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117 Volume 3 Number 3, July-Sept 2010 INDIAN JOURNAL OF DENTAL EDUCATION All right reserved. The views and opinions expressed are of the authors and not of the Indian Journal of Dental Education. The Indian Journal of Dental Education does not guarantee directly or indirectly the quality or efficacy of any product or service featured in the advertisement in the journal, which The Indian Journal of Dental Education (ISSN 0974-6099, Registered with Registrar of Newspapers for India: DELENG/2008/32281) published quarterly, is dedicated to the dissemination of new knowledge and information on all fields of dentistry. The IJDE publishes original peer- reviewed articles that examine all phases of dental treatment, reports on unusual and interesting case presentations and invited review papers. The aim of this journal is to convey scientific progress in dentistry for the benefit of the dental health of the community. The journal serves valuable tool for helping clinicians, general practitioners, teachers and administrators involved in the prevention and treatment of dental disease. Corresponding address Red Flower Publication Pvt. Ltd. 41/48, DSIDC, Pocket-II, Mayur Vihar Phase-I P.O. Box 9108, Delhi - 110 091(India) Phone: 91-11-65270068/48042168, Fax: 91-11-48042168 E-mail: [email protected], Web:www.rfppl.com Editor-in-Chief Balwant Rai Assoc. Prof, Commander, ILWEG Moon Mars Mission, 100 B Kepler Space University, USA Executive Editor Rajnish K. Jain Deputy Editors Jasdeep Kaur, India Maria Catalina, Astronaut Teacher Alliance, NASA JPL Solar System Ambassador, USA Abbas Taher, London, UK Abu-Hussein Muhamad,Athens, Greece Adebola Oluyemisi Ehizele, Nigeria Alexandra Roman, Romania Clement Chinedu Azodo, Nigeria Dean Boss, USA G. Wellam, Belgium Jaipaul Singh, UK Abdel Rahman Mohammad Said, Al-Tawaha,Jordan Inayatullah Padhiar, Karachi Florent Richy, Belgium Ulrich Suchner, Germany Figen Cizmeci Senel, Turkey Bora Bagis, Turkey National Editorial Advisory Board Hamid Jafarzadeh, Iran Aous Dannan, Germany Lojain Jibawi, Syria Marit Vandenbruane , Netherlands Helen James, USA L. James, UK Marcelo Carlos Bortoluzzi, Brazil Natheer H Al-Rawi, UAE Patrick T, Belguim Rafael Manfro, Brazil Sandrine Brunel-Trotebas, Romania B.K. Behra, Rohtak Deepti Dwivedi, Lucknow Manaswin Tripathi, New Delhi Naveen Gupta, New Delhi R. K. Sharma, Rohtak S. C. Narula, Rohtak Surendra Nath, Delhi International Editorial Advisory Board Editor Emeritus S.C. Anand Managing Editor A. Lal Printed at R.V. Printing Press C-97, Okhla Industrial Area Phase-1 New Delhi - 110 020

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Volume 3 Number 3, July-Sept 2010

INDIAN JOURNAL OF DENTAL EDUCATION

All right reserved. The views and opinions expressedare of the authors and not of the Indian Journal ofDental Education. The Indian Journal of DentalEducation does not guarantee directly or indirectlythe quality or efficacy of any product or servicefeatured in the advertisement in the journal, which

The Indian Journal of DentalEducation (ISSN 0974-6099,Registered with Registrar ofNewspapers for India:D E L E N G / 2 0 0 8 / 3 2 2 8 1 )published quarterly, isdedicated to thedissemination of newknowledge and informationon all fields of dentistry. TheIJDE publishes original peer-reviewed articles that examineall phases of dental treatment,reports on unusual andinteresting case presentationsand invited review papers.The aim of this journal is toconvey scientific progress indentistry for the benefit of thedental health of thecommunity. The journalserves valuable tool for helpingclinicians, generalpractitioners, teachers andadministrators involved in theprevention and treatment ofdental disease.

Corresponding address

Red Flower Publication Pvt. Ltd.41/48, DSIDC, Pocket-II, Mayur Vihar Phase-I

P.O. Box 9108, Delhi - 110 091(India)Phone: 91-11-65270068/48042168, Fax: 91-11-48042168E-mail: [email protected], Web:www.rfppl.com

Editor-in-ChiefBalwant Rai

Assoc. Prof, Commander, ILWEG Moon Mars Mission, 100 BKepler Space University, USA

Executive Editor

Rajnish K. Jain

Deputy Editors

Jasdeep Kaur, IndiaMaria Catalina, Astronaut Teacher Alliance, NASA JPL Solar System

Ambassador, USA

Abbas Taher, London, UKAbu-Hussein Muhamad,Athens, Greece

Adebola Oluyemisi Ehizele, NigeriaAlexandra Roman, Romania

Clement Chinedu Azodo, NigeriaDean Boss, USA

G. Wellam, BelgiumJaipaul Singh, UK

Abdel Rahman Mohammad Said, Al-Tawaha,JordanInayatullah Padhiar, Karachi

Florent Richy, BelgiumUlrich Suchner, Germany

Figen Cizmeci Senel, TurkeyBora Bagis, Turkey

National Editorial Advisory Board

Hamid Jafarzadeh, IranAous Dannan, Germany

Lojain Jibawi, SyriaMarit Vandenbruane ,

NetherlandsHelen James, USA

L. James, UKMarcelo Carlos Bortoluzzi, Brazil

Natheer H Al-Rawi, UAEPatrick T, Belguim

Rafael Manfro, BrazilSandrine Brunel-Trotebas,

Romania

B.K. Behra, RohtakDeepti Dwivedi, Lucknow

Manaswin Tripathi, New DelhiNaveen Gupta, New Delhi

R. K. Sharma, RohtakS. C. Narula, RohtakSurendra Nath, Delhi

International Editorial Advisory Board

Editor Emeritus

S.C. Anand

Managing Editor

A. Lal

Printed at

R.V. Printing PressC-97, Okhla Industrial Area

Phase-1New Delhi - 110 020

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Role of oral medicine specialist in disclosing systemic lupus erythematosus:

Adiagnostic dilemma, Running title: systemic luapus erythematosus 121

Zahra Delavarian, Maryam Amir Chaghmaghi, Pegah Mosannen Mozafari,

Mohamad Reza Hatef Fard, Rheumatologist

Oral Health Care of elderly in India: Present Scenario and Future Concerns 127

Pankaj Datta, Sonia Sood

A review on repair of fracture porcelain 133

Roseline Meshramkar

The effect of developer age and file thickness on diagnostic accuracy of

Kodak insight (F-speed) and Ektaspeed plus (E-speed) films in position

assessment of file tip to radiographic apex 139

A. Dabaghi, M. Lomee, S. Saati

Instructions to authors 146

Volume 3 Number 3

July-Sept 2010

Indian Journal of Dental Education

Contents

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Volume 3 Number 3, July-Sept 2010© Red Flower Publication Pvt. Ltd

Indian Journal of Dental EducationVolume 3 Number 3, July-Sept 2010

INTRODUCTION

Systemic lupus Erythematosus (SLE) is oneof the most important immunity relateddiseases with unknown etiology, although

Role of oral medicine specialist in disclosing systemic lupuserythematosus: A diagnostic dilemma

Zahra Delavarian*

Maryam Amir Chaghmaghi**

Pegah Mosannen Mozafari***

Mohamad Reza Hatef Fard****

Author’s Affilation: *Associated Professor of OralMedicine , Dental Research Center of Mashhad Dental Faculty,Mashhad University of Medical Sciences, Mashhad, Iran,**Assistant Professor of Oral Medicine , Dental ResearchCenter of Mashhad Dental Faculty, Mashhad University ofMedical Sciences, Mashhad, Iran, ***Assistant Professor ofOral Medicine , Dental Research Center of Mashhad DentalFaculty, Mashhad University of Medical Sciences, Mashhad,Iran, ****Associated Professor of Rheumatology School ofMedicine, Mashhad University of Medical, Sciences, ImamReza Hospital, Mashhad, Iran.

Reprint’s request: Pegah Mosannen Mozafari, AssistantProfessor of Oral Medicine, Dental Research Center ofMashhad Dental Faculty, Mashhad University of MedicalSciences, Mashhad, Iran. Email: [email protected],Tell:0098 511 8829501-15, Fax :0098 511 8829500, Mobilenumber:0098 915 306 0496.

(Received on 24.08.2010, accepted on 26.010.2010)

ABSTRACT

Systemic lupus erythematosus(SLE) is a connective tissue disease in which organs such as liver, kidneyand heart in addition to skin and mucosa are involved. Oral findings are one of the diagnostic criteriawhich can be presented with ulcer or red and white lesions. In this article we report a case of SLE that isdiagnosed by oral medicine specialist on the basis of oral ulcers. A 16-year-old female was referred to oralmedicine department with 3 months lasting oral ulcers. There was a history of transient artheralgia inreview of systems. In extra oral examination a butterfly diffuse erythema was observed on nasal bridge andmalar prominences. Oral ulcers had different forms and involved different parts of oral mucosa. Due tochronic oral ulcers , malar rash and history of artheralgia ,a presumably diagnosis of SLE was affirmed. Shewas referred and hospitalized to rheumatology department. Oral and skin lesions were improvedsignificantly in follow up examination. Oral findings may be the first diagnostic presentation of SLE. It isimportant for dentists to pay attention to medical history and different systemic symptoms to achieveaccurate clinical diagnosis.

Key words: Systemic lupus erythematosus, Oral ulceration, Case report, Oral Medicine, Iran

several factors such as autoantibodies,immune complex, tissue damage, geneticfactors (e.g. specific HLA types and gene loci),environmental factors (e.g. exposure to sunlight and infections) , endocrine agents anddrugs can predispose an individual to thisdisease (1,2) .There are four main clinic-pathological forms: systemic, discoid (chroniccutaneous),acute cutaneous and subacutecutaneous(3).Organ damage occurs as a resultof direct attachment of autoantibodies to hostantigens or precipitation of immune complexin small vessels and tissues (vasculitis). (1,2,4)

There is a female predominance (10:1) andblacks are involved more frequently.

SLE typically arises in adults aged 15 to 45.(1,2,5)Only 15% of individuals with SLE areyounger than 18 year at the time ofdiagnosis(6).

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Fig 1: Butterfly rash and exfoliation of cheeks and nasal bridge skin and lip crust.

Clinical manifestations of this disease varyupon specific organ involvement. Fever,fatigue and weight loss are of clinicalcomponents. (7) Arthritis is the most commonclinical manifestation of this disease (in 90%of patients) (1,7) and usually appearssymmetrically. Interphalanges, knees, wristand metacarpal joints are affected morefrequently.(1) Malar rash, dry pruritic skin,gasterointestinal disorders and muscle spasmsare of other clinical signs.(1) Diagnosis of thisdisease can be made via clinical andparaclinical findings.. If four of 11 criteriabecome evident simultaneously orconsecutively in the course of this diseasediagnosis can be made with a 75% sensitivityand 95% specificity. (1)

Oral manifestations can be the firstpresentation of disease, and may lead todiagnosis. Incidence of oral manifestations,was first reported by Monach (1931)as 50%,(8) and Vasculitis is considered as the mainetiology of oral lesions (1,7,8,9).

These manifestations include: nonspecificchronic ulcers, erosion, inflammation,erythema and keratotic white lesions (papule,plaque …) or even granulomatous lesions andmalignant transformation of oral ulcers.(1,3,7,8)Candidosis, periodontal disease andtemporomandibular disorders anddesquamative or marginal gingivitis are otheroral findings of SLE. (1, 8, 9, 10,11) In advancedSLE , xerostomia may appear (1).Sometimesdelayed primary and permanent tootheruption and twisted root formation can beencountered as a result of corticosteroidstreatment (10).

The affected sites are the buccal mucosa,gingiva, vermilion border of the lips, palateand tongue (1, 8) .Usually diagnosis of SLE isperformed by physicians but at least one casereport exists about diagnosis of SLE by dentist(11).

This article, presents a case of SLE, in whichthe diagnosis was made based on oralmanifestations. Despite a history of skin lesionsand articular pain, the patient had receivedimproper treatments and Oral MedicineSpecialist could reveal the disease.

CASE REPORT

A 16-year-old female was referred to OralMedicine Department of Mashhad DentalFaculty in OCT 2008. She complained of oralulcers with three months duration. In reviewof systems, there was a history of transientartheralgia in knees, elbows and wrists in 6months before initiation of oral manifestations.

Ibopruphen, calcium and vitamin D wasprescribed for her by an internist, and partialrelief was obtained after this therapy. Therewas also a history of hair loss. In extra oralexamination, generalized erythema was seenon nasal bridge and malar region (Butterflyrash) with exfoliation of skin in some areas(Fig 1) accompanied by a thick crust on thelower vermilion border.

The patient noted exacerbation andexfoliation of Malar rash after sun exposure.She was advised to use sunscreen by adermatologist and a few resolution wasacquired.

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Fig 2: A large deep ulcer of 1×3 cm diameter was present on marginal gingiva of firstright permanent molar extending to hard palate.

Fig 3: Significant improvement in Butterfly rash and lip crust

In intraoral examination multiple ulcerswith different patterns were seen in severalareas of oral mucosa such as palate, buccalregion, gingiva and tounge.

Diffuse map like ulcers were presentbilaterally on buccal aspects of mandibularattached gingiva (canine, premolar region)

and palatal aspects of maxillary gingiva(premolar and molar region) (Fig 2)

Multiple small , clustered ulcers wereobserved in right lateral side of hard palateadjacent to first premolar and molar, involvingan area of 1.5×1.5 cm diameter. there was nokeratotic lesion with reticular pattern

(lichenoid reaction). SLE was considered as apossible clinical diagnosis by an oral medicinespecialist due to chronic oral ulcers, butterflyrash and history of articular involvement. So,because all of these signs represent a systemicdisease, there was no need for biopsy of orallesions (especially when there was no evidenceof lichenoid pathology). The Patient wasreferred to Rheumatology clinic for furtherdiagnostic tests and appropriate therapy.

She was admitted to Imam Reza hospitalwith provisional diagnosis of SLE. Laboratorytests such as CBC, Rheumatoid factor, ANA(Antinuclear antibody), Anti ds (doublestrand) DNA, CRP (C-reactive protein) andESR (Erythrocyte sedimentation Rate) andkidney function tests were ordered for thepatient. The results included: positive ANA,Elevated ESR, Anti ds DNA>300, Hgb=9gr/

dl and lymphopenia. CRP, RF and renalfunction tests were normal.

Our patient’s condition satisfied Six criteriafor a diagnosis of SLE: 1)Malar rash 2)Oralulcers 3)Photosensitivity 4)Lymphopenia5)Positive anti ds DNA 6)Positive ANA, sothe diagnosis of SLE was confirmed.

The treatment was initiated byPrednisolone, Hydroxychloroquine, CalciumD, Cephteriaxon (due to uretral infection).After 2 weeks of flare up control, she wasdischarged with instructions to continue herprior medications. No topical treatment wasneeded for oral ulcers, due to rheumatologicclue.

After 48 days, the patient was examined inOral Medicine Department. Malar rash wasrelatively faded out and there was noexfoliation.( Fig 3)The lip ulcers were

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completely healed and a mild facial edema wasevident (possibly due to corticosteroidtherapy).

Nine months later (Aug 2009) the patientswas admitted once more for ten days, with acomplaint of extreme fatigue, arthralgia andmyalgia . Oral ulcers were not evident in thisvisit. There was no lupus nephritis, avascularnecrosis and cardiopathy. Appropriatetreatment was administered for her byrheumatologist.

In October 2009 she was called and nocomplication was emerged.

DISCUSSION

Although this case represents an unusualdiagnostic dilemma, but it seems that inJuvenile SLE(JSLE) ,this kind of error is not sorare(6) .In JSLE the presenting signs areprotean and many of them are commoncomplaints among adolescents.(e.g. fatigue ,artheralgia),so inexperienced physician mayfail to considered SLE in differential diagnosisof transient artheralgia and a facial rash in anadolescent female.

Children and adolescents have a moresevere disease presentation (6) and developsevere organ damages more quickly. So earlydiagnosis and intervention is a crucial pointto improve overall outcome of treatment. Ourcase had at least nine months diagnostic delaydespite articular and cutaneous symptoms.

Tucker reported a summary of commonpresenting signs of JSLE with mucocutaneusulceration as a relatively rare presenting signsin this age group.(6) He speculated that everyadolescent who appear to have unexplained“un wellness” with vague symptoms of SLEshould be further evaluated for diagnosis ofthis entity. It is more fundamental in a proneethnic group (e.g. Asian adolescents)

Prevalence of oral manifestations of SLE hasbeen reported as %7 to 87.5% (7,12) in differentstudies. The difference can be due to lack ofdiagnosis of SLE at the time of oralpresentation or resolution of these findings

after appropriate treatment (9).In one researchon Venezuelan patients oral lesions werefound in first two years after diagnosis (9) Oralulcer was the main oral manifestation in ourcase. Rhodous has reported other oral findingssuch as xerostomia (%100 of cases), mucositisand glossitis (81/3%), glossodynia (87.5%) andangular cheilitis (87.5%), in evaluatedpatients(7) . the severity of these symptoms iscompatible with disease flare up(7,13)although no significant changes in titers ofc3,ANA or Anti ds DNA has been attributedby some authors(13) Lymphadenopathy andfocal parotid necrosis (14) are anotheroccasional findings in head and neck area.

Fernandes et al (10) attempted to addressoral health an TMJ dysfunction in JSLEpatients. They understood that JSLE patientshad poor oral hygiene , higher incidence ofgingivitis and TMJ dysfunction especially inthose on long corticosteroid andimmunosuppression treatments.

In our patient, because histopathologicexamination of oral ulcers had no benefit andsystemic involvement would lead to diagnosis,biopsy was not performed. There are otherdifferentiated diagnoses for extra oralmanifestations of this patient. Similar malarlesions can be seen in achne rosacea, seboreicdermatitis and achne vulgaris and some kindsof viral infections (15,6) Although othersystemic signs are not compatible with thesediagnoses. Other systemic diseases such asBehçet’s syndrome and dermatomyositis werealso mentioned for this case.

Absence of recurring oral and genital ulcersand presence of malar rash excluded Behçet’ssyndrome. Absence of muscular andpathognomonic skin involvement ruled out thediagnosis of dermatomyositis.

DLE was also included in differentialdiagnosis. But in DLE, the lesions are limitedto skin and mucosa (with no systemicinvolvement) and oral involvement appearsas lichenoid reactions in combination withskin discoid rash (a finding not observed inour case.) (16)

Immunologic findings also are of diagnosticcriteria for SLE. Elevated Anti NuclearAntibody (ANA) titer (1/

40 or high) is the most

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sensitive diagnostic criterion for SLE inserologic tests, and was positive in this case.Elevated ANA titers can be found in %99 ofSLE patients; however, in early stage ofdisease, it can be negative. ANA is not anspecific test for SLE since one study revealedelevated ANA titers in %32 of normal adults(5,16)

ANA is positive in other diseases such asSjögren’s syndrome (%68), sclerodermy (40-%75) and rheumatoid arthritis (25-50%) butlower titers and different immuno fluorescentpattern are observed in these cases.

Anti ds DNA survey has high specificityand low sensitivity for SLE and in JSLE is aprominent laboratory profile. In this patient itwas increased. Although complement levels(C3, C4, C5) are normal in variable kinds ofvasculitis, they are decreased in SLE, as a resultof consumption. In inflammatory process insecond administration (flare up) of this patient,C3 and C4 levels were low. SLE owns episodesof flare up and remission (2, 7) and decreasedlevels of complement is the sign of disease flareup. (17)

The aim of treatment for SLE in acute phaseis management of acute attacks. And becauseof multiple organ involvement, treatment planis based on clinical presentation. (1)

Management regimen in these patientsinclude NSAIDS, corticosteroids, Anti malariadrugs and Immunosuppressants.(1) Prognosisdepends on severity and extent of organinvolvement and complications of treatment.poor prognostic factors are young age at onset,male gender, poor socioeconomic status andpositive titers of antiphospholipid antibodies.(1) Since oral lesions respond well to systemictherapy, no additional treatment is necessary.

CONCLUSION

SLE is a systemic disease with multiple organinvolvement and variable diagnostic features.

So one may be referred to a dentist withchronic oral ulcers, with an undiagnosed SLE.Importance of achieving a complete “reviewof systems” and accompanying signs must be

kept in mind by general dentists to reveal anundetermined systemic condition.

REFERENCES

1. Albilia JB, Lam DK, Clokie CML, Saìndor GKB.Systemic lupus erythematosus: A review fordentists.  J of the Can Den Assoc, 2007; 73(9):823-28.

2. Sharon GC. The pathogenesis of systemic lupuserythematosus. Orthopedic Nursing, 2006; 25(2):140-5.

3. Compilato D, Cirillo N, Termine N, Kerr AR,Paderni C, Ciavarella D,Campisi G.Long-standing oral ulcers: Proposal for a new ‘S-C-Dclassification system’. J Oral Pathol Med, 2009;38(3): 241-253.

4. Ramos-casals,M.Nardi,n.Lagrutta,m.Brito-zeron,P.Bove,A.Delgado,G.(et al) vasculitis insystemic lupus Erythematosus: prevalence Andclinical characteristics in 670 patients. Medicine,2006; 85(2): 95-104

5. Oral lupus Erythematosus[on line].Availablefrom URL:http://www.eaom.net/app/prvt/VediNotizia.d/Notizia-96 .accessed sept 20,2006.

6. Tucker LB. Making the diagnosis of systemiclupus erythematosus in children andadolescents. Lupus, 2007; 16: 546-9.

7. Rhodus, L.Johnson D K. the prevalence of Oralmanifestations of systemic lupus erythematosus.Quintessence International, 1990; 21(6): 461-5.

8. Fernandes, R,L. Review of systemic lupusErythematosus. Oral Surg Oral Med Oral PatholOral Radiol Endod, 2001; 91(5): 512-6.

9. López-Labady J, Villarroel-Dorrego M, GonzálezN,Pérez R, Mata De Henning M .Oralmanifestations of systemic and cutaneous lupuserythematosus in a Venezuelan population . JOral Pathol Med, 2007; 36(9): 524-527.

10. Fernandes, RL,Savioli C,Siqueira JTT,Silva CAA.Oral health and masticatory system in juvenilesystemic lupus Erythematosus. Lupus, 2007; 16:713-9.

11. Jayakumar ND, Jaiganesh R, Padmalatha O,Sheeja V. Systemic lupus erythematosus.Ind JDent Res, 2006; 17: 91-3.

12. Meyer V, kleinheinz J, Handschel J, kruse-loslerB, weingart D, joos V. Oral findings in threedifferent groups of immuno compromisedpatients. J Oral pathol med, 2000; 29(4): 153-8.

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13. Urman JD, Lowenstein MB, Abeles M, WeinsteinA. Oral mucosal ulceration in systemic lupuserythematosus. Artheritis Rheumatism, 2005; 21:58-61.

14. Carron J, Karakla DW, Watkins DV. Focalparotid necrosis in systemic lupuserythematosus: Case report and review of theliterature. Oral Surgery Oral Medicine OralPathology Oral Radiology Endodontology, 1999;88: 455-460 .

15. Zuber MA.Butterfly rash: No lupus. Zeitschriftfur Rheumatologie, 2009; 68(5): 409-10.

16. Gill JM, Quisel AM, Rocca PV, Walter DT.Diagnosis of systemic lupus erythematosus. AmFam Physician, 2003; 68(11): 2179-86.

17. Roane DW, Griger DR. An approach todiagnosis and initial management of systemicvasculitis Am Fam Physician, 1999; 60(5): 1421-30.

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INTRODUCTION

Demographic ageing is a globalphenomenon. India’s booming population ofabove one billion people and improved lifeexpectancy (63 for males and 65 for females)1,3 has led to rapidly increasing number ofelderly people (>60 years age group). Thisincludes both healthy adults and adults whoare cognitively and physically challengedand/or medically compromised.

The 20.2 million population of elderly was5.60% (4) (5.6%) in 1951 which climbed to7.63% in 2001 and is likely to climb to 14% in2025 2. In absolute numbers there are 77

Oral Health Care of Elderly in India: Present Scenario and FutureConcerns

Pankaj Datta*

Sonia Sood**

Author ’s Af filation: *Vice-Principal & Head, Deptt. OfProsthodontics, Inderprastha Dental College & Hospital,Sahibabad, Ghaziabad UP, **Post-graduate Student,Department of Public Health Dentistry, ITS-CDSR,Muradnagar, Ghaziabad , UP

Reqrint’s request: Dr. Pankaj Datta, C-86, Anand Vihar,Delhi – 110 092, Mob; 9811774350/9811274799, E-mail:[email protected].

(Received on 15.08.2010, accepted on 25.11.2010)

ABSTRACT

India has a rapidly growing elderly (60 +) population of 77 million which is likely to rise up to 300million by 2050. For the most of this rapidly growing geriatric population there are no specialized oralhealth services. The elderly suffer from multiple oral health problems. The Indian population in the 21stcentury requires an in-depth understanding of the co-relation between oral health and general well being.1

Viewing these issues through the lens of oral health care provider allows an analysis of current oralhealth care status of the elderly in India; understand the cause of their poor oral health, their attitudes andtreatment needs. The unique combination of growing age, physical disability, personal habits, socio-economic status and our oral healthcare system presents challenges for appropriate oral health care.2 Thepresent article highlights on the need to understand the shortfalls in its current oral heath status in elderlyand formulate strategies to improve its oral healthcare structure as well as education policy in geriatricdentistry to help resolve problems of oral health care for the elderly in India.

Key words: elderly, oral healthcare, dental treatment needs, geriatric dentistry

million and 177 million elderly in the year 2001and 2025 respectively, which will rise to 300million in 2050 3. Special features of the elderlyin India are: 52% of elderly in the country arewomen. 71% of the elderly reside in ruralareas. Nearly 75% of the elderly areeconomically dependent. 30% of the elderlyare below the poverty line. 73% of the elderlyare illiterate. It is estimated that 90% of theold people belong to unorganized sector (i.e.without gratuity, pension etc.) 4. With suchlarge population estimates of the elderly, outof which most of them are underserved,considerable efforts are required to support thegeriatric oral health.

EXTENT OF POOR ORAL HEALTH

As per the National Oral Health Survey(2004), poor oral health among elderly hasresulted in a high level of tooth loss (29.3%),dental caries status (84.7%), periodontal

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disease (79.4%), mucosal lesions (10%) andoral cancer (0.5%) 5.

A LINK TO SYSTEMIC HEALTH

The ill effects of poor oral conditions areparticularly significant among older people inthe form of caries, periodontitis andedentulousness. Direct ill effects cause a stateof partial or complete edentulousness.Extensive tooth loss/ Ill-fitting prosthesesreduces chewing performance and affectsfood choice; edentulous people tend to avoiddietary fiber and prefer refined foods leadingto poor nutrition 6, weight loss 7 and problemsin communication besides low esteem 8.

Poor oral health is a common risk factor formany systemic diseases; severe periodontaldisease is associated with diabetes mellitus 9,ischemic heart disease 10, 11, chronic respiratorydisease 12 and osteoporosis 13. The challengeof maintaining oral health for the nursingelderly holds additional danger of aspirationpneumonia 14, 15.

As more epidemiological evidence linksdental infections and systemic complications,it should be clear that dental and healthbenefits should not be compartmentalizedrather it should be replaced with a newparadigm—that of including dental care incomprehensive medical care improve ourgeriatric patients’ quality of life and outlook.16

CHALLENGES OF ORAL HEALTH CAREIN ELDERLY

As they age, older people are more likely tolive alone, may be socially isolated and someare unable to manage walking withoutassistance, have failing eyesight and otherphysical infirmities.

The maintenance of oral health becomesmore difficult if the elderly person is alsosuffering from other systemic illness e.g.arthritis, diabetes, cardiovascular disease,osteoporosis, neurological diseases associatedwith age such as stroke, Alzheimer’s diseaseand Parkinson’s disease. 17. Many systemic

drugs prescribed for these chronic diseases cancause adverse effects to the oral mucosa,lichenoid reactions, hypersensitivity andxerostomia 18, 19.

Elderly are especially at risk for caries andperiodontal diseases if they suffer fromxerostomia. It may be caused by illness,radiation therapy and chemotherapy apartfrom medication.

Dental professionals must understand thatthe elderly must be considered under thecategory of “special needs and care” fortreatment due to their social, psychological,physical and medical conditions 20. Thus, attimes it may necessitate alterations in thetreatment objectives, deviating from thestandard norms with the prime objective to“compress morbidity and chewing disability”and keeping oro-dental apparatus in a stateof reasonable function.

CURRENT SHORTFALLS IN ORALHEALTH CARE OF THE ELDERLY

To have and maintain oral health, there arethree basics tenets that must be in place. Forolder adults, one or more of these tenets maybe absent. As a result, the prevalence andseverity of oral diseases and conditions in olderadults are a significant public health concern.

1. Knowledge of the importance of oralhealth and its value to overall health.

There are compounding factors such asdeficiencies in knowledge, attitudes, practicesand socioeconomic status which predisposethe elderly to oral health problems. Fear ofsurgical nature of work may make themapprehensive of dental care, and may deterthem from seeking it. Many may not realizethe benefits of good oral health as the effectsat times may not be evident instantly.

The high prevalence of oral cancer in Indiais related to behavioral risk factors such aspoor oral hygiene, improper diet, alcohol andtobacco abuse.

2. Physical ability to maintain oral healththrough oral hygiene practices.

Pankaj Datta, Sonia Sood

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Most elderly due to poor manual dexterityhave difficulty in performing routine oralhygiene procedures, which increases theprevalence of dental decay, periodontaldisease and edentulism in this population 21.

3. Ability to access professional oral healthservices.

In India, primary health centres do not havethe provision for dental care. This has left oralhealth far behind other health services. Itappears that oral health is not a priority inour health care system. Except those inorganized sectors like in government jobs,railways, defense services and public sector,majority of the elderly have no oral healthsecurity.

Most services for geriatric patients are on a“fee-for-service” basis in the private clinicswhich is expensive and not within the reachof most of the elderly with reduced retirementincome. With the paucity of governmentdental colleges/ dental departments ofgovernment hospitals in the country; most ofthe elderly patients do not get comprehensivetreatment either due to lack of facilities or longwaiting period 22. There are no healthinsurance plans which cover dental treatmentexcept in an emergency (trauma).

Improper distribution of dental manpowerin India has created a void in the desiredhealthcare status in the elderly. Older adultsare often at risk of limited access to oral healthcare because of transportation, economics,medical illness, social and personal reasons.

RESPONDING TO GERIATRIC ORALHEALTH NEEDS

INCREASING THE AWARENESS ANDKNOWLEDGE AT COMMUNITY LEVEL

About 70% of the rural population does nothave access to dental facilities 23. Currently,only 2% 24 of the specialists are being trainedin public health dentistry, whereas in acountry like India, there is a greater need forthese specialists to emphasize on theimportance of oral health among elderly.Primary prevention, imparting dental health

education and promotion of oral healthcareof elderly in underserved communities needsto be implemented by outreach activities ofpublic health professionals.

There is need of setting up of mobile oralhealth care services involving multidisciplinaryteams to provide domiciliary services to theelderly in the rural areas. Regular preventivedental care with portable dental equipmentcan be used to serve the functionallydependent elderly at home/nursing homes toreduce the development of harmful oral healthconditions.

Use mass media (particularly TV) to raisethe public awareness and understand theimportance and benefits of good oral hygiene.

Educate the public about the harmful effectsof tobacco and alcohol abuse on the oral healthas it predisposes them to a high risk ofperiodontal disease and precancerous orallesions. Oral cancer is more common after agesixty and early detection is among a majorapproach to prevention of the disease.

TRAINING IN GERIATRIC DENTISTRY

With an increasing awareness in the societyabout oral health and treatment needs, therehas been a greater demand for geriatricspecialists in dentistry. To serve them better,it is important to understand the physical,mental and socioeconomic background of theelderly, their illnesses, medication and age-related disabilities. Thus, special training ingeriatric dentistry is required 22. However,there is no institute to provide it in India. Tillthe time we have geriatric dentists there willremain an urgent need of specialists inendodontics, periodontics, prosthodonticsand public health to club together as a part ofrehabilitative team to minimize the oraldisability and restore the oral health of elderly.

In the current scenario, the dental educationneeds to be reframed with the rising need ofpreparing students to care for the increasingnumbers of medically complex, dentateelderly. It is time for a new model of dentaleducation to be implemented atundergraduate level so that it is more

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integrative with a variety of elderly patients,health care providers and individuals who areinvolved in health care management of olderpopulation.

Apart from people involved in dentistryother health professionals must be providedoral health training and information on thespecific needs of older adults.

Lastly, there is an urgent need to educatecaregivers in families, assisted living,supportive housing and nursing homes onhow they can effectively assist older adults fororal hygiene practices.

NEED TO IMPROVE ORAL HEALTHSERVICES

To fill up the desired level of oral healthamongst elderly in India, National Oral HealthPolicy needs to be implemented. The negativeimpact of poor oral health on the quality oflife of elderly is an important public healthissue which must be addressed by policy-makers. The need of dentists and dentalauxiliaries in National Health Program wassuggested for providing oral health care atprimary health care (PHC) and communityhealth care (CHC) as per the Bajaj CommitteeReport 25 . This was further recommended byNational Oral Health Care Program, butunfortunately still the implementation part ismissing at PHC and CHC level 26. Till the timeany positive step is taken by the governmentit is incumbent on us, as oral healthprofessionals, to deal with this need andprovide access to care for elderly patients.

The major cause of poor oral health due tothe absence of primary health care approachin dentistry is the prime area of focus whereoral health professionals (dentists and dentalauxiliaries) should be increased. In 1990 therewere 3,000 registered hygienists and 5,000laboratory technicians in India. There are noregistered dental nurses, chair side assistantsand denturists 24.

To improve the shortage of dentalprofessionals, permission to open new dentalcolleges was granted. Despite increasednumber of dental colleges (291) in the country

27, there is acute shortage of dental manpowerin the rural areas due to significant geographicimbalance in the distribution of dentalcolleges. This has resulted in two unfavorableoutcomes.

(1) Though it improved the overall dentistto population ratio, there has been a greatvariation in the dentist to population ratio inrural and urban areas. The dentist: populationratio is 1:13,000 in the urban areas 23 and1:250,000 in rural areas 28.

(2) It left a big void in the geriatric oral healthcare services in rural areas. Since, most of thedental colleges provide free dental treatmentto people in nearby periurban and rural areas.

To cover up the shortage of dentists to servethe underserved populations in rural areathere is an urgent need of expanding the useof dental auxiliaries in the provision of dentalservices. Dental auxiliaries can provideservices to rural patients without muchfinancial impact on the health agencies. Whenhygienists are utilized to the full scope ofpreventive practice, they can free time forrestorative procedures by dentists. Denturistscan be utilized for directly providing removableprostheses to the elderly.

Lastly, we need support other than dentists’to help us to lobby government for geriatricdental care. It is time for us to look after thegeneration which brought us to this level andlet them feel proud of themselves for raisingus.

CONCLUSION

There is a growing demand for oral healthcare among elderly in India. India needs acomprehensive gerontological oral health careprogram with the following objectives. First,there is deficient data about the current oralhealth status and disease trends. Second, weneed to learn more about the efficacy of thecurrent treatment modalities. Third, the futuredental needs and demands of the elderly needsto be explored. Fourth, the organization of thedental health care delivery system to catch andaddress the changing and probably new oralhealth problems of the elderly needs to beexpanded. Fifth, to meet these challenges,

Pankaj Datta, Sonia Sood

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geriatric dentistry needs to be developed tocreate a trained and dedicated workforcewhich can effectively plan and administergeriatric oral healthcare delivery, educationand research in India. Finally, the relationshipbetween oral health and general health mustbe understood, if oral health care is to have areasonable chance of success.

REFERENCES

1. Available at http://www.prb.org/pdf08/08WPDS_Eng.pdf (accessed on July 27th 2010)

2. Swami H M, Bhatia V. Primary geriatric healthcare in India needs initiative in the newmillennium. Indian J Prev. Soc. Med, 2003; 34(3):4.

3. Peterson P E, Yamamoto T. Improving the oralhealth of older people: the approach of the WHOglobal oral health programme. Community DentOral Epidemiol, 2005; 33: 81-92.

4. Shah N, Tank P. Rehabilitation and ResidentialCare Needs of the Elderly. Indian journal ofpsychiatry-CPG-2007.

5. National Oral Health Survey and FlourideMapping, 2002-2003. New Delhi: DentalCouncil of India, Ministry of Health and FamilyWelfare, Govt. of India, 2004.

6. Walls AWG, Steele JG, Sheiham A, Marcenes W,Moynihan PJ. Oral health and nutrition in olderpeople. J Public Health Dent, 2000; 60: 304–7.

7. Ritchie CS, Joshipura K, Silliman RA, Miller B,Douglas CW. Oral health problems andsignificant weight loss among community-dwelling older adults. J Gerontol A Biol Sci MedSci 2000;55: M366–71.

8. Smith JM, Sheiham A. How dental conditionshandicap the elderly. Community Dent OralEpidemiol, 1979; 7: 305–10.

9. Shlossman M, Knowler WC, Pettitt DJ, GencoRJ. Type 2 diabetes and periodontal disease. JAm Dent Assoc, 1990; 121: 532–6.

10. Trichopoulos D, Ascherio A, Willett WC. Poororal health and coronary heart disease. J DentRes, 1996; 75: 1631–6.

11. Joshipura KJ, Hung H-C, Rimm EB, Willett WC,Ascherio A. Periodontal disease, tooth loss andincidence of ischemic stroke. Stroke, 2003; 34:47–52.

12. Scannapieco F. Role of oral bacteria inrespiratory infection. J Periodontol, 1999; 70:793–802.

13. Clare Van Sant. Preparing your office and teamfor the care of geriatric patients. Available athttp://www.dentistrytoday.com/ME2/dirmod.asp (accessed on 5th March 2010).

14. Abea S, Ishihaara K, Adachib M, Okuda K. Oralhygiene evaluation for effective oral care inpreventing pneumonia in dentate elderly.Archives of Gerontology and Geriatrics, 2006;l43(1): 53-64

15. Awano S, Ansai T, Takata Y, Soh I et al OralHealth and Mortality Risk from Pneumonia inthe Elderly. J Dent Res, 2008; 87(4): 334-339.

16. Rubinstein Helena Gail. Access to oral healthcare for elders: mere words or action? Journal ofDental Education, 2005; 69(9): 1051-1057.

17. Scully C, Ettinger RL. The influence of systemicdiseases on oral health care in older adults. JAm Dent Assoc, 2007; 138:7S-14S.

18. Abdollahi M, Radfar M. A review of drug-induced oral reactions. J Contemp Dent Pract,2003; 4(1): 10-31.

19. DeRossi SS, Hersh EV. A review of adverse oralreactions to systemic medications. Gen Dent,2006; 54(2): 131-8.

20. Sandra Nagel Beebe. The special needs of elderlypatients. Available at http://www.irishdentist.ie/articles/articles_(accessed on July 24th 2010).

21. Talwar M, Chawla HS. Geriatric dentistry: Isrethinking still required to begin undergraduateeducation? Indian J Dent Res, 2008; 19: 175-7.

22. Shah N. Geriatric dentistry: The need for a newspeciality in India. The National Medical Journalof India, 2005; 18(1).

23. DCI Perspective. Dentistry India. Sep 2007 —Vol. 1, Iss. 1 available at http://www.dentistryindia.net/article.php?id=1010,

24. Tandon S. Challenges to the Oral HealthWorkforce in India. J Dent Educ, 2004; 68 (7).

25. Bajaj Committee report available at http://nihfw.org/NDC/DocumentationServices/Reports/Bajaj%20Committee%20report.pdf(accessed on 2nd August 2010).

26. National Oral Health Care Programme(NOHCP) Implementation Strategies. IndianJournal of Community Medicine, 2004; XXIX(1).

27. Available at http://mohfw.nic.in/Adental.html. (accessed on 21st July 2010).

28. Industry Insight Indian dental industry;available at http://www.cygnusindia.com/pdfs (accessed on 3rd Jan 2010).

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INTRODUCTION

Since 1728, when Fauchard [1] firstsuggested the use of porcelain, the art andscience of ceramics in restorative dentistry hasevolved into a revolutionary method foraesthetically treating dental needs of a widevariety. Porcelain inlays and crowns as wellas the use of porcelain facial veneers arereported several decades ago.[2-4]Althoughaesthetically satisfactory, the brittle nature ofthe early porcelain restorations limited theirwider application.[5]

In the 1960’s gold was used as a reinforcingunder structure. [6], followed by MacLean’sapplication of high aluminous ceramicsubstructure for fixed partial dentures.Because of their high aesthetic qualities andmechanical stability in the oral environment

A review on repair of fracture porcelainA review on repair of fracture porcelain

Roseline Meshramkar

Author’s Affilation: Professor, Dept of Prosthodontics,SDM Collge of Dental Sciences, Dharwad E-mail:[email protected], Received on 01.12.2010,accepted on 06.01.2010

Reprint’s request: Dr. Roseline Meshramkar, Professor,Dept of Prosthodontics, SDM Collge of Dental Sciences,Dharwad E-mail: [email protected].

(Received on 01.12.2010, accepted on 06.01.2010)

ABSTRACT

Because of their high esthetic qualities and mechanical stability in the oral environment, ceramicrestorations are commonly used in daily dental practice. Due to the inherently brittle nature of porcelainrestorative materials, failure of metal ceramic restorations under intraoral conditions is not uncommon.The majority (65%) of failures are observed in the anterior region (60% in labial, 27% in buccal, 50% inincisal and 80% in occlusal regions). Clinical studies show failure rates upto 90% for ceramic veneers.Because it is arduous to remove the ceramic restorations from the mouth, they are repaired intraorally,using a bonding system and composite resins. It is necessary to know the possible causes of fracture ofporcelain, the various bonding systems and the composites resins used for repairing. The current reviewtakes into account the majority of papers published in the last few decades concerning the issue of bondingcomposite resins to porcelains.

Key Words: Porcelain fracture, bonding agent, ceramic repair, composite.

porcelain fused to metal restorations arecommonly used in daily dental practice.[7] It isto be expected that with increased applicationof this technique the number of failures alsowill increase.[8] Clinically failures often beginas porcelain fractures that may be caused byinappropriate coping design, poor abutmentpreparation, technical errors, contamination,physical trauma or premature occlusion.[9]

These fractures are mainly in the maxilla [75%]and predominantly at the labial surface.[10] Itis necessary to assess the possible cause offracture so that the most suitable treatmentcan be recommended. Depending on theextent of the area to be restored, cost and timeavailable treatment may range from makinga new prosthesis, faceting or overcastting toresin composite repairs.[11] Replacement of afailed restoration is not necessarily the mostpractical solution for obvious economicreasons and because of the complex nature ofthe restoration.[12] Because it is arduous toremove these restorations from the mouthceramic restorations are repaired intra-orally.[10]

With development of the compositerestorative materials and the introduction oforganosilanes by Bowen [13] in 1962; solutions

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to the repair problem were possible. Two typesof bond, metal-resin and porcelain-resin areinvolved in the repair process of ceramo-metalrestorations. Surface configuration, reactivityof the bonding surface and the use of adhesiveresins are important for metal-resin andporcelain-resin bond. [14] To achieve asatisfactory bond between porcelain andcomposite resin several mechanical andchemical retention systems were developed.Mechanical roughening of porcelain surfaceswith a coarse diamond, Air-abrasion(sandblasting) and acid etching withhydrofluoric acid[15], acidulated phosphatefluoride [16], Ammonium biflouride [17] orphosphoric acid[18] are some of the commonlyused methods to achieve retentive porcelainsurface texture. The organosilane repairmaterials enhance the adhesions of the repairresin to the porcelain surface.[19,20] Within thelast few years, several types of porcelain repairsystems have been developed for use by thedental profession. The purpose of this articleis to review the treatment pertaining to thevarious porcelain repair systems.

THE EVOLUTION OF PORCELAINREPAIR SYSTEMS

Historically, intraoral repair of fracturedporcelain restorations has requiredroughening of the porcelain surface with arotary abrasive, application of silane fallowedby composite to replace the contour of therestoration. [21,22] Early in the 1960smanufacturers’ reinforced plastics withparticles of glass treated with silane bondingagents, Bowen (1962)[13] used these materialsin the development of composite resins thatwere reported to the dental profession in1963.[23]

Paffenbarger et al 1967[24] bonded porcelainteeth to acrylic resin using silane solution asthe coupling agent. In 1968, Semmelman andKulp [25] reported results of bonding porcelaindenture teeth to acrylic resin with a silanecoupling agent. The study indicated thatfailure occurred not at the tooth resin interface,but within the body of the porcelain indicatinga true bonding. In 1969 Myerson [26] concluded

from his experiments that cold-cured resinsproduced a stronger bond than mechanicallyretained porcelain teeth, but that thermalcycling was detrimental to the bond. A studyof porcelain teeth in cold-cured dentures byDuhaney HN [27] in 1970 indicated thatretention by bonding with silane solution wasas satisfactory as mechanical retention.

Jochen and Caputo [28] reported that theabrasion of the surface of porcelain with adiamond rotary instrument increased theretention of the repair material. In 1978,Eames et al [29] evaluated the composite resinsutilizing silane coupling agents for repair ofporcelain. Porcelain denture teeth were usedin this study and acceptable bond strength fortemporary repairs was reported. In 1978,Newburg and Pameijer [8] also studied thebond strength of composite resin to porcelaindenture teeth utilizing a silane coupling agent,and reported that the samples produced areliable bond. Highton et al [30] 1979 alsostudied the effects of silane coupling agentson the composite resin/porcelain bond. Thestudy indicated that the repair system using abonding agent with acrylic resin wassignificantly stronger than the repair systemusing a composite resin.

Nowlin et al[31] reported that fusion plusconcise (3M Co. Dent products Div., st. PaulMinn) was superior to Dent-mat and 18% ofthe original porcelain strength was regained.

In 1983, Ferrando et al[32] concluded thatEnamalite (Lee pharmaceuticals, South ElMonte, Calif.) was superior to Fusion plusAdaptic (Johnson and Johnson Dentalproducts co., East Windsor, N.J.), Adaptic,Dent-mat porcelain repair kit and cyano-veneer (Ellman International ManufacturingInc., Hewlet., N.Y) in tensile strength and hadthe least leakage at the resin-porcelaininterface.

The adhesion of resin to dental porcelainwas enhanced by etching the porcelain surfacewith hydrofluoric acid (Horn 1983[33]; Calamia1983[34]) and using silane coupling agents(Calamia and Simonsen, 1984). [35]

Combination of hydrofluoric acid etching andthe application of silane coupling agent wasshown to be an effective method for improving

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the adhesion of resin. (Stangel et al 1987;Shetch et al 1988[5]; Aida et al 1990)

As an alternative to hydrofluoric acid,acidulated phosphate fluoride (Lacy et al[25]

1988) or phosphoric acid (Newburg andPameijer [8] 1987; Okamoto et al[36] 1989;Matsumara et al[37] 1989) were investigated.However, neither etching with hydrofluoricacid nor adding silane resulted in an adequateresin bond to some new high-strengthceramics.[38] High-alumina [39] or Zirconia-reinforced ceramics[40] cannot be roughenedby hydrofluoric acid etching since suchceramics do not contain a silicon dioxide (silica)phase.

For this reason, special conditioning systemsare indicated for these newer types of ceramics.Modern surface conditioning methods utilizeair-particle abrasion for achieving sufficientbond strength between the resins and highstrength ceramics that are reinforced eitherwith alumina or Zirconia.[40] In this techniquethe surfaces are air abraded with aluminiumoxide particles modified with silicic acid withdifferent particle sizes ranging from 30 to250µm.[40] The blasting pressure results in theembedding of silica particles on the ceramicsurface, rendering the silica-modified surfacechemically more reactive to the resin throughsilane coupling agents.[41]

THE BOND BETWEEN PORCELAINAND THE RESIN COMPOSITE

Bonding of resin to a ceramic surface isbased on the combined effect ofmicromechanical interlocking and chemicalbonding. The bond strength of composite toporcelain is affected by the surface preparationand the type of bonding agent.[42]

Mechanical roughening of porcelainsurfaces with coarse diamond hasdemonstrated improved repair strength. [28,32]

Sandblasting with aluminium oxide (Al2O

5)

is another method of surface roughening[15]

and porcelain can also be etched withhydrofluoric acid, ammonium biflouride,phosphoric acid or acidulated phosphatefluoride gel to facilitate micromechanical

retention of resin composite.[42] The mechanicalbonding always poses an inherentdisadvantage of microleakage.[43]

Chemical bonding to ceramic surface isachieved by silanization with a bifunctionalcoupling agent.[44] Silane coupling agents canimprove the bonding of composite resin toporcelain by approximately 25%.[5] Silanecoupling agents possess the general chemicalstructure X-(CH

2)

3 Si-(OR)

3 and have ability

to bond chemically to both organic andinorganic surfaces.[45] The coupling agent atone end chemically bonds to the hydrolyzedsilicon dioxide of the ceramic surface and amethacrylate group at the other endpolymerizes with the adhesive resin.[44] Thetype of resin composite also effects of bondstrength to porcelain. It is assumed that largerparticle size resin composites or hybrid.[16]

THE MATERIALS AND THE TESTINGMETHODS USED FOR THE BOND TEST

Material selection and clinicalrecommendation of resin bonding to ceramicsare based on mechanical laboratory tests thatshow great variability in materials andmethods.[7,46] Many methods of measuring thein-vitro bond strength affected by porcelainrepair systems have been described. Theseinclude torsion, flexural,[19] tensile and shearbond strength tests.[47] The most commonlyemployed is the shear bond strength test. Thecrosshead speed used for testing the samplesrange from 0.5 mm/min to 5 mm/min. But asyet there is no universally accepted bondstrength tests for resin composite bonded toceramic.

The ceramic-composite bond is susceptibleto chemical, [48] thermal,[49] and mechanical[50]

influences under intraoral conditions. Anotable feature of some studies [51] is theobservation that, the failure mode is oftencohesive within the ceramic bases rather thanat the adhesive interface. On the basis of whichit has been suggested that the bond strengthexceeds the cohesive strength of the ceramic.But this ignores the nature of the stressesgenerated and their distribution within the

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adhesive zone which can have a profoundinfluence on the mode of failure. Finite elementstress analysis (FEA) has been used to studythe sensitivity of bond strengths to specimendesign and changes in testing conditions. [52]

These studies show that there is need for amore critical approach on the design ofappropriate tests for evaluating the bondstrength of resin composite to ceramic if thedesign for a standardized test procedure is tobe achieved.

RECENT DEVELOPMENTS

Bonding to traditional silica based ceramicsis a predictable procedure yielding durableresults when certain guidelines arefollowed.[45] The physical properties andcomposition of high strength ceramic materialslike aluminium oxide-based [40,53] andZirconium oxide-based ceramics [41] differsubstantially from silica based ceramics andrequire alternative bonding techniques toachieve a strong, long term and durable resinbond.[40]

Modern surface conditioning methodsrequire airborne particle abrasion of thesurface before bonding in order to achievehigh bond strengths. One such system is silicacoating. In this technique the surfaces are airabraded with aluminium oxide particlesmodified with silisic acid. [54] The blastingpressure results in the embedding of silicaparticles on the ceramic surface, tending thesilica modified surface chemically morereactive to the resin through silane couplingagents. Silane molecules after beinghydrolyzed to silanol can form polysiloxanenetwork or hydroxyl groups cover the silicasurface. Monomeric ends of the silanemolecules react with the methacrylate groupsof the adhesive resins by free radicalpolymerization process, when a ceramicexhibits chemical states of silicone and oxygen.The siloxane bond will be achieved as theserepresent the bonding sites for the couplingagent to the ceramic surface.[55]

The phosphate modified resin cement afterairborne particle abrasion provide a long-term

durable resin bond to zirconium oxideceramic [56] The equipments for airborneparticle abrasion are recently simplified andbrought to the chairside.[41]

DISCUSSION

Intraoral repair of fractured porcelainrestorations with resin composite presents asubstantial challenge for clinicians. Newergeneration multipurpose adhesive systemsinvolve several treatment steps and agents forporcelain repair with resin composite.[57]

Several studies focus on mechanical retention,chemical agents and the combination of thesetwo methods.[10,51,42] Because of the insufficientbonding characteristics of the chemical agents,physical alteration of the porcelain surfacemust be used together with these agents topromote adhesion. Wolf et al[45] concluded thatsandblasting with Al2O3 or roughening byburs achieve satisfactory bond strength butwhen more durable and higher bond strengthis desired, hydrofluoric acid etching is the mostsignificant step in the surface treatmentbecause of deep acid penetration.

The silane coupling agents achieve achemical link between the resin composite andporcelain; moreover they promote wetting ofthe porcelain surface so that it enhances theflow of the low-viscosity resin composites.They improve the bond of resin composite toporcelain by approximately 25%.[22]

Aluminium oxide and Zirconium oxide-basedceramics require the use of special resin cementalong with airborne article abrasion.Compared with silica-based ceramics, thenumber of in vitro studies on the resin bondto high-strength ceramics is small. Furthercontrolled clinical trials are required to testspecific treatment modalities and their long-term durability.

REFERENCES

1. Jones DW. Development of dental ceramics: ahistorical perspective. Dent Clin North Am,1985; 29: 621-44.

2. Ernsmere JB. Porcelain dental work. Br J Dent

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Sci, 1900; 43: 547.

3. Wells JO. The evolution of the artificial crown.Dent Sci J, 1901; 44: 540.

4. Pincus CL. Building mouth personality. J CalDent Assoc, 1938; 14: 125.

5. Sheth J, Jensen M, Tolliver D. Effect of surfacetreatment on etched porcelain bond strength toenamel. Dent Mater, 1988; 4: 328-37.

6. Dunswarth FD. Porcelain fused to gold. JProsthet Dent, 1958; 8: 635-9.

7. McLean JW. A higher strength porcelain forcrown and bridge work. Br Dent J, 1965; 119:268-72.

8. Newburg R, Pameijer CH. Composite resinsbonded to porcelain with silane solution. J AmDent Assoc, 1978; 96: 288-91.

9. Kelly JR, Nishumura I, Campbell SD. Ceramicsin dentistry: Historical roots and currentperspectives. J Prosthet Dent, 1996; 75: 18.

10. Appeldoorn RE, Wilwerding TM, BarkmeierWW. Bond strength of composite resin toporcelain with newer generation porcelainrepair systems. J Prosthet Dent, 1993; 70: 6-11.

11. Kussaono CM, Bonfante G, Batista JG, PintoJHN. Evaluation of shear bond strength ofcomposite to porcelain according to surfacetreatment. Braz Dent J, 2003; 14: 132-5.

12. Thurmond JW, Barkmeier WW, Wilwerding TM.Effect of porcelain surface treatments on bondstrengths of composite resin bonded toporcelain. J Prosthet Dent, 1994; 72: 355-9.

13. Bowen RL. Dental filling material comprisingvinyl silane-treated fused silica and a binderconsisting of a reaction product of bisphenoland glycidyl acrylate. US Patent no. 3,066, 12Nov. 1962.

14. Kato H, Matsumura H, Tanaka T, Atsuta M.Bond strength and durability of porcelainbonding systems. J Prosthet Dent, 1996; 75: 163-8.

15. Bertolotti RL, Lacy AM, Watanable LG. Adhesivemonomers for porcelain repair. Int JProsthodont, 1989; 2: 483-9.

16. Llobell A, Nicholls JI, Kois JC, Daly CH. Fatiguelife of porcelain repair systems. Int J Prosthodont1992; 5: 205-13.

17 . Lacy AM, Laluz J, Watanabe LG, Dellinges M.Effect of porcelain surface treatment on the bondto composite. J Prosthet Dent, 1988; 60: 288-91.

18. Hayakawa T, Horie H, Aida M et al. the influenceof surface conditioners and silane agents

on the bond of resin to dental porcelain. DentalMater, 1992; 8: 238-40.

19. Bailey JH. Porcelain to composite bond strengthsusing four organosilane materials. J Prosthetdent, 1989; 61: 174-7.

20. O’Brien WJ. Dental porcelains. In Craig RG ed.Dental Materials Review. Ann Arbor Universityof Michigan Press, 1977; 123-35.

21. Friedman MJ. A 15-year review of porcelainveneer failure- a clinician’s observations.Compend Contin Educ Dent, 1998; 19: 625-36.

22. Hsu CS, Strangel I, Nathanson D. Shear bondstrength of resin to etched porcelain. J Dent

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bases. J Am Dent Assoc, 1967; 74: 1018-23.

25. Semmelman JO, Kulp PR. Silane bondingporcelain teeth to acrylic. J Am Dent Assoc, 1968;

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26. Myerson RL. Effects of silane bonding of acrylicresins to porcelain on porcelain structure. J AmDent Assoc, 1969; 78: 113-9.

27. Duhaney HN. A clinical and laboratory studyof silane bonding of porcelain teeth to the auto-

curing methyl methacrylate base, thesis. BostonUniversity School of Graduate Dentistry, 1970.

28. Jochen DG, Caputo AA. Composite resin repairof porcelain denture teeth. J Prosthet Dent, 1977;38: 673-9.

29. Eames WB, Rogers LB, Feller PR, Price WR.Bonding agents for repairing porcelain and

gold: an evaluation. Oper Dent, 1977; 2: 118-24.

30. Highton RM, Caputo AA, Maryas J.Effectiveness of porcelain repair systems. JProsthet Dent, 1979; 42: 292-4.

31. Nowlin TP, Barghi N, Norling BK. Evaluaiton of the bonding of three porcelain repair systems.J Prosthet Dent, 1981; 46: 516-8.

32. Ferrando J MP, Gracer GN, Tallents RH andJarvis RH. Tensile strength and microleakageof porcelain reapir materials. J Prosthet Dent,1983; 50: 44-50.

33. Horn HR. Porcelain laminate veneers bondedto etched enamel. Dent Clin North Am, 1983; 27:671-84.

A review on repair of fracture porcelain

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34. Calamia JR. Etched porcelain facial veneers: anew treatment modality based on scientific andclinical evidence. NYJ Dent, 1983; 53: 255-9.

35. Calamia JR, Simonsen RJ. Effect of couplingagents on bond strength of etched porcelain. J

Dent Res, 1984; 63: 197.

36. Okamoto A, Kobayashi Y, Nakai T et al. Thestudy of silane coupling agent for reaparingfractured porcelain. Jpn J Conserv Dent, 1989;32: 978-85.

37. Matsumura H, Kawahara M, Tanaka T, AtsutaM. A new porcelain repair system with a silanecoupler, ferric chloride and adhesive opaquesystem. J Dent Res, 1989; 68: 813-8.

38. Rosenstein SF, Gupta PK, Van der Sluys RA,Zimmermann MH. Strength of a dental glass-ceramic after surface coating. Dent Mater, 1993;9: 274-9.

39. Kern M and Thomson VP. Bonding to glassinfiltrated alumina ceramic: adhesive methodsand their durability. J Prosthet Dent, 1995; 73:240-9.

40. Kern M, Wegner SM. Bonding to Zirconiaceramic: adhesion methods and their durability.Dent Mater, 1998; 14: 64-71.

41 Amaral R, Õzcan M, Bottino MA, Valandro LF.Microtensile bond strength of a resin cement toglass infiltrated zirconia-reinforced ceramic: Theeffect of surface conditioning. Dent mater, 2006;22: 283-90.

42. Suliman AA, Swift EJ, Perdigao J. Effects ofsurface treatment and bonding agents on bondstrength of composite to porcelain. J Prosthetdent, 1993; 70: 118-20.

43. Lu R, Harcourt JK, Tyas MJ, Alexander B. Aninvestigation of the composite resin/porcelaininterface. Aust Dent J, 1992; 37: 12-9.

44. chwatz RS, Summit JB, Robbins JW.Fundamental of operative dentistry.Quintessence Publication Co. Inc, 1996.

45. Wolf DM, Powers JM, O’Keefe KL. Bond strengthof composite to porcelain treated with newporcelain repair agents. Dent Mater 1992; 8:158-61.

46. Fradeani M. Six year follow-up with Empressveneers. Int J Periodontics Restorative Dent,1998; 18: 216-25.

47. Chadwick RG, Mason AG, Sharp W. Attemptedevaluation of three porcelain repair systems.What are we really testing? J Oral Rehabil, 1998;25: 610-5.

48. McKinney JE, Wu W. Chemical softening andwear of dental composites. J Dent Res, 1985; 64:1326-31.

49. Palmer DS, Barco MT, Billy EJ. Temperatureextremes produced orally by hot and coldliquids. J Prosthet Dent, 1992; 67: 325-7.

50. Harrison A, Moores GE. Influence of abrasiveparticle size and compressive stress on the wearrate of dental restorative materials. Dent Mater,1985; 1: 14-8.

51. Diaz-Arnold AM, Schneider RL, Aquilino SA.Bond strengths of intraoral repair materials. JProsthet Dent, 1989; 61: 305-9.

52. Von Noort R, Noroozi S, Howard IC, Cardew G.A critique of bond strength measurements, JDent, 1989; 17: 61-7.

53. Zeng K, Oden A, Rowcliffe D. Evaluation ofmechanical properties of dental ceramic corematerials in combination with porcelains. Int JProsthodont, 1998; 11: 183-9.

54. Wegner SM, Kern M. Long-term resin bondstrength to zirconia ceramic. J Adhes Dent, 2000;2: 139-47.

55. Piconi C, Maccauro G. Zirconia as a ceramicbiomaterial. Biomaterials, 1999; 20: 1-25.

56. Strub JR, Stiffler S, Scharer P. Causes of failurefollowing oral rehabilitation: biological versustechnical factors. Quintessence Int 1988; 19: 215-22.

57. Guler AU, Yilmaz F, Ural C, Guler E. evaluationof 24-Hr shear bond strength of resin compositeto porcelain according to surface treatment.Int J Prosthodont, 2005; 18: 156-60.

Roseline Meshramkar

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INTRODUCTION

Radiography is an essential tool in routinedental practice for caries diagnosis and rootcanal treatment [1]. Assessment of the workinglength is an initial important stage in rootcanal therapy. Parallel periapical radiography

The effect of developer age and file thickness on diagnostic accuracy ofKodak insight (F-speed) and Ektaspeed plus (E-speed) films in

position assessment of file tip to radiographic apex

A. Dabaghi*

M. Lomee**

S. Saati***

Author’s Affiliation: *Assistant Professor of Oral andMaxillofacial Radiology, Faculty of Dentistry, Ahvaz JundiShapur University of Medical Science, **Post GraduatedStudent of Endodontics, Faculty of Dentistry, MashhadUniversity of Medical Science, ***Post Graduated Student ofOral and Maxillofacial Radiology, Faculty of Dentistry, AhvazJundi Shapur University of Medical Science.

Reprints’s request: A. Dabaghi, M. Lomee AssistantProfessor of Oral and Maxillofacial Radiology, Faculty ofDentistry, Ahvaz Jundi Shapur University of Medical Science.

(Received on 17.03.2010, accepted on 25.08.2010)

ABSTRACT

Objectives : To determine the effect of developer age and file thickness on diagnosticaccuracy of E and F- speed films in position assessment of file tip to radiographic apex., Studydesign: Endodontic files size 10 and 15 were placed in mandibular first molar and secondpremolar up to the root apex or 1.5 mm shorter. Ten series of radiographs were made withtwo types of film: Kodak insight (F-speed film) and Ektaspeed plus (E-speed film) in differentpositions of file in apex or 1.5 mm short. The films of each series were processed manually oneach day, using Champion chemicals. The films were assessed by four endodontists. Theyrated the position of file tip to radiographic apex using a 3-point confidence scale in thequestionnaires (tip to tip, 1.5 mm under, can not diagnose). The diagnostic performance ofobservers was compared with true diagnosis., Results : Mean Az value of E and F-speedfilms, that shows the diagnostic accuracy is 0.986 and 0.983 for E and F-speed films respectively,that was not significantly different (P = 0.777). Also diagnostic accuracy of films processedduring 10 days was not statistically different (P = 0.726). Assessment of files tip size 10 and 15in lower molar and premolar canals was not significantly different (P = 0.712)., Conclusion :The performance of the F-speed film was not statistically different from E-speed for assessmentof file tip to radiographic apex. Because of less required exposure, we suggest to use Kodakinsight (F-speed film) in clinical examination.

Key words: Diagnostic accuracy, Intra oral radiographic film, Working length

is the best technique for assessment andmeasuring the working length [2]. Ektaspeedplus films usually are used to determine theworking length because of their excessavailability [3,4].

A major objective of diagnostic radiology isto provide images of optimal quality at aradiation dose as low as reasonably achievable[1]. One of the most effective ways to reducepatient radiation exposure is using moresensitive films (Kodak insight F-speed film).These films have larger silver halid grains andthicker emulsion, thus need lower x-rayradiation (20% less x-ray exposure comparedwith E-speed films) to produce equaldiagnostic accuracy [5,6]. According to formerstudies, the conditions of processing influence

© Red Flower Publication Pvt. Ltd

Indian Journal of Dental EducationVolume 3 Number 3, July-Sept 2010

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Indian Journal of Dental Education

the sensiometric characteristics of F-speed films[7,8].

Today in dental office, developers are usedin little volume (about 250 cc) and about oneweek. If the diagnostic accuracy of E and F-speed films in low volume developer wassimilar, it would reduce patients andpersonnel dose and increase x-ray tube life. Inaddition, the effect of developer age and filethickness on diagnostic accuracy of E and F-speed films to determine the position of filetip to radiographic apex, have been studied.

MATERIALS AND METHODS

In order to simulate clinical examination, adried human mandibular segment containingpremolar and molar teeth was used. The rootcanal of the left second premolar and themesiobuccal and distobuccal canals of the firstmolar were accessed. The radiographic lengthof the root canals was determined under thesupervision of endodontist with a #20 K-file(Dentsply-Maillefer, Ballaigues, Switzerland)and Kodak Ektaspeed dental film(EastmanKodak Co. NY, USA). Endodontic #10 and15 K-files (Dentsply-Maillefer, Ballaigues,Switzerland) were placed at the apex or 1.5mm shorter. A light-cured composite resin stopwas used, so that, the files could be reused inthe same position. A series of radiographs withdifferent combinations of correct and short filelength was made with Planmeca Prostyle x-ray unit (Planmeca Oy, Helsinki, Finland)operating at 63 kvp, 8 mA and 36 cm SID.The parallel technique with a endodontic filmholder (Endoray , Rinn Densply) was used tominimize the magnification and distortion.

The exposure time was 0.20s for E-speeddental film and 0.16s for F-speed dental filmaccording to the manufacturer’srecommendation (about 20% less exposure forF-speed film compared with E-speed film).1.7cm selfcure acrylic resin was used asscattering agent to stimulate soft tissue.

Four identical series of radiographs wereobtained with each type of films and file sizes.because of different file length (tip to tip or1.5mm shorter) in three canals, each series

consisted of eight different modes andtherefore 32 radiographs were obtained. Toassessment the effect of developer age ondiagnostic accuracy of radiographs, thisprocedures was done 10 days and finally 320radiographs were made.

The films were processed manually withChampion chemicals (X-ray Iran Co, Tehran,Iran) in the same condition (1min developing,15s washing, 2min fixing and 5min finalwashing) at 25 �C ± 1. For similarity to dentaloffice, little volume developer (250cc) wasused. Every day, 32 radiographs randomlywere divided into eight groups of four. Eachgroup was processed in individual set (eightsimilar set for developer, fixer and water). Tosimilarity the number of processedradiographs with dental office and helpingdeveloper aging, eight radiographs of a step-wedge were processed until day 9th. Fourendodontists were asked to rate the positionof file tip in relation to the apex of the toothon a three-piont scales: U:1.5mm under, T: tipto tip and CD: can not diagnose.

Data analysis was performed with ROC, T-test and ANOVA tests.

RESULTS

Mean

zA

value (showing diagnostic

accuracy) of Kodak insight (F-speed) andEktaspeed plus (E-speed) films weredetermined with ROC analysis and werecompared with each other (Table 1- Figure1).value of E-speed film was 0.986 and for F-speed film was 0.983. According to theanalysis, there was no significant differencebetween two types of films in determining theposition of file tip in relation to the apex (P =0.777).

Diagnostic accuracy of determining theposition of size #10 and 15 K-files, was notstatistically different in mandibular secondpremolar and first molar canals (P=0.712).Also, the comparison of mean Az value fromday 1st to day 10th showed that, diagnosticaccuracy of processed films in 10 days of

A. Dabaghi, M. Lomee, S. Saati

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Volume 3 Number 3, July-Sept 2010

zAof F filmz

Aof E

film

0.9920.994No.1 observer0.9560.969No.2 observer

0.9920.994No.3 observer0.9940.990No.4 observer

0.9830.986z

AMean

value

Table1: zA values of four observers with E and F-speed films, and comparison them with

T-test analysis

zA

Tenth

day

zA

Ninth day

zA

Eighth day

zA

Seventh day

zA

Sixth

day

zA

Fifthday

zA

Fourth day

zA

Third

day

zA

Second day

zA

Firstday

1.0001.0001.0001.0001.00

00.99

00.9900.9790.990

0.979

No.1observe

r

0.9380.9580.9900.9380.96

90.99

00.9380.9900.948

0.969

No.2observe

r

1.0001.0001.0001.0001.00

01.00

00.9900.9690.990

0.979

No.3observe

r

0.9900.9901.0001.0001.00

01.00

01.0001.0000.958

0.979

No.4observe

r

0.9820.9870.9970.9840.99

20.99

50.9790.9840.9710976

zA

Meanvalue

developer aging, was not significantly different(P = 0.726) (Table 2).

DISCUSSION

Figure 1: zA mean values of four observers with E and F-speed films

The effect of developer age and file thickness on diagnostic accuracy of Kodak insight (F-speed) andEktaspeed plus (E-speed) films in position assessment of file tip to radiographic apex

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Indian Journal of Dental Education

The main variable in this study was the film.Syriopulos et al, reported mean value of E andF-speed films, 0.966 and 0.962 respectively andfounded that this two types of films had nosignificant difference in determining theposition of file tip to radiographic apex [4].

According to the analysis, E and F-speedfilms are not different in determining theposition of file tip in relation to the apex andin clinical examination, Kodak insight (F-speed) films can be used because of its lowerx-ray exposure needed.

Another effective parameter in this studywas developer aging. Meanof observers wasnot significant difference in 10 days and werein agreement with Casanova et al findings [3].They showed that useful developer aging infirst 19 days was similar.

Determining the exact useful solution lifewithout volume consideration will not bepractical. We concluded that, Kodak insight(F-speed) films do not have any undesiredeffect on image quality but also reduce thepatient and personnel exposure dose. Thisstudy continued after day 10th with only E-speed film and size15 file. The results indicatedthat, image quality was acceptable until day20th.

In conclusion, we founded that properexposure and careful processing with littlevolume developer can be used in dental officeat least for ten days. Also, under standardconditions of the exposure and processing, filessize #10 and 15 can be used in determiningworking length in normal root canal anatomyand proper position (e.g. posterior ofmandible). It is obvious that, if the position ofteeth is improper (e.g. posterior of maxilla) andthe root canals are unusual, files size #10 and15 will help less often, and larger files (at leastsize20) must be used to determine apexposition.

CONCLUSION

Under the condition of this study, wesuggest to use Kodak Insight (F-speed) filmsin clinical examination, because of lessrequired exposure.

ACKNOWLEDGMENT

This study was supported by a grant fromthe Vice Chancellor of Research Council ofAhvaz Jundi Shapur University of MedicalScience, Iran.

REFERENCES

1. White SC, pharoah MJ. Oral Radiology Principleand Interpretation. 6th ed. St. Louis: Mosby Co,2009: 299-303.

2. Torabinejad M, Walton RE. EndodonticsPrinciples and Practice. 4th ed. St. Louis: WBSaunders, 2009: 252.

3. Casanova MLS, Haiter-neto F. Effecs ofdeveloper depletion on image quality of KodakInsight and Ektaspeed Plus films.Dentomaxillofac Radiol, 2004; 33: 108-113.

4. Syriopoulos K, Sanderink GCH, Velders XL.Sensitometric and clinical evaluation of a newF-speed dental x-ray film. DentomaxillofacRadiol, 2001; 30: 40-44.

5. Haring JI, Jansen L. Dental RadiographyPrinciples and Techniques. 2nd ed. St. Louis: WBSaunders, 2002: 98-99.

6. Farman TT, Farman AG. Evaluation of a new F-Speed dental x-ray film, The effect of processingsolutions and a comparison with D and E speedfilms. Dentomaxillofac Rodiol, 2000; 29(1): 41-5.

7. Ludlow J, Palatin C. Characteristics of KodakInsight, an F-speed intraoral film. Oral Surg OralMed Oral Pathol Oral Radiol Endod, 2001; 9(1):120-129.

8. Sheaffer JC, Eleazer PD, Scheetz JP. Endodonticmeasurement accuracy and perceivedradiograph quality: Effects of film speed anddensity. Oral Surg Oral Med Oral Pathol OralRadiol Endod, 2003; 96: 441-8.

A. Dabaghi, M. Lomee, S. Saati

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By Dr. Rajesh Shukla

ISBN: 81-901846-0-1, Hb, VIII+392 Pages

1st Edition, 2001

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Indian Journal of Dental Education

Indian Journal of Genetics and Molecular Resarch

Call for editorial board member & authors

About the Journal

The Indian Journal of Genetics and Molecular Research (quarterly) will publish high-quality, original research papers, short reports and reviews in the rapidly expanding fieldof human genetics. The Journal considers contributions that present the results of originalresearch in genetics, evolution and related scientific disciplines. The molecular basis of humangenetic disease developmental genetics neurogenetics chromosome structure and functionmolecular aspects of cancer genetics gene therapy biochemical genetics major advances ingene mapping understanding of genome organization.

Editor-in-Chief

Dr. Seema Kapoor

Prof. of Genetics

Dept. of Peadiatrics

Maulana Azad Medical College & Associated LNJP Hospital

New Delhi – 110 002

India

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Volume 3 Number 3, July-Sept 2010

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