Journal of International Dental and Medical Research

Editorial Board of JIDMR 2011

Assoc. Prof. Dr. Izzet YAVUZ Editor‐in‐Chief and General Director

Assist. Prof. Dr. Ozkan ADIGUZEL Associate Editor and Director

Assoc. Prof. Dr. Refik ULKU Associate Editor for Medicine

Prof. Dr. Zulkuf AKDAG, Prof. Dr. Sinerik N. AYRAPETYAN Associate Editor for Biomedical research

Assist. Prof. Dr. Filiz ACUN KAYA, Assist. Prof. Dr. Sabiha Zelal ULKU Associate Editor for Dentistry

PhD. Dr. Ediz KALE Language Editor

Advisory Board

Betul KARGUL (TURKEY) Ferranti WONG (UNITED KINGDOM) Filiz ACUN KAYA (TURKEY) Gauri LELE (INDIA) Gulten UNLU (TURKEY)

Jalen Devecioglu KAMA (TURKEY) Moschos A. PAPADOPOULOS (GREECE) Nik Noriah Nik HUSSEIN (MALAYSIA) Sabiha Zelal ULKU (TURKEY) Sadullah KAYA (TURKEY)

Editorial Board

Abdel Fattah BADAWI (EGYPT) Abdurrahman ONEN (TURKEY) Ahmet YALINKAYA (TURKEY) Ali Al‐ZAAG (IRAQ) Ali BUMIN (TURKEY) Ali GUR (TURKEY) Ali Kemal KADIROGLU (TURKEY) Ali Riza ALPOZ (TURKEY) Alpaslan TUZCU (TURKEY) Aziz YASAN (TURKEY) Benik HARUTUNYAN (ARMENIA) Betul KARGUL (TURKEY) Betul URREHMAN (UAE) Bugra OZEN (TURKEY) Cemil SERT (TURKEY) Christine Bettina STAUDT (SWITZERLAND) Cihan AKGUL (TURKEY) Claudia DELLAVIA ( ITALY ) Emin Caner TUMEN (TURKEY) Ertugrul ERCAN (TURKEY) Ertunç Dayı (TURKEY) Fadel M. ALI (EGYPT) Fahinur ERTUGRUL (TURKEY) Feral OZTURK (TURKEY) Ferhan YAMAN (TURKEY) Feridun BASAK (TURKEY) Feriha CAGLAYAN (TURKEY) Ferranti WONG (UNITED KINGDOM) Figen SEYMEN (TURKEY) Filippo BATTELLI (ITALY) Filiz Acun KAYA (TURKEY) Gajanan Kiran KULKARNI (CANADA) Gamze AREN (TURKEY) Gauri LELE (INDIA) Gokhan KIRBAS (TURKEY) Gonul OLMEZ (TURKEY) Guliz Nigar GUNCU (TURKEY) Gulsen YILMAZ (TURKEY) Gulten UNLU (TURKEY) Gungor ATES (TURKEY) Guvenc BASARAN (TURKEY)

Nihal HAMAMCI (TURKEY) Guven ERBIL (TURKEY) Nik Noriah Nik HUSSEIN (MALAYSIA) Halimah AWANG (MALAYSIA) Nurten AKDENIZ (TURKEY) Hilal TURKER (TURKEY) Nurten ERDAL (TURKEY) Huseyin ASLAN (TURKEY) Orhan TACAR (TURKEY) Igor BELYAEV (SWEDEN) Ozant ONCAG (TURKEY) Ilhan INCI (ZURICH) Ozgur UZUN (TURKEY) Ilker ETIKAN (TURKEY) Ozkan ADIGUZEL (TURKEY) Isil TEKMEN (TURKEY) Rafat Ali SIDDIQUI (PAKISTAN) Isin ULUKAPI (TURKEY) Refik ULKU (TURKEY) Izzet YAVUZ (TURKEY) S. Yavuz SANISOGLU (TURKEY) Jalen DEVECIOGLU KAMA (TURKEY) Sabiha Zelal ULKU (TURKEY) Kemal CIGDEM (TURKEY) Sadullah KAYA (TURKEY) Kewal KRISHAN (INDIA) Sedat AKDENIZ (TURKEY) King Nigel MARTYN (HONG KONG SAR, P R Seher GUNDUZ ARSLAN (TURKEY) CHINA) Selahattin ATMACA (TURKEY) Kursat ER (TURKEY) Selahattin TEKES (TURKEY) M. Ali FADEL (EGYPT) Serdar ERDINE (TURKEY) M. Sabri BATUN (TURKEY) Mahmut METE (TURKEY) Serdar ONAT (TURKEY) Marco MONTANARI (ITALY) Serhan Akman (TURKEY) Margaret TZAPHLİDOU (GREECE) Serhat ATILGAN (TURKEY) Medi GANIBEGOVIC (BOSNIA and Shailesh LELE (INDIA) HERZEGOVINA) Sinerik N. AYRAPETYAN (ARMENIA) Mehmet DOGRU (TURKEY) Smaragda KAVADIA (GREECE) Mehmet Nuri OZBEK (TURKEY) Sossani SIDIROPOULOU (GREECE) Mehmet Zulkuf AKDAG (TURKEY) Stephen D. SMITH (USA) Meliksah ERTEM (TURKEY) Susumu TEREKAWA (JAPAN) Meral ERDİNÇ (TURKEY) Süha türkaslan (TURKEY) Mohamed TREBAK (USA) Süleyman DASDAG (TURKEY) Mohammed Mustahsen URREHMAN (UAE) Tekin YILDIZ (TURKEY) Moschos A. PAPADOPOULOS (GREECE) Ufuk ALUCLU (TURKEY) Mostaphazadeh AMROLLAH (IRAN) Ugur KEKLIKCI (TURKEY) Muhammad FAHIM (INDIA) Xiong‐Li YANG (CHINA) Mukadder ATMACA (TURKEY) Yuri LIMANSKI (UKRAINE) Murat AKKUS (TURKEY) Zafer C. CEHRELI (TURKEY) Murat KIZIL (TURKEY) Zeki AKKUS (TURKEY) Murat SOKER (TURKEY) Zeynep AYTEPE (TURKEY) Mustafa KELLE (TURKEY) Zuhal KIRZIOGLU (TURKEY) Muzeyyen YILDIRIM (TURKEY) Zurab KOMETIANI (GEORGIA) Neval Berrin ARSERIM (TURKEY) Nezahat AKPOLAT (TURKEY)

Journal of International Dental and Medical Research / ISSN: 1309-100X 2010; 3: (3) / TABLE OF CONTENTS DENTISTRY

ARTICLE

SOLUBILITY OF FOUR DENTAL LUTING CEMENTS Ali Abdul Wahab Razooki Al-Shekhli Pages 104-107 ARTICLE AN IN VITRO EVALUATION OF ANTIMICROBIAL ACTIVITY OF DIFFERENT ENDODONTIC SEALERS Sabyasachi Saha, Sonali Saha, Firoza Samadi, J.N. Jaiswal, Ujjala Ghoshal Pages 108-115 ARTICLE TNF-α, IL-1β AND IL-8 LEVELS IN TOOTH EARLY LEVELLING MOVEMENT ORTHODONTIC TREATMENT Filiz Acun Kaya, Nihal Hamamci, Güvenç Başaran, Mehmet Doğru, Tuba Talo Yildirim Pages 116-121 ARTICLE EVALUATION OF THE PLAQUE REMOVING ABILITY OF CONVENTIONAL AND CURVED BRISTLE TOOTHBRUSH IN PEDIATRIC PATIENTS Rohit Anand , F. Samadi, J.N. Jaiswal Pages 122-125 ARTICLE PREVALENCE OF DENTAL TRAUMA AMONG CHILDREN AGE 2-15 YEARS IN THE EASTERN BLACK SEA REGION OF TURKEY Bugra Ozen, Tulay Cakmak, Ceyhan Altun, Bora Bagis, Figen Cizmeci Senel, Esra Baltacioglu, Ozgur Koskan Pages 126-132 CASE REPORT AUDIOVISUAL IATROSEDATION WITH VIDEO EYEGLASSES DISTRACTION METHOD IN PEDIATRIC DENTISTRY: CASE HISTORY Magora Florella, Cohen Sarale, Ram Diana Ram Pages 133-136 CASE REPORT FACIAL LESIONS OF HANSEN’S DISEASE MIMICKING ODONTOGENIC INFECTION: A CASE REPORT Amit Anil Mhapuskar, Neha Nadpurohit Pages 137-140 MULTIDISCIPLINARY treatment APPROACH of patıent wıth ectodermal dysplasıa Ozlem Marti Akgun, Fidan Sabuncuoglu, Ceyhan Altun, Gunseli Guven, Feridun Basak Pages 141-145 REVİEW ESTHETIC FAILURES IN FIXED PARTIAL DENTURES V N V Madhav Pages 146-153 MEDICINE CASE REPORT PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA (PEO): PRESENTATION OF A MITOCHONDRIAL MYOPATHY ACCOMPANIED BY ELECTRON MICROSCOPE Ayfer Aktas, Mehmet Serhan Tasdemir, Nebahat Tasdemir, Yusuf Nergiz Pages 154-157

2010 Volume 3 - Number 3

Journal of International Dental And Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Solubility Of Dental Luting Cements Ali Abdul Wahab Razooki Al-Shekhli

SOLUBILITY OF FOUR DENTAL LUTING CEMENTS Ali Abdul Wahab Razooki Al-Shekhli1* 1* B.D.S.,MSc, Ph.D.; Assistant Prof., Faculty of Dentistry, Ajman University of Science & technology, UAE.

Abstract Solubility is an important feature in assessing the clinical durability of luting cements.

Solubility may cause degradation of the cement, leading to debonding of the restoration and recurrent decay. The aim of this study was to evaluate and compare water solubility values of luting resin cement with other three conventional luting cements Four commercial dental luting cement materials were selected: GIC cement (SPOFA DENTAL a.s ,Markova 238), Zinc polycarboxylate cement (SS White Group.P.C.I,Unit 9 Madleaze Estate, Bristol Road, England), Zinc Phosphate cement (SPOFA DENTAL a.s Praha, Cernok.) and Resin cement (Densply Caulk 38 West Clarke Ave,U.S.A). Ten disc specimens were prepared for each cement material using a stainless steel mold with 10 mm in inner diameter and 2 mm in thickness. Water solubility of different cement materials were calculated by weighting the samples before and after water immersion (15 days) and desiccation. Data were analyzed by one-way ANOVA and Student t-test at 5% level of significance.

Statistical analysis of data by using one-way analysis of variance (ANOVA) revealed that, there was statistically significant difference (P<0.05) in solubility values between the four luting cements being tested.

Resin cement has the highest resistance to solubility in comparison with other conventional luting cements.

(J Int Dent Med Res 2010; 3: (3), pp. 104-107 ) Keywords: Luting cement, cement solubility, cement physical properties.

Received date: 10 June 2010 Introduction Presently, various types of adhesive cement are used for permanent and temporary cementation of indirect restorations. These cements had different mechanical and biological characteristics1-5. Amongst which, the most important characteristic is stability in the oral environment or resistance against decomposition and degradation. Decomposition of cements results in deterioration of restorations, and may even cause secondary caries6. The solubility of restorative materials directly affects their selection criteria. Materials designed for the same clinical purpose differ in their behavior with *Corresponding author: Assistant Prof. Ali Abdul Wahab Razooki Al-Shekhli, Faculty of Dentistry, Ajman University of Science & technology, UAE. E-mail: alirazooki@yahoo.com

Volume 3 路 Number 路 3 路 2010

Accept date: 07 September 2010 respect to long-time aging in water.

Zinc phosphate cement is one of the oldest materials used for the cementation of restorations7-9. But of late, many other adhesive quality cements have been developed. These cements give better results than zinc phosphate cement10. They adhere firmly to the surfaces of both dentin and metal prostheses, and thus reduce microleakage to a greater extent11. These lately developed adhesive cements include glass ionomer cement, polycarboxylate cement, and resin cement12. Besides, composite resins with dual-cure system for bonding inlays and laminate veneers have also been introduced 13, 14.

Solubility is an important feature in assessing the clinical durability of luting cements.

Consequently, solubility of luting cements has been widely evaluated in vitro 15. Solubility may cause degradation of the cement, leading to debonding of the restoration and recurrent decay16.

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Solubility Of Dental Luting Cements Ali Abdul Wahab Razooki Al-Shekhli

Material and Methods Four commercial dental luting cement materials were selected: GIC cement (SPOFA DENTAL a.s ,Markova 238), Zinc polycarboxylate cement (SS White Group.P.C.I,Unit 9 Madleaze Estate, Bristol Road, England), Zinc Phosphate cement (SPOFA DENTAL a.s Praha, Cernok.) and Resin cement (Densply Caulk 38 West Clarke Ave,U.S.A).

Ten disc specimens were prepared for each cement material using a stainless steel mold with 10 mm in inner diameter and 2 mm in thickness (Figure 1).

All the cements were mixed according to the manufacturer's instructions. The materials were placed in the mould and pressed between two plastic matrix strips and glass microscope slides under hand pressure to extrude any excess material. After specimens were removed from the mold, any excess material was removed by gentle, dry grinding on both sides.

The specimens were transferred to an air oven and dried for 2 hours at 37°C. Then the specimens were transferred a desiccator containing silica gel, freshly dried for 2 hours at 20°C. The specimens were weighed using an analytical balance to an accuracy of ± 0.1 mg.

This cycle was repeated until a constant mass (m0) was obtained. For each cement material, ten specimens were prepared (n=10) and placed in a glass vial containing 20 ml distilled water, The vials were wrapped in aluminum foil to exclude light and placed in an incubator at 37°C for 15 days.

The specimens were placed in desiccator using the same cycle as described above but the temperature was 58 °C to obtain (m1). This cycle was repeated until constant mass was obtained.

The values of solubility S were calculated using the following equations (ISO 4049:2000): S= m0m1/V Where m0 is the specimen mass before water immersion (mg), m1 is the specimen mass after immersion and desiccation (mg), and V is the specimen volume before immersion (mm3).

For each group, the means and standard deviations for solubility were calculated.

Statistical analysis for cement solubility values was performed using one-way ANOVA and t-test at a significance level of 0.05.

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Figure 1. The composite stainless steel mould used in this study.

Results Table (1) summarizes solubility means (Figure 2) and standard deviations (in parenthesis) of glass ionomer, Zinc phosphate, Zinc polycarboxylate, and resin cement respectively in µg/mm3.

Statistical analysis of data by using oneway analysis of variance (ANOVA) revealed that, there was statistically significant difference (P<0.05) in solubility values between the four cement groups being tested as shown in Table (2).

Table 1. Mean solubility values and standard deviations (in parenthesis) of the four tested cements.

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Figure 2. Solubility means in µg/mm3 for the four cement groups.

Table 2. One-way Analysis of Variance (ANOVA) test.

Further analysis of the data was needed to examine the differences between different pairs of groups using the t-test analysis and indicated that, pairs no. 2, 4 & 5 showed statistically insignificant difference ( P > 0.05) while pairs no. 1, 3 & 6 showed statistically significant difference ( P < 0.05 ) Table (3).

Table 3. t-test for different pairs of cement groups analysis.

Discussion Solubility or leaching of cement components has a potential impact on both its structural stability and biocompatibility. The rate of dissolution can be influenced by the conditions of the test. Other factors may include time of dissolution, concentration of the solute in the Volume 3 · Number · 3 · 2010

Solubility Of Dental Luting Cements Ali Abdul Wahab Razooki Al-Shekhli

dissolution medium, pH of the medium, specimen shape and thickness, and powder/liquid ratio of cement 17.

The chemical structure of the solutions used for in vitro tests is important because it has to simulate the complexity of the oral environment. The in vitro tests made are only static solubility tests because they do not simulate the pH and temperature changes of the oral cavity18. Clinical conditions vary, even within the same person, making it virtually impossible to reproduce a natural environment19. It was reported in previous studies that long–time storage in water affected the mechanical properties of the cements 20.

Cattani-Lorente et al. 21 found that deterioration of the physical properties of the cements after long–term storage in an aqueous environment could be related to the water absorption of these materials. Part of the absorbed water acted as a plasticizer, inducing a decrease in strength. Weakening resulted to erosion and plasticizing effect of water. In our study, the glass ionomer cement exhibited the highest mean solubility value followed by zinc phosphate cement, polycarboxylate cement and resin cement exhibited the lowest mean solubility value (Figure 2).

Polycarboxylate cement is much less soluble during immersion in distilled water. In contrast, the resin cements are basically insoluble, but may release small amounts of unpolymerized monomer constituents. Therefore, the main cause behind the high solubility values of the glass ionomer cement could be related to the fact that, glass ionomer cements are sensitive to water erosion. It may probably be due to same hydrolysis of the cement components. This phenomenon is apparently aggravated in oral environment due to the presence of aggressive compounds in the saliva22.

Clinical success with glass ionomer cements depends on early protection from both hydration and dehydration. It is weakened by early exposure to moisture, while desiccation, on the other hand, produces shrinkage cracks in the recently set cement23. Some studies conclude that glass ionomer cements are more resistant to degradation than zinc phosphate cements, although Knibbs and Walls 24reported that marginal defects around crowns appeared sooner with glass ionomer than with zinc Page 106

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phosphate, possibly because of the greater susceptibility of glass ionomer to contamination by moisture and this finding is in consistence with the results of this study.

Conclusions Resin cement had the highest resistance to solubility followed by polycarboxylate, zinc phosphate and glass ionomer which exhibited the least resistance to solubility in this study.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

Solubility Of Dental Luting Cements Ali Abdul Wahab Razooki Al-Shekhli

1998 Apr;25(4): 285-91.

16- Umino A, Nikaido T, Tsuchiya S, Foxton RM, Tagami J. Confocal laser scanning microscopic observations of secondary caries inhibition around different types of luting cements. Am J Dent 2005 Aug;18(4):245-50.

17- Wison AD. Specification test for the solubility and disintegration of dental cements: a critical evaluation of its meaning. J Dent Res 1976 Sep-Oct;55(5):721-9.

18- Yap A, Lee CM. Water sorption and solubility of resin-modified polyalkenoate cements. J Oral Rehabil 1997; 24: 310-314.

19- Macorra JC, Praides G. Conventional and adhesive luting cements. Clin Oral Invest 2002; 6: 198-204.

20- Cattani-Lorente MA, Godin C, Meyer JM. Mechanical behavior of glass ionomer cements affected by long–term storage in water. Dent Mater 1994; 10: 37-44.

21- Cattani-Lorente MA, Dupuis V, Payan J, Moya F, Meyer JM. Effect of water on the physical properties of resin-modified glass ionomer cements. Dent Mater 1999; 15: 71- 79.

22- Fukasawa M, Matsuya S, Yamane M. The mechanism for erosion of glass-ionomer cements in organic-acid buffer solutions. J Dent Res 1990; 69: 1175-1179.

23- McLean JW Clinical applications of glass ionomer cements.

Oper Dent 1992; 17: 184-190.

24- Knibbs PJ, Walls AWG. A laboratory and clinical evaluation of three dental luting cements. J Oral Rehabil 1989; 16: 467-473.

References 1- Phillips RW, Swartz ML, Lund MS, Moore BK, Vickery J. In vivo disintegration of luting cements. J Am Dent Assoc 1987; 114:489-492.

2- Watts DC, Kisumbi BK, Toworfe GK. Dimensional changes of resin/ionomer restoratives in aqueous and neutral media. Dent Mater 2000; 16:89-96.

3- Yesil Z. Üç farkli yapistirici simanin tutuculuk kuvvetlerinin incelenmesi (The comparison of bond strength of three different adhesive cements). Atatürk Üniv Dis Hek Fak Derg 1998; 8:3438.

4- Bayindir F, Yesil Duymus Z, Yanikoglu N. Daimi yapistirma isleminde kullanilan dört farkli simanin mikrosizintisinin karsilastirilmasi (The investigation of microleakage of four different cements for use in permanent cementation). Atatürk Üniv Dis Hek Fak Derg 2001; 1:22-26.

5- Yesil Duymus Z D rt geçici yapistirma simaninin tutuculuk kuvvetlerinin incelenmesi (The examination of retentive strength of four temporary cement). Ege Üniv Dis Hek Fak Derg 2000; 3:121-126.

6- Mesu FP. Degradation of luting cements measured in vitro. J Dent Res 1982; 61:665-672.

7- Mitra SB. Adhesion to dentin and physical properties of a lightcured glass-ionomer liner/base. J Dent Res 1991; 70:72-74.

8- Nicholson JW, Aggarwal A,Czarnecka B,Limanowska- Shaw H. The rate of change of pH of lactic acid exposed to glassionomer dental cements. Biomaterials 2000; 21:1989-1993.

9- Patel M, Tawfik H, Myint Y, Brocklehurst D, Nicholson JW. Factors affecting the ability of dental cements to alter the pH lactic acid solutions. J Oral Rehabil 2000; 27:1030-1033.

10- Lewin WA. An evaluation of the film thickness of resin luting agents. J Prosthet Dent 1989; 62:175-178.

11- White SN, Sorensen JA, Kang SK, Caputo AA. Microleakage of new crown and fixed partial denture luting agents. J Prosthet Dent 1992; 67:156-161.

12- Aboush YEH, Jerkins CBG. The bonding of an adhesive resin cement to single and combined adherent encountered in resin bonded bridge work. Brit Dent J 1991; 171:166-169.

13- Cardash HS, Baharav H, Pilo R, Ben-Amar A. The effect of porcelain color on the hardness of luting composite resin cement. J Prosthet Dent 1993; 69:620- 623.

14- Hasegawa EA, Boyer DB, Chan DC. Hardening of dual-cured cements under composite resin inlays. J Prosthet Dent 1991; 66:187-192.

15- Yoshida K, Tanagawa M, Atsuta M. In vitro solubility of three types of resin and conventional luting cements. J Oral Rehabil

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Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

AN IN VITRO EVALUATION OF ANTIMICROBIAL ACTIVITY OF DIFFERENT ENDODONTIC SEALERS Sabyasachi Saha1, Sonali Saha2*, Firoza Samadi3, J.N. Jaiswal4, Ujjala Ghoshal5 1. M. D. S. (Professor & Head) Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, India.

2. Dr., M.D.S. Department of Pedodontics (Senior Lecturer), Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Raibareilly Road, Lucknow, India.

3. M.D.S. Department of Pedodontics, (Professor & Head) Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Raibareilly Road, Lucknow, India.

4. M.D.S. Department of Pedodontics, (Professor & Director), Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, India.

5. M. D. (Assistant Professor) Department of Microbiology Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Abstract Microbes are considered as the primary etiologic agents in endodontic diseases. The ways of reducing these agents are: root canal debridement, antimicrobial irrigants and antibacterial filling materials. But the complexity of the pulp canal system presents a problem for chemo mechanical preparation. One of the factors determining the success of endodontic treatment is the sealing material with a potent bactericidal effect. The aim of the present study was to assess the antimicrobial activity of endodontic sealers of different bases – in vitro.

The antimicrobial activity of three root canal sealers (Endomethasone, AH 26 and Apexit) was evaluated against seven strains of bacteria at various time intervals using the agar diffusion test.

The freshly mixed sealers were placed in prepared wells of agar plates inoculated with the test microorganisms. The plates were incubated for 24, 48, 72 hours and 7 and 15 days. The mean zones of inhibition were measured. All statistical analysis was performed using the SPSS 13 statistical software version. The analysis of variance (ANOVA), Post-hoc Bonferroni test and Paired “t” test were performed to know the effects of each variable and to reveal the statistical significance.

All the data were presented in tabular and Bar diagram form.

Zinc oxide eugenol based sealer (Endomethasone) exhibited the highest antibacterial activity at all time intervals followed by the Epoxy resin based sealer (AH 26) and least by the Calcium hydroxide based sealer (Apexit). Greatest antimicrobial efficacy for all the three sealers was seen at 24 hour time interval which kept on diminishing with time and reached to the lowest level at 7 day time interval.

Results also showed that the zones of inhibition produced by each sealer decreased with time, and was the least after the seven days of incubation. The differences among all the groups were significant statistically (p<0.001) at all the four time intervals under study.

Zinc oxide eugenol based root canal sealer produced largest inhibitory zones followed in decreasing order by Epoxy resin based sealer and least by Calcium hydroxide based root canal sealer.

(J Int Dent Med Res 2010; 3: (3), pp. 108-115 ) Keywords: Antimicrobial activity, root canal sealer, Endomethasone, AH26, Apexit.

Received date: 02 August 2010

Accept date: 15 September 2010 Introduction

*Corresponding author: Dr. SONALI SAHA (Senior Lecturer) Department of Pedodontics, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Rai-bareilly Road, Lucknow, India. Pin- 226025.

Mobile No: +09889234995 E-mail: sonalisaha24@yahoo.co.in

Volume 3 · Number · 3 · 2010

Microorganisms and their by products are considered to be the primary etiologic agents in endodontic diseases1. Failure, during and after endodontic treatment are linked to the presence of bacteria in the root canal2.

This result hence emphasizes the importance of completely eliminating bacteria from the root canal system3. The most effective Page 108

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ways to achieve this aim are by means of instrumentation and irrigation. However, no less important than the biomechanics is an adequate filling of the root canal4.

But the irregularity in shape (lateral canals, anastomosis, bifurcations and curvatures), solid or semisolid root canal filling material alone cannot provide an exact fit5.

Therefore, root canal sealers with good sealing ability and antimicrobial activity are desired to kill and eliminate residual microorganisms6. Hence the present study has been taken up to test the antimicrobial activity of currently used endodontic sealers, against microbes found in the tooth with a vital inflamed pulp or pulpal necrosis.

The aim of the present study was to assess the antimicrobial activity of endodontic sealers of different bases – in vitro.

Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

Composition of the sealers:

Material ad Methods The present study was conducted in the Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, in collaboration with Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh (India).

In this study, the antimicrobial efficacy of three commercially available root canal sealers of different bases namely zinc-oxide eugenol, epoxy resin and calcium hydroxide were evaluated against seven strains of bacteria (aerobes, facultative and obligate anaerobes) known to be common isolates in necrotic pulps and endodontic lesions, at various time intervals using the agar diffusion test.

Previously, a pilot study was carried out in the same departments, to overview the proper study design and to take care of the possible constraints during the main study.

Tested sealers: Root canal sealers used in this study were Endomethasone (Zinc-oxide Eugenol based sealer), AH 26 (Epoxy resin based sealer) and Apexit (Calcium hydroxide based sealer).

The sources of the sealers were as follows.

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This calcium hydroxide based root canal sealer is prepared by mixing equal volumes of base and activator on a mixing pad.

Preparation of the sealers: The sealers were prepared in strict compliance with the manufacturer’s recommendations.

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Test microorganisms: Antibacterial activities of the sealers were evaluated against five aerobes and facultative anaerobes and two obligate anaerobes.

Strains used, their source, and morphotype are given below: Staphylococcus aureus -- ATCC 25923-- Gram positive cocci Streptococcus ß haemolyticus -- ATCC 10556- Gram positive cocci Enterococcus faecalis-- ATCC 29212-- Gram positive cocci Escherichia coli-- ATCC 25922-- Gram negative bacilli Pseudomonas aeruginosa-- ATCC 27853-Gram negative bacilli Peptostreptococcus sp. (obligate anaerobes)-NCTC 9821-- Gram positive cocci Bacteroides fragilis (obligate anaerobes)-ATCC 35406 -- Gram negative bacilli  ATCC= American Type Culture Collection  NCTC= National Culture Type Collection

Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

0.5 on McFarland scale which corresponds to a concentration of 108 colony forming units ml-1.

Petridishes, 90 millimeter diameter, containing four millimeter thick Mueller-Hinton agar (MH; Difco Laboratories, Detroit, Michigan, USA) were used for all the above bacterial strains except Streptococcus ß haemolyticus, for which Blood agar plates were used.

To ensure even distribution of the inoculums, the respective bacterial dilutions were then swabbed evenly onto freshly prepared respective agar plates using the “Lawn Technique”. Each plate (for every individual bacterial strain) was evenly divided into three equal sections. In each section of each plate, wells of six millimeter diameter were created with the help of previously fabricated and sterilized copper wells. (Figure 1) The three wells in each section were then filled with the three different based freshly mixed sealers. (Figure 2)

Procedure: Cultures of the individual bacterial strains were obtained from the laboratory stock of the Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow.

Growth culture:

conditions

and

bacterial

Figure 1. Agar plates showing wells created with previously fabricated and sterilized copper wells.

S. aureus, E. faecalis, E. coli and P. aeruginosa were grown aerobically in Brain Heart Infusion (BHI) Broth and Streptococcus ß haemolyticus in Trypticase soy broth.

Bacteroides fragilis and Peptostreptococcus sp. were grown in BHI containing Hemin & Menadione .

Preparation of the inoculums: Inoculum for each bacterial strain, was prepared by picking up four to five colonies with the help of a circular, previously sterilized loop of four millimeter internal diameter and dissolving them into respective test-tubes containing 5 ml of 0.85% saline solution – to produce a turbidity of Volume 3 · Number · 3 · 2010

Figure 2. The three wells filled with the three different based sealers.

Incubation: The inoculated plates with the sealers were kept for two hours at room temperature to allow the diffusion of the agents through the agar.

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The MH agar plates were incubated at 37oC. The Blood agar plates inoculated with Streptococcus ß haemolyticus strain was incubated in a CO2 incubator (Jouan, Saint Herblain, France) in an atmosphere of 10% CO2. Plates with strict anaerobes were immediately placed into GasPak anaerobic jars [nitrogen (90%) and CO2 (10%)].

The plates for facultative anaerobes were read at 24 hours, 48 hours, 72 hours and lastly at 7 days for size of the zone of inhibition while readings for strict anaerobes were carried out after 48 hours, 7 days and 15 days. The whole experiment was repeated six times for each isolate and the mean zone of inhibition was then calculated.

Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

diagram form. The analysis of variance (ANOVA), Post-hoc Bonferroni test and Paired “t” test were performed to know the effects of each variable and to reveal the statistical significance.

The confidence level of the study was proposed to be 95%, hence a “p” value <0.05 has been considered significant, “p” value <0.01 has been considered highly significant and a “p” value <0.001 has been considered very highly significant.

Results

Measuring the size of Zone of Inhibition: Growth inhibitory zones around each sealer was evidenced by lack of bacterial colonization (clearing of agar) adjacent to each sealer. The most uniform diameter segment of the zone of inhibition was measured with an endodontic millimeter ruler and the six millimeter diameter of the well was extracted from the measurement as the cut - off value. All measurements above this value were considered indicative of significant bacterial growth inhibition.

Wider zones of inhibition were interpreted to indicate greater antimicrobial activity of the involved sealers.

Positive growth control / Negative growth control: Positive growth control:- Seven agar plates were streaked with individual test microorganisms only without the sealers to ensure that the bacterial life cycle did not become inactive before the last 7-day observation in case of aerobes / facultative anaerobes and last 15-day observation in case of obligate anaerobes.

Negative control: - Three different based sealers were placed on seven plates which had not been inoculated with bacteria, and one plate had neither sealer nor bacteria.

Statistical analysis: All statistical analysis was performed using the SPSS 13 statistical software version.

All the data were presented in tabular and Bar Volume 3 · Number · 3 · 2010

Figure 3 & 4. Growth inhibitory zones evidenced by lack of bacterial colonization (clearing of agar) adjacent to each sealer.

Table 1 shows the antimicrobial efficacy of Zinc oxide eugenol based sealer (Endomethasone), Epoxy resin based sealer (AH 26) and Calcium hydroxide based sealer (Apexit) against all the five aerobic microorganisms (Staphylococcus aureus, Streptococcus ß haemolyticus, Enterococcus faecalis, Escherichia coli and Pseudomonas aeruginosa) at 24 hours, Page 111

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48 hours, 72 hours and 7 days time interval.

(Figure 3 & 4)

Table 1. Antibacterial Efficacy of Different Sealers for Aerobic Bacteria (Values in Mean±SD) It was seen that the mean antimicrobial efficacy of Endomethasone was significantly higher as compared to that of AH 26 and Apexit.

Maximum antimicrobial efficacy was seen for Endomethasone (32.97±8.77 mm) at 24 hours while minimum antimicrobial efficacy was seen for Apexit (1.40±1.85 mm) at 7 days.

Table 1a shows analysis of variance (ANOVA) of the three different sealers for the aerobic strains of bacteria. Results reveals a highly significant (p<0.001) difference among the sealer groups for their antimicrobial efficacy against aerobic bacteria at the four different time intervals.

Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

for Apexit (1.25±1.36 mm) at 15 days time interval.

Table 2. Antibacterial Efficacy of Different Sealers for Anaerobic Bacteria (Values in Mean±SD).

Table 2a shows analysis of variance (ANOVA) of the three different sealers for the anaerobic strains of bacteria. Results reveal a highly significant (p<0.001) difference among the groups for their antimicrobial efficacy against anaerobic bacteria at different time intervals.

Table 2a. Analysis of variance of Different Sealers for Anaerobic Bacteria.

Graph 1 reveals the antibacterial efficacy of the three different test sealers against all the seven microbial strains. Statistically significant difference in antibacterial efficacy was seen for different microbial strains and sealers.

Table 1a. Analysis of variance of Different Sealers for Aerobic Bacteria.

Table 2 shows the antimicrobial efficacy of Endomethasone, AH 26 and Apexit against the two anaerobic microorganisms (Bacteroides fragilis and Peptostreptococcus sp.) at 48 hours, 7 days and 15 days time interval. It was seen that the mean antimicrobial efficacy of Endomethasone was significantly higher as compared to that of AH 26 and Apexit. Maximum antimicrobial efficacy was seen for Endomethasone (50.92±2.74 mm) at 2 days while minimum antimicrobial efficacy was seen Volume 3 · Number · 3 · 2010

Graph 1. Antibacterial efficacy of the three different test sealers against all the seven microbial strains.

It was seen that Endomethasone had a higher efficacy as compared to all the other Page 112

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sealers for all the microbial strains. Highest efficacy was seen against Bacteroides fragilis (46.06±7.42 mm) while Apexit was found to be ineffective against four strains. Results also revealed that Endomethasone and AH 26 exhibited the maximum antibacterial efficacy against Bacteroides fragilis, while Apexit showed maximum antibacterial efficacy against Streptococcus ß haemolyticus. Enterococcus faecalis was found to be the most resistant strain.

Discussion Objective of root canal treatment is to eliminate the bacteria by cleaning, shaping and filling of the root canal system. But residual bacteria lead to endodontic failures. Therefore, root canal sealers with good sealing ability and antimicrobial activity are desired to kill the surviving microorganisms6.

To standardize the whole experimental process, great care had been taken regarding the inoculation density, proper incubation, positive and negative growth control, careful reading of zone of inhibition and repetition of the whole experiment six times.

The most commonly used root canal sealers in endodontics are mainly of three types depending on their composition. These are Zinc oxide eugenol based, Calcium hydroxide based and Epoxy resin based root canal sealers6-8.

Most of the studies reported evaluated initial microbial inhibition only, but it seems equally important to determine the effect over a longer time interval9.

It was important to ensure that test bacteria selected were true endodontic pathogens10. If a sealer is effective against these microorganisms, it will probably be effective against the more susceptible ones.

Streptococcus ß haemolyticus represents a standard against which antibacterial action of a sealer should be studied11. E. faecalis was the most resistant species in the oral cavity and possible cause of failure of root canal treatment4.

P. aeruginosa was resistant to all antibiotics and flora of long standing therapy12,13 of the Bacteroides species, B. fragilis has been isolated from infected root canals14.

Most commonly used method in vitro for assessing antimicrobial activity of root canal sealers is the agar diffusion test4, 15, 16. This test maintains the chemical properties of the tested Volume 3 · Number · 3 · 2010

Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

sealers5. ADT is influenced by the diffusibility of the material, hence plates were kept for two hours at room temperature (allow the diffusion) as suggested by Gomes et al. 20044.

A statistically significant fall in the mean antimicrobial efficacy was seen with the progression of time for all the three sealers under study (p<0.05). The results between groups and within groups at all the four time intervals demonstrated a statistically significant value (p=<0.001). Zinc oxide eugenol based sealer (Endomethasone) exhibited the highest antibacterial activity. Epoxy resin based sealer (AH 26) showed significantly higher (p<0.001) antimicrobial efficacy as compared to the Calcium hydroxide based sealer (Apexit) for all time intervals. Greatest antibacterial property was observed at 24 hours interval for all the three sealers. However, the fall in antimicrobial efficacy of Endomethasone was not significant between 48 hours and 72 hours. For AH 26 change between 48 to 72 hours was not significant statistically and for Apexit, the change from 24 to 48 hours, 24 to 72 hours and 48 to 72 hours was not significant statistically (p>0.05). Results also showed that the zones of inhibition produced by each sealer decreased with time, and was the least after the seven days of incubation.

Zinc oxide eugenol based root canal sealer (Endomethasone) produced the largest inhibitory zones against all microorganisms, which was in accordance to similar inhibitory activity of Zinc oxide eugenol based sealers by Cox et al. 1978, Stevens and Grossman 1981, Orstavik 1981, Pupo et al. 1983, Barkhordar 1989, Al Khatib et al.

19901,14,17-20.

Endomethasone showed a continued inhibitory effect for up to seven days and for up to fifteen days. Kaplan et al. (1999) stated that the most effective antimicrobial sealers contain eugenol and formaldehyde9. Pupo et al. (1983) proved Endomethasone to be the most effective among all the Zinc oxide eugenol based sealers19.

A gradual, continuous release of formaldehyde from the paraformaldehyde in the sealer (after setting) accounts for the antibacterial activity14.

Eugenol present is a potent antimicrobial agent (bactericidal agent) 21.

The Epoxy resin based sealer (AH 26) exhibited zones of bacterial growth inhibition but lesser in comparison with the Endomethasone, which was is in accordance to the study of Grossman (1980), Orstavik (1981), Stevens and Page 113

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Grossman (1981), Pumarola et al. 1992, Kaplan et al. 1999, Lai et al. 2001, Gomes et al.

20044,5,9,14,18,22,23.

AH 26 contain Hexamethylenetetramine (methenamine) in its basic composition.

Methenamine is a hydrophilic material and in an acidic environment is hydrolyzed to ammonia and formaldehyde24. Release of formaldehyde during gives the resin based sealer its antimicrobial properties 16. Al-Khatib et al. (1990), showed existence of antibacterial activity of this material on Streptococcus strains and S. aureus1. AH 26 showed good antibacterial activity against E. faecalis 25.

Apexit demonstrated no antimicrobial activity against four of the test microorganisms tested viz E. faecalis, E. coli, P. aeruginosa and B. fragilis and very little antimicrobial effect against S. aureus, Streptococcus and Peptostreptococcus strains. This result was consistent with the studies of Siquera and Lopes (2000)26.

Antibacterial activity of Calcium hydroxide based sealers is based on its ionic dissociation into calcium (Ca2+) and hydroxyl (OH-) ions causing an increase in pH (12.5)3. A pH > 9 may reversibly or irreversibly inactivate cellular membrane enzymes of the microorganism, resulting in a loss of biological activity of the cytoplasmic membrane. Very slight antimicrobial effect with Apexit might be explained by too slow release of hydroxyl ions during the duration of contact6.

Absence of an antibacterial effect on some strains of bacteria could conclude that, the release of hydroxyl ions from calcium hydroxide was not sufficient to inhibit the growth pH of these microorganisms9. In addition, artificial media, mainly those containing blood, have a buffer ability that could provide a reduction of the high pH of calcium hydroxide, making it less effective. In clinical situations, buffer action of blood and tissue fluids may cause the same effects26.

Estrela et al. (1999) observed that calcium hydroxide based root canal sealers were ineffective against P. aeruginosa and Bacteroides species27.

This finding was also in accordance to the present study conducted.

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Antimicrobial Activity of Endodontic Sealers Sabyasachi Saha et al

Conclusions On the basis of the results, observations and statistical analysis the following conclusion could be drawn: 1. Zinc oxide eugenol based root canal sealer produced largest inhibitory zones followed in decreasing order by Epoxy resin based sealer and least by Calcium hydroxide based root canal sealer. Zinc oxide eugenol based root canal sealer showed continued inhibitory effect for periods up to 7days / 15 days respectively, (presence of eugenol and continuous release of formaldehyde) 2. AH 26 exhibited zones of bacterial growth inhibition, at all time intervals, but a lesser growth inhibition in comparison with Endomethasone.

3. Apexit showed no antimicrobial activity against four of the test microorganisms tested – E. faecalis, E. coli, P. aeruginosa and B. fragilis. Very little antimicrobial effect against S. aureus, Streptococcus and Peptostreptococcus strains.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Al-Khatib ZZ, Baum RH, Morse DR, Yesilsoy C, Bhambhani S, Furst ML. The Antimicrobial effect of various endodontic sealers. Oral Surg Oral Med Oral Pathol Endod 1990; 70: 78490.

2. Sundqvist G. Ecology of the root canal flora. J Endodon 1992; 18(9): 427-30.

3. Sjögren U, Figdor D, Spangberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J 1991; 24: 119-25.

4. Gomes BPFA, Pedroso JA, Jacinto RC, Vianna ME, Ferraz CCR, Zaia AA, Souza-Filho FJ. In vitro Evaluation of the Antimicrobial Activity of Five Root Canal Sealers. Braz Dent J 2004; 15(1): 30-35.

5. Pumarola J, Berastegui E, Brau E, Canalda C, Jimenez de Anta MT. Antimicrobial activity of seven root canal sealers. Oral Surg Oral Med Oral Pathol Endod 1992; 74: 216-20.

6. Kayaoglu G, Erten H, Alacam T, Orstavik D. Short-term antibacterial activity of root canal sealers towards Enterococcus faecalis. Int Endod J 2005; 38:483-88 7. Ahangari Z, Ashraf H, Oskooii M, Soltani S, Nasser M. Antibacterial Activity of Three Endodontic Sealers with various Bases. Int Endod J 1996; 29: 280-84.

8. Almeida WAD, Leonardo MR, Filho MT, Silva LAB. Evaluation of apical sealing of three endodontic sealers. Int Endod J 2000; 33: 25-27.

9. Kaplan AE, Picca M, Gonzalez MI, Macchi RL, Molgatini SL.

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10.

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22.

23.

24.

25.

26.

27.

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Antimicrobial effect of six endodontic sealers: an in vitro evaluation. Endod Dent Traumatol 1999; 15: 42-45.

Chong BS, Owadally ID, Pitt Ford TR, Wilson RF. Antibacterial activity of potential retrograde root filling materials. Endod Dent Traumatol 1994; 10: 66-70.

Coogan MM, Creaven PJ. Antibacterial properties of eight dental cements. Int Endod J 1993; 26: 355-61.

Ranta K, Haapsalo M, Ranta H. Monoinfection of root canal with Pseudomonas aeruginosa. Endod Dent Traumatol 1988; 4: 269-72.

Tronstad L, Barnett F, Flax M. Solubility and biocompatibility of calcium hydroxide containing root canal sealers. Endod Dent Traumatol 1988; 4: 152-59.

Stevens RH, Grossman LI. Antimicrobial effect of root canal cements on an obligate anaerobic organism. J Endodon 1981; 7(6): 266-67.

Abdulkader A, Duguid R, Saunders EM. The antimicrobial activity of endodontic sealers to anaerobic bacteria. Int Endod J 1996; 29: 280-83.

Bodrumlu E, Semiz M. Antibacterial Activity of a new Endodontic Sealer against Enterococcus faecalis. Journal of Canadian Dental Association 2006; 72(7): 637.

Cox ST, Hembree JH, McKnight JP. The bactericidal potential of various endodontic materials for primary teeth. Oral Surg Oral Med Oral Pathol Endod 1978; 45(6): 947-54.

Orstavik D. Antibacterial properties of Root Canal Sealers, cements and pastes. Int Endod J 1981; 14: 125-33.

Pupo J, Biral RR, Benatti O, Abe A, Valdrighi L. Antimicrobial effects of endodontic filling cements on microorganisms from root canal. Oral Surg Oral Med Oral Pathol Endod 1983; 55(6): 622-27.

Barkhordar RA. Evaluation of antimicrobial activity in vitro of ten root canal sealers on Streptococcus sanguis and Streptococcus mutans. Oral Surg Oral Med Oral Pathol Endod 1989; 68: 77072.

Hume HR. The pharmacologic and toxicological properties of zinc oxide-eugenol. JADA 1986; 113: 781-91.

Grossman L. Antimicrobial effect of root canal cements. J Endodon 1980; 6(6): 594-97.

Lai CC, Huang FM, Yang HW, Chan Y, Huang MS, Chou MY, Chang YC. Antimicrobial activity of four root canal sealers against endodontic pathogens. Clin Oral Invest 2001; 5(4):23639.

Spangberg LSW, Barbosa SV, Lavigne GD. AH 26 releases Formaldehyde. J Endodon 1993; 19(12): 596-97.

Fuss Z, Charniaque O, Pilo R, Weiss EI. Effect of various mixing ratios on Antibacterial properties and hardness of Endodontic Sealers. J Endodon 2000; 26(9): 519-22.

Siqueira JF, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. Int Endod J 1999; 32: 36169.

Estrela C, Pimenta FC, Ito IY, Bammann LL. Antimicrobial Evaluation of Calcium hydroxide in Infected Dentinal tubules. J Endodon 1999; 25(6): 416-18.

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TNF- α, IL-1β, IL-8 Levels and Orthodontic Movement Filiz Acun Kaya et al

TNF-α, IL-1β AND IL-8 LEVELS IN TOOTH EARLY LEVELLING MOVEMENT ORTHODONTIC TREATMENT Filiz Acun Kaya1*, Nihal Hamamci2, Guvenc Basaran2, Mehmet Dogru3, Tuba Talo Yildirim4 1*. Associated Professor, Department of Periodontology, Faculty of Dentistry, Dicle University, Diyarbakir, TURKEY. 2. Assistant Professor, Department of Orthodontics, , Faculty of Dentistry, Dicle University Diyarbakir, TURKEY. 3. Associated Professor, Department of Chemistry , Faculty of Science and Art, Dicle University, Diyarbakir, TURKEY. 4. MsC Research Asistant, Department of Periodontology, Faculty of Dentistry, Dicle University, Diyarbakir, TURKEY.

Abstract During orthodontic treatment, the early response of periodontal tissues to mechanical stress involves several metabolic changes that allow tooth movement. The aim of the present study was to determine tumor necrosis factor alpha (TNF-α), interleukin 1β (IL-1β) and interleukin 8 (IL-8) levels in GCF in tooth early levelling movement orthodontic treatment.

Seventeen patients, 8 female and 9 male individuals (aged: 16-20 years; mean 18.2 ± 1.4 years), participated in this study. Each subject underwent a session of professional oral hygiene and received oral hygiene instructions. Three months later, a fixed orthodontic appliance was placed. The patients were seen at baseline and between 1-7 days levelling of the teeth.

The concentration of TNF-α, IL-1β and IL-8 were shown in Tables 1. There were statistical differences between the observations at the 1-2 day of levelling for TNF-α, IL-1β and IL-8 (p<.05).

Orthodontic forced induces rapid release of the TNF-α, 1L-1β and IL 8 levels during tooth movement in gingival crevicular fluid (GCF). The results of this study support the hypothesis that proinflammatory cytokines play a potent role in bone resorption after the application of orthodontic force in short time.

(J Int Dent Med Res 2010; 3: (3), pp. 116-121) Keywords: orthodontic treatment, bone remodeling, gingival crevicular fluid, TNF-α, IL-1β, IL-8.

Received date: 15 May 2010 Introduction Orthodontic tooth movement is based on force induced periodontal ligament (PDL) and alveolar bone remodeling.1-4 Mechanical stimuli exerted on a tooth cause an inflammatory response in the periodontal tissue. Inflammatory mediators trigger the biological processes associated with alveolar bone resorption and apposition.1

*Corresponding author: Assoc. Prof. Dr. Filiz ACUN KAYA Dicle University, Faculty of Dentistry, Department of Periodontology, 21280 DIYARBAKIR/ TURKEY. Phone:+90 412 2488105-3430 Fax: +90 412 2488100 E-mail: facunkaya@gmail.com

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Accept date: 20 September 2010 An important breakthrough in bone biology was the identification of the role of cytokines in bone remodeling. Cytokines are involved in initiating, amplifying, perpetuating, and resolving inflammatory responses. They are key mediators for tissue damage and play an important role in tooth movement. Cytokines are classified as proinflammatory and antiinflammatory. Proinflammatory ones are TNF-α, IL-1, interleukin 2 , interleukin 6 and IL-8. Antiinflammatory cytokines are interleukins 4, 10, and 13. The proinflammatory ones are alarm cytokines, inducing vascular dilatation with increased permeability and enhancing inflammatory response.5 TNF-α is a typical mediator of inflammatory response that has been shown to be involved in the process of bone resorption.6,7 TNF-α plays a prominent role in the mechanism controlling the appearance of osteoclasts at compression sites.8,9 This cytokine is produced primarily by activated monocytes and Page 116

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macrophages but also by osteoblasts and has been proven to be an activator of osteoclastic bone resorption.10 IL-1β, a major physiologic form of IL-1, is mainly secreted by monocytes and partially by macrophages, endothelial cells, fibroblasts, and epidermal cells. This secretion is activated by various stimuli11 All these studies demonstrated that mechanical stimuli activate the release of inflammatory cytokines.

IL-8 is a potent proinflammatory cytokine that has a key role in the recruitment and activation of neutrophils during inflammation. It is secreted mainly by monocytes and is important in regulating alveolar bone resorption during tooth movement by acting early in the inflammatory response.12 Various researchers demonstrated elevated levels of cytokines in tooth movement.7,13 Alhashimi et al.7 performed in situ hybridization to measure the messenger RNA (mRNA) expression of IL-1β, IL-6, and TNF-α at 3, 7, and 10 days after application of orthodontic force on rat molars. However, they could not detect mRNA expression of TNF-α, though induction of IL-1β and IL-6 was observed to reach maximum on day 3 and declined thereafter.

They explained this absence by the feedback mechanism caused by increased TNF-α protein levels and species-related differences.

The level of chemokines was significantly increased at the early stages and decreased in 7–10 days, and it was concluded that the early inflammatory response was the main trigger for bone remodeling processes.1 Stashenko et al.14 examined the cytokine levels of IL-1α, IL-1β, and TNF-α in bone resorption and indicated that IL-1β is an important mediator in the mechanism of bone resorption.

The purpose of the present study was to determine TNF-α, IL-1β and IL-8 levels in tooth early levelling movement orthodontic treatment and to evaluated the effect of orthodontic forces on periodontal tissues.

Materials and Methods 8 female and 9 male individuals (age 1620 years; mean 18.2 ± 1.4 years), who attended to Dicle University, School of Dentistry, Department of Orthodontics and diagnosed for the extraction of their first premolar(s) were participated in this study. The inclusion criteria for Volume 3 · Number · 3 · 2010

TNF- α, IL-1β, IL-8 Levels and Orthodontic Movement Filiz Acun Kaya et al

the participants were: (1) a healthy systemic condition, (2) no use of anti-inflammatory drugs in the four months preceding the beginning of the study, (3) the need for extraction treatment with fixed appliances involving distalization of at least one maxillary canine, (4) probing depth values (measured as the distance from the bottom of the sulcus to the most apical portion of the gingival margin) not exceeding three mm in the whole dentition, (5) no loss of periodontal attachment (measured as the distance from the bottom of the sulcus to the cemento-enamel junction) exceeding two mm in any interproximal site, and (6) no radiographic evidence of periodontal bone loss after a full-mouth radiographic periapical examination. Informed consent was obtained from the patients and the parents of patients under 18 years of age.

Clinical procedures Maxillary first premolars were extracted for each participant and, all subjects received repeated oral hygiene instructions (OHIs), which included the correct use of a toothbrush and an interdental brush during the following three months. At the end of this period, before orthodontic treatment with full brackets (Omni Roth, GAC International, Inc, Bohemia NY,USA) was initiated, GCF sampling was performed (baseline). GCF was collected from the mesial and distal aspect of the upper canines in this study. At this appointment orthodontic treatment was begun with 0.014” Nitinol arch wires (GAC International, Inc, Bohemia NY, USA). On the second appointment, patient was instructed to brush their teeth and not to eat anything three hours before other sampling. The forces that are applied on the tooth were still active. Other days (3th, 4th, 5th, 6th, 7th) sampling was performed with the same procedures.

GCF sampling Sample collections were done in the early hours of the day. GCF sampling was obtained with paper strips (Periopaper, Pro Flow, Amityville NY, USA) using the method described

by Rudin et al.15 Sampling was performed only on the vestibular sides of the tooth to prevent salivary contamination (sample sites were isolated with cotton rolls, plaque was removed and the tooth surfaces were air dried). Paper strips were placed into the sulcus and, after waiting 30 seconds, an apparatus (periotron Page 117

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8000, Ora Flow Inc, Plainview NY, USA) was used for determining the GCF volume. Saliva and blood contamination was important so contaminated samples were excluded from the study. Paper strips were stored in sterile tubes at -200C until the day of experimentation. GCF sampling was done before all other clinical examinations were performed to prevent increase in fluid volume. Before examination of the GCF, 1000µl sterile NaCl (9mg/ml) was added to paper strips and the GCF was diluted at 3000g at +50C for 20 minutes.16 Cytokines analysis The kit and the machine used for measuring TNF-α, IL-1β and IL-8 were immunoassay system (Immulite 1000, Diagnostic Products Corp., Los Angeles CA, USA) (Figure 1). For the manual dilution of patient samples, TNF-α, IL-1β and IL-8 free non-human buffer matrix was used. The amount of TNF-α, IL-1β and IL-8 detected in each sample was compared with an TNF-α, IL-1β and IL-8 standard curve that demonstrates a direct relationship between optical dentistry and cytokine concentration. The total amount of TNF-α, IL-1β and IL-8 was determined in picograms.

Statistical evaluation Repeated one way ANOVA was used to determine differences between the GCF TNF-α, IL-1β and IL-8 cytokine levels in experiment days (Table 1).

TNF- α, IL-1β, IL-8 Levels and Orthodontic Movement Filiz Acun Kaya et al

differences between two adjacent points for TNFα, IL-1β and IL-8 concentrations (Table 2).

Descriptive measurements (mean, standard deviation, median, minimum and maximum) of the volume of the gingival crevicular fluid are given in Table 3. All of the statistical evaluations were made using SPSS 10.0 software program.

Table 2: The comparison of two adjacent concentrations of TNFα ,IL-1β and IL-8.

Table 3: The volumes of gingival crevicular fluid (μI).

Results The concentration of TNF-α, IL-1β and IL8 were shown in Table 1. There were statistically significant differences between the observations at the 1-2 day of levelling for TNF-α, IL-1β and IL-8 (p<.05). Moreover, there was no statistically significant difference was detected in GCF levels of TNF-α, IL-1β and IL-8 between the days of 3-7 day of leveling (p>.05).

Table 1: The concentrations of TNF-α, IL-1β and IL-8. (pg/ml) p<.05.

Paired student t test was used to understand the significant differences between the groups at a time interval, by taking the Volume 3 · Number · 3 · 2010

The comparison of two adjacent concentrations of TNFα, IL-1β and IL-8 were shown in Table 2. The comparison between two adjacent observations were not statistically different from each other (p>.05).

Gingival crevicular fluid volumes were given in Table 3. The GCF volume was greater Page 118

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between 1-3 days of levelling and it returned to base line level after 3 days. No statistically significant differences were found between the groups (p>.05).

Discussion Orthodontic tooth movement occurs by the remodeling of the alveolar bone as a result of the force exerted on the periodontium. When a force, greater than capillary blood pressure, is directed on the tooth; a hyaline zone occurs in the direction of force and a tension site occurs on the opposite side. This hyaline zone, free of cells, is necrosed by osteoclasts that originate from the tension site. On the tension side, osteoblasts occur in the bone-apposition process.8 These are well-known histological signs. Proinflammatory cytokines play important roles in bone and root resorption. Determining the levels of various cytokines during various phases of orthodontic treatment undoubtedly contributes to our understanding of the underlying mechanisms of tooth movement.

Biologic aspects of tooth movements should be clearly determined.

IL-1β and TNF-α affect bone metabolism directly. At extremely low concentrations, IL-1β and TNF-α have been implicated in the process of bone remodeling through specific receptors on the bone cell population.13 Monocytes and macrophages do not constituently produce IL-1β or TNF-α, but on “activation” they synthesize and release these cytokines.1,7 Davidovitch et al.1 have ocalized induced levels of IL-1β and TNF-α in the periodontium of teeth undergoing movement.

IL-8 is believed to play an important role in the pathogenesis of various forms of periodontitis, and high levels were detected in such subjects.17 Because periodontal tissues are remodeled at both tension and pressure sites during tooth movement, the increased amount of IL-8 at both sites just after application of mechanical forces might be a sign of neutrophil reaction in the area. After the acute response, IL8 stimulation might be continued at the tension sites. Therefore, under the influence of mechanical forces, pressure sites indirectly contribute to the production of IL-8. Thus, we thought that the production of IL-8 is regulated differentially at tension and pressure sites and Volume 3 · Number · 3 · 2010

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probably plays a major role in the initial stage of remodeling. Similar results were shown by Takahashi et al.18, who tried to clarify the hypothesis that the expression of matrixmetalloproteinase-8 (MMP-8) and matrixmetalloproteinase-13 (MMP-13) are regulated differently by tension and compression.

Alternatively, because of the less active IL-8 production at pressure sites in this study, it was concluded that the initial force might be too heavy for a period and that decreased the cellular activity.

The gingival sulcus was selected as the testing site because of its continuity with the PDL and its accessibility within the oral cavity. The prediction that compression of the PDL in humans could result in the migration of biochemical products into the gingival sulcus is the basis of our experimental design. Previous in situ techniques for biochemical analysis of the gingival crevice involved sampling crevicular fluid using paper strips.1 The paper strip method was used in this study. The upper canines of all patients were monitored in this study because these teeth are accessible and easily cleaned. 19 It has been shown that levels of biochemical markers in GCF might depend on different collection sites.20 For this reason, the canines were used as both the test and control teeth in this study. The control data were collected at baseline, which were obtained before any force was applied. Serra et al.3 stated that age and sex does not increase enzymatic activity so age and sex differences were not considered in this study.

Study were designed to examine the GCF levels of TNF-α, IL-1β and IL-8 during in tooth early levelling movement orthodontic treatment.

The results clearly demonstrated that TNF-α, IL1β and IL-8 levels were increased during study period.

King et al.21 described an early phase of bone resorption (3-5 days), its reversal (5-7 days), and a late phase (7-14 days) of bone deposition in rats. A similar bone cycle has also been reported in humans,17 but in humans this timing seems to be longer than in rats. These studies might support our finding of increased IL-1 and TNF- levels in GCF. In the early stages of orthodontic force application it has been shown that many PDL cells stain positively for IL-1β.1 Also, Lynch et al.22 reported that in the early stages of tooth Page 119

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movement (12 and 24 hours) many PDL cell types stained positively for IL-1β. Lowney et al.23 demonstrated that TNF-α plays a pivotal part in the assessment of orthodontic tooth movement.

Tzannetou et al.24 used low and high forces to the maxillary molars to expand the palate. Low forces were produced by separator placement and higher forces by a palatal expansion device. They observed high levels of IL-1 levels with both of the force levels. Also Kee-Joon Lee et al.25 demonstrated that the mean concentrations of IL-1 increases in the first 24 hours after continuous and interrupted forces. All of these studies examined GCF in short times as compared to the present study.

They found that especially in the first 24 hours, cytokine levels increased and than equilibrium is reached which is higher than the baseline levels.

TNF-α, IL-1β and IL-8 concentration showed highest levels in the pressure sites immediately in the first and 24th hour. This might be caused by an early upregulation of chemotactic activities directly after mechanical force application. This is in accordance with Davidovitch et al.1, Who showed the acute inflammatory response in the initial phase of tooth movement.

The increased production of the other mediators in tooth movement has been shown in several studies.26,27 Conclusions The health condition of the periodontium is important during orthodontic treatment. Forces in different directions, duration, and magnitudes cause changes in the periodontal tissues.

Orthodontic forced induces rapid release of the TNF-α, 1L-1β and IL- 8 levels during tooth movement. Levelling of the teeth evoked increases both in the TNF-α, 1L-1β and IL- 8 levels in the periodontal tissues that can be detected in GCF. The results of this study support the hypothesis that proinflammatory cytokines play a potent role in bone resorption after the application of orthodontic force in short time.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

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TNF- α, IL-1β, IL-8 Levels and Orthodontic Movement Filiz Acun Kaya et al

References 1. Davidovitch Z, Nicolay OR, Ngan PW, Shanfeld JL. Neuromitters, cytokines and the control of alveoler bone remodelling in orthodontics. Dent Clin North Am 1988; 32:411–435.

2. Saito M, Saito S, Ngan PW, Davidovitch Z. Interleukin-1β and prostaglandin E are involved in the response of periodontal cells to mechanical stress in vivo and in vitro. Am J Orthod. 1991; 99:226– 240.

3. Serra E, Perinetti G, D'Attilio M, Cordella C, Paolantonio M, Festa F, Spoto G. Lactate dehydrogenase activity in gingival crevicular fluid during orthodontic treatment. Am J Orthod. 2003; 124:206– 211.

4. Perinetti G, Serra E, Paolantonio M, Brue C, Di Meo S, Filippe MR, Festa F, Spoto G. Lactate dehydrogenase activity in human gingival crevicular fluid during orthodontic treatment: a controlled, short term longitudinal study. J Periodontol. 2005; 76:411–417.

5. Stoycheva MS, Murdjeva MA. Correlation between serum levels of interleukin 1-β, interleukin 1-ra, interleukin-6, interleukin 10, interleukin 12, tumor necrosis factor-α and interferon- with some clinical and laboratory parameters in patients with salmonellosis.

Biotechnol Biotechnol Equip 2005;19:143-6.

6. Jager A, Zhang D, Kawarizadeh A, Tolba R, Brauman B, Lossdörfer S, et al. Soluble cytokine receptor treatment in experimental orthodontic tooth movement in the rat. Eur J Orthod 2005; 27:1–11.

7. Alhashimi N, Frithiof L, Brudvik P, Bakhiet M. Orthodontic tooth movement and de novo synthesis of proinflammatory cytokines. Am J Orthod, 2001 (March); 119 (3):307–312.

8. Thilander B, Rygh P, Reitan K. Tissue reaction in orthodontics. In: Graber TM, Varnarsdall RL, eds. Orthodontics. Current Principles and Techniques. 3rd ed. St Louis, Mo: Mosby; 2000:117–192.

9. Breznak N, Wasserstein A. Orthodontically induced inflammatory root resorption. Part I: the basic science aspects. Angle Orthod 2002; 72:175–179.

10. Azuma Y, Kaji K, Katog, R, Takeshita S, Kudo A. Tumor necrosis factor-alpha induces differentiation of and bone resorption by osteoclasts. J Biol Chem 2000; 275:4858–4864.

11. Scarel-Caminaga RM, Trevilatto PC, Souza AP, Brito RB Jr, Line SRP. Investigation of an IL-2 polymorphism in patients with different levels of chronic periodontitis. J Clin Periodontol 2002;29:587-91.

12. Baggiolini M, Walz A, Kunkal SL. Neutrophil-activating peptide1/IL-8, a novel cytokine that activates neutrophil. J Clin Invest 1989; 84:1045-9.

13. Uematsu S, Mogi M, Deguchi T. Interleukin(IL)-1β, IL-6, tumor necrosis factor-, epidermal growth factor and _2-microglobulin levels are elevated in gingival crevicular fluid during human orthodontic tooth movement. J Dent Res 1996;75:562-7.

14. Stashenko P, Jandinski JJ, Fujiyoshi P, Rynar J, Socransky SS. Tissue levels of bone resorptive cytokines in periodontal disease. J Periodontol. 1991; 62:504–509.

15. Rudin HJ, Overdizk HF, Rateitschack KH. Correlations between sulcus fluid rate and clinical and histological inflammation of the marginal gingiva. Helv Odont Acta 1970;14:21-6.

16. Ramussen L, Hanstörm L, Lerner UH. Characterization of bone resorbing activity in gingival crevicular fluid from patients with periodontitis. J Clin Periodontol 2000;27:41-52.

17. Özmeriç N, Bal B, Baloş K, Berker E, Bulut Ş. The correlation of gingival crevicular fluid Interleukin-8 levels and periodontal status in localized juvenile periodontitis. J Periodontol. 1998; 69:1299–1304.

18. Takahashi I, Nishimura M, Onodera K, Bae JW, Mitani H, Okazaki M, Sasano Y. Expression of MMP-8 and MMP-13 genes in the periodontal ligament during tooth movement in rats. J Dent Res. 2003; 82:646–651.

19. Cumming BR, Löe H. Consistency of plaque distribution in individuals without special home care instruction. J Periodontal Res 1973; 8:94-100.

20. Cuida M, Brun JG, Tynning T, Johnson. Calprotectin levels in oral fluid: the importance of collection site. Eur J Oral Sci 1995; 103:8-10.

21. King, G.J., Keeling, S.D., Wronski, T.J.,1991.

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Histomorphometric study of alveolar bone turnover in orthodontic tooth movement. Bone, 12:401-409.

22. .Lynch PR, Davidovitch Z, Shanfeld J. Interleukin-1β at bone resorption sites: localization during tooth movement in vivo. J Dent Res. 1988; 67:1474.

23. Lowney JJ, Northon LA, Shafer DM, Rossomando EF. Orthodontic forces increase tumor necrosis factor α in the human gingival sulcus. Am J Orthod. 1995; 108:519–524.

24. Tzannetou S, Efstratiadis S, Nicolay O, Grbic J, Lamster I. Interleukin-1beta and beta-glucuronidase in gingival crevicular fluid from molars during rapid palatal expansion. Am J Orthod Dentofacial Orthop 1999;115:686-96.

25. Lee KJ, Park YC, Yu HS, Choi SH, Yoo YJ. Effects of continuous and interrupted orthodontic force on interleukin-1 and prostaglandin E2 production in gingival crevicular fluid. Am J Orthod Dentofacial Orthop 2004;125:168-77.

26. Saito S, Ngan P, Saito M, Kim K, Lanese R, Shanfeld J, Davidovitch Z. Effects of cytokines on prostaglandin E and cAMP levels in human periodontal ligament fibroblasts in vitro. Arch Oral Biol. 1990; 35:387–395.

27. Ngan P, Saito S, Lanese R, Shanfeld J, Davidovitch Z. The interactive effects of mechanical stress and interleukin-1 on prostaglandin E and cycle AMP production in human periodontal ligament fibroblasts in vitro: comparison with cloned osteoblastic cells of mouse. Arch Oral Biol. 1990; 35:717–725.

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Evaluation of the Plaque removing ability Rohit Anand et al

EVALUATION OF THE PLAQUE REMOVING ABILITY OF CONVENTIONAL AND CURVED BRISTLE TOOTHBRUSH IN PEDIATRIC PATIENTS Rohit Anand 1*, F. Samadi2, J.N. Jaiswal3 1. Reader, Department of Pedodontics and preventive dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow (U.P.), INDIA. 2. Professor & Head, Department of Pedodontics and preventive dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow (U.P.), INDIA. 3. Professor & Director, Department of Pedodontics and preventive dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow (U.P.), INDIA.

Abstract The aim of this study was to determine the plaque-removing ability of curved bristle toothbrush compared to conventional, straight bristle, toothbrush The study group consisted of 100 children 12 to 16 years of age. A four week postprophylaxis, parallel, longitudinal, double-blind clinical study was conducted; all volunteers were instructed in specific oral hygiene techniques. Plaque was assessed at baseline and at the end of 1, 2, 3, and 4 weeks using the Quigley-Hein plaque index after disclosing with erythrosine red.

Gingival status was assessed at baseline and at the end of 1, 2, 3 and 4 weeks by using the gingival index of Loe and Silness.

Comparative assessment showed a mean of 2.11 +_0.086 mm for group 1 and 2.37 +_ 0.216 mm for group 2, indicating a significant difference between the plaque-removing efficacy of the curved bristle and straight bristle toothbrush.

The curved bristle toothbrush was more effective in removing plaque than the conventional toothbrush.

(J Int Dent Med Res 2010; 3: (3), pp. 122-125 ) Keywords: Dental plaque , Toothbrush, Bristle, Periodontium.

Received date: 20 August 2010

Accept date: 04 October 2010

Introduction The effect of plaque on the periodontium plays a vital role in the initiation and progression of periodontal diseases. The bacterial plaque initiates an inflammatory process in the supporting structures of the tooth, and if allowed to continue, ultimately may lead to the loss of teeth. Thus, emphasis must be placed on the effectiveness and efficiency of plaque removal devices used to facilitate oral hygiene in these areas.

*Corresponding author: DR . Rohit Anand Department of Pedodontics and preventive dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow (U.P.), INDIA. Email: rohitanand555@yahoo.com

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Tooth brushing twice daily is recommended by most of the dentists in order to improve plaque control and tooth brushing is also regarded as an important vehicle for application of anti-caries agents, such as fluorides.1 The design of the modern conventional manual toothbrush can be attributed to Dr. Robert Hutson, a Californian periodontist, who in the early 1950s developed the multitufted, flattrimmed, endrounded nylon filament brush. 2 However, a few well-controlled clinical trials have compared the effectiveness of various manual toothbrushes. The results of these trials have been inconclusive, but there has been a strong indication that all brushes are least effective on the lingual aspects of lower molars and that a correct preset angulations of the brush head improves plaque control in such areas3.

Previous studies have shown that curved bristle toothbrushes were more effective in removing plaque when used in assisted brushing Page 122

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and in handicapped children4. The aim of this study therefore was to investigate in children whether the curved bristle toothbrush was more efficient in removing plaque than the conventional toothbrush.

Materials and Methods Criteria for Grouping One hundred children participated for the study. Their age was with a range of 12 to 16 years. Informed consent was obtained from each participant in the present study.

All the children who were selected satisfied the following criteria: 1) no clinical gingival inflammation; 2) no adverse restorations; 3) no dental caries; 4) no history of antibiotics or oral antiseptic therapy.

The subjects were divided into two groups of 50 depending on the toothbrush assigned: group 1, curved bristle toothbrushes; and group 2, conventional, slender head toothbrushes (both manufactured by Colgate-Palmolive Limited).

The subjects were informed about the project and written consent for participation was obtained. The study was a 4-week postprophylaxis, parallel, longitudinal, double-blind design. The two brushes used in the study were an experimental curved bristle toothbrush and a conventional toothbrush; i.e. one with a slender head with 3 rows of bristles.

At the time of the initial examination, the subjects randomly picked toothbrushes that were numbered from 1 to 100 and the coded numbers marked on the covers were recorded. All the participants in the study were provided with common toothpaste and were asked to follow the instructions. Plaque was assessed at the end of 1, 2, 3, and 4 weeks. After 4 weeks, the findings obtained were subjected to statistical analysis by using z test.

Brushing Techniques Curved bristle toothbrush. The brush is applied in an occlusal/incisal direction to hug the tooth. The curved bristles thus engage the labial and lingual aspects of the tooth and are directed at an approximately 450 angle; the middle row occupies the occlusal areas.

The brush is activated with very short horizontal strokes. No vertical motion is used so that the brushing technique is similar to the modified Bass technique. The terminal ends of Volume 3 · Number · 3 · 2010

Evaluation of the Plaque removing ability Rohit Anand et al

the curved bristle resemble the shape of a curet.

It is directly applied to the junctional epithelium unlike the straight bristles, which can easily puncture the epithelial lining.

Conventional toothbrush. The Modified Bass technique5 was used, in which the brush is applied at a 450 angle to the long axis of the tooth and directed into the gingival sulcus. A small back-and-forth motion is performed, without disengaging the bristle ends from the sulcus.

Recommended measures for hygienic tooth brushing in: children.1,2  Ensure that each child has his or her own

toothbrush, clearly marked with identification.

Do not allow children to share or borrow toothbrushes.  To

prevent cross contamination of the toothpaste tube, ensure that a pea-sized amount of toothpaste is always dispensed onto a piece of wax paper before dispensing any onto the toothbrush.

 After the children finish brushing, ensure that

they rinse their toothbrushes thoroughly with tap water, allow them to air-dry, and store them in an upright position so they cannot contact those of other children.  Provide children with paper cups to use for

rinsing after they finish brushing. Do not allow them to share cups, and ensure that they dispose of the cups properly after a single use.

Plaque Measurement After thorough oral prophylaxis and polishing, plaque was disclosed with erythrosine red and assessed on the buccal , lingual, and inter proximal surfaces of all teeth excluding third molars, according to the plaque index of Quigley and Hein6 Plaque scores were then reviewed and recorded at 1, 2, 3 and 4 weeks.

Gingival index in each patient, gingival inflammation was clinically assessed at 6 sites ( mesiobuccal, buccal, distobuccal, mesiolingual, lingual, and distolingual) on teeth . Scores were then reviewed at 1, 2, 3, and 4 weeks using the Loe and Silness gingival index.7 The investigators reproducibility was tested prior to the trial by examining plaque scores in 50 subjects twice with an interval of 15 minutes between examinations and calculated by expressing the percentage of duplicated scores. This was found to be 98%.

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Results Results showed that the experimental brush was significantly more effective in removing plaque than the conventional brush.

Table 1 shows a comparison of means and standard deviations between groups 1 and 2 and reveals statistical significance at a 1% level.

Evaluation of the Plaque removing ability Rohit Anand et al

significant difference at baseline and at different weeks.

Table 4. Mean Plaque Values and Standard Deviation in Different Weeks and different Groups.

Table 1. Comparison of Mean Plaque Values between the Groups.

Table 2 shows a comparison of means and standard deviations in the anterior and posterior teeth within the groups and demonstrates statistical significance. When means and standard deviations in the two groups and at different weeks were compared, there was reduction in plaque scores. It was found to be statistically significant at a 1% level when comparison was made between weeks 1 and 2, 1 and 3, and 1 and 4 between the two groups.

Table 2. Comparison of Mean Plaque Values between the Groups in Anterior and Posterior Teeth.

Table 3 shows the baseline scores between groups 1 and 2, which were not significant. However, weeks 2 and 4 demonstrated significance at the 5% level, and no significance was found between weeks 2 and 3 and 3 and 4 in group 1.

Table 3. Comparison of Mean Plaque Values and Standard Deviation at Baseline Between the Groups.

No significance was noticed between weeks 2 and 3, 2 and 4, and 3 and 4 in group 2 as shown in Table 4.

Table 5 shows gingival scores, with no Volume 3 路 Number 路 3 路 2010

Table 5. Mean Gingival Score and Standard Deviation in Different Weeks and Different Groups.

Discussion The children who participated in the study exhibited great variations in their ability to clean their teeth and were presumably dependent on manual dexterity, motivation, and ability to follow instructions as in the study by Gibson et al.3 Kang BH et al 10 examined the effect of tooth-brushing education on the oral health of preschoolers and said that tooth-brushing education was partially effective in improving oral health of preschoolers.

The effectiveness of a curved bristle toothbrush shown in this study may, in part, be due to the brushing time being effectively reduced or to prolonged contact duration of the brush and teeth, compared to techniques used with the conventional brush. However, it may also be attributed to the curvature of the bristles, which allows entry into sulcular areas with a drawing action. Because of the softness of the curved bristles, any resistance theoretically causes the bristles to bend back on themselves.

Other studies using curved bristle brushes found them to be effective in children and when used by home care providers6, 8.

The results of the current study strongly indicate that the curved tooth brush is more effective on the lingual and inter proximal aspects of lower molars, it may be due to better adaptation of the correctly angulated bristles reaching the protected areas. This is in contrast Page 124

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with results of previous trials indicating that brushes were least effective on lingual and inter proximal aspects of lower molars it may be due to better adaptation of the correctly angulated bristles reaching the protected areas7, 8. This is in contrast with results of previous trials indicating that brushes were least effective on lingual aspects of lower molars. According to Cohen, trial periods of 3 weeks are advisable if a brush is to be tested accurately. 9,10 The findings of this study support this view showing the trend towards progressively reduced plaque score with the curved bristle brush during the third and fourth weeks of the trial. This contrasts with the results of a previous trial, where an experimental toothbrush was found to produce lowest plaque scores in the first week. One explanation may be that patients tend to revert to the technique they are most comfortable with.11 The present study, revealed that 90% of the subjects found the curved bristle brushes more comfortable to use.

Evaluation of the Plaque removing ability Rohit Anand et al

8.

Tirapelli C, de Carvalho JF, Ribas JP, Panzeri H. Dental plaque removal efficacy of three toothbrushes with different designs: A comparative analysis. Oral Health Prev Dent. 2006; 4 (2):105-11.

9. Kang BH , Park SN, Sohng KY, Moon JS. Effect of a Toothbrushing Education Program on Oral Health of Preschool Children. J Korean Acad Nurs. 2008 ; 38(6) :914-22.

10. Attin T, Hornecker E . Tooth brushing and oral health: how frequently and when should tooth brushing be performed? Oral Health Prev Dent. 2005; 3(3) :135-40.

11. Cugini M, Warren PR. The Oral-B Cross Action manual toothbrush: a 5-year literature review. J Can Dent Assoc.

2006 ;72(4):323

Conclusions In conclusion, this study has shown that a curved bristle toothbrush is comparatively more effective in removing plaque than a conventional toothbrush.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Ash MM, Githin BN, Smith WA. Correlation between plaque and gingivitis. J periodontal. 1964; 35:424-429.

2. Scopp IW, Chen G, Cancro LP, Bolston S. Clinical evaluation of a newly designed contoured toothbrush. J Periodontal.

1976:47:87-90.

3. Gibson MT, Joyston-Bechal S, Smales FC. Clinical evaluation of plaque removal with a double headed toothbrush. J Clin Periodontol .1988; 15:94-98.

4. Williams NJ, Schuman NJ. The curved bristle toothbrush: An aid for handicapped population. J Dent Child. 1988; 55: 291293.

5. Ramfjord SP. The periodontal disease index (PDI). J Periodontol. 1967; 38: 602-610.

6. McCracken GI, Heasman L, Stacey F, Steen N, DeJager M, Heasman PA. A clinical comparison of an oscillating/rotating powered toothbrush and a manual toothbrush in patients with chronic periodontitis. J Clin Periodontol. 2004 ; 31(9): 805-12.

7. Loe H, Silness J. Periodontal disease in pregnancy. 1.

Prevalence and severity. Acta Odontol Scand. 1963; 21: 533551.

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Prevalence of Dental Trauma Among Children Bugra Ozen et al

PREVALENCE OF DENTAL TRAUMA AMONG CHILDREN AGE 2-15 YEARS IN THE EASTERN BLACK SEA REGION OF TURKEY Bugra Ozen1*, Tulay Cakmak2, Ceyhan Altun3, Bora Bagis4, Figen Cizmeci Senel5, Esra Baltacioglu6, Ozgur Koskan7 1. Dr.Dt., Tepebaşı OHC, Pediatric Dentistry Clinics, Ankara / Turkey.

2. Dt., Department of Pediatric Dentistry, Faculty of Dentistry, Karadeniz Technical Univeristy, Trabzon / Turkey.

3. Associate Professor, Department of Pediatric Dentistry, Center of Dental Sciences, Gulhane Medical Academy, Ankara / Turkey.

4. Associate Professor, Department of Prosthodontics, Faculty of Dentistry, Karadeniz Technical Univeristy, Trabzon / Turkey.

5. Associate Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical Univeristy, Trabzon/Turkey.

6. Associate Professor, Department of Periodontics, Faculty of Dentistry, Karadeniz Technical Univeristy, Trabzon / Turkey.

7. Assistant Professor, Department of Animal Science, Biometry and Genetics, Agriculture Faculty, Süleyman Demirel University, Isparta / Turkey.

Abstract The aim of the present study was to investigate the prevalence and etiology of dental trauma in children aged 2-15 in the Eastern Black Sea Region of Turkey.

The study evaluated 226 patients (139 boys, 87girls) with 346 traumatized teeth who were referred to the Department of Pediatric Dentistry at the Faculty of Dentistry of Karadeniz Technical University in Trabzon, Turkey over a one-year period.

Trauma was found to occur most frequently in girls aged 8 years and boys aged 10 years. The majority of injured teeth were permanent teeth (77.2%). Most trauma occurred in the maxillary arch (89.6%), with the maxillary central incisors the most affected tooth in both primary (69.6%) and permanent (83.5%) dentition. Single-tooth injury was predominant in all age groups (64.2%).

Children with an overjet greater than 3 mm accounted for a greater percentage of dental injuries (73.9%) than those with an overjet less than 3 mm, but the difference between the two groups was not statistically significant. Moreover, overjet was not found to have a significant effect on the number of teeth involved in a traumatic dental injury. The most common cause of dental trauma was ‘falls’ (48.7%). The most frequent type of injury was enamel-dentin crown fracture without pulpal exposure in permanent dentition (38.8%) and lateral luxation in primary dentition (21.0%).

Families and health-care systems need to provide safe and appropriate first-aid treatment for traumatic dental injuries, with follow-up treatment by dental-health providers.

(J Int Dent Med Res 2010; 3: (3), pp. 126-132 ) Keywords: Traumatic dental injuries, permanent teeth, primary teeth.

Received date: 01 October 2010 Introduction Traumatic dental injuries (TDI) occurring in childhood are very common among children and account for a significant number of pediatric dentistry patients1-3. Epidemiological information as to the magnitude of the problem has been obtained through studies of prevalence and *Corresponding author: Dr. Bugra OZEN Tepebası OHC Pediatric Dentistry Clinics, Ankara, Turkey.

Phone: +90 532 2567227 E-mail: bugra_dt@yahoo.com

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Accept date: 12 November 2010 incidence, and includes research into the etiology of traumatic dental injuries among children4-6.

TDI in children is a source of serious problems that can affect both physical and psychological aspects of daily life7-11. Social activities such as speaking and laughing can be negatively affected by such injuries8, 12, 13. At the same time, treatment of TDIs and the short- or long-term disruption they cause may be a considerable financial burden14.

The costs to injured individuals and to their communities that arise from such injuries are substantial, and understanding the factors that predispose a tooth to fracture is essential for developing a concept of prevention11. Further Page 126

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research is needed to identify the causes of and the personal and environmental risk factors for dental injuries in order to provide a basis for their prevention14, 15.

The present study is the first to provide epidemiological data in the field of dental and oral trauma in the Eastern Black Sea Region of Turkey. The aims of the study were:  to investigate the prevalence and etiology of dental trauma in children aged 2-15 in the Eastern Black Sea Region of Turkey (Trabzon, Giresun, Rize, Artvin, Gümüşhane, Ordu) referred to the Department of Pediatric Dentistry at Karadeniz Technical University, in Trabzon, Turkey.  to determine the relationship between overjet and the number of teeth involved in traumatic dental injuries.

Materials and Methods The study comprised all episodes of trauma affecting primary and/or permanent teeth in children aged 2-15 years presenting at the Karadeniz Technical University Faculty of Dentistry’s Department of Pediatric Dentistry over a one-year period from July 2005-July 2006. The university is located in northeastern Turkey, bordering on Georgia, a demographically and geographically homogenous region on the Black Sea that is characterized by mountainous woodlands above a narrow coastal strip. The Faculty of Dentistry, which began daily operations in July 2005, is the only dental faculty in the region, and has attracted patients from six provinces in the region (Trabzon, Giresun, Rize, Artvin, Gümüşhane, Ordu).

A total of 226 patients [139 boys (mean age: 9.29± 2.81), 87 girls (mean age: 7.70± 3.05)] with 346 traumatized teeth were evaluated over the course of the study. Clinical and radiographic examinations were performed on all patients, and the following information was recorded:  Patient sex and age at the time of trauma;  Time elapsed between the time of traumatic injury and seeking care;  Etiology of the traumatic incident;  Affected teeth;  Number of teeth involved;  Overjet;  Type of injury.

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Prevalence of Dental Trauma Among Children Bugra Ozen et al

Type of injury was recorded according to Andreasen’s classification, as follows: 1. Enamel crown fracture (including enamel chipping); 2. Enamel-dentin crown fracture without pulpal involvement; 3. Enamel-dentin crown fracture with pulpal involvement; 4. Root fracture; 5. Crown-root fracture without pulpal involvement; 6. Crown-root fracture with pulpal involvement; 7. Concussion; 8. Subluxation; 9. Intrusive luxation; 10. Extrusive luxation; 11. Lateral luxation; 12. Avulsion.

All information was recorded by two clinicians on standardized trauma assessment forms in line with diagnostic criteria previously provided by one of the authors. Both clinicians simultaneously evaluated each patient, and there was no disagreement between clinicians.

Data analysis included frequency distributions and cross-tabulations. Associations between dental injuries and sex/age were statistically assessed by T-test and z proportion test, whereas chi-square goodness-of-fit and z proportion tests were used to assess relations between the causes and types of trauma, tooth type, number of teeth involved and overjet (P<0.05).

Results Over a 1-year period, 226 children [139 boys (61.5%), 87 girls (38.5%)] suffered traumatic injury to a total of 346 teeth, representing an injury rate of 1.53 teeth per traumatic incident.

Children aged 2-7 years accounted for 27.9 percent (n=63) of all TDI cases, children aged 8-10 years accounted for 47.3 percent (n=107), and children aged 11-15 years accounted for 24.8 percent (n=56). When looked at by age group and sex, the incidence of TDI in children aged 2-7 was significantly higher (p<0.01) among girls (n=39, 44.83%) than among boys (n=24, 17.27%), whereas in children aged 8-10, the incidence of TDI was significantly higher (p<0.01) among boys (n=76, 54.67%) than among girls (n=31, 35.63%). Among children aged 11-15, no significant difference (p=0.149) was found in the incidences of TDI among boys Page 127

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Prevalence of Dental Trauma Among Children Bugra Ozen et al

(n=39, 28.06%) and girls (n=17, 19.54%). The highest trauma rates occurred at age 8 for girls and at age 10 for boys (Figure 1).

30

n of patients

25 20 Girl

15

Boy

10 5 0 2

3

4

5

6

7

8

9

10 11 12 13 14 15

Age

Figure 1. Distribution of dental injuries by age and sex.

The distribution of injuries according to affected tooth is presented in Table 1. Of the 346 teeth injured, 79 were primary teeth (22.8%) and 267 were permanent teeth (77.2%).The maxillary arch was more affected (89.6%) than the mandibular arch, with no significant difference between right and left side. The maxillary central incisors were the most frequently affected in both primary (69.6%) and permanent dentition (83.5%).

When the length of time elapsed between a child’s traumatic injury and clinical presentation was examined, it was found that 31.4 percent of parents waited for 12 months or more before seeking care. In 4.0 percent of cases, the parents did not remember exactly when the trauma had occurred (Table 2).

In terms of etiology, falls (48.7%), followed by accidents while playing (19.5%), were found to be the main causes of TDI (Table 3).

From one to six teeth were found to be affected in a single traumatic incident (Table 4).

Most injuries involved only one tooth (64.2%), regardless of the age of the child at the time of trauma. The incidence of injury was higher among children with an overjet greater than 3 mm (73.9%) than those with an overjet less than 3 mm; however, this difference was not statistically significant. Moreover, overjet size had no significant affect on whether or not a traumatic injury involved a single tooth or multiple teeth (p=0.717).

The distribution of injuries according to Andreasen’s classification is presented in Table 5.

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Table 1. The distribution of injuries according to the tooth affected.

Table 2. Distribution of dental injuries by time elapsed before treatment.

Crown fracture involving both enamel and dentin, without pulpal exposure, was the most frequent type of injury among permanent dentition, whereas lateral luxation was the most frequent among primary dentition. While the majority of teeth (n=325, 93.93%) exhibited only one type of trauma, 21 teeth (6.07%) exhibited more than one type of trauma. Of the latter, 12 involved injury to soft tissue only (7 lateral luxation+intrusive luxation, 5 lateral luxation+extrusive luxation) and 9 involved both fracture and soft-tissue injury (2 enamel fracture+concussion, 7 enamel-dentin fracture without pulpal involvement+ subluxation).

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Table 3. The distribution of the injuries regarding the etiology of trauma.

Table 4. Number and percentage of injured teeth per patient.

*Teeth with more than one of the different types of dental injuries are shown in each respective group.

Table 5. The distribution of injuries according to Andreasen classification.

Discussion Population-based studies of traumatic dental injuries have been performed throughout Turkey, with the exception of the Eastern Black Sea Region. This lack of regional-specific information regarding traumatic dental injuries is of concern, as the socio-economic and cultural characteristics of the Eastern Black Sea Region differ vastly from those of other regions in Turkey.

Most previous studies of other regions and countries have found higher incidences of traumatic dental injuries among boys than girls2, 11, 16-19 . In line with the majority of studies, the present study found that overall, boys (61.5%) sustained more injuries than girls (38.5%); however, in the 2-7 year age group, girls had Volume 3 路 Number 路 3 路 2010

Prevalence of Dental Trauma Among Children Bugra Ozen et al

significantly higher rates of dental trauma than boys. These findings may reflect more vigorous play in general among boys than girls, as well as the fact that boys tend not to begin participating in aggressive play and contact sports until they get older. Earlier studies have found no differences in traumatic injury between the sexes 5, 20-22 .

In agreement with Skaare and Jacobsen 23 , this study found children aged 8-10 years to have the highest incidence of TDI, with the rate of injury to boys in this age group nearly 2.5 times higher than that of girls. The decrease in the occurrence of TDI after age 10 found in this study may reflect the higher level of social support found in the school environment in general rather than any specific type of physical environment24. Moreover, older children are better able to protect themselves from injury than younger children. The present study is in line with previous studies showing dental injuries to be most frequent during the first decade of life24-26 and to decrease gradually thereafter.

There is consensus in the literature that anterior teeth are the most commonly traumatized2, 11, 24, 27-29. The present study found the maxillary central incisors to be the most frequently injured teeth in both primary (69.6%) and permanent (83.5%) dentition. This is in agreement with the literature on dental trauma2, 7, 21, 23, 30 , and may be explained by the more proclined position of the upper central incisors in comparison to the lower central incisors, so that the upper teeth tend to be the first to receive a direct blow. Moreover, the lower jaw is flexible and thus tends to reduce the impact of forces directed on the lower anterior teeth, whereas the upper jaw is fixed to the skull and rigid24, 31.

Finally, the behavioral characteristics of individual children and other etiological factors may affect the frequency of dental trauma3.

In several previous studies11,32-34, parental levels of education and awareness of oral health care have been reported to influence the length of time elapsed between the incidence of dental trauma and seeking professional care for the child. Traebert et al1 noted that parents lack awareness regarding treatment and follow-up protocols designed to observe possible sequelae to teeth, bones and soft-tissues following minor enamel-dentine fractures. The study also found that the cost of private dental treatment, which was unaffordable to the majority of the population, Page 129

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and the lack of complex treatment available through public services, contributed to a delay in seeking treatment. Similarly, although the Eastern Black Sea region has numerous dentists in private practice, some are unable to cope with complex dental trauma, and prior to the opening of the Faculty of Dentistry, there were no pediatric dentistry specialists available. As a result, more than half of the patients (51.3%) in the present study delayed seeking professional dental treatment for at least 4 months following injury. Effective and timely treatment, as well as raising public awareness about the importance of proper management of traumatic dental injuries, has been shown to help reduce or avoid later complications, costs and time for patients, parents and dental health care providers18, 35.

In line with earlier studies2, 7, 11, 29, 30, the present study found falls (48.7%), followed by accidents during play (19.5%) and collisions (12.8%), to be the main cause of traumatic tooth injuries.

Other authors2, 11, 20, 21 have demonstrated that most traumatic injuries involve a single tooth, although Wright et al. (36) found the majority of dental trauma to affect multiple teeth. In the present study, more than half of children (64.16%) had only one traumatized tooth.

The present study also found the majority of children (73.9%) with traumatic tooth injuries had an overjet of more than 3 mm. There is disagreement in the literature as to what value should be used to define ‘increased overjet’.

Whereas some studies use a value greater than 3 mm 37, 38, others use a value greater than 5 mm 10, 13, 39 .

Nguyen et al40 compared the results of several studies assessing the relationship between overjet and dental injuries and concluded that children with an overjet greater than 3mm are at approximately twice the risk of dental trauma as those with an overjet of less than 3mm. Soriano et al.13 found a significant association between dental trauma and overjet and concluded that an overjet of more than 5mm and inadequate lip coverage were predisposing factors for TDI41.

Järvinen42 found injury rates of 14.2 percent among children with normal overjet (0-3 mm), 28.4 percent among children with increased overjet (3-6 mm) and 38.6 percent among children with extreme overjet (>6 mm). He also determined that the range of injuries increased in Volume 3 · Number · 3 · 2010

Prevalence of Dental Trauma Among Children Bugra Ozen et al

relation to the degree of overjet. The present study found no significant differences in incidences of dental trauma or multiple-tooth versus single-tooth injuries between children with an overjet in excess of 3mm and children with an overjet less than 3 mm.

According to data in the literature, luxation injuries occur more frequently in primary dentition, while hard-tissue injuries are more commonly seen in permanent dentition16, 17, 18, 21, 29, 41, 43.

In agreement with the literature, the present study found lateral luxation to be the most prevalent type of injury among primary dentition and enamel-dentin fracture without pulpal exposure to be most prevalent among permanent dentition. The high frequency of lateral luxation in primary dentition can be explained by the facts that young children lack sufficient motor co-ordination to minimize injuries when their faces strike an object and that the resiliency of supporting tissue tends to result in tooth displacement5, 7, 44.

A study conducted in Northern Sweden also found crown fractures dominated among permanent dentition18.

Conclusions In some countries where the incidence of dental caries is declining, dental trauma has become a major oral health issue among children, and studies are beginning to look at different methods of prevention in an effort to minimize related developmental disturbances4, 16, 45.

In view of the potential that traumatic dental injuries have for affecting children’s daily life by causing physical as well as psychological pain and discomfort, specific public health policies are needed to lower the high prevalence of traumatic dental injury among children and minimize their effects on children’s quality of life 8,46 .

Families also need to be educated about the significance of traumatic dental injuries, and health-care systems need to provide safe and appropriate first-aid treatment for traumatic dental injuries, with follow-up treatment by dental-health providers.

Acknowledgements The authors thank, Agriculture Faculty, Suleyman Demirel University for their support Page 130

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and contributes in data analysis.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Traebert J, Bittencourt DD, Peres KG, Peres MA, de Lacerda JT, Marcenes W. Aetiology and rates of treatment of traumatic dental injuries among 12-year-old school children in a town in southern Brazil. Dent Traumatol 2006;22:173-8.

2. Saroğlu I, Sönmez H. The prevalence of traumatic injuries treated in the pedodontic clinic of Ankara Universty, Turkey, during 18 months. Dent Traumatol 2002;18:299-303.

3. Cunha RF, Delbem AC, de Mello Vieira AE, Pugliesi DM. Treatment of a severe dental lateral luxation associated with extrusion in an 8-month-old baby: a conservative approach.. Dent Traumatol 2005;21:54-6.

4. Grimm S, Frazão P, Antunes JL, Castellanos RA, Narvai PC. Dental injury among Brazilian schoolchildren in the state of Säo Paulo. Dent Traumatol 2004;20:134-8.

5. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45:2-9.

6. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dentoalveolar trauma and its treatment in an adolescent population. Part I. The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J 1997;182:91-5.

7. Caldas AF Jr, Burgos ME. A retrospective study of traumatic dental injuries in a Brazilian dental trauma clinic. Dental Traumatol 2001;17:250-3.

8. Trabert J, Peres MA, Blank V, Böell Rda S, Pietruza JA. Prevalence of traumatic dental injury and associated factors among 12-year-old school children in Florianópolis, Brazil. Dental Traumatol 2003;19:15-8.

9. Marcenes W, al Beiruti N, Tayfour D, Issa S. Epidemiology of traumatic injuries to the permanent incisors of 9-12-year-old schoolchildren in Damascus, Syria. Endod Dent Traumatol 1999;15:117-23.

10. Marcenes W, Alessi ON, Traebert J. Causes and prevalence of traumatic injuries to the permanent incisors of school children aged 12 years in Jaraguá do Sul, Brazil. Int Dent J 2000;50:87-92.

11. Zuhal K, Semra OE, Hüseyin K. Traumatic injuries of the permanent incisors in children in southern Turkey: a retrospective study. Dent Traumatol 2005;21:20-5.

12. Cortes MIS, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14-years-old children. Community Dent Oral Epidemiol 2002;30:193-8.

13. Soriano EP, Caldas Ade F Jr, Diniz De Carvalho MV, Amorim Filho Hde A. Prevalence and risk factors related to traumatic dental injuries in Brazilian schoolchildren. Dent Traumatol 2007;23:232-40.

14. Levin L, Samorodnitzky GR, Schwartz-Arad D, Geiger SB. Dental and oral trauma during childhood and adolescence in Israel: occurrence, causes, and outcomes. Dent Traumatol 2007;23:356-9.

15. Locker D. Prevalence of traumatic dental injury in grade 8 children in six Ontario communities. Can J Public Health 2005;96:73-6.

16. Skaare AB, Jacobsen I. Primary tooth injuries in Norwegian children. Dent Traumatol 2005;21:315-9.

17. Forsberg CM, Tedestam G. Traumatic injuries to teeth in Swedish Children living in an urban area. Swed Dent J 1990;14:115-22.

18. Borssén E, Holm AK. Treatment of traumatic dental injuries in a cohort of 16-year-olds in northern Sweden. Endod Dental Traumatol 2000;16:276-81.

19. Kargul B, Çağlar E, Tanboğa I. Dental trauma in Turkish

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children, İstanbul. Dent Traumatol 2003;19:72-5.

20. Hargreaves JA, Cleaton-Jones PE, Roberts GJ, Williams S, Matejka JM. Trauma to primary teeth of South African pre-school children. Endod Dent Traumatol 1999;15:73-6.

21. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol 2003;19:299-303.

22. Mestrinho HD, Bezerra AC, Carvalho JC. Traumatic dental injuries in Brazilian pre-school children. Braz Dent J 1998;9:101-4.

23. Skaare AB, Jacobsen I. Dental injuries in Norwegians aged 718. Dent Traumatol 2003;19:67-71.

24. Oliveira LB, Marcenes W, Ardenghi TM, Sheiham A, Bönecker M. Traumatic dental injuries and associated factors among Brazilian preschool children. Dent Traumatol 2007;23:76-81.

25. Gassner R, Bösch R, Tuli T, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:27-33.

26. Eilert-Petersson E, Schelp L. An epidemiological study of bicycle-related injuries. Accid Anal Prev 1997;29:363-72.

27. Sandalli N, Cildir S, Guler N. Clinical investigation of traumatic injuries in Yeditepe University, Turkey during the last 3 years. Dent Traumatol 2005;21:188-94.

28. Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:839.

29. Rodríguez JG. Traumatic anterior dental injuries in Cuban preschool children. Dent Traumatol 2007;23:241-2.

30. Llarena Del Rosario ME, Acosta Alfora VM, Garcia-Godoy F. Traumatic injuries to primary teeth in Mexico City children. Endod Dent Traumatol 1992;8:213-4.

31. Baghdady VS, Ghose LJ, Enke H. Traumatic anterior teeth in Iraqi and Sudanese children- a comparative study. J Dent Res 1981;60:677-80.

32. Garcia-Godoy F, Garcia-Godoy F, Garcia-Godoy FM. Reasons for seeking treatment after traumatic dental injuries. Endod Dent Traumatol 1989;5:180-1.

33. Onetto JE, Flores MT, Garbarino ML. Dental trauma in children and adolescents in Valparaiso, Chile. Endod Dent Traumatol 1994;10:223-7.

34. Cunha RF, Pugliesi DM, de Mello Vieira AE. Oral trauma in Brazilian patients aged 0-3 years. Dent Traumatol 2001;17:210-2.

35. Al-Jundi SH. Type of treatment, prognosis, and estimation of time spent to manage dental trauma in late presentation cases at dental teaching hospital: a longitudinal and retrospective study.

Dent Traumatol 2004;20:1-5.

36. Wright G, Bell A, McGlashan G, Vincent C, Welbury RR. Dentoalveolar trauma in Glasgow: an audit mechanism and injury.

Dent Traumatol 2007;23:226-31.

37. Petti S, Tarsitani G. Traumatic injuries to anterior teeth in Italian schoolchildren: prevalence and risk factors. Endod Dent Traumatol 1996;12:294-7.

38. Otuyemi OD. Traumatic anterior dental injuries related to incisor overjet and lip competence in 12-year-old Nigerian children. Int J Paediatr Dent 1994;4:81-5.

39. Cortes MIS, Marcenes W, Sheiham A. Prevalence and correlates of traumatic injuries to the permanent teeth of schoolchildren aged 9-14 years in Belo Horizonte, Brazil. Dent Traumatol 2001;17:22-6.

40. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship between overjet size and traumatic dental injuries. Eur J Orthod 1999;21:503-15.

41. Andreasen JO. Traumayology of the teth. Hannover: Schlütersche Verlagsanstalt; 1988.

42. Järvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 1978;36:359-62.

43. Soriano EP, Caldas AF Jr, Góes PS. Risk factors related to traumatic dental injuries in Brazilian schoolchildren. Dent Traumatol 2004;20:246-50.

44. Oikarinen K, Kassila O. Causes and types of traumatic tooth injuries treated in a public dental health clinic. Endod Dent

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Traumatol 1987;3:172-7.

45. Ranalli DN. Prevention of sports-related traumatic dental injuries. Dent Clin North Am 2000;44:35-51.

46. Tumen EC., Adiguzel O, Kaya S, Uysal E, Yavuz I, Atakul F. The Prevalence and etiology of dental trauma among 5-72 months preschool children in South-Eastern Anatolia, Turkey. Journal of International Dental and Medical Research 2009;2:40-44.

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Audiovisual Distraction Magora Florella et al

AUDIOVISUAL IATROSEDATION WITH VIDEO EYEGLASSES DISTRACTION METHOD IN PEDIATRIC DENTISTRY: CASE HISTORY Magora Florella1*, Cohen Sarale1, Ram Diana Ram2 1. MD Dept. Anesthesiology & Critical Care Hadassah Medical Center Jerusalem, Israel 2. PHD Dept. Anesthesiology & Critical Care Hadassah Medical Center Jerusalem, Israel 3. DMD,Dept. of Pediatric Dentistry Hadassah School of Dental Medicine Jerusalem Israel.

Abstract Audiovisual wireless eyeglasses method of distraction (AVD) is able to replace the visual and auditory signals from the environment by a pleasant movie. This method offers the possibility of non-pharmacological sedation in patients undergoing dental treatment.

The effect of AVD in four children is reported. The children wore the AVD eyeglasses before the local anesthetic injection and throughout the whole dental procedure. All four children were rated as uncooperative (Frankl 1) before the treatment. During treatment with Audiovisual distraction (AVD) ratings on the Houpt behavior scale showed that the children were very good or excellent ( Houpt 5-6) during all the dental sessions. Satisfaction VAS ratings 0-10 given separately by the children, parents and dentists were between 8-10.

AVD is an additional non pharmacologic, easy to use behavior management technique for pediatric dentistry. It may be of benefit especially to uncooperative, very anxious children and prevent pharmacologic means of sedation by offering a pleasurable method without adverse effects.

(J Int Dent Med Res 2010; 3: (3), pp. 133-136 ) Keywords: Audiovisual glasses, iatrosedation, pediatric dentistry.

Received date: 29 June 2010 Introduction The question of how to sedate effectively during pediatric dental procedures is of paramount importance to clinicians and families.

The need for methods to avoid sedation sessions with general analgesic agents is widely acknowledged. Non pharmacological adjunct behavioral management methods of treatment such as parental presence and reassurance, tranquilizing verbal approaches, physical contact by light touching or stroking and music, are commonly used tactics to diminish anxiety and reinforce children’s cooperative behavior in the pediatric dental pactice1-6. *Corresponding author: Florella Magora MD Professor Em. Anesthesiology 20 Rav Berlin Str. Jerusalem 92503, ISRAEL E-mail: dflor@cc.huji.ac.il

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Accept date: 08 October 2010 Though sometimes helpful, these methods have been of limited effectiveness especially for highly anxious children.

Audiovisual distraction (AVD) is a promising technique that offers an additional non pharmacological mode of sedation conceived to diminish the unpleasantness often associated with dental procedures in children7,8 and adults9-11.

It is a powerful distraction tool because it takes control in an enjoyable way over two types of sensations, hearing and visual. At the same time it succeeds in partially isolating the patient from the sounds and the sight of the unfriendly medical environment. The recognition of the distraction potential from audiovisual techniques has led many dentists to install television screens in the dental operatory. The development of wireless audiovisual eyeglasses that are easy to use, inexpensive, and comfortable for the dentist and the child has opened further opportunities for usage in dental treatment. A controlled research study with children compared ADV using wireless glasses with nitrous oxide and the results Page 133

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Audiovisual Distraction Magora Florella et al

confirmed the efficacy of the AVD methodology8.

The case reports presented will exemplify cases in which this technique has been used successfully and may encourage other practitioners to try this technique particularly for anxious children.

Case Reports Four illustrative cases are described to exemplify the merit of the AVD eyeglasses on children's behavior during dental treatment. All four children were referred to the University Hospital Pediatric Dental Clinic by their outside treating dentists because of a combination of poor cooperation and the necessity for complex procedures that required sedation. The parents agreed to AVD sedation for their child and signed a consent form approved by the Hospital Ethical Committee.

At the initial visit a pediatric dentist examined each one of the children and classified their status on the anxiety/cooperative Frankl rating score as Frankl 1 because of disruptive behavior manifested by strong fear, refusal of treatment and other evidence of extreme negativism 12. On treatment day, before beginning the invasive procedure, the child was asked to choose a movie from a selection of known popular children's movies (e.g. Mickey Mouse, Pinocchio, Toy Story, Madagascar). The child and the parent were told that they should feel free to interrupt viewing anytime, and withdrawal will have no effect on the dental care the child will receive. Then the audiovisual video, wireless eyeglasses with earphones (Mobile Theatre MT320, Prober Industries) were demonstrated, and the glasses were secured in place. See Figure 1. During the whole dental procedure pulse, respiration and oxygen saturation were monitored every few minutes and the child’s behavior, limb and body movements and crying were observed and a summed score was obtained according to the Houpt scale 1-6 representing: aborted, poor, fair, good, very good, excellent 13. Every treatment lasted more than 30 minutes and included technically complex procedures such as direct restoration, crowns, and root canals. At the end of treatment a satisfaction score was obtained from the child, his parent and the dental clinician on a VAS scale 0-10: not at all satisfied to completely satisfied with the AVD treatment.

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Figure 1. Illustrates the child's eye fixation on the movie while dental treatment is being performed.

Case 1: A 10 year- old- boy with cleft lip repaired when he was 5 months old was referred to the pediatric dental clinic. The child was cooperative over the years during multiple dental evaluation and treatments. When he was 10 years he had to undergo a new series of complex prolonged difficult sessions before he was considered ready for bone graft implant. At that point, he became uncooperative and the treatment had to be continued under oral conscious sedation. He received oral sedation with diazepam 0.3 /1 kg syrup1 mg./1cc. The child vomited repeatedly during the treatment, suffered from severe headache following the procedure and was left with memories of a very unpleasant experience in the dental chair. Both the child and the parents were reluctant to continue the dental restoration procedures under this type of sedation. For the subsequent 3 visits dental procedures included pulpotomies, stainless steel crowns, amalgam filling, composite fillings and fissure sealants using AVD together with local anesthesia yielding excellent results.

Case 2: A 6 year-old-girl received restorative dental interventions under nitrous oxide. However, she cried and complained during these sessions and rejected further nitrous oxide treatment . AVD method was suggested by the dentist for continuation of the dental work required. The girl was offered the option of viewing a movie through the AVD glasses during the treatment. The mother told us that the girl is a fan of the SpongeBob show on TV. The girl was then treated with AVD eyeglasses using the SpongeBob movie. As she watched the movie, she sat willingly on the dental chair and cooperated without crying or interfering in any Page 134

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way with the procedures. The dental procedures performed were: amalgam fillings, composite fillings and stainless steel crowns. Furthermore, the child refused to be treated without the glasses in the future sessions.

Case 3: A highly anxious 5 year-old-boy was referred to the University Dental Pediatric Clinic due to extremely uncooperative behavior.

He had a very bad dental experience with nitrous oxide sedation. A thorough clinical examination revealed that the child could not breathe through the nose due to enlarged adenoids and therefore was unable to take advantage from previous sedation with the nitrous oxide mask. The dental work was completed successfully with AVD during three consecutive sessions where stainless steel crowns, dental extractions and space maintainer were performed.

Case 4: A 9 year- old -Sudanese boy arrived at the clinic lacking a common language with the medical staff . The child, unable to communicate, sat in the dental chair but then was unnaturally quiet as if paralyzed by the unfamiliar surroundings and terrified by all those trying in vain to alleviate his fear. He refused to open his mouth. A translator was sent for to comfort and to communicate commands but was not immediately available AVD was considered as a way to help until the translator appeared.

Viewing a Mickey Mouse cartoon through the wireless eyeglasses caused the child to relax and the amalgam filling procedure was completed with no need for further assistance.

Results During repeated dental treatments with AVD sedation, Houpt scores in all four children, were either values of 5 or 6 which translates as very good or excellent overall behavior. The local anesthetic was always preceded by topical analgesic ( lignocaine 2%). Brief movements of the limbs occurred in the 5 year old boy (case 3) and the Sudanese boy (case 4) during the injection. In all four children no signs of distress were observed during any of the dental procedures as all four children were engrossed in the movie. At the conclusion of each treatment in all four cases VAS general satisfaction ratings obtained separately from the child, the parent, and the dentist were between 8-10 (very satisfied to completely satisfied). These results were similar when additional AVD dental treatment Volume 3 路 Number 路 3 路 2010

Audiovisual Distraction Magora Florella et al

sessions were performed with these cases, There were no adverse effects observed with the use of AVD. Discussion The cases in this report, during repeated dental treatment using audiovisual eyeglass sedation showed positive changes in the behavior from the reactions prior to the use of the ADV. No changes in physiological parameters measured or any adverse effects were observed during the procedures. This method allowed completion of complex dental treatments in children such as who had unpleasant experiences with oral and nitrous oxide sedation.

It is known that fixation on memories of a disturbing nature, leads to uncooperative behavior of the child during subsequent visits, by a decrease in pain threshold and tolerance and an enhanced level of anxiety 14-16. The application of AVD sedation techniques in the four children achieved not only avoidance of discomfort and improvement of children positive behavior during treatment, but also prevented the adverse effects of distressing memories and anticipatory anxiety and fear as shown by eagerness to participate in AVD at the repeated visits.

Dental care demands repeated multiple visits for adequate preventive and restorative treatment. However, beneficial effects of dental care are, at best, limited in uncooperative children afflicted by severe anticipatory anxiety and distress. For this reason dental care is often avoided or delayed resulting in unnecessary complications and poor oral health status7. In a controlled study with children, audiovisual distraction using a regular television screen has been shown to supply sedative effects to children without adverse effects and/or interference with vital processes such as consciousness, sympathetic reflexes, or the arterial oxygen saturation 7. Similar results were found for the four cases presented here as well as in a study comparing AVD with nitrous oxide sedation8.

Some dentists in pediatric private practice are using TV screens and earphones.

Nevertheless, the video eyeglasses technique has the advantage to detach the child from the medical environment by cutting off most of the sounds and sight of the dental instruments (e.g. syringe, clamp, rubber dam, drill) and transfer him into a movie world of the child's choice. With Page 135

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development in technology the video eyeglasses have become lighter, wireless, more user friendly and at an affordable price.

Conclusions In conclusion the AVD method may contribute an additional good quality mode of sedation able to diminish the unpleasantness for every child undergoing dental interventions. AVD iatrosedation is particularly indicated to avoid pharmacologic means of sedation in highly anxious children .

Audiovisual Distraction Magora Florella et al

13.

Houpt MI, Koenigsberg SR, Weiss NJ, Desjardins PJ. Comparison of chloral hydrate with and without promethazine in the sedation of young children.

Ped Dent 1985; 7:41-6.

14. Tsao JC, Myers CD, Craske MG, Bursch B, Kim SC, Zeltzer LK. Role of anticipatory anxiety and anxiety sensitivity in children's and adolescents laboratory pain responses. J Pediatr Psych.

2004;29:379-88.

15. Rocha EM, Marche TA, von Baeyer Cl. Anxiety in children's memory for procedural pain. Pain Res Manage 2009;14: 233-237.

16. Chen E, Zeltzer LK, Craske MG, Katz ER. Alteration of memory in the reduction of children distress during medical procedures. J Consult Clin Psychol 1999;67:481-90.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Gonzalez JC, Routh DK, Armstrong FD. Effects of maternal distraction versus reassurance on children’s reactions to injections. J Pediatr Psychol 1993;18:593–601.

2. Sharath A, Rekka P, Muthu MS, Rathna Prabhu V, Sivakumar N. Children’s behavior pattern and behavior management techniques used in a structured postgraduate dental program. J Indian Soc Pedod Prev Dent 2009;27:22–26.

3. Pinkham JR. Behavior management of children in the dental office.

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4. Greenbaum PE, Lumley MA, Turner C,Melamed BG. .Dentist’s reassuring touch: Effects on children’s behavior. Pediatr Dent 1993;15:20–24.

5. Lahmann C, Schoen R, Henningsen P, et al. Brief relaxation versus music distraction in the treatment of dental anxiety. A randomized clinical trial. J Am Dent Assoc 2008;139:317–324.

6. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music on pain, anxiety and behavior in pediatric dental patients. Pediatr Den 2002;24:114–118.

7. Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prevent Dent 2007;25:177–182.

8. Ram D, Shapira J, Holan G, Magora F, Cohen S, Davidovich E. Audiovisual video eyeglass distraction during dental treatment in children. Quintessence Int 2010; 41; 8: 673-679.

9. Frere CL, Crout R, Yorty J, McNeil W. Effects of audiovisual distraction during dental prophylaxis. J Am Dent Assoc.

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10. Bentsen B, Svensson P, Wenzel A. Evaluation of effect of 3d video glasses on perceived pain and unpleasantness induced by restorative dental treatment. Eur J Pain 2001;5:373-8.

11. Bentsen B, Wenzel A, Svensson P. Comparison of the effect of video glasses and nitrous oxide analgesia on the perceived intensity of pain and unpleasantness evoked by dental scaling. Eur J Pain 2003;7:49-53.

12. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? J Dent Child 1962;29:150-63.

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Facial Lesions of Hansen’s Disease Amit Anil Mhapuskar and Neha Nadpurohit

FACIAL LESIONS OF HANSEN’S DISEASE MIMICKING ODONTOGENIC INFECTION: A CASE REPORT

Amit Anil Mhapuskar1*, Neha Nadpurohit2 1. Dr. [Masters in Dental Surgery] Reader, Department of Oral Medicine and Radiology, Bharati Vidyapeeth University Dental College and Hospital, Pune, INDIA. 2. Dr. [Bachelor of Dental Surgery] Postgraduate Student, Department of Oral Medicine and Radiology, Bharati Vidyapeeth University Dental College and Hospital,Pune, INDIA.

Abstract Hansen's disease (leprosy) is a chronic infectious disease of humans cause by Mycobacterium leprae (M. leprae) commonly affecting the peripheral nerves and skin. The disease spreads mostly by droplet infection or through skin contact. Hansen's disease has got a wide spectrum of clinical manifestations depending upon the immune status of the host. Oral lesions, although rare, may be seen in leprosy with palate being the most common site of involvement. The diagnosis of leprosy is made from the clinical presentation, skin bacilloscopy and histopathology.

Current treatment of multidrug therapy (MDT) for leprosy involves 3 drugs: rifampicin, clofazimine and dapsone. We present to you a rare case of a swelling thought to be of odontogenic origin that was eventually, on histopathological grounds, diagnosed as Hansen's disease; Borderline Tuberculoid in reaction. This case emphasizes the need for health care professionals to have a sound knowledge of orofacial manifestations of common infectious diseases.

(J Int Dent Med Res 2010; 3: (3), pp. 137-140 ) Keywords: Leprosy, Mycobacterium Infections.

Received date: 31 March 2010 Introduction Hansen’s disease (leprosy) is a chronic infectious disease of humans commonly affecting the peripheral nerves and skin1. Less often it involves the mucosa of the upper respiratory tract and mouth, the reticuloendothelial system, eyes, bones, testis, liver and kidney2. It is caused by the obligate intracellular organism Mycobacterium leprae (M. leprae).

According to official reports received by the World Health Organisation (WHO) from 118 countries and territories, the global registered prevalence at the beginning of 2008 stood at 212,802 cases3. The pockets of high endemicity *Corresponding author: Dr Amit Mhapuksar 321/1, 2 nd floor, Munot Bhavan, Shanti Nagar Hsg. Soc., Timber Market Road Pune – 411042 Maharashtra Cell No: +91 9850285143 E-mail: draam@rediffmail.com, neha_1185@rediffmail.com

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Accept date: 06 September 2010 are areas of Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal, and the United Republic of Tanzania4. About 70% of the total cases in the world are found in South-East Asia alone5 and India harbours 65% of the world’s population of leprosy patients6.

Ridley & Jopling described a five point spectrum classification of the disease, the polar varieties of the disease being the lepromatous and tuberculoid forms7. In endemic areas, younger age groups acquire the disease early. It is more common in adult males than in adult females (1.6:1)1. The disease spreads mostly by droplet infection or through skin contact. The important portal of entry and exit is the oronasal mucosa. Generally people in the lower socioeconomic strata are affected. Climatic conditions, malnutrition, stress situations also influence the disease.

Hansen’s disease has got a wide spectrum of clinical manifestations depending upon the immune status of the host8. Skin lesions include either single or few flat and Page 137

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hypopigmented, raised, erythematous patches or plaques. After a period of hyperesthesia, the lesions become hypoesthetic or anesthetic.

Involvement of the oral cavity in Hansen’s disease ranges from 19 to 60%, mostly seen in lepromatous leprosy patients9. Oral lesions are common in men than in women10. The palate is the most frequently affected location11. Various types of lesions observed are infiltration, ulceration, perforation, reddish or yellow reddish nodules or tumour-like masses (lepromas)12, sessile or pedunculated, varying from 2-10 mm, some confluent and prone to ulceration. There may also be destruction of the anterior maxilla and loss of teeth13.

The diagnosis of leprosy is made from the clinical picture but must be complimented by skin bacilloscopy and histopathology14. Current treatment of multidrug therapy (MDT) for leprosy involves 3 drugs: rifampicin, clofazimine and dapsone15. MDT aims at effectively eliminating M. Leprae in the shortest possible time to prevent occurrence of drug resistance.

We present to you a rare case of a swelling thought to be of odontogenic origin that was eventually on histopathological grounds diagnosed as Hansen’s disease – Borderline Tuberculoid in reaction.

Facial Lesions of Hansen’s Disease Amit Anil Mhapuskar and Neha Nadpurohit

mandibular second premolar was started 3weeks ago. Past medical history was unremarkable.

Her physical examination revealed no other abnormality. Radiography revealed periapical pathology in lower left second premolar and generalised moderate periodontitis (Figure 2). A provisional diagnosis of swelling secondary to chronic periapical abscess in lower left second premolar was made.

Figure 1. Clinical presentation of extraoral swelling.

Case report Panoramic radiograph A 72 year-old woman presented with a painless swelling and redness on overlying skin in the parasymphysis region of left side of mandibular jaw (Figure 1) of 8-months duration.

Clinical examination revealed a diffuse, soft to firm consistency swelling extending from the left commissure to around 5 cm laterally, inferiorly up to the left inferior border of mandible. Swelling was non tender, compressible in few regions with the overlying skin being erythematous.

There was no evidence of any intraoral swelling or lymphadenopathy. The patient had a fixed prosthesis over her lower posterior teeth which was dislodged 8 years ago causing trauma to her alveolar mucosa in that region. This was the first time she noticed an extraoral swelling in left parasymphyseal region which responded mildly to antibiotics. Since then the swelling had gradually increased in size with increase in erythema on overlying skin and had failed to respond to intermittent antibiotic courses.

Endodontic treatment for her left Volume 3 · Number · 3 · 2010

Figure 2. Panoramic radiograph revealing periapical pathology in mandibular left second premolar and generalized moderate periodontitis.

The patient was prescribed seratiopeptidase medication for a period of one week and recalled. There was no change in the extraoral swelling on any of the subsequent visits (Figure3). The patient was referred for further investigations when the swelling did not subside even after completion of endodontic therapy (Figure 4) as odontogenic cause was ruled out.

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Figure 3. No change in extraoral swelling.

Facial Lesions of Hansen’s Disease Amit Anil Mhapuskar and Neha Nadpurohit

Figure 5. Histopathological picture revealing atrophic epidermis and multiple granulomas, papillary oedema, perivascular and perineural lymphocytic infiltrate.

Figure 4. Intraoral periapical radiograph of mandibular left second premolar after completion of endodontic therapy.

An ultrasound examination suggested the swelling to be an inflammatory process. She was then referred to the Department of Dermatology where a deep skin biopsy was preformed.

The histological findings were that of Hansen’s disease-borderline tuberculoid variety (Figure5). Special stains for acid and alcohol-fast bacilli were negative. The patient is currently under treatment with antileprotic drugs Rifampicin (600mg once a month) and Dapsone (100mg once a day) for a period of 6 months (Figure 6).

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Figure 6. Clinical presentation one month after treatment initiation.

Discussion The diagnosis of Hansen’s disease due to its variable clinical presentations and long incubation period may often be delayed16. One such instance is the above case, where a long standing swelling was treated for associated odontogenic infection for 8-months, until a skin biopsy confirmed the disease. The lesions of Hansen’s disease vary in their manifestation depending upon the host immunity.

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The clinical lesion in the present case was an asymptomatic erythematous nodular thickening on skin without any nerve thickening and impairment of sensation. Nerve injury is a hallmark of leprosy because of the affinity of M. leprae to nervous tissue17. It might occur in earliest stages of the disease or may progress as a chronic process over a period of many years18.

The histopathology sections showed characteristics of borderline tuberculoid variety of Hansen’s disease, which is a paucibacillary condition, probably hence no oral lesions were noted19. Also, acid-fast bacilli were not identified in the smears suggesting the non-contagious nature of the condition. The patient has been put on multidrug therapy for paucibacillary leprosy as per WHO recommendations for a period of 6 months20. This form of leprosy carries a good prognosis21. Hansen’s disease was considered a very serious, mutilating and stigmatizing disease prior to the advent of MDT in 1982. Dapsone (diaminodimethyl sulfone), introduced as standard chemotherapy for leprosy, is used worldwide for treatment of both multibacillary and paucibacillary form of the disease22.

Additional antimicrobial agents like rifampicin and clofazimine used in combination with dapsone constitute the MDT. Management also includes education of the affected individuals and their families about the nature of the disease and that it is completely curable.

Individuals should be reinsured that MDT renders patients non-infectious within 72 hours20 and there are very few chances of relapse. A completely normal social life should be encouraged.

Conclusions Health care workers, especially in endemic countries like India, must be able to recognize the disease in its early stage. Oral lesions, although rare, may be seen in leprosy.

Therefore, thorough oral mucosal evaluation by dental health professionals is mandatory as oral lesions may act as a source of infection.

Facial Lesions of Hansen’s Disease Amit Anil Mhapuskar and Neha Nadpurohit

References 1. Prabhu SR, Wilson DF, Daftary DK, Johnson NW. Oral diseases in the Tropics. Delhi: Oxford University Press 1993: pp. 202-14.

2. Krishnamurthy P. Diagnosis of leprosy. J Indian Med Assoc 2006; 104(12): 680-5.

3. Leprosy today-a report by World Health Organization, 2009.

4. Leprosy: Prevalence rates, World Health Organization Report, 2007.

5. World Health Organization: Leprosy Forum, Leprosy-Incidence, 2007 6. Rao NP. Recent advances in control programs and therapy of leprosy. Indian J Dermatol Venereol Leprol 2004; 70(5): 269-76.

7. Ridley DS, Jopling WH. A classification of leprosy according to immunity – a five group system. Int J Lepr 1966; 34: 255-73.

8. Majumdar S, Srivastava G, Kumar P. Clinicohistological disparity in leprosy. Indian J Dermatol Venereol Leprol 2003; 9(2): 178-9.

9. Rao AG, Jhamnani KK, Konda C. Palatal involvement in lepromatous leprosy. Indian J Dermatol Venereol Leprol 2008; 74(2): 161-2.

10. Scheepres A, Lemmer J, Lownie JF. Oral manifestations of leprosy. Lepr Rev 1993; 64(1): 37-43.

11. Motta AC, Komesu MC, Silva CH, Arruda D, Simão JC, Zenha EM, Furini RB, Foss NT. Leprosy-specific oral lesions: a report of three cases. Med Oral Patol Oral Cir Bucal 2008; 1;13(8): e479- 82.

12. Shafer, Hine, Levy. Shafer’s textbook of oral pathology; Bacterial infections of the oral cavity. 5th ed. Elsevier, 2006, pp. 443-5.

13. Chimenos Küstner E, Pascual Cruz M, Pinol Dansis C, Vinals Iglesias H, Rodríguez de Rivera Campillo ME, López López J. Lepromatous leprosy: A review and case report. Med Oral Patol Oral Cir Bucal 2006; 11(6): e474-9.

14. Ramos-e-Silva M, Rebello PF. Leprosy. Recognition and treatment. Am J Clin Dermatol 2001;2(4):203-11.

15. Communicable Disease Management Protocol – Leprosy.

2001; Report by Manitoba Health Publication, Communicable Disease Control Unit.

16. Kumar B, Dogra S. Leprosy: a disease with diagnostic and management challenges. Indian J Dermatol Venereol Leprol 2009; 75(2): 111-5.

17. Browne SG. Leprosy- clinical aspects of nerve involvement.

Contemp Neurol Ser 1975; 12: 1-16.

18. Scollard DM. The biology of nerve injury in leprosy. Lepr Rev 2008; 79(3): 242-53.

19. de Abreu MA, Alchorne MM, Michalany NS, Weckx LL, Pimentel DR, Hirata CH. The oral mucosa in paucibacillary leprosy: a clinical and histopathological study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(5):e48-52.

20. Walker SL, Lockwood DNJ. The clinical and immunological features of leprosy. British Medical Bulletin 2006; 1-19.

21. Grugni A, Nadkarni NJ, Kini MS, Mehta VR. Relapses in paucibacillary leprosy after MDT-a clinical study. Int J Lepr Other Mycobact Dis 1990; 58(1):19-24.

22. Scollard DM, Adams LB, Gillis TP, Krahenbuhl JL, Truman RW, Williams DL. The continuing challenges of Leprosy. Clin Microbiol Rev 2006; 19(2): 338–81.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

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Dental Treatment of Patient with Ectodermal Dysplasia Ozlem Marti Akgun et al

MULTIDISCIPLINARY TREATMENT APPROACH OF PATIENT WITH ECTODERMAL DYSPLASIA Ozlem Marti Akgun1*, Fidan Sabuncuoglu2, Ceyhan Altun3, Gunseli Guven3, Feridun Basak4 1. Assistant, DDS, Department of Pediatric Dentistry, Central of Dental Sciences, Gulhane Medical Academy, Ankara, TURKEY. 2. Assistant, DDS, PhD, Department of Orthodontics, Central of Dental Sciences, Gulhane Medical Academy, Ankara, TURKEY. 3. Associate Professor, DDS, PhD, Department of Pediatric Dentistry, Central of Dental Sciences, Gulhane Medical Academy, Ankara, TURKEY. 4. Professor, DDS, PhD, Department of Pediatric Dentistry, Central of Dental Sciences, Gulhane Medical Academy, Ankara, TURKEY.

Abstract In this paper dental treatment of a 10-year-old male patient with ectodermal dysplasia was presented.

A 10-year-old male patient with ectodermal displasia referred to Gulhane Medical Academy, Department of Pedodontics. Radiographic evaluation revealed that several teeth germs were absent. The treatment was planned by a multi-disciplinary team of pediatric dentist, orthodontist and prosthodontist. At first the conical central incisors were reshaped with direct composite restorations. Minimal orthodontic intervention was applied to close the diastema. To improve his facial esthetics, speech and oral function, removable prosthesis were applied.

The results were significant improvements in speech, masticatory function, and facial esthetics, contributing to the development of normal dietary habits, and the improved and more rapid social integration of the patient.

(J Int Dent Med Res 2010; 3: (3), pp. 141-145 ) Keywords: Ectodermal Dysplasia, Congenitally Missing Teeth, Dental Prosthesis..

Received date: 08 September 2010 Introduction Ectodermal dysplasia (ED) is a hereditary disease characterized by anomalies in the structures of ectodermal origin1. The disease effects skin, saliva, sebasseous and sweet glands (anhidrosis or hypohidrosis), hair (atrichosis or hypotrichosis), nail and teeth (anodontia or hypodontia)2. In some cases, depressed immune system may cause an increased susceptibility to certain infections or allergic reactions and effected children experience respiratory infections, chronic nasal passages inflammation, eczema and asthma3.

ED was firstly identified in 1860’s by Darwin4. A hundred years after Darwin’s *Corresponding author: Ozlem Marti AKGUN Research Fellow, Department of Pediatric Dentistry Gulhane Medical Academy, Etlik/ANKARA, TURKEY Telephone: +90 (312) 3046045 E-Mail: ozlemmartiakgun@gmail.com

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Accept date: 11 October 2010 definition, the disease now have more than 150 subtypes and all of them appear to be genetic in etiology5. ED have two different forms named Clouston syndrome (autosomal inherited form) and Christ-Siemens syndrome (hypohidrotic form)6. Recently a new classification has been proposed based on the alterations in the proteic molecular functions that lie behind it7. The disease affects both males and females.

Prevalence of ED appraised to be 7 in 10.000 live births8. Hypohydrotic ED is the most common ED (%80) and is often inherited as an X-linked disorder9,10. The disorder is fully declared in man only, nevertheless women who carry a single copy of the disease gene may exhibit some of the symptoms and findings associated with the disorder11. Spontaneous gene mutation is also possible12. Most of the patients have normal life expectancy and normal intelligence. Early diagnosis is important for these patients because in early infancy, the lack of sweat glands may lead to hyperthermia, followed by brain damage or death if unrecognized2.

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ED patients have characteristic facial abnormalities such as prominent forehead, sunken nasal bridge (saddle noise), thick lips, large chin and darkly pigmented skin around the eyes. On most of the patients’ body, the skin may be abnormally thin, soft and dry with an abnormal lack of pigmentation.13 The most characteristic findings of ED are hipodontia and abnormal shape of teeth14.

In addition to the absence of teeth, ED can also lead to underdevelopment of the jaws (2). This kind of craniofacial deformities can be effect physically and psychologically to the ED patient and may inhibit normal social interactions.

The oral rehabilitation of patients needs a multidisciplinary approach.

Additional considerations, such as the patient's age, stage of growth, inherent anatomic deficiencies present in conjunction with the missing teeth, soft tissue defects, existence of malformed dentition, severe diastemas and psychological status, must be considered15. Prosthetic treatment is a great value to these patients from the functional standpoint as well as for psychological and psychosocial reasons16.

Case Report A 10-year-old male patient with ectodermal dysplasia referred to Gulhane Medical Academy, Pediatric Dentistry Department because of nutrition, speech and esthetic problems due to the lack of teeth. The patient exhibited the classical features of ED including abnormally thin, dry and soft body skin, sparse hair, eyelashes and eyebows, characteristic face (so-called “old man face”), a saddle shaped noise and hypohidrosis. He was the first child of consanguineous parents. There was no family history associated with his condition. The patient was mentally normal.

A comprehensive clinical and radiographic evaluation was performed. In extraoral examination a facial physiognomy typical of ED was observed. The facial height indicated an extremely decreased vertical dimension of occlusion.

The intraoral examination revealed that only six teeth (two anterior and four posterior permanent maxillary teeth) and bone atrophy of the alveolar ridges, on both the maxilla and the mandibula. Some of the existing teeth were short, conical and pointed (Figure 1). In addition oral mucosa was slightly Volume 3 · Number · 3 · 2010

Dental Treatment of Patient with Ectodermal Dysplasia Ozlem Marti Akgun et al

dry and sticky. Radiographic examination confirmed the clinical findings. The treatment was planned by a multi-disciplinary team of pediatric dentist, orthodontist, prosthodontist and was clarified to both the patient and his parents.

Figure 1. Intraoral appearance of the patient.

After the permission was received from the parents, the conical central incisors were etched with a 37% phosphoric acid gel for 20 seconds, the area was rinsed for 20 seconds then dried gently with air. An adhesive (Excite DSC, Ivoclar Vivadent AG, Schaan, Liechtenstein), was applied according to the manufacturer’s instructions. Finally, to meet esthetic requirements for the anterior segment, the dental restoration (3M ESPE, USA) was completed with composite using the incremental technique and occlusal adjustment was performed. (Figure 2,3).

Figure 2. Conical central incisors were reshaped with direct composite restorations.

Minimal orthodontic intervention was applied to close the diastema (Figure 4,5). The fixed appliance was fitted to the upper central incisors and power chain was applied to begin Page 142

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space closure along a 0.016 x 0.022-inch stainless steel (SS) wire. Treatment phase, more root uprighting had been carried out to the central incisors using second-order bends in the archwire. Four months later, enough closure of the central incisors and good root parallelism had been achieved.

Dental Treatment of Patient with Ectodermal Dysplasia Ozlem Marti Akgun et al

To improve his facial esthetics, speech and oral function and to limit the resorption of the alveolar ridges removable prosthesis were applied (Figure 6,7). After this application hygiene instructions for the dentures were given to the patient and his parents. Further recalls have taken place every week for 1 month and then every 3 months. The patient had no discomfort and seemed to be adapting well on the following visits.

Figure 3. Panoramic radiograph after composite restorations.

Figure 6. Dental rehabilitation with removable prosthesis.

Figure 4. Minimal orthodontic intervention was applied to close the diastema.

Figure 7. Extraoral view of definitive removable prosthesis.

Discussion Figure 5. Intraoral appearance after orthodontic intervention.

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EDs are a heterogenous group of disorders characterized by a group of findings involving defects of two or more of the teeth, skin Page 143

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and appendageal structures including hair, nails and eccrine and sebaceous glands17. It is commonly transmitted as an X-linked recessive disorder. However rarely autosomal recessive and autosomal dominant inheritance have also been seen18.

In most of ED patients in addition to the delay in teething, the teeth are abnormal in shape and structure19. Not only is the shape abnormal but also the number. Some cases have congenitally anodontia14. The main goals of dental treatment are to improve esthetics and oral functions especially mastication and phonetics20.

Early prosthetic therapy for children with ectodermal dysplasia may require the coordinated efforts of a multi-disciplinary team of pediatric dentists, orthodontists, prosthodontists 21 . Although removable prosthesis is most frequently reported treatment modality for the dental management of ED as used in the present case22, implants should be an alternative treatment in patients with ED. Patients with ectodermal dysplasia-because of tooth absencehave reduced alveolar bone with "knife-edge" morphology, making implant reconstruction a challenge. Therefore, patients frequently require bone grafting and sinus-lift procedures23.

Kramer at al.24 reported the case of a boy at the age of 8 years with ectodermal dysplasia who exhibited a severe hypodontia and who was treated with implants inserted into the anterior mandible and recommended the early insertion of dental implants in children with severe hypodontia. Growing implant patients present a unique age-related problem regarding implant positioning and prosthetic outcomes. Guler at al.

25 reported that dental implants with or without bone grafts can be used in patients over 12 years of age, Because of the economical situation of our patient, removable prosthesis applied instead of implant therapy.

According to Vieira at al.13, prosthetic management is important for ED patients because it provides good esthetics, phonetics, and masticatory comfort, maintains healthy supporting tissues throughout a lifetime of denture wearing experience and helps the patient develop a good psychologic self-image. The prosthesis must be periodically modified in young adults as alveolar growth, erupting teeth and rotational jaw growth change21. In this case the prosthesis was replaced after 12 months Volume 3 · Number · 3 · 2010

Dental Treatment of Patient with Ectodermal Dysplasia Ozlem Marti Akgun et al

because of skeletal growth, and new ones applied.

In some cases before the application of removable prosthesis, restorative and orthodontic treatment may be necessary to improve facial esthetic14. In present case the conical central incisors were reshaped with direct composite restorations and minimal orthodontic intervention was applied to close the diastema.

It is important to take the motivation of the patient and parents as well as the patient's acceptance for dental treatment into consideration. In all the stages of the prosthetic treatment behavior management should be performed by “tell-show-do” method20. After the application of removable prosthesis we gave hygiene and utilization instructions for the dentures to the patient and his parents. The patient learned to use his prosthesis quickly and usage and condition of the prosthesis were evaluated at each recall appointment.

The main difficulty consisted in dental treatment of ED patient is to keep the mandibular denture in mouth. To improve and facilitate the denture’s adaptation dentist may advice to patient to use a denture adhesive paste for the first few days16. In our case the patient had no discomfort and adapting of the prosthesis was well on the first visit. In further recalls only discomfort areas were relieved. Retention and stabilization of the dentures were clinically acceptable.

Conclusions The primary goals of dental treatment of patients with ED are enhancing esthetics and improving masticatory function. The treatment requires the cooperation of a multi-disciplinary dental team of pediatric dentist, orthodontist and prosthodontist.

Acknowledgements The authors would like to thank Dr. Dt. Bülent BÜYÜKGÜRAL who helped for restorative treatment of the patient.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

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References 1. Ramesh K, Vinola D, John B. Hypohidrotic ectodermal dysplasiaDiagnostic aids and a report of 5 cases. J Indian Soc Pedod Prevent Dent 2010; 1: 47-54.

2. Mortier K, Wackens G. Ectodermal dysplasia syndrome. Ned Tijdschr Tandheelkd 2003; 110: 190-2.

3. Crawford PJ, Aldred MJ, Clarke A. Clinical and radiographic dental findings in X linked hypohidrotic ectodermal dysplasia.J Med Genet 1991; 28: 181-85.

4. Kaul S, Reddy R. Prosthetic rehabilitation of an adolescent with hypohidrotic ectodermal dysplasia with partial anodontia: Case report. J Indian Soc Pedod Prevent Dent 2008; 26: 177-81.

5. Motil KJ, Fete TJ, Fraley JK at al. Growth characteristics of children with ectodermal dysplasia syndromes. Pediatrics 2005; 116: 229-34.

6. Clarke A. Hypohidrotic ectodermal dysplasia. J Med Genet 1987; 24: 659-63.

7. Lamartine J. Towards a new classification of ectodermal dysplasias. Clin Exp Dermatol 2003; 28: 351-5.

8. Dall’Oca S, Ceppi E, Pompa G, Polimeni A. X-linked hypohidrotic ectodermal dysplasia: A ten year case report and clinical considerations. Eur J Ped Dent 2008; 9: 14-8.

9. Lexner MO, Bardow A, Hertz JM, Nielsen LA, Kreiborg S. Anomalies of tooth formation in hypohidrotic ectodermal dysplasia. Int J Pediatr Dent 2007; 17: 10-8.

10. Dalkız M, Beydemir B. Pedodontic complete dentures. Turk J Med Sci 2002; 32: 277-81.

11. Shah NK. Ectodermal dysplasia, eMedicine from WebMD, http://emedicine.medscape.com/article/1110595-overview, 2009.

12. Kupietzky A, Houpt M. Hypohidrotic ectodermal dysplasia: Characteristics and treatment. Quintestence Int 1995; 26: 28591.

13. Vieira KA, Guirado CG. Prosthodontic treatment of hypohidrotic ectodermal dysplasia with complete anadontia: Case Report.

Quintessence Int 2007; 38: 75-80.

14. Köymen G, Karaçay Ş, Başak F, Akbulut E, Altun C. Ectodermal Dysplasia: Case Report. Gulhane Med J 2003; 45: 79-81.

15. Hobkirk JA, Nohl F, Bergendal B, Storhaug K, Richter MK. The management of ectodermal dysplasia and severe hypodontia: International conference statements. J Oral Rehabil 2006; 33: 634-7.

16. Shigli A, Reddy RPV, Hugar SM, Deshpande D. Hypohidrotic ectodermal dysplasia: a unique approach to esthetic and prosthetic management: a case report. J Indian Soc Pedod Prev Dent 2005; 23: 31-4.

17. Saini GS, Gupte S, Gupta RK. Anhidrotic Ectodermal Dysplasia.

JK Science 2002; 2: 89-91.

18. Zinana J, Elder ME, Schnieider LC et al. A novel X·linked disorder of immune deficiency and hypohidrotic ectodermal dysplasia is allelic to incontinentia pigmenti and due to mutation in IKK·gamma (NEMO) Am J Hum Genel 2000; 67: 1555-62.

19. Balshi TJ, Wolfinger GJ. Treatment of congenital ectodermal dysplasia with zygomatic implants: a case report. Int J Oral Maxillofac Implants 2002; 17: 277-81.

20. Raducanu AM, Pâuna M, Feraru IV. A simple prosthetic restorative solution of a single peg-shaped upper central primary incisor in a case of ectodermal dysplasia: Case Report.

Rom J Morphol Embryol 2010; 51: 371-74.

21. Murdock S, Lee JY, Guckes A, Wright JT. A costs analysis of dental treatment for ectodermal dysplasia. J Am Dent Assoc 2005; 136: 1273-76.

22. Altun S, Altun Ş, Yavuz İ, Agüloğlu S. Ektodermal Displazi: 3 Vaka Raporu. Turkiye Klinikleri J Dental Sci 2001; 7: 154-60.

23. Worsaac N, Jensen BN, Holm B, Holsko J. Treatment of severe hypodontia-oligodontia: An interdisciplinary concept. Int J Oral Maxillofac Surg 2007; 36: 473-80.

24. Kramer FJ, Baethge C, Tschernitschek H. Implants in children with ectodermal dysplasia: a case report and literature review.

Clin Oral Implants Res 2007; 18: 140-6.

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25. Güler N, Çıldır Ş, İşeri U, Sandallı N, Dilek Ö. Hypohidrotic ectodermal dysplasia with bilateral impacted teeth at the coronoid process: A case report Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 34-8.

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Esthetic Failures in Fixed Partial Dentures Veu N.V.Madhav

ESTHETIC FAILURES IN FIXED PARTIAL DENTURES V N V Madhav1* 1. Dr, M.D.S. (Prosthodontics), Reader, Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune, India.

Abstract Esthetic dentistry encompasses those procedures designed to enhance and improve form and appearance of the maxillofacial region. Esthetic dentistry procedures are performed on both hard and soft tissue to correct either subjectively or objectively, patient perceived deformities.

Perceptions of esthetic deformities or needs are highly subjective. In this article an effort has been made to outline the possible esthetic errors which occur in the absence of careful treatment planning during the fabrication of fixed partial denture procedure.

(J Int Dent Med Res 2010; 3: (3), pp. 146-153 ) Keywords: Esthetic Failures, Shade Selection, Gingival Esthetics, Esthetic Smile.

Received date: 19 July 2010 Introduction The surge of interest in the use of toothcolored restorative materials and systems in recent years has been attributed partly to rapid developments in dental materials science and also to patient demand and operator interest.

When overall dental appearance is considered, several factors are of significance, including tooth color, shape, and position; restoration quality; and the general arrangement of the dentition, especially of the anterior teeth.

Each factor may be considered individually, but all components together act in concert to produce the final esthetic effect. However, although the clinician must be mindful of the patient's desires for a favorable cosmetic result, materials and techniques must be carefully selected, and restorations should be sufficient to withstand the forces of occlusion and mastication and provide long-term function and esthetics1.

The elective nature of esthetic procedures requires that the patient is thoroughly educated about possible risks and adverse consequences *Corresponding author: Dr. V.N.V.Madhav, M.D.S. (Prosthodontics) Reader, Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune .

E-mail: vnvmadhav@yahoo.co.in

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Accept date: 21 September 2010 along with need for dedicated maintenance. The proper selection of treatment occurs through a comprehensive dialogue between the Prosthodontist and the patient in which both subjective and objective evaluations are utilized to determine appropriateness of treatment and thus enable the assumption; of reasonable risk / benefit ratio. The irreversibility of many esthetics procedures requires that the patient be fully aware of future additional and / or alternative treatments if their initial esthetic goals are not met. In this article an effort has been made to outline the possible esthetic errors which occur in the absence of careful treatment planning during the fabrication of fixed partial denture procedure.

Evolution of Ceramics as an Esthetic Alternative The metal-ceramic crown was introduced to the profession over four decades ago. At the time there was tremendous excitement generated by the concept because it theoretically combined the esthetics of the porcelain jacket crown with the potential for clinical longevity2.

However, it is likely safe to state that most clinicians were somewhat disappointed by the initial clinical results obtained with this treatment modality. It is highly likely that most early esthetic failures with metal-ceramic restorations were due to a combination of errors in tooth preparation, cervical margin design and soft-tissue management. Nevertheless, the disappointment with metal-ceramic restorations was the genesis Page 146

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for the development of numerous all-ceramic alternatives to the metal-ceramic restoration. The past two decades has witnessed the unprecedented introduction of alternatives to the metal ceramic crown 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16.

In addition, many different techniques for fabrication of all-porcelain labial margins have been developed to improve the inherent esthetic performance of metal-ceramic restorations 17, 18, 19, 20, 21, 22 . In clinical situations with sufficient remaining enamel, etched porcelain laminate veneers may also be considered to restore the teeth to both optimum esthetics and function 23, 24, 25, 26 .

Thus, the contemporary host of indirect alternatives for the esthetic restoration of anterior teeth. It is also clear that ceramic technology has matured to the point that it is possible to mimic nature and provide restorations that defy detection to even the trained observer.

Classification of Esthetic Errors27; (Richard E. Lombardi; 1974) I. Inharmonious dento-facial ratio 1. Shade disharmony 2. Compositional incompatibility  Static prosthesis in dynamic mouth  Inharmonious strength or weakness of dental composition compared to background features. a. Weak mouth with strong face. b. Strong mouth with weak face.

II. Intrinsic dental disharmony 1. Space allocation errors  Inadequate vertical space allocation  Excessive vertical space allocation  Excessive horizontal space allocation 2. Structural line errors  Elevated occlusal plane  Occlusal plane drops down posteriorly  Asymmetrical occlusal plane 3. Unnatural lines  Reverse smiling line  Unnatural axial inclination  Cusp less posterior teeth  Gradation errors  Age-sex personality disharmony 4. Single-line errors  Vertical deviation  Horizontal deviation  Line conflict 5. Imbalance Volume 3 · Number · 3 · 2010

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 Midline error  Imbalance of directions  Artifact error  Diastema error Factors Affecting Esthetic Failures One of the goals of any dental restoration should be patient satisfaction. The restoration should fulfill the requirements of correct mastication function, appropriate morphology, superficial staining, abrasion and other characterization. Finally, the shade selected must correspond to the individual, age related appearance of the patient and should be identical to the remaining natural teeth. Problems that arise during fabrication can be overcome in spite of the difficulty level, which varies from case to case and depends in part on whether the restoration involves a single crown or a fixed partial denture. A general requirement for the success of laboratory work by the dentist (i.e.; proper shade selection, correct tooth preparation and final impression).

Tooth Shape The facial surface of the tooth is a part of tooth form. It is decisive in shaping tooth's appearance, particularly when severe changes occur in old age. The incisal edge, which may be slightly convex in shape initially, changes as well.

As a consequence of abrasion it may eventually become concave. All of these variable characteristics of tooth shape combine to determine the effect of the tooth in the mouth, to a significantly greater degree than does the shade. The changes in the cervical region, through gingival recession for example, also lead to an appearance typical of a certain age. These changes have a more pronounced effect on the appearance of the dental arch than on the shade.

Because the gingiva usually recedes inter-proximally as well, it leaves the crown of the tooth with a more triangular appearance. If these teeth are replaced by a restoration having a square form, they will appear more unnatural. It is expected that the form of the clinical crown correspond to the course of the root, which is often exposed because of periodontal disease.

Surface Structure and Characterizations The natural surface detail is most extensive in a young tooth. Many fine, detailed Page 147

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irregularities occur, particularly on the labial surface. At the first glance one sees horizontal depressions. Vertical lines become visible with more careful observation, so that a pattern of very fine, slightly displaced rectangles is seen.

The older a tooth becomes, the less prominent these structure become. Millions of lip movements in the same direction lead to formation of large smoothed regions between which few structured zones are retained. Enamel tears, abrasions, discoloration, incisal edge irregularities, bright spots, and band-shaped shade variations are not the only characterizations that must be evaluated.

Cervical erosions and fine lines that separate the clinical crown and the root, which may result from simple aging or from oral hygiene procedures, must also be evaluated.

Color Nature of Color: When we talk about color, we are making reference to a sensation which is captured by our eyes. The human eye is an organ specialized in the reception of images obtained from an electromagnetic radiation that we refer to as light, and which actually corresponds to a narrow segment of the entire spectrum, situated between the 400 and 800 nm wavelengths approximately, and which we perceive as the so-called “colors of the rainbow”.

Radiations below these wavelengths are not visible to the human eye, and are referred to as ultraviolet; those which are situated above these wavelengths are not visible either, and are referred to as infrared.

There are generally three accepted dimensions of color:  Hue, tonality: this indicates the feature which is normally referred to as color, directly related to the wavelength of the observed luminous radiation observed (e.g. red, green, blue, yellow…).  Value, luminosity: this expresses the amount of light that makes up the color under study, and would be like the black and white image of the observed object, corresponding to the tonalities of grey ranging from a maximum value, white, and a minimum value, black.  Chroma, saturation: this refers to the amount of dye that the color contains, the chromatic brightness that we observe. This dimension refers to the different dilutions of the base color we are starting from.

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To these three dimensions, and within the field of dentistry, we must add a fourth one which would include all of the chromatic features that personalize the tooth apart from its average color, and which are fundamental for the reproduction of the color of a tooth.

Gingival Esthetics Factors Affecting Gingival Esthetics: The morphology and dimension of supracrestal periodontal tissues undoubtedly represent the most important parameters to be taken into consideration in designing a fixed prosthesis28.

The Esthetic Width; As the supracrestal connective tissue attachment is resected during tooth preparation, so should the esthetic width be respected when designing the prosthetic framework, a distinct space is necessary between the coronal border of the gingiva and the cervical margin of the framework to provide adequate room for the application of specific shoulder porcelain.

The Umbrella Effect; A careful analysis of clinically relevant optical phenomena should always include the effect produced by the lips, particularly the upper lip, because this feature will significantly influence the interaction of light with the teeth and their supporting tissues. When the lips are retracted, the apical extension of the framework generally will not have a strong impact on the optical behavior of the crown, because the light can be directly distributed into the tissues.

When the upper lip is in its normal position, however, the difference becomes significant, because direct penetration of light into the surrounding periodontal tissues is prevented.

In contrast, an adequately reduced framework does not demonstrate the so-called umbrella effect.

Esthetic Smile The smile is expressed by muscular action around the lips in the inferior third of the face by a brightening of the eyes. The pleasing smile is one of our special forms of nonverbal communication, and it expresses joy.

The elements that effect in an esthetic smile are;  The upper lip position  The upper lip curvature Page 148

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 The parallelism of the anterior incisal curve with the lower lip  The relationship between the maxillary anterior teeth  The number of teeth displayed in a smile The most attractive smiles have nearly perfect harmony between the arcs of curvature of the incisal edges of the maxillary incisor and the upper border of the lower lip, and the upper lip can be at the height of the gingival margin of the maxillary central incisor. It was found that in an attractive smile, the full shape of the maxillary anterior teeth was displayed between the upper and power lip. The upper lip curved upward or was straight, the maxillary anterior incisal curve was parallel to the lower lip, and the teeth were displayed to the first molar.

SHADE SELECTION FAILURES To date, there is no systematic training on visual shade determination 29, 30, 31 for dental technicians or dentists32. Therefore; all attempts to improve the color communication fail at this barrier.

The many difficulties associated with visual shade determination of manufactured or customized shade tabs for natural teeth are further complicated by the fact that color interpretation by the human eye is influenced by a variety of factors.

Shade selection is an important procedure to provide patients with an aesthetic restoration that harmoniously blends to the patient’s existing dentition. Knowledge of the scientific basis of color from understanding light to also interpreting the artistic aspects of shade selection ensures a successful result. Shade selection involves the perception of color, which depends on three entities: 1. Light 2. Object; and 3. Visual detection The visual system of the eye is only capable of detecting wavelengths from 380 (violet) to 780nm (red). Isaac Newton showed that light had no color, as it is only when it interacts with an object that color is produced.

Light The color of an object can change depending on the illuminant, e.g. tungsten light may cast a yellow color compared to daylight.

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The property of light source to influence color of objects is called “color rendition”. There are three main illuminants within any dental practice: natural, incandescent and fluorescent.

Natural sunlight is itself variable with light appearing blue at noon when the sun has fewer atmospheres to penetrate and red/orange during the morning and evening. Incandescent lighting is predominantly red/yellow and lacking in blue while fluorescent lighting is high in blue tones and low in red.

There are special that are color corrected to emit light with a more uniform distribution of color that can be utilized. Initial shade selection should be initially made with be matched under different lights to avoid metamerism (the phenomenon that occurs when shades appear to match under one lighting condition and not another).

Factors Affecting Light Conditions  Gingival shade  Influence of the surroundings  Type and arrangement of the shade guide  Position of the shade tab  Different color perception capacities  Knowledge about color and its perception  Experience in shade selection  Acting mechanism of the eye (simultaneous contrast, contrast increase) When determining a color, the human eye perceives a certain shade; however, under modified light conditions, the color perception and the subsequent shade selection can be completely different. This implies that when shade guides are used exclusively, the tooth shade required is always described in an insufficient manner33-35.

It is important to use auxiliary tools and a shade indicator that is arranged according to a logical system oriented by the natural model Object Color possesses three dimensions: value, hue and chroma. A high value object often reflects most of the light falling on its surface and appears bright. The converse is true with a dark object absorbing most of the light and appearing dull or of low value. Hue is wavelength of light, and dependent on the spectral reflectance from an object. Chroma is the concentration of color or color intensity Page 149

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Visual detection The third part of stimulus for color is the spectral response of the detector, or eye. The difficulty of shade selection is that clinicians must be able to interpret a multi-layered structure of varying thickness, opacities and optical surface characteristics. This can affect the way that the eye perceives color. The basic hue of the tooth is determined by the color of the underlying dentine, while value is a quality of the enamel overlay.

Muia in 1993 stated, “The dentine imparts the entire color. Enamel is like a fiberoptic structure conducting light through its rods”.

Chroma is the saturation of color in the dentine, but is influenced by the value and thickness of the enamel. Teeth are often termed “polychromatic” and have the variation in hue, value and chroma within the teeth and give three dimensional depth and characteristics. A young dentition is characterized by opaque, high value enamel, which blocks underlying dentine. As teeth age, the enamel becomes more translucent and dull (low value) revealing the underlying dentine. This layering can make reading of tooth color difficult since the value of enamel and surface luster often complicate color evaluation of the underlying dentine.

Contrast Effect When a dental restoration is being fabricated, the surroundings of the teeth, especially the shade of the gingival tissues, are decisive for the color integration of the restoration.

With the conventional visual shade determination, so-called simultaneous contrast effects and contrast increases occur 36, 37, 38.

To explain briefly: Shade selection is performed in a reddish environment-skin, lips, and gingival tissues. This environment, and especially the reddish-violet color of the gingival tissues, leads to a marked decrease in the receptiveness of this area to the color spectrum The brain replaces the apparent excess of red with the complementary shades green to yellow.

This leads to a subjectively modified color perception, which expresses itself in a tendency toward seemingly objective yellowish shades.

This contrasting effect can be neutralized by the use of a gingival mask.

Tips to Remember During Shade Selection Procedure  Shade selection should be completed before Volume 3 · Number · 3 · 2010

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preparation as teeth can become dehydrated and result in higher values.  Shades should be done when the dental team is not fatigued as in the end of the day.  Ensure surgery surroundings are of neutral color so that there is no color cast onto the teeth.  Remove lipstick; ask patients not to wear lurid clothing or any items that may distract the attention of the teeth.  Make sure teeth are clean and unstained before attempting shade selection.  Patient should be in an upright position at a level similar to the operator and the shade guide should be at arms length. This ensures that the most color sensitive part of the retina will be used.  Observations should be made quickly (5 seconds) to avoid fatiguing the cones of the eyes. If longer than this, the eye cannot discriminate and the cones become sensitized to complement the observed color.  Blue fatigue can accentuate yellow sensitivity so dentists can look at a blue object, bib, etc, while resting the eyes.  Use color corrected light illumination, which should be of a diffuse nature.  Choose basic shade at the middle of the tooth - using the Vita System 3D-Master technique of value, chroma then hue. Viewing tabs through half-closed eyes can decrease ability to discriminate color but increases the ability to match value. Look at the other parts of the teeth, dividing the teeth into nine sections from apical to incisal and mesial to distal.  Necks of shade tabs often can be removed as they have a great deal of colorants that may introduce errors.  Examine tooth for translucency and any characterizations, e.g. craze line, hyopcalcification, etc.  Create a shade/chromatic map – divided into different sections to ensure correct placement of different effects, characterizations and shades.  In case of color blindness, seek the help of the assistant  Shade selection is done before tooth preparation  Don't dry the tooth while selecting the shade  Moisten the shade tab  Canine is the darkest tooth Page 150

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 Premolars are of lighter shade than canine  For premolar select contra-lateral premolar  When maxillary anteriors are missing, shade of the mandibular anteriors are considered  In case of a non-vital tooth, cover it and select the shade of the adjacent tooth.  Photograph teeth and tabs using different lighting conditions to minimize metamerism, e.g. flash (5500K) and natural daylight (6500K).  Photograph teeth at 1:1 ratio for detailed characterizations.  Send digitized images and shade map to ceramist.

thus

Stump shade selection With the increasing use of all-ceramic restorations, it is important to communicate the prepared tooth or “stump” shade to the ceramist so that they can build the restoration with the right opacity/translucency. It may be necessary as in to use a more opaque ceramic to block out discoloration, e.g. an alumina- or zirconia based restoration may be a better choice than a glassbased ceramic like Empress.

Although no single shade guide or combination of guides includes all of the color combinations that may be encountered in clinical practice, a reasonably high level of clinical color matching has been achieved, which attests to the artistic skills of many dentists in selecting the best available shade and determining what color modifications are necessary to further enhance the color match.

Instrumental Shade Selection Given the great subjectivity that predominates all during the color measurement process in the clinic, a series of electronic instruments designed to facilitate and make more objective the process of color measurement have recently been appearing on the market. The practitioner thus needs only to use these devices in order to be able to indicate the tooth’s color in a more precise, reliable and repeatable way.

Knowledge of the correct use of the conventional color measurement systems is becoming more and more important if we wish to satisfy present day esthetic demands.

This, together with the gradual entry and perfection of the electronic color meter systems, will serve to reduce the possibilities of aesthetic Volume 3 · Number · 3 · 2010

failure, and restorations.

increase

the

quality

of

Table 1. Commercially Available Digital Shade Guides.

As a summary reasons for esthetic failures can be summarized as following.  Failure to identify patient expectations regarding esthetics  Improper shade selection  Failure to transfer the shade to dental laboratory  Excessive metal thickness at incisal and cervical region  Thick opaque layer application  Surface blistering ("chalky" appearance)  Over glazing or too much smooth surface  Metal exposure in connector, cervical and incisal regions  Dark space in cervical third due to improper pontic selection (Anteriors)  Failure to produce incisal and proximal translucency  Improper contouring  Failure to harmonize contra-lateral tooth morphology 1. Contour 2. Color 3. Position 4. Angulations  Discoloration of facing The contemporary restorative dentist has a host of options with which to help his or her patients are treated. Many of these options are considerably less invasive than many of our conventional restorative therapies. Many patients present for esthetic restorative treatment, and are becoming increasingly sophisticated in their expectations of the final results. Additionally, manufacturers are bringing a myriad of new products to the market, often accompanied by a blizzard of information purported to demonstrate the benefits and efficacy of these new products.

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Careful evaluation of patient’s expectations and needs and proper choice of materials and techniques along with sound knowledge and skill of the operator can decrease the failures in the esthetic outcomes in fixed partial dentures.

Conclusions Today’s dental restoration is consolidated around three mainstays: the use of non- metallic materials, such as composite resins and ceramics; adhesion to dental structures; and the achievement of a natural cosmetic look. The level of esthetic requirement and demand by patients in restorations has risen spectacularly in recent years, and this has made it necessary for dental professionals to explore this field in order to satisfy the existing social demand in this area.

The dental materials that are available nowadays offer us the possibility of imitating the tooth’s natural esthetic look, so long as the right one is chosen for a given situation. The first step to achieving clinical success in esthetic dentistry will therefore be to correctly identify the patient’s needs and to imitate tooth color with the material that most closely matches, and to communicate this information to the laboratory if the restoration is to be carried out there.

Color measurement may seem to be a minor element within the field of Restorative Dentistry, but its importance is essential, although not from the biological point of view. But given the present day level of esthetic exigency, a technically correct restoration can be a clinical failure if it fails to achieve the esthetic integration the patient nowadays demands.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Qualtrough AJ, Burke FJ, A look at dental esthetics, Quintessence Int. 1994 Jan; 25(1):7-14.

2. Jones DW. Development of dental ceramics. An historical perspective. Dent Clin North Am 1985: 29: 621–644.

3. Adair PJ, Grossman DG. The castable ceramic crown. Int J Periodontics Restorative Dent 1984: 4: 32–46.

4. Andersson M, Oden A. A new all-ceramic crown, a dense sintered, high-purity alumina coping with porcelain. Acta Odontol Scand 1993: 51: 59–64.

5. Anusavice KJ. Recent developments in restorative dental ceramics. J Am Dent Assoc 1993: 124: 72–84.

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6. Cho GC, Donovan TE, Chee WWL. Rational use of contemporary all-ceramic crown systems. J Calif Dent Assoc 1998: 26: 113– 120.

7. Donovan TE. Contemporary ceramic restorations: a comparative evaluation. Alpha Omegan 1988: 81: 57–64.

8. Lehner C, Studer S, Brodbeck U, Scharer P. Short-term results of IPS-Empress full-porcelain crowns. J Prosthodont 1997: 6: 20– 30.

9. Malament KA. Considerations in posterior glass-ceramic restorations. Int J Periodontics Restorative Dent 1988: 8: 32–49.

10. McLean JW. New dental ceramics and esthetics. J Esthet Dent 1995: 7: 141–149.

11. Probster L. Four-year clinical study of glass-infiltrated, sintered alumina crowns. J Oral Rehabil 1996: 23: 147–151.

12. Rinke S, Huls A. Copy-milled aluminous core ceramic crowns: a clinical report. J Prosthet Dent 1996: 76: 343–346.

13. Sorensen JA, Choi C, Fanuscu MI, Mito WT. IPS Empress Crown system: three-year clinical trial results. J Calif Dent Assoc 1998: 26: 130–136.

14. Sozio RB, Riley EJ. The shrink-free ceramic crown. J Prosthet Dent 1983: 49: 182–187.

15. Wohlwend A, Scharer P. The Empress technique: a new technique for the fabrication of full ceramic crowns, inlays, and veneers. Quintessence Int 1990: 16: 966–978.

16. Wohlwend A, Strub JR, Scharer P. Metal-ceramic and all porcelain restorations: current considerations. Int J Prosthodont 1989: 2: 13–26.

17. Donovan TE, Adishian S, Prince J. The platinum bonded crown: a simplified technique. J Prosthet Dent 1984: 51: 273–275.

18. Kessler JC, Brooks TD, Keenan MP. The direct lift-off technique for constructing porcelain margins. Quintessence Dent Technol 1986: 10: 145–150.

19. Prince J, Donovan TE. The esthetic metal-ceramic margin: A comparison of techniques. J Prosthet Dent 1983: 50: 185–192.

20. Prince J, Donovan TE, Presswood RG. The all-porcelain labial margin for metal-ceramic restorations: a new concept. J Prosthet Dent 1983: 50: 793–806.

21. Toogood GD, Archibald JF. Technique for establishing porcelain margins. J Prosthet Dent 1978: 40: 464–466.

22. Vryonis P. A simplified approach to the complete porcelain margin. J Prosthet Dent 1979: 42: 592–593.

23. Cho GC, Donovan TE, Chee WWL. Clinical experiences with bonded porcelain laminate veneers. J Calif Dent Assoc 1998: 26: 121–127.

24. Friedman MJ. The enamel-ceramic alternative: porcelain veneers vs. metal-ceramic crowns. J Calif Dent Assoc 1992: 20: 27–33.

25. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983: 27: 671–684.

26. Materdomini D, Friedman MJ. The contact lens effect enhancing porcelain veneer esthetics. J Esthet Dent 1995: 7: 99–103.

27. Lombardi Richard E: a method for classification of errors in dental esthetics. J Prosthet dent. 1974; 32: 501-513.

28. Malament Kenneth A: Periodontics and Prosthodontics. Goals and objectives and clinical reality. J Prosthet dent. 1992; 67: 259-263.

29. Egger B. Der Status quo der Ästhetik. Quintessenz Zahntech 1997; 23:191–204.

30. Preston JD. Der gegenwärtige Entwicklungsstand der Farbbestimmung und Farbanpassung. Part I. Quintessenz Zahntech 1985; 11:863–873.

31. Preston JD. Der gegenwärtige Entwicklungsstand der Farbbestimmung und Farbanpassung. Part II. Quintessenz Zahntech 1985; 11:957–965.

32. Clark BE. The color problem in dentistry. Dent Digest 1931:8.

33. Miller L. A scientific approach to shade matching. In: Preston JD. Perspectives in Dental Ceramics. Proceedings of the Fourth International Symposium on Ceramics. Chicago: Quintessence, 1988:193–208.

34. Miller L. Organizing color in dentistry. J Am Dent Assoc 1987; 12(special issue):26E–40E. 35. Miller L. Shade matching. J Esthet Dent 1993; 5:143–153.

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36. Egger B. Shofu ShadeEye: Der Sinn computergestützter Farbreproduktions-Systeme—ein einjähriger Erfahrungsbericht.

Quintessenz Zahntech 1999; 25:409–416.

37. Yamamoto M. The idea of a new system for computerized color determination (CCS) system and innovative ceramic materials – The development of the Vintage Halo-CCS system (III). Berlin: Quintessenz, 1997.

38. Küppers H. Das The basic law of color theory DuMont, 1978.

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Progressive External Ophthalmoplegia: A case report Ayfer Aktas et al

PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA (PEO): PRESENTATION OF A MITOCHONDRIAL MYOPATHY ACCOMPANIED BY ELECTRON MICROSCOPE Ayfer Aktas1*, Mehmet Serhan Tasdemir2, Nebahat Tasdemir3, Yusuf Nergiz4 1. Assit.Prof.Dr. University of Dicle Medical Faculty, Department of Histology, 21280 Diyarbakir, Turkey.

2. PhD University of Dicle Medical Faculty, Department of Histology, 21280 Diyarbakir, Turkey.

3. Prof.Dr.University of Dicle Medical Faculty Department of Neurology, 21280 Diyarbakir, Turkey.

4. Prof.Dr.University of Dicle Medical Faculty, Department of Histology, 21280 Diyarbakir, Turkey.

Abstract Kearns-Sayre syndrome is a mitochondrial disease, presenting findings before the age of 20 and characterized by chronic progressive external ophthalmoplegia and pigmentary retinal degeneration. It affects many organs, resulting in a very wide spectrum of complications.

In this work, a 24-year-old female, whose complaints first started at the age of 12, showing progressing external ophthalmoplegia and diagnosed with Kearns-Sayre disease following mitochondrial changes in muscle electron microscope investigation was presented. Ways of diagnosing in mitochondrial diseases, especially those in children were tried to be evaluated.

(J Int Dent Med Res 2010; 3: (3), pp. 154-157) Keywords: Kearns-Sayre syndrome, mitochondrial diseases, progressive external ophthalmoplegia, electron microscope.

Received date: 17 November 2010 Introduction Mitochondrial disease include a group of systemic diseases that include structural or functional anomalies and show clinical and biochemical heterogeneity.

Kearns-Sayre syndrome (KSS) is a mitochondrial disease resulting from mitochondrial DNA deletion1,2.

This aspect was first mentioned in 1962

by Luft et al. In this disease, mitochondries produce energy without control due to failure in oxidation phosphorylation. However, this energy is not stored as ATP. Resulting energy is recorded as heat3.

In 1958, Kearns and Sayre described a syndrome with external ophthalmoplegia, pigmentary degeneration of the retina and

*Corresponding author: Ayfer AKTAS, University of Dicle, Medical Faculty, Department of Histology, 21280 Diyarbakir, Turkey Phone:+90 412 2488001-4123 Faks:+90 412 2488435 E-mail: aaktas@dicle.edu.tr

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Accept date: 19 August 2010 complete heart block. Progressive external ophthalmoplegia (PEO) clinically follows a benign route. Ophthlamoplegia without diplopia is characterized by pitosis and weakness of extremities in different degrees. They showed abnormal mitochondries by using Gomori’s trichrome stain in muscle biopsies and after this, most of ocular myopathy cases were accepted as mitochondrial myopathies4.

Mitochondrial dysfunction and lack of energy supply to tissues because of inability to make oxidative phosphorylation play roles in the pathogenesis of the disease. Basically, despite presence of this lack of energy in all tissues, tissues with higher energy requirement like central nervous system, retina, heart muscle and skeletal muscles are affected more. As a result of this different level of effect, clinical findings are very diverse5.

We found it appropriate to present the case with external ophthalmoplegia starting before the age of 20 and showing progression, whose myopathy was identified by mitochondrial changes shown in the muscle electron microscope investigation, in order to discuss the separation from other possible diagnosis criteria.

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Progressive External Ophthalmoplegia: A case report Ayfer Aktas et al

Case Report Complaints of HA, 24-year-old female patient, started at the age of 12, describing problems in far sight and reading the blackboard.

She did not describe double vision in the inquiry.

Lowering of the right eyelid was told to her by a doctor making medical examination in the school.

This lowering did not change between morning and evening. Later, left eyelid also started to lower. In 2-3 years, dysfunction started in eyelid movements and total ophthalmoplegia developed. Diplopia was not identified. In 1996, she was diagnosed with Myastenia Gravis and started to receive mestinon treatment. She did not show any benefits from this treatment. In 1997, decremental response was achieved in repetitive stimulation. She underwent a thymectomy operation, but did not show any benefits. She did not have family history.

Neurological examination displayed limitation of horizontal and vertical eye movements in both eyes (Figures 1, 2, 3, 4). She had bilateral pitosis and complaint of pain during vertical and horizontal movements of the eyes.

Light reflexes were normal. Pupils were isochoric. Eye bottom examination was normal.

All extremities showed 4/5 muscle power. Brain stem and deep tendon reflexes were normal.

There were no pathologic reflexes.

Cerebellar system examination was normal. Cranial MR and thyroid function tests were normal. ANA, Asthma and cardiolipin antibodies were within normal limits. Eye bottom and light reflex was normal. CK, ECG, USG were normal. ECO showed left ventricle diastolic dysfunction. Anti HBs was positive. ASO and CRP were normal.

Sedimentation (S): 22 – 31 mmHg/s.

ENMG motor and sensory transmission speed measurements were normal. In the needle EMG, short time low amp. Polyphasic MUP’s in proximal muscles were visualized. Repetitive stimulation was normal. Muscle biopsy material from deltoid muscle was investigated with electron microscope.

Enlargement of mitochondries and common crystolisis findings were shown. Z bands were noticed to be irregular, or even to disappear completely in some places. Loss of myofilaments were noticeable in places were Z bands disappeared (Figures 5, 6, 7, 8).

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Figure 1.2.3.4.

Neurological examination displayed limitation of horizontal and vertical eye movements in both eyes.

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Figure 5. Common crystolisis in mitochondrions.

It is seen that crystals of some are deleted completely and these have transformed into giant mitochondrions, having vacuolary vision. Obvious deletion in Z bands and loss myofilaments are also visibile (Uranyl acetate -Lead citrate, X 12000).

Figure 6. Mitochondrions are seen to have grown and common crystolisis visible. It is noticeable that Z bands are irregular in places, completely deleted in some others. Myofilaments obviously deleted where Z bands are completely deleted (Uranyl acetate -Lead citrate, X 12000).

Discussion Kearns-Sayre syndrome, which is seen in early adolescence, was first identified in 1958 4.

This disease, resulting from sporadic mitochondrial DNA deletion, is not hereditary1.

Analyses of muscle tissues have shown mitochondrial DNA deletion in approximately 80% of cases2.

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Progressive External Ophthalmoplegia: A case report Ayfer Aktas et al

Figure 7. Myofilament deletion are very common in some areas. Z bands are seen to completely have disappeared in these areas. Crystolisis in mitochondrions are also obvious in these areas (Uranyl acetate -Lead citrate, X 12000).

Figure 8. Nuclei belonging to myocytes are seen in normal structure. Myofilaments near nucleus and myofibrils formed by these are nearer to normal structure. While crystolisis is present in mitochondrions in this area, growth is not observed (Uranyl acetate -Lead citrate, X 120 .

Kearns-Sayre syndrome is characterized by chronic progressive external ophthalmoplegia, pigmentary retina and heart transmission failures.

Progressive external ophthalmoplegia is a syndrome defined by clinical attributes. This syndrome is generally defined by progressive pitosis, external ophthalmoplegia, bilateral strain, strain of muscles innerved by more than one nerve, protection of the pupil, slow progression, lack of remission, presence of cardiac strain and lack of findings of a specific disease.

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Mitochondrial diseases that include a heterogen group disease often cause diagnosis confusion for the clinician. Diagnosis of mitochondrial diseases can be made by detection of anomalies in muscle biopsy and number and structure of mitchondries. In order to make the diagnosis definite, staining techniques like Gomori’s trichrome, cytochrome oxidase, succinic dehydrogenase and NADH should be applied to skeletal muscle biopsy sections. The importance of muscle histology is that it easily differentiates the disease from other diagnoses.

Lipid droplets can be seen among myofibrils.

These droplets are specific to Kearne-Sayre and Peo and are not seen in Melas and Merrf.

Mitochondrions are the energy stations of the cell and mitochondries constantly divide and multiply in order to supply energy to the cell in the presence of defective mitochodries, especially due to mutation. However, this multiplication does not have any benefit, apart from formation of new defective mitochondries.

As a result, as clinical findings related to inability to supply sufficient energy to the cell develop, defective mitochondrions accumulate in groups. This accumulation is more intense in subsarcolemmal area and is easily visible in TEM investigation6.

Due to aging and oxidant stresses, nonfunctional defective mitochondrions might accumulate. Therefore, for diagnosis of mitochondrial diseases, apart from TEM, lack of COX activity in ragged blue fibers in combined enzyme staining and SDH staining enables the definite diagnosis of mitochondrial myopathies.

Progressive External Ophthalmoplegia: A case report Ayfer Aktas et al

References 1. Carod-Aral F J, Lopez Gallardo E, Solano A, Dahmani Y, Herrero MD, Montoya J: Mitokondrial DNA deletions in Kearns- Sayre syndrome. Neurologia 2006; 21:357-364.

2. Moraes CT, DiMauro S, Zeviani M, Lombes A, Shanske S, Miranda AF, Nakase H, Bonilla E, Werneck LC, Servidei : Mitochondrial DNA deletions in progressiye external ophthalmoplegia and Kearns-Sayre syndrome. N Engl J Med. 1989; 320:1293-1299.

3. R. Luft, D. Ikkos, G. Palmieri, L. Ernster and B. Afzelius, A case of severe hypermetabolism of nonthyroid origin with a defect in the maintenance of mitochondrial respiratory control: a correlated clinical, biochemical, and morphological study, J. Clin. Invest. 41.

1962; pp. 1776–1804.

4. Kearns TP, Sayre GP: Retinitis pigmentosa, external ophthalmologia and complete heart block. AMA Arch Ophthalmol 1958; 60:280-289.

5. Sundaram C, Kanikannan MA, Jagarlapudi MM, Bhoompally VR, Surath M: Diagnosis of mitochondrial disease. Clinical and histological study of sixty patients with ragged red fi bers. Neurol India 2004; 52:353-358 6. Carpenter,S, Karpati G: Pathology of skelat muscle. 2nd ed.

Newyork, Oxford University pres,2001; 259-179.

Conclusions Mitochondrial diseases that include a heterogen group disease often cause diagnosis confusion for the clinician. Mitochondrial changes shown in the muscle electron microscope investigation.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

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