the self.

The patient is entitled to find out the truth.

Thus, when the patient needs to be informed

that he/she has cancer, AIDS or a pathology

which jeopardizes his vital prognosis, the

moment is often feared by the practitioner.

The pain of the announcement adds to the

pathology. The words and gestures gain

importance in order to protect the patient and

respect his right to hope. The practitioner-

patient relationship, apart form the

announcement of a serious diagnosis, also

faces the limits of a simple care relationship.

The two characters are actually confronted in

a complex opposition which needs to be

solved with calm and comprehension.

Our conscience is faced with three

possibilities: to speak, to keep silent or to lie.

Some other times, the patient is the one who

wants to know nothing.



10

Everyone acts according to one’s own

nature, sensitivity, moral, ethical and

religious convictions, without mentioning the

knowledge on the patient with whom

affective relationships are mingled with

deontological rules.

All efforts need to be taken to make the

patient listen to the explanations provided and

admit the truth, because the refusal to admit it

exposes him to multiple and serious

complications. It takes time to talk to oneself

and to take care not to make sudden

disclosures, empty of all humanity.

There is no wonder rule in the

announcement of a bad diagnosis. Two

people have in their hands the human and

professional conscience which should serve

as a beacon on a difficult and twisted road,

but very rich in satisfaction when the

amelioration of an individual’s health occurs.

This information guarantees the respect of

autonomy.

THE AUTONOMY

The ethical principle of the respect for the

autonomy is at the same time inescapable in

the medical practice and very controversial

from the point of view of its application and

value. It means that the patient is entitled to

take part to the decision which concerns him

and it is based on the idea that pursuing one’s

own values is the foundation of the

individual.

This suggests and proclaims that as long as

the autonomy is the spontaneous expression

of a liberty, it remains under the influence of

the values, education, experience and

perception that the patient has or receives on

his medical condition and of his relationship

his general health. The confidence and

beneficence thus become two poles of

indispensable agreement in order to attempt

to check presentiments and define the

autonomy of the patient in his relationship

with the practitioner.

“Any individual takes, with the health

professional and taking into account the

information and predictions provided, the

decisions regarding his health”. The

fundamental role of the quality of

information, of the pertinence of predictions

condition the bases of reasoning on which the

autonomy decision of the patient needs to

rest.

In this decision taking relationship,

autonomy is not possible unless it observes

for the individual concerned the ethical

principle of respect for one’s person as

human being which should lead him to

decide not the “WHAT” is desirable,

hypothetical, surreal, irrational, but on

“WHAT” is preferable on the gradual basis

of the knowledge, information and

concrete possible clinical solutions. The

convictions and personal sensibilities of each

patient should only interfere at a later stage.

Bringing the autonomy of the patient’s

decision to position itself ideally in the

interest of his health and aspirations, as little

as possible dependent on the influence of his

impressions and as close as possible to faith,

credibility on the data received courtesy of

the surgeon-dentist for the longest term

possible constitute a warranty for the quality

of the care relationship.

The doctors also need to learn to listen,

beyond words, to what the patient has to say,

often in a non-verbal communication, the

gestures, looks, to know at which point the

patient feels concerned by the importance of

what goes on in front of him. The diversities,

the differences between all human beings also

play a tremendous role. Certain people are

capable of acknowledging death or the

announcement of a fatal diagnosis, others

refuse to consider even the perspective. There

is no taboo word, no taboo gesture.

Hope should never be destroyed, the door

on hope should remain open, this way we

may expect to soften the shock of the moment



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when he finds out the truth.

Humility is, at these moments, one of the

most important virtues of the doctor, he

“knows” for sure and, due to this medical

knowledge, he may think himself more

powerful than the patient to whom he is about

to disclose the truth.

The passion for ethics, the passion to act

properly and adequately, will remind the

surgeon-dentist of the exigencies of this

ethical reflection. Our society warrants the

right to health, the right to be cared for and,

more exactly, the right to oral health which,

for Comité National Odontologique d’Ethique

de France is determined by: "oral health

means talking, eating, smiling and loving,

with an oral integrity and real or alleged

absence of oro-facial pathology, in a

condition of physical and social wellbeing."

But these rights need to be justified by an

obligation which acknowledges not a life

quality for the human life but a quality to life;

a unique value to protect.

REFERENCES

1 Pirnay P., Ethique, qualité de vie et santé bucco-dentaire. L’Information Dentaire, 2008; 32:1768-70.

2 Devillers A, Paysant F., Comment expliquer nos traitements aux patients? L'Information Dentaire

26: 28-29, 2011.

3 Valcarcel J, Spranzi M. Autonomie du patient: Qui décide du traitement ? L'Information Dentaire,

2013;14:65-67.

4 Le Breton G, Khayat D. Comment annoncer à son patient un pronostic grave ? L’Information

Dentaire, 2009; 19: 1022-26.

5 Pirnay P. et coll. L'éthique en médecine bucco-dentaire. Paris, Espace ID, 2012



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INFLUENCE OF HYALURONIC ACID IN PERIODONTAL TISSUE

REGENERATION

Vera Radojkova Nikolovska1*

, Mirjana Popovska1, Ana Minovska

2, Bruno Nikolovski

3,

Biljana Kapusevska1

1University “St Cyrilus and Methodius", Faculty of Dentistry, Skopje, Republic of Macedonia

2University “Goce Delcev" - Stip, Republic of Macedonia

3PHO “Eternadent”- Skopje, Republic of Macedonia

*Corresponding author: Vera Radojkova Nikolovska, Assistant, PhD

University “Ss Cyril and Methodius”,

Skopje, Republic of Macedonia

e-mail: [email protected], phone: +389 7 0355-030

ABSTRACT

Hyaluronic acid is a high molecular weight polysaccharide (glycosaminoglycan), which plays a vital role in the

functioning of extracellular matrices, including those of mineralized and non-mineralized periodontal tissues.

Hyaluronic acid is also important because of its numerous actions in the mechanisms associated with

inflammation and the wound healing process. Hyaluronic acid has been identified in all periodontal tissues in

varying quantities, being more prominent in the non-mineralized tissues, such as gingiva and periodontal

ligament, compared to mineralized tissues, such as the cement and alveolar bone. Preliminary evidence suggests

that hyaluronic acid is a very promising candidate as a mediator of periodontal tissue regeneration and

periodontal disease treatment, by promoting a rapid remission of symptoms, not only to the marginal gingiva,

but also to the deeper seated periodontal tissues. However, further researches for the therapeutic effects of

hyaluronic acid in periodontal disease sites are essential to be fully realized the true benefits of hyaluronic

administration in periodontal tissue regeneration..

Key words: hyaluronic acid, gingival inflammation, periodontal disease, periodontal reparation.

INTRODUCTION

Increasing advances in our knowledge of

the mechanism of inflammation and healing

process associated with periodontal disease

indicated the potential of the components of

the extracellular matrix as promoters of

periodontal tissue regeneration and healing.

Numerous evidence supporting the role of

one of these matrix components, emphasized

hyaluronic acid as one possible candidate in

regeneration of periodontal tissues.

STRUCTURE OF HYALURONIC ACID

Hyaluronic acid is a high molecular weight

polysaccharide with a molecular weight of 10

000 to 10 000 000 Daltons, a polymer

composed of repeated disaccharide units of

N-acetyl glucosamine and D-glucuronic acid

and belongs to a family of

glycosaminoglycanes with chemical formula

(C14H2O NNaO11) n N-acetyl-D-

glucosamine D-glucuronic acid.

PHYSIOLOGY OF HYALURONIC ACID

Hyaluronic acid is non sulphurous

component, which plays a vital function in

the structure and function of the extracellular

matrix of several tissues: corpus vitreum,



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synovial fluid, umbilical cord, synovial joints,

skin - where in the presence of 55% is a

major component of the basal epidermis and

in the mucosa of the oral cavity, including the

one in mineralized and non-mineralized

periodontal tissues.

Hyaluronic acid has been identified in all

periodontal tissues in a different quantity,

more present in non mineralized - gingival

tissue and periodontal ligament, compared to

mineralized - cement and alveolar bone [1].

As a result of the high level of hyaluronic

acid in the blood sera, it is constantly present

in the gingival fluid as a serum factor in large

quantities [2,3].

PHYSIOLOGY OF HYALURONIC ACID

IN GINGIVAL TISSUE

Endogenous hyaluronic acid is a natural

biological substance, which is a major

component of the matrix of connective tissue,

especially the gingiva. Its interaction with

other proteoglycans and collagen gives

stability and elasticity of the extracellular

matrix of connective tissue.

Hyaluronic acid binds to various proteins

and water molecules through hydrogen bonds,

forming viscous macro aggregate whose

primary function is to regulate the hydration

of the tissues and allows the flow of

substances in the interstitial space.

Hyaluronic acid is able to absorb water 50

times more than its normal dry weight. This

makes the tissue matrix highly compact and

increases exchange and diffusion of small

molecules, but also acts as a barrier to

diffusion of macromolecules and other

invasive substances. When hyaluronic acid

binds to cell receptors that are presented only

on active defense cells, it acts as a regulator

of migration and cellular defense mechanisms

that are particularly important in wound

healing and tissue repair. Hyaluronic acid

probably binds to CD44, heparin-type

proteoglycan containing sulfate that is

specific for epithelial cells of epithelial-

mesenhimal border and regulating reactions

between cells and the extracellular matrix,

especially their binding with hyaluronic acid.

This same type of receptor is involved in the

interaction between gingival fibroblasts and T

and B lymphocytes, and can speed up the

gingival immune response in the presence of

pathogenic bacterial flora. Its production rises

by bacterial endotoxin stimulation performed

on fibroblasts [4,5].

HYALURONIC ACID AND

PERIODONTAL DISEASE

Periodontal tissue represents a unique

complex where gingival epithelium as non

mineralized and other mineralized tissues

formed union at cement-enamel

junction(CEJ) [6]. Maintaining the integrity

of the union is essential in providing an

effective barrier against microbial invasion

and preventing the destruction in the deeper

periodontal tissues such as periodontal

ligament, cement and alveolar bone from

bacterial toxins, enzymes, etc. Structural

integrity of the union has been lost by the

chronic inflammation associated with

periodontal disease in which such

developments have harmful effects on the

components of the extracellular matrix of the

deeper periodontal tissues including collagen,

proteoglycans and hyaluronic acid. Clinical

studies indicate that hyaluronic acid in

chronic inflamed gingival tissue undergoes

extensive degradation to low molecular

products, which reduces hyaluronic function,

whereas related sulphurized

glycosaminoglycans, as hondroitin4-sulfate

and dermatan sulfate, remain relatively intact

[7, 8]. Primarily responsible for degradation

of hyaluronic acid in these cases are thought

to be bacterial enzymes - hyaluronidases [9].

The growing number of evidence also

suggest additional role of cellular reactive

oxygen species as superoxide radicals (O2-)



14

and hydroxyl radicals (OH) obtained during

hyaluronic destruction in periodontal disease

[10,11,12].

HYALURONIC ACID AND

PERIODONTAL REGENERATION

Hyaluronic acid has more structural and

physiological functions in tissues, including

extracellular and cellular interactions,

interactions with "growth" factors and the

regulation of osmotic pressure and tissue

lubrication, which helps in maintaining the

structural and homeostatic integrity of tissues

[13]. Hyaluronic acid is a key component of

chronic injuries during wound healing

processes among mineralized and non-

mineralized periodontal tissues, namely in the

processes of inflammation, granulation tissue

formation and remodeling of the epithelium.

[14].

Diseased tissue in the early stage of

reparation is rich in hyaluronic acid [15-16]

with the origin of the extracellular matrix

cells (fibroblasts and keratinocytes in the

gingiva and periodontal membrane,

cementoblasts in cement and osteoblasts in

alveolar bone) in inflamed areas, or derived

from vascular blood supply in affected site

[1,8,17,18].

Hyaluronic acid has multiple roles in the

initial inflammatory stages, such as providing

a structural framework, through interaction of

hyaluronic acid with fibrin plug, which

modulates the infiltration of inflammatory

cells from the extracellular matrix of the host.

Hyaluronic acid also induces the production

of a series of polypeptide molecules

(proinflammatory cytokines) from fibroblasts,

keratinocytes, cementoblasts and osteoblasts.

[1,18], which promotes the inflammatory

response and consequently stimulates

hyaluronic synthesis by endothelial cells of

blood vessels [19]. Hyaluronic acid continues

to be involved in the activation of

inflammatory cells such as

polymorphonuclear leukocytes and

macrophage function, including their

migration and adherence at site of injury,

phagocytosis and destruction of microbial

pathogens [20-22], in order to affect the

colonization and proliferation of anaerobic

pathogenic bacteria in the gingival sulci and

surrounding periodontal tissue. With

somewhat contradictory role, hyaluronic acid

can regulate the inflammatory response

through removal of reactive oxygen species

[8,22-24] that are released by inflammatory

cells, which may contribute to the

stabilization of granulation tissue matrix.

Furthermore, hyaluronic acid may indirectly

act on the development of inflammation and

granulation tissue stabilization, preventing the

release of enzymes- proteases of inflamed

cells that break down extracellular matrix

proteins, such as healing progresses [25].

Acid content of hyaluronic acid in non-

mineralized tissues where are chronic

changes, increases during subsequent

formation of granulation tissue and restoring

the epithelium [26-27], which is due to

increased hyaluronic synthesis of fibroblasts

and keratinocytes [6]. In mineralized

periodontal tissues such as alveolar bone, the

phase of granulation tissue is gradually

replaced by mineralized callus [18]. During

these stages, hyaluronic acid participates in

multiple cellular functions, such as promoting

the migration of cells from the extracellular

matrix in the matrix of the injury, cell

proliferation and granulation tissue

organization. These developments allow

reattachment of basal layer of gingival

epithelium to the basal lamina and full

maturation of mineralized tissues, resulting in

the reformation of the union of the tooth

surface. In later granulation stage, hyaluronic

synthesis stops and the existing hyaluronic

acid depolimerized by host enzymes

hyaluronidase, which results in the formation

low molecular compounds and alteration of



15

the granulation tissue composition. This

indicated that low molecular hyaluronic

fragments formed after subsequent

hyaluronidases activity promote the formation

of blood vessels (angiogenesis) in the lesion,

although the precise mechanism of action is

unknown [28-30].

EXOGENOUS APPLICATION OF

HYALURONIC ACID

Participation of hyaluronic acid in the

control mechanisms of tissue regeneration

was an advantage to be used as an exogenous

agent with more functional role in the

treatment of chronic inflammatory changes.

As a consequence of its non-toxicity,

biocompatibility and numerous biochemical

and physio-chemical features, topic and

systemic application of exogenous hyaluronic

acid offers benefit effects in modulation and

acceleration of the host response through

mechanisms described in numerous medical

fields. In system administration, hyaluronic

acid is distributed in plasma with a half-life of

10 minutes and is metabolized in the liver.

After local application plasma concentrations

are very low, thus allowing optimal presence

of the drug at the site where have to act [31-

33]. Studies in mice and rats showed no acute

toxic effects or chronic and reproductive

effects at doses up to 200mg/kg.

Indications for application of hyaluronic

acid in dentistry are numerous:

restoration, healing and gingival tissue

regeneration as an integral element in the

treatment of gingivitis;

addition in periodontal treatment;

in the treatment of stomatitis;

treating irritations and lesions on the

gingiva and oral mucous membranes

(such as aphthae);

irritations caused by dentures, fixed or

mobile, or during oral surgery

procedures;

care and maintenance of the gingiva when

dental implants are placed.

Hyaluronic acid is a natural and safe

physiologically important substance that can

be used by children during the second

dentition, pregnant women and the elderly.

CONCLUSIONS

So far conducted and published clinical

studies have shown good results and a high

degree of tolerance and acceptability by

patients, which is an indicator of clinical

value of hyaluronic acid in the treatment and

handling gingival disease [34].

It is evident that it has a more functional

role in the treatment of chronic changes,

including those that occur during periodontal

disease. Preliminary evidence suggests that

hyaluronic acid is a promising candidate as a

mediator of periodontal tissue regeneration

and treatment through promoting rapid

remission of symptoms, not only in the area

of the marginal gingiva, but in deeper

periodontal tissues [35-37]. However, further

investigations for therapeutic effects of

hyaluronic application in periodontal disease

are essential for the real benefit of its

application and full realization of periodontal

tissue regeneration.

REFERENCES

6 Rahemtulla, F. Proteoglycans of oral tissues. Crit. Rev. Oral Biol. Med. (1992), 3: 3-67.

7 Engstro'm-Laurent, A., Laurent, UBG, LiUa, K., Laurent, TC Concentration of

sodium hyaluronate in serum. Scand. J. Clin. Lab. Invest. (1985), 45: 497-504.

8 Embery, G., Waddington, RJ, Hall, RC, Last, KS Connective tissue elements as

diagnostic aids in periodontology. Periodontoi 2000 (2000), 24:193-214.

9 Kobayashi, H., Terao, T. Hyaluronic acid-specific regulation of cytokines by human

uterine fibroblasts. Am. J Physiol. (1997), 276: Cl 151-Cl 159.



16

10 Mohamadzadeh, M., DeGrendale, H., Arizpe, H., Estess, P., Siegelman, M.

Proinflammatory stimuli regulate endothelial hyaluronan expression and CD44 / H independent

primary adhesion. J Clin. Invest. (1998), 101: 97-108.

11 Aukhil, I. Biology of wound healing. Periodontol. 2000 (2000), 22: 44-50.

12 Embery, G., Oliver, W.M., Stanbury, J.B. The metabolism of proteoglycans and

glycosaminoglycans in inflamed human gingiva. J Periodont. Res. (1979), 14: 512-519.

13 Bartold, P.M., Page, R.C. The effect of chronic inflammation on gingival connective

tissue proteoglycans and hyaluronic acid. J Oral PathoL (1986), 15: 367-374.

14 Tipler, L.S., Embery, G. Glycosaminoglycan-depolymerizing enzymes produced by

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17

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Periodontol (2001) 72, 9: 1192-1200



18

EXPLORING THE ASSOCIATION OF CARIES EXPERIENCE WITH

SOCIAL AND BEHAVIOURAL FACTORS AMONG

SCHOOLCHILDREN FROM IASI, ROMANIA

Dana Baciu*, Ioan Danila, Carina Balcos

Dentoalveolar and Oro-Maxillofacial Surgery Department, Faculty of Dental Medicine,

"Grigore T. Popa" University of Medicine and Pharmacy - Iasi, Romania

*Corresponding author: Dana Baciu, DMD, PhD student

"Grigore T. Popa" University of Medicine and Pharmacy,

Iasi, Romania

e-mail: [email protected], tel. +40.740986883

ABSTRACT

Aim of the study To explore the relationship between sociodemographic and oral health behavioural factors

with dental caries experience in 6-8- and 11-13-year-old schoolchildren from Iasi. Materials and Methods: A

cross-sectional study of 306 in first grade and 278 in sixth grade children was conducted in Iasi in 2012.

Information on child socio-demographic characteristics and dental behaviours was collected through

questionnaires. Clinical examinations were performed by one trained dentist using the ICDAS II system and

caries experience was measured using dmfs/DMFS index. Oral hygiene status was assessed using the Silness

and Loe plaque index. The association of sociodemographic and behavioural characteristics and oral hygiene

status with caries experience (dmfs/DMFS) was assessed using negative binominal regression models. Results:

For 6-8 years old children, socio-economical position, sugary food consumption between meals, treatment and

dental pain as reason for the last dental visit and oral hygiene status were found to be significantly associated

with dental caries experience in both unadjusted and adjusted models. For 11-13 years old children, oral health

status and relatives supervision when child not at school were strongly associated with high levels of caries

experience, while all the other factor were not significantly associate with caries experience in both unadjusted

and adjusted models. Conclusion: Sociodemographic and behavioural variables and oral hygiene status were

found to be risk factors for caries experience in 6-8-yr-old children, while the first two indicators were not

significantly associated in 11-13-yr-old children. Epidemiological data can be used for improved public oral

health service planning and resource allocation within the region. Future oral health promotion and education

programmes should address these risk factors for dental caries experience.

Key words: dental caries, sociodemographic, oral health behaviour, children

INTRODUCTION

The majority of industrialized countries

have experienced a significant reduction in

the prevalence of dental caries due to the

continuous improvement of living conditions,

adoption of healthy lifestyles, improved self-

care practices, effective use of fluorides and

implementation of preventive oral care

programs [1] while in developing countries

has been observed an increasing level of

dental caries and treatment need [2].

Although globally the levels of dental

caries have decreased over the past decades, it

is still the most prevalent oral health disease

affecting children and teenagers [3].

Untreated dental decay is a major cause of



19

pain which impacts children’s quality of life

and daily activities such as the ability to eat,

speak, sleep, study or socialize [4,5].

Because dental caries in the primary

dentition is a strong predictor for cariogenic

risk of the permanent dentition [6-10], it`s

imperative to develop and implement oral

health promotion programme after we

evaluated the oral risk factors.

Petersen has observed [11] that at the

population level, oral health outcomes are

related to socio-environmental factors and

characteristics of the oral health services

available. In addition to the use of oral health

services, modifiable risk behaviors such as

oral hygiene practices, dietary habits, tobacco

use and excessive consumption of alcohol

were found. Across countries and oral health

systems, the existence of a social gradient

(economic characteristics and educational

background) in dental caries prevalence was

found.

Therefore, aim of this study was to explore

the influence of socio-demographic, oral

hygiene status and behavioural determinants

on dental caries experience in schoolchildren

from Iasi.

MATERIAL AND METHODS

A cross-sectional study of oral health

status of schoolchildren was conducted in Iasi

in 2012, where four public schools were

selected based on having a dental chair

operating within their premises, for detailed

clinical oral examinations. All 588 first-grade

and sixth-grade children in the selected

schools were invited to participate in the

survey.

Permission to conduct this study was

obtained from the Research Ethics Committee

of the “Gr. T. Popa” University of Medicine

and Pharmacy Iasi. Parents were fully

informed about the study and given the

opportunity to opt out. A written consent

form was obtained from parents before their

children’s participation.

Data were collected through

questionnaires and clinical oral examinations.

Questionnaires were used to gather

information on child socio-demographic

characteristics and dental behaviours. Family

socio-economic position (SEP) was assessed

based on parents’ occupation according to the

Classification of occupation in Romania and

education level. Child’s dental behaviours

included consumption of sugary food

between meals, reason for the last dental visit

and toothbrusing frequency.

Oral hygiene status was assessed using the

plaque index of Silness and Loe which

determines the quality of oral hygiene by

quantifying the soft debris on tooth surfaces.

The teeth surfaces examined were vestibular

for 16, 21, 24, and lingual for 36, 41 and 44.

When the permanent tooth had not erupted,

assessments were done on the corresponding

deciduous tooth. The scores were: 0=no

plaque, 1=plaque detected by using the probe

on the tooth surface in contact with the

gingival margin, 2=moderate plaque

accumulation visible to the naked eye,

3=tooth surface covered with a significant

amount of plaque. The mean plaque index

was calculated by the total scores divided by

the number of teeth examined. Furthermore,

to determine oral hygiene status the final

results were grouped in four categories: 0=

very good oral hygiene, PI<0.4; 1=good oral

hygiene, PI=0.4-1.0; 2=less good oral

hygiene, PI=1.1-2.0; 3= poor oral hygiene,

PI>2.0.

Dental health status was assessed

according to the ICDAS II diagnostic criteria,

which uses a two-digit coding method to

identify restorations/sealants (with the first

digit - codes 0 to 8), the actual stage of the

carious lesion (with the second digit - codes 0

to 6) and the reasons for the missing teeth

(four special codes) [12].

All examinations were carried out by one



20

trained and calibrated dentist (DB), in the

respective school’s dental office, where a

dental unit with functioning operation light

and air syringe was available, using plane

mouth mirrors and CPI probes, following the

International Caries Detection and

Assessment System (ICDAS) recommended

protocol [13]. Before clinical examination

children cleaned their teeth with a toothbrush

supervised by the school dentist. No

radiographs were taken. Intra-examiner

reliability in caries diagnosis was determined

by re-examining 58 children randomly

selected from first- and sixth-grade after a

week. Kappa value was 0.85 at surface level.

Data were analyzed using IBM SPSS

Statistics 20.0 for Windows. Children’s caries

experience was measured using the dmfs for

6-8 year olds and the DMFS for 11-13 year

olds. The ICDAS II caries codes were

classified in two groups of severity levels:

non-cavitated enamel carious lesions – at a

d/D1-2 level (codes 1 and 2), and cavitated

carious lesions – at a d/D3-6 level (codes 3 to

6). The f/F component included surfaces with

fillings associated or not with early lesions

(codes 1 and 2) on the same tooth surface.

Fillings diagnosed in conjunction with

cavitated carious lesions (codes 3 to 6) were

added to the d/D-component for calculation

of dmfs/DMFS scores. The occlusal surfaces

with full or partial sealants were considered

as healthy (code 0). Each age cohort (6-8 and

11-13 year olds) was analysed separately.

Caries experience (dmfs/DMFS index) was

the outcome measure for analysis. The

association of sociodemographic and

behavioural characteristics and oral hygiene

status with caries experience (dmfs/DMFS)

was assessed using negative binominal

regression models because dmfs/DMFS

scores were count variables and over-

dispersed. Rate ratios (RR) were therefore

reported. In Model 1 the association was

adjusted for demographic factors (SEP,

child’s sex and age) and in Model 2 for

caregiver when child not at school, oral

hygiene status and dental behaviours (sugary

food between meals, toothbrushing frequency

and reason for last dental visit). Significance

was assumed at ≤ 0.05.

RESULTS AND DISCUSSIONS

Socioeconomic status is the basis of many

inequalities in health, including oral health.

Occupational status, income and education

are found in a close relationship with each

other becoming measurement instruments. In

general, population groups which have a poor

oral status are those groups who have low

incomes and a marked lack of education,

while for those with high socioeconomic level

access to healthcare services is directly

proportional to their income and education

increases the opportunity for adequate

sanitary behaviour.

The original sample comprised a total of

588 children, but children who could not

provide information about their parents’

occupation were excluded from this study.

Therefore the number of children included

was 584, 306 6-8-yr-old children (mean age:

7.3, SD: 0.53) in first grade, and 278 11-13-

yr-old children (mean age: 12.7 years, SD:

0.52) in sixth grade.

Table 1. Sample description of children from year 1 (n=306) and year 6 (n=278) by sex, socio-

economic position, caregiver and oral health behaviors

Characteristics 6-8 yr olds 11-13 yr olds

n % n %

Sex

Boys 152 49.7% 128 46.0%

Girls 154 50.3% 150 54.0%



21

Socio-economic position

High level 134 43.8% 70 25.2%

Medium level 78 25.5% 82 29.5%

Low level 94 30.7% 126 45.3%

Caregiver when child not at school

Parents 72 23.5% 178 64.0%

Relatives 152 49.7% 58 20.9%

Other 26 8.5% 2 0.7%

No one 56 18.3% 40 14.4%

Sugary food between meals

Yes 252 82.4% 226 81.3%

No 54 17.6% 52 18.7%

Reason for the last dental visit

Dental check 98 32.0% 152 54.7%

Treatment 94 30.7% 58 20.9%

Dental pain 36 11.8% 44 15.8%

Never been to the dentist 78 25.5% 24 8.6%

Toothbrushing frequency

Once a day or less 218 71.2% 144 51.8%

Twice a day or more 88 28.8% 134 48.2%

Oral hygiene status

Very good 52 17.0% 44 15.8%

Good 160 52.3% 116 41.7%

Less good 62 20.3% 82 29.5%

Poor 32 10.5% 36 12.9%

Details about the description of the sample

are presented in Table 1. Approximately 50%

of children come from high and low SEP

families in 6-8-yr-old children and in 11-13-

yr-old children, respectively. Most children

(over 80%) reported to eat sweet food

between meals, and more than half that they

brush their teeth once a day or less, and went

to the dentist for a dental check.

Regarding the association between SEP

and caries experience among first grade

children we found that the mean values of

decayed component at both levels has a

significant increase as the SEP level decrease,

while the values of m and f components were

lower in children living in medium SEP

families. In sixth grade children, we found

that the mean value of decayed component at

3-6 level has a significant increase as the SEP

level decrease while all other differences are

not statistical significant (Table 2). Same

results were found in the study made in Brazil

[14].

The relationship of health-related

behaviors with socioeconomic position and

with oral health on the other hand, implies

that behaviors play an important role in the

socioeconomic disparities in oral health.

Particularly as some oral health enhancing

behaviors, such as preventive dental visits,

are restricted by costs [15].

Table 2. Mean of decayed, missing and filled surfaces (dmfs/DMFS) by parents’ socio-economic

position and the statistical significance of the differences between groups

Caries

measure

High SEP Medium SEP Low SEP p value

for

trend Mean [95% CI] Mean [95% CI] Mean [95% CI]

6-8 year olds

d1-2s 0.24 [0.14-0.33] 0.51 [0.31-0.72] 0.60 [0.36-0.83] <0.001

d3-6s 5.78 [4.59-6.96] 12.05 [10.05-14.05] 11.00 [9.38-12.62] <0.001

ms 1.18 [0.46-1.89] 0.23 [0.00-0.46] 2.04 [1.28-2.81] 0.002

fs 1.00 [0.71-1.29] 0.23 [0.06-0.40] 0.26 [0.11-0.40] <0.001



22

d3-6mfs 7.96 [6.54-9.37] 12.51 [10.51-14.51] 13.30 [11.47-15.13] <0.001

11-13 year olds

D1-2S 1.91 [1.36-2.47] 2.83 [2.34-3.32] 1.92 [1.52-2.32] 0.674

D3-6S 4.29 [2.33-6.24] 5.41 [4.43-6.40] 5.13 [4.36-5.89] 0.361

MS 0.14 [-0.06-0.34] 0.00 [0.00-0.00] 0.16 [0.00-0.31] 0.409

FS 1.03 [0.54-1.52] 1.10 [0.61-1.59] 0.59 [0.35-0.83] 0.007

D3-6MFS 5.46 [3.23-7.69] 6.51 [5.50-7.53] 5.87 [5.00-6.75] 0.775

P value for trends calculated using negative binomial regression models

In Table 3 are presented the negative

binomial regression models for d3-6mfs in

association with the baseline characteristics.

Table 3. Regression models for the association between age, sex, SEP, caregiver, oral health

behaviors and number of decayed, missing, filled surfaces (d3-6mfs) in first year schoolchildren

from Iasi at baseline (n=306)

Characteristics Unadjusted Model 1 Model 2

RR [95% CI] RR [95% CI] RR [95% CI]

Age in years 1.05 [0.84-1.32] 1.07 [0.84-1.35] 0.99 [0.78-1.26]

Sex

Girls 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Boys 0.97 [0.77-1.23] 1.02 [0.81-1.30] 0.96 [0.74-1.23]


High 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Medium 1.57 [1.17-2.11]** 1.57 [1.17-2.10]** 1.51 [1.10-2.07]*

Low 1.67 [1.27-

2.20]*** 1.69

[1.28-

2.23]*** 1.83

[1.34-

2.48]***


Parents 1.00 [Reference]

1.00 [Reference]

Relatives 0.94 [0.70-1.26]

0.99 [0.73-1.36]

Other 1.16 [0.73-1.85]

1.32 [0.79-2.20]

No one 1.28 [0.89-1.84]

1.24 [0.85-1.83]


No 1.00 [Reference]

1.00 [Reference]

Yes 1.75 [1.28-2.39]**

1.60 [1.15-2.22]


Dental check 1.00 [Reference]

1.00 [Reference]

Dental pain 1.68 [1.13-2.50]*

1.54 [1.01-2.34]*

Treatment 1.40 [1.04-1.89]*

1.42 [1.05-1.93]*

Never been to the dentist 0.92 [0.67-1.25]

0.75 [0.53-1.06]


Once a day or less 1.00 [Reference]

1.00 [Reference]

Twice a day or more 0.86 [0.67-1.12]

0.89 [0.67-1.18]

Oral hygiene status

Very good oral hygiene 1.00 [Reference]

1.00 [Reference]

Good oral hygiene 2.03 [1.45-

2.85]***

1.79 [1.26-2.55]**

Less good oral hygiene 2.44 [1.65-

3.62]*** 2.27

[1.51-

3.41]***

Poor oral hygiene 3.00 [1.89-

4.77]*** 3.01

[1.82-

4.99]***

Negative Binomial regression models were fitted and rate ratios reported (RR).

Model 1 adjusted for SEP and child’s sex and age, and Model 2 further adjusted for caregiver when child not

at school, sugary food between meals, reason for the last dental visit, toothbrushing frequency and oral hygiene

status.

* p<0.05, ** p<0.01, *** p<0.001

As shown, for 6-8 years old children, SEP,

sugary food consumption between meals, the

reason of treatment and dental pain for the

last dental visit and oral hygiene status were



23

found to be significantly associated with

dental caries experience in the unadjusted

models. In children living in families with

low and moderate SEP the d3-6mfs increased

by 57% and 67% compared to those from

high SEP families. This association was

attenuated but remained significant after

adjusting for demographic factors (Model 1)

and child’s caregiver, dental behaviours and

oral hygiene status (Model 2).

Diet, as a person’s preferences for a kind

of food (healthy or fast food with high level

of carbohydrates), and purchasing power can

be associated with an increase level of caries

offering a materialist explanation for

inequalities in oral health. In industrialized

societies, lower socioeconomic groups

purchase higher amounts of sugars, and

refined carbohydrates increasing risk factors

for oral diseases such as dental caries, than

higher income groups. Healthier diets

containing higher amounts of fruit and

vegetables are more expensive, and may

therefore be out of reach to low-income

families [16, 17, 18].

Oral hygiene status which was found to be

significantly associated with dental caries

experience could be argued by the presence

of calculus which is a confounding factor

with oral disease and can be used as a marker

of oral hygiene behavior [19]. Cleanliness of

teeth, as measured by plaque and calculus,

plays an essential role in periodontal health

[20] and tooth loss [21].Calculus is also

associated with dental plaque and oral

hygiene related behaviors [22].

Children having sugary snacks are 1.75

times (95% CI: 1.28-2.39) more likely to

have a high d3-6mfs score than those who

don’t eat sugary food between meals.

However, this association was no longer

significant after adjustment (Model 2). Dental

pain and treatment, as reasons for the last

dental visit, were also associated with high

levels of caries experience than those who

went to the dentist for dental check-up, in

which case d3-6mfs increased by 68% and

40%, respectively, and this association was

attenuated but remained significant after

adjustment. In children having a good, less

good or poor oral hygiene status the d3-6mfs

increased by 103%, 144% and 200%,

respectively, than in those who have a very

good oral hygiene status and this association

was attenuated but remained significant after

adjustment (Model 2).

Table 4. Regression models for the association between age, sex, SEP, caregiver, oral health

behaviors and number of decayed, missing, filled surfaces (D3-6MFS) in sixth year

schoolchildren from Iasi at baseline (n=278)

Characteristics Unadjusted Model 1 Model 2

RR [95% CI] RR [95% CI] RR [95% CI]

Age in years 1.16 [0.91-1.48] 1.17 [0.92-1.50] 1.13 [0.86-1.47]

Sex

Girls 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Boys 0.91 [0.71-1.18] 0.89 [0.69-1.16] 0.87 [0.67-1.14]


High 1.00 [Reference] 1.00 [Reference] 1.00 [Reference]

Medium 1.19 [1.85-1.69] 1.18 [0.83-1.67] 1.24 [0.86-1.80]

Low 1.08 [0.78-1.48] 1.07 [0.77-1.47] 1.13 [0.79-1.61]


Parents 1.00 [Reference]

1.00 [Reference]

Relatives 1.41 [1.02-1.93]*

1.41 [1.00-1.98]*

Other 1.22 [0.28-5.43]

0.99 [0.21-4.70]

No one 0.69 [0.47-1.01]

0.72 [0.48-1.09]


No 1.00 [Reference]

1.00 [Reference]



24

Yes 1.07 [1.14-1.72]

1.12 [0.79-1.59]


Dental check 1.00 [Reference]

1.00 [Reference]

Dental pain 0.93 [0.64-1.33]

0.98 [0.65-1.49]

Treatment 1.06 [0.76-1.46]

0.99 [0.70-1.39]

Never been to the dentist 0.67 [0.41-1.07]

0.66 [0.40-1.09]


Once a day or less 1.00 [Reference]

1.00 [Reference]

Twice a day or more 1.20 [0.93-1.55]

1.17 [0.90-1.51]

Oral hygiene status

Very good oral hygiene 1.00 [Reference]

1.00 [Reference]

Good oral hygiene 1.78 [1.20-2.63]**

2.01 [1.34-3.03]**

Less good oral hygiene 2.19 [1.46-3.30]***

2.40 [1.56-3.68]***

Poor oral hygiene 2.12 [1.31-3.45]**

2.71 [1.61-4.57]***

Negative Binomial regression models were fitted and rate ratios reported (RR).

Model 1 adjusted for SEP and child’s sex and age, and Model 2 further adjusted for caregiver when child not

at school, sugary food between meals, reason for the last dental visit, toothbrushing frequency and oral hygiene

status.

* p<0.05, ** p<0.01, *** p<0.001

In Table 4 are presented the negative

binomial regression models for D3-6MFS in

association with the baseline characteristics.

For 11-13 years old children, for those

supervised by relatives (especially

grandparents) when not at school, the D3-

6MFS score significantly increased by 41% in

both unadjusted and adjusted models. Good,

less good or poor oral hygiene status were

also associated with high levels of caries

experience than those who had a very good

oral hygiene, in which case D3-6MFS score

increased by 78%, 119% and 112%,

respectively, and this association significantly

increased after adjustment (Model 2) .Our

findings show that all the other factors were

not significantly associated with caries

experience in both unadjusted and adjusted

models. A systematic review of previous

literature confirmed a fairly strong evidence

for an inverse relationship between SEP and

the prevalence of caries among children [23].

A study on 13 year olds concluded that dental

caries experience and oral hygiene status of

children were strongly correlated to

socioeconomic status [24, 25].

Behavioral risk factors do not occur in

isolation but are by socio-environmental

factors. Higher levels of caries experience

might be expected in areas less supportive

socio-environmental condition [11].

CONCLUSIONS

Our study has concluded that:

- Frequency of sugar intake, snacking

frequency (between meals) and socio-

economic status may play an important

role in caries experience of

schoolchildren.

- Systematic community-oriented oral

health promotion programmes are needed

to target lifestyles and the needs of

children, particularly for those in low

socio-economic position. A prevention-

oriented oral health care policy would

seem more advantageous than the present

curative approach.

- Adjusting for health-related behaviors

attenuated but did not eliminate the

socioeconomic disparities in oral health.

- Oral health policies which aim changing

behaviors are unlikely to completely

eliminate disparities in oral health.

Acknowledgements

This research was supported by "Grigore T. Popa” University of Medicine and Pharmacy, Iasi,

Romania, which is the beneficiary of the Financing Contract POSDRU/88/1.5/S/58965.



25

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26

SALIVARY PERIODONTAL MARKER BACTERIA RELATED TO

COMMUNITY PERIODONTAL INDEX (CPI) IN NONSMOKERS

VERSUS SMOKERS ROMANIAN ADULTS

Cristina Nuca1*

, Victoria Badea2, Aureliana Caraiane

3

1Ovidius University - Constanta, Romania, Faculty of Dental Medicine,

Department of Preventive Dentistry 2Ovidius University - Constanta, Romania, Faculty of Dental Medicine,

Department of Oral Microbiology 3Ovidius University - Constanta, Romania, Faculty of Dental Medicine,

Department of Oral Rehabilitation

*Corresponding author: Cristina Nuca, Associate Profesor, DMD, PhD

Ovidius University - Constanta, Romania

e-mail: [email protected], phone/fax: 0040 241 66 57 27

ABSTRACT

Background While the relation smoking - periodontal disease is evident, the effect of smoking on oral

microbiota is not fully investigated. Aim of the study To compare the presence of 10 periodontal marker

bacteria in saliva of smokers vs. nonsmokers, in relation with CPI Index. Material and methods A sample of

286 adults (44.05% smokers, 55.94% nonsmokers) participated in a clinical study for collecting unstimulated

saliva (2.5 ml) and recording CPI Index; the salivary samples were analysed for the presence of 10 periodontal

bacteria (classified and scored by pathogenicity), by direct microscopic exam, bacterial cultures and automatic

identification. Ethics approval was obtained. Statistics used SPSS 12. Results CPI and microbiological score

were significant higher in smokers vs. nonsmokers, and correlated with each other (p<0.05). The presence of

periodontal bacteria in the saliva samples was 67.9%, more frequent (p<0.05) in smokers (75.3%) than in

nonsmokers (61.9%); E.corrodens, P.micros, T.denticola, A. actinomycetemcomitans and P.gingivalis were

found more frequently in smokers saliva, the last two being related with CPI; F.nucleatum was found more

frequently in nonsmokers saliva, being related with CPI; the prevalence of P.nigrescens, C.rectus and

P.intermedia did not record significant differences in nonsmokers vs. smokers. Conclusions The smokers saliva

varies considerably from that of non-smokers in terms of periodontal marker bacteria prevalence, this being

related with the periodontal profile assessed by CPI; because the relation between the salivary periodontal

markers bacteria and periodontitis in smokers vs. nonsmokers is essential for the prevention and treatment of

periodontal disease, it needs further long-term studies to elucidate.

Key words: periodontal marker bacteria, smoker, CPI Index, periodontal disease

INTRODUCTION

Periodontal disease is one of the most

common chronic infectious diseases in

humans and is the most prevalent cause of

tooth loss [1]; it is a multifactorial disease of

the tooth supporting structures, elicited by a

microbial biofilm (dental plaque) [2].

The main causes of the development of

periodontal disease are periodontal

pathogens, genetic predisposition within the

immune system, poor oral hygiene, smoking,

systemic diseases and stress; periodontal



27

disease is the clinical result of a complex

interaction between the host and plaque

bacteria [3].

Where an active periodontitis is

developing, the body’s defence system plays

a central role. The quantity and virulence of

microorganisms on one hand and host

resistance factors (immune status, genetics

and therefore heredity, as well as the presence

of risk factors) on the other hand are the

primary determinants for the initiation and

progression of periodontal destruction [2].

Normally low concentrations of periodontal

pathogens present even in a healthy sulcus

can be kept in check by an intact immune

system. However, if the defence system is

impaired by a genetic predisposition

(interleukin-1 polymorphism), medication or

smoking, the bacteria can proliferate freely

leading to the manifestation of profound

periodontitis.

The 215 cm2 surface area of the oral cavity

presents numerous surfaces for microbial

colonization, and are continuously bathed in a

bulk fluid, saliva [4]. The teeth provide a

solid, non-shedding surface for the

colonization of potentially pathogenic

bacterial species as well as a wide range of

hostcompatible species [5].

The microorganisms that colonize the oral

surfaces produce biofilms of differing

complexities depending on intraoral location,

genetic background and environmental

factors individual to each subject. As

complex as this microbiota may appear,

approximately 800 species may be detected in

dental plaque and at least 500 in the

periodontal pockets [4,6]. While the majority

of these organisms are commensals subsets of

them are implied in the initiation and

progression of periodontal diseases [7].

Even if it was established the role of some

microorganisms such as Actinobacillus

actinomycetemcomitans (Aa),

Porphyromonas gingivalis (Pg), Bacteroides

forsythus (Bf), Treponema denticola (Td),

Prevotella intermedia (Pi) and Fusobacterium

nucleatum (Fn) in different forms of

periodontal diseases [8], there is no evidence

for any specific pathogen in chronic

periodontitis and therefore it may be

considered as a non-specific bacterial disease

[9].

However, studies of Socransky et al. [4,5,

10, 11, 12, 13], Slots et al. [14, 15, 16] and

others [3,17, 18, 19], have shown that

periodontal disease is caused by a finite set of

bacterial species; only a few of the bacterial

species present in the oral cavity have a high

pathogenic potential that can cause profound

periodontal disease.

A number of possible pathogens have been

suggested on the basis of their association

with disease, animal pathogenicity, virulence

factors, immunological response of the host

to a species, the presence of interacting

bacterial species and the local environment of

the periodontal pocket [5]. Suspected

pathogens (risk markers) of periodontitis

belong to the group of obligatory anaerobic

black-pigmented bacterial species such as

Actinobacillus actinomycetemcomitans,

Porphyromonas gingivalis, Bacteroides

forsythus, Prevotella intermedia, Treponema

denticola and others [3]. According to their

pathogenicity, the first three are considered

very strong pathogenic species, as they

possess a whole range of pathogenic factors,

and their presence in the gingival pocket has

the potential to cause further tooth loss. In

addition to these highly pathogenic species,

other moderate pathogenic species may also

have a pathogenic potential dependent upon

the concentrations in which they are present

(Table 1) [20, 21, 22].

In the same time, Socransky et al. placed

the microorganisms within the oral

microbiota in "complexes" [12, 23]. This

concept emphasized that microorganisms

create their own habitat and interact with each



28

other by successive associations till the

appearance of the periodontal disease [8, 12,

23].

Table 1. Pathogenicity of Periodontal Marker Bacteria* [about 20, 21, 22]

Very strong Strong Moderate

Actinobacillus

actinomycetemcomitans (Aa)

Prevotella intermedia

(Pi) Eikenella corrodens (Ec)

Porphyromonas gingivalis (Pg) Treponema denticola

(Td) Prevotella nigrescens (Pn)

Bacteroides forsythus (Bf) Peptostreptococcus micros (Pm)

Fusobacterium nucleatum (Fn)

Campylobacter rectus (Cr)

*the list is not complete

Because all the oral biofilms consist of a

surface needed for the attachment, the biofilm

community itself and the “bulk fluid” (saliva

and/or gingival crevicular fluid) that passes

over the biofilm [4], the microbiological

diagnosis of the periodontal disease can be

made by analyzing dental plaque (sub- and

supragingival), and also by analyzing the

salivary microbial composition.

As a diagnostic fluid, saliva offers some

advantages: non–invasive and easy collection

procedure and high sensitivity and correlation

with levels in blood for detection of many

oral and systemic diseases [24, 25, 26, 27].

Saliva contains locally-produced microbial

and host response mediators, as well as

systemic (serum) markers that may be used in

the diagnosis of periodontal disease [28, 29,

30].

Based on the literature [28, 31], salivary

markers that have been studied as potential

diagnostic tests for periodontal disease

include proteins of host origin (i.e., enzymes,

immunoglobulins), phenotypic markers, host

cells, hormones (cortisol), ions and volatile

compounds and also bacteria and bacterial

products.

Determination of the numbers of a given

bacterial species in non-stimulated saliva may

indicate whether it is actively growing in

plaque and microbiological tests on the oral

flora should be used to monitor the oral health

[32], especially since the comparison of

microbial composition of biofilms on teeth,

soft tissues and saliva [17] showed a very

high similarity regarding the mean species

proportion.

As we enter the era of genomic medicine,

the salivary analysis plays an increasingly

important role in the detection and monitoring

of oral and systemic diseases [33].

Against this background, the aim of this

study is to compare the presence of 10

periodontopathic bacteria, classified by their

pathogenicity, in whole saliva of smokers vs.

nonsmokers, in relation with their periodontal

status assessed by CPI Index.


A. Study population and sample:

The study subjects consisted of 286

individuals from Constanta District (6%

sampling error; 95% confidence level), with

age range 35-44 years (mean 40± 4 years),

including 126 (44.05%) smokers and 160

(55.94%) nonsmokers who had not received

antibiotics within the previous three months.

B. Generation and collection of the saliva

samples

Total unstimulated saliva samples

(minimum 2.5 ml) were collected from all

subjects using a standard method (passive



29

collection in sterile containers). The saliva

samples were transported immediately after

collection to the microbiology laboratory

(Ovidius University, Faculty of Dental

Medicine), in order to carry out the

microbiological examination.

C. Clinical examination

The clinical examination of the subjects

was made by two trained and calibrated

examiners, recording the CPI Index using

World Health Organization (W.H.O.) 1997

criteria [34].

The clinical examination was carried out

in the selected family offices, using plain

mouth mirrors, W.H.O. (621 type)

periodontal probes and sterile gloves, under

artificial optimal light and respecting the

usual infection-control protocols. No

instruction in tooth brushing or oral

prevention was given to the participants prior

to the start of the study. Each examination

was performed in the morning (between 10

and 12 a.m.).

All the CPI Index teeth (or all the

remainder teeth in a sextant where there is no

index tooth) were examined at 6 sites, and the

highest score was recorded; each sextant was

given a CPI score (0 - healthy; 1 - gingival

bleeding; 2 - calculus; 3 - shallow pockets; 4 -

deep pockets) and the maximum CPI was

recorded as the individual’s Index.

D. Microbiological testing of the saliva

samples

The saliva samples were

microbiological tested in order to identify the

following 10 anaerobic bacteria (periodontal

marker bacteria):

1. Eikenella corrodens (Ec),

2. Prevotella nigrescens (Pn),

3. Peptostreptococcus micros (Pm),

4. Fusobacterium nucleatum (Fn),

5. Campylobacter rectus (Cr),

6. Prevotella intermedia (Pi),

7. Treponema denticola (Td),

8. Actinobacillus actinomycetemcomitans

(Aa),

9. Porphyromonas gingivalis (Pg),

10. Bacteroides forsythus (Bf).

For each sample, the bacteriological exam

followed the next stages:

I) direct microscopic exam;

II) bacterial cultures;

III) biochemical automatic identification

using mini API® system.

I) The direct microscopic exam was made by:

direct optical examination made on fresh

preparation between blade and slide and also

on simple and Gram stained smear; this exam

allowed to identify the morphological

features of the targeted bacteria;

dark-field microscopy - this method

reveals only the morphotypes of bacteria, i.e.

the shape of bacteria and their motility, but

does not permit any identification of bacterial

classifications or species; it permits

differentiation between inactive and active

samples; if the sample reveals primarily cocci

and non-motile rods, it is an indication of

only few active pathogens; if the field

exhibits numerous motile bacteria (e.g., rods

and spirochetes) it is an indication of a

potentially pathogenic flora.

II) Bacterial cultures :

selective culture media were used, as

follows:

- Schaedler agar with neomycin,

vancomycin and 5% ram blood for

A.actinomycetemcomitans (Aa),

P.intermedia (Pi), P.nigrescens (Pn)

and F.nucleatum (Fn) identification;

- Schaeldler agar with K vitamin for

B.forsythus (Bf); Columbia agar with

5% ram blood for P.gingivalis (Pg),

C.rectus (Cr), E.corrodens (Ec) and

T. denticola (Td) identification.

the biological products seeded on these

culture media were incubated in



30

microaerophilic conditions at 36°C±20C for 5

days in order to identify the facultative

anaerobic species (Aa) and in strictly

anaerobic conditions (Jar anaerobic system

and Anaerocult® A sachets containing

components which chemically bind oxygen,

creating an oxygen-free anaerobic milieu and

a CO2 atmosphere) at 36°C (±20C) for 7-10

days for the obligatory anaerobic bacteria

(Merck KGaA, Germany) [35].

the bacteria colonies developed after

incubation were verified by direct

microscopic exam made on Gram stained

smear and were then transplanted for

achieving pure cultures and for further

identification in API system.

III) Biochemical automatic identification

the identification of bacterial species was

made using an API bioMérieux system and

API® 20 A strips (bioMérieux® SA, France),

which allow the rapid identification of

anaerobic bacteria using 21 biochemical tests

(on the basis of 20 dehydrated and

miniaturized culture medium) [36];

the preparation of the bacterial suspension

was made with the verification of the optimal

density, using a densimat; the optimal

turbidity for anaerobic bacteria identification

was calculated at 3 Mc Farland units;

the API® 20 A were inoculated with

bacterial suspension and incubated at 360C

±20C for 24 - 48 hours in an anaerobic jar;

as a result of metabolic processes, in the

incubation period spontaneous and chemical

induces by adding supplementary reagents as

XYL (xylose), BCP (1-bromo-3-

chloropropane) and EHR (Ehrlich’s Reagent),

colour changes took place;

reading and interpretation of the results

(after the incubation period) was made using

the corresponding tables (identification

profiles) and was then confirmed using the

identification soft provided by mini API®

expert system.

Ethics approval

Ethical permission to conduct the study

was given by the Professional Ethical

Committee of Ovidius University, Constanta.

Free-written informed consent (including

patient information on the aim and methods

of the study) was obtained from all the

participants. Participation was optional, and

the time for thinking (express the consent or

refusal) was 48 hours.

Statistical analyses

These were made using SPSS 12 for

Windows. Chi-square test was used for

testing intra-group variation. ANOVA was

used for testing the between-groups variation.

Spearman and Pearson coefficients were used

for measuring the correlation/association

between variables. U-statistic (Wilks’

Lambda) was used for the multivariate

analysis.

RESULTS

A. The CPI Index

The mean value of CPI Index was

2.45±1.07, significant higher in smokers

(2.71±1.00) vs. nonsmokers (2.26±1.09)

(p=0.000; ANOVA).

The frequencies of CPI values in

nonsmokers and smokers are shown in Table

2.

Table 2. The CPI Index values in nonsmokers vs. smokers

CPI Index nonsmokers smokers

Count % Count %

0 (healthy) 18 11.3% 6 4.8%

1 (gingival bleeding) 6 3.8% 2 1.6%



31

2 (calculus) 73 45.6% 45 35.7%

3 (shallow pockets) 43 26.9% 43 34.1%

4 (deep pockets) 20 12.5% 30 23.8%

Total 160 100% 126 100%

p<0.05 (Chi-square statistics)

B. The microbiological score

The targeted identified bacteria were

classified according to their pathogenicity

(Table 1) in the following categories [20, 21,

22]:

moderate pathogenic species: Eikenella

corrodens (Ec), Prevotella nigrescens

(Pn), Peptostreptococcus micros (Pm),

Fusobacterium nucleatum (Fn),

Campylobacter rectus (Cr).

strong pathogenic species: Prevotella

intermedia (Pi), Treponema denticola

(Td).

very strong pathogenic species:

Actinobacillus actinomycetemcomitans

(Aa), Porphyromonas gingivalis (Pg),

Bacteroides forsythus (Bf).

According to this classification, in order

to statistically analyze the results of the study,

each subject was given a microbiological

score, corresponding with the highest

pathogenic species category of bacteria

identified in its individual saliva sample, as

follows:

0 - the microbiological exam did not

reveal the presence of any bacterial

species;

1 - the microbiological exam revealed

other species than those targeted in the

study;


moderately pathogenic anaerobic species

± other species;


strongly pathogenic anaerobic species ±

other species;


very strongly pathogenic anaerobic

species ± other species.

The targeted periodontal bacteria were

found in 67.9% (n=194) of the saliva

samples, more frequently (p<0.05; Chi-

square statistics) in smokers (75.3%) than in

nonsmokers (61.9%); 32.1% of samples,

significant more (p<0.05; Chi-square

statistics) in nonsmokers (38.2%) than in

smokers (24.6%), could not reveal the

presence of periodontal marker bacteria

(Table 3).

Table 3. The microbiological score values in nonsmokers vs. smokers

Microbiological

score

nonsmokers smokers Total

n % n % n %

no targeted

bacteria

0 30 61

18.8 38.2

11 31

8.7 24.6

41 92

14.3 32.1

1 31 19.4 20 15.9 51 17.8

with targeted

bacteria

2 35

99

21.9

61.9

27

95

21.4

75.3

62

194

21.7

67.9 3 25 15.6 28 22.2 53 18.5

4 39 24.4 40 31.7 79 27.6

Total 160 100.0 126 100.0 286

100.0 p<0.05 (Chi-square statistics)

The frequencies of the microbiological scores in nonsmokers vs. smokers and in the



32

entire sample are shown in Table 3; the mean

value of the general microbiological score

was 2.27±1.40, significant higher in smokers

(2.52±1.31) vs. nonsmokers (2.07±1.44)

(p=0.007; ANOVA).

Some of the bacterial cultures obtained

after the first inoculation and API® 20A

strips with the final results are presented in

figures 1-4.

Figure 1. Prevotella (above) and Bacteroides

and Porphyromonas (down) species Figure 2. Prevotella and Porfiromonas

species.

Figure 3. Actinomices and Bacteroides

species identified on API® 20A strips Figure 4. Prevotella and Bacteroides

species identified on API® 20A strips

C. The relationship between individual’s

microbiological score and CPI Index in

smokers/nonsmokers

The analysis of the possible relationship

between individual’s microbiological score

and CPI Index showed that there is a positive

correlation (Spearman coefficient=0.575;

p.=0.000) between the general microbial

score and CPI Index in the entire study

sample, for nonsmokers (ns) and also for

smokers (sm) (Table 4).

D. The periodontal anaerobic bacteria

identification

The comparison of the 10 periodontal

marker bacteria identification in the saliva of

nonsmokers vs. smokers was made only on

subjects with microbiologic scores 2, 3 and 4,

were at least 1 of the targeted bacteria was

identified; the subjects with microbiological

score 0 (n=41; 14.3%; Table 3) and 1 (n=51;

17.8%; Table 3) were excluded from this

analysis.

The new study sample comprised 194

subjects (99 nonsmokers and 95 smokers) and

the frequency of each targeted bacteria

identification is shown in Table 5.



33

Table 4. The relationship between microbiological score and CPI in nonsmokers/smokers

Smoker category CPI Index microbiological score Sperman correlation

(value/sig.) 0 1 2 3 4

ns

(n=160)

0 11 3 3 1 0

0.604/0.000

1 2 1 3 0 0

2 17 20 16 10 10

3 0 7 11 12 13

4 0 0 2 2 16

sm

(n=126)

0 3 1 0 1 1

0.484/0.000

1 1 1 0 0 0

2 6 14 12 7 6

3 0 3 9 14 17

4 1 1 6 6 16

Table 5. Frequency of bacteria identification in nonsmokers vs. smokers

Bacteria

Bacteria identification (n, %)

p (ANOVA) Total frequency (n, %)

nonsmokers smokers

Ec 7 (7.1%) 16 (16.8%) 0.035 23 (11.9%)

Pn 9 (9.1%) 0 (3.2%) 0.087 12 (6.2%)

Pm 10 (10.1%) 22 (23.2%) 0.014 32 (16.5%)

Fn 23 (23.2%) 11 (11.6%) 0.033 34 (17.5%)

Cr 16 (16.2%) 25 (26.3) 0.084 41 (21.1%)

Pi 28 (28.3%) 17 (17.9%) 0.087 45 (23.2%)

Td 14 (14.1%) 29 (30.5%) 0.006 43 (22.2%)

Aa 17 (17.2%) 31 (32.6%) 0.012 48 (24.7%)

Pg 13 (13.1%) 25 (26.3%) 0.021 38 (19.6%)

Bf 14 (14.1%) 12 (12.6%) 0.759 26 (13.4%)

E. corrodens, P.micros, T.denticola,

A.actinomycetemcomitans and P.gingivalis

were found more frequently in the smokers’s

saliva, and F.nucleatum was found more

frequently in the nonsmokers saliva (p<0.05;

ANOVA).

The prevalence P.nigrescens, C.rectus and

P.intermedia din not record significant

differences between nonsmokers and smokers

(p>0.05).

E. The relationship between the

periodontal marker bacteria and CPI Index

in nonsmokers/smokers

CPI Index was significant correlated

(Spearman coefficient) with F.nucleatum,

P.gingivalis and A.actinomycetemcomitans

presence in nonsmokers and with

F.nucleatum, P.gingivalis and B.forsythus

presence in smokers (Table 6).

F. The association between the

periodontal markers bacteria in

nonsmokers/smokers and their relationship



34

with CPI Index

The associations (Pearson coefficient)

between the targeted bacteria in

nonsmokers/smokers are shown in Table 7.

The multivariate analysis of the linear general

model showed that only some of these

bacteria associations are related (U-statistic)

with CPI Index.

Table 6. The relationship between bacteria identification and CPI in nonsmokers/smokers

Bacteria

category

Smoker

category

Bacteria

identification

CPI Index p

(Spearman) 0 1 2 3 4

Ec

ns no 4 3 34 31 20

p=0.853 yes 0 0 2 5 0

sm no 2 - 22 33 22

p=0.278 yes 0 - 3 7 6

Pn

ns

no 3 2 34 32 19 p=0.482

yes 1 1 2 4 1

sm no 1 - 24 39 28

p=0.070 yes 1 - 1 1 0

Pm

ns

no 4 2 33 30 20 p=0.554

yes 0 1 3 6 0

sm no 1 - 20 31 21

p=0.863 yes 1 - 5 9 7

Fn

ns

no 2 1 22 32 19 p=0.000

yes 2 2 14 4 1

sm no 2 - 19 36 27

p=0.037 yes 0 - 6 4 1

Cr

ns no 3 3 29 32 16

p=0.881 yes 1 0 7 4 4

sm no 1 - 22 27 20

p=0.279 yes 1 - 3 13 8

Pi

ns no 4 3 25 26 13

p=0.319 yes 0 0 11 10 7

sm no 1 - 21 32 24

p=0.619 yes 1 - 4 8 4

Td

ns no 3 3 34 29 16

p=0.133 yes 1 0 2 7 4

sm no 1 - 20 27 18

p=0.317 yes 1 - 5 13 10

Aa

ns no 4 3 33 28 14

p=0.012 yes 0 0 3 8 6

sm no 1 - 18 29 16

p=0.317 yes 1 - 7 11 12



35

Pg

ns no 4 3 33 33 13

p=0.009 yes 0 0 3 3 7

sm no 2 - 24 26 18

p=0.007 yes 0 - 1 14 10

Bf

ns no 4 3 31 32 15

p=0.201 yes 0 0 5 4 5

sm no 2 - 25 34 22

p=0.017 yes 0 - 0 6 6

Table 7. Bacteria associations in nonsmokers/smokers

Smoker category Bacteria associations p

(Pearson)

p

(U-statistic)

nonsmokers

Pn and Pi 0.049 p>0.05

Pm and Pi 0.019 p>0.05

Fn and Pg 0.034 p=0.000

Fn and Bf 0.026 p>0.05

Cr and Bf 0.032 p>0.05

smokers

Ec and Cr 0.046 p>0.05

Ec and Aa 0.001 p>0.05

Ec and Pg 0.000 p=0.038

Fn and Aa 0.014 p=0.001

Fn and Pg 0.035 p>0.05

Cr and Pi 0.035 p>0.05

Cr and Aa 0.039 p>0.05

Cr and Bf 0.027 p>0.05

Pi and Pg 0.032 p>0.05

Td and Aa 0.034 p>0.05

Aa and Pg 0.003 p=0.025

Aa and Bf 0.007 p>0.05

Pg and Bf 0.001 p=0.018

DISCUSSIONS

Numerous studies have examined the

relationship between smoking and periodontal

diseases, showing a higher level of

periodontal disease in terms of increased

alveolar bone loss, less bleeding on probing,

increased number of deep periodontal pockets

and greater attachment level loss in current

smokers than in non smokers (past and never

smokers) [4, 37-44].

While the strong relationship between

smoking and severity of periodontal disease is

evident, the effect of smoking on the

composition of oral microbiota is less clear.

Numerous studies were made in terms of

microbial composition of the subgingival

plaque in smokers vs. nonsmokers, with

various results.

Some studies showed that cigarette

smoking has little impact on subgingival

plaque composition. Preber et al. [45] showed

that counts of A.actinomycetemcomitans,



36

P.gingivalis, and P.intermedia were not

significantly different in smokers vs.

nonsmokers in deep pockets on adult

periodontitis subjects; Stoltenberg et al. [46]

found no significant differences between

smokers and nonsmokers in the prevalence of

A.actinomycetemcomitans, P.gingivalis,

P.intermedia, E.corrodens, and F.nucleatum

and Lie et al. [47] found no difference in

smokers vs. nonsmokers in the counts of nine

subgingival species in adults with gingivitis.

There are also other studies that have

found differences between the subgingival

microbiota of smokers and nonsmokers.

The study of Eggert et al. [48]

demonstrated that P.gingivalis, P. intermedia,

and A. actinomycetemcomitans were found

more frequently in the shallow pockets of

smokers than in similar sites in nonsmokers.

Kamma et al. [49] found that proportions

and/or prevalence of P.micros, C.concisus, B.

forsythus, C.rectus, C.gracilis, Selenomonas

sputigena, and P.gingivalis were significantly

elevated in smokers, whereas Spreptococcus

intermedius, A.naeslundii, Actynomices

israelii, and Eubacterium lentum were

significantly higher in nonsmokers. Zambon

et al. [50] found that smokers had

significantly higher levels of B..forsythus than

nonsmokers.

Data from the study of Haffajee and

Socransky [51] indicated that, even if there

were no significant differences in levels and

proportions of 29 test species from

subgingival microbiota in different smoking

groups, the prevalence of several orange,

E.nodatum, F.nucleatum, P. intermedia, P.

micros, and P. nigrescens, as well as all three

red complex species P. gingivalis, T.

forsythia, and T. denticola was significantly

greater in smokers than in non smokers; the

difference in prevalence of subgingival

species among smoking groups was

particularly marked in deep pockets.

The relation between dental plaque (supra-

and subgingival) and salivary microbiota is

also well documented. A study of Umeda et

al. [52] compared the presence of 6

periodontopathic bacteria in whole saliva and

subgingival plaque. Their results indicated

that whole saliva is superior to pooled

periodontal pocket samples to detect P.

gingivalis, P. intermedia, P. nigrescens, and

T. denticola in the oral cavity; however, little

agreement between samples was found for A.

actinomycetemcomitans and B. forsythus. The

comparison made by Mager et al. [17] on

three oral clusters of biofilms (plaque, soft

tissues and saliva) showed that there is an

over 80% similarity between the mean

species proportion from saliva and dental

plaque and the study of Rodrigues de Araújo

Estrela [53] showed no differences for the

prevalence of P.intermedia and P.gingivalis

in saliva, other oral sites (tongue dorsum,

buccal mucosa) and dental plaque (supra- and

subgingival).

Even if these studies demonstrated the

usefulness of salivary microbial composition

analysis for periodontal health, the studies

regarding the relation between salivary

microbiota, smoking and periodontal health

are not so numerous.

Our study found that the presence of the

targeted periodontal bacteria in the saliva

samples was by 67.9%, more frequent in

smokers (75.3%) than in nonsmokers

(61.9%);, and the general mcrobiological

score (the presence of the targeted bacteria)

was correlated with the periodontal status

assessed by CPI. In the same time, the present

results showed that E.corrodens, P.micros,

T.denticola, A. actinomycetemcomitans and

P.gingivalis were found more frequently in

the smokers saliva, the last two being related

with CPI; F.nucleatum was found more

frequently in the nonsmokers saliva, being

also related with CPI. The frequency of

P.nigrescens, C.rectus and P.intermedia

identification din not record significant



37

differences between nonsmokers and

smokers.

In a study regarding the salivary

periodontitis bacteria, Darout et al. [54]

showed that a high percentage of the subjects

had detectable levels of several bacterial

species in saliva; between 12% and 16% of

the subjects showed high salivary levels of

the periodontitis-associated bacteria A.

actinomycetemcomitans, P. melaninogenica,

P. intermedia, C. rectus and E. corrodens,

whereas only two (3.6%) and four (7.1%)

subjects had high levels of P. gingivalis and

F. nucleatum, respectively. There were

significantly higher levels of A.

actinomycetemcomitans, C. rectus, P. micros,

and significantly lower levels of P.

intermedia, F. nucleatum, E. corrodens in the

smokers than in the nonsmokers group.

Comparing with this study, our study

showed higher rates of all these evaluated

bacteria (between 11.9 and 24.7%) and a very

high presence of the targeted periodontal

bacteria in saliva; regarding the bacteria

prevalence in smokers vs. nonsmokers, our

results are in agreement with the results of the

cited study, showing that the periodontal

bacteria presence was more frequent in

smokers than in nonsmokers. Comparing with

the study of Rodrigues de Araújo Estrela et

al. [53], our study found similar results

regarding the prevalence of P. intermedia and

P. gingivalis in saliva.

Regarding the differences of bacterial

presence in smokers vs. nonsmokers, the

present study is in accordance with the study

of Darout et al. [54] in terms of a higher

frequency of A. actinomycetemcomitans and

P. micros and a lower frequency of F.

nucleatum in smokers.

The study made by Umeda et al. [55]

found that past smokers had a decreased risk

of harboring A. actinomycetemcomitans in

saliva, while current smokers had an

increased risk of harboring T.denticola,

although the risk of colonization by P.

intermedia and P.nigrescens did not differ

among smoking groups. Our study found

similar results regarding the absence of

differences between smokers and nonsmokers

in terms of P. intermedia and P.nigrescens

prevalence, and also regarding the higher

presence of A. actinomycetemcomitans and

T.denticola in smokers saliva.

The results of the present study regarding

the associations between bacteria and their

relationship with CPI Index are in agreement

with the studies made by Haffajee and

Socransky [51], showing significant

associations between all the bacteria of the

red complex (P.gingivalis, B.forsythus -

intensely and T.denticola - strongly

pathogenic) and also associations of Aa

(purple complex, intensely pathogenic) with

some of the red complex bacteria

(P.gingivalis and B.forsythus - intensely

pathogenic) in smokers; the main associations

regard the highly and strongly pathogenic

bacteria and are related with CPI. In

nonsmokers, the red complex bacteria

(P.gingivalis and B.forsythus, intensely

pathogenic) are associated with bacteria with

less pathogenic potential (F.nucleatum -

orange complex, and C.rectus - green

complex, both moderately pathogenic) and

the main associations regard the strongly

(P.intermedia) and the moderately bacteria

(P.micros, F.nucleatum), the most being not

related with CPI. There are also two

associations present in both smokers and

nonsmokers, between intensely and

moderately pathogenic bacteria (as

F.nucleatum with P.gingivalis, C.rectus with

B.forsythus), depending on CPI.

We can conclude that the present study is

enrolling in the actual studies regarding the

salivary microbial profile of smokers vs.

nonsmokers in relation with the periodontal

status, showing that smokers saliva varies

considerably from that of non-smokers in



38

terms of significant differences in the

prevalence and abundance of periodontal

marker bacteria, these being related with the

periodontal profile assessed by CPI Index.

Because of the increasing prevalence of

both smoking habit and periodontal disease in

adults but especially in young people at a

global level, long-term longitudinal studies

are required to establish the relationship

between the salivary periodontal markers

bacteria and prevalence and progression of

periodontitis in smokers vs. nonsmokers,

saliva being a readily available and cost-

effective diagnosis fluid for periodontal

disease assessment in large populations.

Acknowledgements

The authors would like to thank to all subjects for their unconditional co-operation and

support.

This work was supported by CNCSIS – UEFISCSU, project number PNII – IDEAS

1216/2008 - “Studies for evaluation of cotinine and other biomarkers in the oral fluids, as a base

for the development of a non-invasive diagnosis method and a prognosis model of the periodontal

disease in smokers”.

Statement of conflicts of interest

The authors of this article are not aware of any conflicts of interests regarding this study.

Abbreviations:

CPI - Community Periodontal Index

WHO - World Health Organization

SPSS - Statistical Package for the Social Sciences

versus - vs.

Eikenella corrodens - E. corrodens / Ec

Prevotella nigrescens - P. nigrescens / Pn

Peptostreptococcus micros - P.micros / Pm

Fusobacterium nucleatum - F.nucleatum / Fn

Campylobacter rectus - C.rectus / Cr

Prevotella intermedia - P.intermedia / Pi

Treponema denticola - T.denticola / Td

Actinobacillus actinomycetemcomitans - A.actinomycetemcomitans / Aa

Porphyromonas gingivalis - P.gingivalis / Pg

Bacteroides forsythus - B.forsythus / Bf

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41

TREATMENT OF THE BACTERIAL CORNEAL ULCER

Claudia F. Costea1*

, D. Petraru1, A. Cărăuleanu

2

“Gr. T. Popa” University of Medicine and Pharmacy of Iaşi, Faculty of Dental Medicine 1Clinic no. II of Ophthalmology, “Prof. Nicolae Oblu” Clinical Emergency Hospital of Iaşi

2Clinic of Gynecology, “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology of Iaşi

*Corresponding author: Claudia F. Costea, DMD, PhD


Iasi, Romania

e-mail: [email protected]

ABSTRACT

We present to you the case of a 15-year-old patient, of Iaşi County, with a history of Intrasellary Bilateral

Polylobed Giant Craniopharyngioma, Operated Iteratively (2011-2012) and at the left eye. Bacterial Corneal

Ulcer, Post-trichiasis, therapeutically neglected. The biomicroscopic examination highlighted the fact that the

corneal ulceration of the left eye had affected the central and inferior part of the cornea, presenting a

descemetocele, so a surgery was performed and the loss of substance at cornea level was covered by a fragment

of amniotic membrane.

Key words: corneal ulcer, trichiasis, amniotic membrane

INTRODUCTION

The corneal ulceration and the corneal scar

which remains after the healing are blindness

causes in the emergent countries. The corneal

ulcers are divided into 2 categories: infectious

(caused by bacteria, fungi, viruses and

parasites), non-infectious (autoimmune,

neurotrophic, toxic) and secondary to the

entropion, blepharitis, neglected corneal

traumatisms. The treatment must be set up,

after the realization of a culture on different

culture media, in order to highlight the

pathological aspect. The infectious corneal

ulcer shall be treated with topic and systemic

antibiotics, most frequently, anti-

inflammatory, corneal cicatrizant drugs, and

vitamin C for stimulating the local immunity.

If the ulcer does not heal and the evolution is

adverse to desmecetocele, one can choose the

therapeutic contact lens, coverage with

amniotic membrane, conjunctive coverage,

tarsoraphy or keratoplasty.

CLINICAL CASE

The patient H. A., 15 years old, Iaşi

County, was admitted in the Clinic no. II of

Ophthalmology, by transfer from the Clinic

no. III of Neurosurgery of the “Prof. Dr.

Nicolae Oblu” Emergency Clinical Hospital

of Iaşi, being admitted on October 18, 2012

with the symptoms: profound ocular

congestion, mucopurulent secretions,

epiphora, diffuse ocular pain, foreign body

sensation, progressive decrease of the left eye

visual acuity (left eye visual acuity=2/50).

The patient was diagnosed after an inter-

clinical examination with bacterial corneal

ulcer of the left eye, on September 3, 2012;

the examination of the lesion scraping on

different culture media highlighted the

presence of Escherichia Coli bacterium,

sensitive to ofloxacin. The patient neglects



42

the therapeutic indications, being admitted in

the Clinic of Ophthalmology, with the

exacerbation of the anterior pole symptoms,

the ulceration evolving towards

descemetocele. The patient presents the

following general pathologic antecedents:

Operated Craniopharyngioma (2010);

Operated Intrasellary Bilateral Polylobed

Giant Craniopharyngioma (2011, 2012);

Hypophysis Nanism (2012); Right Eye –

Post-operatory Total Palpebral Ptosis (2012);

Right Eye – Severe Amblyopia with

Temporal Hemianopsia; Right Eye – Partial

Atrophy of The Optic Nerve; Left Eye

Bacterial Corneal Ulcer (2011). Living

conditions are precarious. The results of the

general objective clinical examination show

other pathological modifications: nanism,

hepatosplenomegaly. Pupillary reflexes –

photomotor: right eye – fixed mydriasis, left

eye - present. Chromatic sense: right eye –

does not register, left eye - present. The

examination of the ocular annexes: edema

and diffuse congestion at the level of the

upper eyelid, left eye – palpebral cilia

implanted viciously at the cilliary margin of

the inferior eyelid (trichiasis), right eye –

complete palpebral ptosis (post-operatory)

(Fig.1). Ocular motility: left eye – normal in

all the vision directions, right eye

exodeviation. The biomicroscopic

examination of the right eye highlights:

anterior pole, with normal aspect, except the

fixed mydriasis. Left eye – intense perikeratic

congestion, central ulceration and in the

inferior 1/3 of the cornea, close to the

sclerocorneal limb (fixes the fluorescein),

which invades the stroma up to the Descemet

membrane (descemetocele), with

mucopurulent deposit, margins of the

infiltrated ulceration, perilesional corneal

edema, small anterior chamber; normally

located crystalline with diffuse opacities (Fig.

2).

Figure 1. Right eye - palpebral ptosis Figure 2. Left eye – Corneal Ulcer

The ophthalmologic examination

highlights: visual acuity of the right eye =

zero; visual acuity of the left eye = 2/50, with

the reduction of the inferior visual field,

because of the corneal opacities. Light

perception and projection, right eye - absent,

left eye - present. The ophthalmoscopic

examination highlights at the right eye: total

atrophy of the optic nerve; left eye: cannot be

examined because of the corneal opacities.

The data from the anamnesis, the general

objective clinical and overall ophthalmologic

examination directs towards the probability

diagnostic: Left Eye - Bacterial Corneal

Ulcer, Descemetocele, Left Eye - Trichiasis,

Right Eye – Post-operatory Total Palpebral

Ptosis, Right Eye – Total Atrophy of the

Optic Nerve. The determination of the

positive diagnostic and the realization of the

actual biological configuration of the patient

require the following target complementary

explorations: hemoleucogram; abdominal



43

echography: it highlights the

hepatosplenomegaly and the vesicular

lithiasis. The pediatric examination

establishes the diagnostics: Toxic

Hepatocitolisis Syndrome, Familial

Hypercholesterolemia, Vesicular Lithiasis.

We recommend the admission in the Pediatric

Clinic of the “Sf. Maria” Hospital of Iaşi,

after the treatment of the acute ocular

symptoms. Based on the data from the

anamnesis, from the general objective and

ocular examination and on the

complementary explorations, the following

positive diagnostic was identified: Left Eye –

Bacterial Corneal Ulcer, Descemetocele, Left

Eye - Trichiasis, Right Eye – Post-operatory

Total Palpebral Ptosis, Right Eye – Total

Atrophy of the Optic Nerve, Iterative

Operated Intrasellary Bilateral Polylobed

Giant Craniopharyongiom (2011, 2012),

Hypophysis Nanism, Toxic Hepatocitolisis

Syndrome, Familial Hypercholesterolemia,

Vesicular Lithiasis. Clinical symptoms at the

left eye: diffuse pain, intense congestion,

epiphora, mucopurulent secretions, foreign

body sensation, progressive decrease of the

left eye visual acuity, associated to the

biomicroscopic aspect of the anterior pole of

the left eye, which highlights the central and

inferior corneal ulceration, with infiltrated

margins and mucopurulent deposit, with

descemetocele, with the loss of the anterior

chamber.

Differential diagnostic

The differential diagnostic of the bacterial

corneal ulcer was performed with: fungal

corneal ulcer, dendritic ulcer, Acanthamoeba

keratitis, neurotrophic ulcer, Mooren ulcer,

keratitis produced by the Varicelo-Zosterian

virus, allergic keratoconjunctivitis, resistant

bacterial ulcer (with Methicillin-resistant

Staphylococcus Aureus).

Treatment

During the hospitalization, he received

topic treatment with non-steroidal anti-

inflammatory drugs (Indomethacin 1 drop x

5/day topic, Diclofenac 100 mg/day),

antibiotics (Ofloxacin 1 drop every 30 min;

Ceftriaxone 1 g every 12 hours i.v.), corneal

cicatrizant drugs, Tropicamid 1% (1

dropx3/day), ocular hypotension drugs

(Dorzolomid and Timolol 1 drop x 2/day),

Vitamin C 1g/day, Euthyrox 62.5 µg/day,

Prednisone 5 mg/day, Carbamazepine 200

mg/day, Omeprazole 20 mg/day. The absence

of the anterior chamber, vision reduction

from 2/50 to 1/500 and the presence of the

corneal descemetocele imposed the

emergency surgical intervention, under the

general anesthesia of the patient: we covered

the corneal ulceration with a fragment of

amniotic membrane and we performed the

depilation of the palpebral cilia of the left eye

(October 16, 2012). The evolution was

favorable: in the first day after the surgery,

the bio microscopic examination shows

conjunctive congestion at the left eye, the

amniotic membrane fragment was correctly

located on the cornea surface; adherent to its

surface, the anterior chamber was present.

The patient is discharged 10 days after the

surgery, following a treatment with topic

antibiotics, non-steroidal anti-inflammatory

drugs, corneal cicatrizant drugs; 4 weeks after

the intervention, the biomicroscopic

examination shows: left eye diffuse

conjunctive congestion, resorption of the

amniotic membrane fragment, present central

corneal ulceration, but with small dimensions,

peripheral vascularization of the cornea. On

November 20, 2012 the patient is admitted

again and he is subject to a double coverage

with an amniotic membrane fragment of the

remaining corneal ulceration, under general

anesthesia at the left eye (November 23,

2012). After the surgery (November 29,

2012), the patient follows a topic treatment



44

with antibiotics (ofloxacin 1 drop x 5/day),

anti-inflammatory, corneal cicatrizant, ocular

hypotension drugs. The evolution a month

after the surgery: at the left eye, the amniotic

membrane fragments at cornea level was

resorpted, the corneal ulceration was

reepithelialised, the margins of the old

ulceration were transparentized, almost 2-3

mm, from the sclerocorneal limb. The patient

must maintain the topic treatment with non-

steroidal anti-inflammatory drugs

(Indomethacin 1 drop x 3/day) and corneal

cicatrizant drugs (1 drop x 5/day); 3 months

following the surgical intervention, the

patient presented the following visual acuity

suitable for reading and walking: visual

acuity of the left eye = 4/50 (Fig. 3).

Figure 3. Left eye – reepithelialized corneal

ulceration

Prognostic

In the clinical case presented above, the

evolution was favorable; the ulceration

regressed, being replaced by a dense fibrous

tissue. However, the prognostic of this case

remains reserved, because the vision of the

right eye is zero and of 4/50 at the left eye

after the healing of the ulceration, being

indicated the keratoplasty, in a next stage,

after the stabilization of the corneal scar.

Distinctiveness of the case

This case is distinct because the trichiasis

was subsequently the cause of corneal

erosion, infected with the Escherichia Coli

bacteria, causing a corneal ulceration,

therapeutically neglected by patient’s non-

compliance; subsequently, it worsened,

evolving towards descemetocele and the loss

of the anterior chamber. The surgical

treatment aimed at reconditioning the corneal

plan with the amniotic membrane fragments,

which has a double role – reconditioning the

corneal continuity and stimulating the corneal

reepithelialization, by the contribution of the

stem cells.

DISCUSSIONS

In the clinical case presented above, after

the diagnostic was certain, besides the topic

intensive drug treatment we also performed

the surgical treatment, the coverage of the

corneal ulceration with amniotic membrane

fragments, which had a maximum efficiency.

The amniotic membrane fragments, which

applie at ulceration level have the role of:

regenerating the corneal stroma, facilitating

the migration of the corneal epithelial cells,

reducing the corneal pannus, regulating the

inflammatory process, diminishing the

fibrosis process, preventing the epithelial

cells apoptosis and it has anti-microbial

properties.

According to the specialty literature, the

treatment set up must have in view the

removal of the mechanical causes which

provoke the corneal ulcer (ablation of the

conjunctive calculi, entropion, trichiasis,

lagophtalmia), treatment of the infections

(dacryocystitis, conjunctivitis) and of the

post-traumatic erosions. The treatment aims

at fighting against the infection, by

destructing or neutralizing the pathogen

agent. One shall recommend an immediate

and dynamic treatment with broad-spectrum

antibiotics, which shall be subsequently

amended according to the results provided by

the antibiogram. In the bacterial ulcers, the

antibiotics are administrated both locally

(instillations, sub conjunctive injections) and



45

generally. Antibiotics therapy failure in the

bacterial ulcers requires a non-specific local

treatment, in order to destroy the pathogen

agent and stop the progression of the

infiltration of the ulcer’s margins (curettage,

iodized alcohol). In certain ulcers located in

the marginal area, a conjunctive coverage is

needed. In order to favor ulcer cicatrization,

the poor condition of the organism shall be

combated and general tonics and vitamins

shall be administered. In the trailing ulcers,

one shall perform coverage with an amniotic

membrane fragment or keratoplasty.

CONCLUSIONS

The drug and surgical treatment performed

in this clinical case determined the

improvement of the useful visual acuity from

1/500 to 4/50. In the therapeutic approach of

this disease it is essential to suppress any

mechanical cause, which determines,

maintains or aggravates the ulcer (in our case:

trichiasis), but also patient’s compliance to

the topic treatment.

REFERENCES

1 American Academy of Ophthalmology, The Eye M.D. Association, Basic and Clinical Science

Course, External Disease and Cornea. Singapore; 2008-2009: 8.

2 American Academy of Ophthalmology, The Eye M.D. Association, Confront Corneal Ulcers, AAO-

APAD Chicago; 2012.

3 BJO British Journal of Ophthalmology, Acry Sof Natural, Impruv Within, Alcon Surgical; 2006:

90(8).

4 Kanski J. J., Clinical Ophthalmology a systematic Approach. Elsevier Publishing House, 6th issue:

2007

5 Pérez Silguero D, Bernal Blasco I, Méndez de Pando M.D., Jiménez Garcia M.A., Pérez Silguero

M.A., no.16 Caso Clinico, „Membrana amniotica: nuestra experiencia”,Arch. Soc. Canar. Oftal.;

2005



46

CLINICAL ASPECTS IN PROSTHETIC CONVENTIONAL

REMOVABLE TREATMENT FOR ELDERLY PATIENTS

Dan Nicolae Bosînceanu*, Dana Budală, Norina Consuela Forna

“Gr. T. Popa" U.M.Ph. - Iași, Romania,

Faculty of Dentistry, Department of Proshodontics

*Corresponding author: Dan Nicolae Bosînceanu, DMD, PhD


Iasi, Romania


ABSTRACT

Reconstructing the edentulous arches is a very serious issue for the elderly patient because of the difficulties that

may occur during the process of making the dentures, re-establishing the vertical dimension, recovering the

facial aspect modified with age, cleaning and maintaining the dentures, all problems due to the third age.

Material and methods The study was conducted on a group of 46 patients, 19 men and 27 women, with

complete or subtotal edentation, denture wears or not, with ages over 60 years old, average age being 70,3.

Patients came in our clinic accusing previous treatments and asking for their optimization or for re-establishing

the function of the stomatognat system. Results Statistics proves that from 46 examined patients, 24 of them had

a stressed geroindex, 17 of them were near the normal limits and 5 were younger than their biological age.

Conclusions Prosthetic treatment for the elderly must have an integrative concept and not a standard one,

being necessary an individualized treatment for each patient and for every stage of the treatment being

adjusted for the main reason the patient came in, adjusted to their general health, their oral hygiene and

attitude towards the previous treatments.

Key words: removable prosthesis, prosthetic treatment, elderly

INTRODUCTION

Reconstructing the edentulous arches is a

very serious issue for the elderly patient

because of the difficulties that may occur

during the process of making the dentures, re-

establishing the vertical dimension,

recovering the facial aspect modified with

age, cleaning and maintaining the dentures,

all problems due to the third age. The

organism is also changed and not so flexible,

the habits, the changes in the environment ask

for changes that the elderly is no longer

available to do them Adjusting to new

conditions is difficult if not impossible

sometimes and this is a real impediment for

patient, which had also lower the ability to

recognize shape and dimension of objects.

It seems that need time to adept for partial

dentures is shorter, the feeling of a foreign

object is rare and the satisfaction after the

treatment is higher that is why we strongly

recommend to keep any tooth that may be

kept on the arches, when other conditions are

accomplished.


The study was conducted on a group of 46

patients, 19 men and 27 women, with

complete or subtotal edentation, denture

wears or not, with ages over 60 years old,



47

average age being 70,3 (Table 1).

Patients came in our clinic accusing

previous treatments and asking for their

optimization or for re-establishing the

function of the stomatognat system.

Each patient was thoroughly examined and

everything was wrote down in a clinical

paper, with information about the general and

local exam, diet habits, situation of arches

and denture (if case), age, adaptation,

comfort, quality and quantity of saliva, etc.

Table 1. Repartition on ages and sexes

AGE men % women %

60-70 6 31,57% 14 51,85%

71- 80 9 47,36% 8 29,62%

>81 4 21,05% 5 19,61%

Clinical local exam was completed with

paraclinical exams (cast for study,

orthopantomography, tomography for

temporomandibular joint) which determine

the final diagnosis.

The treatment was conducted taking into

consideration the age, sex, general conditions.

Patients with general state of health

influenced were supplementary observed in

order to ensure the quality of the treatment.

There were chosen simply solutions,

sustainable, easy to manipulate, which does

not change much the cranio mandibular

existing rapports and the masticatory type.

Patients with good general state of health

the prosthetic treatment considered the

geroindex, with minor cautions for

prophylaxis and efficacy. There were taking

into account the following:

1. the reason for which the patient came in

2. state of oral and denture hygiene

3. the existing teeth and their prosthetic value

4. the patient attitude towards the previous

treatments.

Very important was considered the

medical education of each patient, which

considered the biological, psychological and

social features for the age of more than 60

years old, which is a very fragile age,

characterized by regressions and restructuring

of the tissues.

RESULTS

The repartition of the patients by age and

sex proves a preference for feminine sex

(58,69%) while the male was 41,30% as in

table 1. The patients were framed by sex, age

and general state of health (Table 2).

Table 2. Repartition by age, sex and state of health

SEX State of health influenced Total Good state of health Total

60-70 71-80 >80 60-70 71-80 >80

Male 4 6 4 14 2 3 - 5

Female 8 5 5 18 6 3 - 9

Total 12 11 9 32 8 6 - 14

Table 3. Repartition by geroindex and oral health

Age Patients Geroindex Oral health

Subunit Normal Higher Complete edentation

bimaxillary

Complete/ sub or

extended unimaxillary

Treated Not treated Treated Not treated

60-70 20 8 9 3 1 8 5 6

71-80 17 7 8 2 7 2 3 5

>80 9 9 - - 6 - 3 -



48

Total 46 24 17 5 14 10 11 11

General exam, anamnesis,

interdisciplinary allowed establishing a very

precise diagnosis of general state of health

(heart diseases, metabolic diseases, lungs or

kidney diseases, osseous disease, etc).

Statistics proves that from 46 examined

patients, 24 of them had a stressed geroindex,

17 of them were near the normal limits and 5

were younger than their biological age (Table

3).

From table 3 we can see that complete

bimaxillary edentulous patients were 24, most

of them denture wearers and the other 22

were complete/subtotal or extended partial

edentulous unimaxillary.

The oral exam showed facial changes

caused by age and edentation: lower inferior

floor, facial asymmetries, stressed wrinkles

and ditches, reduced lips, etc (Fig. 1-5).

Figure 1. I.P., 82 years Figure 2. C.E., 73 years Figure 3. G.F., 71 years

Figure 4. I.C., 76 years Figure 5. N.P., 65 years

Intraoral evaluation of the prosthetic field

allowed us to fit them using Sangiuolo

classification and Kennedy–Applegate,

Koeler-Rusov and Schroder also. The existing

remaining teeth caused problems in using

special devices for support, maintenance and

stability (Fig. 6-15).

Examination of old dentures revealed

many times disastrous, degraded ones, with

incorrect retention elements, with tartar

deposits, porosities that emphasises the

irritating effect on the mucosa. The occlusal

reports were changed and caused the

instability and the lower masticatory

efficiency (Fig. 16-17).



49

Figure 6. Figure 7. Figure 8.




Examining the old dentures stability we

could find a good stability for maxillary and

absent stability for mandible. The instability

was caused in 8 cases by changes in vertical

dimensions and poor occlusal reports, in 6

cases were cause by large flanges of dentures,

in 3 cases were the result of clinic or

technological errors and in 5 cases were

caused by a lack of fitting on the prosthetic

field (table 4).

Medical education for the elderly was

done by simple dialogues, with a lot of

patience and tact.

We presented the techniques for oral and

denture hygiene, which were better

understood by the patients with low

geroindex, because they learn these on their

natural dentition and remembered it even now

and even than the conditions were changed.



50

Table 4. Distribution by denture age and stability

Denture

age

Cases Stability Instability

Large

flanges

Errors Vertical dimension and

modified occlusion

Lack of fitting

0-5 9 2 4 2 1 -

5-10 8 1 2 1 2 2

>10 8 - - - 5 3

TOTAL 25 3 6 3 8 5

We insisted on some general rules for

prevention:

• well balanced life style, avoiding

sedentariness with daily long walks;

• gymnastics;

• massages, balnear treatment;

• avoid stress and overloading –factors of

premature wear of organism;

• good food ration, with a lot of vitamins,

less salt, fats and more proteins and

minerals.

In conducting the treatment we considere

the reduced capacity for moving and choose a

solution of treatment very easy and easy to

improve if necessary.

The type of denture was commended by

the state of hygiene and the prosthetic value

of remaining teeth, partial dentures being

recommended when teeth were with a low

value and hygiene index lower than 1.

Reduced lower face floor and

malocclusion asked for an exploratory

redimension of the facial floors.

We also used graphic method for

determining central relation in some of the

patients, with incorrect muscular pattern (Fig.

18 – 20).

We used overdentures were teeth were

correct treated and covered with capes (Fig. 21,

22).

If not we extracted the teeth and made an

immediate denture which lead to a better

acceptance of the denture (Fig. 23, 24).

Figures 18, 19, 20. Recording gothic angle

Figures 21, 22. Caps overdenture



51

Figures 23, 24. Immediate denture

In patients with old dentures, making them

new ones wasn’t always a good solution,

because they were used with old ones and

their flows and couldn’t accept the correct

dentures.

Tartar deposits were removed with

enzymatic solutions, avoiding hypocloritis for

dentures with metallic parts and repaired

dentures were cleaned with soft brushes and

clorhexidine.

After the correct treatment is very

important to also tracking down the patients

and see the way they adjust to their new

situation, the way that the dentures remake

the functionality of the stomatognat system,

state of oral health and oral mucosa.

CONCLUSIONS

1. Increasing the average period of life, the

technical and scientific progress prolonged

the age of complete edentation increasing the

role that physiological involution plays in the

prosthetic treatment

2. Recovering the arches is very difficult

especially for elderly because of the stability

and maintenance problems, because of the

reduced lower facial floor and because of the

problems caused by change position of the

mandible

3. Prosthetic treatment for the elderly must

have an integrative concept and not a

standard one, being necessary an

individualized treatment for each patient and

for every stage of the treatment being

adjusted for the main reason the patient came

in, adjusted to their general health, their oral

hygiene and attitude towards the previous

treatments.

REFERENCES

1 Asker R.M., Davenport J.C., Tomlin H.R., Prosthodontic Treatment of the Edentulous Patient, Third

edition: MacMillian; 1992.

2 Borţun C., Bratu D., Protezarea edentaţiei totale. Timişoara: Ed. Marineasa; 1998: pp. 314-321.

3 Halperin R.A., Graser N.G., Rogoff S.G., Plekavich J.E., Mastering the Art of Complete Denture:

Quintessence, Publishing Co. Inc.; 1988: pp. 149-153.

4 Hayakawa I., Principles and Practices of Complete Denture. Tokyo: Quintessence Publishing Co.,

Ltd.; 2001: pp. 16-19, 111-230.



52

CONVENTIONAL VERSUS LASER-ASSISTED THERAPY WITH

AGGRESSIVE PERIODONTITIS

Mirjana Popovska1*

, Milco Ristoski2, Aneta Atanasovska-Stojanovska

3, A. Minovska

4,

V. Radojkova-Nikolovska1, Biljana Kapusevska

5, Kristina Mitic

1, Lindita Zendeli-

Bedzeti3, Spiro Spasovski

1

1 University “Ss Cyril and Methodius”, Skopje, Republic of Macedonia, Faculty of Dental Medicine,

Department of Oral Pathology and Periodontology 2 University “Ss Cyril and Methodius”, Skopje, Republic of Macedonia, Faculty of Medicine,

Institute for Pathologic Anatomy 3 University Dental Clinical Center ”St. Pantelejmon”, Skopje, Republic of Macedonia, Clinic for

Oral Pathology and Periodontology 4University “Goce Delcev”, Stip, Republic of Macedonia, Clinic for Oral Pathology and

Periodontology 5University “Ss Cyril and Methodius”, Skopje, Republic of Macedonia, Faculty of Dental Medicine,

Department of Prosthetics Dentistry

*Corresponding author: Mirjana Popovska, Professor, PhD

University “Ss Cyril and Methodius”,

Skopje, Republic of Macedonia

e-mail: [email protected], phone: +389 2 3299-038

ABSTRACT

Aim of the study To evaluate tissue response in aggressive periodontitis (AgP) after conventional and

conventional supplemented with laser-assisted therapy. Material and methods This study included 50 subjects

with AgP, aged 10 -24 year, which were divided into two subgroups. Firs subgroup 25 subjects treated only

with conventional therapy (CP) and second subgroup of 25 subjects which were treated with laser assisted

therapy (CP-LA). Low-level diode laser (630-670 nm, 1.875 J/cm) was applied, each sextant for 4 minutes,

Scorpion C- 405 7A (Optica Laser, Sofia, Bulgaria). The control group consisted of 20 individuals, aged 13-24

years, without signs of periodontal disease. Gingival tissue biopsies were obtained from the controls and from

the study group before and after conventional and with laser assisted treatment. Tissue specimens were

embedded in paraffin and cryostat procedures were performed. Results Gingival tissue specimens from study

group compared to controls showed dense infiltrate. Subject with AgP revealed heterogeneous inflammatory

infiltrate with dense and less dense areas. Almost equal values from quantitative measurements of connective

tissue inflammatory infiltrate were obtained. Mean values for study group before treatment were 39,18± 14,02 .

For the first subgroup mean values ranged 35,92± 14,02, and mean values for the second subgroup were 35.01

± 13.25. Qualitative analysis in study group after conventional without and with lasser assistance revealed

insignificant values of mononuclear and plasma cells and Russell bodies. Conclusions Laser application did not

induce quantitaive nor qualitative changes in the gingival tissue inflammatory infiltrate in study group. On

the basis of our findings we suggest that low level laser assisted therapy does not proof to be efficient in the

treatment of aggressive periodontitis.

Key words: Aggressive periodontitis, Low-level diode laser, Gingiva, Periodontal therapy



53

INTRODUCTION

Aggressive periodontitis is a disease with

destructive and progressive inflammatory

reaction, not being in association with local

irritating factors. Although many causes have

been reported, the etiology of the disease still

remains unknown. Ren et al [1] report genetic

heterogeneity of AgP existed in Chinese Han

nationality. The genetic mode was autosomal

recessive inheritance in general, and

autosomal dominant inheritance could not be

excluded in families whose parent(s) suffered

from severe chronical periodontitis. The

results imply the genetic heterogeneity of

AgP, and further demonstrate that AgP was a

multifactorial disease with major genetic

component in the disease etiology. Each

immunologic disorder triggers local tissue

response which is being evaluated according

to the inflammatory infiltrate content.

According to Artese et al [2] bioptic tissue

specimens in aggressive periodontitis reveal

CD20 cells. He suggests that gingival

specimens display vascular endothelial

growth factor, micro vascular density, nitric

oxide synthetase 1 and 3, and Ki-67 in

individuals with aggressive and chronic

periodontitis.

Different variations of immune response

are in direct relation to each individual

immunological genetic constitution and the

variations of the local immunity reflect the

histological structure of periodontal tissues

and its inflammatory infiltrate.

Literature data point to the role of bacteria

relating them to tissue histology alterations

associating them with the cause. Histological

examination revealed increased inflammatory

infiltrate, significantly increased

immunostaining for interleukin IL-6 and -

1beta and tumor necrosis factor-alpha, in

subjects with aggressive periodontitis (AgP)

[3]. Christersson [4] reports that treatment

lesions of juvenile periodontitis with scaling

and root planing resulted in minimal clinical

and microbiological changes during a 16

week follow-up period.

On the basis of our previous experience

and literature data, our investigation was

focused on pathohistological verification of

AgP in gingival specimens, comparing biopsy

tissue structure before treatment, and

evaluation of tissue response after

conventional and conventional, supplemented

with laser assisted treatment.


At the Department for Oral Pathology and

Periodontology, Faculty of Dentistry in

Skopje, R.of Macedonia, in the period 2006-

2010, 50 patients, both, males and females,

aged 10-24 years, diagnosed periodontitis,

with rapid, advanced and foudroyant course,

aggressive periodontitis (AgP) according to

the American Academy of Periodontology

from 1999.

Diagnosis was established on dental and

medical history data, clinical periodontal

examination and radiographic evaluation.

Subjects with any persisting systemic

diseases, as well as familiar predisposition

were excluded from the study.

Study group were divided into two

subgroups. Firs subgroup 25 subjects treated

only with conventional therapy and second

subgroup of 25 subjects which were treated

with laser assisted therapy.

The control group consisted of 20 subjects,

aged 13-24 years, with no clinical signs for

periodontitis who were referred for dental

examination before tooth extraction for

orthodontic reasons.

Radiographic verification was performed

before and after the treatment for each subject

in both groups.

Each participant was asked to sign a

Consent Term and the investigation was

approved by the Ethic Board of the Faculty of

Dentistry in Skopje, R. Macedonia.

Gingival tissue biopsies were provided for



54

each participant, including the controls. Each

gingival tissue biopsy was divided in two

smaller parts. One part was embedded in

physiologic medium and the other in 10%

formalin and further processed at the Institute

for Pathologic Anatomy at the Faculty of

Medicine in Skopje. Pathohistology analysis

was performed on biopsy specimens, both,

before therapy, after conventional and

conventional with laser assisted treatment.

Pathohistological analysis methodology

included the following procedures:

standardization in taking biopsy, dissection,

paraffin and cryostat processing, use of

standard (hematoxylin and eosin) and

differential staining (Giemsa, Von Gieson,

PASS, and trichrom), microscopy, and

photography and morphometric analysis. The

study group received a laser assisted

treatment. A low-level diode laser apparatus

Scorpion C-405 7A was used (Optica Laser,

Sofia, Bulgaria) with wavelength 630-670

nm. Laser beam was applied for 16 minutes

in ten subsequent daily courses. The gingival

tissue from both jaws was treated. Each

sextant was radiated for 4 minutes. Power

1.875 J/cm2 was used for 2 minutes duration

(per area, vestibular i.e. oral).

Results from study group were compared

to the control and between themselves, as

well. Twofold results comparisons within the

study group were performed, after

conventional periodontal and conventional

with laser assisted treatment. The results were

statistically processed using the Student’s „t“

distribution.

RESULTS

Tissue specimens from control and study

groups were submitted to histology

examination. Qualitative histology analysis

shows dense infiltrate rich in inflammatory

cells.

Infiltration density differs depending on

histological localization (epithelium and

lamina propria). A dense infiltrate was found

in all specimens of lamina propria. Epithelial

infiltrate is rare, still, presenting much more

inflammatory cells in the sulcus than in the

oral epithelium.

Tissue inflammatory infiltrate density in

the controls and study group before and after

therapy, are presented in Table 1.

Table 1. Inflammatory infiltrate mean values for connective tissue in the control and study

group before and after CT and CT-LA therapy (%)

Control group Study group

Before therapy After therapy

CT CT-LA

ICT% 9.1 ± 6.20 39.18 ± 14.02 35,92 ± 13.25 35.01 ± 13.25

Legend:

ICT- inflamed connective tissue

CT- conventional therapy

CT-LA – conventional therapy with laser assisted

Increased density of the inflammatory

infiltrate in two different therapeutic

approaches, conventional treatment (CT) and

conventional treatment assisted with laser

therapy (CT-LA) study subgroups compared

to the controls was found. Inflammatory

infiltrate density between the tissue

specimens obtained after therapy with CT and

CT-LA is almost equal, subsequently,

quantitative analysis shows no statistically

significant difference between them. Density

of the inflammatory infiltrate in tissue

specimens before therapy was 39,18±14,02

and show low statistically significant



55

difference with tissue specimens after two

kinds of the treatment.

Minor decrease of inflammatory infiltrate

in both studied groups after conventional and

laser assisted treatment is evident.

Expectedly, as values for both subgroups are

very close, our quantitative analysis shows no

statistically significant difference between

them. All above measurements were

performed in three scopes (3 0,7 mm2 =

0,21 mm2).

Nevertheless, in several single tissue

specimens, heterogeneity of inflammatory

infiltrate density in the study subgroups after

conventional treatment and in those after

conventional and laser assisted treatment was

found, unlike in the control group.

Tissue specimens with heterogeneous

inflammatory infiltrate distribution are,

further, classified into two forms: with dense

and less dense infiltration areas. Table 2

presents mean values of specimens of two

subgroups which had areas with less dense

infiltration areas and with dense

inflammatory areas.

Table 2. Quantitative analysis of inflammatory infiltrate density in gingival tissue samples

in subjects with AgP who received conventional, and conventional with laser assisted

treatment

Study group

CT CT-LA

Less dense area Dense area Less dense area Dense area

25.18 ± 4.06 45.1 ± 5.20 24.28 ± 5.04 44.18 ± 5.03

Legend:

CT- conventional therapy

CT-LA – conventional therapy with laser assisted

Specimens with less dense inflammatory

infiltrate areas occupy an average of 25% of

the measured surface, while 45% of the

measured area in those with dense infiltrate

(Figure 1).

a) b)

Figure 1. Gingival tissue sample. Connective tissue fragment: a) less dense infiltrate area; b)

dense infiltrate area (PAS, 10 x 10)

Binary illustration of the distribution of the

inflammatory infiltrate depending on the

density in both fragments is given in Figure 2.

Blue areas show the connective tissue and the

white ones the inflammatory infiltrate.

Same results, differentiation of second

subgroup according to inflammatory infiltrate

density, were obtained by quantification using

the method of profile function from Lucia M

image analysing system that measures nuclear



56

density along more lines in a given scope

(Graph 1 and 2).

Figure 2. Binary illustration of the

inflammatory infiltrate surface: a) left –

dense infiltrate; b) right – less dense

infiltrate

Comparison of both graphs reveals that the

graph 1 curve, compared to that one in graph

2, refracts more from the “x” axis. The reason

for the curve amplitude is increased count of

inflammatory cells in the gingival fragment,

which suggests increased amount of nuclear

material incorporating into the basic cellular

and intercellular matrix.

Analysis of the inflammatory infiltrate

cells obtained from the AgP group after

conventional therapy without and with laser

assisted treatment did not show any

qualitative differences.

Inflammatory cells were mostly

mononuclear with rare plasma cells. Plasma

cells were joined by immature forms of

plasma cells, differentiated plasma cells, and

plasma cells with Russell bodies, degenerated

and degraded plasma cells. Inflammatory

infiltrate tissue samples obtained from

subjects treated only conventionally did not

reveal qualitative difference compared to

those in subjects after conventional and laser

assisted treatment (Figure 3).

Graph 1. Mean nuclear density in gingival tissue specimens in fragments with less dense

inflammatory infiltrate in AgP connective tissue specimens from subjects after CP and CP-

LA therapy

Graph 2. Mean nuclear density in gingival tissue specimens in fragments with dense

inflammatory infiltrate in AgP connective tissue specimens from subjects after CP and CP-

LA therapy

Samples analysis of study group revealed

sub epithelial connective tissue alterations.

Dissociation, disruption and loss of collagen

fibres in the fragments with dense

inflammatory infiltrate were registered in

study group treated with conventional



57

therapy. Minor and insignificant differences

were found even after laser assisted

treatment.

Figure 3. Inflammatory infiltrate sample

from gingival connective tissue fragment

with Russell particles

DISCUSSION

Gingival tissue inflammatory infiltrate

samples of high density were found in study

group, regardless therapy modality

(conventional, with or without laser assisted

treatment). Gingival tissue specimens taken

from group treated conventionally against

group treated with laser assisted did not show

statistically significant differences. Almost

equal quantitative and qualitative findings

study group after conventional and

conventional with laser assisted treatment

suggest that laser application does not have

significant influence on local tissue response

in both study groups.

There are controversies in literature on the

efficiency of laser application in chronic

periodontitis treatment. Some authors report

[5-8] that low-level diode laser application

and photodynamic therapy are efficient

supplementary aid in the treatment of chronic

periodontitis. On the other side, literature

offers opposite reports [9-10] suggesting that

laser application has limited efficiency.

Chronic periodontitis treatment assisted

with low-level laser can be favourable

additional therapy method stimulating

improvement and stable therapeutic results

[11] only if periodontal follow up

appointments are sceduled each two months.

Karsson et al [12] does not agree that laser

assisted therapy is efficient pointing to further

clinical investigations.

If inflammatory cells are found in the

connective tissue samples of the controls they

have the role of immunologic barrier to react

against potential intruding agents (infective,

mechanical, immunological or other genuine

factor) [12].

In the treatment of chronic periodontits

even solely conventional therapy proves to be

efficient. Lovelance et al [13] reports that the

produced antibodies against plaque antigens,

gingival and sulcus tissue antigens could have

local origin. In the case of early-onset

periodontitis our results differed. Namely,

after treatment (without and with laser

assistence) both study groups revealed almost

equal inflammatory infiltrate, which, on our

opinion, suggests to involvement of other

physiological mechanisms.

Another investigation points that low-level

diode laser influence in the local metabolic

processes favours analgesic and anti-

inflammatory effects and reparatory processes

[14]. Stimulation of local response, cell

proliferation and collagen synthesis are

among the most frequent processes induced

by laser therapy [15-18].

Unfortunately, information on the effect of

laser on early-onset periodontitis tissue are

poor.

de Oliveira et al [19], investigating

mediators in the inflamed gingival tissue,

using photodynamic and conventional therapy

in early-onset periodontitis reports that TNF-

alfa factor approaches referent values, and

Kamma et al [20] of a positive response in

some clinical and microbiological results.

Our study shows that inflammatory

infiltrate density is in relation to clinical



58

feature, nature and the stage of disease

progression. Similar findings and positions

reveals Sanguin [21]. He points out that at

different disease stages globulin levels in

tissue specimens increase proportionally with

the intensity of the inflammation. Yet,

sometimes, the presence of different cells in

the inflammatory infiltrate favours increase of

the entire infiltrate. On the other hand, the

increased inflammatory infiltrate density in

the connective tissue suggests that there is a

grouping tendency according to the

percentage of the occupied area. This

polarity, if our investigation sample consisted

of a larger number of participants, could be

expected to reveal higher or lower dispersion

level, still retaining the boarder lines of an

inflammatory infiltrate.

In our investigation, except other, plasma

cells in tissue specimens were found being an

indirect indicator that the infiltrate density

increase induces increased immunoglobulin

carrier cells count. Plasma cells, as well as,

plasma cells with Russel-bodies reveal

extensive B cell differentiation and

maturation of plasma cells along with

intensive immunoglobulin synthesis. This

inflammatory infiltrate type suggests to

alteration of the local immunologic cell and

humoral response. Artese et al [22] using

immunohistochemical methods found CD20

cells in bioptic specimens supporting the

theory of the role of cell immune

mechanisms. Our findings agree with Mangan

et al [23] reporting of heterogeneity of cell

infiltrate in periodontitis affected gingival

tissue.

The inflammatory infiltrate, mostly

mononuclear, persists even study groups were

subjected to conventional, with or without

laser assisted treatment. From

pathohistological aspect of view, these

findings suggest that the disease is a chronic

inflammatory process. Rare granulocytes, as

well as necrotic and degraded particles, could

be related to acute exacerbation process,

because it is well known that the disease itself

is presented with frequent acute exacerbations

and short remissions.

CONCLUSION

Our results suggest that there is no

difference in the pathhistological findings of

study groups after conventional, without and

with laser assisted treatment. Persistence of

the gingival tissue inflammation in study

groups after conventional therapy without and

with laser is probably due to some other

etiopathogenetic mechanisms and not to local

irritating factors. On the basis of our findings

we suggest that low-level diode laser assisted

therapy does not proof to be efficient in the

treatment of aggressive periodontitis.

REFERENCES

1 Ren XY, Xu L, Meng HX, Lu RF, Chen ZB, Feng XH. A preliminary study on the genetic mode of

aggressive periodontitis in Chinese Han nationality. Zhonghua Kou Qiang Yi Xue Za Zhi. 2012;

47(2): 75-80.

2 Artese L, Piattelli A, deGouveia Cardoso LA, Ferrari DS, Onuma T, Piccirilli M, Faveri M, Perrotti

V, Simion M, Shibli JA. Immunoexpression of angiogenesis, nitric oxide synthase, and proliferation

markers in gingival samples of patients with aggressive and chronic periodontitis. J Periodontol

2010; 81(5): 718-726.

3 Rogers JE, Li F, Coatney DD, Rossa C, Bronson JP, Krieder JM, Giannobile WV, Kirkwood KL.

Actinobacillus actinomycetemcomitans lipopolysaccharide-mediated experimental bone loss model

for aggressive periodontitis. J Periodontol 2007; 78(3): 550-558.

4 Christersson LA. Actinobacillus actinomycetemcomitans and localized juvenile

periodontitis.Clinical, microbiologic and histologic studies. Swed Dent J Supp.1993; 90:1-46.

5 Bottura PE, Milanezi J, Fernandes LA, Caldas HC, Abbud-Filho M, Garcia VG, Baptista MA.



59

Nonsurgical periodontal therapy combined with laser and photodynamic therapies for periodontal

disease in immunosuppressed rats. Transplant Proc. 2011; 43(5): 2009-2016.

6 Igić M, Kesić L, Apostolović M, Kostadinović L. Low-level laser efficiency in the therapy of chronic

gingivitis in children. Vojnosanit Pregl. 2008; 65(10): 755-757.

7 Pejcic A, Kojovic D, Kesic L, Obradovic R. The effects of low level laser irradiation on gingival

inflammation. Photomed Laser Surg 2010; 28(1): 69-74.

8 Angelov N, Pesevska S, Nakova M, Gjorgoski I, Ivanovski K, Angelova D, Hoffmann O, Andreana

S. Periodontal treatment with a low-level diode laser: clinical findings. Gen Dent 2009; 57(5): 510-

513.

9 Cobb CM . Lasers in periodontics: a review of the literature. J Periodontol 2006; 77(4): 545-64.

10 Niederman R. Are lasers as effective as scaling for chronic periodontitis? Evid Based Dent 2011;

12(3): 80-1.

11 Lu RF, Xu L, Meng HX, Hu WJ. Clinical effects of non-surgical treatment on severe generalized

aggressive periodontitis. Zhonghua Kou Qiang Yi Xue Za Zhi 2008; 43(5): 264-268.

12 Karlsson MR, Diogo Löfgren CI, Jansson HM. The effect of laser therapy as an adjunct to non-

surgical periodontal treatment in subjects with chronic periodontitis: a systematic review. J

Periodontol 2008); 79(11): 2021-2028.

13 Lovelenace BM, Thompson JJ, Yukina RA. Evidence of local immunoglobulins, complement and

immune complexes in inflamed human gingiva. Acta Odontol Scand 1987; 45: 187-193.

14 Lins RD, Dantas EM, Lucena KC, Catão MH, Granville-Garcia AF, Carvalho Neto LG.

Biostimulation effects of low-power laser in the repair process. An Bras Dermatol 2010; 85(6): 849-

855.

15 Smith KC. Laser (and LED) therapy is phototherapy. Photomed Laser Sur 2005; 23: 78-80.

16 Vladimirov YA, Osipov AN, Klebanov GI. Photobiological principles of therapeutic applications of

laser radiation. Biochemistry 2004; 69: 81-89.

17 Minatel DG, Frade MA, França SC, Enwemeka CS. Phototherapy promotes healing of chronic

diabetic leg ulcers that failed to respond to other therapies. Lasers Surg Med 2009; 41: 433-441.

18 Desmet KD, Paz DA, Corry JJ, Eells JT, Wong-Riley MT, Henry MM, et al. Clinical and

experimental applications of NIR-LED photobiomodulation. Photomed Laser Surg 2006); 24: 121-

128.

19 de Oliveira RR, Schwartz-Filho HO, Novaes AB, Garlet GP, de Souza RF, Taba M, Scombatti de

Souza SL, Ribeiro FJ. Antimicrobial photodynamic therapy in the non-surgical treatment of

aggressive periodontitis: cytokine profile in gingival crevicular fluid, preliminary results. J

Periodontol. 2009; 80(1): 98-105.

20 Kamma JJ, Vasdekis VG, Romanos GE. The effect of diode laser (980 nm) treatment on aggressive

periodontitis: evaluation of microbial and clinical parameters. Photomed Laser Sur 2009; 27(1): 11-

19.

21 Sanguin D, Eratalay K, Caglayan G, Gugen Y. The effect of periodontal treatment on immune

response. Hacettepe Dis Hek Fak Derg 1985; 19: 587-590.

22 Artese L, Simon MJ, Piattelli A, Ferrari DS, Cardoso LA, Faveri M, Onuma T, Piccirilli M, Perrotti

V, Shibli JA. Immunohistochemical analysis of inflammatory infiltrate in aggressive and chronic

periodontitis: a comparative study. Clin Oral Investig 2011; 15(2): 233-240.

23 Mangan DF, Won T, Lopatin DE. Nonspecific induction of immunoglobulin M antibodies to

periodontal disease associated microorganisms after policlonal human B limphocyte, activation by

fusobacterium nucleatum. Infect Immunol 1983; 41: 1038-1047.



60

STUDY ON THE Ph INFLUENCE ON SURFACE MICROHARDNESS

OF SOME REPAIR MATERIALS USED IN ENDODONTICS

Liana Aminov1*

, Mihaela Salceanu1, T.Hamburda

1, Anca Melian

1,

Dana Cristiana Maxim2, Maria Vataman

1

“Gr. T. Popa" U.M.Ph. - Iași, Romania, Faculty of Dental Medicine 1Department of Odontology- Periodontology – Fixed Prosthetics

2Department of Oral and Maxilo-Facial Surgery

*Corresponding author: Liana Aminov, Assistant Professor, DMD, PhD


Iasi, Romania


ABSTRACT

Introduction The irrigating solutions used in endodontic therapy have different pH values and different

chemical properties that have sometimes been found to adversely affect the physical and chemical

characteristics of reparing materials. These materials are used mainly in areas of inflamed tissue, with a lower

pH. Aim of the study To evaluate the changes in the hardness of two dental materials depending on pH

variations and to determine which of the additives they are combined with gives them greater stability to pH

variations. Material and methods The changes in surface microhardness (Vickers microhardness) of two repair

materials: Grey MTA (Dentsply Tulsa Dental, USA) and BioAggregate (Innovative BioCeramix Inc.,

Vancouver, Canada), mixed with four different vehicles (distilled water, physiological saline, lidocaine and

calcium chloride) and subsequently subjected to different environmental pH values. Vickers microhardness of

each specimen was measured by means of Emcotest M1C 010 model. Results The analysis of the average

surface hardness of the two repair materials showed a significant increase in hardness at high pH (pH = 7) and

higher values for BioAggregate as compared with MTA. Conclusions Ph variations of the environment in

which biomaterials are setting reduce their microhardness and surface resistance, and this was more

significant when the two materials were combined with lidocaine and distilled water .

Key words: endodontic treatment, repair materials, surface hardness, low pH

INTRODUCTION

During endodontic therapy, irrigating

solutions are used in different concentrations

and for different time periods depending on

several factors, such as: lesion diagnosis,

associated symptoms, stages of treatment,

presence of allergies, and possibility of

ensuring good isolation, etc. To remove the

organic material, microorganisms and their

toxins, many types of irrigating solutions

have been proposed, which together with the

mechanical action of instruments can achieve

a satisfactory debridement and antisepsis of

root canals [1], [2], [3].

MTA is a tricalcium mineral complex and

is considered to be a potentially ideal material

for perforation repair, retrograde fillings,

apexifications, and vital pulp therapy [4],[5].

When MTA is dissolved in water, calcium

ions are released and precipitate with silica

gel which solidify in less than 4 hours,

reaching a high resistance to compression [6].



61

Following final irrigation with a chemical

solution, part of the irrigant may remain

within the canal area, thus affecting the

properties of MTA. Smith et al. evaluated the

effect of EDTA and BioPure MTAD on the

rough surface of MTA and found that

BioPure MTAD increases its roughness [7].

Yan et al. evaluated the effects of Na

hypochlorite (5.25%), CHX (2%) and Glyde

File Prep on in vitro bond strengths of MTA-

dentin and suggested that Glyde File Prep

may adversely affect them [8].

MTA contains 50% to 75% (by weight) of

calcium oxide and 15% -25% silicon dioxide.

Adding water, the cement hydrates and forms

a silicate hydrate gel. The physicochemical

basis of MTA is attributed to the production

of hydroxyapatite when the calcium ions

removed by MTA come into contact with

tissue fluid. This release of calcium ions

promotes an alkaline pH. Therefore, MTA

was used to repair root perforations, as apical

filling material, for pulp capping, and

pulpotomy procedures [9]. In addition, given

its sealing ability, it has been suggested as

apical sealant in the treatment of open apex

teeth and pulp necrosis [10].

The hydration rate is characteristic to the

cement setting process [11], when sufficient

water intake is required. Besides the positive

aspects of its use, the MTA also has some

drawbacks, such as the relatively long setting

time, which favours its disintegration and

dislodgement. Its granular consistency makes

it difficult to insert in cavities [12]. In many

clinical applications, MTA is placed in an

environment that is inflamed and has a low

pH [13]. Torabinejad et al. (1995)

demonstrated that initially MTA has a pH of

10.2, which increases 3 hours after mixing to

12.5. Variations in pH values of host tissue

response are likely in the case of pre-existing

pathological conditions, which affect its

physical and chemical properties. Recently,

several studies were conducted to improve the

physical and chemical properties of MTA,

new additives usable in patients are studied to

solve the clinical deficiencies [14]. Thus,

MTA combined with other common additives

may increase its compressive strength [15].

DiaRoot BioAggregate, another root repair

material, is a biocompatible pure white

powder containing ceramic nano-particle.

Upon mixing DiaRoot with BioA-liquid, the

hydrophilic BioAggregate powder forms a

hermetic seal inside the root canal. It is also

characterized by antibacterial effectiveness

and ease of material manipulations. The

liquid- BioA-liquid (1 vial x 0.38 ml) is the

exact amount required for 1.0 g powder.

Excess Liquid BioA may affect setting time

and material properties.

PURPOSE OF THE STUDY:

The aim of this study was the comparative

evaluation of changes in surface

microhardness (Vickers microhardness) of

two root repair materials: Grey MTA

(Dentsply Tulsa Dental, USA) and

BioAggregate (Innovative BioCeramix Inc.,

Vancouver, Canada) mixed with 4 different

vehicles (distilled water, physiological saline,

lidocaine, and calcium chloride) and

subsequently subjected to different pH values

of the setting environment.


Microhardness testing procedure involves

a series of easy tasks using a diamond

indenter to make an indentation that is

measured and converted to a hardness value.

It is very useful for testing a wide range of

materials, as long as the test samples are

carefully prepared. Usually loads are very

light, ranging from a few grams to one or

several kilograms. Methods for hardness

testing are used for metals, ceramics,

composites, various cements - almost any

material.

As vehicles for each of the two study



62

materials we chose: distilled water (the

original liquid with which the two materials

are mixed according to the instructions), an

anaesthetic commonly used in practice

(lidocaine), saline solution, and calcium

chloride 2% (CaCl2), available in the dental

office. The materials were mixed according to

manufacturer's instructions. Each MTA

sample was mixed with the recommended

amount of water and the same amount of

saline solution, lidocaine and CaCl2. Mixed

materials were weighed and placed in

polycarbonate tubes with inner diameter of 6

mm and a height of 5 mm.

The samples were divided into 2 groups:

GR 1 (MTA) and GR2 (BioAggregate), 8

specimens of each liquid mixing vehicle

being obtained under each group (a total of 32

samples per group. Specimens were then

subjected to a constant vertical force using an

amalgam condenser with inner diameter

similar to that of the polycarbonate ubes. A

wet cotton pellet was placed both over the

openings of MTA and BioAggregate

containing polycarbonate tubes to ensure a

moist environment, and the specimens were

stored at room temperature (30 ° C), covered,

for 3 days. Each of the 8 specimens of each

liquid vehicle were divided into two: in 4

samples a pellet soaked in acetic acid pH 4.5

and in the remaining 4 a pellet soaked in

neutral aqueous solution, pH = 7 were placed

at the bottom of the tube. One vial was used

as control.

After 3 days, the samples were removed

from vials. The surface exposed to acid of

each specimen was then wet polished at room

temperature using minimum hand pressure

and silicon carbide sand paper of different

particle size (600, 800 and 1200) to obtain a

surface smooth and facilitate testing. Then,

the polished specimens were gently washed

under light pressure distilled water to remove

surface debris and then gently air dried.

Vickers microhardness of each specimen

was measured using Emcotest M1c 010

model and a square based diamond with a

with a full load of 50 gms for 5 seconds at

room temperature, which produced

quadrangle depressions with two equal

orthogonal diagonals. Five 1-mm apart

indentations were made on the polished

surfaces of each specimen. Then, Vickers

microhardness was read and recorded for

each specimen The results were processed by

means of a system using heavy -load XY

tables with integral highest-precision highly-

focused optical encoders Data were processed

using Newage C.A.M.S with automatic data

storage system.

For statistical analysis, One-Way ANOVA

Tukey Post-Hoc analysed the differences

between experimental groups after the

calculation of mean ± standard deviation.

RESULTS

The mean microhardness values obtained

in each group with their standard deviation at

95% confidence intervals are shown in Tables

1 and 2 and graphically in Figures 1,2,3,4.

The highest value among all groups and

subgroups was recorded in the with CaCl2

group at pH 7. A lower mean was obtained in

the saline group. The difference between the

means was analysed by One-Way ANOVA

and showed that the difference between the

means was statistically significant at pH 7

and 4.5 (Figure 1).

Correlational analysis showed a slightly

higher increase of microhardness value for

BioAggregate when compared with MTA (r =

0.99 vs. R = 0.98). Also the results showed a

significant correlation between pH and

microhardness values when distilled water

was used as additive (Figure 2).

Correlational analysis demonstrated a

greater increase of microhardness value for

BioAggregate when compared with the

increase recorded for MTA (r = 0.80 vs. R =

.67). Also, the results demonstrated a



63

significant correlation between pH and

microhardness values when saline solution

was used as additive (Figure 3).

Figure 1. Statistical indicators of microhardness (distilled water) in relation with the used

biomaterial and pH value

Figure 2. Statistical indicators of microhardness (saline solution) in relation with the used


Categ. Box & Whisker Plot: Apa distilata

pH_4.5: F(1,22) = 133.5514, p = 0.0000;

Kruskal-Wallis-H(1,24) = 17.5238, p = 0.00003

pH_7: F(1,22) = 277.1384, p = 0.0000;


Ap

a d

istila

ta

Mean

Mean±SE

Mean±SD

pH - 4.5

23.85

26.52

23.85

26.52

MTA BioAggregate20

25

30

35

40

45

50

55

60

65

pH - 7

55.58

60.08

55.58

60.08

MTA BioAggregate

23.85

26.52

55.58

60.08

Categ. Box & Whisker Plot: Ser fiziologic

pH_4.5: F(1,22) = 16.5187, p = 0.0005;


pH_7: F(1,22) = 45.9626, p = 0.00000;


Se

r fizio

log

ic

Mean

Mean±SE

Mean±SD

pH - 4.5

17.17

18.35

17.17

18.35

MTA BioAggregate16

17

18

19

20

21

22

23

pH - 7

18.43

21.00

18.43

21.00

MTA BioAggregate

17.17

18.35 18.43

21.00



64

Figure 3. Statistical indicators of microhardness (lidocaine) in relation with the used


Figure 4. Statistical indicators of microhardness (calcium chloride) in relation with the

used biomaterial and pH value

Categ. Box & Whisker Plot: Lidocaina

pH_4.5: F(1,22) = 201.7516, p = 0.0000;


pH_7: F(1,22) = 1.7255, p = 0.2025;


Lid

oca

ina

Mean

Mean±SE

Mean±SD

pH - 4.5

20.52

17.23

20.52

17.23

MTA BioAggregate10

20

30

40

50

60

70

pH - 7

62.32 62.0262.32 62.02

MTA BioAggregate

20.52

17.23

62.32 62.02

Categ. Box & Whisker Plot: CaCl2

pH_4.5: F(1,22) = 260.0518, p = 0.0000;


pH_7: F(1,22) = 566.0758, p = 0.0000;


Ca

Cl2

Mean

Mean±SE

Mean±SD

pH - 4.5

62.85

71.78

62.85

71.78

MTA BioAggregate60

62

64

66

68

70

72

74

76

78

80

82

pH - 7

73.38

80.30

73.38

80.30

MTA BioAggregate

62.85

71.78

73.38

80.30



65

Correlational analysis showed a slightly


BioAggregate compared with the increase

recorded for MTA (r = 0.99 vs. R = .98).

Also, the results demonstrated a significant

correlation between pH and microhardness

values when lidocaine was used as additive

(Figure 4).

Correlational analysis demonstrated a


MTA as compared with that for

BioAggregate (r = 0.97 vs. R = .95). Also, the

results demonstrated a significant correlation

between pH and microhardness values when

CaCl2 was used as additive.

Table 1. Mean values obtained for MTA ( MPa)

Additives

Surface microhardness (Mpa) MTA

pH 4,5

Mean ± Standard

deviation

pH 7

Mean ± Standard

deviation

Distilled water 23.85±0.61 55.58±0.62

Saline solution 17.17±0.63 18.43±0.64

Lidocaine 20.52±0.70 62.33±0.64

Calcium chloride 62.85±0.88 73.38±0.63

Table 2. Mean values obtained for BioAggregate ( BA) ( MPa)

Additives

Surface microhardness (MPa) BioAggregate

pH 4.5

Mean ± Standard

deviation

pH 7

Mean ± Standard

deviation

Distilled water 26.52±0.52 60.08±0.70

Saline solution 18.35±0.78 21.00±1.15

Lidocaine 17.23±0.40 62.02±0.47

Calcium chloride 71.78±1.70 80.30±0.79

Figure 5. Mean values for MTA and BioAggregate ( BA) (MPa)



66

Analysis of the mean surface hardness

values of the two materials used as repair

materials in endodontics prepared by mixing

with various additives showed a significant

increase in hardness in case of high pH (pH =

7) and also higher values for BioAggregate as

compared with MTA (Figure 5).

DISCUSSION

The literature indicates that humidity

affects various physical properties of MTA

such as sealing ability, hardening time and

elasticity [16]. Various previous papers

concluded that the sealing ability of MTA in

an aqueous environment may be

compromised in the first 72 hours due to the

increased solubility of the material [17].

Bondanezi et al. have shown that when MTA

discs were immersed in an aqueous medium,

there was a continuous increase in weight of

MTA rings, statistically superior to Portland

cement and empty control discs over 168

hours (7 days).

Endodontic therapy includes the use of

some irrigating solution with different pH

values and chemical properties that have

sometimes been found to adversely affect the

physical and chemical properties of the used

materials [18]. In addition, the studied

materials are mainly used in areas of inflamed

tissue, that is of lower pH. For these reasons

we aimed at evaluating the changes in the

hardness of materials in relation with pH

variations, and which of the additives they are

mixed with give them greater stability to pH

variations. MTA in combination with CaCl2

was used because this solution can release

calcium ions and was confirmed not to be

toxic to human cells in vitro [19].

It was also noticed that a CaCl2

concentration higher than 2% affects the

cement, increasing the risk of setting

contraction and decreasing final strength. At

pH 4.5 MTA in combination with saline

solution was not completely hardened even

after the three days of the experiment and had

the lowest Vickers microhardness value. In

conclusion, surface hardness of both MTA

and BioAggregate mixed with 2% CaCl2 was

found not to be significantly affected by an

acidic medium, the differences between them

being minimal.

CONCLUSIONS

Low pH adversely affects the physical

properties of both MTA and

BioAggregate, decreasing their surface

hardness.

According to this study it can be

concluded that pH changes in the

environment in which these biomaterials

set reduce surface strength and

microhardness, and this decrease is more

significant when the two materials are

mixed with lidocaine and distilled water.

By combining the two powder types with

2% CaCl2 there was a significant increase

in surface hardness in both cases and an

increased strength to environmental pH

lowering, the parameter investigated in

this study, Vickers microhardness,

remaining almost unchanged.

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(2%), and Glyde File Prep on the bond strength of MTA-dentin. J Endod 2006; 32: 58–60.

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10 Shabahang S, Torabinejad M –Pract Periodontics Aesthet Dent; 2000; 12: 315-20.

11 Taylor HFW Cement Chemistry; 1997; 2nd edn. London Thomas Telford Ltd

12 Cummings GR, Torabinejad M –J Endod; 1995; 21: 228.

13 Malamed SF 4th edn. St.Louis, Mosby-Year Book; 1997.

14 Lee YL, Lee BS, Lin FH, Yun Lin A, Lan WH, Lin. Biomaterials; 2004; 25: 787-93.

15 N. Mohan, Lora Mishra, Ravishanker C.V.Subba rao. Int. J of Dental Science 2010; 8(2).

16 Walker MP, Diliberto A, Lee C.. J Endod 2006; 32: 334–6.

17 Nekoofar MH, Adusei G, Sheykhrezae MS, Hayes SJ, Bryant ST, Dummer PM. Int Endod J; 2007;

40: 453-61.

18 Lee YL, Lee BS, Lin FH, Yun Lin A, Lan WH, Lin CP. Biomaterials 2004; 25: 787–793.

19 Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I (2005). J Endod 31:97–100.

20 Gilman JJ, Chemical and physical hardness. Materials Research Innovations; 1997; 1: 71-6.



68

SURGICAL AND LASER TREATMENT CHIRURGICAL OF

MAXILLARY OSTEITES

Bonchis Iuliu Alexandru

Faculty of Dentistry, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

*Corresponding author: Bonchis Iuliu Alexandru, PhD Student

“Carol Davila” University of Medicine and Pharmacy,

Bucharest, Romania


ABSTRACT

Osteitis is an inflammatory process localized accurately at maxillary bones. From the surgical point of view of

the procedure, the treatment should be very conservative. Laser therapy is a relatively new procedure in the

dentistry field, but with remarkable results.

It has been unanimously agreed that both

quality and effectiveness of surgical treatment

are determined by the way in which the

patient is prepared, by the surgical

instruments, by the drug preventing infections

and bleeding, by the professional training and

technical skills of the dentist, by the post-op

checks [1].

Surgical interventions in osteitis must be

as conservative as possible, so as to sacrifice

to the least extent the bone, the periosteum

and the teeth. The treatment of osteitis is

mainly endodontic; in case the patient does

not respond to such treatment, endodontic

therapy is helped by surgical treatment, and in

case of failure, the last resort is dental

extraction [1, 2].

Surgical treatment aims at draining the

septic process by an incision of the periosteal

abscesses and enlarging the fistulas, followed

by local lavage with antiseptics [3].

Surgical treatment is indicated in

suppuration drainage and to remove the

portions of necrotized bone. The incisions

made in due time prevent deperiostations by

septic process.

Sequestrectomy is practiced only after

complete elimination of sequestra, in the

phase when these are mobile, after

approximately 3-5 weeks from debut, and

bone regeneration takes place 6-8 weeks

thereafter [1, 4].

The intervention is preferably practiced

endo-orally, by protecting the periosteum,

which has an important role in the bone

regeneration. The teeth with major indication

for extraction are the causal ones ant those

implanted on sequestra. The other

neighbouring mobile teeth may be conserved,

because mobility disappears after the

remission of the inflammatory process [5].

The teeth will be protected to the maximum

extent even if they are mobile, because, after

the withdrawal of the inflammation, they get

fixed and recover entirely their functional

capacity. Only the teeth that caused the

osteomyelitical process will be extracted [6].

Bone decortication consists of removing

the external cortical bone in the area of

inflammatory process (in subacute or chronic

phase). Due to the presence of the

inflammatory process, the cortical is



69

avascular and the microbial germs in the

medullar micro abscesses cannot be subjected

to the action of antibiotics administered. By

removing the cortical and applying the

vestibular graft ensure drainage and

vascularization in the medullar zone, which

quickens the extinction of the septic process

[7]. In mandible fractures with tendency for

complication by superinfection in an

osteomyelitical process, prophylactic

corticotomy is practiced successfully. It is

interesting to note that, in such cases, which

were a rule followed by delays in

consolidation or pseudo arthroses, the fracture

heals in an even shorter time. Prophylactic

corticotomy is practiced successfully, with

osteosynthesis with miniaturized plate and

even with wire [5, 8].

Interventions may be followed even by

installing of a temporary device that ensures

irrigation – aspiration of the septic focus. In

the situations indicated, when there is a

danger of fractures in pathological bone,

surgical treatment is preceded by the

manufacture of some acrylic plates to protect

the wounds, or even by mounting of

immobilization devices [9].

In the followings images (Fig. 1 – 4) the

case of a patient R.D., 39 years old, male is

present. He was investigated in Oro-

Maxilofacial Surgery Department, Faculty of

Dentistry from Bucharest. The ozone applied

locally through the trajectory of fistulas or

through incisions limits the production of

sequestra and quickens the healing process.

Also, the introduction in the endo-osseous

geodes of some acrylic pearls with antibiotics

released slowly during approximately 2

weeks has a beneficial effect on the evolution

of the local infection [10].

In the disease forms that resist other

treatments, a common practice is to introduce

the patients in rooms with oxygen under

pressure, which is stimulated the development

of fibroblasts and neoformation of blood

vessels.

Figure 1. Acute apical periodontitis 44.

Remaining root, indication of extraction Figure 2. X-ray image – remaining root 44:

radio translucency - apical periodontitis

Figure 3. 44 – Remaining rest after

removing the premolar - extraction with

pliers

Figure 4. Postextractional X-ray image

after extraction of 44 - the

demineralisations of the apical bone can be



70

noticed

Osteitis and osteomyelitis may leave a

series of sequestra, among which we mention:

mandible development disorders, extended

maxillary defects, mandible constrictions

[11].

In the treatment of osteitis, laser therapy

has been used successfully of late. Laser is an

abbreviation for Light Amplification by

Stimulation Emission of Radiation. The

degree of penetration of laser radiation in

tissues depends very much on its wavelength.

The most used wavelengths are those in red

spectrum. In the red spectrum, after a

penetration of 2-3 mm through live tissues,

the wave intensity decreases down to half,

which makes this type of laser very effective

in treating the mucosa and skin diseases. The

laser in the red spectrum reduces its intensity

down to half after penetrating 5-6 mm in live

tissues. These lasers are used for treating deep

structures (ligaments, muscles, tendons, bone

formations). Since the energy transmitted by

the laser is absorbed by a small tissue portion,

and we want that the most irradiated should

be somewhere deep, it is recommended that

the emission power should be at least 50 mw.

In the treatment of perimaxillary osteitis, the

infrared spectrum laser is recommended [13].

The physical parameters of the laser,

measuring units depending on: wavelength,

output power of the laser radiation, power

density, modulation frequency.

Biological effects of laser:

analgesic effect

myorelaxing effect

antiedematous effect

biostimulating effect

vasodilator effect.

All these effects are confirmed by

objective studies which were checked:

improved microcirculation

increase of intracellular activity of several

enzymes, particularly of the krebs cycle

increase of oxygen, more effective use of

glucose

stimulation of DNA synthesis

increase of fibroblast activity

activation of phagocytosis

activation of membrane Na / K pump

activation of metabolic processes at the

cell level, partially by the activation of

membrane Na / K pump and of Ca

transport, partially by the activation of the

mitochondrial system

changes at the local level of some

important mediators

In perimaxillary osteitis it is recommended

to use the infrared spectrum laser with the

following parameters:

Density (J/cm2) – 4.0

Frequency (Hz) – 6.0

Therapeutic effect – A++, B++

Number of weekly treatments – every

other day (3 times a week)

Recommended power of the probe 200

mW, 300 mW

Treatment of post-extraction osteitis:

Disinfection of post-extraction wound with

chlorhexidine

Positioning of the probe in the wound and

starting treatment

Filling the post-extraction wound with

Avolgyl or Repin

Repeating treatment 1 – 3 times

After laser therapy there will be noted the

acceleration of the healing process, decrease

of pain in the lymph node, the positive results

appearing immediately after the first session

[12, 13].

CONCLUSION

Surgical treatment is very important, it

must be as much conservative as possible, so

as to sacrifice to the least extent the bone, the

periosteum and the teeth. As prophylaxis,



71

timely cleansing of the oral cavity is done,

fractures should be treated correctly, purulent

collections will be incised extensively and

timely, so as to ensure an effective drainage,

and correct, non-traumatizing surgical

techniques should be used, subject to the

observance of the rules of asepsis and

antisepsis.

The biological effects of laser are:

analgesic, muscle relaxants, antiedematos,

biostimulation, and vasodilation.

REFERENCES

1 Laskin M. Daniel, "Oral and Maxillofacial Surgery", C.V. Mosby Co, 1985 + 2005.

2 Ragno J.R., Szkutnik A.J., "Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar

osteitis", Oral Surgery, Oral Medicine, Oral Pathology, 1991.

3 Adeyemo W.L., Ladeinde A.L., Ogunlewe M.O. and et al, "Influence of trans-operative

complications on socket healing following dental extraction", Journal of Contemporary Dental

Practice, 2007.

4 Bonine F.L., "Effect of clorhexidine rinse of the incidence of dry socket in impacted mandibular

third extraction sites", Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 2005.

5 Krekmanov L. and Nordenham A., "Post – operative complications after surgical removal of

mandibular third molars", International Journal of Oral Maxillofacial Surg., 2006.

6 Larsen P.E., "The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the

surgical removal of impacted mandibular third molars", Journal of Oral & Maxillofacial Surgery,

1991.

7 Caso A., Hung L.K. and Beirne O.R., "Prevention of alveolar osteitis with chlorhexidine – a meta

analytic review", 2005.

8 Delilbasi C., Saracoglu U. and A. Keskin, "Effects of 0,2% chlorhexidine gluconate and amoxicillin

plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar

extractions", Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics, 2002.

9 Pankhurst L., Lewis D.A., Clark D.T., "Prophylactic application of an intra-alveolar socket

medicament to reduce post-extraction complication in HIV – seropositive patients", Oral Surgery,

Oral Medicine, Oral Pathology, 1994.

10 Vezeau P.J., "Dental extraction wound management medicating post extraction socket", Journal of

Oral Maxilofacial Surg, 2000.

11 Kwon P.H. and Laskin D.M., "Manual of oral and Maxillofacial Surgery", Quintessence Publ. Co.

Inc, 1991.

12 Scrivani J.S. and Weith D.A., "Temporo – mandibular disorders", Dentistry today, 2000.

13 Odyssey Diode Lasers clinical Guide-Power and mode parameters for dental procedures – Manual

BTL 2005



72

FINITE ELEMENT ANALYSIS OF PERIODONTAL STRESSES IN

FIXED PROSTHODONTICS

Valeria Pendefunda, Arina Ciocan – Pendefunda, Nicoleta Ioanid, Alina Apostu,

Oana Ţănculescu

Odontology, Periodontology and Fixed Prosthodontics Department

Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy – Iaşi, Romania

*Corresponding author: Valeria Pendefunda, DMD, PhD

“Gr. T. Popa” University of Medicine and Pharmacy,

Iasi, Romania


ABSTRACT

Aim The aim of the study is to determine by finite element analysis the existence of direct correlations between

the abutment periodontal tissues condition and the cantilever bridge in the context of functional occlusion.

Materials and method In order to reveal the changes occurring in the periodontal ligament, a distal dental

cantilever bridge was considered, retained on 34 and 35, subjected to a force of 350N, deemed to be the

maximum force developed by the masseter and pterygoid muscles during mastication. The ALGOR 15

FEMPRO software was used to analyze the periodontal ligament stress. Results Finite element analysis was

employed to determine the stresses, specific deformations and displacements undergone by the ligaments under

survey. The maximum stress was recorded in the periodontal ligament of the first premolar since this load

configuration produces a first degree lever effect with a fulcrum located on the premolar 35 root apex.

Conclusions The overstress of periodontal ligament under occlusal forces leads implicitly to the tearing of the

ligament fibers either in their body, or in its insertion into the dentin and bone.

Keywords: finite element, dental cantilever bridge, periodontal stress

INTRODUCTION

Periodontal biomechanics is a particularly

challenging issue to be dealt with by

clinicians, as the supraliminal stresses of poor

bridgework affects, in time, the neighboring

periodontium. Together with the remaining

arch, any cantilever bridge will have to bear

various stresses of different directions,

orientations, fulcra and strengths. The

prosthetic environment – dental cantilever

bridge binomial requires biomechanical

stability [3, 4]. A successful prosthetic

therapy depends, on the one hand, on the

patient’s periodontal health status and, on the

other hand, on the observance of the

biological and biomechanical requirements by

the bridge design, by the materials chosen and

by the actual manufacture of the prosthesis.

Since it is fairly difficult to conduct an in

vivo or in vitro assessment of the forces

acting on the periodontal ligament, finite

element analysis is preferred as, if the

modeling is accurate, it may provide very

useful information on the stresses, specific

deformation and displacements undergone by

both the ligament and the bone [1, 6]. This

information is particularly useful when

assessing the impact of non-physiological

stresses (such as value, direction or fulcrum),

of the materials included in the bridgework



73

and of the bridge design or geometry.

The purpose of our research is to

determine, by FEA, the direct correlations

exiting between the periodontal changes

occurred and the type and morphology of the

dental bridges, in the context of functional

occlusion.

MATERIALS AND METHOD

A dental cantilever bridge, retained on 3.4

and 3.5, and a distal extension (3.6) were

considered. This type of bridgework is still

rather common in dental practice, as it fulfills

some needs (such as avoiding removable

prostheses in terminal edentations, or

preparing the second molar when it is healthy

but the premolars are not) but at the same

time it involves some risks (such as

periodontal premolar overstress or extension

breaking) [7].

In order to be able to perform the best

simulation of the mechanical phenomena

occurring in the dental bridge and in the

odonto-periodontal support, the geometric

model needs to be as realistic as possible.

Therefore, we used the AutoCAD 2009

software (Fig. 1) to achieve 3D images of the

mandible, of the premolars prepared for 3.4

and 3.5 cover crowns, of the periodontal

ligaments and of the cantilever extension.

The meshing of the prepared structures

was done by means of the Algor 15 FEMPRO

software (Fig. 2).

The material properties used were:

modulus of elasticity, Poisson’s ratio and

material density. As the aim of our study was

to determine the mechanical stresses on the

periodontal ligament, we preferred a nickel-

chrome alloy for the bridge. The values of

these parameters are shown in Table 1.

Load application considered the maximum

force developed by the masseter and

pterygoid muscles during mastication: 350N

scalar value and 150 force deviation from the

vertical line (Fig. 3).

Figure 1. The mandible – periodontal

ligaments – abutment teeth – dental bridge

group

Figure 2. The mandible – dental bridge

group

Table 1. Material characteristics for each component of the analyzed structure

Component Modulus of elasticity

(Mpa) Poisson’s ratio

Density

(Kg/m3)

Bone 14200 0.33 1450

Dentine 13800 0.31 1900

Periodontal ligament 11.8 0.45 1250

Ni-Cr Alloy 207000 0.31 8931.7



74

Figure 3. Application of the resulting

forces corresponding to the masseter and

pterygoid muscles

Figure 4. Support to: the molar 36 area

(top); the premolar 3.5 area (middle), the

contact in premolar 3.4 area (bottom)

Figure 5. Stress distribution throughout

the whole group Figure 6. Stress distribution when the

force is applied on 36 (distal extension)

The action of the forces developed by the

manducatory muscles produces reaction

forces in two areas, during mastication,

namely in the temporomandibular joint and in

the area where the dental bridge touches the

food. The following options were considered

for the dental bridge (Fig. 4):

contact on the area corresponding to the

missing molar 3.6;

contact on the area corresponding to

premolar 3.5;

contact in the premolar 3.4 area.


The analysis results were shown

depending on the areas on the bridge where

the stresses were applied.

Support on the distal extension (3.6)

The forces applied on the distal extension

revealed stresses, specific deformations and

displacements within the whole bone-

ligaments-premolars-bridge group (Fig. 5).

Further to the analysis of the forces acting

on the bridge, we noted certain stress

concentrators, especially between molar 36

and premolar 3.5, which indicate the highest

stress area, i.e. the area with the highest

breaking risk (Fig. 6).

The analysis of the stresses on the

periodontal ligaments showed that the

maximum stress values were lower than the

ones acting on the dental bridge - 1,5 Mpa

(Fig. 7). This may be accounted for by the

low modulus of elasticity of the periodontal

ligament as compared to the dental bridge



75

material.

Specific deformations occur especially in

the periodontal ligament of premolar 3.4,

which is normal since its modulus of

elasticity is three orders of magnitude lower

than that of the surrounding structures

(dentine, alveolar bone). Also, specific

deformation distribution is similar to that of

the stresses, since the proportionality factor

between the two is shown by the modulus of

elasticity of the periodontal ligament. When

one isolates the two ligaments, one may

notice that the displacements are

predominantly horizontal, as shown in figure

8, which also illustrates the position of the

non-displaced ligament.

More stress was applied on the ligament of

premolar 34, since we may say that this load

configuration produces a first degree lever

effect with a fulcrum located on the premolar

35 root apex. This type of bridge is not

recommendable, since the loads that cause

considerable asymmetries in the stress and

displacement distribution may lead to the

tearing of the ligament body or of the

ligament-bone junction and, hence, they may

impair on the dental implant and bridgework.

Support on premolar 35

When the same maximum stress value, i.e.

45Mpa, was applied, we noted that this time

the stresses were lower in the bridge area due

mainly to the absence of the tipping

movement that characterized the previous

case.

The ligament stress distribution value was

also low, just like the specific deformations,

the values of which were lower than in the

previous case (Fig. 9). The deformations

(displacements) were also low, almost

undetectable, symmetric, and similar to those

occurring in normally loaded premolars.

Figure 7. Stress distribution (left) and

specific deformation distribution (right) on

the periodontal ligaments of premolars 3.4

and 3.5, when the support is on 3.6

Figure 8. Deformations of the periodontal

ligaments of premolars 3.4 and 3.5 when

the support is on the distal extension



the periodontal ligaments of premolars 3.4

and 3.5, when the support is on PM 3.5.



the periodontal ligaments of premolars 34

and 35, when the support is on PM 3.4.



76

Figure 11. Deformations of the two periodontal ligaments

Support on premolar 34

Stress distribution in this case was also

lower than in the first one, although this time

the stress applied to the bridge was higher in

the support area. Just like in the previous

cases, the stress on the ligaments had a high

value, but the stress and specific deformation

distribution was pretty similar to that of the

first case (Fig. 10).

Although the stresses and specific

deformations were somewhat similar to the

first case, when the support was on the distal

extension, the deformations or displacements

showed considerable differences. On the one

hand, as it may be seen in figure 11, there was

compression of the ligament of premolar 34

towards the canine and expansion from

premolar 3.5. Also, the ligament of premolar

35 suffered compression towards premolar

3.4 and expansion from the molar 3.6 area.

Just like in the first case, the ligament

deformation values are rather high and,

associated with the existing stresses, they

may lead to periodontal ligament tearing in

the upper area, especially in the premolar 3.4

area. The loss of this ligament results in

overstraining the ligament of premolar 3.5

and finally in the jeopardizing of the whole

dental implantation and of the bridgework

stability [8, 9].

CONCLUSIONS

Finite element analysis was employed to

determine the stresses, specific deformations

and displacements undergone by the

periodontal ligaments considered.

The overstress of periodontal ligament

under occlusal forces leads implicitly to the

tearing of the ligament fibers either in their

body, or in its insertion into the dentin and

bone.

The dental cantilever bridge supported by

the abutment premolars 34 and 35 and the

cantilever extension for 36 overstrain the

ligament of premolar 34, especially when the

force acts on the distal extension (3.6), since

we may say that this load configuration

produces a first degree lever effect with a

fulcrum located on the premolar 3.5 root

apex.

In order to have the same characteristics

and functionality of the substitute item that it

replaces, a dental cantilever bridge must show

very good congruence and stability in the

prosthetic environment.



77

REFERENCES

1 Algor FEA: 3DCAD Tutorials – www.3dcadtutorials.com/index.php

2 Alhouri N, Watts DC, McCord JF, Smith PW. Mathematical analysis of tooth and restoration contour

using image analysis. Dent Mater. 2004;20(9):893-9

3 Burlui V, Forna N, Ifteni G. Clinica şi terapia edentaţiei parţiale intercalate reduse. Ed.Apollonia,

Iaşi 2001

4 Forna N (sub red). Protetica Dentară (Vol I),Ed. Enciclopedica Bucureşti, 2011

5 Forna N. Evaluarea stării de sănătate afectate prin edentaţie. Ed. Demiurg, Iaşi 2007

6 Gârbea D. Analiză cu elemente finit. Ed.Tehnică, Bucureşti 1990

7 Manda M, Galanis C, Georgiopoulos V, Provatidis C, Koidis P. Effect of varying the vertical

dimension of connectors of cantilever cross-arch fixed dental prostheses in patients with severely

reduced osseous support: a three-dimensional finite element analysis. J Prosthet Dent. 2010

Feb;103(2):91-100.

8 Mârţu S, Mocanu C. Parodontologie clinică, Ed. Apollonia, Iaşi 2000

9 Eraslan O, Sevimay M, Usumez A, Eskitascioglu G. Effects of cantilever design and material on

stress distribution in fixed partial dentures - a finite element analysis. J Oral Rehabil. 2005

Apr;32(4):273-8.



78

STUDY CONCERNING THE INFLUENCE OF THE FINISHING AND

POLISHING SYSTEMS ON THE SURFACE STATE OF VARIOUS

TYPES OF COMPOSITE RESINS

Simona Stoleriu*, Gianina Iovan, Galina Pancu, Irina Nica, Sorin Andrian

“Gr. T. Popa" U.M.Ph. - Iași, Romania, Faculty of Dental Medicine,

Department of Odontology, Periodontology and Fixed Prosthodontics

*Corresponding author: Simona Stoleriu, Lecturer, DMD, PhD


Iasi, Romania


ABSTRACT

The aim of the study was to evaluate the effect of three different one-step and two-steps polishing systems on

the surface roughness of two composite resins, one with nanoparticles and one microhybrid: Filtek Supreme XT

(3M ESPE) and Filtek Z 250 (3M ESPE). 35 samples (30 mm X 8 mm X 2 mm) were made from each material.

5 samples of each material were polished using the finishing long flame bur for composite resins (NTI, Kahla

GmbH, Germany) without water cooling, 5 samples using the one-step abrasive rubber P20032 (NTI, Kahla

GmbH, Germany) without water cooling, 5 samples using the two-steps finishing system which uses the

abrasive rubbers P1932 and P19032 (NTI, Kahla GmbH, Germany). The other samples were finished with the

same systems, but under water cooling. 5 non-finished and non-polished samples of each material were

considered control samples. The samples surfaces were analyzed using the atomic force microscopy. The use of

two-steps polishing systems led to a significantly smoother surfaces of both types of composite resins when

comparing with the one-step polishing systems (Anova and Bonferroni statistical test, p<0,05). All finishing and

polishing systems used in association with water led to a significantly smoother surfaces when comparing to

those obtained using the same systems without water for both types of composite resins.

Key words: AFM, finishing and polishing systems, composite resins

INTRODUCTION

The quality of the restoration surface has a

significant importance in ensuring the

longevity of the restoration in oral cavity. The

surface roughness of composite resins

influences the bacterial plaque adhesion [1],

the resistance to abrasion and wear kinetics

[2,3], as well as tactile perception [4]. Also,

the surface roughness of the restoration

influences its resistance to discoloration [5,6]

and the natural shine of the restoration [7,8].

The existent finishing and polishing systems

are far from achieving ideal characteristics.

On top of that, many practitioners give less

attention to the finishing and polishing of the

used material, either due to negligence or to

lack of time.

Over the years were used finishing and

polishing systems with multiple steps, this

category including fine and ultra-fine

diamond burs, abrasive discs and soft rubber

cups with diamond particles. In recent years

there have been introduced into practice the

one-step finishing systems. Some studies

have shown that they are superior or at least

comparable in effectiveness to those who use



79

several steps for finishing [8, 9, 10,11]. In

some studies the results were influenced by

the type of product [12] and were closely

correlated with the initial finishing regime

[13].

This study evaluated the effect of three

one-step and two-steps finishing and

polishing systems on the surface roughness of

two composite resins: a nanocomposite and a

microhybrid resin.


The materials used in this study were a

nanocomposite resin: Filtek Supreme XT (3M

ESPE) and microhybrid composite resin:

Filtek Z 250 (3M ESPE). There were chosen

A1 enamel color for Filtek Supreme XT

material and B2 enamel color for Filtek Z 250

material. 35 samples (30 mm long, 8 mm

wide and 2 mm thick) were made from each

material. The samples resulted after the resins

polymerization in contact with a mylar matrix

strips placed between two glass slabs. Curing

was carried out sequentially by the top plate

40 seconds and 40 seconds below the top

plate using the curing lamp Ledent (Ivoclar,

Vivadent). After polymerization the samples

from each material were randomly divided

into 7 groups. 5 samples of each material

were polished using the finishing long flame

tungsten carbide instrument for composite

resins (NTI, Kahla GmbH, Germany) (ISO

500314249041) without water cooling. 5

samples of each material were polished using

the same bur under continuous water cooling.

The polishing speed was 160,000 rotations

per minute. For other 5 samples was used the

one-step abrasive rubber P20032 (NTI, Kahla

GmbH, Germany) without water cooling,

while for other 5 samples was used the same

one-step rubber under water cooling. The

finishing speed was 10,000 rotations per

minute. 5 samples using the two-steps

finishing system that uses the abrasive rubber

P1932 and P19032 (NTI, Kahla GmbH,

Germany). The polishing speed was 10,000

rotations per minute for the first of these two

rubbers and 5,000 rotations per minute for the

second. Finishing time was 60 seconds (two

periods of 30 seconds) for each system used.

The remaining 5 samples of each material

were not finished and polished, being

considered control samples. The surface of

the samples was analyzed using atomic force

microscopy. The results were expressed as

root mean square surface roughness.

RESULTS

For Filtek Supreme XT composite resin the

mean roughness was 16.2 nm in control group,

64.4 nm when the one-step abrasive rubber

finishing system was used without water, 35.4

nm when the two-steps abrasive rubber

finishing system was used without water, 125

nm when tungsten carbide burs were used

without water. When using the finishing and

polishing systems with water, the mean values

of surface roughness were 43.2 nm for the one-

step abrasive rubber finishing system, 34.5 nm

for the two-steps abrasive rubber finishing

system and 66.2 nm when tungsten carbide burs

were used.

For Filtek Z 250 composite resin a marked

trend to increase the surface roughness after

finishing and polishing was found. From a

mean roughness values of 16.8 nm in control

group, the values increased to 103.6 nm when

the one-step abrasive rubber finishing system

was used without water, to 51.6 nm when the

two-steps abrasive rubber finishing system was

used without water, to 146.6 nm when tungsten

carbide burs were used without water. When

using the finishing and polishing systems with

water, the mean values of surface roughness

were 67.2 nm for the one-step abrasive rubber

finishing system, 37,2 nm for the two-steps

abrasive rubber finishing system and 92 nm

when tungsten carbide burs were used.

The roughness values for the microhybrid

resin were higher than those observed for the

resin with the nanoparticles, irrespective of the



80

system used for finishing and polishing. The

two-steps polishing system that use abrasive

rubber has led to a lower surface roughness of

both types of the composite resins studied when

comparing to single-step polishing systems. The

results showed that finishing and polishing

procedure using a tungsten carbide bur has led

to a higher surface roughness when comparing

to the one or two-step abrasive rubber polishing

systems. There were a tendency for all finishing

and polishing systems used in combination with

water to lead to a smoother surfaces than those

obtained when using the same systems without

water for both types of composite resins

studied. The results were statistically analysed

using ANOVA and post hoc Bonferroni tests.

Significant differences were obtained in the

surface roughness for Filtek Z 250 composite

resin when all three finishing and polishing

systems were used when comparing to surface

roughness from control group (Table 1). The

one-step and to-steps abrasive rubber systems

conducted to a significant lower surface

roughness for Filtek Z 250 composite resin

when comparing to the surface roughness when

one step tungsten carbide bur was used (Table

1).

Table 1. Statistical ANOVA and post hoc Bonferroni tests results for Filtek Z 250 composite

resin

without water

control

group

one-step abrasive

rubber

two-steps

abrasive rubber

one step tungsten

carbide bur

with

water

control group - 0.000 0.000 0.000

one-step abrasive

rubber

0.000 0.008 - -

two-steps

abrasive rubber

0.000 - 0.008 -

one step tungsten

carbide bur

0.000 - - 0.008

For Filtek supreme XT composite resin

significant differences were obtained in the

surface roughness when all three finishing

and polishing systems were used when

comparing to surface roughness from control

group (Table 2). The one-step and to-steps

abrasive rubber systems conducted to a

significant lower surface roughness of

composite resin when comparing to the

surface roughness when one step tungsten

carbide bur was used (Table 2).

Table 2. Statistical ANOVA and post hoc Bonferroni tests results for Filtek Supreme XT

composite resin

without water

control

group

one-step abrasive

rubber

two-steps

abrasive rubber

one step tungsten

carbide bur

with

water

control group - 0.009 0.009 0.008

one-step abrasive

rubber

0.000 0.008 - -

two-steps

abrasive rubber

0.000 - 0.008 -

one step tungsten

carbide bur

0.000 - - 0.009



81

DISCUSSIONS

The correct finishing and polishing

procedures improve the longevity of the

restorations and the aesthetic results. The

residual rough surface of the restorations

favors bacterial plaque accumulation, which

can cause gum inflammations, superficial

staining and secondary caries lesions. The

finishing and polishing procedures are

influenced by the composition of the material

for filling, the degree o polymer shrinkage,

the hardness and size of the abrasive particles,

the applied pressure and the application time

during the procedures. The composite

surfaces resulted after polymerization in

contact with mylar matrix strips present the

smoothest possible surface. However, in spite

of the correct placement of the matrix, it is

often necessary to remove excess material

and reshaping bonding. This will require a

certain degree of finishing and polishing,

which would violate the smoothness achieved

with a matrix. Several factors can influence

surface roughness evaluation in trials.

Frequently, manual preparation of the

samples is used because it more accurately

simulate the clinical conditions. When

finishing and polishing are carried, there are a

wide variety of finishing speed and time used

by the practitioners [14]. It is generally

accepted that the preparation under different

conditions can create different surface

qualities [7]. Varied experiences and skills of

the operators can equally affect the final level

of surface roughness. Therefore in the present

study sample preparation was performed by a

single practitioner.

The effects of the single-step and multiple-

steps finishing systems on the surface

roughness of the material is still much

discussed. It was proved that a larger number

of steps of finishing produce a more

pronounced smoothing effect. In a study

conducted by M. Jung in 2007, he

demonstrated that a three-steps finishing

system has brought about better results

compared with the two-steps system and with

the one-step system [15]. Also, in the present

study, the best results with regard to the

surface roughness of the resins studied have

been obtained when there were used the two-

steps finishing systems compared to the one-

step systems. The influence of the method of

initial finishing on surface roughness

increases with decreasing the number of steps

used for finishing. In M. Jung's mentioned

study, the greatest influence of the finishing

method on the roughness of studied materials

was recorded for the polishing brushes. The

use of 30 μm grit diamond bur and the

polishing brushes caused the greatest

roughness of composite materials. In our

study the use of finishing bur has brought

about a lower roughness compared to that

resulting from the use of two-steps and one-

step rubber systems. In the case of composite

resins indicated for the anterior area, finishing

systems containing diamond particles appear

to result in a smoothest surfaces [10]. For

microhybrid and microfil composite resins

same finishing system was more effective

than the multi-steps system that uses flexible

abrasive discs. [8]. Other studies have found

no significant differences in the roughness of

the surface obtained after the use of one-,

two- or multi-steps finishing systems [9, 11,

16]. Consistent with the results obtained in

this study, Jung (2007) and Watanabe (2005)

discovered that finishing with several steps

systems was superior to that obtained with the

one-step systems [15, 17].

Nanotechnology has had a beneficial

effect on the integration of stable chemical

particles in the matrix of composite materials.

It is believed that this contributes to the low

rate of wear of the materials [12, 18]. In the

case of surface deterioration caused by

contact with the abrasive instruments for

finishing, the surface of the nanoparticles

seems to suffer the least loss of minerals. This



82

would explain the low roughness of the

surface of the samples made from these

materials. However, the studies showed that

the nanocomposite materials do not represent

a homogeneous group regarding the surface

roughness. Comparing data from different

studies is difficult because many factors can

influence the results of each study. In three

studies that evaluated the surface roughness

of Filtek Supreme, the results were

controversial. When Super Snap abrasive

discs were used for finishing and polishing,

the mean roughness was 0.33 μm [12], when

Sof-Lex discs were use, the mean value was

0.125 μm and when it was used Po-Go

system, the mean roughness was 0.11 µm

[18]. In a study conducted by Jung in 2007

two of the nanocomposite showed a quality of

the surface which was not better than

traditional hybrid composites [15]. For this

reason it was considered to be another factor

that influences the behavior of the

nanocomposites surface upon finishing. The

roughness is correlated with the percentage of

weight and volume of fillers. IWith regard to

the materials tested in this study, the resin

component of the Filtek Supreme XT material

is one with a low polymerization shrinkage,

resulting from the mixture of BIS-GMA, BIS-

EMA, UDMA with small amounts of

TEGDMA – a combination of non-

aggregated fillers/non-agglomerated silica

having a diameter of 20 nm and agglomerated

linked to nanoclusters of zirconia/silica

containing primary nanoparticles of

zirconia/silica with a diameter of 5-20 nm.

Clusters size varies between 0.6 and 1.4 μm.

The amount of filler is 78.5% by weight. The

resin matrix of composite resin Filtek Z 250

is BIS-GMA and TEGDMA. Fillers occupy

66% by volume, being represented by the

zirconia/silica particles. The particle size

ranges of 0.01 to 3.5 μm, with an average of

0.6 μm.

CONCLUSIONS

The two-steps polishing system that use

abrasive rubber has brought a significant

lower surface roughness of both types of the

composite resins studied when comparing to

single-step polishing systems. Finishing using

the tungsten carbide bur has led to a

significant higher surface roughness when

comparing to the one or two-step abrasive

rubber polishing systems. The use of all

finishing and polishing systems in

combination with water resulted in a

significant smoother surfaces than those

obtained when using the same systems

without water for both types of composite

resins studied. Nanocomposite resin used in

this study showed a smoother surface after

finishing and polishing with any of the

systems used when comparing to microhybrid

resin.

REFERENCES

1 Kawai K, Urano M. Adherence of plaque components to different restorative materials. Oper Dent

2001; 26(4): 396-400.

2 Mandikos MN, McGivney GP, Davis E, Bush PJ, Carter JM. A comparison of the wear resistance

and hardness of indirect composite resins. J Prosthet Dent 2001; 85(4) 386-395.

3 Tjan AH, Clayton CA. The polishability of posterior composites. J Prosthet Dent 1989; 61(2): 138-

146.

4 Jones CS, Billington RW, Pearson GJ. The in vivo perception of roughness of restorations. Brit Dent

J 2004; 196(1): 42-45.

5 Patel SB, Gordan VV, Barrett AA, Shen C. The effect of surface finishing and storage solutions on

the color stability of resin-based composites. J Am Dent Assoc 2004; 135(5): 587-594.

6 Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness on stain resistance of dental resin



83

composites. J Esthet Restor Dent 2005; 17(2): 102-108.

7 Heintze SD, Forjanic M, Rousson V. Surface roughness and gloss of dental materials as a function of

force and polishing time in vitro. Dent Mat 2006;22(2): 146-165.

8 Paravina RD, Roeder L, Lu H, Vogel K, Powers JM. Effect of finishing and polishing procedures on

surface roughness, gloss and color of resin-based composites. Am J Dent 2004: 17(4): 262-266.

9 Yap AU, Yap SH, Teo CK, Ng JJ. Finishing/polishing of composite and compomer restoratives:

Effectiveness of one-step systems. Oper Dent 2004; 29(3): 275-279.

10 Turkun LS, Turkun M. The effect of one-step polishing system on the surface roughness of three

esthetic resin composite materials. Oper Dent 2004; 29(2): 203-211.

11 St Georges AJ, Bolla M, Fortin D, Muller-Bolla M, Thompson JY, Stamatiades PJ. Surface finish

produced on three resin composites by new polishing systems Oper Dent 2005; 30(5): 593-597.

12 Yap AU, Ng JJ, Yap SH, Teo CK. Surface finish of resin-modified and highly viscous glass ionomer

cements produced by new one-step systems. Oper Dent 2004; 29(1): 87- 91.

13 Jung M, Bruegger H, Klimek J. Surface geometry of three packable and one hybrid composite after

polishing. Oper Dent 2003; 28(6): 816-824.

14 Jones CS, Billington RW, Pearson GJ. Interoperator variability during polishing. Quint Int 2006;

37(3): 183-19

15 Jung M, Eichelberger K, Klimek J. Surface Geometry of four nanofiller and one hybrid composite

after one-step and multiple-step polishing. Oper Dent, 2007, 32(4): 347-355

16 Gedik R, Hurmuzlu F, Coskun A, Bektas OO, Ozdemir AK. Surface roughness of new microhybrid

resin-based composites. J Am Dent Assoc 2005; 136(8): 1106-1112.

17 Watanabe T, Miyazaki M, Takamizawa T, Kurokawa H, Rikuta A, Ando S. Influence of polishing

duration on surface roughness of resin composites. J Oral Sci 2005; 47(1): 21-25.

18 Turssi CP, Rodrigues Jr.AL, Serra MC. Textural characterization of finished and polished

composites over time of intraoral exposure. J Biomed Mater Res .2006 ;76(2): 381-8.



84

TECHNOLOGICAL ASPECTS IN THE CONSTRUCTION OF

PROSTHETIC REHABILITATION WITHOUT METAL FRAMEWORK

Diana Diaconu1*, Monica Tatarciuc

1, Andrei Melinte

2, Anca Viţalariu

1

1“Gr. T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,

Department of Implants, Removable dentures restorations and Prosthesis Technology 2“Gr. T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry, student

*Corresponding author: Diana Diaconu, DMD, PhD, Lecturer

“Gr. T. Popa" University of Medicine and Pharmacy

Iași, Romania


ABSTRACT

Ceramic materials tend to replace, in recent years, other restorative materials used for prosthetic constructions,

due to their special properties (biocompatibility, mechanical resistance greater longevity over time, chemical

and dimensional stability). The newest materials on zirconium basis, enriched with yttrium and alumina-based

ceramic continues to be studied. Clinical studies have shown that the most common cause of failures in all

ceramic prosthesis is the fracture of plating material. The question that was put in that situation was whay could

be the cause- the different behavior of the two materials or insufficient knowledge of the quality of the interface

of zirconia-ceramic. In the present article we wanted to illustrate two methods for the prosthetic ceramic

restorations on the zirconium framework. Choosing the best material for the realisation of prosthetic

constructions, so as to be satisfied both requirements of aesthetic and biomechanical, is a decision of the dental

team - in accordance with the wishes of the patient and the clinical situation.

Key words: zirconia, ceramic materials, clinical and technological algorithm

INTRODUCTION

Choosing the best material in order to

achieve fixed prosthesis is still a subject of

controversy even for specialists.

Aesthetic demands of patients have greatly

increased in recent decades, therefore, we

cannot speak today of a functional

rehabilitation without a physiognomic

recovery as close to perfection.

The recent spread of dental materials

diversified the technologies of achieving

prosthetic constructions. Knowing the

particularities of each method, with

advantages, disadvantages and their

limitations, allows the practitioner to choose

appropriate therapeutic solutions and solve

the most difficult clinical situations properly.

For a long time, metal-ceramic prosthesis

was the solution of choice for restoration of

stomatognathic system functions. The

marketing of ceramics based on zirconium

opened a new area of research, with many

studies highlighting the advantages and

disadvantages of these restorations.

A number of studies show that zirconia-

ceramic fixed restorations have a high

resistance to fracture values -between 443.6

and 740 N [1,2,3,4,5]

Recent literature has provided some

arguments on longevity of the zirconium-

based crown and bridges. So, in the

technologies based on zirconia, ceramic

sintering cycles must be less [6], best

infrastructure protection being made by the



85

parametric design of infrastructure and

occlusion. [7]

Recently, prosthetic restorations made

entirely of zirconium were imposed in

practice (Zirkonzahn Prettau), without using

cladding. This construction presents greater

transparency, colour tones very close to

natural teeth as well as higher surface

hardness; although high endurance is

associated with antagonist tooth wear but the

studies do not confirm such a correlation. [8]

Newest zirconia-based ceramics, enriched

with yttrium and alumina-based ceramics

continue to be studied. Clinical research has

shown that the most common cause of failure

in total-ceramic prosthesis is the mass

fracture. The question asked in this situation

was the cause of these fractures, despite the

fact that ceramic is a material with high

mechanical strength. Then which should be

the optimal mechanical parameters for a

ceramic material to be long-term resistant

maintaining the functional requirements and

how may currently available ceramic masses

be optimized to achieve prosthesis with

greater longevity? Research in this area

continues, aiming to improve the properties

of materials and current technologies.


The aim of this article is to illustrate

methods of performing ceramic constructions

on zirconia core. Regardless of the

technology used, the algorithm involves

creating a framework with higher hardness, to

be later coated with ceramics, which will

restore the morphology and functionality of

teeth and dental arches.

In the first clinical case, the patient M.N.,

aged 28, presented himself in the dental office

for aesthetic disorders as in large coronary

destructions at 13 and 23. The dentist

performed the endodontic treatment correctly

and completely, making two casted corono-

radicular reconstructions. Over these two

reconstructions ceramic crowns on zirconium

structure will be applied. The zirconium

infrastructure was obtained by manual

method Celay.

The impression of the prosthetic territory

was registered and temporary crowns was

applied to the patient, using Nu Form self-

curing composite resin (Fig. 1).

Figure 1. Temporary crowns

In order to obtain the zirconium

framework, a wax-up was made, using blue

inlay wax; in this study was used the wax

calibrated foil method, because this technique

is rapid and leads to a model with uniform

thickness of 0.4 mm, with smooth surface,

without retention. The wax constructions are

fixed in a base made out of a special resin and

applied to the milling machine. The

appropriate ceramic block is chosen and set to

achieve milling.

The technician will perform

simultaneously the scanning of the model

contour and the milling in the ceramic block.

At first scan, the morphology will be broadly

represented and in a second scan the details

will be recorded; for milling morphological

details a fine diamond bur will be used (Fig.

2).



86

Figure 2. Milling the zirconium framework

The zirconium core is then removed from

the holder and processed to verify and

adjustments on the die. The aim is to be well

adapted, both in axial, transversal and

cervical direction. After processing, the

framework is again analysed on the stone die

and then sent to office for intraoral

examination (fig. 3).

Figure 3. Checking the infrastructure on the stone die and into the oral cavity

In order to increase the resistance of the

framework, it will be placed in a special

sintering furnace and heat treated at 1600°C.

After heat treatment, the endurance of the

zirconium core will highly increase,

exceeding that of the metal, due to reduced

space between the particles of the structure.

After sintering, the constructions are removed

and were it comes the next step, of recovery

of coronary morphology and functional

rehabilitation.

For this purpose there were used special

veneering ceramics. By eliminating the metal

frame and making a total ceramic

infrastructure, a strong bond between the

framework and the plating mass will be

created, in addition to improving the

physiognomy.

After verifying them, the crowns were sent

to the office for checking the cervical and

transverse adaptation, the proximal

convexities, static and dynamic occlusal

contacts and, not least, correct colour

restoration and restore functions. After all

these are checked, the crowns will be

permanently mounted in the oral cavity (Fig.

4).

In the second case report it was realised

ceramic restorations on zirconia framework in

the front maxillary group 1.2, 1.1, 2.1 and

2.2.



87

Figure 4. Checking the crowns on the model and mounting them in the oral cavity

After making the required treatment and

preparing the oral cavity, the impression is

registered by the dentist, which sends it to

the dental laboratory. The technician will

make the stone die and the provisional

bridge (Fig. 5), which allows the patient to

resume stomatognathic system functions,

pending the completion of

treatment. Models are fitted in the

simulator in order to assess correctly

interarch reports (Fig. 6).

Figure 5. Temporary bridge Figure 6. The model mounted in the

simulator

For the infrastructure of zirconium we

have opted in this case for the CAD-CAM

technology, with a shorter working time.

The software establishes the position of

each item, followed by the virtual model

verification. If after the initial scan there are

parts that are not visible on the virtual model,

the area is scanned again. This process is

repeated until a highly accurate virtual model

is achieved.

After scanning the die, future prosthetic

components are designed using software. The

details are all setting and the design of the

future prosthesis can start (Fig. 7).

After the design phase of the restoration,

there comes the milling phase. A zirconium

disc, with a suitable size is chosen and, based

on data, the CAD component of the system

performs the frame shaping (Fig. 8).

After the trimming, we cut the support

rods and verify the restoration in the oral

cavity, establishing the color of the veneering

component. Then, the construction is sent to

the laboratory where it is placed in a solution

of liner, depending on the color we choose;

the synthesizing process is performed, in

special chamber, for eight hours. The

framework shall be processed and refined

with a water turbine, in order to ensure

gradual cooling, thus avoiding the



88

overheating which can lead to cracks in

framework. (Fig. 9)

After processing the prosthetic framework

and checking on the die, we can start adding

the ceramic layers, for veneering, depending

on the color that was set. The first stage was

to apply the liner on to the zirconium

framework, and then, the ceramic layers, step

by step. (Fig.10)

The reconstruction was intraoral verified

and it was applied the final coat- the glaze-

and the bridge is sent to the dental office for

cementation. (Fig.11)

Figure 7. Setting the prosthetic restoration design

Figure 8. Milling the zirconia framework Figure 9. The zirconium framework after

sintering

Figure 10. Application of the veneering ceramic layers



89

Figure 11. Final prosthetic result


New ceramic materials, with mechanical

and optical properties similar with dental

tissues, allowed optimal prosthetic

restorations. A ceramic construction on a

zirconium framework will have a very good

resistance and will allow a complete

functional recovery. Zirconium oxide is a

very hard material, with a stabile structure

due to the yttrium oxide composition. The

zirconium framework can be realised by

manual or computerised technology (Celay or

CAD-CAM); after the sintering, the

infrastructure becomes very strong, with

strength of approximately 850 Mpa.

Computerised technologies allow accurate

and quick realization of the prosthetic

restoration, eliminating many intermediate

laboratory steps; in addition, the use for

milling of materials industrial made allow the

realization of structures with homogeneous

and stable internal architecture and with a

better mechanical resistance.

Among the main disadvantages of the

ceramic restoration on zirconium framework

is the high cost, compared to other restorative

options. Being a material introduced

relatively recently in the dental practice, there

are not enough studies to certify the

superiority, compared to the metal-ceramic

crowns, in terms of durability and longevity.

CONCLUSIONS

Zirconium has emerged as a necessity,

since metal-ceramic works don’t always

correspond to the desires of patients.

The main indication for ceramic crowns on

zirconium support is restoring anterior teeth

because they have much stronger visual

impact. Zirconia-ceramic crowns are more

aesthetic than metal-ceramic crowns and also

resistant than full ceramic crowns.[9] A key

element in the outcome of these restorations

is excellent technician skills. Indication of

choice for zirconium is definitely in the front

area and especially when adjacent teeth are

natural.

Zirconium allergy risk is null; there are no

patients allergic to this material, zirconium

being biocompatible, bioinert and also

thermally inert. It does not conduct heat so

that thermal variations are not transmitted to

the dental pulp and thus the risk of pulpal

irritation decreases. Due to extremely precise

zirconium crowns adjustment, they can be

cemented with biocompatible materials that

do not cause pulpal irritation.[10]

The main disadvantages of hard ceramic

zirconium crowns are certainly high

production costs compared to other options of

coronal restoration. Sophisticated technology

is reflected in price, quality of material and

high level of skill of the technician and

physician.

Being a relatively new material introduced

in dental practice, yet there are not enough

studies to certify net superiority of ceramic

crowns on zirconium support instead of

metal-ceramic crowns in terms of

sustainability.

We therefore conclude that although

zirconium implementation technology still

raises many questions, it is certainly an

exceptional therapeutic solution both

aesthetically and mechanically speaking. Also

in the future zirconium will be a convenient

solution for the dental labs because the

technology is fast and accurate.



90

REFERENCES

1 Yildirim M., Fischer H., Marx R., Edelhoff D. In vivo fracture resistance of implant supported all-

ceramic restorations. J Prosthet Dent, 2003: 80 (2), pp. 325-331.

2 Att W., Kurun S., Gerds T., Strub JR. Fracture resistance of single-tooth implant supported all-

ceramic restorations: an in vitro study. J Prosthet Dent, 2006: 95 (2), pp. 111-116.

3 Sundh A., Sjörgren G. A study of the bending resistance os implant-supported reinforced alumina

and machined zirconia abutments and copies. Dent Mater, 2008: 24(5), pp. 611-617.

4 Kerstein R., Radke J. A comparasion of fabrication precision and mechanical reliability of 2 zirconia

implant abutments. Int J Oral Maxillofac Implants, 2008: 23(6), pp. 1029-1036.

5 Stawarczyka B. The fracture load and failure types of veneered anterior zirconia crowns: An analysis

of normal and Weibull distribution of complete and censored data, Dental Materials, 2012: 28, pp.

478–487.

6 Zeighami S. The Effect of Multiple Firings on Microtensile Bond Strength of Core-Veneer Zirconia-

Based All-Ceramic Restorations, Journal of Prosthodontics, 2013: 22, pp. 49–53.

7 Mainjot A. La Zircone: analyse des causes d’échec, Entretiens de Bichat, d’Odontologie-

Stomatologie, 2010, pp. 49-51.

8 Jardel V. Réalisation de restaurations céramo-céramique en zircone Prettau a l’aide du systeme

pantographe Zirkonzahn en pratique journaliere, Quintessence Revue Internationale de Prothese

Dentaire, 2011: 3, pp. 226-235.

9 Beur F, Aggstaller H, Fishcher T, Soiegl K, Schweiger J, Gernet W. Clinical behavior of zirconia

based bridges: two-years results. Dent Res. 2007; 86 (Spec Iss A):0901.

10 Wolfart S, Eschbach S, Kern M. Outcome of posterior FPDs of veneered zirconia ceramic (Cercon).

J Dent Res. 2007; 86 (Spec Iss A) :0292.



91

RESEARCHES REGARDING THE BEHAVIOUR OF ACRYLIC

RESINS VERSUS SILICONIC MATERIALS INVOLVED

PROSTHETIC RECONSTITUTIONS

Doriana Forna1*, Mariana Cazacu

2, Magda –Ecaterina Antohe

1

1“Gr. T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,

Department of of Implants, Removable dentures restorations and Prosthesis Technology 2„Petru Poni” Institute of Macro-molecular Chemistry, Iasi, Romania

*Corresponding author: Doriana Forna

“Gr. T. Popa" University of Medicine and Pharmacy

Iași, Romania


ABSTRACT

The variety of facial traumatisms, the tumour pathology resulted in substance loss, are only part of the issues

that leave their mark in a mutilating way upon the patients, modifying significantly and sometimes irreversibly

their behaviour, from active and social to isolation, these aspects leading without a doubt to the need of

diversification of the materials used in the prosthetics solutions for these clinical entities. This study is aimed at

the improvement of the biomaterials used in the field of entirely removable prosthesis quality. The essential

lucrative directions regarding acrylate and silicon materials with structural modifications and correspondent

associations determine the elaboration of new prosthetic constructions that have an increased degree of comfort

in comparison with present stomatologic solutions. A number of 19 test-tubes were made under the shape of

thin, rectangular plates, 40mm long and 20mm wide and a depth varying from 1,8 to 2,5. Out of these, 14

traction test-tubes were realized with aluminium sticked (cyanoacrilate adhesive) ends. The trials were made

with a HEKERT 50 machine (on a scale of 10 kN) and with a Textenser (maximum force of 500 kN). The

polyethylene reinforcement is better than the metallic reinforced system, as the tension distribution is more

uniform, with tension concentrators less powerful. Negative results from the Candida adherence point of view

were found for test-tubes with AM88, M88 copolymers and for random and longwise arranged polyethylene

reinforced test-tubes. These significantly negative results are based on the antibacterial effect of the two

copolymers made at the Macromolecular Chemistry Institute „Petru Poni” in Iasi. The role of siliconic materials

regarding the biologic integration is already known, but the structural modifications that we induced can meet

high point in biocompatibility, chromatic range, and it is an essential condition for the overcoming of congenital

or acquired facial flaws, reaching the state of reconstructive art.

Key words: siliconic biomaterials, candida albicans, acrilate, biocompatibility

INTRODUCTION

The terrible clinical reality of the total and

subtotal edentulous seen from the impact on

the patient’s general status point of view, with

extremely serious perturbations upon the

body scheme, in relation with the variety of

clinical situations and always influenced by

present social aspects, all these are just a few

directions that argue for the necessity of the

present study which is aimed at optimizing

both the clinical and technological level, with

the differentiation of the interrelation between

the two sides of the prosthetics therapy [1, 2].

The variety of facial traumatisms, the



92

tumour pathology resulted in substance loss,

are only part of the issues that leave their

mark in a mutilating way upon the patients,

modifying significantly and sometimes

irreversibly their behaviour, from active and

social to isolation, these aspects leading

without a doubt to the need of diversification

of the materials used in the prosthetics

solutions for these clinical entities.

PURPOSE

This study is aimed at the improvement of

the biomaterials used in the field of entirely

removable prosthesis quality. The essential

lucrative directions regarding acrylate and

silicon materials with structural modifications

and correspondent associations determine the

elaboration of new prosthetic constructions

that have an increased degree of comfort in

comparison with present stomatologic

solutions. One important aspect taken into

consideration is the adhering of the Candida

albicans fibers, a bacterium frequently met at

the oral cavity level of old patients, to

different variations of acrylate, in search of

ways of counter-attacking this tendency of a

very resistant microbial structure. Candida

albicans has negative effects on acrylate to

which it adheres due to its fiber-like structure,

contributing significantly to the degradation

of the acrylic material. This is why the

discovering of non-adhering possibilities is

extremely important.


A number of 19 test-tubes were made

under the shape of thin, rectangular plates, 40

mm long and 20 mm wide and a depth

varying from 1.8 to 2.5 (fig. 1).

Figure 1. The standard test tube for traction

trial

Out of these, 14 traction test-tubes were

realized with aluminum sticked (cyanoacrilate

adhesive) ends. The trials were made with a

HEKERT 50 machine (on a scale of 10 kN)

and with a Textenser (maximum force of 500

kN).

We made a number of 8 test-tubes in

which we used various proportions of two

types of copolymers elaborated at the Institute

of Macromolecular Chemistry „Petru Poni” in

Iasi (fig. 2):

- M88 – Maleic anhidride copolymer, metil

metacrilat 1:3 parts

- AM88 – Na maleat copolymer, metil

metacrilat 1:3 parts.

Combination proportions varied from 1:1

to 1:3.

Figure 2. M88 and AM88 Copolymers

In a subsequent stage, the acrylate was

mixed with the monomer, the final material

being inserted into the mould and

polymerized. A number of 4 samples were



93

cocked with polyethylene fiber arranged in

various patterns, respectively metallic net,

which is the most frequent method used in

practice as reinforcement (fig. 3).

A sandwich-like sample was made to unite

the silicon material elaborated at the Macro-

molecular Chemistry Institute „Petru Poni” in

Iasi, with the acrylic structure, separated by

the cocking net. The adhering method of the

siliconic rubber to the acrilate and,

respectively, to the metallic net which allows

the mixing of the two materials through its

wholes, was made possible by using a

coupling agent – siliconic adhesive cmv-40

(fig. 4 a, b).

During the next step, the cocking element

represented by the metallic net, was applied

over the siliconic material, which was pressed

this way. The final pressing phase will take

place with the compressing of the sink.

Further on, the acrilate layer will be laid, thus

completing the sandwich shape of the test-

tube (fig. 5 a, b).

The following step, identical with the

making of the other test-tubes, consists of

hermetically shutting down the sink and

introducing it under the pressing machine,

steps that are absolutely necessary for the

removal of the excess material and for the

compression of the elaborated structure.

The second direction of the study is

concerned with the synthesis and analysis of a

new siliconic material with various excess

materials, these aspects being necessary

because of the different types of underlying

tissue (fig. 6).

Figure 3. Aspects of

reinforced acrylic structure

sample

Figure 4a, b. Preparing the sandwich-like sample

Figure 5 a, b. Preparing the sandwich-like test-tube Figure 6. Aspects of

siliconic sample of various

resilient materials

New silicone (synthesized in collaboration

with the “Petru Poni” Institute of Macro-

molecular Chemistry , Iasi, Romania) based

materials having a higher biocompatibility as

compared with those commercially available

(Mollosil), have been prepared and used for

improvement of the removable dentures’

structure, but also for their lining. The



94

polymeric matrix consisting in a high molecular

weight dimethylmethylvinylsiloxane copolymer

has been synthesized by cationic ring-opening

copolymerization of the appropriate cyclic

monomers (octamethylcyclotetrasiloxane and

methylvinylcyclotetrasiloxane).

Table 1. Characteristics of the studied variants of materials

Variant Longitudinal elasticity

module E [Pa]

Poisson

Coefficient

Roughness

[µm]

Density

[kg/m3]

Variant 1 4.000.000 0.37 1 1100

Variant 2 2.000.000 0.40 1.5 1050

Variant 3 1.000.000 0.42 2 1000

Variant 4 500.000 0.44 2.5 950

The testing of biofilms formation capacity

The Candida albicans stem isolated from a

paraprosthetic affection was applied on the

Sabouraud agar for 24 hours, on a 35 degrees

Celsius temperature; out of the colonies

developed, one suspension of larvar cells was

prepared in saline peptonated tomato sauce,

with pH 7 and a density of 106 cells/ml.

Small portions (0.5 x 1.0 cm) of the tested

materials were emerged in this suspension for

90 min., at 35 degrees Celsius – the adhesion

phase.

After time expiry, the samples were rinsed

carefully in distilled water and then emerged

in the culture liquid environment – Sabouraud

liquid [1,2,6] with 8% glucose and incubated

for 60 hours at 35 degrees Celsius –

conditions that favour the biofilms formation

from the adhering larva on the materials

surface which were not removed by rinsing

(fig. 7).

Figure 7. Aspects of distilled water rinsed test-tubes

Colored with saphranin 1% for 1 min.,

those which retained the color were

considered positive for biofilm presence and

those which didn’t were considered negative.

Out of all the samples used, only the one

taken from material no. 7, which represented

the most resistant material used in lining and

the most frequent modality of ensuring the

longlasting resistance of removable

prosthesis, allowed the forming of Candida

albicans biofilm. This fact was observed at

the microscope (by putting the sample on

resin, by sectioning and PAS coloring) under

the form of a positive PAS band (formed of

larvas and polyshugarry matrix) on the

surface of the sample – the section was made

perpendicular on the sample.


After analysing the test-tubes for traction



95

forces, we reached the following conclusions:

The breaking of the base material was

followed by the taking over of the force by

the metallic net: the small (elastic) distortions

of the acrylate were not simultaneous with the

distortions of the reinforcement materials.

Polyethylene fibers are made by twisted

threads and it presents a lower elasticity

module compared to that of the acrylic resin,

especially due to the undulation of the fibers.

In the case of the metallic net reinforced

material it was observed that the cracking of

the resin was perpendicular towards the

direction of the force and that the metallic

reinforcement was insignificantly distorted

(fig. 8).

Figure 8. Aspects of the fracture line of the test-tubes

The total transversal breaking of the

unreinforced test-tubes, compared to those

with a reinforced structure, presented in this

study, is also confirmed in the literature by

N’Dindin’s research (2000) on test-tubes

made with metallic polymetacrilate,

reinforced with carbon fiber, compared with

unreinforced structures.

The simulation methods are avangardistic

and absolutely mandatory in the stage

precursory to the practical research steps,

giving shape to ways of practical

applicability. This way, the final results will

be the more pertinent as they were obtained in

the conditions of a double set of experimental

methods which recreated the clinical situation

to be analysed (fig. 9).

Figure 9. The evaluation of the internal tension force for a lining with the siliconic material

produced in collaboration with the „Petru Poni” Institute in Iasi

In order to determine the experimental

conditions, a simulator which respects both

the mandibular cinematic and dynamic must

be projected first.

In this regard, some considerations of

mandibular biomechanics nature must be

made as the mandatory starting point for the

projection of the simulator (fig. 10, 11).



96

Figure 10. Description of the simulator

Figure 11. The evaluation of the interval stress condition for completely edentated prosthetic

field, resolved with polyetilene reinforcement

The 2D analysis presents an advantage in

regard of visualization of the internal tensions

in a section, unlike the 3D analysis, in space,

which allows only the visualization of the

surface tensions of the system.

The polyethylene reinforcement is better

than the metallic reinforced system, as the

tension distribution is more uniform, with

tension concentrators less powerful.

Negative results from the Candida

adherence point of view were found for test-

tubes with AM88, M88 copolymers and for

random and longwise arranged polyethylene

reinforced test-tubes. These significantly

negative results are based on the antibacterial

effect of the two copolymers made at the

Macromolecular Chemistry Institute „Petru

Poni” in Iasi. It is known in the literature that

all maleic anhydridic copolymers and their

derivates have bioactive effects [3].

In the context of the previous data, it

would have been probable for the two

copolymers to induce these characteristics. It

is important to mention that the two

copolymers can be combined with groups of

the eugenol and timol type, with antibacterian

effects, creating polymer systems with

controlled release of antibacterial substances.

The chemical structure of the AM88

copolymer influences the antimicrobial action

in the presence of sodium carboxilate, which

confers a polielectrolyte character. The

chemical structure differences between the

two copolymers are also visible in the

biomechanical behavior. The sodium maleat

copolymer leads to elastic structures, a

feature which is very important for the

finished product.

Comparing the depositing of Candida

larvas at the acrylat-mollosyl and acrylat-



97

silicon test-tubes, it was observed that the

deposit was more intense with the mollosyl

compared to the more discreet deposit on the

silicon made at the Macromolecular

Chemistry Institute „Petru Poni” in Iasi.

This essential aspect recommends the

usage of silicone as lining material in the

process of long-term reoptimising, compared

to the mollosyl which is indicated in the

tissular conditioning (fig. 12, 13).

Figure 12. Acrylic and siliconic samples Figure 13. Aspects of the Candida

structures

A very important direction for the

validation of biocompatibility of synthesized

and tested materials is represented by the

evaluation of the Candida albicans larvas

adherence on their surfaces. It is worthwhile

to observe that these microbial structures are

present at an alarming rate in the territory of

stomatologic pathology, with chronic low-

immunitised patients of the third age, as a

marker of biologic degeneration [4].

The role of the siliconic materials in the

biologic integration is well known, but the

structural modifications designed by us can

meet very high values of performance as far

as the biocompatibility, chromatic range and

sine que non condition in overcoming the

facial congenital or achieved flaws are

concerned, reaching the state of

reconstructive art.

Regarding tests of biocompatibility, the

protocol of introducing test-tubes under the

laboratory animals skin comprises the

following: Animal species: Domestic Rabbit

(Oryctolagus cuniculus), male, 2.5 kg;

Anesthezic: Neuroleptanalgesic: Time 1:

Atropina 0.05 mg/kg underepidermic after 5

min; Time 2: Xilasine 3mg/kg intramuscular;

After 15 min. Time 3 : Ketamine 20 mg/kg

intramuscular.

After 10 days a skin biopsy was made on

the implanted areas to find out the momentary

biocompatibility evaluation. The biopsy

samples were fixed in formol and then

subdued to histological techniques and HEA

coloring, in order to obtain permanent

histological samples.

From the clinical point of view, 10 days

after implantation we could observe the

absence of any inflammatory reaction,

sequestration tendency, a marker of body

acceptance of the siliconic implant. The

histological samples underline the presence of

normal collagenic formations, without the

appearance of PMN ( polymophonuclear) in

the case of synthesized silicones

manufactured in collaboration with „Petru

Poni” Institute.

The microscopic aspects, marker of

immediate biocompatibility, revealed a

reduced limphoplasmocite infiltration,

accompanied by sequestration through fiber

tissue. General results at the implanting site

of siliconic test-tubes with moderated and

reduced composition of eogenol show that



98

negative elements represented by giant cells,

attributed to test-tube no.7 which contains

siliconic elastomer without silver, are

optimized by introducing silver in the same

structure (fig. 14 a, b).

The structure of the epitheses, which is

dictated by the interested substrate implies the

combination of two types of materials, the

frequently used combination of acrilate

silicon, its adherence being essential, the

current research being a conclusive starting

point to this point in the field of the

elaboration of epitheses (fig. 15 a,b, 16 a, b).

Figure 14. Reduced limfo-histocitary infiltration, sequestration through fiber tissue

Figure 15. Clinical aspect of applications of our new siliconic material in lost of substances

cases

Figure 16. Final aspects of surgical obturator (siliconic biomaterials)

The association of acrylic resins with

copolymers and silicones of different

resilience level, and not eluding the

combination with antiseptic substances were

an experiment and an also answer to the

questions: Which should be the structure and

resilience of revetment materials for

removable denture? or Which are the

conditioning materials for prosthetic implants

therapy and for surgical obturator?



99

CONCLUSIONS

1. The role of siliconic materials regarding

the biologic integration is already known,

but the structural modifications that we

induced can meet high point in

biocompatibility, chromatic range, and it

is an essential condition for the

overcoming of congenital or acquired

facial flaws, reaching the state of

reconstructive art.

2. An important direction for validating the

biocompatibility of synthesized and tested

materials is represented by the evaluation

of Candida albicans larvas adherence on

their surface and it is important to notice

that these microbial structures are present

at an alarming rate in the territory of

stomatologic pathology, with chronic

low-immunitised patients of the third age,

as a marker of biologic degeneration.

3. Among the advantages of the use acrylic

bases reinforcement with polyetilene

fibers we notice its lower interface effect

in comparison with the not acrylic

reinforcement.

4. The mathematical simulation is an

important step for the choice of the

optimal materials regarding the stress that

is transmitted on the muco-osseuse

support.

REFERENCES

1 Held W. Silicones: Their Science, Production and Major Qualities, Centre european des silicones -

report January 2003.

2 Zappini G., Kammann A., Wachter W. Comparison of fracture tests of denture base materials, The

Journal of Prosthetic Dentistry; 2003: 90(6), pp. 578-15.

3 Forna N., Burlui V. Clinical guidelines and principles in the therapy of partial extended edentation,

Ed. Apollonia, 2001, pp. 470-477.

4 Jagger DC, Jagger RG, Allen SM. An investigation into the transverse and impact strength of high

strength denture base acrylic resin, Journal of Oral Rehabilitation; 2002: 29(2), pp. 263-267.

5 Forna N. Actualities in therapy of partial edentation, Ed. Demiurg, 2009.

6 Black J. Biological Performance of Materials. New York: Marcel Dekker, 1992.

7 Power MJ., Sakaguchi RL. Craig’s restorative dental materials (12th ed), 2006.

8 Bayne SC. Perspective: our future in restorative dental materials. J Esthet Dent 2000;4:175–83

9 Finer Y, Santerre JP. Salivary esterase activity and its association with the biodegradation of dental

composites. J Dent Res 2004;83:22–6.

10 Teughels W, Van Assche N, Sliepen I, Quirynen M. Effect of material characteristics and/or surface

topography on biofilm development , Clin Oral Implants Res. 2006;17 Suppl 2():68-81.



100

SEM STUDY REGARDING DENTAL EROSION ON EXTRACTED

TEETH IMMERSED IN HYDROCHLORIC ACID

Cristina-Angela Ghiorghe*, Claudiu Topoliceanu, Galina Pancu, Simona Stoleriu,

Gianina Iovan

“Gr. T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dental Medicine

Department of Odontology, Periodontology and Fixed Prosthodontics

*Corresponding author: Cristina – Angela Ghiorghe, Lecturer, DMD, PhD

“Gr. T. Popa" University of Medicine and Pharmacy,

Iași, Romania


ABSTRACT

The aim of study was to determine, using SEM microscopy, the changes of enamel surfaces of teeth imersed in

0,06 ml0/l hydrochloric acid (pH1,2). The choice for this solution is to simulate the gastric juice attack related to

erosive lesions on oral dental surfaces of patients with gastroesophageal reflux disease (GERD). The study

group included 20 extracted healthy human teeth, 10 maxillary teeth and 10 mandibular teeth. After samples

preparation, every tooth was cut in three slices. The three slices were imersed in distilled water (control sample),

hydrochloric acid (30 minutes), hydrochloric acid (1 hour). The samples were analysed in SEM microscopy,

followed by a analysis of minerals concentration. The results showed, for samples imersed in hydrochloric acid,

the apparition of important surface changes, as enamel pores enlargement, irregular structure of enamel prisms

and significantly decrease of calcium, phosphat ions concentrations. Conclusions: The demineralisation of

enamel tissues is directly related to repeated acid attacks; the dissolution rate of enamel in acid erosion depends

on chemical parameters of solution (pH, concentration); the study highlights the risk of gastroesophageal reflux

disease (GERD) for the hard dental tissues.

Key words: dental erosion, enamel, hydrochloric acid, SEM microscopy

INTRODUCTION

The ultrastructural aspects of dental

erosion and physical and chemical features of

affected dental surfaces under erosive attack,

can be assessed using diverse laboratory

techniques.

SEM microscopy performs qualitative

analysis of the enamel surfaces changes under

erosive processes. SEM microscopy

determines the extension of the affected

enamel surfaces regarding the alteration

degree of enamel prisms accordingly to SEM

images [1].


The study included 20 unaffected human

teeth extracted for periodontal and

orthodontic reasons, 10 maxillary and 10

mandibular teeth. After extraction, teeth were

stored in formalin solution 10%.

The organic and anorganic debris were

removed using mechanical and chemical

procedures (immersion in NaOCl sol.5,25%).

The coronal samples were cut in

vestibular-oral and mesio-distal plans, using

diamond discs. Every dental crown was

divided in three slices. The three slices were

immersed in distilled water (control sample),

hydrochloric acid (30 minutes), hydrochloric

acid (1 hour). Every slice was prepared using

paper discs to obtain 10 μm slices. After

washing in clean water, every slice was



101

immersed in resin plate. The samples were

analysed in SEM microscopy (SEM model

VEGA II LSH,, TESCAN Cehia. The SEM

microscope was connected to a EDX detector

(QUANTAX QX2, BRUKER/ROENTEC,

Germany).

RESULTS

The microscopic images (Fig. 1) show the

enamel-dentine junction (EDJ). The enamel

prisms are unaffected and present regular

orientation.

The microscopic images (Fig. 2) show

porous enamel, with irregular structure

associated with small hydroxyapatite crystals

condensed at enamel surface.

After immersion of teeth fragments in

hydrochloric acid for 1 hour (Fig. 3), SEM

images show the enlargement of the enamel

pores, the destruction of the enamel structure

and the apparition of small fissures.

Figure 1. Images 100X, 500 X SE 1 (control sample)

Figure 2. Images 100 X SE, 500 X SE (sample 1, after 30 minutes)



102

Figure 3. Images 100 X SE, 500 X (sample 1, after 1 hour)

The study included the analysis of enamel

chemical composition, related to

concentration of calcium, phosphate and

oxygen. The samples immersed in

hydrochloric acid for 30 minutes and 1 hour,

were compared with control sample. The

study was performed using Bruker AXS

detector (QUANTAX QX2,

BRUKER/ROENTEC, Germany). Using this

device, it were recorded the chemical

spectrum of the enamel composition and

minerals quantity (μg).

In figure 4 (control sample 1), the

chemical analysis records 45,64 μg% calcium

concentration and 19,34 μg% phosphate

concentration. The recorded values are close

to the normal concentration range.

Figure 5 (sample 1, 30 minutes

immersion) shows an important decrease of

enamel calcium and phosphate concentrations

( calcium = 3,35 μg%, phosphate= 2,50 μg%)

as well as the apparition of another

microelements (carbon= 15,99 μg%, chlorine

= 2,75 μg%). The carbon ions results from the

degradation of the enamel organic structure,

chlorine ions penetrate the dilated enamel

pores.

After 1 hour, enamel chemical

composition analysis records a reprecipitation

of calcium and phosphate ions, associated

with microscopic aspect of microcristals

stored on the enamel surface (Fig. 6).

Figure 4. Enamel chemical composition spectrum (control sample 1)



103

Figure 5. Enamel chemical composition spectrum (sample 1, after 30 minutes)

Figure 6. Enamel chemical composition spectrum (sample 1, after 1 hour)

DISCUSSIONS

The SEM study confirms the results

highlighted by other similar studies regarding

the demineralisation processes of enamel and

dentine under the action of hydrochloric acid

(major component of gastric acid). The

clinical effect, produced by the opening of

dentinal tubules, is the apparition of cervical

dentinal sensitivity, as a result of dynamic

changes of dentinal fluids and dental tissues

loss.

Field J. & al. (2010), in a study performed

on extracted teeth, observed that SEM can be

used to measure in vitro resorption of hard

dental tissues. The SEM images can analyse

the composition, structure, can highlight

small areas and can be viewed 3-D. The

dental surfaces, in conventional SEM, must

be covered with gold to prevent electrostatic

loading [1].

Pollyana S. Castro, Alex S. Lima, Tiago L.

Ferreira, and Mauro Bertotti (2011), showed

that the enamel dissolution rate in acid

erosion, depends on some chemical

parameters (pH, calcium and phosphate ions

concentration). The enamel dissolution is a

fast process that produces the extensive

diffusion of protons layer in solution. The

dissolution mechanism is controlled by

interfacial processes. The presence of fluorine

ions can reduce the erosion rate of

hydroxyapatite. SEM microscopy can

investigate the chemical reactions associated

with the acid erosion and can clear up the

protective mechanisms. The covering with

NaF varnishes represents one of the



104

preventive techniques regarding dental

erosive demineralization. The profilometry is

another monitoring method that can be used

regarding the evolution of acid erosion and

the efficacy of diverse preventive and

therapeutic approaches [2].

Barbour & al.(2006) demonstrated that the

increase of calcium ions concentration can

diminish the erosive effects. The decrease of

enamel hardness after immersion in juices

with high concentrations of citric acid is

similar with the results obtained in our study

[4,5].

The values of calcium and phosphate ions

obtained in our study are related with the

results obtained in other similar studies

focused on the enamel demineralisation

processes produced by diverse acids [5]. SEM

microscopy observed first changes of enamel

structure at the interface prism/prism wall.

Further the hidroxyapatite crystals reduced

their diameters. After 1 hour of immersion in

hydrochloride acid, SEM images show the

destruction of organic component and micro

fissures. The quantitative analyse

demonstrates the enamel minerals loss by the

carbon ions apparition, after one hour of

immersion in hydrochloride acid.

CONCLUSIONS

The demineralisation of enamel tissues is

directly related to repeated acid attacks;

The dissolution rate of enamel in acid

erosion depends on chemical parameters

of solution (pH, concentration);

SEM analysis of enamel structural

changes as well as chemical analysis can

clear up the dental erosion mechanisms;

The study highlights the risk of

gastroesophageal reflux disease (GERD)

for the hard dental tissues.

REFERENCES

1 J. Field , P. Waterhouse, M. German. Quantifying and qualifying surface changes on dental hard

tissues in vitro. Journal of De n t i s t r y 3 8 ( 2 0 1 0 ) 1 8 2 – 1 9 0

2 Pollyana S. Castro, Alex S. Lima, Tiago L. Ferreira, and Mauro Bertotti. Scanning

ElectrochemicalMicroscopy as a Tool forthe Characterization of Dental Erosion. International

Journal of Electrochemistry, Volume 2011, Article ID 952470, 6 pages

3 Barbour ME, Rees GD. The role of erosion, abrasion and attrition in tooth wear. J Clin Dent.

2006;17(4):88-93

4 Barbour ME, Rees JS. The laboratory assessment of enamel erosion : a review. J Dent 2004; 32: 591-

602.

5 Barbour ME, Finke M, Parker DM, Hughes JA, Allen GC, Addy M. The relationship between

enamel softening and erosion caused by soft drinks at a range of temperatures. J Dent 2005.



105

ELECTRON MICROSCOPY VALIDATION OF ICDAS CODES 5 AND 6

FOR PROXIMAL CARIES

Elena – Cristina Marcov*, Narcis Marcov

“Carol Davila" University of Medicine and Pharmacy - București, Romania,

Faculty of Dentistry, Department of Restorative Dentistry

*Corresponding author: Elena Cristina Marcov, DMD, Phd, Teaching Assistant

e-mail: [email protected], tel. +40.723.335.162

ABSTRACT

Aim of the study The purpose of this study was to evaluate the possibilities of electron microscopy validation

of the visual ICDAS codes 5 and 6 for proximal surfaces using a ROC statistical analysis. Material and

methods 110 proximal surfaces of anterior and posterior extracted teeth were visually inspected by 6 observers.

65 caries were classified as ICDAS code 5 and 45 cases were classified as ICDAS code 6. These surfaces were

photographed, the teeth were sectioned and the fragments of interest were analyzed at the scanning electronic

microscope (SEM). The SEM images were used as validation tools for the initial diagnostic ICDAS code.

Results The results of the six observers were used in the statistical analysis for evaluating the diagnostic

performance for each code. The mean value of the diagnostic performance A(z) was 0,766 for the code 5 caries

and 0,850 for the code 6 caries (p>0,05). Conclusions The electron microscopy validation was efficient and

the diagnostic performance proved that code 6 was identified easier than code 5.

Key words: SEM validation, ICDAS codes, restorative dentistry

INTRODUCTION

The aim of this study was to evaluate the

possibility of electron microscopy validation

of the visual ICDAS codes 5 and 6 for

proximal surfaces using a ROC statistical

analysis.

The ICDAS Foundation defines the

International Caries Detection and

Assessment System as a "simple, logical,

evidence-based system for detection and

classification of caries in dental education,

clinical practice, dental research and dental

public health.

The ICDAS detection codes for coronal

caries range from 0 to 6 depending on the

severity of the lesion. There are minor

variations between the visual signs associated

with each code depending on a number of

factors including the surface characteristics

(pits and fissures versus free smooth

surfaces), whether there are adjacent teeth

present (mesial and distal surfaces) and

whether or not the caries is associated with a

restoration or sealant".

The ICDAS Foundation presents the

general description of the codes as follows:

0 - Sound;

1 - First visual change in enamel (seen

only after prolonged air drying or restricted to

within the confines of a pit or fissure);

2 - Distinct visual change in enamel;

3 - Localized enamel breakdown (without

clinical visual signs of dentinal involvement);

4 - Underlying dark shadow from dentin;

5 - Distinct cavity with visible dentin;

6 - Extensive distinct cavity with visible

dentin [1, 2].

Therefore, the ICDAS code 5 for



106

proximal carious lesions is defined as a

"cavitation in opaque or discolored enamel

exposing the dentin beneath involving less

than half of the tooth surface. The

WHO/CPI/PSR probe can be used to confirm

the presence of a cavity in dentin. This is

achieved by sliding the ball end along the

surface and a dentin cavity is detected if the

ball enters the opening of the cavity" [3].

ICDAS code 6 for proximal carious

lesions is defined as "an extensive distinct

cavity with visible dentin, cavitation in

opaque or discolored enamel exposing the

dentin beneath involving at least half of the

tooth surface. Obvious loss of tooth structure,

and dentin is clearly visible on the walls and

at the base in a cavity that involves at least

half of a tooth surface. The marginal ridge

may or may not be present" [3].


110 proximal surfaces of anterior and

posterior extracted teeth were visually

inspected by 6 observers with different levels

of clinical and research experience. 65 caries

were classified as ICDAS code 5 and 45 cases

were classified as ICDAS code 6.

These surfaces were photographed, the

teeth were sectioned and the fragments of

interest were analysed at the scanning

electronic microscope (SEM).

The SEM images were used as validation

tools for the initial diagnostic ICDAS code.

Each of the 6 observers was trained so as

to be familiar with the presentation format.

Oral and written instructions about the

method protocol were provided. In addition,

the project coordinators were available to

answer any of the observers’ questions.

The observers had to identify the presence

or absence of carious lesion ICDAS code 5 or

6 according to the ROC statistical analysis

algorithm.

The accurate assessment of the codes

involves several conditions for a proper

examination: proper light, cleaned and dry

teeth.

Ground truth was established with a gold

standard represented by scanning electronic

microscopic (SEM) evaluation. The sectioned

teeth were put in glutaraldehide solution 4%

and sodium cacodilate 0,15M with pH of 7,2-

7,4 for 4 hours. Then, they were layered with

osmium tetraoxide 1% and dehydrated in

ethylic alcohol solutions of variable

concentrations. The pieces were fixed with

Leit-C, Neubauer adhesive were gold coated

using the Sputter Coater (Polaron) SC 502

and visualized using Philips XL 20 electronic

scanning microscope.

The answers of all observers were

provided as scores (1, 2, 3, 4 or 5) which

were statistically analysed and classified

using MedCalc 12.5.0. The scores that the

observers gave us were statistically analysed

using the comparison with the gold standard

imaged by the microscopic results.

The ROC curves were, then, completed

and the next step was to analyse the data

provided by the areas under these curves.

The five point confidence scale is standard

for any ROC analysis: 1- caries definitely

absent; 2- caries probably absent; 3-

undecided; 4- caries probably present; 5-

caries definitely present.

The statistic coefficients used in the

analysis (A(z), 95% CI for the mean, 95% CI

for the median, standard deviation, relative

standard deviation, standard error of the

mean, coefficient of Skewness, coefficient of

Kurtosis, Kolmogorov-Smirnov test for

normal distribution) have different meanings

and they represent intermediate parameters of

the final calculations. These parameters were

established for every observer.

So, the mean is the arithmetic average

obtained after dividing the sum of all the

scores to the number of observations.

The IS 95% for the value of the mean

contains a number of values which



107

correspond for sure to the calculated

arithmetic average.

The standard deviation is the square root

of the variation and the relative standard

deviation is the value of the standard

deviation divided by the average.

The standard error of the mean is used to

calculate the confidence intervals for the

mean.

A(z) indicates the diagnostic performance

and its values fit between 0,5 and 1. The

Skewness coefficient measures the symmetry

of the distribution of the results and the

Kurtosis coefficient measures the superior

and inferior limits in the distribution.If the

value of p is small (< 0,5) the distribution is

abnormal and the Skewness coefficient is

high. The Kurtosis coefficient follows the

same rules. The Kolmogorov – Smirnov test

is a conclusion of the type of distribution of

the answers, the values higher than 0,05

showing a normal distribution.


The results of the six observers are

presented in the next section. An upper

lateral incisor (22) was selected for

presentation. The mesial surface has an

extended carious lesion (ICDAS code 6)

(fig.1) and the distal surface has a ICDAS

code 5 carious lesion (fig.2).

Figure 1. ICDAS code 6 carious lesion

(mesial surface of 22) Figure 2. ICDAS code 5 carious lesion

(distal surface of 22)

The fragments of the broken tooth were

viewed at the at the scanning electronic

microscope (SEM) establishing the ground

truth for the statistical analysis (fig.3 A, B,

C).

The results of the six observers were used

in the statistical analysis for evaluating the

diagnostic performance for each code. The

A(z) values represent the diagnostic

performances after analysing the surfaces of

the teeth.

A- General view of the decayed areas B - Detailed view of the decayed ISCDAS

code 6 area



108

C - Detailed view of the decayed ISCDAS code 6 area

Figure 3. Electronooptical images

The mean value of A(z) for each observer

and the ROC curves obtained after evaluating

the code 5 carious cavities (fig. 4) indicate the

second observer as having the worst

diagnostic performance and the fifth observer

as being the best.

The ROC curves belonging to the fifth

observer have high amplitude, drawing big

surfaced A(z) areas and proving very good

diagnostic accuracy after analysing most of

the cases.

Figure 4. The ROC curves for all observers

after evaluating code 5 carious cavities

The histograms indicate wheather the

distribution of data is simmetrical and

normal. The cumulated distribution graphics

indicate the frequencies of good and by

chance answers. The graphics are simetrical

when parameter p is higher than 0,05. The

histogram of the data distribution (fig.5A)

and the cumulated distribution frequencies

graphic of the best observer (fig.5B) indicate

normal distribution and high performance

after evaluating code 5 carious cavities.

A

B

Figure 5. The histogram of the data

distribution and cumulated distribution

frequencies for the fifth observer after

evaluating code 5 carious cavities



109

The mean value of A(z) for each observer

and the ROC curves obtained after evaluating

the code 6 carious cavities (fig.6) place the

same second observer at the bottom of

diagnostic performance (A(z)) list and the

fifth observer at the top.

The histograms of the data distribution and

the cumulated distribution frequencies of the

best observer show the level of his

performance (fig.7A, fig.7B) after evaluating

the code 6 cavities.

Figure 6. The ROC curves for all observers

after evaluating code 6 carious cavities

A B

Figure 7. The histogram of the data distribution and cumulated distribution frequencies for the

fifth observer after evaluating code 6 carious cavities

The mean value of the diagnostic

performance A(z) was 0,766 for the detection

of code 5 caries and the mean value A(z) was

0,850 for the code 6 caries (p>0,05).

CONCLUSIONS

5. The electron microscopy is an efficient

way for 5 and 6 ICDAS codes validation.

6. The diagnostic performance varies

according to the observers' level of

clinical experience.

7. The mean diagnostic performance proves

that code 6 is identified easier than code

5.

8. The overall diagnostic performance

indicates that ICDAS system is a

valuable, easy to use and learn tool for

caries detection and assessment.

REFERENCES

1 Braga, M.M., Oliveira, L.B., Bonini, G.A., Bönecker, M., and Mendes FM. Feasibility of the

International Caries Detection and Assessment System (ICDAS-II) in epidemiological surveys and

comparability with standard World Health Organization criteria. Caries Research 43(4): 245-249.

2 Ismail, A. I., Sohn, W., Tellez, M., Amaya, A., Sen, A., Hasson, H., and Pitts, N. B. The

International Caries Detection and Assessment System (ICDAS): an integrated system for measuring

dental caries. Community Dentistry and Oral Epidemiology 35: 170-178.

3 Rationale and Evidence for the International Caries Detection and Assessment System (2011).



110

THE IMPACT OF KINETO-THERAPY AND OF THERAPEUTICALLY

MASSAGES TO IMPROVE LIFE QUALITY OF PATIENTS WITH

SDSS

Laura Checheriţǎ1*

, Nicoleta Ioanid1, Cornelia Brezulianu

1, Liliana Foia

3,

Antonela Beldiman2, Amelia Surdu

2

“Gr. T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dental Medicine, 1Department of Odontology-Periodontology and Fixed Prosthesis

2Department of Oral Implantology 3Department of Surgical Sciences

*Corresponding author: Laura Checheriţǎ, Assistant Professor, DMD, PhD

“Gr. T. Popa" University of Medicine and Pharmacy,

Iași, Romania


ABSTRACT

Muscular relaxation offers the opportunity of muscular reconditioning by means of balneotherapy with the

establishment of new neural-muscular engrams. Our study aims investigation of two methods of treatment

,through kinetics factors and massage therapy, the assessment of action and efficiency, along with the

integration of these methods within a therapeutic algorithm that would finally, lead to stomatognathic system

and cephalic musculature homeostasis.

Key words: stomatognathic system, myorelaxation, masotherapy, kinetotherapy

INTRODUCTION

The muscles of stomatognatic system are

implicated in dysfunction as an etiological

factor, or as a determining factor, by

modifying the proprioceptiv information with

an important role in coordination of muscular

contraction. All the modern ethiopathogenic

theories incriminate the muscles of

stomatognathic system in producing the

dysfunction, no matter if the determining

agents have the action at the systemic level or

at the supra-systemic level.

The precision of motor acts and the

complexity of movements for the

mobilization muscles of mandible, of facial

and lingual muscles, is nervously directed

based on the peripheral impulses generated at

stomatognathic structures level. Any

affectation of an element of the

stomatognathic system determines the

modification of muscular engrames. To avoid

the obstacle the joint and muscular

dysfunction is being installed, with spasms,

contractures, muscular tiredness, pain, and the

mandible is deviated from its normal dynamic

trajectory [1,2,3].

The physiologic theory assumes that the

spasm of masticatory muscles is the essential

factor responsible in the aetiology of

dysfunctional syndrome of stomatognathic

system [4,5]. The clinical effect of

stomatognathic disturbances is spreading at

the whole body level. At head and neck level,

the muscles are in continuous antagonist



111

equilibrium, as from Brodie’s scheme; with

the purpose of maintain the vertical position

of the head and the rest position of the

mandible. Any muscular lack of poise have

implications on functionality of

neighbourhood muscles and can determine

stomatognathic dysfunctions for the patients

with postural bad habits [6,7,8].

The dysfunctional syndrome of

stomatognathic system has multiple clinical

forms based on the debut of the syndrome of

an element of this system, or based on clinical

symptoms which localize the dysfunction on

one element, even the others are implicated in

this dysfunction. The complex treatment of

any clinical form of the dysfunctional

syndrome is constituted by multiple

therapeutically techniques [9,10,11].

The balneo-physio-kinetic-therapy is a

component of medicine which use the

physical factors, natural or artificial, for

therapeutically aims. The big number of these

factors determined the differentiation of

special therapeutically branches, in

concordance with the used agent: balneo-

therapy, hydro-therapy, elecktro-therapy,

thermo-therapy, kinetic-therapy [12 ,13, 14].

Indicated with a prophylactic aim based on

the incentive action of natural physical factors

on defence mechanisms, and therapeutically

aims, or as adjuvant for other therapies, the

balneo-physio-therapy is an important method

for the rehabilitation of muscular functions of

cephalic extremity [15 ,16, 17].

AIM OF THE STUDY

The muscular dysfunction is determined

by a heterogenic activity of muscular fibres,

this hypotheses being considerate as adequate

in explaining the pathogenic and therapeutic

effects for rehabilitations of modified

muscular function. As a result of modified

muscular tonus and of muscular contraction

there is installed the spasm, the muscular pain

and the muscular tiredness.

The muscular relaxation offer the

possibility of muscular reconditioning by

kinetic-therapy methods with new neuro-

muscular engrames and of course, new

typologies of mandibular dynamics; the aim

of this study was to observe different

treatment methods by physical factors, by

actions and efficiency of these factors, beside

the integration of these methods in a

treatment algorithm, to equilibrate the

stomatognathic system and cephalic muscular

extremity.

The grown incidence of muscular

dysfunctions, demonstrated by

epidemiological studies, is the base of

establishing the programs of kinetic-therapy,

which is compulsory to apply in complex

rehabilitation of stomatognathic system.


The study was a clinical experiment and it

was realised on a sample with 63 patients

with the muscular activity modified as a

result of diminution or increasing of muscular

tonus, or modifications of muscular

contractions, from a number of 81 persons

which participate at this study and were

paraclinical electromyography investigated,

from 1st of October 2007 till 1st of March

2012, at Prosthetic Dental Clinic from Iaşi

(Fig. 1); the evaluation was made from the

point of view of objectives of the study, both

during the dental treatment and the follow-up

period. The obtained results constituted the

data base, and the statistical data were

processed using the Microsoft Excel Program.

The distribution after sex of the sample

study was: 34 female and 29 men, with ages

between 18 and 67 years old, (Fig. 2) from

urban and rural area, (Fig. 3) with clinical

signs of muscular dysfunctions, with

diminution or increasing of muscular tonus,

interested for rehabilitation of functions

affected. This choice was deliberated taken to

avoid the further abandon from the patient’s



112

parts in participation to this study. Based on

the edentate diagnosis: complete edentate

(21) and incomplete edentate (24) or partially

edentate (18).

Figure 1. Percentage of patients with

muscular dysfunction Figure 2. Distribution by years of

dysfunctional patients

Figure 3. Distribution by provenance of

dysfunctional patients Figure 4. Distribution by diagnosis of

dysfunctional patients

The including criteria for the patients in

this study sample were represented by the

presence of modifications of muscular tonus

and muscular contractions, clinical and

paraclinical perceptible based on

electromyography exam and t-scan analyses.

Also, there were included subjects with signs

and symptoms for muscular dysfunctions, as:

pain of muscular stomatognathic system, the

limitation in mouth opening and deviation of

mandible from the middle line at the mouth

opening moment, muscular tiredness of

cephalic extremity muscles and functional

affecting of stomatognathic system.

The excluding criteria for the patients were

represented by the joint affections, the third

molar pathology, bone - arthropathy, cancer,

uncooperative patients, or patients which do

not respect the treatment proposed, and the

use in therapeutic purpose for this study, the

different forms of movements by therapeutic

massage and kinetic-therapy.


The active and passive mobilization of

cephalic extremity muscles is realized by two

techniques of treatment frequently used:

massage and kinetic-therapy.

The massage represents the ensemble of

movements handle or mechanic that mobilize

the tissues or the segments of the body. The

skeletal muscles massage has a great weight,

being frequently applied and requested; also,

has a great efficiency therapeutically,

prophylactic and curative, and recuperate.

The massage treatment acts by mechanic



113

mechanism, reflex and metabolic, all the

procedures having effect on the free nervous

terminations from skin and muscles,

connected with the receptors for temperature,

pressure and with the glands and blood

vessels.

From the point of view of the effects of the

massage treatment during the time, these can

be classified in immediate and late effects.

The immediate effects are obtained and

determined by the aim, nature, technique and

the duration of the massage methods used; the

late effects are secondary, both for the region

were the massage was applied and in the

depth of the tissue or at the distance.

For the non-invasive technique there are

no secondary effects when is applied

correctly, so this massage method was

indicate as therapy for 51 patients, each

session of treatment was of 15-20 minutes,

for 1-3 days period.

To appreciate the clinical results, after

using the massage therapy method, we used

the classification Soulayrol and co. presented

in Table 1.

Table 1. Classification Soulayrol and co

Efficiency on spasm Good 2

Medium 1

Zero 0

Efficiency on muscular tonus Good 2

Medium 1

Zero 0

The duration of efficiency >3 days 2

1-3 days 1

<3 days 0

Secondary effects Yes 0

No 1

Evolution

(after multiple applications)

Improvement 1

Worsening or without worsening 0

Pain Totally suppress 2

Partial suppress or improvement 1

No efficiency 0

The results for the study sample obtained

after evaluation the procedures of massage,

with different techniques, are presented in

Table 2.

Table 2. Results obtained after evaluation

the procedures of massage

Nr. pacienţi Scor (scala 0-10)

8 10

24 9

17 8

4 7

After we applied the therapy for tonifying

and muscular relaxing, we observed a

normalization of muscular tonus visible by

the electromyography aspect and the values

of muscular tonus registered through

tonometry (Fig. 5).

The therapeutic efficiency of the massage

techniques applied on those 51 subjects was

reduced for short time period, for mono-

therapy, but there was a grown efficiency

when the therapy was associated with drug

therapy for relaxing, a good efficiency was

observed for a long period of time,

associating the massage with different



114

techniques of hydrotherapy.

The results of the massage therapy are

observed especially after 3-4 weeks of

complex therapy, combining with other

methods of rehabilitation for the treatment of

dysfunctional syndrome of stomatognathic

system. The pain is improved or partial

suppressed, the efficiency is good after 3

days, and there was no secondary effect.

Figure 5. Patient that applied masotherapy

– (self-casuistry)

The kinetic-therapy is a branch of

therapies that uses different types of

movements with the purpose of establish,

maintain or stimulate the function of a

segment, the representative aspect being the

movement and/or muscular contraction.

The therapy by movements applied for

cephalic extremity follow the relaxing,

correcting of posture and the alignment of the

body, improvement of joint mobility, growth

of muscular forces and muscular resistance,

coordinating, control and equilibrium, etc.

The methods, by which we can realize

these desiderata, are numerous:

- De Lorme-Watkinss method follow the

growing of muscular force using exercises

with progressive resistance;

- Jacobson and Schulze method for

progressive muscular relaxing;

- Kabat method to facilitate the voluntary

muscular contraction by summing the

facilitator neuro-muscular elements;

- Muller-Hettinger method for muscular

tonifying using isometric exercises;

- Fay, Phelps, Tardieu, Vojta, Voss,

Brunnstrom, Perffetti and Salvini, Albert

methods to recuperate the cases with

central nervous system lesions.

The kinetic-therapy can be prophylactic,

curative or recuperative, its objectives being

represented by: restoring the muscular force,

improving the coordinating function, control

and equilibrium at cephalic extremity level,

efficiency of the stomatognat system

functions, etc.

A classification criteria taking into account

in this study was the intensity of physic

effort, and the exercises recommended in

these cases can be (Fig. 6):

- Exercises base on growing of the physic

effort; interposition of a resistance force in

growing;

- Exercises base on subtraction of the physic

effort – needs a minimum muscular effort,

movements being facilitate and directing

by using voluntary muscular contractions

and relaxing without displacing the joint

segments.

We can not generalize the kinetic therapy

method and the exercises must be established

for each patient after a clinical exam and

diagnosing the type of dysfunction. It is

compulsory that we establish some dental or

tissues marks to guide the patient for a correct

execution of the exercises; for extern

pterigoidian muscle it can be used the Cohen

appliance (Fig. 7).

There are others methods for the muscles

of stomatognatic system that can be realized

by the patient after correct understanding the

technique. With a rubber tube placed between

the frontal teeth, the patient performs

maximal lateral movements maintaining the

mandible in this position for 20 seconds.

After that, 10 seconds need for relaxation and

the patient repeat the exercise for 10 times.

Another technique consists of placing the



115

right hand under the mandible, on the right

side, and the left hand on the left temporal

region to stabilize the position. The patient

will make the movements to displace the

mandible to the right with a slow speed. The

patient will maintain this position for 10

seconds, after that needs to relax, and repeat

the exercise for 10 times. The patient will

repeat the same exercises for the other side

(Fig. 8).

Figure 6. Exercises base on growing of the physic effort/ Exercises base on subtraction of

the physic effort: Patient that applied kinetotherapy - self casuistry)

Figure 7. Exercises for tonifying the muscles of stomatognathic system (personal cases

images) : Patient that applied kinetotherapy - self casuistry)

Figure 8. Assisted movements for tonifying the external pterigoidian muscles

(personal cases images) : Patient that applied kinetotherapy - self casuistry)

The postural re-education represents the

final target for all the exercises of re-

education, modifying the existing equilibrium

at cephalic extremity level (Brodie`s the triple

antagonism) being the departure point in

affecting the muscular function at

stomatognathic system level.

Following these theories, we indicated to

the patients some exercises to correct the

posture of cephalic extremity, and of course,

the position of the mandible reported to skull.

The aim of these exercises was:



116

- Growing the level of consciousness of

the patient on modification of the postural

position of cephalic extremity and of the

mandible, establishing the new posture

position to modify the muscular

engrames;

- Re-establishing a normal amplitude for

TMJ ’s movements;

- Establishing a correct and comfortable

position of mandible in report with the

skull.

Figure 9. Movements of descending and

ascending of shoulders (personal cases

images): Patient that applied

kinetotherapy - self casuistry)

Figure 10. The axial extension of the neck

(personal cases images): Patient that

applied kinetotherapy - self casuistry)

The exercises can be perform in orthostatic

position or sitting, the maximum time to

maintain the position must be 1 minute, and

the exercises will be repeated 6 times each

exercise, for 6 times every day (Fig. 9, 10).

The results followed by these exercises

are: restoration of the muscular function and

the joint function, with tonifying the muscles

for a correct functioning of stomatognatic

system. The steps of the therapy are stilled

and gradually.

Table 3. Classification of the patients according to the clinical results obtained after the

kineto-therapy methods

Efficiency on spasm Good 2

Medium 1

Zero 0

Efficiency on muscular tonus Good 2

Medium 1

Zero 0

The duration of efficiency >3 days 2

1-3 days 1

<3 days 0

Secondary effects Yes 0

No 1

Evolution

(after multiple applications)

Improvement 1

Worsening with or without improvement 0

Pain Totally suppress 2

Partial suppress or improvement 1

No efficiency 0



117

To appreciate the clinical results after the

kineto-therapy methods for 47 subjects from

the whole study sample, we used the

classification presented in Table 3. The

results for the study sample obtained after

evaluation the procedures of massage, with

different techniques, are presented in Table 4.

Table 4. Results obtained after evaluation

the procedures of massage

Nr. pacienţi Scor (scala 0-10)

13 9

24 8

8 7

2 6

After we applied the therapy for tonifying

and muscular relaxing and kinetothetapy,

we observed a normalization of muscular

tonus visible by the electromyography aspect

and the values of muscular tonus registered

through tonometry. Two patients presented

values partially modified, and the cause of

this fact is bounded to non-observance the

programme of the exercises and the terms of

the treatments. The efficiency of the tonifying

methods is tight bounded with the application

time of the technique, for a short period of

time, the modifications of the muscular tonus

being not so visible, but the clinical and

paraclinical re-evaluation of the patients at a

period of 2, 3 and 6 months demonstrated the

modification of the electromyography values.

CONCLUSIONS

1. The functions of stomatognat system are

grounding on the neuro-muscular activity

that assure the static and dynamic activity

of mandible, the relaxation, the functional

re-education being compulsory for a

complex rehabilitation of stomatognatic

system. The balneo-physio-kinetic-therapy

methods have as objective the muscular

relaxation, tonifying and reducing the

muscular tonus, improving the mandible

functionality and also of the temporo-

mandibular joint activity.

2. The kinetic-therapy techniques and the

massage therapy details the place of

muscular dysfunction and the effects of

it’s, and also, offer a base for diagnosis

and treatment.

3. The exercises that can be applied both for

rehabilitation of acute and chronic

dysfunctions, but with modifications for

the grade, duration, frequency and

direction for applied movements. The

exercises are simple to be applied even

towards the patient if he had correctly

understood the technique.

4. The kinetic-therapeutic treatment and the

massage treatment are compulsory to

perform with the respect of the terms of

therapeutic scheme established and applied

in Dental Prosthetic Clinic of Iasi. Only

this way we can speak about the

rehabilitation of muscular functions of

stomatognatic system.

5. For the study sample were obtained

variable results, from very good to

satisfactory: totally improvement of

muscular symptoms, partially remission of

symptoms till to no modification of

presented symptoms. The quantification of

the results was done with an easy to

applied classification.

6. For the studied sample of patients it was

observed that, on short time, the best

results were registered to the patients to

whom kinetic-therapy and massage

therapy was associated with etiologic and

symptomatic therapies.

7. These measures have a general aspect,

referring to maintaining the homeostasis of

the entire body, and a specific character,

especially for the stomatognatic system.

8. The elaboration of promoting programmes

for health of stomatognatic system will

include these measures in order to

conserve the oral health status.



118

REFERENCES

1 Albino JEN - The National Institutes of Health Technology Assessment Conference statement on the

management of temporomandibular disor¬ders. J Oral Rehabil, 1996, 127:1595-1599.

2 Alling C.C.III, Mahan P.E. - Facial Pain, 2nd Eds, 1977, Lea and Febiger, Philadelphia.

3 Ash M.M. - Current Concepts in the Etiology, Diagnosis and Treatment of TMJ and Muscle

Dysfunction, J. of Oral Rehab, 1986, 13: 1-20.

4 Ash MM, Ramfjord SP- Occlusion, ed 4, Philadel¬phia, 1995, WB Saunders.

5 Austin BD, Shupe SM- The role of physical thera¬py in recovery after temporomandibular joint

sur¬gery J Oral Maxillofac Surg, 1993, 51: 495-498.

6 Bell WE- Temporomandibular disorders: classification, diagnosis and management, ed 3, Chicago,

1990, Year Book, pg 215-363.

7 Blanchard F, Andrasik F, Evans D, Neff D, Apple¬baum K, et al. Behavioral treatment of 250

chron¬ic headache patients: a clinical replication series, BehavTher, 1985, 16: 308-327.

8 Bonica JI- Management of myofascial pain syn¬dromes in general practice, JAMA, 1957, 164: 732-

738.

9 Bornstein PH, Hamilton SB, Bornstein MT. Self¬monitoring procedures. In Ciminero AR, Calhoun

KS, Aams HE, editors: Handbook of behavioral assessment, New York, 1986, John Wiley & Sons,

pg 176-222.

10 Burdette BH, Gale EN. The Effects of Treatment on Masticatory Muscle Activity and Mandibular

Posture in Myofascial Pain-Disfunction Patients, J. Dent. Res. 1988, 67:1126¬-1130.

11 Burdi A. R. –Morphogenesis. In Sarnat, Laskin: The temporomandibular joint: a biological basis for

clinical practice. 4th ed. Saunders, Philadelphia 1992, pg 36-47.

12 Carlson C, Bertrand P, Ehrlich A, Maxwell A, Bur¬ton RG. Physical self-regulation training for the

management of temporomandibular disorders, Orofac Pain, 2001, 15: 47-55.

13 Carlson CR Ventrella MA, Sturgis ET- Relation training through muscle stretching procedures: a

pilot case, J Behav Ther Exp Psychiatry, 1987, 18: 121-126.

14 Carlson CR, Bertrand P- Self-regulation training manual, Lexington, KY, 1995, University Press.

15 Carlson CR, Collins FL Jr, Nitz AJ, Sturgis ET, Rogers JL. Muscle stretching as an alternative to

relaxation training procedure, J Behav Ther Exp Psychiatry, 1990, 21:29-38.

16 Carlson CR, Okeson JP, Falace DA, Nitz AJ, Ander¬son D. Stretch-based relaxation and the

reduction of EMG activity among masticatory muscle pain patients, J Craniomandib Disord, 1991, 5:

205-212.

17 Di Fabio RP- Physical therapy for patients with TMD: a descriptive study of treatment, disability,

and health status, J Orofac Pain, 1998, 1: 124-135.

18 Forna N. Dental Prosthetics Ed. Demiurg, Iaşi, 2009.



119

PARTICIPATION OF SUPERFICIAL MUSCULO-APONEUROTIC

SYSTEM OF THE FACE IN CORRECT DENTAL OCCLUSION

Marius V. Hinganu*, Delia Hinganu, Laurian L. Frîncu 1“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania,

Faculty of Medicine, Department of Anatomy

*Corresponding author: Marius V. Hinganu

Faculty of Medicine, Department of Anatomy

“Grigore T. Popa" University of Medicine and Pharmacy

ABSTRACT

Facial SMAS is a unitary structure with both general and particular characters, specific for each topographic

region, with alternating of tension zones with others more lax. Authors have proposed to follow, through various

methods of exploration, anatomy of musculofascial formations and of terminal branches of facial nerve with

perioral topography. Dissection of anatomical pieces, intraoperatory and imagistic studies, bring arguments

about the role of support provided to superficials layers of the face, affecting indirectly, but decisively

achievement of correct occlusion and therefor mastication. Dermal insertion of perioral superficial facial

muscles allow lip mobilizing and their zygomatic and mandibular attachments provides symetric occlusion in all

3 axes of space. Supporting force vectors of SMAS in zygomatic and temporal attachments act as levers for

proper contraction of masticatory muscles.

Key words: facial fascia, facial muscles, dental occlusion, SMAS

INTRODUCTION

Knowledge and understanding of

subcutaneous layers in different regions of the

face is important in various surgical

specialties, but especially for the plastic

surgeon, for which superficial musculo-

aponeurotic system of face (SMAS) is a

guiding structure. The latter was the first to

recognize the existence of this complex

structure, some anatomist and surgeons

contest, even now the presence of SMAS.

Architecture of soft tissue of the face can

be described as being arranged in a series of

concentric layers: skin, subcutaneous fat

tissue, superficial fascia, muscles of facial

expression, deep fascia (parotidomaseteric),

plan of facial nerve, of parotid duct and

buccal fat tissue (1).

Overlooking on anatomy of musculo-

fascial layers of the face

At the face level are described two fascial

layers with different topographic relations,

according to functional particularities of each

region:

1. Superficial fascia covers superficial

muscles of facial expression (platysma,

orbicularis oris, major and minor

zygomatiscus);

2. Deep facial fascia represents a

continuation of cervical fascia cephalized to

face, most important being the relation with

terminal branches of facial nerve located deep

to it;

3. There are two types of relations

between superficial and deep fascia: in some

regions fascial planes are separated by an

areolar plan, while in other regions the two



120

fascia are intimately adherent to each other

through a series of dense fibrous attachments.

It was described two distinct types of

SMAS, differentiated by the presence or not

of fat lobules separated by connective tracts

(2), repercussions being of functional nature.

Perioral SMAS insertions give the muscles

annexed to orbicularis oris the possibility of

mobilizing the lips. This is extremely

important because it allows both the correct

sound articulation and occlusion. Lip

movements leads, in turn, a normal dental

occlusion and a proper mastication.

SMAS involvement in making a

correct dental occlusion reveals most clearly

when is altered the innervation of its

muscular component. Thus, in Moebius

syndrome (congenital atresia of facial nerve)

patients can reach an advanced state of

cachexia due to the fact that in time (15-20

years), the muscles supplies by the trigeminal

nerve (masticatory muscles) will also be

suffered. They will be subjected to abnormal

demands because they have to support also

the superficial layers of the face. The

suffering is longer, the masticatory muscle

tone decreases more. In this situation,

reconstructive surgery will be required as

early as possible. Present study continues

previous research (3, 4, 5) regarding

functional anatomy of the superficial layers of

the face (SMAS). We intend to follow,

through various methods of exploration,

anatomy of musculofascial structures and

terminal branches of facial nerve with

perioral topography.


The material used was represented by 12

formolizated cephalic extremity (24 parts)

and 10 operatory pieces from Maxilofacial

Surgery Clinic of the Emergency Hospital

”St. Spiridon” (dr. G. Mihalache) and

Department of Plastic Surgery and

Reconstructive Microsurgery of Emergency

Hospital ”St. Ioan” (dr. A. Lazăr) from Iași.

People have been explored imagistically

(MRI) at Medical Imaging Center ˮArcadiaˮ

(dr. Tiutiucă Iuliana).

On pieces conserved in formol was

performed meticulous bilateral dissection of

the face, under the operator microscope SOM

62 Kaps, plan by plan. It was revealed fascial

plans, adipose and muscular, ligament

attachment formations, representative images

being acquired.

Surgical interventions have allowed

parceling anatomical studies, according to

objective of surgical intervention, providing

live view of fascial and muscular structures,

the possibilities of plans dissociation, but also

assessments regarding their vasculature.

Imaging method that provides the most

convincing images regarding the structure of

cervicofacial soft tissue is magnetic

resonance imaging (MRI). MRI is able to

demonstrate sectional anatomy data in detail

(6) and better differentiate soft tissue on

transversal, sagittal and coronal sections.


In the following we approach functional

anatomy of the face from a relatively new

perspective: that of a continuous superficial

layer, which is closely related to both the skin

region and the subjacent muscle layer. The

latter is the defining characteristic of

separating it from the other region. The

concept of unique superficial layer is of

extreme importance, both in anatomy and

reconstructive medical practice.

By dissection of anatomical and

intraoperatory pieces we watched the relation

of SMAS with skin region, the architecture

of superficial muscles of the face (muscles of

facial expression), and also the relation with

deep fascia and with subjacent neurovascular

elements. From a functional perspective are

of utmost importance paramount ways of

attachment of SMAS to viscerocraniu, these



121

offering facial skin firmness and acting the

role of fixed point in facial muscles

contraction (Fig. 1).

Figure 1. Ligaments adhesions that secures

SMAS to deep fascia. Dissection piece.

In nasolabial groove, superficial fascia of

nose adheres to the cheek fascia, forming a

thickening which adheres by periostum.

Laterally of the groove, there are fibrous

extensions of superficial fascia which covers

high fat lobules (Fig. 2).

Figure 2. Perioral muscles and nasal region;

levator anguli oris muscle, alae nasi,

orbicularis oris muscle, SMAS in the upper

and lower lips.

Deep muscular layer of the nasolabial

groove is formed by buccinator muscle. At

the nose wing that provision of layers is no

longer maintained. Under the dermis we will

find collagen fibers, fat cells and muscle

fibers mixed with nasal muscle fibres. All this

forms a layer between the dermis and the

nasal muscles (Fig. 3).

Figure 3. Nasolabial groove in the inferior

part. Dissection piece.

Medially to nasolabial groove, zygomatic

muscles, levator labi superioris, levator anguli

oris have dermal insertion. In addition,

orbicularis oris muscle intimately adheres to

the deep surface of dermis (Fig. 2).

Nasolabial groove is the result of dermal

insertion of zygomatic muscles, levator labi

superioris and levator anguli oris.

Other authors (7) consider that in nasal

region there are five layers, which, from

superficial to deep are: subcutaneous adipose

tissue, fibromuscular layer, deep adipose

layer, a fibrous longitudinal layer and a layer

that contain interdomal ligament. They

believe that at this level SMAS is represented

by a second layer, the fibromuscular one,

which interconnects with alar muscles and

distribute them power to the dermis. We

conclude that the role of SMAS in the nose is

intimately linked to a proper oral occlusions

in close contact with perioral muscles.

Buccal region has as main characteristic

the existence of on infraSMAS space filled

with adipose tissue. This space is a way of

spreading for an infection into neighbouring

regions. The infraSMAS connective tissue

from here contains fibers organized as

conjunctive tracts which separate adipose



122

lobules (Fig. 4).

Figure 4. Adipose connective tissue in the

perioral region. Dissection piece.

Perioral muscles adhere closely to the deep

dermis region, crossing the superficial fascia.

Here, into the thickness of the musculo-

aponeurotic system there is adipose tissue

divided by conjunctive septa and labial

vascular nervous structures, superior and

inferior. The insertion is firm, almost

impossible to dissect. Because of this,

superficial fascia is extremely difficult to be

shown by classic anatomical dissection, of

choice for examination of this region and also

for nasal one being the operator microscope

(Fig. 5).

Figure 5. SMAS on the lips; mesoscopic

dissection.

Relations of SMAS with nasolabial fold

are still controversial. Mitz and Peyronie (8)

described the anterior continue of SMAS into

upper lip, overlying muscular layer. Barton

(9) describes a thin fascial layer which covers

zygomatic muscles and extends into superior

lip but does not identify subcutaneous

extension of SMAS. Pensler et al. (10)

identified SMAS medial to nasolabial fold,

meanwhile Yousif et al. considers there is an

adipose supraSMAS layer on the cheek and

upper lip.

Mesoscopic dissection shows up the

continuation of the SMAS with the superficial

fascicles of orbicularis oris muscle,

suggesting that this layer represents SMAS

into superior lip, separated by the overlying

fascial layer (Fig. 5).

Dissecting downward to inferior lip, we

have easily revealed a musculofascial

infradermic layer on anterior mandibular

surface. It offers attachment support for

mental muscles (Fig. 6).

Figure 6. SMAS on anterior mandibular

surface.

Imaging methods for revealing the soft

cervicofacial tissues bring us a completely

new and clear light over the organization and

the functionality of SMAS. They demonstrate

once again its existence and regional

particularities. I will illustrate using MRI the

superficial musculo-aponeurotic system of the

face.

MRI aspects of SMAS on healthy persons

are the first step in diagnosing pathological



123

lesions (inflammations, tumors,

malformations etc).

Right above superior border of mandibula

SMAS behaves differently:

a. medially gives attachment to

orbicularis oris muscle (inferior fascicle) and

then to depressor anguli oris.

b. laterally it becomes mobile, ascending

first above jugal fat pad, buccinator and than

maseter muscle (Fig. 7).

Figure 7. Horizontal section through inferior

mandibular border; transSMAS insertion of

orbcularis oris’s inferior fascicle.

At the level of superior lip, superficial

layers become fixed once again. This happens

due to attachment of orbicularis oris muscle

(superior fascicle) and levator labii superioris

on the profound surface of the skin,

transfascially. Even if superficial fascia gets

thinner and thinner to modiolus its thickness

is still enough to appear as a clear tissue blade

on MRI. The same thing is revealed on

dissected specimens.

Looking up to the nasal septum, the two

fascias (superficial and profound) are united

into a dense conjunctive network. Going to

the nasolabial fold in its medial part we’ll see

that superficial fascia becomes more clearly,

offering protection for the superior branch of

angular artery and for superior labial fascicles

of buccal branch from facial nerve. Injures of

these branches of facial nerve or of its trunk

cause static deformities of this region,

alimentation and phonetic difficulties,

depending by the scale of the injury. Their

appearance is caused by dermic attachment of

the muscles and the continuity SMAS to the

other regions involves their step by step

transmission. Dissection and imaging allow

us to state that the SMAS are identical in the

two lips.

Figure 8. Transversal MRI which

illustrates transSMAS insertion of levator

labii superioris muscle.

CONCLUSIONS

1. Facial SMAS, anatomical and surgical

entity is an unitary structure with general

and particular characteristics, specific to

each topographic region alternating

tensioned areas with more lax.

2. Facial dermis is fixed on facial bones by a

fibrous multiligamentary support system,

with fixing ligaments and superficial



124

fascia which includes SMAS and

retinacula cutis.

3. Central portion of each hemifacies is the

highest mobility area and lateral portions

are fixed as a result of fixation structures,

cutaneous muscular attachments and the

different thickness of the infraSMAS

layer. Central regions of the face (orbital,

nasal and oral) are “of relationship”, being

attached to the lateral regions (“of

sustaining”) by intermediary areas (jugal).

4. In most of anterior regions of the face

(zygomatic, oral and mental) the number

of their layers is reduced. Profound part of

dermis becomes densely, offering support

for attachments of superficial facial

muscles and laterally being mobile and

ascending.

5. At the superior mandibular border SMAS

behaves differently: medially is fixed,

allowing muscular attachments and to the

lateral side is mobile and goes upwards.

6. SMAS gives support to superficial layers

of the face, indirectly influencing but

decisive the achievement of proper

occlusion and thus mastication. SMAS

supporting forces vectors in the zygomatic

and temporal attachments act as levers for

proper jaw muscle contraction.

7. Dermal insertions of the superficial facial

muscles allow movements of the lips and

their zygomatic and mandibular

attachments assure a symmetrical

occlusion in the 3 axes of the space.

8. Dental occlusion is modified by action of

superficial perioral muscles (“relational”)

on one hand and on the other hand is

weighty influenced by sustaining

structures (ligaments and ligamentary

adhesions) which are close to

temporomandibular joint.

REFERENCES

1 Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias:

relevance to rhytidectomy and aging. Plast Reconstr Surg, 1992, 89(3):441-9.

2 Dzubow LM. A histologic pattern approach to the anatomy of the face. J Dermatol Surg Oncol,

1986, 12(7):712-8.

3 Frîncu DL, Frâncu LL, Hînganu MV. Definirea anatomochirurgicală a sistemul musculo-aponevrotic

superficial al feţei. Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de

Antropologie, 2004; 3(2):24-7.

4 Hînganu M, Frâncu L, Farcaș Delia, Frîncu Doina Lucia. Caracterele regionale ale sistemului

musculo – aponevrotic superficial al feței. Revista Română de Anatomie funcţională şi clinică,

macro- şi microscopică şi de Antropologie, 2010; 9(1):29-35.

5 Hînganu MV, Frâncu LL, Tiutiucă Iuliana, Farcaș Delia, Frîncu Doina-Lucia. Dovezi imagistice prin

rezonanță magnetică privind sistemul musculo-aponevrotic cervicofacial. Revista Română de

Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie, 2010; 9(2):151-9.

6 Marinkovic S, Schellinger D, Milisavljevic M, Antunovic V. Sectional and MRI Anatomy of the

Human Body. A photographic atlas. Thieme Verlag, Stuttgart, 2000.

7 Leturneau A, Daniel RK, Firmin F. The superficial musculoaponevrotic system of the nose. Plast

Reconstr Surg, 1988, 82:48-55.

8 Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek

area. Plast Reconstr Surg, 1976, 58:80-8.

9 Barton FE. The SMAS and the nasolabial fold. Plast Reconstr Surg, 1992, 89:1054-9.

10 Pensler JM, Ward JW, Parry SW. Superficial musculoaponeurotic system in the upper lip: an

anatomic study in cadavers. Plast Reconstr Surg, 1985, 75: 488-94.

11 Yousif NJ, Gosain A, Matloub HS, Sanger JR, Madiedo G, Larson DL. The nasolabial fold: an

anatomic and histologic reappraisal. Plast Reconstr Surg. 1994; 93(1):60-9.



125

CLINICAL ANALYSIS OF A DIGITAL METHOD FOR

RADIOGRAPHIC ROOT CANAL LENGTH DETERMINATION

Narcis M. Marcov*, Elena-Cristina G. Marcov

“Carol Davila" University of Medicine and Pharmacy - București, Romania,

Faculty of Dentistry, Department of Restorative Dentistry

*Corresponding author: Narcis Marcov, DMD, PhD, Lecturer

e-mail: [email protected], tel. +40.722.519.453

ABSTRACT

Aim of the study The objective of this analysis was to investigate a digital method for radiographic working

length determination. Material and methods 300 scanned periapical radiographs for 240 clinical cases with

undergoing endodontic treatment had the working length digitally measured using a distance measurement

program. A mathematical algorithm of calculus based on proportionality ratio between clinical and radiological

dimensions of dental crown and root was used for each tooth. The data (before and after treatment) obtained for

each analysed case from 10 observers were used to evaluate the accuracy of the method for each group of teeth.

Results The mean determinations for initial and postoperative working length were in the range of the golden

standard provided by the statistical data. The accuracy of the method varied for the pre and post treatment

measurements in a direct correlation with the root particularities (degree of curvature, apex spatial orientation).

Conclusions The results of this study suggest that the digital measurement tool combined with an appropriate

algorithm of calculus can be used for clinical working length determination regardless the morphological

endodontic particularities.

Key words: digital radiography, working length, endodontics

INTRODUCTION

Radiographic examination is an essential

part of any endodontic treatment. It plays an

important role in estimating and confirming

the lengths of root canals before and during

instrumentation.

Cleaning, shaping and filling of the root

canal system cannot be accomplished

accurately unless the working length is

correctly measured [1,2]. Working length is

always measured in relation to the position of

root apex because its precise location is a

problem which causes countless endodontic

failures [3].

There are several methods for determining

the working length, but traditionally, the root

length is determined by direct measurement

on conventional periapical radiographs. This

method can be changeling for excessively

curved or with peculiar spatial orientation

roots due to the subjectivity of the examiner

[4-6].

Therefore, the aim of this study is to

evaluate a digital method for radiographic

working length determination in endodontic

treated teeth with varied degrees of root

curvature and without an initial marker.


300 scanned radiographs for 240 clinical

cases with undergoing endodontic treatment

were used to make digital measurements of

the working length on the computers monitor

with a program for distance measurement.



126

The radiographs were taken in the

Radiology Department of Universitary

Hospital ”Prof.Dr. Dan Theodorescu” using a

periapical semistandardized technique.

Radiographs (with optimal degree of

radiographic coverage and processing level)

for anterior and posterior, upper and lower

teeth, from adult patients and both genders

were accepted.

The digital measurement tool was

provided by Xray Vision 3.7 (Apteryx Inc.,

Akron, OH, USA, 2010). The initial

radiographs were not digitally enhanced and

they were standardized scanned on a flatbed

scanner.

A mathematical algorithm of calculus

based on proportionality ratio between

clinical and radiological dimensions of dental

crown and root was used for each tooth.

The data regarding the pair of

determinations (before and after treatment)

obtained for each analyzed case from 10

observers (with different radiologic and

clinical background) were used to evaluate

the diagnostic accuracy of the method for

each group of teeth.

The quality of the odontometric

determinations for each case was evaluated

by a double initial (I) and final (II) analysis.

I. INITIAL ANALYSIS

Individual comparative etalonation was

made on each initial image for the graphic

measurement tool by establishing some

general landmarks:

→ the coronal part of the investigated tooth

was clinically measured with a caliper and

the obtained value was marked as DC (k) ,

were D = dimension, C = clinical, k = case

number ;

→ the coronal part of the investigated tooth

was radiographic measured with the digital

program and the obtained value was marked

as DRx (k), were D = dimension, Rx =

radiographic, k = case number.

The ratio between DC.k and DRxk

generated a correction factor that was used to

determine the real length of the root canal

(RL.k) by multiplication with the initial

radiographically digitally measured length

(RxL.k= WL).

For each case the mathematical algorithm

of calculus was :

DC

RL = ------------------- x RxL

DRx

The initial determination (ID) of RxL

was measured considering two referral points:

- cervical/ coronal landmark- the

radiographic separation line between the

coronal and root endodontic territory

(selected due to a variability of coronal

integrity amongst the treated teeth) or the

coronal point of access to the endodontic

system;

- apical landmark– the point detected as

the radiographic projection of the

physiologic apex (fig. 1).

The digitally obtained working length

Rx.L. was used during the endodontic

treatment and after its completion the

determinations accuracy was radiographic

evaluated in the final analysis.

Figure 1. Initial determination

II. FINAL ANALYSIS

New digital determinations of the working



127

length were made on the posttreatment

radiographic images with the already

described individual comparative etalonation

method and the final values obtained (FD)

were compared with the initial determinations

(ID) (fig.2).

Figure 2. Final determination

The observers used the zoom function and

the isodensity determination program for

identifying the apical landmark.

All the determination were made for initial

and final analysis, in a random selection in

order to avoid observers subjectivity.

The digital determinations were made

automatically using the measurement

program for points and segments and the

clinical determinations for the coronal parts

were made with a calliper with a precision of

0,1 mm.

RESULTS

The data obtained for initial and final

determinations (for each case) were compared

and after that, the information were

statistically processed using an algebraic ratio

to give a mean value (with a standard

deviation of 0,5 mm) for each dental group

anterior and posterior, upper and lower.

Initial and final working length

determinations (mm) are presented in table I

and II.

Table 1. Median Lower WL

Mandible Central I Lateral I Canin 1PM 2 PM 1Molar M/D 2MolarM/D

ID 12,6± 0,5 12,4

±0,5

16,1

± 0,5

14,1

± 0,5

14,3

± 0,5

D14,2 ± 0,5

M13,4 ± 0,5

14 ± 0,5

13,3 ± 0,5

FD 12,5± 0,5 12,3

±0,5

16

±0,5

14

± 0,5

14,2

± 0,5

14 ± 0,5

13,3 ± 0,5

13.9 ± 0,5

13,2 ± 0,5

ΔD 0.992 0.991 0.993 0.992 0.993 0.985- 0.992 0.984- 0.992

Table 2. Median Upper WL

Maxilla Central I Lateral I Canin 1PM 2PM 1Molar 2 Molar

ID 13,5±0,5 12,6±0,5 17±0,5 13,7

±0,5

13,8

±0,5

P 14,5±0,5

V11,3/11± 0,5

P14±0,5

V10,7±0,5

FD 13,4±0,5 12,4±0,5 16,9±0,5 13,5

±0,5

13,7

±0,5

P14,3±0,5

V11,2/10,8±0,5

P13,8 ±0,5

V 10,5±0,5

ΔD 0.996 0.984 0,994 0,985 0,992 0,981-0,990 0,981-0,985

The meanings of the abbreviations are as

follows:

ID - initial determination;

FD - final determination (mm);

ΔD - variation of determination

ΔD=FD /ID.

The degree of acceptance as a equivalent

determination was at a maxim variation of

0.01 which corresponds to a precision of

determination of 10µ.



128

The variation of determination ΔD varied

for all dental groups in a range of 0,981 to

0,996 (for maxilla 0,981-0,996 and for

mandible 0,985-0,993). Initial working length

determinations (ID) are slightly oversized in

comparison with the posttreatment

measurements (FD) but all results agree with

the statistic data regarding the root length.

Some specific observations can be made

regarding the dental groups digitally

measured.

For the incisors group the digitally

determined working length had the highest

accuracy (up to 0.996) for the central upper

(fig. 3) followed by the central lower and

lateral lower due to their particular

endodontic morphology with straight roots

and well defined apex.

The exception was the lateral maxilar

incisors group with the lowest degree of

accuracy ΔD = 0,984 because of the disto-

oral root curvature in the apical third and the

variety of apex location. In this case the

digital odontometric method used a dot by dot

measurement technique, the segmental

method having no applicability (fig. 4).

Figure 3. ID and FD (11) Figure 4. ID and FD (22)

The upper molars presented the widest

endodontic variety and so, the digital

measurements presents a wide range ΔD =

0,984-0,992 for the lower molars and ΔD =

0,981- 0,990 for the upper molars (fig. 5, 6).

For the lower molars the segmental

measurement tool was used on the straight

part of the root and the dot by dot addition

measurement tool was used for the curved

part until the detected radiographic apex was

reached.

Figure 5. 16. Initial determination Figure 6. 16. Final determination



129

The different determinations can be

explained by the misinterpretation of the

mesial canals position and length due to the

eccentrical projection.

At the upper molars group the

determinations were rather consistent for the

oral and distobucal roots, major radiometric

differences occurred for the mesiobucal root

with extreme curvature and a high degree of

overlapping with the oral root.

At the opposite side, the curved canals

final determinations may be shorten with up

to 1mm comparative to initial determinations

as the canal is straightened out by

instrumentation.

CONCLUSIONS

1. Radiographic digital techniques have a

superior precision in identifying the

radiologic apex in comparison with the

classic film based visual method when

they are used in combination with the

selective image amplification and the

histogram based on optical isodensity.

2. Digital odontometry obtained with

distances measuring programs has values

comparable with the statistic determined

root lengths and it eliminates the

observers subjectivity based on different

radiologic and clinical background.

3. The radiographic digital working length

determination has a quick learning curve

and can be used in most cases regardless

morphologic complexity and spatial

particularities of the endodontic system.

4. Digital odontometric technique has some

limitations regarding the ortoradiality

(especially for multiple root canals), but

an individual digital approach for each

root can easily overcome this problem.

5. This digital method provides better results

for narrow roots with a limited

radiographic aspect on classic radiographs

after an initial digital enhancement in

order to get the correct working length.

REFERENCES

1 Marcov N., Popa B., Baştan E.C. Valoarea sistemelor digitale directe în determinările

odontometrice. Revista Naţională de Stomatologie, 2002 vol V, nr. 3, pg.6-10.

2 Marcov N., Baştan E.C., Vârlan C.M., Vârlan V. Aprecierea odontometrică paraclinică a structurilor

dentare cu morfologie radiculară particulară prin metode radiologice digitale directe. Revista

Naţională de Stomatologie. 2002, vol V, nr.4, pg. 3-7.

3 Nisha Garg, Amit Garg. Textbook of Endodontics, 2010, Jaypee Brothers Medical Publishers

4 Orosco FA, Bernardineli N, Garcia RB, Bramante CM, Duarte MA, Moraes IG. In vivo accuracy of

conventional and digital radiographic methods in confirming root canal working length

determination by Root ZX. J Appl Oral Sci. 2012 Sep-Oct;20(5):522-5.

5 Alothmani, O.S., Friedlander, L.T., Monteith, B.D., Chandler, N.P Influence of clinical experience

on the radiographic determination of endodontic working length. International Endodontic Journal

2013:46 (3), pp. 211-216

6 Woolhiser GA, Brand JW, Hoen MM, Geist JR, Pikula AA, Pink FE. Accuracy of film-based,

digital, and enhanced digital images for endodontic length determination. Oral Surg Oral Med Oral

Pathol Oral Radiol Endod. 2005 Apr;99(4):499-504.

Documents

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