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v. 12 – n. 3 – July/September 2015

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ISSN: Electronic version: 1984-5685

RSBO

Joinville – SC

v. 12

n. 3

97 p.

2015

Rector Sandra Aparecida Furlan Vice-Rector Alexandre Cidral Dean for Education Sirlei de Souza Dean for Research and Post-Graduation Denise Abatti Kasper Silva Dean for Extension and Community Affairs Claiton Emilio do Amaral Dean for Administration Cleiton Vaz Editorial Production Editora UNIVILLE Luciana Lourenço Ribeiro Vitor – Text revision and translation e-mail: llribeiro_3@hotmail.com Raphael Schmitz – Graphic design Marisa Kanzler Aguayo – Diagramming EDITORIAL BOARD Editor-in-chief Flares Baratto-Filho – Univille and UP, Brazil Administration Editors Fabricio Scaini – Univille, Brazil Luiz Carlos Machado Miguel – Univille, Brazil Carla Castiglia Gonzaga – UP, Brazil Tatiana Miranda Deliberador – UP, Brazil Associate Editors Edson Alves de Campos – Unesp, Brazil Sandra Rivera Fidel – Uerj, Brazil Gisele Maria Correr Nolasco – UP, Brazil Luiz Fernando Fariniuk – PUC/PR, Brazil Kathleen Neiva – University of Florida, USA Claudia Brizuela – University of Andes, Chile Johannes Ebert – University of Erlangen, Germany Nicolas Castrillon – University São Francisco of Quito, Ecuador

Editorial Board Alessandro Leite Cavalcanti – UEPB, Brazil Carlos Estrela – UFG, Brazil Christoph Kaaden – University of Munich, Germany Fernanda Pappen – UFPel, Brazil Fernando Branco Barletta – Ulbra, Brazil Fernando Goldberg – University of Salvador, Argentine Frank Lippert – Indiana University, USA Guilherme Carpena Lopes – UFSC, Brazil Jesus Djalma Pécora – Forp/USP, Brazil José Antônio Poli de Figueiredo – PUC/RS, Brazil José Carlos Laborde – Catholic University of Uruguay, Uruguay José Luiz Lage-Marques – USP, Brazil José Mondelli – FOB/USP, Brazil Juan Carlos Pontons-Melo – Sao Marcos University, Peru Lourenço Correr Sobrinho – FOP/Unicamp, Brazil Lúcia Helena Cevidanes – University of North Carolyn at Chapel Hill, USA Luciana Shaddox – University of Florida, USA Luis Sensi – University of Florida, USA Luiz Narciso Baratieri – UFSC, Brazil Manoel Damião Sousa-Neto – Forp/USP, Brazil Marco C. Bottino – Indiana University, USA M a r í a Merc e de s A z uer – Javer i a n a Un i versit y, Colombia Mário Tanomaru Filho – Unesp, Brazil Miguel González Rodríguez – Odonthos Institute, Dominican Republic Mu ha nad Hat a m leh – Un iversit y of Ma nchester, England Osmir Batista de Oliveira Júnior – Unesp, Brazil Pedro Bullon Fernandez – University of Sevilha, Spain Regina M. Puppin-Rontani – FOP/Unicamp, Brazil Richard L. Gregory – Indiana University, USA Rivail Antônio Sérgio Fidel – Uerj, Brazil Rodrigo Neiva – University of Florida, USA Sandra Milena Brinez Rodriguez – Javeriana University, Colombia Saulo Geraldeli – University of Florida, USA Ulrich Lohbauer – University of Erlangen, Germany Valentina Ulver de Beluatti – University of Maimonides, Argentine Valeria Gordan – University of Florida, USA Yara Teresinha Corrêa Silva Sousa – Unaerp, Brazil

The content of the articles is of sole responsibility of the authors.

Table of Contents Guest editorial................................................................................................................................................ 242

Original Research Articles Assessment of oral health status of children with special needs in Delhi, India.......................................... 244 Abhishek Mehta, Rachika Gupta, Saleha Mansoob, Shahnaz Mansoori

Effect of contact time between alginate impression and type III dental stone on cast model properties........ 252 Amna Adam Ibrahim, Mohammed Nasser Alhajj, Magdi Wadie Gilada

Accuracy of Root ZX mini and Raypex 6 in locating the apical foramen of molars: radiographic and microscopic evaluation............................................................................................................................ 258 Berenice R. García-Herverth, Norberto J. Broon, Alvaro Cruz, Claudia A. Palafox-Sánchez, Santiago Andaracua G, Ricardo Ayón-García

Validation of pH cycling model to induce artificial carious lesions in bovine dentin....................................... 266 Ana Caroline Fumes, Raquel Assed Bezerra da Silva, Daniele Lucca Longo, Andiara De Rossi, Mônica Campos Serra

Oral health status of patients with special needs from a rehabilitation association in Curitiba (PR, Brazil)...................................................................................................................................................... 272 Cecim Calixto Junior, Marilisa Carneiro Leão Gabardo, João Armando Brancher, Mariana Dalledone, Tatiana Luzzi, Eduardo Pizzatto

Postgraduate students’ knowledge on oral health ......................................................................................... 278 Valéria Freire Morais, Gabriela Martelli, Edson Alfredo, Silvio Rocha Corrêa da Silva

Analysis of the time required for dissolving the pulp tissue according to different methods of sodium hypochlorite activation...................................................................................................................... 285 Ana Luíza Leichtweis, Tiago André Fontoura de Melo, Gustavo Golgo Kunert

Epidemiological study to determine factors associated with dental caries in schoolers . ............................... 289 Camila Castro, Carolina Dea Bruzamolin, João Gilberto Duda, João Armando Brancher, Eduardo Pizzatto

Resistance to fracture evaluation of endodontically treated roots of first maxillary premolars ..................... 297 Rosany Laurentina Santos de Carvalho, Carolina dos Santos Guimaraes, Marcia Maria Fonseca da Silveira, Diana Santana de Albuquerque, Raquel Azevedo de Moraes, Flávia de Lima Cavalcanti Spinelli

Literature Review Articles Can quality of life index measure oral health over the years? A systematic review......................................... 302 Paulo Roberto Silva, Márcia Cristina Lopes, Wellington M. Zaitter, Edgard Michel Crosato

Case Report Articles Oral rehabilitation of a child with dentinogenesis imperfecta – case report....................................................311 Kelly Maria Silva Moreira, Cibele Aparecida Silva, Rayen Milanao Drugowick, José Carlos Pettorossi Imparato, Juliana Braga Reis

Prosthetic rehabilitation using association of total and implant-supported total denture (Branemark protocol) – case report.................................................................................................................316 Rodrigo Lorenzi Poluha, Clóvis Lamartine de Moraes Melo Neto, Sérgio Sábio

Bleaching and enamel microabrasion in the smile esthetics: a case report..................................................... 323 Thais de Paula Faccio Alves, Ana Flávia Simões Barbosa, Thaís Fantinato Trindade, Carolina de Andrade Lima Chaves, Walter Raucci Neto, Vivian Colucci

Oral rehabilitation in a patient with bipolar affective disorder: clinical case report........................................ 330 Eduardo Rossetti, Érico Kruchinski de Azevedo, Bruna Eliza Zanini, Vanessa Carriço Lemes, João Armando Brancher, Maria Fernanda Torres, Andréa Paula Fregoneze

Guest editorial The use of amalgam and its relation to mercury toxicity Recently, it was approved and then withdrawn a proposal banning the use of dental amalgam in Brazil, the Project Law n. #654/15. According to the author of the proposal, this measure would be a protection to the health of dental professionals, patients, and environment. It is true that the prohibition of the use of dental amalgam is already in place in several countries, including Sweden, Norway, Denmark, Germany, Bulgaria, Vietnam, Thailand, and Japan. But the discussion on the subject persists in many other countries. The entire controversy is around the use and disposal of amalgam, due to the presence of mercury in its composition, which is a highly toxic heavy metal. There are two opinions to address the problem related to mercury toxicity: the risk of human contamination and the risk of environmental contamination. Brief ly, mercury may be present in nature in three conditions: forming organic compounds (methylmercury, for example), in the form of inorganic salts (linked to chlorine, sulfur, oxygen) and as a metal compound. The human body can absorb the mercury in three different ways: ingestion, skin absorption, and inhalation of vapors. In the form of organic compounds, the main intoxication pathway occurs by ingestion, such as when we eat fish contaminated with mercury (Minamata disease), and this is the main (and more severe) way of human contamination. However, this is not related to dental practice because the mercury in dental amalgam is used as metal compound. Metal compound is not absorbed by ingestion, but it has high vapor pressure and is much absorbed by inhalation, which are odorless and colorless. Thus, for dental professionals, the main â&#x20AC;&#x153;dangerâ&#x20AC;? is mercury vapors, which can be released into the atmosphere during various stages of production or removal of a restoration, mainly during polishing and removal of amalgam restoration without proper refrigeration. The mercury vapor can enter the bloodstream through the lungs by inhalation and can preferably be deposited in the lungs and kidneys, which can lead to failure by high intensity acute exposure. Furthermore, the mercury can also affect the central nervous system causing neurological abnormalities and intoxication due to chronic exposure of low intensity, known as erethism. However, it should be remembered that although not as common in dental environment, mercury poisoning can be considered a public health problem for certain groups of workers such as miners and industry workers, such as lamp factories. For the dentist, the main problem relates to the disposal of amalgam remnants and other materials with mercury, such as light bulbs, batteries, and thermometers. The metallic mercury, when disposed improperly in the environment can lead to contamination of water and other animals. But the most serious fact is that it can undergo a process known as biotransformation, when the metallic mercury is converted into an organic form by the action of algae and bacteria. And it is this organic form that can contaminate the environment, be absorbed by animals, as fish, and be related to the primary cause of mercury poisoning by ingestion. In clinical practice, the risks can be minimized by adopting simple measures such as: good ventilation; use floors that allow quick handling in the event of leakage or accidental discharge of mercury; use of capsules, which have a lower amount of mercury and less possibility of contact and leakage; use of masks and gloves to avoid contact with vapor and skin absorption; proper washing of the instruments prior to sterilization, preventing possible amalgam remnants in the instruments can lead to increased formation of mercury vapors. Finally, at the time of polishing or removing amalgam fillings heating and release of vapors should be avoided by the use of new drills, intermittent cutting and abundant cooling. Amalgam remnants should be discarded in a hermetically sealed glass filled with fixing solution

or water, which must be stored on site at the office with low temperature and without receiving direct sunlight until referral to specialized laboratories in management of dental waste. There is no scientific evidence of poisoning by mercury of dental amalgam both in patients and dental professionals. Therefore, in countries like Brazil, dental amalgam can still be a restorative material. However, the contamination risks in the environment should still be discussed and minimized. Profa. Dra. Carla Castiglia Gonzaga Prof. Dr. Leonardo Fernandes da Cunha Profa. Dra. Gisele Maria Correr

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):244-51

Original Research Article

Assessment of oral health status of children with special needs in Delhi, India Abhishek Mehta1 Rachika Gupta1 Saleha Mansoob1 Shahnaz Mansoori1 Corresponding author: Abhishek Mehta Department of Public Health Dentistry – Faculty of Dentistry Jamia Millia Islamia – New Delhi – India E-mail: mehta_abhishek2003@yahoo.co.in 1

Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia – New Delhi – India.

Received for publication: July 27, 2015. Accepted for publication: August 12, 2015.

Keywords: children with special needs; oral health assessment; intellectually disabled.

Abstract Introduction: Children with special needs are considered to be a high risk group for dental diseases especially dental caries and periodontal diseases. Objective: Assessment of oral health status of children with special needs in Delhi, India. Material and methods: A cross sectional survey was conducted on 414 children with special needs belonging to four different disability groups i.e. Intellectually Disabled (ID), Physically Challenged, visually and hearing impaired. WHO Oral Health Assessment Form for children, 2013 was used for assessment of various parameters of oral health among the study population. Results: Of the 414 children, 305 were males and 109 females. Overall caries prevalence was 38%. Mean DMF value was 3.71 with ID children having higher mean than the other groups. A significant positive correlation was also observed between age and dental caries. Gingival condition was also worse in ID children and best in physically challenged ones. Highest numbers of trauma cases were recorded in visually impaired group. Delayed eruption of permanent teeth was most common in hearing impaired. 98.7% children required some form of dental treatment. Conclusion: Oral health of children with special needs was poor and urgent attention is required to plan a comprehensive dental health care programme for them.

245 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

Introduction

Material and methods

The American Health Association defines a child with disability as a “child who for various reasons cannot fully make use of all his or her physical, mental and social abilities”. According to WHO estimates, individuals with disability comprise 10% of the population in developed countries and 12% in developing countries [6]. Census of year 2011 has revealed that over 26.8 million people in India as suffering from one or the other kind of disability. Among the total disabled in the country i.e. 26.8 million – 15 million are males and 11.8 million females. According to the census, 20.3% of the disabled are physically challenged followed by hearing impaired (18.9%) and visually impaired (18.8%). Nearly 5.6% of the disabled population is in ID group [7]. O ra l hea lt h a f fect s one’s aest het ic a nd communication abilities; also it has strong biological, psychological, and social projections. People with disabilities deserve the same opportunities for oral health and hygiene as any other human being [1]. Unfortunately oral health care is one of the greatest unattended health needs of the disabled people. Children �� with disabilities may have more marked oral pathologies, either because of their actual disability or for other medical, economic or social reasons, or even because their parents find it very difficult to carry out proper daily oral hygiene (e.g., cariogenic effect of medicines with high sugar content, excessive tooth grinding with self-mutilating behaviours) [13]. A higher prevalence and severity of oral diseases was observed by various investigators in disabled individuals around the World [1, 3, 10, 19] and India [2, 5, 11, 12, 16, 18]. On the basis of these reports there are many unmet dental needs in disable population which need more attention. However, only limited studies have been done to compare dental health of different kinds of children with special needs [2, 18]. Majority of these studies have concentrated on one or two aspects of oral health while assessing oral health status of this group of children. A detail picture of oral health status of children with special needs is important when planning for a comprehensive dental programme for them as well as for lobbying efforts with health authorities. Keeping above facts in mind, an oral health survey was designed utilizing WHO oral health assessment form, 2013 [21] which will provide us a full picture of oral health status o f c h i l d r e n with special needs in the age range of 3-15 years attending various special schools in Delhi.

A cross sectional descriptive survey was conducted among 414 children of 3-15 years of age who are suffering from various kinds of disabilities and attending special needs schools in different parts of Delhi state in India.

Survey groups and sample size There is no data available on number of children attending special schools in Delhi, therefore data from census of 2011 was utilized to find out total disabled population in Delhi state. The census states that total disabled population, includes all age groups, is less than 1.75% of total population of Delhi; in 0-6 year age group, 13,760 children are suffering from various disabilities [7], therefore by highest estimate possible and checking the data from previous census, the sample population will not be more than 50,000. Hence, the calculated sample size is 381 at 95% confidence interval, 80% power and expected frequency of dental caries at 50% (Statcalc, Epinfo version-7). The survey included 4 major disability groups as mentioned below with their sample size i. Intellectually disabled (ID)=100; ii. Visually impaired (VI)=90; iii. Hearing impaired (HI)=132; iv. Physically challenged (PC)=92.

Ethical clearance and informed consent Informed consent was obtained from parent/ guardians and p ermission h a d b e e n taken from respective school authority prior to the clinical examination of children. Ethical clearance was obtained from the Ethical Research Committee of Jamia Millia Islamia University, New Delhi. In total eleven institutions located in various part of Delhi state were shortlisted for the study, out of these, nine institutions gave their consent to participate in the study.

Training and calibration of examiners Clinical data was collected by three investigators under one main researcher. A recording clerk also assisted during the process. Before starting the main survey, a pilot study was conducted on 25 subjects of similar age group in the Out Patient Department of Public Health Dentistry for the purpose of training and calibration of examiners. Cohen’s Kappa coefficient for assessment of dental caries was 0.82, indicating a good interexaminer reliability.

246 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

Inclusion and exclusion criteria Children present on the day of examination were included in the study. A second visit was made to examine absentees. Those who are not willing to participate or unwell were excluded. Data was collected over a period of two months.

Data recording Dental examinations were held in the respective schools u nder nat u ra l l i g ht w it h su f f icient illumination with participants seated in the ordinary chair. Examination was carried out using mouth mirror and Community Periodontal Index probe. Help of Teachers/care taker were utilized for communication with the children. WHO Oral Health Assessment Form (2013) for children’s was used for recording oral health status of the subjects. Information collected through this form included general information pertaining to study subjects like Name, Date of Birth, Age, and Gender. Clinical assessment includes recording of dentition status of child for caries and its effect like missing or filled teeth due to caries. Gingival status was assessed by recording gingival bleeding using CPI probe. Presence and severity of Dental erosion, Dental fluorosis and dental trauma were also been assessed. A tooth was classified as missing if it had not erupted after six months of its expected eruption

date. A tooth was classified as retained if it was still in the arch after six months of its expected date of exfoliation. Intervention urgency / treatment needs were also mentioned according to the type of treatment required for an individual. After the examination children in need of dental treatment were referred to the faculty for rendering specialty care.

Statistical analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS), version 17 (IBM Software Company, USA). Epinfo version 7 was used for calculating the sample size. Frequency tables were prepared and mean and standard deviation were calculated. As the data was not following normal distribution, Mann Whitney U test was applied for pairwise comparison and Kruskal Wallis for comparing more than two variables. Pearson correlation test was used to check correlation between age and dental caries experience. Statistical significance was set at P ≤ 0.05.

Results A total of 414 children comprised the sample, among them males were in overwhelmingly majority, representing 73.6% (305) of the total population (graph 1).

Graph 1 – Distribution of subjects according to disability and gender

247 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

Mean Decayed Missing Filled Teeth (DMF) and Standard Deviation were calculated for various groups and are presented in table I. Overall comparison between groups using Kruskal-Wallis test showed that there was significant difference between the groups for dental caries experience in permanent dentition. When pairwise comparison was done using Mann Whitney test, it was found t hat denta l ca ries ex perience was higher in intellectually disabled when compare to physically challenged group only, other comparisons were

not significant. The largest component in DMFT was D component and F had very low values. In primary dentition, physically challenged children had significantly higher mean def values compared to visually impaired group (p<0.01) (table II). Overall caries prevalence was 38% in study population.�� A significant positive correlation was observed between age and dental caries (p<0.001, Pearson correlation test). Enamel �� fluorosis of different severity was present in 63 (15.2%) subjects. There was no case of severe fluorosis (graph 2).

Table I – Comparison of mean DMF values among different groups

Disability group ID (1)** PI (2)** VI (3) HI(4) Total

Decayed teeth (SD) 1.17 (1.79) .57(1.3) .79(1.2) .74(1.37) 3.27(5.66)

Filled with caries (SD) 0 0 .03(.3) 0 .03(.3)

Filled with no Missing due to caries (SD) caries (SD) 0 .20(.81) 0 .15(.72) 0 .04(.32) 0 .02(.19) 0 .41(2.04)

Mean DMF (SD)* 1.37(2.5) 0.72(2.08) 0.86(1.93) 0.76(1.56) 3.71 (8.07)

* Kruskal Wallis test, p=0.007 (significant), degree of freedom (df)=3 ** Mann Whitney U test, p=0.001(significant); statistical difference between group 1 and 2

Table II – Comparison of mean def values among different groups

Disability group ID (1) PI (2)** VI (3)** HI (4) Total

Decayed teeth (SD) .85 (1.777) 1.91(4.087) .43(1.17) .73(1.66) .84(2.1)

Filled with caries (SD) .01(0.1) .07 (.442) 0 .01(0.08) .01(.17)

Filled with no Extracted due to caries (SD) caries (SD) .02(0.2) .02(0.2) .02(.147) .26(.82) 0 .01(.1) 0 .03(0.17) .01(0.11) .05(.33)

** Kruskal Wallis test, p=0.01 (significant), df=3 ** Mann Whitney U test , p=0.002 (significant); statistical difference between group 2 and 3

Graph 2 – Distribution of subjects according to presence or absence of enamel fluorosis

Mean def (SD)* 0.9(2.27) 2.26(5.48) .44(1.27) 0.77(1.91) 0.91(2.71)

248 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

Overall prevalence of dental trauma was 21%. Inter-group comparison was statistically significant and pairwise comparison showed that visually impaired were having highest cases of dental trauma in comparison to all the other groups (table III). Table III – Distribution of subjects according to prevalence of gingival bleeding and dental trauma

Disability group

Gingival bleeding*

Total number of trauma cases**

ID (1)

69 (69)

15 (15%)

PI (2)

22 (23.9)

14 (15.2%)

VI (3)

60 (66.6)

31 (34.4%)

HI (4)

78 (59.09)

27 (20%)

*Mann Whitney U test, p=0.0001 (significant); statistical difference between group 1 and 2 ** Kruskal Wallis test, p=0.001 (significant), degree of freedom (df)=3

In total 55.3% of children was suffering from gingival bleeding. There was statistically significant difference between the groups with intellectually disabled children having higher gingival bleeding score. When pairwise comparison was done, intellectually disabled had statistically significant higher gingival bleeding score than Physically

impaired group only and not significant with other two groups (table III). Pattern of delayed eruption of permanent teeth was also analyzed. In total 24% of children had delayed eruption of one or more teeth. Highest number was seen in hearing impaired children. (graph 3).

Graph 3 – Delayed eruption of permanent teeth in different groups

Only five children out of 414 did not require any form of dental treatment. Prompt dental treatment including scaling was required in 214 (51.6%) children, immediate treatment needed due to pain or infection due to dental/oral origin in 13% and preventive or routine treatment in 34% of the total sample population (table IV).

249 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

Table IV – Distribution of subjects according to treatment needs

Intervention urgency

No treatment required

Preventive or routine treatment needed

Prompt treatment needed

Immediate treatment needed

Total

ID (1)

100

PI (2)

VI (3)

HI (4)

132

Total (%)

5 (0.01%)

141 (34%)

214 (51.6%)

54 (13%)

414

Discussion Oral health is an integral part of general health and well being. Disabled people have equal right for good oral health as any other citizen of the country. Unfortunately due to their condition and lack of awareness towards oral health, dental diseases get undiagnosed in these children leading to accumulation of high unmet demand for dental care later in life. A cross-sectiona l descriptive survey was conducted in various institutes opened for children with special needs in Delhi state, India. In total 414 children, 305 males and 109 females, from nine institutes were examined for various oral diseases and treatment needs. Due to this imbalance in gender number, no comparison was done of various parameters between males and females. One reason for such disparity in sex ratio could be due reluctance of parents to send girl child to special institutions in India. Dental caries is a rapidly emerging oral health problem amongst the children of India. According to a National Oral Health Survey conducted in 2003-4, caries prevalence in India was 51.9, 53.8 and 63.1% at ages 5, 12 and 15 years, and mean DMF values were 2, 1.8 and 2.3 respectively [14]. As per WHO Oral Health report (2003), mean DMF among 12 year children in Indian population was in range of 1.2-2.6 [15]. The mean DMF value was 3.71 which is higher than as reported in above mentioned nationwide surveys, this means that although few children were suffering from dental caries, the severity of caries was higher in these children as compared to general population of children. Second explanation can be because of prior removal of carious teeth or due to periodontal reasons, especially among

those with severe intellectual disabilities, living in institutional settings [9]. The mean DMF value in ID children was lower than various studies conducted around India [12, 16]. Similarly, visually and hearing impaired had slightly less mean DMF value as compared to studies done on special children in Bhopal [18], Delhi [5], Rajasthan [20] and comparable to that of Udaipur and Delhi [11, 21]. In our study, overall caries prevalence was 38%. A partial explanation for low caries prevalence in comparison with general population may be that in many institutional and group settings, residents receive a well balanced diet, with supervised intake of refined carbohydrates [9]. A positive correlation of caries experience was observed with age, this finding is significant as it implies that burden of caries is going to increase in this population if necessary steps are not take immediately. Various studies [2, 17, 20] and systematic review [4] have reported poorer oral hygiene especially among children with intellectual disabilities as compare to general population. In the current study, oral hygiene was assessed by presence or absence of gingival bleeding. Overall presence of gingival bleeding was 59.09%. Intellectually disabled had worst oral hygiene with 69.9% of them suffering from gingival bleeding. Physically impaired were having better gingival status among all the four groups. Similar results were obtained in study done by Shukla et al. [21]. Various reasons can be predicted for such finding like lack of intellectual abilities that precludes adequate oral hygiene practice. �� Individuals with problems of vision are able to comprehend oral hygiene instructions and also have more normal kinetic skills; however, they may still

250 â&#x20AC;&#x201C; RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. â&#x20AC;&#x201C; Assessment of oral health status of children with special needs in Delhi, India

have difficulty seeing and removing plaque. Thus the most important variable in determining oral health status is the type of disability and how that disability impacts the maintenance of adequate or sound oral hygiene [17]. Many different types of specially designed manual toothbrushes have been developed. Among them is the triple-headed brush, which is designed to clean the oral, buccal, and occlusal surfaces of the teeth with a single stroke and is recommended for certain individuals with limited manual skills [8]. Current study reported the highest incidence of dental trauma especially in maxillary incisors in visually impaired children; reason for this finding is obvious as this group has difficulty in seeing properly, hence they are more prone to accidents/fall. Delayed eruption of teeth was seen in all groups but highest prevalence was observed among hearing impaired children. This finding requires further research. Demand for dental treatment was quite high in these children as only five children did not require any dental treatment. This finding implies that all groups were deprived of dental care with very high unmet needs. Among the limitations of the study are utilization of convenience sampling technique, no attempt was being made to evaluate the severity of disabilities and level of motor skills of the study population and also the social and behavioral factors which are associated with oral health.

Conclusion From the results, it can be concluded that oral health status of the children with special needs was poor with very low prevalence of treatment done and high unmet needs. The mean DMFT was significantly higher among ID and visually impaired individuals, whereas poor gingival condition and delayed eruption reported in hearing impaired individuals. Dental trauma was seen more in visually impaired children. The level of treatment or care by the society of its neglected and dependent part determines its cultural level and evolution. Children with special needs deserve special attention in the area of oral health as reflected in this study.

Acknowledgement We are thankful to ICMR-STS programme for the approval of this project and to all the students

and head of institution of special schools who participated in this study.

References 1. Altun C, Guven G, Akgun OM, Akkurt MD, Basak F, Akbulut E. oral health status of disabled individuals attending special schools. Eur J Dent. 2010 Oct; 4(4):361-6. 2. Ameer N, Palaparthi R, Neerudu M, Palakuru SK, Singam HR, Durvasula S. Oral hygiene and periodontal status of teenagers with special needs in the district of Nalgonda, India. J Indian Soc Periodontol. 2012;16:421-5. 3. Anaise JZ. Periodontal disease and oral hygiene in a group of blind and sighted Israeli teenagers 1417 years of age. Community Dent Oral Epidemiol. 1979;7:353-6. 4. Andres Al, Davis EL. Oral health of patients with intellectual disabilities: a systematic review. Spec Care Dentist. 2010;30(3):110-7. 5. Avasti K, Bansal K, Mittal M, Marwaha M. Oral health status among sensory impaired children in Delhi and Gurgoan. International Journal of Dental Clinics. 2011:3(2):21-3. 6. Baykan Z. Causes and prevention of disabilities, handicaps, and defects. J Cont Med Educ. 2003;9:336-8. 7. Census of India 2011. Data on Disability. Available from: URL:http://www.censusindia.gov. in. 8. Dogan C, Alacam A, Asici N. Clinical evaluation of the plaque removing ability of three different toothbrushes in a mentally disabled group. Acta Odontol Scand. 2004;62;350-4. 9. Gabre P, Martinsson T, Gahnberg L. Incidence of, and reasons for, tooth mortality among mentally retarded adults during a 10-year period. Acta Odontol Scand. 1999;57:55-61. 10. Hashemi Z, Hajizamani A, Bozorgmehr E, Omrani F. Oral health status of a sample of disabled population in Iran. J Oral Health Epidemiol. 2012;1(1):23-8. 11. Jain M, Mathur A, Kumar S, Dagli RJ, Duraiswamy P, Kulkarni S. Dentition status and treatment needs among children with impaired hearing attending a special school for deaf and mute in Udaipur, India. J oral Science. 2008;50(2):161-5.

251 – RSBO. 2015 Jul-Sep;12(3):244-51 Mehta et al. – Assessment of oral health status of children with special needs in Delhi, India

12. Jain M, Mathur A, Sawla L, Choudhary G, Kabra K, Duraiswamy P et al. Oral health status of mentally disabled subjects in India. Journal of Oral Science. 2009;51(3):333-40. 13. McPherson M, Arango P, Fox H. A new definition of children with special health care needs. Pediatrics. 1998;102:137-40. 14. National Oral Health Survey and Fluoride mapping of India. Dental Council of India 20022003.

18. Reddy VK, Chaurasia K, Bhambal A, Moon N, Reddy EK. A comparison of oral hygiene status and dental caries experience among institutionalized visually impaired and hearing impaired children of age between 7 and 17 years in central India. J Indian Soc Pedod Prev Dent. 2013;31:141-5. 19. Shaw L, Maclaurin ET, Foster TD. Dental study of handicapped children attending special schools in Birmingham, UK. Community Dent Oral Epidemiol. 1986;14:24-7.

15. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;31(Suppl 1):3-23.

20. Singh A, Kumar A, Berwal V, Kaur M. Comparative study of oral hygiene status in blind and deaf children of Rajasthan. J Adv Med Dent Sci. 2014;2(1):26-31.

16. Purohit BM, Acharya S, Bhat M. Oral health status and treatment needs of children attending special schools in South India: a comparative study. Spec Care Dentist. 2010;30:235-41.

21. Shukla D, Bablani D, Chowdhry A, Zafri Z, Ahmed N, Mishra S. Oral health status and dental caries experience in mentally challenged individuals. Ann Public Health Res. 2014;1(2):1008-12.

17. Rao D, Amitha H, Munshi AK. Oral �� hygiene status of disabled children and adolescents attending special schools of South Canara, India. Hong Kong Dent J. 2005;2(2):107-13.

22. World Health Organization. Oral health surveys-basic methods. 5. ed. Geneva: WHO; 2013.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):252-7

Original Research Article

Effect of contact time between alginate impression and type III dental stone on cast model properties Amna Adam Ibrahim1, 2 Mohammed Nasser Alhajj1, 3 Magdi Wadie Gilada1 Corresponding author: Mohammed Nasser Alhajj Department of Oral Rehabilitation, Faculty of Dentistry, Khartoum University Khartoum, Sudan E-mail: dr_alhaj@hotmail.com Department of �� Oral Rehabilitation�� , Faculty of Dentistry, Khartoum University – Khartoum – Sudan. Department of Prosthodontics, Faculty of Dentistry, Al-Gazira University – Wad Medani – Sudan. 3 Department of Prosthodontics, Faculty of Dentistry, Thamar University – Thamar – Yemen. 1 2

Received for publication: June 23, 2015. Accepted for publication: July 8, 2015.

Abstract Keywords: alginate impression; dental stone; contact time; cast model properties.

Objective: To measure the effect of different contact time between the alginate impression and type III dental stone on cast model properties in the terms of dimension stability, hardness and surface details reproduction. Material and methods: Sixty-seven cast models were obtained from stainless steel cylinder using alginate impression material and type III dental stone. Thirty-seven cast models were separated after one hour (control group) and 30 cast models were separated from impressions after 9 hours. The samples were evaluated under light microscope for surface details, measured by digital caliper for dimension stability and hardness was tested by making indentation on the cast then measuring the depth using digital caliper. Results: The dimension stability of cast models was not affected by increasing contact time between type III dental stone and alginate impression while surface details decreased. In the meanwhile, hardness was improved with increasing contact time. Conclusion: According to the results of this study, pouring of impression up to 9 hours can negatively affect the cast model properties in the term of details richness.

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Introduction In dentistry, there is a need for a replica of oral-dental tissues for diagnosis and treatment of oral diseases [11, �� 19]�� . These replicas are made from impressions that poured to make what called cast model or die �� [14, 19, 21]�� . The most extensively used materials for this purpose are alginate and gypsum products �� [8]�� . The alginate is a hydrocolloid material used in dentistry since 1940 because of its easy mixing, low cost and well accepted by patient �� [8, 15, 17]�� . It consists of a powder containing calcium or potassium sulfate and fillers as primary components. Commercial alginate has some additives to calcium salt which improves its properties such as diatomaceous earthfiller to increase rigidity and facilitate mixing, tetra sodium pyrophosphate (retarder), magnesium oxide (pH modifier) and setting aids such as sodium fluorosilicate �� [2, 14]�� . This product is regulated by ISO 1563:1990 and its properties are described in ANSI/ADA specification no. 18-1992 for alginate impression materials [2]� ��. Unfortunately, alginate is not dimensionally stable thus it is necessary to pour the impression immediately after molding has been accomplished [12, 15]�� or within up to 60 minutes if the impression is kept in 100% humidity �� [23]�� . These changes in dimension can be explained by two main phenomenons; syneresis which results in impression contraction and imbibition that makes the impression expands [12, �� 14]�� . The ADA specification no 18 accept an error of 75 µm in the alginate impression as a maximum dimension change �� [2]��. It is of a good practice to separate the impression from the cast before the hydrocolloid dehydrates because that the dried alginate can cause abrasion on the cast during its removal �� [7]�� . Working cast model and die of gypsum used in fabrication of dental restoration must provide dimensional stability, strength, and resistance to abrasion as well as they must reproduce surface details [5]�� . Specification no. 25 of ADA revealed that details reproduction is satisfactory when a copy line of 50µm in diameter reproduced continuously across the stone cast. These details can be affected by the type of impression material used and disinfection method �� [1, 3, 4, 10]��. Hardeners are added to stone to improve the hardness of the cast. Cyanoacrylate increases the surface hardness 150% and abrasion resistance 48% �� [6, 9]�� . Although some studies showed that the surface hardness was not affected by impression disinfection �� [22]�� , others disagree with these results [13]�� . The dimension stability of the cast model is not only affected by alginate syneresis and imbibition

but also depends on the clinician handling of alginate impression and prolongs contact time between alginate impression with gypsum product [14, 20]�� . The hypothesis that was tested in this study was that the effect of contact time between alginate impression and type III dental stone on model properties after different interval periods.

Material and methods For conduction of t his study a stainless cylindrical model was constructed according to ADA specification no. 18 for alginate impression material �� [2]�� . The dimensions of the cylindrical model were 25 mm in width and 15 mm in length with reference lines in surface 75 µm, 50 µm and 25 µm in width and 2.5 mm apart from each other. These lines were used to measure surface details reproduction. Two bisecting lines (x and x’) were marked to test the dimension stability by measuring the distance in between. The hardness was assessed by making indentation along the 50µm longitudinal line and measuring the micro scratches [2, �� 10, 23]�� . Ten special trays were made from chemical cure acrylic resin (Superacryl Plus, SpofaDental, Markova, Czech). Two wax sheets (2.8 mm in width) evenly lied around the cylinder then acrylic dough was applied to grantee an equal width of alginate impression material around the cylinder. After material setting, the special trays were finished and perforated. All impressions of the cylinder were made using high precision, chromatic alginate (Alginmax, Major, Moncalieri, Italy) and the instructions of the manufacturer were followed. The impressions were poured with type III dental stone (Gyproc, Prevest Denpro, Jammu, India) to produce the cast models. Sixty-seven cast models were obtained from impressions after different interval times, they were randomly divided into two groups; Group A (no=37): is the control group where the casts were removed after one hour, and Group B (no=30): is the study group where the casts were removed after 9 hours. All casts were preserved for 48 hours in well-sealed plastic bag until testing. All properties were carried out by one examiner. The properties of the resultant casts were tested as follows:

Dimension stability examination The dimension stability measured indirectly from the cast between x and x’ along the 50µm line by using digital caliper (Digital Caliper, Hornady, New York, USA).

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Surface details examination The surface details were evaluated by reproduction of A, A’, A’’ according to the scores index (table I). Evaluation was performed under x4 magnification and 100 watt artificial light (VanGuard, VEE GEE Scientific, Kirkland, USA). Table I – The surface details index

Score

Impression surface

None of three lines were visible

Only line (75 µm) was clear

Line A (75 µm) was clear and line A’ (50 µm)presented

Lines A (75 μm) and A’ (50 μm) were clear

Lines A (75 μm), A’ (50 μm) and A” (25 μm) were clear

Hardness examination Hardness was measured by depth of indentation made by 997 Newton in 15 seconds. The casts were mounted on the machine (W&T, Avery, Birmingham, England) to accommodate the ball along the 50µm line. The cast was released and measuring of the indentation was performed using digital caliper.

Results St at ist ic a l Pack a ge for Socia l Sciences Software (SPSS V20, IBM, Chicago, USA) was used to perform the statistical analysis. Table II shows the descriptive statistics of dimension stability in mm and hardness measured along the 50µm line. Student’s t-test was utilized to measure the significance of differences between the groups. There was no significant difference (P-Va lue = 0.120) in t he term of dimension

stabilit y bet ween the t wo groups while high significant difference (P-Value=0.0001) in hardness readings existed. Regarding surface details the results of the study shows that the two groups could duplicate two lines clearly 50 µm and 75 µm (table III). For analyzing the comparison in surface details between the two groups MannWhitney non-parametric test was applied because the data is not quantitative (ordinal scale). No significant difference between group A and group B was observed (P-Value=.051).

Table II – Descriptive Statistics for dimension and hardness by groups

Dimensions from x to x’ along 50 µm line in mm

Hardness reading

Mean

17.45

0.52

Std. Deviation

1.66

0.24

Minimum

7.64

0.20

Maximum

17.99

1.17

Mean

17.84

.1860

Std. Deviation

0.267

0.12

Minimum

17.23

0.04

Maximum

18.44

0.41

Groups

Group A (one hour)

Group B (9 hours)

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Table III – Surface details by group

Groups

Group A (one hour) Group B (9 hours) Total

Surface details

Only two lines were clear A (75 µm) and A’ (50 µm)

All lines were clear A (75 µm), A’ (50 µm) and A” (25 µm)

Count

0.00%

100.00%

count

10.00%

90.00%

100.00%

Total

count

4.48%

95.52%

100.00%

Discussion In daily dental practice immediate pouring of the alginate impressions may not be always accessible. Thus, the impressions are wrapped in a paper towel or saved in a well-sealed bag with appropriate humidity. Failure to achieve these requirements will affect the properties of these materials [18]�� . Nevertheless, taking a long time to separate the cast from the impression will result in deterioration on some properties of the model cast. This study was set out to investigate the possible changes of the properties on the cast model after different time contact between the gypsum type III dental stone and alginate impression material. The results showed that there were no significant changes in the dimension stability of the stone cast models in different periods. Surface details and hardness evaluation showed differences among the two tested groups. The hardness significantly increased with increase contact time while the surface details richness decreased with increase contact time. Despite this, very few studies have investigated the impact of the prolonged contact time between alginate impression and dental stone. Marquezan et al. [15]�� found that the contact time between alginate impression material and type III dental stone did not affect the dimension of cast models. Although their study was conducted to test the properties between one hour and 12 hours of contact time the results regarding the dimension stability was also as that obtained from this study which compared the results between one hour and 9 hours of contact time. The surface details were not destroyed in this study, the two groups duplicate lines 75 µm and 50 µm clearly which are satisfied according to ADA specification no 18 for alginate impression material, and no. 25 for gypsum product respectively [1, �� 2]��.

All model casts of Group A (one hour contact time) could reproduce the line 25 µm whereas about 10% of Group B samples (nine hours contact time) failed to reproduce that line. This might indicate that increased contact time between alginate impression material and stone can affect the richness of details. On the other hand this difference in reproducing line 25 µm is not of considerable clinical importance according to ADA measures. However, the two groups could effectively reproduce the other two lines (50 µm and 75 µm). These results are similar to another study conducted by Murata et al. [16]�� which showed that the alginate impression material and type III dental material are compatible to each other and could reproduce the surface details effectively. They explained that result by the presence of specific interaction between alginate impression material and dental stone led to surface roughness of the dental cast. On the other hand, the results of Mariana et al. showed that when increase contact time most of the samples did not reproduce line 50 µm, and did not comply with the ISO standard [2]�� . This difference in results may be due to the difference of the materials brands used in each study, handling of the materials, and the environmental circumstances. Hardness evaluation of the tested samples in this study showed that the depth of scratches decreased as the contact time increased, group A was significantly different from group B in the depth of the scratches. These findings further support the results of Marquezan et al. �� [15]�� . These results also match those observed in earlier study conducted by Hiraguchi �� [13]�� . However, several limitations of this study should be noted; use of digital caliper in measurement instead of profilometer – in spite that digital caliper used in this study produced good reproducibility between repeated readings for each

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linear measurement, direct comparison with other studies is somewhat difficult because the differences exist in material brands and measuring techniques, and testing only two interval periods with long time in between. Thus, further studies with more accurate devices and multiple interval periods with short time in between are recommended.

Conclusion Within the limitations of this study, it can be concluded that increased contact time between alginate impression material and type III dental stone: • Did not affect the dimension stability of stone cast model; • Decreased richness of details after nine-hour contact (it is not clinically significant according to ADA measures); • Improved the hardness of the stone cast model after nine-hour contact much more than one-hour contact.

References 1. Revised American National Standards Institute / American Dental Association Specification n. 25 for Dental Gypsum Products. J Am Dent Assoc. 1981;102:351. 2. Revised American National Standards Institute / American Dental Association Specification n. 18. Alginate Impression Materials. 1992. 3. Abass S, Mahmood M, Khalaf B. Effect of microwave irradiation on disinfection, dimensional accuracy, and surface porosity of dental casts. MDJ. 2011;8:177-87. 4. Abdullah MA. Surface detail, compressive strength, and dimensional accuracy of gypsum casts after repeated immersion in hypochlorite solution. J Prosthet Dent. 2006;95:462-8. 5. Ahila S, Subramaniam E. Comparative evaluation of dimensional stability and surface quality of gypsum casts retrieved from disinfected addition silicone impressions at various time intervals: an in vitro study. J Dent Oral Hyg. 2012;4:34-43. 6. Azer SS, Kerby RE, Knobloch LA. Effect of mixing methods on the physical properties of dental stones. J Dent. 2008;36:736-44. 7. Chen SY, Liang WM, Chen FN. Factors affecting the accuracy of elastometric impression materials. J Dent. 2004;32:603-9.

8. Faria AC, Rodrigues RC, Macedo AP, Mattos G, Ribeiro RF. Accuracy of stone casts obtained by different impression materials. Braz Oral Res. 2008;22(4):293-8. 9. Ghahremannezhad HH, Mohamed SE, Stewart GP, Weinberg R. Effects of cyanoacrylates on die stone. J Prosthet Dent. 1983; 49:639-46. 10. Guiraldo RD, Borsato TT, Berger SB, Lopes MB, Gonini Jr A, Sinhoreti MA. Surface detail reproduction and dimensional accuracy of stone models: influence of disinfectant solutions and alginate impression materials. Braz Dent J. 2012;23:417-21. 11. Habib F, Fleischmann LdA, Gama SKC, Araújo TM. Obtenção de modelos ortodônticos. Rev Dent Press Ortodon Ortop Facial. 2007;12:146-56. 12. Hamedi Rad F, Ghaffari T, Safavi SH. In vitro evaluation of a stability of alginate impressions after disinfection by spray and immersion methods. J Dent Res Dent Clin Dent Prospects. 2010;4:130-5. 13. Hiraguchi H, Nakagawa H, Wakashima M, Miyanaga K, Saigo M, Nishiyama M. Effects of disinfecting alginate impressions on the scratch hardness of stone models. Dent Mater J. 2006;25:172-6. 14. Imbery TA, Nehring J, Janus C, Moon PC. Accuracy and dimensional stability of extendedpour and conventional alginate impression materials. J Am Dent Assoc. 2010;141:32-9. 15. Marquezan M, Jurach EM, Guimarães VD, Valentim RG, Nojima LI, Nojima C. Does the contact time of alginate with plaster cast influence its properties? Braz Oral Res. 2012;26:197-201. 16. Murata H, Kawamura M, Hamada T, Chimori H, Nikawa H. Physical properties and compatibility with dental stones of current alginate impression materials. J Oral Rehabil. 2004;31:1115-22. 17. Nallamuthu NA, Braden M, Patel MP. Some aspects of the formulation of alginate dental impression materials – Setting characteristics and mechanical properties. Dent Mater 2012;28:75662. 18. Nassar U, Aziz T, Flores-Mir C. Dimensional stability of irreversible hydrocolloid impression materials as a function of pouring time: a systematic review. J Prosthet Dent. 2011;106:126-33.

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19. Powers JM, Wataha JC. Dental materials: properties and manipulation. Elsevier Health Sciences; 2014. 20. Rudd KD, Morrow RM, Bange AA. Accurate casts. J Prosthet Dent. 1969;21:545-54. 21. Van Noort R: Introduction to dental materials: introduction to dental materials. Elsevier Health Sciences; 2013.

22. Vandewalle KS, Charlton DG, Schwartz RS, Reagan SE, Koeppen RG. Immersion disinfection of irreversible hydrocolloid impressions with sodium hypochlorite. Part II: effect on gypsum. Int J Prosthodont. 1994;7:315-22. 23. Walker MP, Burckhard J, Mitts DA, Williams KB. Dimensional change over time of extendedstorage alginate impression materials. Angle Orthod. 2010;80:1110-5.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):258-65

Original Research Article

Accuracy of Root ZX mini and Raypex 6 in locating the apical foramen of molars: radiographic and microscopic evaluation Berenice R. García-Herverth1 Norberto J. Broon2 Alvaro Cruz3 Claudia A. Palafox-Sánchez4 Santiago Andaracua G5 Ricardo Ayón-García6 Corresponding author: Alvaro Cruz Av. Francisco Javier Gamboa, n. 230, Col. Arcos Sur CP 44150 – Guadalajara – Jalisco – México E-mails: endoacruz@yahoo.com / endobr1@hotmail.com Endodontic Specialist, Military School of Sanidad Graduates, University of Army and Air Forces – Mexico, D.F. Private practice in Endodontics. Health Sciences University Center, University of Guadalajara – Guadalajara – Mexico. 3 Biomedical Sciences Investigation Institute, Professor in the Endodontics program of the Health Sciences University Centre, University of Guadalajara – Guadalajara – Mexico. 4 Biomedical Sciences Investigation Institute, Professor in the Biomedical Sciences Postgraduate program and in the Endodontics program at the Health Sciences University Centre, University of Guadalajara – Guadalajara – Mexico. 5 Private practice in Endodontics. Autonomus �� University of Queretaro – Queretaro – Mexico. 6 Student in the Endodontics program at the Health Sciences University Centre, University of Guadalajara – Guadalajara – Mexico. 1 2

Received for publication: December 2, 2014. Accepted for publication: September 14, 2015.

Abstract Keywords: apical locator; odontometry; working length.

Introduction: The precise localization of the apical foramen and the odontometry determination is an important stage since it locates the apical limit for instrumentation and filling. Objective: To compare the accuracy of Root-ZX Mini and Raypex 6 in locating apical foramen in extracted molars. Material and methods: 80 mesial and buccal canals from 40 mandibular and maxillary human molars were used. A size #15 K-file was introduced to canal, until the locator indicated the apical foramen (red bar/line in both devices). With the file in position, it was re-adjusted for Root-ZX II Mini on the green bar and on the two yellow bars for Raypex 6. All the samples were measured from the tip of the file to the apical foramen with radiovisiograph and the Sidexis software. The apical third of the

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root was shaved until exposure of the file. The distance from the file tip to the most coronal border of the apical foramen was obtained and it was measured with a clinical microscope at 16-fold magnification. The measured lengths with the radiovisiograph and the clinical microscope were analyzed with the statistical Student’s T-test. Results: The average length from the tip of the file to the apical foramen using Root-ZX Mini was 0.695 mm and 0.543 mm with Raypex 6. There was no significant difference. Conclusion: Two devices were accurate in locating apical foramen with an adequate level of reliability.

Introduction In endodontic treatment, the precise localization of the apical foramen and the working length determination is an important stage since it locates the apical limit for instrumentation and filling [22]. The location aims to endodontic procedures are performed within the anatomic limits of the root canal [18]. The radiographic technique has been used to determine the working length, however, it shows diverse clinical limitations: it has a subjective interpretation; there is overlapping of anatomic structures; there may be image distortion; it is difficult to determine the position of the apical foramen; the quality of the film or of the sensor may affect the image; it´s a bi-dimensional image of a three-dimensional object. In addition, some clinical circumstances limit its use, such as patients with macroglossia, nausea, pediatric patients or pregnant women [9]. The electronic method to locate the apical foramen was firstly introduced by Custer [4] in 1918, using the electrical conductivity principle [9]. In 1942, Susuki [24] indicated that the electrical resistance between an instrument inserted inside the root canal and an electrode adhered to the oral mucosa, registered constant values [11, 13]. Based on this principle, Sunada [23] developed a simple direct-current device to measure the canal length. Later, equipment that employed impedance at simple or multiple frequencies were designed, which have overcome some observed problems in the first models and they have been overcoming the problems that the first devices had [8]. The fourth generation apparatus employed two separate frequencies (400 Hz and 8 kHz), and measured the resistance of two frequencies of alternating current at the same time, obtaining in this way the impedance ratio [9].

These locators are not affected by the presence of irrigants inside the canal, nevertheless, some inaccurate measurements are due to morphological (l atera l, acce s sor y a nd convergent c a n a ls, bifurcations, resorptions and perforations) and technical aspects (contact with metals) [2]. To determine the working length, it is advisable to combine the use of periapical radiography and electronic apex locator [1, 9, 16, 26]. However, in clinical situations with difficulty to obtain the working length with periapical radiograph [6], only the electronic device is used. The release of new models of devices for electronic working length requires their assessment to allow the verification of their reliability. Thus, the purpose of this study is to compare the accuracy in locating of the apical foramen in mesial and buccal canals of extracted molars, using Root ZX Mini and Raypex 6, with radiographic and microscopic evaluation.

Material and methods Eighty mesial and buccal canals from forty mandibular and maxillary human molars were used with approval of the Bioethics Committee of the Military Hospital. They were obtained from the Maxillofacial Surgery Service from the Dental Specialist Centre of the Mexican Army and Air Force, México. The Root ZX Mini (JJ Morita, Tokyo-Japan) and Raypex 6 (VDW, Munich-Germany) devices were used, dividing the samples in two study groups of 40 canals each, the electronic measurements were made with both devices. With a diamond disc (SS White – USA) the clinical crown was cut off from all the pieces at the cementum-enamel junction; they were individualized into mesial or buccal roots, sectioning the roots in cross direction to the longitudinal axis to obtain

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a flat border with the teeth root axis, achieving in this way direct vision to the root canal. The canals were located with the DG16 (SS White – USA) explorer and they were negotiated with #15 or 10 K file (Dentsply-Maillefer, Ballaigues – Switzerland). The entrance to the canals was irrigated with a 5 ml of 5.25% sodium hypochlorite (NaOCl) (Viarzonit T – México, D.F.) and the canals orifices were enlarged with #4 Gates-Glidden drills (Dentsply-Maillefer Ballaigues – Switzerland). The pulp chamber was flooded with NaOCl. The roots were positioned vertically in a vegetal sponge wetted with a 3 ml. 0.9% Sodium Chloride solution (Kabipac – Mexico, D.F.), the sponge was placed in a glass container, simulating the natural oral humidity. The manufacturer’s recommendations were followed for both devices. The electrode was placed in contact with the humidity of the sponge to complete its circuit. A size #15 K file (Dentsply-Maillefer, Ballaigues – Switzerland) was inserted in the root canal until the apical foramen was felt. The file-holder was placed at the stem of the instrument and the position of the file inside the apical foramen was confirmed with either one or the other electronic device (the red bar was illuminated). The working length was re-adjusted. In the case of the Root ZX Mini, it was on the green bar and with the Raypex 6 in the first two yellow bars (both devices at 0.5

mm). The lecture was left to stabilization for 5 seconds. Then the file-holder was removed from the number 15 K file and it was fixed to the root dentin with cyanoacrylate adhesive (Kola-loka, Mexico) and light-cured resin (3M ESPE, Germany), verifying the reading again in the foramen locator. Digital radiographs were taken with collimator (Dentsply-Mexico) using the parallelism technique; a phosphorus film scanner “Vista Scan Dürp Dental” (Henry-Schein – México, D.F.) was used on all the samples, on to which was previously placed a scaled template. The measurements were done by two operators in the digital radiography, using the Radiovisiograph (Sirona-Germany) and the Sidexis Sirona Dental X-Ray software (Sirona-Germany). The pointer was positioned from the file tip (initial point) and a line was drawn towards the apical radiographic apex (figure 1), registering the distance in millimeters in a data-collection sheet. With the use of the clinical microscope Ompi 99 (Zeiss, Germany) at 16-fold magnification and a fine-grain conical diamond bur (SS White, México) at high speed the 4 apical millimeters were trimmed in longitudinal direction until the file was exposed. Pictures were taken (figure 2) using the clinical microscope OPMI 1 FR pro (Zeiss-Mexico) at 16-fold magnification and a digital camera (Sony-Japan).

Figure 1 – Measurement with the Sidexis Sirona Dental X-Ray and imaging system software (Sirona –Germany)

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Figure 2 – Measurements with Root ZX Mini (A) and Raypex 6 (B)

To perform the microscopic measurements, 2 calibrated examiners used Corel-Draw 4 software. In the first place, the CDJ zone and the apical foramen were identified. A line from the mesial to the distal wall was drawn on both anatomical zones. The intersection of the straight line coming from the tip of the file towards the center of the apical foramen was considered as the measuring point. These results were grouped in three categories, according to Piasecki et al. [15]. All the values were registered in a data-collection sheet and

were analyzed with the Student’s T-test, with a significance level of 0.05.

Results The radiographic and microscopic measurements results are shown in the graph 1. The results grouped in the 3 qualitative results: long, acceptable, and short are shown in graphs 2 and 3. No significant difference was observed between both electronic devices, in all of the evaluating methods.

Graph 1 – Arithmetic mean of the radiographic and microscopic measurements of the distance between the file tip and the foramen using Root ZX Mini and Raypex 6

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Graph 2 – Qualitative results obtained with radiograph

Graph 3 – Qualitative results obtained with microscope

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Discussion The major canal is apically limited by the apical foramen. The pulp and periodontal tissues converge at the CDJ (cement dentin junction), located on average 1 to 2 mm from the apical foramen [9]. However, it is not possible to determine the exact position of the CDJ using radiographs in a precise way [12, 15], moreover, this joint of cement and dentin may be present at different heights in the same canal, depending on the observed wall; thus, it also could be referred as CDJ zone and not CDJ limit. This CDJ zone is located on average 1 to 1.5 mm from the apical radiographic apex, but this length may vary [9]. The precision of the electronic devices is based on the fact that the double-frequency devices possess a calibration that allows the indication of the variation of impedance relative values (quotient or difference) from the apical region, permitting the location of the instrument tip near 1 mm of the apical foramen, which is near to the apical constriction [9]. This position was proved when the ability of Root ZX to detect the presence of the apical constriction in teeth, with or without foramen patency, was tested. The analysis of the impedance values showed that the equipment was actually based on the detection of the decrease in the dentin thickness in the apical third of the root canal [9]. The electronic method yields similar results as the radiographic one [16, 17, 25], regarding to the apical foramen localization. Nevertheless, the electronic devices have the advantage that their reference point is the apical foramen, which is imperceptible in the radiographs [12]. The radiographic method has as reference point, the radiographic apical apex, which in the majority of cases differs in the location of the major foramen [19]. The precision was evaluated of three electronic foramen locators and compared them with the digital radiograph [1]. They observed that there was no significant difference between the two examined radiographic planes in comparison with the electronic measurements. In the present study, it was observed an interval from 0.543 mm to 0.387 mm between the precision of the radiographic location of the foramen with both devices, which in the clinical practice will allow locating the CDJ zone. The localization of the foramen is clinically acceptable, with a ±1 mm margin from the CDJ zone, however, the ±0.5 mm margin to the minor diameter of the CDJ zone is acceptable [7, 15, 20].

The accuracy of locating the apical foramen of the Root ZX and Novapex also was evaluated with a ±0.5 mm tolerance [3]. They observed the foramen location between 82% (Novapex) and 89% (Root ZX) with no statistical difference between them. With a margin of ±1 mm. MiniApex locator and Raypex 5 was evaluated and obtained a precision of 100%, whereas with the margin of ±0.5 mm, the two devices had the 75% of accuracy, with no statistical difference between them [21]. With the same measuring range were evaluated ex vivo the reading accuracy of Root ZX, Bingo 1020 and Ipex in respect to the real measure of the teeth. They concluded that all electronic devices tested were able in determining the precise tooth length when considered a variation of 1 mm from the position of apical foramen [10]. Root ZX, Raypex 5 and the Elements Apex locator regarding to their precision to detect the minor foramen and the morphological factors that inf luence the determination of the working length [5]. They point out that the minor foramen morphology and the major foramen location are influencing factors on the measurements by the apical locators. Another factor that they may interfere on the location of the foramen is the presence of apical resorption in teeth with apical periodontitis, however, Root ZX showed precision for the location of the apical foramen in the presence of apical periodontitis [15]. Elsewhere Root ZX II and Propex II were compared to establishment working length and direct visual measurement. Both apex locators showed an acceptable percentage of correct readings [14]. In the present study, recently extracted teeth were used, without considering if apical resorption existed or not. In this study both electronic locators, Root ZX Mini and Raypex 6, showed reliability for the determination of the apical foramen, showing precision in ±1 mm with no statistical difference between them.

Conclusion Under the ex vivo conditions in this study, Root ZX Mini and Raypex 6 were precise in locating the apical foramen in mesial canals of lower molar and buccal canals of upper molar teeth, with the same reliability as the digital radiographs of the extracted roots. It is recommended to perform in vivo clinical studies with these devices, to consider all the variables present in clinic.

264 – RSBO. 2015 Jul-Sep;12(3):258-65 García-Herverth� et al. – Accuracy of Root ZX mini and Raypex 6 in locating the apical foramen of molars: radiographic and microscopic evaluation

Acknowledgements To Dr. Luis Gera rdo Gascón Guerra for facilitating the use of the clinical microscope of the post graduation program in Endodontics from the Health Sciences University Centre, University of Guadalajara, Mexico. To Drs. Carlos Guerrero Bobadilla and Gustavo Martin del Campo Plascencia for teaching the clinical use of microscope from the Health Sciences University Centre, University of Guadalajara, México.

References 1. Cianconi L, Angotti V, Felici R, Conte G, Mancini M. Accuracy of three electronic apex locators compared with digital radiography: an ex vivo Study. J Endod. 2010;36:2003-7. 2. Cruz GA, Rojas JV, Rosano AL. Endodoncia: Fundamentos científicos para la práctica clínica. Guadalajara: Amate Editorial; 2012. p. 103-46. 3. Cunba FL, Albuquerque DS, Correia L. The ability of two apex locators to locate the apical foramen: an in vitro study. J Endod. 2006;32: 560-2. 4. Custer LE. Exact methods of locating the apical foramen. J Natl Dent Assoc. 1918;5:815-9. 5. Ding J, Gutmann JL, Fan B, Lu Y, Chen H. Investigation of apex locators and related morphological factors. J Endod. 2010; 36:1399403.

11. Hembrough JH, Weine FS, Pisano JV, Eskoz N. Accuracy of an electronic apex locator: a clinical evaluation in maxillary molars. J Endod. 1993;19:242-6. 12. Jakobson SJM, Westphalen VPD, Neto UXS, Fariniuk LF, Picoli F, Carneiro E. The accuracy in the control of the apical extent of rotary canal instrumentation using Root ZX and protaper instruments: an in vivo study. J Endod. 2008;34:1342-5. 13. Jenkins JA, Walker WA, Schindler WG, Flores CM. An in vitro evaluation of the accuracy of the Root ZX in the presence of various irrigants. J Endod. 2001; 27:209-11. 14. Miguita KB, Cunha RS, Davini F, Fontana CE, Bueno CES. Comparative analysis of two electronic apex locators in working length determination at endodontic therapy: an in vitro study. RSBO. 2011;8:27-32. 15. Piasecki L, Carneiro E, Fariniuk LF, Westphalen VPD, Fiorentin MA, Silva Neto UX. Accuracy of Root ZX II in locating foramen in teeth with apical periodontitis: an in vivo study. J Endod. 2011;37:1213-6. 16. Ravanshad S, Alireza A, Anvar J. Effect of working length measurement by electronic apex locator or radiography on the accuracy of working final length: a randomized clinical trial. J Endod. 2010;36:1753-6.

6. Dummer PHM, McGinn JH, Ress DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J. 1984;17:192-8.

17. Renner D, Grazziotin-Soares R, Gavini G, Barletta FB. Influence of pulp conditions on the accuracy of an electronic foramen locator in posterior teeth: an in vivo study. Braz Oral Res. 2012;26:106-11.

7. Duran-Sindreu F, Stöber E, Mercadé M, Vera J, Garcia M, Bueno R et al. Comparison of in vivo and in vitro readings when testing the accuracy of the Root ZX apex locator. J Endod. 2012;38:236-9.

18. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2. A histological study. International Endodontic Journal. 1998;31:394-409.

8. Fan W, Fan B, Gutmann JL, Bian Z, Fan MW. Evaluation of the accuracy of three apex locators using glass tubules. Int Endod J. 2006;39:127-35. 9. Gordon MPJ, Chandler NP. Electronic apex locators. Int Endod J. 2004;37:425-37.

19. Saito T, Yamashita Y. Electronic determination of root canal length by newly developed measuring device. Influences of the diameter of apical foramen, the size of k-file and root canal irrigants. Dent Japan. 1990;27:65-72.

10. Heidemann R, Vailati F, Teixeira CS, Oliveira CAP, Pasternak Junior B. Análise comparativa ex vivo da eficiência na odontometria de três localizadores apicais eletrônicos: Root ZX, Bingo 1020 e Ipex. RSBO. 2009;6:8-12.

20. Somma F, Castagnola R, Lajolo C, Holtzman LP, Marigo L. In vivo accuracy of three electronic root canal length measurement devices: Dentaport ZX, Raypex 5 and Propex II. Int Endod J. 2012;45:552-6.

265 – RSBO. 2015 Jul-Sep;12(3):258-65 García-Herverth� et al. – Accuracy of Root ZX mini and Raypex 6 in locating the apical foramen of molars: radiographic and microscopic evaluation

21. Stöber EK, de Ribot J, Mercadé M, Vera J, Bueno R, Roig M et al. Evaluation of the Raypex 5 and the mini apex locator: an in vivo study. J Endod. 2011;37:1349-52. 22. Stoll R, Klein UB. Effectiveness of four electronic apex locators to determine distance from the apical foramen. Int Endod J. 2010;43:808-17. 23. Sunada I. New method for measuring the length of the root canal. J Dent Res. 1962;41:375-87.

24. Suzuki K. Experimental study of iontoforesis. Japanese J Stomatol. 1942;16:411-29. 25. Williams CB, Joyce AP, Roberts S. A comparison between in vivo radiographic working length determination and measurement after extraccion. J Endod. 2006;32:624-7. 26. Wrbas KT, Ziegler AA, Altenburger MJ, Schirrmeister JF. In vivo comparison of working length determination with two electronic apex locators. Int Endod J. 2007;40:133-8.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):266-71

Original Research Article

Validation of pH cycling model to induce artificial carious lesions in bovine dentin Ana Caroline Fumes1 Raquel Assed Bezerra da Silva1 Daniele Lucca Longo1 Andiara De Rossi1 Mônica Campos Serra2 Correspondence author: Ana Caroline Fumes Departamento de Clínica Infantil, Faculdade de Odontologia de Ribeirão Preto Universidade de São Paulo Av. do Café, s/n – Monte Alegre CEP 14040-904 – Ribeirão Preto – SP – Brasil E-mail: carolfumes02@hotmail.com 1 2

Department of Pediatric Clinics, Ribeirão Preto Dental School, University of Sao Paulo – Ribeirão Preto – SP – Brazil. Department of Restorative Dentistry, Ribeirão Preto Dental School, University of Sao Paulo – Ribeirão Preto – SP – Brazil.

Received for publication: December 22, 2014. Accepted for publication: September 14, 2015.

Keywords: dental caries, tooth remineralization, tooth demineralization.

Abstract Introduction and objective: The purpose of the study was to evaluate different pH cycling protocols on the induction of artificial carious lesions in bovine dentin, since the most appropriate protocol to be applied is still not fully established. Material and methods: Fragments of bovine dentin (4 x 4 x 2 mm) were embedded in resin, polished and 7 mm² of each fragment was isolated with wax. The specimens were divided into three groups (A, B, C) according to the time of immersion in the demineralizing solution (1.5 ml). Group A – 15 minutes; Group B – 30 minutes; Group C – 60 minutes and subsequently immersed for 22 hours in a remineralizing solution (1.5 ml). Microhardness measurements were conducted initially, daily and after each pH cycling for 4 days. The Split-plot design (ANOVA) was applied. Results: There was a significant interaction between time and cariogenic challenge (p<0.0001). Bonferroni comparisons were executed to identify the differences over the cariogenic challenge, showing that increasing the immersion time in demineralizing solution for each pH cycling assessed, the cariogenic challenge aggressiveness increased (A <B <C). Also, for each protocol tested there was a significant decrease in the hardness in the cariogenic challenge over the time. Conclusion: The three models tested proved to be viable, regardless of the time of cariogenic challenge that was applied.

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Introduction Dental caries are a result of changes in pH caused by acids driven by the biofilm (in contact with mineralized tissues), reducing the mineral content of these tissues [16, 31]. Although the process of formation of caries is currently better understood, there are still many details to be investigated [7, 8]. Methods and protocols have been proposed and used for the induction of artificial caries [1, 5, 11, 19, 24, 27, 28]. Considering the limitations of in vitro studies, the protocols that use pH cycling are those that most resemble the natural process, simulating events of demineralization and remineralization, as it happens clinically [29]. Models using pH cycling for the development of caries have been proposed in bovine dentin [5, 11-14, 19, 21, 25, 30]. The bovine substrate presents a more uniform composition, which enables a smaller variability in experimental response [18]. Furthermore, bovine dentin has similar characteristics to human dentin, in terms of diameter and number of dentinal tubules [6, 9, 26]. In addition, several studies have used these teeth as a substrate due to the ethical aspects and also because they are more easily obtained and manipulated [6, 11-14, 19, 24, 26, 30]. However, there is still no standardized protocol for the induction of artificial caries using pH cycling in bovine substrate. The objective of this study was to evaluate the protocols of induction of caries in vitro, through the use of pH cycling on bovine teeth in order to contribute to the standardization of studies and a better understanding of the lesions progression.

separate the coronal from the root portion. New sections were performed, yielding ten dental fragments measuring 4 x 4 x 2 mm. Then these fragments were embedded in polyester resin (Milflex), exposing only the external face. After the inclusion in resin, the specimens were then flattened and polished (β Phonix – Buehler) with a decreasing granulation sandpaper of Al2O3 (400, 600 and 1200 grit) and an abrasive alumina, under water cooling (4). This was performed until the exposition of the dentin. Subsequently, the specimens were washed with deionized water and subjected to ultrasound for 10 minutes in deionized water and then identified and stored individually in containers with relative humidity of 37ºC.

Standardization in the area of lesion induction On the surface of each specimen of dentin, a circular area about 7 mm² was left exposed (figure 1). This area was isolated with a standard nail polish, and the exposed dentin surface left to contact with the DE and RE solutions for the dynamic induction of the carious lesions.

Material and methods Experimental design The object of the study was a model that induces caries performed in three different immersion times: 15 minutes of demineralization (DE) and 22 hours of remineralization (RE); 30 minutes of DE and 22 hours of RE, and 60 minutes of DE and 22 hours of RE. Forty-five experimental fragments of bovine dentin (n = 15) were used. The used variable was the surface microhardness test (Knoop).

Preparation of the specimens Bovine teeth were sectioned precisely (Isomet 1000, Buehler), in cementoenamel junction, to

Figure 1 – Circular area of substrate exposed to cariogenic challenge

Readings of initial microhardness The specimens initially prepared, were assessed for their initial surface microhardness. To this purpose, HMV-2 microdurometer and a Knoop indenter with a load of 10 grams for 10 seconds were used in the dentin (defined in the preliminary tests). There were five indentations in each tested fragment (figure 2) and in a total of 70 specimens, 45 were selected.

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minutes and afterwards, immersed for 22 hours in RE solution (1.5 ml). Microhardness measurements were conducted initially, daily and after each pH cycling for 4 days.

Statistical analysis

Figure 2 – indentations

Disposition

initial

microhardness

pH cycling The artificial caries in dentin were induced by a dynamic model of demineralization and remineralization, similar to that described by Hara et al. [11]. Other studies that applied pH cycling, inducing lesions in both enamel [2] and dentin [12, 14], added fluorine to the solutions [2, 12, 14], and limited the time of solution in DE to decrease the aggressiveness of the cariogenic challenge. The solutions applied were: DE solution (1.4 mM Ca, 0.9 mM P, 0.03 ppm F, 0.05 M acetate buffer, pH 5.0); RE solution (1.5 mM Ca, 0.9 mM P, 0.05 ppm F, 0.1 M Tris buffer, pH 7.0). Forty-five specimens were then divided into three groups (A, B, C) (n = 15) according the immersion time in DE solution (1.5 ml): group A – 15 minutes; group B – 30 minutes; group C – 60

For the statistical measuring, the average values of microhardness obtained initially and after each pH cycling, were considered. After checking the homoscedasticity and normality, the Split-Plot design (ANOVA) was used - because there where repeated measures - in the evaluation of the effect of cariogenic challenge factors and in the number of pH cycles, as recommended by Montgomery [20]. Since the interaction between the factors was positive, Bonferroni comparisons were performed to identify differences over the cariogenic challenges.

Results The split-plot design (ANOVA) was performed, and the adjustment of the (R2) model was 0.8884, indicating the adequacy of the mathematical model to analyze the data. There was a significant interaction between the time-cariogenic challenge (p <0.0001). The increase of immersion time in DE solution for each pH cycle, increased the aggressiveness of the cariogenic challenge (A <B <C). The microhardness values of the dentin showed a significant decrease along the cariogenic challenge (figure 3). Table I illustrates data concerning the decrease in microhardness values.

Figure 3 – Progression of artificial caries lesions over the cariogenic challenges employed

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Table I – Mean values of microhardness over the cariogenic challenges employed

Experimental Groups Group A

Initial 62.17

a A

(8.1) Group B

56.80

59.71 ab A (5.7)

51.48

a B

(9.5)

(7.5) Group C

1 pH cycle

39.23

(9.4)

44.00

a C

(7.7) bB

(7.0) 40.00

2pH cycles

32.45 24.62 (5.1)

36.03

a D

(5.5) bC

(6.3) bB

3 pH cycles

27.59 18.99 (3.9)

30.47

a E

(4.7) bD

(3.2) c C

4 pH cycles

23.22 b E (3.7)

c D

14.64

c E

(2.7)

* Lower case letters are comparisons in column, uppercase letters are comparisons in line and between brackets is the standard deviation

Discussion The result of dental caries is determined by a dynamic balance between pathological factors that lead to demineralization and protective factors that promote remineralization [8, 17]. Among the existing models for the induction of caries, all have advantages and limitations. However, the use of pH cycling is considered the closest and more [29] dynamic process of formation of carious lesions (alternating periods of demineralization and remineralization) [7, 8, 29]. Thus, based on a model of pH cycling, described by Featherstone et al. (1986) and modified by Hara et al. [11], so that the microhardness readings could be made in dentin surface, over the time of the cariogenic challenge, modifications to the model had to be performed [3]. The volume and time of immersion in demineralizing solution were decreased. Also were added small concentrations of fluorine (0.03 ppm in demineralizing solution and 0.05 in the remineralizing solution), these concentrations based on the model described by Argenta et al. [2]. Considering fluoride, the key to the control of dental caries, it is known that it can act to inhibit demineralization, inhibit bacterial enzymes and enhance remineralization [7]. The addition of f luoride and other changes were to contain the aggressive agent promoted by the cariogenic challenge and thereby enabling microhardness measurements daily. It is considered that the evaluations of the changes, in the values of the surface microhardness of the dental substrates, are an extremely important factor in relation to demineralization and remineralization processes, since the main interactions between the dental tissues and oral environment occur at the surface layer [2].

In this in vitro study, the methodology applied for the induction of artificial caries lesions allowed the induction of a demineralized dentin in both substrates. Unlike the enamel, dentin presents a lower mineral content – is formed by inorganic (70%), organic material (20%) and water (10%) components (23) – and the used model as an absence of organic compounds in the remineralizing solution. The formation of caries clinically, can extend for weeks, months or years, given the biological responses that may occur as the formation of reactionary dentin [32]. In contrast to the induction of artificial caries, which is usually accomplished in few hours. Another aspect to be considered is the fact that some authors criticize the use of microhardness to evaluate changes in the dentin. Guided by a shrinkage of the indentation that needs to be done [32], otherwise the results are incorrect. However, in the study the microhardness data were obtained from specimens that were not hydrated and the values of hardness were measured immediately after the indentation was performed. Thereby avoiding the influence of the elastic deformation [15], and standardizing the conditions for all samples. The results of this study showed that based on the application of a pH cycling model in dentin, the longer the solution of demineralization was applied, the faster the loss of mineral content, which may be observed by the decrease in microhardness values. The application of such methodology may be relevant to studies that suggest, for example, the evaluation of adhesive systems in dentin. It is known that the bond strength studies are usually conducted in healthy dentine, for convenience and comfort, but the truth is that clinically, the dentin adhesive system is not applied in a healthy substrate, but in an sclerotic and demineralized dentin [4,

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10, 22], similar to the one obtained in this study. On the other hand, pH cycling model studies in enamel can also be performed, as showed after comparing the effects of 5 children’s toothpastes (calcium phosphate, Pooneh, Biotin, Crest and Darougar) [17]. The knowledge obtained from this study can be used as a viable model for the evaluation and development of measures and materials that can help controlling the in vivo process. It can be concluded that all three models tested were shown to be viable in obtaining artificial carious lesions in bovine dentin, regardless of the time of cariogenic challenge applied.

8. Featherstone JD. The continuum of dental caries evidence for a dynamic disease process. J Dent Res. 2004;83:39-42.

Conflic of interest

12. Hara AT, Queiroz CS, Giannini M, Cury JA, Serra MC. Influence of the mineral content and morphological pattern of artificial root caries lesion on composite resin bond strength. Eur J Oral Sci. 2004;112:67-72.

All the authors state that they have no conflicts of interest.

References 1. Amaechi BT, Higham SM, Edgar WM. Factors affecting the development of carious lesions in bovine teeth in vitro. Arch Oral Biol. 1998 Aug;43(8):619-28. 2. Argenta RMO, Tabchoury CPM, Cury JA. A modified pH-cycling model to evaluate fluoride effect on enamel demineralization. Pesquisa Odontológica Brasileira. 2003;17:241-6. 3. Comar LP, Souza BM, Gracindo LF, Buzalaf MA, Magalhães AC. Impact of experimental nano-HAP pastes on bovine enamel and dentin submitted to a pH cycling model. Braz Dent J. 2013;24(3): 273-8. 4. Choi K, Oshida Y, Plat JA, Cochram MA, Matis BA, Yi K. Microtensile bond strength of glass ionomer cements to artificially created carious dentin. Operative Dentistry. 2006;31:590-7. 5. de Menezes M, Turssi CP, Faraoni-Romano JJ, Serra MC. Susceptibility of bleached enamel and root dentin to artificially formed caries-like lesions. Am J Dent. 2007;20:173-6. 6. Dutra-Correa M, Anauate-Netto C, Arana-Chavez VE. Density and diameter of dentinal tubules in eatched and non-eatched bovine dentine examined by scanning electron microscopy. Arch Oral Biol. 2007;850-5. 7. Featherstone JD. Caries detection and prevention with laser energy. Dent Clin North Am. 2000 Oct;44(4):955-69.

9. Garberoglio R, Brännström M. Scanning electron microscopic investigation of human dentinal tubules. Arch Oral Biol. 1976;21:355-62. 10. Marshall Jr GW, Marshall SJ, Kinneyt JH, Balooch Mehdi. The dentin substrate: structure and properties related to bonding. Journal of Dentistry. 1997;25:441-58. 11. Hara AT, Queiroz CS, Freitas PM, Giannini M, Serra MC, Cury JA. �� Fluoride release and secondary caries inhibition by adhesive systems on root dentine. Euro J Oral Sci. 2005;113:245-50.

13. Hara AT, Queiroz CS, Paes Leme AF, Serra MC, Cury JA. Caries progression and inhibition in human and bovine root dentine in situ. Caries Res. 2003;37:399-44. 14. Hara AT, Magalhães CS, Serra MC, Rodrigues Jr AL. Cariostatic effect of fluoride-containing restorative systems associated with dentifrices on root dentin. Journal of Dentistry. 2002;30: 205-12. 15. Herkströter FM, Witjes M, Ruben J, Arends J. Time dependency of microhardness indentations in human and bovine dentine compared with human enamel. Caries Res. 1989;23:342-4. 16. Kidd EAM. Fejerskov O. What constitutes dental caries? Histopatology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res. 2004;83 (Spec Iss C):C35-8. 17. Malekafzali B, Ekrami M, Mirfasihi A, Abdolazimi Z. Remineralizing effect of child formula dentifrices on artificial enamel caries using a pH cycling model. J Dent (Tehran). 2015 Jan;12(1):11-7. 18. Mellberg JR. Hard-tissue substrates for evaluation of cariogenic and anti-cariogenic activity in situ. J Dent Res. 1992 Apr;71:913-9. 19. Molina GF, Costa de Almeida GR, de Souza Guerra C, Cury JA, de Almeida AP, Barroso RC et al. Lead deposition in bovine enamel during a pH-cycling regimen simulating the caries process. Caries Res. 2011;45:469-74.

271 – RSBO. 2015 Jul-Sep;12(3):266-71 Fumes� et al. – �� Validation of pH cycling model to induce artificial carious lesions in bovine dentin

20. Montgomery DC. Design and analysis of experiments. 4th ed. 1997.

scanning electron microscopic investigation. Arch Oral Biol. 2000;45:355-61.

21. Mukai Y, ten Cate JM. Remineralization of advanced root dentin lesions in vitro. Caries Res. 2002;36:275-80.

28. Serra MC, Cury JA. The in vitro effect of glassionomerr cement restoration on enamel subjected to a desmineralization and remineralization model. Quintessence Int. 1992;23:143-7.

22. Nakajima M, Sano H, Burrow MF, Tagami J, Yoshiyama M, Ebisu S et al. Tensile �� bond strength and SEM evaluation of caries-affected dentin using dentin adhesives. J Dent Res. 1995;74:1679-88. 23. Nanci A. Ten Cate’s oral histolog: development, structure and function. 6th ed. 2003. 24. Queiroz CS, Hara AT, Paes Leme AF, Cury JA. pH-cycling models to evaluate the effect of low fluoride dentifrice on enamel de- and remineralization. Braz Dent J. 2008;19:21-7.

29. ten Cate JM, Duijsters PPE. Aternating demineralization and remineralization of artificial enamel lesions. Caries Res. 1982;16:201-10. 30. ten Cate JM. In vitro studies on the effects of fluoride on de- and remineralization. Journal of Dental Research. 1990;69 (Spec Issues):614-9. 31. Turssi CP, Lima RQ, Faraoni-Romano JJ, Serra MC. �� Rehardening of caries-like lesions in root surfaces by saliva substitutes. Gerodontology. 2006;23:226-30.

25. Rodrigues E, Delbem AC, Pedrini D, Cavassan L. Enamel remineralization by fluoride-releasing materials: proposal of a pH-cycling model. Braz Dent J. 2010;21:446-51.

32. Vyavhare S, Sharma DS, Kulkarni VK. Effect of three different pastes on remineralization of initial enamel lesion: an in vitro study. J Clin Pediatr Dent. 2015 Winter;39(2):149-60.

26. Schilke R, Lisson JA, Bauss O. Geurtsen W. Comparison of the number and diameter of dentinal tubules in human and bovine dentine by

33. Wefel JS, Heilman JR, Jordan TH. Comparison of in vitro root caries models. Caries Res. 1995;29:204-9.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):272-7

Original Research Article

Oral health status of patients with special needs from a rehabilitation association in Curitiba (PR, Brazil) Cecim Calixto Junior1 Marilisa Carneiro Leão Gabardo1 João Armando Brancher1 Mariana Dalledone1 Tatiana Luzzi1 Eduardo Pizzatto1 Corrresponding author: Eduardo Pizzatto Rua Prof. Pedro Viriato Parigot de Souza, 5.300 – Campo Comprido CEP 81280-330 – Curitiba – PR – Brasil E-mail: epizzatto@up.edu.br 1

Program of Master Science in Clinical Dentistry, Positivo University – Curitiba – Paraná – Brazil.

Received for publication: May 14, 2015. Accepted for publication: July 13, 2015.

Keywords: oral health; epidemiology; people with special needs.

Abstract Introduction: Patients with special needs commonly show significant systemic and oral diseases. Objective: We carried out a survey on the oral health status from individuals with special needs of Associação Paranaense de Reabilitação (APR), in Curitiba, PR, Brazil. Material and methods: Clinical oral examination was performed and a specific questionnaire was applied to 87 individuals, aged from 5 to 14 years-old. Results: The mean age average was 9 yearsold, and 57.5% were males. The mean DMFT was 1.4, and 54% of the sample showed DMFT = zero. The oral health status from the studied sample was similar to that found in the same age group of the general population. Conclusion: We indicate that strategies for controlling oral health diseases tailored for this group must be stimulated, once the vulnerability is present.

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Introduction The patient with special needs is considered as every individual that has either simple or complex physical, organic, intellectual, social, emotional changes; of acute or chronic nature; and requires special education and additional instructions, temporarily or permanently [27]. The fact that an individual has special needs somehow implies limiting conditions, whose origin can be congenital or acquired over life [5]. In 2010, 23.9% of the population claimed to have some type of disability, with higher concentration in urban areas [19]. Evidences indicate that the highest concentration of people with special needs (PSNs) occurs in groups with unfavorable conditions, such those with low income [13, 39]. PSNs commonly present systemic and oral characteristics. The most prevalent oral disease is dental caries and periodontal disease [10, 20, 22, 24, 34, 37, 40]. There are indications that the institutionalized PSNs may be at increased risk of caries development compared to non-institutionalized [14, 18]. More compromising disability cases are found more often in specialized institutions, which coincide with the fact that these individuals have higher rates of diseases [22, 34]. These finding are caused by common set of factors such as poor oral hygiene [10], use of psychoactive drugs [10] and dietary patterns [7, 30], which increase the risk of developing diseases. In different locations worldwide, studies highlight the need for improvements in organizational strategies to strengthen preventive measures, together with the rehabilitative interventions for this population, supported by changes in the health policies aimed at expanding the service to these patients [1, 13, 24, 34, 35, 37]. Early dental care of PSNs and multidisciplinary care have an important role, but challenges the dentist according to the skills [7-9, 23-25, 32]. In Brazilian population, the difficulty lies in having few specialized centers to provide assistance to these patients and the limited number of qualified professionals for the treatment, either in public or private practice [16, 31]. One should also consider the complexity of the answers that can be given by families concerning the problems presented by these children [11]. The family motivation and disinterest may arise in relation to oral health of PSNs [36], as well as the lack of oral health knowledge and attitudes of professionals for the education of patients with special needs [28].

The educational process in dentistry, attempting to cha nge t he behav ior, is essent ia l for t he maintenance, acquisition, and promotion of selfcare in oral health [36, 38], is now not relevant, and hence the restorative treatment is necessary. In this context and as a result, the quality of life associated with oral health is impacted [17], theme addressed in the context of PSNs [32]. This study aimed to evaluate the oral health status of a group of PSNs from the Paranaense Association of Rehabilitation (APR), at the city of Curitiba, Brazil.

Material and methods This cross-sectional study with non-probabilistic sa mple was composed of st udents from a n institution (Curitiba, Brazil). Inclusion criteria comprised the age range of 5 to14 years-old and prior signing of the Free and Clarified Consent Form by the parent/legal guardian. Eight-seven of 205 individuals participated in the study. This study was submitted and approved by the Ethical Committee in Research of Positivo University under protocol no. #155/2009. The following variables were evaluated: age, gender, periodontal disease, soft tissue alteration, occlusion, fluorosis, and dental caries. The intraoral clinical examination followed the standards recommended by the World Health Organization [26]. Periodontal disease was measured through the identification of gingival changes and recorded as absent or present. The same classifications were possible for the change of soft tissue and the presence of visible plaque. Occlusion was classified as normal, mild, moderate, or severe malocclusion. For fluorosis, the possibilities were: normal, questionable, very mild, mild, moderate or severe. The examinations were performed by calibrated examiners, under artificial light, with wooden spatula, with the patient sat and the examiner stood up. The collected data were recorded, tabulated, and analyzed through Statistica 8.0 software.

Results The result of the Kappa test to evaluate the interexaminer agreement was 0.86. The sample mean age was 9 years (SD = 2.5).

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Male individuals accounted for 57.5% of the sample. With regard to the oral status evaluated, the gingival changes are shown in 6.9% of examined PSN, with the presence of visible plaque in 57.5%, while the soft tissue changes were present in 4.6% of cases. Occlusal problems were found in over 50% of the examined according to standard

classifications (47.1%) in mild (36.8%) and moderate or severe malocclusion (16.1%). Fluorosis represented 3.3% of subjects, with equitable distribution rate of 1.1% between mild, moderate and severe scores. The average DMFT value was 1.4 (SD = 2), and 54% of the examined had DMFT = zero. The distribution of DMFT values can be observed in graph 1.

Graph 1 – DMFT distribution in patients with special needs from APR at Curitiba, Brazil, in 2009 (n = 87)

Discussion The literature suggests that the most prevalent oral disease in patients with special needs is caries and periodontal disease [10, 20, 22, 24, 34, 37, 40]. However, the results of this study did not indicate a significant proportion of these diseases, because the estimates of oral conditions were close to those of the same age groups of the population considered as “normal” [3, 4]. With regard to caries, the DMFT average (1.4) was lower than values found in the literature ranging from 2.27 [15], 2.41 [20], 2.48 [24], 3 [14] to 5.4 [34]. In a recent study with Indian PSNs caries was found in 79.2% of respondents [37]. This study did not set aimed to compare PSNs with other groups of individuals, but considering DMFT variable, the mean value (1.4) was close to the average for 12-year-old children in the city Curitiba, in 2010, whose value was 1.53 [4]. ]. However, we highlight that possible differences in the methodology of the studies can lead to variation in the results. The high consumption of drugs among PSNs is considered the source for increased risk of caries development [10], although there are contradictions

[15]. The institutionalization was also considered a risk factor [14, 18, 22, 34]. Recognition of the role of poor oral hygiene in triggering problems [10], especially in those individuals with higher psychomotor difficulties, is a critical issue. The low frequency of gingival changes found in this study corroborates previous findings [6], but contradicts other recent findings, in which healthy periodontal condition was not found in any participant [37]. The Brazilian epidemiological survey conducted in 2003 pointed to a rate slightly higher than 6% of gingival changes in 5-year-old children [3]. The soft tissue changes are also highlighted with many types [33]. In this present study, a low prevalence of this disease was seen. Concerning to malocclusion, these are often detected in patients with special needs, especially in Down syndrome as a result of muscle hypotonia and macroglossia [31, 37]. These findings of this study corroborate the literature and the data of the 5 to 12-year-old Brazilian population [3, 4]. Several studies have been conducted to achieve knowledge on oral health status of PSNs seeking the implementation of programs and educational/

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preventive actions [1, 13, 24, 25, 34, 35]. Also, other points have to be overcome, such as lack of training in handling these patients [2, 16, 23, 31], the lack of multidisciplinary care [7-9, 23-25, 32, 35], and the need to instruct the parents/guardians to perform effective oral hygiene [9, 21, 32, 38]. In Brazil the specialty of Dentistry for Patients with Special Needs was regulated by Federal Council of Dentistry in December 2001 [12]. This particular training is of utmost importance, since the dentists attending children with special needs report experiencing difficulties in describing the real demands of these patients [16]. It must be considered that the high prevalence of dental caries admittedly has impacts on the quality of life of all people [17], likely PSNs [32]. Further studies are necessary to clarify the association of other variables, e.g. socioeconomic and oral health-related quality of life, with the oral health status of PSNs.

Conclusion Based on the results obtained in this study, it is concluded that PSNs, in general, showed good oral health status, with data similar to those found in the general population. Efforts should be encouraged to seek the proper oral health of these individuals because of their vulnerability.

References 1. Abreu MHNG, Castilho LS, Resende VL. Assistência odontológica a indivíduos portadores de deficiências: o caso da Associação Mineira de Reabilitação e Escola Estadual João Moreira Salles. Arq Odontol. 2001;37(2):153-61. 2. Ahmad MS, Razak IA, Borromeo GL. Undergraduate education in special needs dentistry in malaysian and Australian dental schools. J Dent Educ. 2014;78(8):1154-61. 3. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Ministério da Saúde; 2004. 68 p. 4. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. Ministério da Saúde; 2012. 116 p.

5. Brugnera Jr A. Conceituando o paciente com necessidades especiais. In: Varellis MLZ. O paciente com necessidades especiais na Odontologia. Manual prático. São Paulo: Livraria Santos; 2005. p. 3-12. 6. Campos JADB, Giro EMA, Orrico SRP, Oliveira APC, Lorena SM. Correlação entre a prevalência de cárie e a utilização de medicamentos em pacientes com necessidades especiais institucionalizados e não institucionalizados. Salusvita. 2006;25(1):35-42. 7. Campos JADB, Zuanon ACC, Giro EMA, Abreue-Lima FCB. Padrão de alimentação do paciente com necessidades especiais e seu reflexo na cavidade bucal. JBP Rev Ibero-am Odontopediatr Odontol. 2005;8(42):127-34. 8. Cançado Figueiredo M, Carvalho e Silva SR, Preto Guimarães F, Araujo VP. Perfil de pacientes con necesidades especiales. Bol Assoc Argent Odontol Niños. 2003;32(1):8-11. 9. Carvalho ACP, Figueira LCG, Utumi ER, Oliveira CO, Oliveira LPN, Pedron IG. Considerações no tratamento odontológico e periodontal do paciente deficiente visual. Rev Odontol Bras Central. 2010;19(49):97-100. 10. Carvalho EMC, Araújo RPC. A saúde bucal em portadores de transtornos mentais e comportamentais. Pesq Bras Odontoped Clín Integr. 2004;4(1):65-75. 11. Ciênc Saúde Coletiva. 2003 Jan [cited 2014 Sep 12]; 8(3):830-1. Available from: URL: http://www.scielosp.org/scielo.php?script=sci_ arttext&pid=S1413-81232003000300018&lng =en. 12. Conselho Federal de Odontologia – CFO. Resolução CFO-22/2001. Baixa normas sobre anúncio e exercício das especialidades odontológicas e sobre cursos de especialização revogando as redações do Capítulo VIII, Título I; Capítulo I, II e III, Título III, das normas aprovadas pela Resolução CFO-185/93, alterada pela Resolução CFO-198/95. CFO; 2001. 27 p. 13. Costa MLP, Costa MABT, Pereira MF. Perfil clínico-epidemiológico de pacientes com paralisia cerebral assistidos em um centro de odontologia do Distrito Federal. Comun Ciênc Saúde. 2007;18(2):129-39. 14. De Jongh AD, van Houtem C, van der Schoof M, Resida G, Broers D. Oral health status, treatment needs, and obstacles to dental care among noninstitutionalized children with severe mental disabilities in The Netherlands. Spec Care Dentist. 2008;28(3):111-5.

276 – RSBO. 2015 Jul-Sep;12(3):273-7 Calixto�� Junior et al. – Oral health status of patients with special needs from a rehabilitation association in Curitiba (PR, Brazil)

15. Donnel DO, Sheiham A, Wai YK. Dental findings in 4-, 14-, and 25- to 35- year-old Hong Kong residents with mental and physical disabilities. Spec Care Dentist. 2002;22(6):231-4. 16. Fonseca ALA, Azzalis LA, Fonseca FLA, Botazzo C. Análise qualitativa das percepções de cirurgiõesdentistas envolvidos nos atendimentos de pacientes com necessidades especiais de serviços públicos municipais. Rev Bras Crescimento Desenvolv Hum. 2010;20(2):208-16. 17. Gabardo MCL, Moysés ST, Moysés S. Autopercepção de saúde bucal conforme o Perfil de Impacto da Saúde Bucal (OHIP) e fatores associados: revisão sistemática. Rev Panam Salud Publica. 2013;33(6):439-45. 18. Giro EMA, Orrico SRP, Campos JADB, Lorena SM, Cortez LMS. Prevalência de cárie em pacientes com necessidades especiais institucionalizados ou não-institucionalizados: consumo de carboidratos simples. Rev Odontol Unesp. 2004;33(2):75-9. 19. Instituto Brasileiro de Geografia e Estatística – IBGE. Censo demográfico 2010. Características gerais da população, religião e pessoas com deficiência. Rio de Janeiro; 2012. 215 p. 20. Jain M, Mathur A, Kumar S, Dagli RJ, Duraiswamy P, Kulkarni S. Dentition status and treatment needs among children with impaired hearing attending a special school for the deaf and mute in Udaipur, India. J Oral Science. 2008;50(2):161-5. 21. Marcelino G, Parrilha VA. Educação em saúde bucal para mães de crianças especiais: um espaço para a prática dos profissionais de enfermagem. Cogitare Enferm. 2007;12(1):37-43. 22. Mitsea AG, Karidis AG, Donta-Bakoyianni C, Spyropoulos ND. Oral health status in Greek children and teenagers, with disabilities. J Clin Pediatr Dent. 2001;26(1):111-8. 23. Moraes ABA, Batista CG, Lombardo I, Horino LE, Rolim GS. Verbalizações de alunos de Odontologia sobre a inclusão social de pessoas com deficiência. Psicologia em Estudo. 2006;11(3): 607-15.

26. Organização Mundial da Saúde – OMS. Levantamentos básicos em saúde bucal. 4. ed. São Paulo: Santos; 1999. 66 p. 27. Peres AS, Peres SHCS, Silva RHA. Atendimento a pacientes especiais: reflexão sobre aspectos éticos e legais. Rev Fac Odontol Lins. 2005;17(1):49-53. 28. Pomarico L, Souza IPR, Tura LFR. Oral health profile of education and health professionals attending handicapped children. Pesqui Odonto Bras. 2003;17(1):11-6. 29. Rao DB, Hedge AM, Munshi AK. Caries prevalence amongst handicapped children of South Canara district, Kamataka. J Indian Soc Pedod Prev Dent. 2001;19(2):67-73. 30. Resende VLS, Castilho LS, Viegas CMS, Soares MA. Fatores de risco para a cárie em dentes decíduos de portadores de necessidades especiais. Pesq Bras Odontoped Clín Integr. 2007;7(2):111-7. 31. Santangelo CN, Gomes DP, Vilela LO, Deus TS, Vilela VO, Santos EM. Avaliação das características bucais de pacientes portadores de síndrome de Down da Apae de Mogi das Cruzes – SP. Editorial ConScientiae Saúde. 2008;7(1):29-34. 32. Santos BMO, Aquino DJN, Pires-de Sousa FCP, Almeida GL, Garcia LFR. Assistência odontológica a portadores de necessidades especiais sob a ótica dos cuidadores. Ciênc Odontol Bras. 2009;12(2): 49-56. 33. Santos GG, Marcucci G. Contribuição para o estudo da prevalência das alterações dos tecidos moles da boca em pacientes especiais. Rev Odontol Univ São Paulo. 1989;3(2):357-62. 34. Shyama M, Al-Mutawa SA, Morris RE, Sugathan T, Honkala E. Dental caries experience of disabled children and young adults in Kuwait. Community Dent Health. 2001;18(3):181-6. 35. Silva OMP, Panhoca L, Blachman IT. Os pacientes portadores de necessidades especiais: revisando os conceitos de incapacidade, deficiência e desvantagem. Salusvita. 2004;23(1):109-16.

24. Oliveira AC, Czeresnia D, Paiva SM, Campos MR, Ferreira EF. Uso de serviços odontológicos por pacientes com síndrome de Down. Rev Saúde Pública. 2008;42(4):693-9.

36. Silva ZCM, Pagnoncelli SD, Weber JBB, Fritscher AMG. Avaliação do perfil dos pacientes com necessidades especiais da Clínica de Odontopediatria da Faculdade de Odontologia da PUCRS. Rev Odonto Ciênc. 2005;20(50):313-8.

25. Oliveira ALBM, Giro EMA. Importância da abordagem precoce no tratamento odontológico de pacientes com necessidades especiais. Odonto. 2011;19(38):45-51.

37. Solanki J, Gupta S, Arya A. Dental caries and periodontal status of mentally handicapped institutilized children. J Clin Diagn Res. 2014;8(7): ZC25-7.

277 – RSBO. 2015 Jul-Sep;12(3):273-7 Calixto�� Junior et al. – Oral health status of patients with special needs from a rehabilitation association in Curitiba (PR, Brazil)

38. Tomita NE, Fagote BR. Programa educativo em saúde bucal para pacientes especiais. Odontologia e Sociedade. 1999;1(1/2):45-50. 39. Waldman HB, Perlman SP. Children with special health care needs: results of a national survey. J Dent Child. 2006;73(1):57-62.

40. Whyman RA, Treasure ET, Brown RH, MacFadyen EE. The oral health of long-term residents of a hospital for the intellectually handicapped and psychiatrically ill. N Z Dent J. 1995;91(404):49-56.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):278-84

Original Research Article

Postgraduate students’ knowledge on oral health Valéria Freire Morais1 Gabriela Martelli1 Edson Alfredo1 Silvio Rocha Corrêa da Silva1 Corresponding author: Silvio Rocha Corrêa da Silva Av. Costábile Romano, 2.201 – Ribeirânia CEP 14096-900 – Ribeirão Preto – SP – Brasil E-mail: silvio.rocha.correa@gmail.com 1

Dentistry Course, University of Ribeirão Preto – Ribeirão Preto – São Paulo – Brazil.

Received for publication: May 23, 2015. Accepted for publication: July 12, 2015.

Keywords: health promotion; disease prevention; education.

Abstract Objective: This study aimed to evaluate the oral health knowledge of postgraduate students comparing the results according to the area (exact sciences, health and humanities). Material and methods: The descriptive study consisted of a questionnaire with 12 open and closed questions applied to 120 students enrolled in post-graduation courses at the University of Ribeirão Preto. All responses were analyzed using descriptive statistics and the comparison among the student's areas was performed using Chi-square test with 5% significance level of significance. Results: The results showed that the average age of participants was 30.8 years, but with statistically significant difference among the three areas (humanities - 32.8 years; health - 27 and exact - 30.8 years). The last visit to the dentist in the last 12 months for 48.7% of the graduates in the humanities, 69.0% in the health area and 74.4% in the exact area, in a private practice (43.6% of Human, 71.4% health and 79.5% exact area) (p<0.05). About what is plaque, 25.6% of graduates in humanities, 23.8% in health area, and 17.9% in exacts could not answer. Concerning to plaque removal, 43.6% of the humanity and health area graduate thought that only the dentist can remove it. Dental caries primarily occurs because of poor hygiene for 59.0% of the graduates in the humanities, 81.0% of health care and 69.2% of the exact area. About fluoride, most knew about their usefulness (prevention and protection), but 31.0% of the graduates in healthcare associated fluoride to cleaning. Statistically significant differences in the questions about knowledge were found. Conclusion: It was concluded that the knowledge presented by graduates was limited and incomplete, regardless of the area.

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Introduction Caries and periodontal disease are the main oral health problems in Brazil, not only by the high prevalence, but also due to their individual and community impact, affecting the quality of life [13]. Beside the biological risk factors, environmental factors are related to behavior and the personal habits, especially among people with unfavorable socioeconomic level, which refers to the importance of health education in the promotion of oral health as a way to establish preventive habits for these diseases [2]. The oral health education comprises actions aimed at the appropriation of knowledge about the health-disease process, including risk and protective factors to oral health [4]. Thus, education actions in oral health should not be limited to biological aspects, but should also be considered the social context. A mon g t he hea lt h educat ion st rateg ies, t he supply of i n format ion is seen a s a key element. Favorable outcomes targeted to health education range from increased knowledge and understanding of patients about their conditions, about their perceptions and experiences of the disease and treatment to impacts on health behavior and, consequently, the health status [6]. According to Menezes and Cavalcanti [14], the level of knowledge of the people about oral health is increasing, thus justifying an improvement in people's quality of life. Research conducted by the Brazilian Federal Council of Dentistry [5] showed that 72% of people go to the dentist at least once a year. In general, this percentage is good but the same study compared participants who have the habit of going to the dentist with those who do not have the habit and there emerge two distinct realities: the average age of those who do not go is 50 years (compared to 37 years among those who usually go at least once a year to the dentist), 67% have the basic education level (they are 32% among those who usually go), 64% have family income of up to two salaries minimum (they are 41% among those who usually go), 37% are D/E Class (compared to 14% among those who go to the dentist) and 35% live in the Northeast (compared to 26% among those who go to the dentist). Differences between groups show that healthcare needs to be thought in a setting that there is a social dimension, because it is determined by

the working conditions and the way of life. So the hypothesis of this study is that people who attended the university and then return to course specialization have good habits and positive knowledge about oral health. The lacto sensu post-graduate or specialization course was created for the professionals with high education and aims at professional expertise and knowledge of a particular area in a specific way. It is recommended for those seeking a different qualification, to keep updated knowledge in the chosen field, focusing on the professional market. This study aimed to evaluate the oral health knowledge of lacto sensu graduates by comparing the results according to the training area (exact, health, and humanity sciences).

Material and methods This was a descriptive, qua ntitative a nd transversal study developed during the year 2013 in the city of Ribeirão Preto, Brazil. It consisted of a questionnaire in a sample of professionals enrolled in lacto sensu postgraduate courses of the University of Ribeirão Preto in different areas. The study population consisted of graduates enrolled in a lacto sensu post-graduation course 2013. The convenience sample, i.e. composed by students who agreed in participating and signed the informed consent, totalized 120 students. The data collection instrument was a semi structured questionnaire composed of 12 open and closed questions that was filled in the classroom. The questionnaire was developed for this study and could be divided into two parts. The first part was composed with questions for the characterization of the participant, such as gender, age and area of graduation, while the second part evaluated the habits and knowledge on oral health. A questionnaire was used with some open questions to encourage the preservation of the multiplicity of information, avoiding targeting of responses. In the analysis, responses were grouped according to common terms used. Before the final application, a pre-test with eight professionals selected randomly was conducted to change and/or adequacy of the questions to the study objectives. It was also performed the testretest with the same pre-test professional, to confirm reproducibility of the questionnaire by applying the Kappa test according to the criteria proposed

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by Landis and Koch [11]. The first and second applications were performed by the same investigator and with a seven-day interval between them. The agreement measured by Kappa test was 90%. All responses were tabulated by Epi-Info Version 7 and analyzed using descriptive statistics, by absolute and relative frequencies. The comparison between the students’ areas was performed using Chi-square test with level significance of 5%.

Results The study sample consisted of 120 lacto sensu graduates. Of these, 39 did their undergraduate degree in the humanities, 42 in the health area

and 39 in the exact area. The average age of participants was 30.8 (± 8.3) years, but with statistically significant difference (p<0.05) among areas (humanities with 32.8 ± 9.9 years, health area with 27.5 ± 4.2 years and exacts with 30.8 ± 7.5 years). Table I shows the gender, access to dental treatment, and satisfaction w ith their teeth. Concerning to gender, there was greater participation of women, especially in health and humanities. The last visit to the dentist was carried out in the last 12 months and at private practice. Most were satisfied with their teeth, and the most dissatisfied occurred in the humanities.

Table I – Distribution of respondents according to person characteristics and habits on oral health (2013)

Question

Graduation in Humanities

Health

Exacts

Male

8 (20.5%)

4 (9.5%)

36 (92.3%)

0.000*

Female

31 (79.5%)

38 (90.5%)

3 (7.7%)

Up to 1 year

19 (48.7%)

29 (69.0%)

29 (74.4%)

From 1 to 2 years

18 (46.2%)

9 (21.4%)

6 (15.4%)

More than 2 years

1 (2.6%)

2 (4.8%)

2 (5.1%)

Do not know

1 (2.6%)

2 (4.8%)

2 (5.1%)

Private practice

17 (43.6%)

30 (71.4%)

31 (79.5%)

Health insurance

15 (38.6%)

8 (19.0%)

8 (20.5%)

7 (17.9%)

4 (9.5%)

0 (0.0%)

Dissatisfied

9 (23.1%)

0 (0.0%)

2 (5.1%)

Neither satisfied nor dissatisfied

7 (17.9%)

7 (16.7%)

10 (25.6%)

19 (48.7%)

23 (54.8%)

19 (48.7%)

4 (10.3%)

12 (28.6%)

8 (20.5%)

Gender

Last visit to dentist 0.104

Type of service

Public health

0.005*

Satisfaction with teeth

Satisfied Very satisfied

0.008*

* Statistically significant difference, Chi-square test p<0.05

Table II highlights the answers on the dental plaque. All questions regarding these issues were with open answers and, therefore, each response was categorized into one of the items shown.

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Table II – Distribution of answers on the knowledge on dental plaque (2013)

Question What is dental plaque? Bacteria Remains of food Dirt Other answers Do not know How can dental plaque be removed? Brushing By dentist Do not know

Humanities

Graduation in Health

Exacts

12 (30.8%) 9 (23.1%) 5 (12.8%) 3 (7.7%) 10 (25.6%)

12 (28.6%) 11 (26.2%) 6 (14.3%) 3 (7.1%) 10 (23.8%)

16 (41.0%) 10 (25.6%) 5 (12.8%) 1 (2.6%) 7 (17.9%)

0.945

14 (35.9%) 17 (43.6%) 8 (20.5%)

21 (50.0%) 14 (33.3%) 7 (16.7%)

21 (53.8%) 14 (35.9%) 4 (10.3%)

0.615

About dental plaque or biofilm, a high percentage of respondents could not answer, while for 41.0% of graduates in exacts the plaque is the presence of bacteria. They were also cited food debris on the teeth and dirt that was not removed. Comparing the areas of student education there was no statistically significant difference. About plaque remova l, while ha lf of t he graduates in health and exact answered it is done through the hygiene of teeth, 43.6% of graduates in humanities said that only the dentist could perform

it, but without statistically significant difference. Table III shows the results on caries and fluoride. Dental caries arises primarily as a cause of poor hygiene. The presence of bacteria and food consumption with sucrose had low percentage of responses. About fluoride, it is observed that most knew about their usefulness (prevention and protection), but still some of the participants associated the fluoride to cleaning. About where the fluoride can be found, water and toothpaste were the most frequent answers.

Table III – Distribution of answers about knowledge on caries and fluoride (2013)

Question What causes caries? Poor hygiene Sweet foods Bacteria in the mouth Other answers Do not know Fluoride function Prevention Cleanliness Other answers Do not know Where is fluoride found? Water Toothpaste Rinse Foods Other answers Do not know

Humanities

Graduation in Health

23 (59.0%) 4 (10.3%) 10 (25.6%) 0 (0.0%) 2 (5.1%)

34 3 4 0 1

31 (79.5%) 6 (15.4%) 1 (2.6%) 2 (4.8%) 16 (41.0%) 8 (20.5%) 2 (5.1%) 3 (7.7%) 5 (12.8%) 5 (12.8%)

(81.0%) (7.1%) (9.5%) (0.0%) (2.4%)

Exacts 27 3 3 3 3

(69.2%) (7.7%) (7.7%) (7.7%) (7.7%)

0.071

24 (57.1%) 13 (31.0%) 2 (4.8%) 3 (7.1%)

28 (71.8%) 8 (20.5%) 1 (2.6%) 1 (2.6%)

0.171

7 (16.7%) 16 (38.1%) 0 (0.0%) 1 (2.4%) 6 (14.3%) 12 (28.6%)

15 (38.5%) 10 (25.6%) 1 (2.6%) 0 (0.0%) 7 (17.9%) 6 (15.4%)

0.095

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Discussion The population surveyed – students of lacto sensu post-graduation courses –, constituted a homogenous group with similar answers and without demonstrating greater knowledge from one area over the other with regard to knowledge about oral health. They were young, and graduates in health care had the lowest average age, while the humanities had the higher age. A similar result at least in health area was also found by Maciel et al. [12], who when assessing graduates of specialized courses in family health found, on average, 51% of respondents aged 20-30 years old. The search for a specialization course may occur because professional necessity due to a job or just after graduation so that the student has better preparation to face the job market, so this low average age. The last visit to the dentist occurred within 1 year prior to study enrollment for most participants and was almost always at a private practice, but without statistically significant difference among the areas. Graduates in humanities attended more dental insurance practices or the public practices than those graduate in health or exacts, who most attended private practice. These data on access to dental treatment were expected, at least in the areas of health and exacts, because it is a young group with university education and conditions to cover either private or insurance fees. Menezes and Cavalcanti [14], evaluating students in the health area, obtained an annual rate of 88.5%. The results of this study in the fields of exacts and health, are closer to the figures released by the Brazilian Federal Council of Dentistry in the national survey conducted in 2014 [5], in which 72% went to the dentist in the last year; 70% of the appointments were in private practice. Peres et al. [16] found that between 2003 and 2008 the use of dental services increased, while decreased the lack of access to these services. For the authors, the situation has improved due to socioeconomic factors and health sector, because the average income of the population and employment rates increased in the period, which may have influenced the demand for private care or agreements. In the same period, there was an increase in supply in the public sector with the Health Family Strategy and the implementation of specialized dental clinics. The satisfaction with teeth showed difference between the participants. In the health area, the percentage of graduates satisfied or very satisfied

reached 83.4%. Once a ga in, students of t he humanities were those with the highest percentage of dissatisfaction with the teeth (23.1%), which should be related to previous data access to dental treatment. The Brazilian Oral Health Project in 2010, conducted by the Ministry of Health [3] across the country, revealed a different situation, with only 40.3% of respondents sat isfied or very satisfied, while 37.8% were dissatisfied or very dissatisfied. The perception of the people and the judgment of oral health are related to self-image, needs and the search for dental care. There is also evidence that the negative perception of health is related to indicators of social inequalities, highlighting the deleterious effects of social determinants on health [9]. Unfer and Saliba [19] surveyed users of public health services and 45.7% of them rated their oral health as regular. When asked about the reason of this perception, the respondents mentioned to present some necessity, mainly expressed by “Need of prosthesis”, “I need root treatment”, “I have decay”, “I have gum problem”, “I have to go to the dentist”; while 30% when considering your oral health as good, expressed “nothing bothers”, “feel nothing”, “I went to dentist”, “good”. On the knowledge that students have on dental plaque or biofilm, it was observed that this is not a clear concept, with responses that overlap and do not adequately explained. The plaque is formed by microorganisms adhered to tooth surface. Santos et al. [17] stated that the dentists themselves are responsible for the confusion that people do, because when trying to explain the concept more easily use inappropriate terms such as “dirt” or “food remains”. Granville-Garcia et al. [10] also found large misinformation on dental plaque among elementary school teachers, with 58.5% of the participants of their study not knowing to answer about its constitution. About plaque removal, lack of knowledge is evident when 43.6% of graduates in humanities said that only the dentist can perform it, which may show, as already mentioned by Santos et al. [17] that people can confuse plaque removal with the dental calculus. Caries biological factors (diet, microorganisms, bad hygiene) appeared in the answers partially with the predominance of poor hygiene. The influence of diet on the occurrence of caries had a secondary role. According to Unfer and Saliba [19], the campaigns of candy manufacturers, promoting their products as natural, socially acceptable, and

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linked to displays of affection, compete with big advantage over educational messages about the sugar consumption and oral health. In the study of Santos et al. [17], only 20.4% of respondents associated caries and multifactorial process. Almas et al. [1] also found that caries is the result of incorrect brushing, according to 88% of their respondents. Ferreira et al. [7] studied pedagogy graduates and 55% of them cited poor hygiene and consumption of sugar. Freire et al. [8], in a study on the oral health knowledge of pediatricians, observed that, in relation to the etiology of caries, doctors have knowledge about the biological factors, but none mentioned the social and economic determinants that influence installation and development of the disease. Bacterial factors were strongly related to caries, but the role of diet, on the other hand, was not recognized by most pediatricians. Moreover, most of who cited the diet reported food in general, and among those who cited the sugar (45.5%), none mention sucrose. About fluoride, it is observed that most knew about their usefulness (prevention and protection), but 31.0% of graduates in health area associated fluoride to cleaning. Very researched, fluoride is an essential element in the control and prevention of caries and should be used by all people at all ages, in addition, it is important to be present steadily and in small concentrations in the oral cavity. More than fluoride effectiveness, it is important to consider the perceptions that people have of their reality, so Ferreira et al. [7] called attention to one important aspect: the popularization of scientific knowledge, that is, although the benefits of fluoride to teeth is already known by dentists, information on oral health are still few disseminated among the general population Morano et al. [15] verified the knowledge on oral health of a group of graduates in teaching and 76.9% of respondents said they would know to say how important the fluoride is to the teeth, but only 4.1% correctly answered about its importance. Unfer and Saliba [19], studied adult users of public health services found that 61.6% answered that fluoride protect teeth, and 20.5% did not know what to answer. About which fluoride can be found, in water and toothpaste were the most prevalent answers, but 28.6% of graduates in health could not answer. Not knowing where fluoride can be found was also seen by Unfer and Saliba [19], in which 23.0% of the participants did not know how to answer. Draws attention in that study that 37.5% mentioned the

pharmacy and 26.2% the dental office as a place to find fluoride. Santos et al. [18], in a study with elementary school teachers, found that 53.3% answered water and 50.0% toothpaste. This study was conducted with the lacto sensu post-graduate students of a single educational institution, by convenience sample. Thus, the results cannot be extrapolated to the general population or even for students from other institutions. Its importance lies in the fact that it was conducted in order to verify the knowledge on oral health and it was found that this is limited and incomplete. Even professionals trained in health care present similar knowledge in relation to graduates in the areas of humanities and exacts.

Conclusion It was concluded that the knowledge presented by students was limited and incomplete, regardless of the training area.

References 1. Almas K, Al-Malik TM, Al-Sheri MA, Skaug N. The knowledge and practices or oral hygiene methods and attendance pattern among schools teachers in Riyach. Saudi Med J. 2003 Oct;24(10):1087-91. 2. Brasil. Ministério da Saúde. A política nacional de saúde bucal do Brasil: registro de uma conquista histórica. Brasília: Organização Pan-Americana da Saúde; 2006. 3. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Coordenação Geral de Saúde Bucal. Projeto SB Brasil 2010: resultados principais. Brasília; 2011. 92 p. 4. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília: Ministério da Saúde; 2004. 68 p. 5. Conselho Federal de Odontologia. Saúde bucal: pesquisa 2014. Available from: URL:http://cfo.org. br/wp-content/uploads/2014/11/H%C3%A1bitosA titudeseComportamentosnaSa%C3%BAdeBucal. pdf. 6. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. Br Med. 2007 Jul;335(7609):24-7.

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7. Ferreira JMS, Massoni ACLT, Forte FDS, Sampaio FC. The knowledge of oral health of undergraduate students of Pedagogy. Interface – Comunic, Saúde, Educ. 2005 Mar-Aug;9(17):381-8. 8. Freire MCM, Macedo RA, Silva WH. Conhecimentos, atitudes e práticas dos médicos pediatras em relação à saúde bucal. Pesq Odont Bras. 2000 Jan-Mar;14(1):39-45. 9. Gabardo MCL, Moysés ST, Moysés SJ. Autopercepção de saúde bucal conforme o perfil de impacto da saúde bucal (OHIP) e fatores associados: revisão sistemática. Rev Panam Salud Publica. 2013 Jun;33(6):439-45. 10. Granville-Garcia AF, Silva JM, Guinho SF, Menezes V. Conhecimento de professores do ensino fundamental sobre saúde bucal. RGO. 2007 Jan;55(1):29-34. 11. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977 Mar;33(1):159-74. 12. Maciel ELN, Figueiredo PF, Prado TN, Galavote HS, Ramos MC, Araújo MD et al. Avaliação dos egressos do curso de especialização em Saúde da Família no Espírito Santo, Brasil. Ciênc Saúde Col. 2010 Jul;15(4):2021-8. 13. Melo EH, Freire EJ, Bastos HFBN. Ensinoaprendizagem de conceitos científicos em saúde bucal nas séries iniciais do ensino fundamental I à luz da análise da conversação. Revista Eletrônica de Divulgação Científica em Língua Portuguesa, Lingüística e Literatura. 2005 Feb;2(2):1-17.

14. Menezes RD, Cavalcanti AL. Estudo comparativo da informação em saúde bucal entre estudantes de cursos da área da saúde, João Pessoa. Pesq Bras Odontoped Clín Integr. 2003 Feb;3(2):27-33. 15. Morano Júnior M, Silva CMC, Mialhe FL, Lido YJVL. Conhecimentos acerca de saúde bucal de estudantes de um curso de magistério. Pesq Bras Odontoped Clín Integr. 2007 May-Aug;7(2):1317. 16. Peres KG, Peres MA, Boing AF, Bertoldi AD, Bastos JLA, Barros JD. Redução das desigualdades sociais na utilização de serviços odontológicos no Brasil entre 1998 e 2008. Rev Saúde Pública. 2012 Oct;46(2):250-8. 17. Santos PA, Rodrigues JA, Garcia PPNS. Avaliação do conhecimento dos professores do ensino fundamental de escolas particulares sobre saúde bucal. Rev Odontol Unesp. 2002 JulDec;31(2):205-14. 18. Santos PA, Rodrigues JA, Garcia PPNS. Conhecimento sobre prevenção de cárie e doença periodontal e comportamento de higiene bucal de professores de ensino fundamental. Ciênc Odontol Bras. 2003 Nov;6(1):67-74. 19. Unfer B, Saliba O. Avaliação do conhecimento popular e práticas cotidianas em saúde bucal. Rev Saúde Pública. 2000 Apr;34(2):190-5.

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Original Research Article

Analysis of the time required for dissolving the pulp tissue according to different methods of sodium hypochlorite activation Ana Luíza Leichtweis1 Tiago André Fontoura de Melo1 Gustavo Golgo Kunert1 Corresponding author: Gustavo Golgo Kunert Rua Florêncio Ygartua, 271 – sala 201 – Moinhos de Vento CEP 90430-010 – Porto Alegre – RS – Brasil E-mail: gustavogkunert@gmail.com Department of Dentistry, Center of Post-Graduation São Leopoldo Mandic/SP, unit Porto Alegre – Porto Alegre – RS – Brazil. 1

Received for publication: May 12, 2015. Accepted for publication: July 24, 2015.

Keywords: dental pulp; dissolution; ultrasound.

Abstract Introduction and Objective: To analyze the time required to dissolute the pulp tissue under different methods of sodium hypochlorite activation. Material and methods: 30 bovine pulp fragments, with an approximate volume of 45 ± 5 mg were divided into three experimental groups (n = 10). In group 1, only the fragments were immersed in 15 ml of 2.5% sodium hypochlorite. In group 2, the irrigant was manually stirred with an endodontic instrument type K size 40. In group 3, we used the ultrasonic insert n.39, driven by ultrasound device Jet Sonic Total. The time required for total dissolution of bovine tissue was measured and recorded for statistical analysis. Results and Conclusion: According to analysis of variance (Anova), with p<0.05, Group 1 showed significantly higher dissolution time than Groups 2 and 3. Moreover, no difference between the use of ultrasound and manual activation of the irrigating solution was found.

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Introduction While the mechanical action shapes the root canal, the chemical action acts to inactivate microorganisms and eliminate the organic and inorganic components present therein. O ne o f t he mo s t u s e d a nd a c c e pt a bl e solutions for endodontic irrigation is sodium hypochlorite. Hypochlorite properties are based on its concentration, temperature, and pH [18]. This irrigating solution has low surface tension [3], antimicrobial action [19], and dissolution capacity of organic matter [14]. However, because of the root canal system present a complex anatomy, with the lateral canals, isthmuses, ramifications and apical delta, the efficiency of irrigation is compromised on the action of dissolving pulp tissue in dentin reentrances [15]. Some studies suggest conducting a process of active irrigation in order to increase the effectiveness in cleaning the root canal system [1, 5, 8]. According to Juchem et al. [10], the contact area of the solution can be increased by activation through either mechanical or hand technique. T hus, t h i s st udy a i med to a na ly z e t he dissolution capacity of the pulp tissue according to different methods for the activation of 2.5% sodium hypochlorite.

Material and methods Tissue preparation F i f t e e n b ov i ne i nc i s ors w e re obt a i ne d in Slaughterhouse of São Roque/Cerro Largo (RS). These teeth were immersed in distilled water and stored at a temperature of -20° C until use. The teeth were defrosted at room temperature. Two longitudinal grooves were made with a doublesided diamond disc (KG Sorensen, Barueri, São Paulo, Brazil), on all the fullest extent of the tooth sample at the buccal and lingual surfaces, in order to enable tooth cleavage with size 7 spatula (Golgran, São Paulo, São Paulo, Brazil). The pulp tissue was removed and washed with distilled water. Each tissue sample was divided into two fragments of similar size (45 ± 5 mg), resulting in a total of 30 parts of pulp tissue.

Tissue dissolution process The bovine tissue fragments were divided and placed into individual clears plastic flasks and

randomly divided into three groups (n = 10). The experiment of all groups was run at the same day. In group 1, the pulp fragments were only immersed in 2.5% sodium hypochlorite solution at room temperature (Asfer – Chemical Industry Ltda., São Caetano do Sul, São Paulo, Brazil.). In group 2, the tooth samples were immersed in 2.5% sodium hypochlorite solution and the solution was hand activate with size #40 K-type endodontic instrument (Dentsply Maillefer, Ballaigues, VD, Switzerland). This protocol was performed three times for 40 seconds (totalizing 120 seconds). In group 3, we used the same mechanism of action of group 2, but with the ultrasonic insert #39 for agitation. The tip was employed with power of 30% and without water (Jet Sonic Total, Gnatus Medical Dental Equipment Ltda., Ribeirão Preto, São Paulo, Brazil). Time and the solution agitation cycle in group 3 was the same of group 2. The amount of sodium hypochlorite solution in each flask was standardized at 15 ml. The time counting for dissolving tissue was started at the time of immersion of the bovine pulp fragment into the solution with the aid of a digital stopwatch. The observation of complete tissue dissolution was conducted by a single examiner, without any knowledge on the objectives of the study. The time obtained was noted in a spreadsheet. The maximum time set for the experiment was 2 hours. If the pulp tissue was not completely dissolved after that time the sample was considered unable to promote tissue dissolution.

Statistical analysis The dat a were subm it ted to A NOVA, by comparing the average percentage of dissolution in the three experimental groups. The significance level was set at 5% (P<.05).

Results None group elapsed the maximum time set for the experiment. As shown in figure 1, the pulp tissue in group 1 took approximately 60 minutes to be completely dissolved. In groups 2 and 3, the average time was 30 minutes. No statistical difference between was seen between the use of agitation with either endodontic or ultrasonic instrument.

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Figure 1 – Tissue dissolution of the bovine pulp in relation to the methods of irrigating solution agitation

Discussion The use of irrigating solution during root canal treatment is justified by the fact that there are variations in internal anatomy of the root canal system that hinder the action of endodontic instruments around the dentin complex. In t his present st udy, we chose sodium hypochlorite because it is the solution most used in Endodontics and the most cited in the literature. According to Cobankara et al. [4] and Morgental et al. [13], hypochlorite has the power of tissue dissolution and an antimicrobial capacity exceeding the other irrigant solutions. Based on the studies of Hand et al. [9] and Moorer and Wesselink [12], it is known that the tissue dissolution capacity caused by sodium hypochlorite solution is related to a number of factors, such as their concentration, volume and temperature. Thus, caution was taken to standardize the study regarding to the volume of 15 ml of solution used [10] and the agitation time, both manual and mechanical (ultrasound) for three cycles of 40 seconds. With regard to the use of bovine pulp, this has been successfully employed in the studies of Al-Jadaa et al. [2] and Macedo et al. [11] to assess the dissolution power of endodontic irrigants. The result analysis showed that, regardless of the agitation method of the irrigant solution, the tissue dissolution time was shorter in the group which the pulp tissue remained only immersed

into the solution. These results corroborate those from Stojicic et al. [17], who found that agitation promoted greater dissolution capacity. The lack of statistically significant difference between the groups 2 and 03 (manual and ultrasonic) in the present study can be justified because one is unable to measure the similar relationship between manual and ultrasonic agitation. One of the phenomena caused by the ultrasonic oscillation is called cavitation. [6]. Cavitation is limited to a distance of less than 100 µm (0.0001 m) from the generating source. Thus, it is difficult to measure whether the power loss of this phenomenon influenced on the result of this study, because bovine pulp was immersed into sodium hypochlorite at a depth of 10 mm (0.01 m). According to the study of Stojicic et al. [17], probably only the effect caused by the phenomenon of acoustic micro stream might have occurred Moreover, a greater difference occurred in the dissolution time, when the liquid remained static compared to the solution that had undergone agitation; which is in agreement with the study of Só et al. [16]. The authors found that 2.5% hypochlorite solution completely dissolved samples in less than two hours probably because the movement of the solution causes a larger number of solid particles are in contact with the f luid by increasing the contact surface, since the contact area is a factor to consider in dissolution [10]. Guneser et al. [7] also found a higher tissue dissolution capacity with agitation of the irrigant solution.

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Conclusion According to the results, it can be concluded that: • The process of agitation of 2.5% sodium hypochlorite solution showed a reduction in bovine pulp tissue dissolution time by 50% compared to no agitation; • There was no statistical difference in tissue dissolution time in relation to the use of an endodontic instrument or an ultrasonic tip for agitation of sodium hypochlorite solution.

References 1. Al-Jadaa A, Paqué F, Attin T, Zehnder M. Acoustic hypochlorite activation in simulated curved canals. J Endod. 2009;35(10):1408-11. 2. Al-Jadaa A, Paqué F, Attin T, Zehnder M. Necrotic pulp tissue dissolution by passive ultrasonic irrigation in simulated accessory canals: impact of canal location and angulation. Int Endod J. 2009;42(1):59-65. 3. Andersen M, Lund A, Andreasen JO, Andreasen FM. In vitro solubility of human pulp tissue in calcium hydroxide and sodium hypochlorite. Endod Dent Traumatol. 1992;8(3):104-8. 4. Cobankara FK, Ozkan HB, Terlemez A. Comparison of organic tissue dissolution capacities of sodium hypochlorite and chlorine dioxide. J Endod. 2010;36(2):272-4. 5. Deleu E, Meire MA, De Moor RJ. Efficacy of laser based irrigant activation methods in removing debris from simulated root canal irregularities. Laser Med Sci. 2015;30(2):831-5. 6. Grundling GL, Zechin JG, Jardim WM, de Oliveira SD, de Figueiredo JA. Effect of ultrasonics on Enterococcus faecalis biofilm in a bovine tooth model. J Endod. 2011;37(8):1128-33. 7. Guneser MB, Arslan D, Usumez A. Tissue dissolution ability of sodium hypochlorite activated by photon-initiated photoacoustic streaming technique. J Endod. 2015;41(5):729-32. 8. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod. 2014;40(8):1178-81. 9. Hand RE, Smith ML, Harrison JW. Analysis of the effect of dilution on the necrotic tissue dissolution property of sodium hypochlorite. J Endod. 1978;4(2):60-4.

10. Juchem CB, Pereira GB, Soares RG, Irala LED, Salles AA, Limongi O. Avaliação da capacidade de dissolução de tecido pulpar bovino pelo ácido tricloroisocianúrico nas concentrações de 1%, 2%, 3% e 4% comparativamente ao hipoclorito de sódio 1%. RSBO. 2008;5(1):34-41. 11. Macedo RG, Wesselink PR, Zaccheo F, Fanali D, Van Der Sluis LW. Reaction rate of NaOCl in contact with bovine dentine: effect of activation, exposure time, concentration and pH. Int Endod J. 2010;43(12):1108-15. 12. Moorer WR, Wesselink PR. Factors promoting the tissue dissolving capability of sodium hypochlorite. Int Endod J. 1982;15(4):187-96. 13. Morgental RD, Singh A, Sappal H, Kopper PM, Vier-Pelisser FV, Peters OA. Dentin inhibits the antibacterial effect of new and conventional endodontic irrigants. J Endod. 2013;39(3): 406-10. 14. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004;30(11):785-7. 15. Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obtured in the presence or absence of detectable microorganisms. Int Endod J. 2002;35(8):660-7. 16. Só MVR, Vier Pelisser FV, Darcie MS, Smaniotto DGR, Montagner F, Kuga MC. Pulp tissue dissolution when the use of sodium hypochlorite and EDTA alone or associated. Rev Odonto Ciênc. 2011;26(2):156-60. 17. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo M. Tissue dissolution by sodium hypochlorite: effect of concentration, temperature, agitation, and surfactant. J Endod. 2010;36(9):1558-62. 18. Vianna ME, Gomes BP, Berber VB, Zaia AA, Ferraz CC, de Souza-Filho FJ. In vitro evaluation of the antimicrobial activity of chlorhexidine and sodium hypochlorite. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):79-84. 19. Vianna ME, Horz HP, Gomes BP, Conrads G. In vivo evaluation of microbial reduction after chemomechanical preparation of human root canals containing necrotic pulp tissue. Int Endod J. 2006;39(6):484-92.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):289-96

Original Research Article

Epidemiological study to determine factors associated with dental caries in schoolers Camila Castro1 Carolina Dea Bruzamolin1 João Gilberto Duda1 João Armando Brancher1 Eduardo Pizzatto1 Corresponding author: Eduardo Pizzatto Departamento de Odontologia, Universidade Positivo Rua Professor Pedro Viriato Parigot de Souza, 5.300 – Campo Comprido CEP 81280-330 – Curitiba – PR – Brasil 1

Department of Dentistry, Positivo University – Curitiba – PR – Brazil.

Received for publication: April 13, 2015. Accepted for publication: July 12, 2015.

Keywords: dental caries; socioeconomic factors; oral health.

Abstract Introduction: Dental caries is a large problem affecting all population. In Brazil, caries prevalence has decreased over the last years, but it is still a public health issue requiring frequent evaluation and care by dentists. Objective: To evaluate the oral health conditions of schoolers aged 5-12 years relating them with socioeconomic and demographic determinants. Material and methods: The children were examined by a previously calibrated examiner to obtain DMF and dmf scores. The parents answered a questionnaire regarding to the socioeconomic condition. Prior to the examinations, the parents signed a free and clarified consent form and only their children were evaluated. The results were analyzed descriptively and by Chi-square test, at significance level of p<0.05. Results: The sample (n=111) showed a mean age of 7+1.7 years (mean + standard deviation), composed of 58 boys and 58 girls. 66.6% of the sample exhibited dmf values = 0, while 102 schoolers had DMF values = 0. With regard to the parents’ education level, 78.37% of the mothers had more than 9 years of education and 43.34% of the fathers had 9 to 11 years of study. Concerning to family income, 36.93% of the families presented mean income of 1-3 minimum wages (R$ 788.00 to R$ 2,364.00). No statistically significant differences (p≤0.05) were seen between caries rates vs. parents’ education and caries rates vs. family income. Conclusion: 5-12 year schoolers showed low dmf and DMF values, suggesting that parents’ education and income might have influenced

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on the results. Further studies are necessary to understand/assess the predisposing factors to dental caries development.

Introduction Dental caries is a multifactorial disease affecting most of the worldwide population. Interconnected factors influenced on the risk for developing the disease, among them environmental factors (oral bacteria), behavioral factors (diet and oral hygiene), endogenous resources (tooth position and morphology; enamel composition; salivary composition and flow), and demographic characteristics (age, sex, race, socioeconomic status and access to oral health care) [1, 8]. Moysés [16] observed that the worst socioeconomic conditions are directly related to a higher consumption of sugar, worst oral health condition, difficulty of access to toothbrushes and dentifrices, difficulty of access to dental care, leading the population more exposed to these risk factors consequently increasing dental caries prevalence. Baldani et al. [3] conducted an epidemiologic survey associating dental caries to socioeconomic factors in many cities of Parana, Brazil through DMF value and social aspects showed in databases (IBGE and DataSUS) and found that the cities with the lower incomes and education had the higher caries prevalence. The study of Martins et al. [14] aimed to investigate through multivariate analysis the association of caries with variables as: parents’ education, number of people living in same house, school type and family income. The data were collected through DMF scores and questionnaire. The authors found a direct relationship between caries development in children having the lowest family income, studying in public schools and whose parents had the smallest education level. The epidemiologic surveys are necessary both for knowing the prevalence of oral diseases and evaluating the oral treatment needs [19]. These studies are associated with the application of structured questionnaires with demographic, socioeconomic, behavioral and access to health service variables. Such methodology enables to evaluate the possible association of these variables with caries disease. One way of diagnosing and measuring the problems in oral health area is to use the health indicators. In Dentistry, an index frequently employed in epidemiologic surveys to assess the number of teeth affected by caries is DMF (dmf), proposed by Klein and Palmer, in 1937. Over the last decades, other indexes have been created and modified to meet the research’s objectives. However, DMF index is a valuable, reliable, sensible, and acceptable index

to be used to assess oral health regarding to caries in a population [22]. It is of utmost importance for any planning and action in health promotion to collect epidemiologic data to evaluate the situation of the health conditions of a given population. Notwithstanding, some Brazilian cities, as the city of Pinhais, does not have epidemiologic data on oral health of 5-12 year schoolers, the age range considered by WHO [4]. Given that importance and aiming to understand the oral health situation this study aimed to investigate the association between caries severity and its determinants in 5-12 year schoolers in the city of Curitiba, Parana, Brazil.

Material and methods This present study was conducted according to Declaration of Helsinki and after the approval of the Institutional Review Board regarding ethical aspects (protocol no. #879404). The sample comprised 111 schoolers of the Municipal School Campo Mourão (city of Curitiba, Parana, Brazil) aged between 5 and 12 years, regularly enrolled and living in the city of Curitiba whose parents read and signed a free and clarified consent form. Exclusion criteria comprised the presence of fixed orthodontic appliances and lack of signature on the free and clarified consent form. DMF and dmf indexes were used to evaluate dental caries, according to the guidelines of the World Health Organization [19]. Both the examiner and the note taker were trained and calibrated. All examinations were performed with the aid of disposable wooden spatula, and both the child and the examiner were seated, under natural light, strictly following the biosecurity guidelines. Both the examiner and note taker wore apron, hat, mask and disposable gloves during the examinations. A iming at t he socioeconomic a na lysis, a questionnaire was sent to all parents comprising the following variables: years of education of the father and mother; number of rooms in the house; house type; number of people living in the house; number of gadgets in the house (TV, DVD, computer, car, and washing machine); and parents’ perception towards the oral health of the child. This questionnaire was based on the interview guide of SB Brazil Project, with some modifications to meet the aims of this present study and the age range of interest. The data were tabulated and submitted to descriptive statistics analysis to obtain the final results.

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Results With regard to sample characterization, the schoolers (n=111) had mean age of 7+1.7 yeas (mean + standard deviation), with 58 males and 53 females (n=111). Considering dmf values (primary teeth), most of the sample showed values equal or close to 0 (66.6%), with mean ± standard deviation of 0.86±1.61 (figure 1). For permanent dentition, DMF values evidenced very low caries rate because DMF mean ± standard deviation was 0.13±0.469 (figure 2).

Figure 1 – Percentage relative frequencies of dmf indexes (0 to 8) in 5-12 year schoolers (0.86±1.61)

Figure 2 – Percentage relative frequencies of DMF indexes (0 to 3) in 5-12 year schoolers (0.13±0.469)

With respect to the parents’ education, the mothers exhibited a mean of 3.89 ± 1.33 years of study. 6.3% did not answered, 0.9% did not attend school, and 5.4% had from 1 to 4 years of study (basic education), 9% had from 5 to 8 years of study (elementary school), 41.44% from 9 to 11 years of study (high school) and 36.93% more than 12 years of study (college) (figure 3). On the other hand, 43.34% of the fathers had from 9 to 11 years of study with mean + standard deviation of 3.74 ± 1.27 (figure 4).

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Figure 3 – Relative frequencies regarding to the mothers’ education (3.89 ± 1.33)

Figure 4 – Relative frequencies regarding to the fathers’ education (3.74 ± 1.27)

It was possible to verify the family income and 36.93% of the families had an income from 1 to 3 minimum wages (R$ 788.00 to R$ 2,364.00), 27.92% had from 3 to 5 minimum wages (R$ 2,364.00 to R$ 3,940.00) (2.42 ± 1.24). 13.5% of the respondents did not report the family income (figure 5).

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Figure 5 – Frequencies related to the family income of 5-12 schoolers (2.42 ± 1.24)

The association between the dmf and DMF indexes, parents’ education, and family income did not show statistically significant differences (p≤0.05) (table I). Table I – Association of the caries determinant factors (family income and education) with dmf and DMF values (p≤0.05)

Caries determinants Mother’s education Illiterate 1 to 4 years 5 to 8 years 9 to 11 years 12 years or + Father’s education 1 to 4 years 5 to 8 years 9 to 11 years 12 years or + Family income Did not answer Up to 1 wage From 1 to 3 wages From 5 to 15 wages Higher than 15 wages

Caries index (mean±standard deviation) dmf 0±0,0 1.33±2.42 1.4±1.8 0.76±1.53 0.88±1.6 0.33±0.81 1±1.5 0.83±1.7 0.84±1.3 0.87±1.4 0.78±1.4 1.06±2 0.73±1.4 0±0.0

Significance p≤0.05

p=0.881

p=0.903

p=0.928

DMF 0±0.0 0±0.0 0.1±0.31 0.17±0.57 0.7±0.34 0±0.0 0±0.0 0.33±0.44 0.1±0.39 0.33±0.61 0±0.0 0.20±0.64 0.03±0.10 0±0.0

Significance p≤0.05

p=0.932

p=0.06

p=0.438

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Discussion The result of this study exhibited a mean dmf/DMF of 0.86 and 0.13, respectively, for 5-12 year-old children. These are favorable data when compared to those of the Brazilian health survey, whose means were 2.46 for 5 years and 1.53 for 12 years [6]. By analyzing this aforementioned result, one can infer that dental caries has been controlled and prevented in the studied population, providing a better quality of life to the children. The epidemiologic studies have been frequently conducted and enable the monitoring of the caries experience in children and adults in Brazil. Most of these studies cover the prevalence and severity of caries in preschoolers and schoolers, by assessing the prevalence of decayed teeth, oral hygiene, and factors associated with the parents and/or guardians [23]. Many researches indicate that the relation of demographic, socioeconomic and behavioral factors is also of utmost importance for dental caries development. The factors most having the highest positive association with dental caries development were: low parents’ education, family income, social class [1, 5, 9, 10, 17, 23-26], and school type [7, 14]. The evaluated children studied at a public school in the city of Curitiba. Notwithstanding, they showed low index of decayed tooth with 91.89% of the sample without decayed primary tooth and 74.77% of the sample without decayed permanent tooth. These results are different from those observed by Barbosa et al. [4], who evaluated the dental caries prevalence in 5 year-old children studying in public schools in the city of Curitiba and found a high dental caries index (52.9%). Some authors considered that socioeconomic situation is a determinant factor for risk to caries disease and this can be characterized as a disease of developing countries, such as Brazil [12, 16]. It is worth affirming that in this present study, the families mostly exhibited (48.63%) an income equal to or higher than R$ 2,364.00, classified as middle class. One can infer that the social level interfere on dmf and DMF values, because the schoolers had low caries index, although without statistically significance (p≤0.05). In the studies of Mendes et al. [15] and Nicolau et al. [18], youths of families with incomes of up to 2.4 minimum wages (R$ 1,891.2) had more prevalence of decayed teeth than those having family income higher than 2.4 minimum wages. Thus, low family income is associated with dental caries experience.

The studies of Oliveira et al. [20], Perera and Ekanayake [22], Aida et al. [1] and Van Nieuwenhuysen et al. [28] demonstrated that the family income and the parents’ education were or were not related with caries presence. A study showed that the mothers with more than five years of education put their children at a higher risk of developing caries lesions than those mothers with higher education. The literature has reported that the parents’ low education will influence the adoption of healthy oral hygiene habits of the children, so that periodical actions of oral health education and promotion are necessary towards to the parents and guardians are necessary [27]. In this present study, no statistically significance differences (p<0.05) were found in the association of parents’ education with the caries index exhibited by the studied population, because both the mothers (78.37%) and the fathers (70.26%) had high education. Notwithstanding, the high education of the parents/guardians can be used as a possible explanation for the low dmf (66.6%) and DMF (91.89%) value equal to 0. Within this context, we can assume that the parents’ education influence on the presence of the caries lesions of their children. Identifying the collective factors predisposing to dental caries in preschoolers is a fundamental tool to enable suitable oral health care and redirection of the actions that should be targeted to health attention. It is of outmost importance during daily dental practice that both the individual and the collective oral health are treated through the universal access to the dental services and assuring the equity and resolutivity in treating the general and individual dental needs of a given population.

Conclusion Based in the results, it can be concluded that: • 5-12 year-old schoolers had low dmf/DMF values, indicating a healthy oral health and adequate oral hygiene care; • The parents’ education and the family income seems to influence on the caries index of the studied population; • By relating the socioeconomic factors (family income) with parents’ education, no statistically significant differences (p≤0.05) in the dmf/DMF values were found; • Further similar studies are necessary to evaluate better the caries determinants in schoolers from public schools aiming at meeting the demands according to their needs.

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References 1. Aida J, Ando Y, Oosaka M, Niimi K, Morita M. Contribuitions of social context to inequality in dental caries: a multilevel analysis of Japanese 3-year-old children. Community Dent Oral Epidemiol. 2008;36:149-56. 2. Ajayi DM, Abiodun-Solanke IF. Sociobehavioural risk factors of dental caries among selected adolescents in Ibadan, Nigeria. Pediatric Dental Journal. 2014;24(1):1-6. 3. Baldani MH, Vasconcelos AGG, Antunes JLF. Associação do índice CPO-D com indicadores sócio-econômicos e de provisão de serviços odontológicos no estado do Paraná, Brasil. Cad Saúde Pública. 2004;20(1):143-52. 4. Barbosa APM, Kriger L, Moyses ST, Moyses SJ. Prevalência da doença cárie em crianças de cinco anos de idade na cidade de Curitiba – análise crítica. Epidemiol Serv Saúde. 2007;16(2): 142-5. 5. Bucker WCV, Pessôa CP, Alves TDB, Oliveira MC. Associação entre severidade de cárie dentária e aspectos sociocomportamentais em escolares de 12 anos no município de Feira de Santana, Bahia. Revista Baiana de Saúde Pública. 2001;35(1): 103-11. 6. Brasil. Ministério da Saúde. Projeto SB Brasil 2010: pesquisa nacional de saúde bucal. Resultados principais. Brasília; 2012. 7. Cypriano S, Hugo FN, Sciamarelli MC, Tôrres LHN, Souza MLR, Wada RS. Fatores associados à experiência de cárie em escolares de um município com baixa prevalência de cárie dentária. Ciência & Saúde Coletiva. 2011;16(10):4095-106. 8. Declerck D, Leroy R, Martens L, Lesaffre E, Garcia-Zattera MJ, Broucke VS et al. Factors associated with prevalence and severity of caries experience in preschool children. Community Dental Oral Epidemiol. 2008;36:168-78. 9. Dini EL, Holt RD, Bedi R. Caries and its association with infant feeding and oral healthrelated behaviours in 3-4-year-old Brazilian children. Community Dent Oral Epidemiol. 2000;28:241-8. 10. Freire MCM, Reis SCGB, Figueiredo N, Peres KG, Moreira RF, Antunes JLF. Individual and contextual determinants of dental caries in Brazilian 12-year-olds in 2010. Rev Saúde Pública. 2013;47(Supl 3):1-10.

11. Guerra LM, Pereira AC, Pereira SM, Meneghim MC. Avaliação de variáveis socioeconômicas na prevalência de cárie e fluorose em municípios com e sem fluoretação das águas de abastecimento. Rev Odontol Unesp. 2010 Sep/Oct;39(5):255-62. 12. Gushi LL, Soares MDAC, Forni TI, Vieira V, Wada RS, Sousa MDAL. Cárie dentária entre os adolescentes e sua relação com as variáveis sócioeconômicas. J Appl Oral Sci. 2005;13(3):305-11. 13. Instituto Brasileiro de Geografia e Estatística – IBGE. Perfil dos municípios brasileiros 2009 [cited 2015 May 5]. Available from: URL:http:// www.ibge.gov.br/. 14. Martins MT, Sardenberg F, Abreu MH, Vale MP, Paiva SM, Pordeus IA. Factors associated with dental caries in Brazilian children: a multilevel approach. Community Dent Oral Epidemiol. 2014;42(4):289-99. 15. Mendes LGA, Biazenic MGH, Crosato ME, Mendes MOA. Dental caries and associated factors among Brazilian adolescents: a longitudinal study. Braz J Oral Sci. 2008;7:1614-9. 16. Moysés SJ. Desigualdades em saúde bucal e desenvolvimento humano: um ensaio em preto, branco e alguns tons de cinza. Rev Bras Odonto Saúde Col. 2000;1(1):7-17. 17. Narang R, Saha S, Mittal L, Anamika, Gupta YK. Socioeconomic status of the family and caries experience among 2e6 years old preschool children of Lucknow city, India. International Journal of Dental Science and Research. 2013:12-5. 18. Nicolau B, Marcenes W, Bartley M, Sheiham A. A life course approach to assessing causes of dental caries experience: the relationship between biological, behavioural, socioeconomic and psychological conditions and caries in adolescents. Caries Res. 2003;37:319-26. 19. Oliveira AGRC, Unfer B, Costa ICC, Arcieri RM, Guimarães LOCG, Saliba NA. Levantamentos epidemiológicos em saúde bucal: análise da metodologia proposta pela Organização Mundial da Saúde. Rev Bras Epidemiol. 1998;1(2). 20. Oliveira LB, Sheihman A, Bonecker M. Exploring the association of dental caries with factors and a nutritional status in Brazilian preschool children. Eur J Oral Sci. 2008;116:37-43. 21. Organização Mundial de Saúde. Levantamento epidemiológico básico em saúde bucal: manual de instruções. 4. ed. Genebra: OMS; 1997.

296 – RSBO. 2015 Jul-Sep;12(3):289-96 Castro� et al. – �� Epidemiological study to determine factors associated with dental caries in schoolers

22. Perera I, Ekanayake L. Social gradient in dental caries among adolescents in Sri Lanka. Caries Res. 2008;42:105-11. 23. Peres KGA, Bastos JRM, Latorre MRDO. Severidade de cárie em crianças e relação com aspectos sociais e comportamentais. Rev Saúde Pública. 2000;34(4):402-8.

26. Shaffer JR, Polk DE, Feingold E, Wang X, Cuenco KT, Weeks DE et al. Demographic, socioeconomic, and behavioral factors affecting patterns of tooth decay in the permanent dentition: principal components and factor analyses. Community Dent Oral Epidemiol. 2013;41:364-73.

24. Peres MA, Latorre MRDO, Sheihman A, Peres KG, Barros FC, Hernandez PG et al. Determinantes sociais e biológicos da cárie dentária em crianças de 6 anos de idade: um estudo transversal aninhado numa coorte de nascidos vivos no Sul do Brasil. Rev Bras Epidemiol. 2003;6(4).

27. Silva PF, Freitas CHSM. Análise de motivos que dificultam a adoção de hábitos de higiene bucal saudáveis com relação à cárie dentária: avaliação de uma escola pública da Paraíba. 2011;47(1):38-44.

25. Pizzo G, Piscopo MR, Matranga D, Luparello M, Pizzo I, Giuliana G. Prevalence and sociobehavioral determinants of dental caries in Sicilian schoolchildren. Med Sci Monit. 2010;16(10): 83-9.

28. Van Nieuwenhuysen JP, Carvalho JC, D’Hoore W. Caries reduction in Belgian 12-year-old children related to socioeconomic status. Acta Odontol Scand. 2002;60:123-8.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):297-301

Original Research Article

Resistance to fracture evaluation of endodontically treated roots of first maxillary premolars Rosany Laurentina Santos de Carvalho1 Carolina dos Santos Guimaraes1 Marcia Maria Fonseca da Silveira1 Diana Santana de Albuquerque1 Raquel Azevedo de Moraes1 Flávia de Lima Cavalcanti Spinelli1 Corresponding author: Rosany Laurentina Santos de Carvalho Rua Dr. Osvaldo Salsa, n. 100, apto 1.501 – Graças CEP 52011-170 – Recife – PE – Brasil E-mail: rosanycarvalho@hotmail.com 1

Department of Dentistry, University of Pernambuco – Camaragibe/Recife – PE – Brazil.

Received for publication: October 29, 2014. Accepted for publication: September 14, 2014.

Keywords: Endodontics; fracture compression; dental fissures; tooth fractures.

Abstract Introduction: One of the most common dental procedures associated to vertical root fractures is the endodontic treatment with excessive dentin wall wear and another increasing risk factor is the use of intraradicular post. Objective: This study evaluated the resistance to fracture of the buccal and palatal roots of maxillary first premolars with endodontically treated canals and spaces for posts. Material and methods: Twenty two first permanent premolar roots (11 buccal and 11 palatal) composed the experimental sample. The canals were prepared with Protaper Universal® system until file F3 and then filled with gutta-percha cone F3 and endodontic sealer and received spaces for posts keeping 4 mm of filling at the apical third. The roots were subjected to compression test in a universal testing machine (Kratus). The roots were subjected to a progressive compression stress at a speed of 0.5 mm / min. A load cell of 200 kg was used. Results: Statistical analysis revealed significant differences between the strength values and resistance limit between groups (P<0.05), as analyzed by t Student test. The values of resistance to fracture of 0.44 kgf/mm2 for group 1 (buccal roots) and 0.31 kgf/mm2 for group 2 (palatal roots) were found. Conclusion: The resistance to fracture of the buccal roots was higher than that of palatal roots of first premolars submitted to biomechanical preparation and root preparation for intraradicular post.

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Introduction The root fractures are injuries that cause damage to the mineralized tissues, periodontal ligament, and pulp and are classified into vertical, horizontal, and oblique and may occur in the cervical, medium, or apical third [7, 16]. The dental procedure that is most commonly associated as a cause of vertical root fracture (VRF) is the endodontic treatment with excessive wear of dentin walls and the use of intracanal posts. This situation combined with the age of the patient may increase susceptibility to root fracture. The mandibular molars and maxillary premolars are the most affected teeth [3, 5, 13, 18, 21]. VRF is a condition difficult to diagnosis and repair, often resulting in failed attempts of endodontic retreatment. The anatomical characteristics and the mesial-distal flatness of the root of some teeth have been identified as the main predisposing factors for this fracture type, increased when the need for reconstruction by intraradicular post. In order to minimize this risk the dentist should select the root of higher strength with the easiest post placement, which should follow the shape of the selected root [15, 20]. This study aimed to evaluate the fracture strength of the buccal and palatal roots of maxillary first premolars treated endodontically and with spaces made for post, for through compression tests in universal testing machine.

Material and methods The st udy was approved by t he Et hica l Committee in Resea rch of t he Universit y of Pernambuco (CEP / UPE) under the protocol CAAE: 13092913.3.0000.5207, and developed at the Laboratory of Mechanical Tests in Pernambuco Dental School, University of Pernambuco (FOP / UPE). This is a laboratorial in vitro study. The sample comprised 22 roots of the maxillary first premolars, newly-extracted for therapeutic reasons, which on visual inspection showed straight roots and formed apex. Teeth, after the initial

Figure 1 – Cutting of the roots and mounting in PVC rings

cleaning, were placed in 0.5% sodium hypochlorite, sterilized, and kept in distilled water under cooling, according to the protocol of the Bank of Teeth of BDH / FOUSP [14]. The teeth were radiographed to check the absence of calcifications or anatomical variations, inspected with an optical microscope (Callmex model – Q705M, Florianópolis, SC, Brazil), at x10 magnification, to observe the integrity of the roots. Both the crown opening and access to the root canal were executed with the aid of spherical diamond burs at high speed (KG Sorensen, São Paulo, SP, Brazil), according to the pulp chamber size, and Endo – Z burs (KG Sorensen, São Paulo, SP, Brasil), to remove pulp ceiling. The teeth were sectioned vertically, with double-sided diamond disc (KG Sorensen, São Paulo, SP, Brazil), at the furcation, separating the buccal and palatal roots. The roots were divided into two groups: group I (11 buccal roots) and group II (11 palatal roots). The working length of the roots was determined by the visual method by introducing a size 15 file (Flexofile, Dentstply, Maillefer, Switzerland), inside the root canal until it reaches the foramen, then backing up a millimeter. The channels were prepared using the Protaper Universal® system (Dentsply Maillefer – Ballaigues-Switzerland) and X-Smart ® motor (Dentsply Maillefer – Ballaigues-Switzerland), set up in 250 rpm rotation and 3N torque, always under irrigation with 1.0% sodium hypochlorite (Fórmula & Ação – São Paulo, Brazil). The canals were filled with gutta-percha point size F3 and AH Plus sealer. Then the spaces for the posts were made with the aid of Gates Glidden drills size #3, keeping 4 mm at apical third. Next, the roots were wrapped in a sheet of lead and Vaseline were applied on the samples centralized in rings of polyvinylchloride (PVC) measuring 25x10 mm, closed at its base with utility wax no. #7, filled up to the cementumenamel limit with chemically activated acrylic resin (Art. Odontológicos Clássico Ltda., São Paulo, SP), creating an artificial socket. The lead sheet was removed from each tooth and a polyester-based molding material of high viscosity was inserted into the artificial socket with the aid of spatula no. #24, to mimic the periodontal ligament (figure 1).

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The teeth were stabilized and subjected to compression test on a universal testing machine (Kratos Equipamentos Industriais / model IKCL3 – USB), through a metal device with a tapered finger spreader D, 25 mm (Maillefer Dentsply), adapted on its upper end, allowing the force applied inside the canal was perpendicular to the long axis of the tooth (figure 2).

Figure 2 – Tooth inserted into the universal testing machine

The teeth were subjected to a progressive compressive force with a load of 200 at 0.5 kg mm/min. The vertical pressure was maintained until fracture, which was perceived by the sudden change of the chart on the computer screen. A chart was generated for each sample tested, and the values of resistance to fracture forces were submitted to statistical test for comparison between the experimental groups. The study evaluated the resistance to fracture of the buccal and palatal roots of the maxillary first premolar by using a laboratory method (compression test). The statistical program used for data entry and statistical calculations was Statistical Package for Social Sciences version 21 (SPSS). Statistical significance was set at p<0.05 and confidence interval were determined at the level of 95%. Data regarding to the average basic measures, standard deviations, and variation coefficients were analyzed by Student's t test.

Results Statistical analyzes of the strength values and tensile strength, as shown in Table I, evidencing the comparison between the groups exhibited a statistically significant difference (P<0.05). Table I – Student t test with respect to the fracture resistance threshold comparing buccal and palatal roots

Root

Resistance to fracture values (Kgf/mm2)

Buccal

0.441 ± 0.092

Palatal

0.311 ± 0.092

1) means obtained after 11 repetitions; 2) confidence interval; 3) Different letters bet ween lines means statistically significant differences in the resistance limits and the maximum forces applied to the buccal and palatal roots, using the Student t test (P<0.05)

The resistance to fracture values were 0.44 Kgf/ mm2 for group I (buccal roots) and 0.31 Kgf/mm2 for group II (palatal roots). Thus, one can say with 95% confidence interval that there are significant differences between the resistance to fracture of

the buccal roots when compared to palatal roots of teeth with root canal and post.

Discussion Vertical root fractures can occur both in vital and devitalized teeth endodontically treated or not. The highest prevalence is related endodontically treated teeth. The literature confirms this statement [11, 19, 21], identifying as causes, most often, iatrogenic factors, as poorly-constructed intraradicular post and core, inadequate selection of teeth as fixed prosthesis abutments, poorly conducted endodontic treatment using excessive force to the spacer during the filling of the root canal system of through the lateral condensation technique. The clinical decision-making regarding the best material and technique for reconstruction of teeth with severe coronary destruction should consider variables related to the patient (occlusion, masticatory force, level of alveolar bone, parafunctional habits) and variables related to the tooth morphology (length and volume of roots), to maximize the longterm prognosis of teeth endodontically treated and prepared for intraradicular post and core.

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The first premolar has commonly two roots, and root variations consist of fused roots with separate canals, roots fused and linked or “tangles”, roots fused with a common apical foramen and possibly teeth with three roots or two roots with three canals [17]. In this study, we selected roots anatomically individualized, with similar length and root diameter in order to standardize the samples and reduce the possibility of misinterpretation regarding the best choice of position for cementation of intraradicular post and core [8]. It is always controversial determining which root is more appropriate to anchor to intraradicular post and core in endodontic treatments with prosthetic reconstruction of the first premolars with two roots. There is debate about the risk of fracture and the need for anchoring in one or both roots. The anatomy of the root canal and is crucial to the success in placing intraradicular ´posts and the root preparation should be as the most conservative way as possible, especially in teeth with anatomical mesial-distal flattening [2, 22]. In the case of the maxillary first premolars, the prevalence of two canals is around 95% in separate or fused roots, which result into a strong mesialdistal flattening at the cervical and middle thirds. The deep knowledge of tooth morphology, proper radiographic analysis, and aid of magnification, complemented with good lighting, decrease the occurrence of iatrogeny due to excessive wear of the remaining root and help in choosing the most appropriate root to anchor the post when the teeth require prosthetic reconstruction [12]. The present study was designed to determine which root would be the most suitable to receive the intraradicular post in endodontically-treated maxillary first premolar subjected to compressive loads. The compression models have been adopted in the literature to evaluate the resistance to fracture of the various tooth types with biomechanical preparation and intracanal posts [1, 7, 10]. However, they have not been used in the resistance to VRF analysis comparing the same tooth type, as performed in this study. One clinical scenario was simulated in this study with an artificial periodontal ligament using a molding material to coat the root, which has a modulus of elasticity very similar to natural periodontal ligament [4]. The posts were not made after preparation of intracanal space to eliminate the parameters such as the material’s structure, shape, length, and thickness of the posts. Thus, only the structural

integrity and resistance to fracture of the root remnant after the post preparation was be tested more precisely [6]. The applicat ion of compressive force i n endodont ica lly t reated teet h is a met hod of resistance to fracture evaluation with a high degree of clinical relevance, since it can simulate conditions for applying forces similar to those of clinical conditions. The mean values of kg force needed to fracture these specimens were approximately 2.20 kgf for buccal roots and 1.56 kgf for palatal roots. Similar research conducted by Lertchirakarn et al. [11] also calculated the safe load limit required to avoid VRF in several teeth. Six groups of ten teeth were tested: central incisors, premolars and upper and lower molars. The average fracture load was variable, with the upper incisors requiring higher load (17.2. kg) and the lower incisors lower load (6.2 kg). The results suggest that only the lateral condensation should not be the direct cause of VRF and situations where most wear occurs for the placement of intracanal post probably increases this risk, corroborating this study results, where all the tested specimens received intracanal post preparation, thereby increasing the wear of dentin walls [9, 11].

Conclusion The results of this study indicate greater resistance to fracture of buccal root than the palatal root of maxillary premolars filled and with preparation for intraradicular post and core. Anatomical aspects as volume and direction of the root canal should support the choice of the root to receive the post and core.

References 1. Al-Wahadni AM, Hamdan S, Al-Omiri M, Hammad MM, Hatamleh MM. Fracture resistance of teeth restored with different post systems: in vitro study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Aug;106(2):e77-83. 2. Bellucci C, Perrini N. A study on the thickness of radicular dentine and cementum in anterior and premolar teeth. Int Endodont J. 2002;35(7): 594-606. 3. Cohen, Berman LH, Blanco L, Bakland L, Kim JS. A demographic analysis of vertical root fractures. J. Endod. 2006 Dec;32(12):1160-3.

301 – RSBO. 2015 Jul-Sep;12(3):297-301 Carvalho� et al. – �� Resistance to fracture evaluation of endodontically treated roots of first maxillary premolars

4. Coolidge ED. The thickness of the human periodontal ligament. J Am Dent Assoc. 1937;24:1260. 5. Dekon S, Zavanelli A, Resende C, Paulo R, Neves R. Alternativas clínicas para confecção de núcleos protéticos estéticos. Rev Bras Prót Clín Lab. 2002;4(21):387-91. 6. Dilmener FT, Sipahi C, Dalkiz M. Resistance of three new esthetic post- and-core systems to compressive loading. J Prosthet Dent. 2006 Feb;95:130-6. 7. Garcia LFM, Caldeira, CL. Vertical fracture resistance of endodontically treated teeth with different root filling materials. Rev Odontol Univ Cid São Paulo. 2010 May-Aug;22(2):104-10. 8. Hegde J, Ramakrishna, Bashetty K, Srirekha A, Lekha S, Champa. An in vitro evaluation of fracture strength of endodontically treated teeth with simulated flared root canals restored with different post and core systems. J Conserv Dent. 2012 Jul-Sep;15(3):223-7. 9. Juloski J, Apicella D, Ferrari M. The effect of ferrule height on stress distribution within a tooth restored with fibre posts and ceramic crown: a finite element analysis. Dental Materials. 2014 Oct;30(12):1304-15. 10. Kathuria A, Kavitha M, Khetarpal S. Ex vivo fracture resistance of endodontically treated maxillary central incisors restored with fiberreinforced composite posts and experimental dentin posts. J Conserv Dent. 2011 Oct;14(4):401-5. 11. Lertchirakarn V, Palamara JEA, Messer HH. Load and strain during lateral condensation and vertical root fracture. J Endod. 1999 Feb;25(2): 99-103. 12. Martins JNR. Primeiro pré-molar superior com três canais: diagnóstico e tratamento – quatro casos clínicos. Rev Port Estomatol Med Dent Cir Maxilofac. 2011;52:43-51.

13. Mireku AS, Romberg E, Fouad AF, Arola D. Vertical fracture of root filled teeth restored with posts: the effects of patient age and dentine thickness. Int Endod J. 2010 Mar;43(3):218-25. 14. Nassif AC, Tieri F, da Ana PA, Botta SB, Imparato JC. Structuralization of a human teeth bank. Pesqui Odontol Bras. 2003 May;17(1):70-4. 15. Nothdurft FP, Seidel E, Gebhart F, Naumann M, Motter PJ, Pospiech PR. The fracture behavior of premolar teeth with class II cavities restored by both direct composite restorations and endodontic post systems. J Dent. 2008 Jun;36(6):444-9. 16. Pitts DL, Matheny HE, Nicholls JI. An in vitro study of spreader loads required to cause vertical root fracture during lateral condensation. J Endod. 1983;9(12):544-50. 17. Portela CP, Baratto Filho F, Tomazinho FSF, Correr GM, Moro A, Moresca RC. Estudo da anatomia interna dos pré-molares – revisão de literatura. Odonto. 2011 Jan-Jun;19(37):63-72. 18. Seow LL, Toh CG, Wilson Nairn HF. Strain measurements and fracture resistance of endodontically treated premolars restored with all-ceramic restorations. Journal of Dentistry. 2015 Jan;43(1):126-32. 19. Sharath Chandra SM. Sharonlay – a new onlay design for endodontically treated premolar. JCD. 2015 Mar-Apr;18(2):172-5. 20. Souza EM, Pappen FG, Leonardi DP, Flores VO, Berbert FLCV. O papel da anatomia radicular na colocação de pinos pré-fabricados: uma visão endodôntica. Rev Gaúc Odontol. 2007 Jan/ Mar;55(1):77-82. 21. Wilcox LR, Roskelley C, Sutton T. The relationship of root canal enlargement to fingerspreader induced vertical root fracture. J Endod. 1997 Aug;23(8):533-4. 22. Yang SF, Rivera EM, Walton RE. Vertical root fracture in nonendodontically treated teeth. J Endod. 1995 Jun;21(6):337-9.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):302-10

Literature Review Article

Can quality of life index measure oral health over the years? �� A systematic review Paulo Roberto Silva1 Márcia Cristina Lopes1 Wellington M. Zaitter2 Edgard Michel Crosato1 Corresponding author: Paulo Roberto Silva Faculdade de Odontologia – Universidade de São Paulo Rua Lineu Prestes, 2.227 – Butantã CEP 05508-000 – São Paulo – SP – Brasil E-mail: paulorobertosilva@usp.br 1 2

Department of Social Dentistry, University of São Paulo – São Paulo – SP – Brazil. Positivo University– Curitiba – PR – Brazil.

Received for publication: June 19, 2015. Accepted for publication: July 24, 2015.

Abstract Keywords: longitudinal studies; oral health; quality of life.

Introduction: The referred quality of life has been increasingly used in dental studies to measure the impact that the dental treatment can cause on the individuals. However, there are few studies that monitor longitudinally this condition. Objective: The aim of this study was verify the behavior of the impact of the quality of life of the individuals through a systematic review on observational or interventional longitudinal studies. Literature review: The articles were selected in the period from February 5th to March 15th of 2014, with selection criteria: Objectives of the study, longitudinal studies, assessment of the quality of life of the studied population. The determination of the 24 selected articles was conducted by two examiners and revised together. Results: The study generated five tables related to common areas of dentistry: prosthesis, dental caries, geriatric health, orthodontics and oral oncology. The impact achieved in the quality of life of the people with the treatment was not maintained over the years. Conclusion: The quality of life of the individuals is little influenced by dental treatments over the years, with the exception of the cases of prosthesis and severe orthodontic treatments. The impact of the quality of life seems to be a measurement of occasional use, preferably carried soon after some oral intervention and not for longitudinal studies in which other factors cannot be controlled.

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Introduction Quality of life related to the oral health is a term used at the present time to describe or quantify the level of impact of the oral health on the quality of life of an individual. The measurements initially designed as subjective or socioeconomic indexes of the oral health, are now used as reference measurements of the impact on the quality of life. In this context, the functional and psychosocial impacts of perceived dental problems, generated by a composite score, may suggest the perceived changes in the life of the individual. An issue that is still approached ref lects the concern of the studies to show how these measurements were developed [20, 30, 35, 37], however the frequency of the functional and psychosocial impacts of the oral diseases may still establish equivocally the meaning and the importance of this impact on the quality of life [24]. This can be well defined after the conclusion of a dental treatment [33], as well as the measurement of a direct relation between the social impact and the dental care necessity perceived by the patient [26]. However, how these oral disorders really affect the quality of life of an individual over the time have not been clearly elucidated in the literature yet. That is, what happens with the quality of life indexes of these individuals after the treatment or re-treatment and after some years of the oral interventions. In face of what is exposed, this study aimed at answering through a systematic review the behavior of the quality of life impact described in observational longitudinal studies or of the intervention in the individuals.

Data collection and analysis For the conduction of this systematic revision, the articles were selected in the period from February 5th to March 15th of 2014, by two independent examiners (Kappa > 0.8). The researched databases were: Medline (1997-2014), Scopus, Cochrane Library and Lilacs, in English, Portuguese and Spanish. The keywords used were: quality of life, oral health and longitudinal studies. The criteria of inclusion in this first stage were: Objectives of the study, longitudinal studies, assessment of the quality of life of the studied population. 71 articles were detected at Scopus (limited to dentistry), 548 at Medline and six at Lilacs. Being that no reference was found at Cochrane Library. Of these, 35 articles were selected initially without duplicated. For this stage, the exclusion criteria were: abstracts not

in accordance with the objective of the research (Flowchart). In an agreement, four articles were excluded by the two examiners and the reviewer of the study after abstract analyses. Making use of pre-structured instruments in full text, the 31 selected articles brought the following complementary information: authors, local where the study was carried out, year of the publication, journal, period of the study, objective of the study, age or age range of the studied population, quality of life index used, main findings and/or conclusions. Of these, seven failed to meet the inclusion criteria. Reasons for exclusion were: three studies were not longitudinal [1, 18, 19], one study did not specify well the quality of life [28], one study was the description of a new index [11], one study was not related to oral health [21] and one study used the same data [9]. At the end, 24 articles were selected for a careful analysis and reported according to systematic review, for presenting similar characteristics the authors found it convenient to divide the subjects by common areas of the dentistry. This way, the articles were grouped in five big tables according to the affinity of the area once, with this division, more specific data was generated for the conclusions.

Results and Discussion On the table I, regarding the dental prosthesis, the quality of life indexes presented improvements and are maintained under the initial one after some years. In either cases, with prosthesis supported or not by implants, there is a decrease in the quality of life indexes [3, 2, 4, 8, 17, 23, 26, 29, 36]. However, in the implant supported patients the improvement in the quality of life was higher [3, 4, 8, 29]. For treatments of conventional denture, the patients who requested prosthesis over the implant, but received conventional prosthesis, obtained few changes in the quality of life [3]. However, in patients who requested conventional prosthesis and received them, there was an improvement in the quality of life [23]. Removable dentures require a longer period for the improvement in the quality of life of the patients [17, 36]. According to the authors, this is the adaptation time. The improvement in the quality of life can also be associated with the desire or personal expectations that suffer interferences with the time [23]. By the results found in table II, children without dental caries have a quality of life, in general,

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better than the ones who have dental caries [13]. However, the earlier treatment of these children with caries improves their quality of life according to the parents along the time. Now, in adolescents, the presence or absence of dental caries does not affect their quality of life [16]. However, according to the author, the lack of a strong association between the incidence of caries and the quality of life along the three years in these adolescents, also raises questions about the capacity of an index to reflect changes in the experience of caries and its effect on the quality of life in this population. In the area of oral oncology (table III) the quality of life seems to be more associated to the size of the injuries and their recovery expectations. Being that the physical aspects of the quality of life always reduce after the surgery they, however, start to return to the normality after 6 months or 1 year [5, 27, 31, 32]. Factor associated mainly to the complaint about difficulties in the mastication, besides difficulties to swallow, pain and lack of saliva [5]. Suggesting that the oral functional deficiency continues even after the surgeries [27]. Longitudinal studies about the quality of life, oral health and more senior citizens (table IV) showed that changes in the oral clinical status along the time are reflected directly on the quality of life of these people [7, 10, 14, 15, 22]. In this case in especial, two studies were maintained, due to their use of different measures of the quality of life of these same studied people [7, 22]. Social behaviors such as the low educational level and personal behaviors like smoking, directly affect the oral health-related and general quality of life of this population [7, 14]. With the increasing age, other health problems also affect the quality of life of this population [10, 15]. However, for the oral health the main complaints regarding the decrease in this quality of life are: toothache, abscesses and difficulties in the mastication due to tooth losses. Patients satisfied with the dental appearance describe a better quality of life [22]. Longitudinal studies about the quality of life and orthodontics (table V) showed that only patients with severe orthodontic problems presented changes in the quality of live along the years, mainly regarding the women [6, 12, 25, 34, 38]. In the surgical cases, the quality of life improves only after the performance of the orthognathic surgery [12, 25]. It was surprising the conclusion that only the orthodontic treatment does not influence the quality of life in adolescent or adult patients [6, 38]. Nevertheless, the orthodontic treatment improves

the appearance, oral function, health and social well-being of the people.

Conclusion By means of the proposed objective of the study, it is observed that the oral health-related quality of life of the people undergo changes during the entire studied period. Prosthesis and severe orthodontic treatments are the procedures that can maintain the impact on the improvement of the quality of life the longer. Our study could not determine the exact time in which these quality of life measurements start to recede, so other studies shall be conducted verifying this question. Some cohort studies which also generate results in defined demographic populations should be seen with endorsement. Due to the fact that these articles use measurements in scales, it is difficult the comparison of all the studies as a single one, as well as a single conclusion, but the study suggests us a scientific evidence that the quality of life of the people is little influenced by dental treatments along the years, with the exception in the case of prosthesis and orthodontic severe dental treatments. In summary, oral health-related quality of life is a measurement that should be used in a timelier manner, preferably soon after some oral intervention and not for longitudinal studies in which other factors cannot be controlled.

Implications for research Studies that aim at measuring the impact of the quality of life make use of indexes that suffer influence from both the lifestyle that the people and different habits and places. Consequently, studies with more uniform groups are valid for assessing the impact that the dentistry can cause on the life of these people along the time. The use of different instruments of quality of life can measure the additional positive aspects of patients regarding their perceptions of the oral health in specific cases (such as of the prosthesis), as well as in negative aspects (such as of misguided treatments). Articles that can better elucidate these aspects, in which it is also achieved the homogeneity of the dental treatment and successive collections regarding the quality of life of these people in more controlled periods become necessary.

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Table I – Longitudinal studies on the quality of life and prosthesis Authors and objective of the study Allen et al. [3] Evaluate the quality of life of people who received prosthesis under implants and conventional prosthesis Allen et al. [4] Evaluate the psychosocial well-being and the quality of life of individuals with complete and implant supported dentures John et al. [17] Compare the quality of life differences in patients with treatment of fixed, removable and complete dentures Meng and Gilbert [23] Verify if the improvement in the mastication ability improves the quality of life of the patient Berretin-Felix et al. [8] Verify the quality of life in patients with supported implant denture Alfadda et al. [2] Monitor the quality of life of the patients for 5 years regarding two types of conventional dental implants and immediate loading Stober et al. [36] Evaluate the quality of life in patients with complete dentures Petricevic et al. [29] Evaluate the difference in the quality of life of patients with removable denture and implant supported prosthesis in the posterior region.

Local

Newcastle – United Kingdom

HalleWittenberg, Germany

Florida, USA

Bauru, Brazil

Toronto, Canada

Heidelberg, Germany

Zagreb, Croatia

Index

OHIP 49

Time Before the treatment and 3 months after the placement of the prosthesis

3 years, initial and final

OHIP 49 items

12 months (Initial, 1 month, 6 months and 1 year)

Satisfaction in the mastication ability, yes or no

Initial, 6 months, 12, 18 and 24 months

OIHP 14, OIDP and World Health Organization Quality of Life – WHOQOLBREF

Initial, 3, 6 and 18 months

OHIP -20

Initial, 1 year and 5 years

OHIP-EDENT with 19 items. And satisfaction of the patient

Initial, 6 months, 1 year and 2 years

OHIP49

Initial, 3 weeks after the placement of the prosthesis and 3 years later

Sample

Age

Results

75 patients

Average between 55 and 65 years old

There was a decrease in the OHIP index of the patients, however the greatest decrease was in the patients who received implants

98 patients

Average between 60 and 65 years old

The quality of life increase for who received prosthesis under implants. It was equal for the control that had teeth

107 Patients

873 participants

from 24 to 82 years old

The 3 groups had a decrease in the OIHP index

The majority of the 45 years edentulous improves old or older the quality of life with the prosthesis

15 edentulous

Average of 66 years old

There was a change in the quality of life of the physical and dental factors, but not in the social factors

77 patients

Edentulous for more than 9 years

The quality of life index decreased in the period of 1 year and then maintained the same level

52 edentulous

from 45 to 87 years old

62 individuals

from 37 to 72 years old

The quality of life indexes decreased in the 2 years of the study

There was a decrease in the OIHP index for both groups and it was maintained in the 3rd year

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Table II – Longitudinal studies about the quality of life and dental caries in children and adolescents Authors and objective of the study Cunnion et al. [13] Check the quality of life in children with caries and with no caries and after the treatment Foster Page and Thomson [16] The difference in the quality of life of the adolescents with or with no caries

Local Washington and Columbus, United States

Taranaki, New Zealand

Index

POQL

CPQ 11-14

Time

Sample

Age

Initial, 6 months and 12 months

Children 501 parents from 2 to of the 8 years children old

3 years (initial and final)

430 adolescents. Finished with 255

Results Children with no caries have a better quality of life than the ones with dental caries, according to the parents

from 12 Lack of a strong and 13 association between years the incidence of old to 15 caries and the quality and 16 of life years old

Table III – Longitudinal studies about the quality of life and oral oncology Authors and objective of the study Rogers et al. [32] Evaluate if the quality of life of the patients after the first oral surgery improves after 6 months and 1 year later

Local

Liverpool, England

Index

UwQol

1 year

UwQol

18 months (Initial, 6, 12 and 18 months)

Rogers et al. [31] Evaluate if the quality of life of the patients after the first oral surgery improves after 6, 12 and 18 months and then relate it with the past record of the patient

Liverpool, England

Andrade et al. [5] Longitudinal monitoring of modifications in the self-rating of the quality of life in patients with oral squamous cell carcinoma

São Paulo, Brazil

UwQol

Amsterdam, Netherlands

The EORTC QLQ-C30 (cancer-specific questionnaire)

Oskam et al. [27] Evaluate the changes in the quality of life of patients treated for oral and oropharynx cancer for a long period

Time

1 year

11 years (initial, 6 months, 1 year and from 8 to 11 years later)

Sample

Age

Results

The quality of life Average Initial 130 index decreased in between patients, 79 the first 6 months 73 and 87 completed but started to years old the study increase in the second half year

Initial 272 patients 239 completed the study

Initial 100 patients 66 completed the study

Initial 80 patients 27 completed the study

Average of 60 years old for the men and 64 for the women

The physical aspects of the quality of life improved after the surgery, but began to increase again with the time

60 years old in average

The quality of life decreases after 1 year

from 23 to 74 years old

All the scales of symptoms presented deteriorated values along the monitoring in relation to the basal levels

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Table IV – Longitudinal studies about the quality of life, oral health and senior population Authors and objective of the study Chavers et al. [10] Describe the incidence and the oral standards in adult patients for 2 years. Verify this impact in the quality of life Meng et al. [22] Evaluate the quality of life of the patients regarding the dental appearance

Local Florida – USA

Florida – USA

Ekback et al. [14] Longitudinal monitoring of changes in the oral health of the patient and impact on the quality of life

Sweden (2 cities)

Index

Time

Telephone Interview

2 years (6, 12 and 18 and 24 months)

Satisfaction with the appearance (Self-rated oral health) by telephone

2 years (every 6 months)

Initial 873 people final 764 people

15 years (interview in 5 10 and 15 years)

Initial 6346 people and final 4143 people

from 50 to 65 years old

The quality of life decreased mainly in individuals who smoke, have a low level of education and had dental losses

15 years (interview in 5 10 and 15 years)

Initial 6346 people and final 4143 people.

from 50 to 65 years old

The wear of the oral quality was associated with inadequate behaviors

from 60 to 80 years old

There was a decrease in the GOHAI index with the age, however not relevant

Interview

Astrom et al. [7] Verify if the social and behavioral situation of the individual at the age of 50 affect the quality of life at the age of 65 regarding the oral health

Sweden (2 cities)

(OIDP) oral impacts on daily performances

Enoki et al. [15] Verify if the quality of life can be affected by changes in the oral functions in a long period

Osaka – Japan.

GOHAI - Geriatric Oral Health Assessment Index

7 years

Sample Initial 873 people final 764 people

Initial 411 people final 130 people

Age

Results

45 years old or older

The quality of life regarding the dental caries gets worse in the older patients

45 years old or older

The quality of life is better for patients with no tooth stains

Table V – Longitudinal studies about the quality of life and orthodontic treatments Authors and objective of the study Cunningham et al. [12] Evaluate and test if the instrument of quality of life could capture this reality in orthognathic patients

Taylor et al. [38] Evaluate if the orthodontic treatment affects the quality of life of the adolescents

Rusanen et al. [34] Evaluate the quality of life in patients with severe malocclusion and dental-facial deformities before and after the treatment

Local

Index

Time

Sample

Age

Results

South East of England

Orthognathic Quality of Life Questionnaire (OQLQ) and a visual analogue scale (VAS)

Initial, before the surgery and 8 weeks after the orthodontic treatment

Initial 65 people final 62 people

Average of 22 years old

The quality of life improved in all the aspects: Social, functional and aesthetic

from 11 to 14 years old

Malocclusion and orthodontic treatment do not seem to affect the quality of life in general or of the oral health for a measurable level of these adolescents

Average of 35 years old

In comparison with the general population, the patients with severe malocclusion report high levels of oral impacts in the quality of life, mainly the women

Washington – USA

Oulu, Finland

OHIP 14 and SWLS (index of life satisfaction)

OHIP 14

2 years (initial and after the orthodontic treatment)

3 years

293 patients

Initial 249 people and final 170 people

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Arrow et al. [6] Evaluate if the orthodontic treatment affects the life of the person when adult

Murphy et al. [25] Evaluate if the orthognathic surgery improves the quality of life of the patients

Adelaide, Australia

OHIP 14 and SWLS (index of life satisfaction)

17 years

Cork, Ireland

(Orthognathic Quality of Life Questionnaire (OQLQ)) and a visual analogue scale (VAS). And Global Transition Scale (GTS)

Initial and 6 months after the surgery

Flowchart – The screening process to select articles for the review

Initial 7673 people and final 421 people Initial 62 people and final 52 people

from 13 to 30 years old

There was no association between malocclusion and quality of life in the adult life

from 18 to 38 years old

The clinical impacts were moderate, however the quality of life of the patients after the surgical recovery improved

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References 1. Agou S, Locker D, Streiner DL, Tompson B. Impact of self-esteem on the oral-health-related quality of life of children with malocclusion. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4): 484-9. 2. Alfadda SA, Attard NJ, David LA. Five-year clinical results of immediately loaded dental implants using mandibular overdentures. Int J Prosthodont. 2009 Jul-Aug;22(4):368-73. 3. Allen PF, McMillan AS, Walshaw D. A patientbased assessment of implant-stabilized and conventional complete dentures. J Prosthet Dent. 2001 Feb;85(2):141-7. 4. Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants Res. 2003 Apr;14(2):173-9. 5. Andrade FP, Antunes JL, Durazzo MD. Evaluation of the quality of life of patients with oral cancer in Brazil. Braz Oral Res. 2006 OctDec;20(4):290-6. 6. Arrow P, Brennan D, Spencer AJ. Quality of life and psychosocial outcomes after fixed orthodontic treatment: a 17-year observational cohort study. Community Dent Oral Epidemiol. 2011 Dec;39(6):505-14. 7. Astrom AN, Ekback G, Ordell S, Unell L. Social inequality in oral health-related quality-of-life, OHRQoL, at early older age: evidence from a prospective cohort study. Acta Odontol Scand. 2011 Nov;69(6):334-42. 8. Berretin-Felix G, Nary Filho H, Padovani CR, Machado WM. A longitudinal study of quality of life of elderly with mandibular implant-supported fixed prostheses. Clin Oral Implants Res. 2008 Jul;19(7):704-8. 9. Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent. 2002 Summer;62(3):140-7. 10. Chavers LS, Gilbert GH, Shelton BJ. Two-year incidence of oral disadvantage, a measure of oral health-related quality of life. Community Dent Oral Epidemiol. 2003 Feb;31(1):21-9.

11. Cunningham SJ, Garratt AM, Hunt NP. Development of a condition-specific quality of life measure for patients with dentofacial deformity: I. Reliability of the instrument. Community Dent Oral Epidemiol. 2000 Jun;28(3):195-201. 12. Cunningham SJ, Garratt AM, Hunt NP. Development of a condition-specific quality of life measure for patients with dentofacial deformity: II. Validity and responsiveness testing. Community Dentistry and Oral Epidemiology. 2002 Apr;30(2):81-90. 13. Cunnion D, Spiro A, Jones J, Rich S, Papageorgiou C, Tate A et al. Pediatric oral healthrelated quality of life improvement after treatment of early childhood caries: a prospective multisite study. J Dent Child (Chic). 2010 Jan-Apr;77(1): 4-11. 14. Ekback G, Nodrehaug-Astrom A, Klock K, Ordell S, Unell L. Satisfaction with teeth and life-course predictors: a prospective study of a Swedish 1942 birth cohort. Eur J Oral Sci. 2010 Feb;118(1):66-74. 15. Enoki K, Ikebe K, Matsuda KI, Yoshida M, Maeda Y, Thomson WM. Determinants of change in oral health-related quality of life over 7 years among older Japanese. J Oral Rehabil. 2013 Apr;40(4):252-7. 16. Foster Page LA, Thomson WM. Caries prevalence, severity, and 3-year increment, and their impact upon New Zealand adolescents' oralhealth-related quality of life. J Public Health Dent. 2012 Fall;72(4):287-94. 17. John MT, Slade GD, Szentpetery A, Setz JM. Oral health-related quality of life in patients treated with fixed, removable, and complete dentures 1 month and 6 to 12 months after treatment. Int J Prosthodont. 2004 Sep-Oct;17(5):503-11. 18. Katsoulis J, Nikitovic SG, Spreng S, Neuhaus K, Mericske-Stern R. Prosthetic rehabilitation and treatment outcome of partially edentulous patients with severe tooth wear: 3-years results. J Dent. 2011 Oct;39(10):662-71. 19. Kressin NR, Reisine S, Spiro A 3rd, Jones JA. Is negative affectivity associated with oral quality of life? Community Dent Oral Epidemiol. 2001 Dec;29(6):412-23. 20. Locker D. Measuring oral health: a conceptual framework. Community Dental Health. Mar 1988;5(1):3-18.

310 – RSBO. 2015 Jul-Sep;12(3):302-10 Silva� et al. – �� Can quality of life index measure oral health over the years? A systematic review

21. McGrath C, McMillan AS, Zhu HW, Li LS. Agreement between patient and proxy assessments of oral health-related quality of life after stroke: an observational longitudinal study. J Oral Rehabil. 2009 Apr;36(4):264-70. 22. Meng X, Gilbert GH, Litaker MS. Dynamics of satisfaction with dental appearance among dentate adults: 24-month incidence. Community Dent Oral Epidemiol. 2008 Aug;36(4):370-81. 23. Meng X, Gilbert GH. Predictors of change in satisfaction with chewing ability: a 24-month study of dentate adults. J Oral Rehabil. 2007 Oct;34(10):745-58. 24. Michel-Crosato E, Biazevic MGH, Crosato E. Relationship between dental fluorosis and quality of life: a population based study. Brazilian oral research. 2005 Apr-Jun;19(2):150-5. 25. Murphy C, Kearns G, Sleeman D, Cronin M, Allen PF. The clinical relevance of orthognathic surgery on quality of life. Int J Oral Maxillofac Surg. 2011 Sep;40(9):926-30. 26. Nuttall N, Steele J, Pine C, White D, Pitts N. Adult dental health survey: the impact of oral health on people in the UK in 1998. Br Dent J. 2001 Feb 10;190(3):121-6. 27. Oskam IM, Verdonck-de Leeuw IM, Aaronson NK, Witte BI, de Bree R, Doornaert P et al. Prospective evaluation of health-related quality of life in long-term oral and oropharyngeal cancer survivors and the perceived need for supportive care. Oral Oncol. 2013 May;49(5):443-8. 28. Peek CW, Gilbert GH, Duncan RP. Predictors of chewing difficulty onset among dentate adults: 24-month incidence. J Public Health Dent. 2002 Fall;62(4):214-21. 29. Petricevic N, Celebic A, Rener-Sitar K. A 3-year longitudinal study of quality-of-life outcomes of elderly patients with implant- and tooth-supported fixed partial dentures in posterior dental regions. Gerodontology. 2012 Jun;29(2):e956-63.

30. Reisine ST, Fertig J, Weber J, Leder S. Impact of dental conditions on patients’ quality of life. Community Dentistry and Oral Epidemiology. 1989 Sep;17(1):7-10. 31. Rogers S, Kenyon P, Lowe D, Grant C, Dempsey G. The relation between health-related quality of life, past medical history, and American Society of Anesthesiologists’ ASA grade in patients having primary operations for oral and oropharyngeal cancer. Br J Oral Maxillofac Surg. 2005 Apr;43(2):134-43. 32. Rogers SN, Lowe D, Fisher SE, Brown JS, Vaughan ED. Health-related quality of life and clinical function after primary surgery for oral cancer. Br J Oral Maxillofac Surg. 2002 Feb;40(1):11-8. 33. Rosenberg D, Kaplan S, Senie R, Badner V. Relationships among dental functional status, clinical dental measures, and generic health measures. Journal of Dental Education. 1988 Nov;52(11):653-7. 34. Rusanen J, Lahti S, Tolvanen M, Pirttiniemi P. Quality of life in patients with severe malocclusion before treatment. Eur J Orthod. 2010 Feb;32(1): 43-8. 35. Slade GD, Spencer AJ. Development and evaluation of the oral health impact profile. Community Dental Health. 1994 Mar;11(1):3-11. 36. Stober T, Danner D, Lehmann F, Seche AC, Rammelsberg P, Hassel AJ. Association between patient satisfaction with complete dentures and oral health-related quality of life: two-year longitudinal assessment. Clin Oral Investig. 2012 Feb;16(1):313-8. 37. Strauss RP, Hunt RJ. Understanding the value of teeth to older adults: influences on the quality of life. Journal of the American Dental Association. 1939 Jan;124(1):105-10. 38. Taylor KR, Kiyak A, Huang GJ, Greenlee GM, Jolley CJ, King GJ. Effects of malocclusion and its treatment on the quality of life of adolescents. Am J Orthod Dentofacial Orthop. 2009 Sep;136(3): 382-92.

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Case Report Article

Oral rehabilitation of a child with dentinogenesis imperfecta – case report Kelly Maria Silva Moreira1 Cibele Aparecida Silva2 Rayen Milanao Drugowick3 José Carlos Pettorossi Imparato4 Juliana Braga Reis2 Corresponding author: Kelly Maria Silva Moreira Rua Alferes José Caetano, 1.858, apto. 41 – Centro CEP 13400-126 – Piracicaba – São Paulo – Brasil E-mail: kellynhaodonto@yahoo.com.br Department – Brazil. 2 Department 3 Department 4 Department 1

of Pediatric Dentistry, School of Dentistry of Piracicaba, State University of Campinas – Piracicaba – São Paulo of Pediatric Dentistry, São Leopoldo Mandic School – Belo Horizonte – Minas Gerais – Brazil. of Pediatric Dentistry, Uniararas/Fundação Hermínio Ometto – Araras – São Paulo – Brazil. of Pediatric Dentistry, School of Dentistry, University of São Paulo – São Paulo – São Paulo – Brazil.

Received for publication: March 12, 2014. Accepted for publication: August 4, 2015.

Keywords: dentinogenesis imperfecta; child; oral rehabilitation.

Abstract Introduction and Objective: To report the clinic case of a 5-yearold boy with presenting yellow-gray teeth and generalized severe tooth crown wear. Case report: After clinical and radiographic examination, he was diagnosed with dentinogenesis imperfecta. After the behavior management, we performed the adequacy of oral environment and diet and oral hygiene instructions. Study models were obtained and then, the rehabilitation treatment was performed through acetate crowns and orthodontic bands. Conclusion: Early diagnosis and treatment are very important in preventing further damage to dental tissues, other oral diseases, and orthodontic changes. Therefore, knowledge of the etiology and family history of the patient is crucial.

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Introduction

Case report

Odontogenesis is the tooth formation process involving interactions between the epithelium and ectomesenchyme. These interactions are genetically determined and highly regulated, resulting in forming dental and periodontal tissues. The process of dentin formation is called dentinogenesis and occurs by odontoblasts differentiation [11, 19]. According to some studies [16, 20, 21], there might be hereditary changes in dentinal development, affecting the organic matrix and its mineralization. The dentinogenesis imperfecta (DI) is a localized form of mesodermal dysplasia of dentin, which affects both dentitions, occurring most in primary teeth [3, 14]. With regard to the prevalence, DI signs usually occur in the half number of each offspring with equal frequency between male and female [7]. There a re t hree t y pes of dent inogenesis imperfecta: Type I (dentinal changes associated with osteogenesis imperfecta presence), Type II (only changes in teeth), and Type III (only the teeth are affected, but with varied clinical findings such as pulp exposures and bell-shaped crowns). The presence of enlarged pulp chamber was radiographically observed in patients with type III dentinogenesis, different from types I and II [7, 16]. The only similarity of type I and II dentinogenesis imperfecta hinders the diagnosis. Mild forms of the osteogenesis imperfecta may be associated with dentinogenesis imperfecta without diagnosis so that the treatment is postponed [3, 8]. However, preventive measures must be taken early to avoid fractures and occlusion changes, because teeth with dentinogenesis imperfecta have a reduction in surface hardness [12] and are extremely susceptible to wear [13]. T he c or re ct d i a g no si s en a ble s prop er, comprehensive and treatment plan, based on health promotion and in restoring the aesthetic [6, 15], self-image [2], and the patient’s quality of life [9, 17]. Early diagnosis and treatment are essential to obtain a favorable prognosis, because late management complicates treatment [18]. This study a imed to describe t he denta l treatment of a patient with dentinogenesis imperfecta to reestablish the function, vertical dimension, aesthetic, growth, and development of alveolar bone in the vertical direction through orthodontic bands alternatively for rehabilitating the posterior teeth.

A 5 year-old boy attended the Graduate Clinics of the School of Dentistry of São Leopoldo Mandic (Belo Horizonte, Brazil). His mother agreed with the treatment and signed a free and clarified consent form. This study was submitted and approved by the Institutional Review Board regarding ethical aspects under protocol number #2015/0392. First, at the anamnesis, we gather information on general health. At intraoral clinical examination, the patient showed complete primary dentition At intraoral clinical examination, the patient showed complete primary dentition with yellow-gray teeth and generalized severe wear of tooth crowns (figure 1 A-C). Also, we note the presence of vertical dimension loss. Radiographically, the coronal pulp was retracted and the density of the enamel layer was smaller than normal, because of heavy wear (figure 2 A-D). The patient had very agitated behavior, but no embarrassment because of dental aesthetics. However, the mother reported that he complained about his appearance. After clinical and radiographic examination, the boy was diagnosed with dentinogenesis imperfecta. At anamnesis, the mother reported that she, her older son, and her father had dentinogenesis imperfecta. The rehabilitative treatment was the best option because of the large loss of tooth structure and vertical dimension. The topical application of fluoride was performed to decrease dentinal sensitivity, improving toothbrushing. At the first appointment, the patient underwent behavior management, diet and oral hygiene counseling. Also, plaque disclosing, supervised toothbrushing and prophylaxis was carried out. Moreover, periapical and bitewing radiographs were requested.

Figure 1 – a) Occlusal view photograph at initial clinical examination; b) Maxilla; c) Mandible

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Figure 2 – A) Periapical radiograph of maxillary anterior teeth; B) Periapical radiograph of mandibular anterior teeth; C) Bite-wing radiograph of right primary molars; D) Bite-wing radiograph of left primary molars

At the second appointment, an impression with alginate was taken to obtain study casts. Other prophylaxis and toothbrushing instruction was performed at the third appointment and we opt to reestablish the vertical dimension by placing orthodontic bands (Morelli) on teeth #55, #65, #75 and #85 cemented with glass ionomer cement (Maxxion R, FGM), because of the lack of tooth structure (figure 3 A-B). After this period, the patience was followedup until mixed dentition. At the first transitional period, the rehabilitation treatment began. The teeth #52, #53, #55, #62, #63, #65, #73, #74, #75, #83, #84, #85 were rehabilitated with acetate crowns and resin composite (Filtek Z350 XT – 3M ESPE) to reestablish the function and aesthetics of the patient. The teeth #54 and #64 were extracted due to lack of structure for placing post and crown (figure 4 A-D). Space maintainers were installed to prevent space loss.

Figure 3 – A) Orthodontic bands placed on teeth #75 and #85; B) Orthodontic bands placed on teeth #55 and #65

Figure 4 – A) Left lateral photograph of mixed dentition; B) Right lateral photograph of mixed dentition; C) Maxillary occlusal view of rehabilitation; D) Mandibular occlusal view of the rehabilitation

Discussion In this case report, imperfect dentinogenesis presented hereditary character, similar to other cases reported by other studies in which this anomaly showed an autosomal dominant inheritance with high penetrance and variable expressivity [3, 14, 16, 20, 21]. One of DI clinical features is tooth opacity, ranging from brownish to bluish-gray. Because DI is a mesodermal change, the enamel is normal, but it detaches or breaks due to changes in ena mel-dentina l junction. Dentin is severely hypomineralized [5] after exposure, it becomes soft and quickly undergoes wear, reaching the cervical level, which leads to loss of the vertical dimension [6, 7], as observed in this case report. The radiographic might show bulb-shaped crowns with obliterated pulp chambers and canals; short and tapered roots; and periapical rarefaction in the primary dentition; but, apparently without pulp exposure or necrosis [1, 3, 14], similar to which was observed in this case report. Many approaches can treat DI: direct and indirect restorations with resin composite and placement of stainless steel crowns on posterior teeth [13]. Alternatively, we opted to place orthodontic bands on posterior teeth, because of tooth structure loss which made the use of SSCs inviable. Acetate crowns have been used with composite resin to rehabilitate anterior teeth and prefabricated metal crowns to restore the vertical dimension [7]. In this present case report, we use resin

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composite with acetate crowns because this was a more conservative approach not requiring large preparations. According to some authors, the reestablishment of vertical dimension should be performed immediately [3], as in this present case report. Similarly to what was observed in other study [17], we noticed heavy wear of the primary teeth, some at gingival level, and we opted by the extraction due to the lack of structure for endodontic therapy and installation of post and crown. The adhesion of restorative materials is greatly reduced, as reported in other case [4], requiring strict patient’s following-up with further oral hygiene and diet instructions, topical application of fluoride and repair of restorations. Thus, both aesthetic and functional rehabilitation positively and psychologically impact on the individual’s quality of life [10].

Conclusion Early diagnosis and treatment of patients with dentinogenesis imperfecta are very important to prevent a more severe destruction of tooth tissues, caries and periodontal disease, and orthodontic changes. Therefore, knowledge of the etiology and familiar history of the patient is crucial.

References 1. Bailleul-Forestier I, Molla M, Verloes A, Berdal A. The genetic basis of inherited anomalies of the teeth. Part 1: clinical and molecular aspects of non-syndromic dental disorders. Eur J Med Genet. 2008 Jul-Aug;51(4):273-91. 2. Biethman R, Capati LR, Eldger N. Dentinogenesis imperfecta: a case report of comprehensive treatment for a teenager. Gen Dent. 2014 JulAug;62(4):18-21. 3. Cardoso T, Cunha R, Cardoso IL. Dentinogênese imperfeita: breve revisão. Rev Port Estomatol Med Dent Cir Maxilofac 2011 Jan-Mar;52(1):52-5. 4. Caseiro CG, Long SM, Chelloti A, Raggio DP, Camargo LB. Dentinogênese imperfeita – relato de caso clínico. Rev Inst Ciênc Saúde. 2009 Jun;27(2):185-8. 5. de La Dure-Molla M, Philippe Fournier B, Berdal A. Isolated dentinogenesis imperfecta and dentin dysplasia: revision of the classification. Eur J Hum Genet. 2015 Apr;23(4):445-51.

6. Devaraju D, Devi BY, Vasudevan V, Manjunath V. Dentinogenesis imperfecta type I: A case report with literature review on nomenclature system. J Oral Maxillofac Pathol. 2014 Sep;18(1):131-4. 7. Freitas KP, Antonio AG, Winx MLP, Castro RAUL, Vianna RBC. Dentinogênese imperfeita tipo III e tipo II em crianças: relato de casos. Rev Odonto. 2008 Jul-Dec;16(32):130-6. 8. Kantaputra PN. Dentinogenesis imperfectaassociated syndromes. Am J Med Genet. 2001 Nov;104(1):75-8. 9. Leal CT, Martins LD, Verli FD, de Souza MA, Ramos-Jorge ML. Case report: clinical, histological and ultrastructural characterization of type II dentinogenesis imperfecta. Eur Arch Paediatr Dent. 2010 Dec;11(6):306-9. 10. Machado CV, Pastor IMO, Telles PDS, Rocha MCBS. Osteogênese imperfeita associada à dentinogênese imperfeita: relato de caso. RFO/UPF. 2012 Sep-Dec;17(3):336-41. 11. Mafra RP, Vasconcelos RG, Vasconcelos MG, Queiroz LMG, Barboza CAG. Desenvolvimento dental: aspectos morfogenéticos e relações com as anomalias dentárias do desenvolvimento. Rev Bras Odontol. 2012 Jul-Dec;69(2):232-7. 12. Min B, Song JS, Lee JH, Choi BJ, Kim KM, Kim SO. Multiple teeth fractures in dentinogenesis imperfecta: a case report. J Clin Pediatr Dent. 2014;38(4):362-5. 13. Rafeek RN, Paryag A, Al-Bayaty H. Management of dentinogenesis imperfecta: a review of two case reports. Gen Dent. 2013 May-Jun;61(3):72-6. 14. Ruschel HC, Modesto A, Marassi CS. Dentinogênese imperfeita: abordagem clínica e relato de casos na dentição decídua. RGO. 2000 Jul-Sep;48(3):147-54. 15. Sapir S, Shapira J. Dentinogenesis imperfecta: an early treatment strategy. Pediatr Dent. 2001 May-Jun;23(3):232-7. 16. Shields ED, Bixler D, El-Kafrawy AM. A proposed classification for heritable human dentin defects with a description of a new entity. Arch Oral Biol. 1973 Apr;18(4)543-53. 17. Silva KOR, Azevedo TDPL. Dentinogênese imperfeita: relato de caso clínico. Rev Odontol Bras Central. 2011;20(55):354-58. 18. Surendra P, Shah R, Roshan NM, Reddy VVS. Dentinogenesis imperfecta: a family which was affected for over three generations. J Clin Diagn Res. 2013 Aug;7(8):1808-11.

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19. Thesleff I. Epithelial-mesenchymal signalling regulating tooth morphogenesis. J Cell Sci. 2003 May;116(9):1647-8. 20. Witkop CJ. Hereditary defects of dentin. Dent Clin North Am. 1975 Jan;19(1):25-45.

21. Witkop CJ. Amelogenesis imperfecta dentinogenesis imperfecta and dentin dysplasia revisited: problems in classification. J Oral Pathol. 1989 Nov;17:547-53.

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Case Report Article

Prosthetic rehabilitation using association of total and implant-supported total denture (Brånemark protocol) – case report Rodrigo Lorenzi Poluha1 Clóvis Lamartine de Moraes Melo Neto1 Sérgio Sábio1 Corresponding author: Rodrigo Lorenzi Poluha Departamento de Odontologia – Universidade Estadual de Maringá Avenida Mandacaru, 1.550 – Vila Santa Izabel CEP 87080-000 – Maringá – Paraná – Brasil E-mail: rodrigopoluha@gmail.com 1

Department of Dentistry, State University of Maringá – Maringá – Paraná – Brazil.

Received for publication: June 29, 2015. Accepted for publication: August 4, 2015.

Keywords: dental implants; dental prosthesis; dental prosthesis, implantsupported.

Abstract Introduction: The rehabilitation with implant-supported fixed prosthesis is an effective therapy for the treatment of edentulous patients, especially for mandibles, following Brånemark protocol. Case report: A male patient, aged 62 years, fully edentulous, already had 05 implants, between mental foramen. The rehabilitative therapy employed used both maxillary total denture upper associated with mandibular implant-supported denture following Brånemark protocol. Conclusion: The implant-supported denture following Brånemark protocol is a viable alternative, providing stability to the denture, masticatory efficiency, and aesthetics. Each case should be carefully analyzed and planned to reach a successful treatment.

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Introduction The functional and esthetic rehabilitation of edentulous patients has always challenged the dentists in clinical practice. The use of dental implants is of great value to provide the most clinically successful rehabilitation [5, 14]. This type of therapy is particularly used in edentulous jaws [10, 12]. Among the implant-supported options, the prosthesis following the Brånemark protocol has good longevity [6] and clinical efficacy. This prosthesis is characterized by the placement of four to six implants in the anterior mandible, among mental foramen, with distal cantilever on both sides to replace the posterior teeth. Also, the prosthesis is composed by metallic infrastructure and resin base to bond to the acrylic resin teeth [1]. To perform the rehabilitation with the highest quality, the dentist should know all clinical steps, as well as the analysis of the details of each case. This case describes the association of a maxillary total denture with a mandibular implant-supported fixed denture following Brånemark protocol type, and discusses the case characteristics affecting the technical steps.

Case report A male patient, aged 62 years, melanoderm, with no contributory disease, searched the Dental Prosthesis Clinics of the State Universit y of Maringa, for prosthetic treatment. At clinical and radiographic examinations, the patient exhibited an edentulous maxillary arch, with consistent alveolar ridge, within the normal range; he has been using the same total denture for 23 years, which was poorly adapted and had severe tooth wear. The patient complained about the function and esthetics. In the mandible, the patient no longer wore prosthesis for several years due to low stability. Five implants Tissue Level (TL) (Straumann®, São Paulo, SP, Brazil) Ø 4,1 mm, length of 10 mm, Regular Neck (RN), Slactive surface, with prosthetic platform of 4.8 mm were installed 90 days ago in the specialization course in periodontics. The patient’s file showed that all implants had excellent primary stability with insertion torque above 35 Ncm, also with uneventful post-operative occurrences. After surgery, the patient was absent from the city because of his work for three months, after which he returned and sought care. The implants had no pockets, bleeding to probing, degree of mobility or significant bone loss observed on radiographs (figures 1 and 2).

Figure 1 – Implants Tissue level

Figure 2 – Initial panoramic radiograph

The patient sought a stable, functional, and aesthetically pleasing prosthetic rehabilitation. Thus, the proposed treatment planning included a new maxillary total denture and mandibular implantsupported fixed total denture following Brånemark protocol on the five implants. After the explanation of the advantages and disadvantages of this therapy and signature of consent form, an impression of the current maxillary dentures and mandibular implants was carried out, followed by the registering of the maxillo-mandibular relationship, the facial bow, and mounting in semi adjustable articulator, along with the kit selection of TL components (Straumann®, São Paulo, SP, Brazil), to optimize the choice for the prosthetic components. Seeking a position favoring an aesthetic solution for the screws and a single passive insertion axis, five abutments SynOcta (Straumann®, São Paulo, SP, Brazil), regular neck, height 1.5 mm were selected. Defined the components, the work impression was executed with molding hoods bolted with integrated guide screw (Straumann®, São Paulo, SP, Brazil), with height of 21 mm. After that, the hoods were united with self-curing low shrinkage polymethylmethacrylate (Pattern Resin®, GC, Tokyo); elapsed 15 minutes for maximum releasing of contraction forces, and already out of the mouth,

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the structure was sectioned into five blocks with the use of a thin cutting disc. Then, again screwed to implants, the blocks were joined with the same polymethylmethacrylate; elapsed more 15 minutes, with a previously customized tray, a new impression was taken with the aid of light and heavy addition silicone (Elite®, Zhermack, Italy) through doublemixture technique, following the manufacturer’s instructions. After polymerization, the screw guide of the hoods were withdrew and the whole set was removed; assured the a good reproduction of the RN implant analogs (Straumann®, São Paulo, SP, Brazil), length of 12 mm de, Ø 4,8 mm, were inserted into the impression. After 1 hour, the artificial gingiva was applied (Gingifast®, Zhermack, Italy) around the analogs followed by its polymerization. The dental cast was obtained with type VI plaster (Durone®, Dentsply, DE, USA), following the manufacturer1s instructions (figures 3 and 4).

procedure, a fter the poly methylmethacrylate polymerization time, there was no use of any impression material. The assembly was removed, the analogs were screwed and positioned in a container with type VI plaster (figure 5 and 6).

Figure 5 – Impression hoods joined to construct the template

Figure 3 – Hoods surrounded by polymethylmethacrylate Figure 6 – Impression template

Figure 4 – Working cast

As an additional measure, a template of the impression was made through the use of impression hoods screwed to the implants. Unlike the impression

In the maxilla, an impression a with alginate (Cavex®, Haarlem, DV, Netherlands), casted in type III plaster (Asfer®, São Paulo, SP, Brazil), to construct a customized tray; followed by the functional impression with the aid of low fusion Godiva (Godibar®, São Paulo, SP, Brazil), for peripheral sealing, and zinc-enolic paste (Lysanda®, São Paulo, SP, Brasil), with the following pouring with type VI plaster. In the next step, the proof of the chrome-cobalt metallic bar took place. Following, the abutments SynOcta were screwed on the implants, the bar was inserted passively at single axis and its perfect match was found through visual inspection, probing of interfaces with the aid of a sharp explorer, and bitewing radiographs (figures 7 and 8).

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The selected teeth were Chroma-4 A1/ED6 (NOVA DFL®, São Paulo, SP, Brazil). The waxed teeth were proved, and the Class I occlusion, prot rusive a nd ca nine guides, bilatera l a nd simultaneous subsequent contacts, alignment, exposure to smile, shape, and color were verified, with the approval by the patient and subsequent acrylization (figure 10).

Figure 7 – Metallic bar

Figure 10 – Proof of teeth

Figure 8 – Adaptation proof of the bar on the abutments

At t he sa me appoi nt ment, t he ma x i l lo mandibular relationship was recorded, establishing a new vertical dimension of occlusion (VDO), lip support, buccal corridor, occlusal plane, high smile lines, medium and labial commissures, color selection and size of the teeth. Throughout this stage the patient actively participated, expressing their desires and aesthetic considerations (figure 9).

Figure 9 – Maxillo-mandibular record

At t he prost hesis del iver y appoi nt ment abutments SynOcta 1.5 mm were placed on the implants and tightened to a torque of 35 Ncm. The mandibular fixed prosthesis was installed, verifying the adaptation to the implants and the good relationship with mandibular ridge, checking for access to interdental brushes; at that time, the patient received detailed instructions to perform oral hygiene. Then, the screw holes were closed with the aid of polytetrafluoroethylene tape (Tigre S/A®, Joinville, SC, Brazil) and light-cured composite resin (Brilliant New Line®, Rio de Janeiro, RJ, Brazil). The maxillary denture was adjusted regarding adaptation and extension. The patient was very satisfied with the aesthetic and functional outcomes (figures 11-17).

Figure 11 – Maxillary total denture

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Figure 15 – Dentures installed

Figure 12 – Occlusal view of the implant-supported denture following Branemark protocol

Figure 16 – Smile

Figure 13 – Internal view of the implant-supported denture following Branemark protocol

Figure 17 – Final panoramic radiograph

Discussion

Figure 14 – Abutments SynOcta installed

Fixed implant-supported dentures are the most desired ones among edentulous patients, because they promote greater masticatory efficacy and comfort, less maintenance, and eliminate

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the removable aspect of other modalities such as conventional dentures or overdentures, adding positive psychological factors. However, the technique is difficult, more expensive, and requires more care and attention to daily hygiene processes [13]. All these factors were discussed with the patient and, in addition to their understanding, we did not find the existence of any cognitive or physical disability that could prevent or hinder the correct cleaning of the prosthesis. The protocol t y pe prostheses show good indication because of some conditions such as occlusal compatibility in cases where the patient uses antagonist denture, low cost compared to metallic-ceramic, good functionality, and they can be indicated for most of mandibular cases [16]. The proper planning of all stages of this prosthesis is critical to a successful outcome. In our case, there was some difference of inclination between implants, which could suggest the use of a ngled components. However, during t he component selection step, it was found that the use of angled abutments of this system, even short, would create different axes of insertion, which would hinder the passive fit of the bar. With the straight abutments, the vertical area of the components was smaller, facilitating the insertion of the bar. Passivity is extremely important, because a structure without passivity can lead to loss of osseointegration [8, 9]. In the open or work impression, direct transfer of components was used, which duri ng t he impression removal from the tray will stay in the impression. They allow the union to each other with resin. After polymerized, they are separated with discs and again linked directly in the mouth, a fact that reduces the amount of acrylic and polymerization shrinkage and its interference with the position of the implants [2]. In addition to conventional work impression, a template was confectioned with the hoods attached without the potential interference of the impression material over the conventional impression materials. This measure provides a counter proof of the impression and enable a more detailed analysis of the bar settlement and adjustments still in the laboratory, saving clinical time. The wax bases were made to allow the recording of the ma xillo-mandibular relationship. The determination of the vertical dimension of occlusion (VDO) is established following the patterns of facial anthropometry [15]. In this case report, the VDO reestablishment was fundamental to the esthetic and functional modifications requested; as he did not

use any prosthesis on the mandible, the lower third of the face was shorter, consequently the patient had a frequent injury on labial commissures due to saliva accumulation and wounds in the region. It was not necessa r y to cut t he meta llic infrastructure because the adaptation had been tested both on the working cast and on the template and the necessary corrections already made in the laboratory. The bar design itself compensated the different inclinations of the implants, searching to maintain a uniformity in the resin thickness that would be applied, and maintaining additional retention for better retention with it. Technically, it is recommended for the mandible that the cantilever length does not exceed 18 to 20 mm [11]; the cantilever of this case report had 18 mm on the right and 19.5 mm on the left side. At the proof of the teeth step, it is essential to examine the labial/buccal and lingual contours of the prosthesis, so that there is interference in the movements of the lips and tongue during speech and swallowing [4, 15]. All the aesthetic, phonetic, and functional proofs and the acceptance by the patient should be analyzed [15]. The bottom surface of t he protocol t y pe prosthesis was also covered by resin including the metallic structure, because once this area is involved by the resin, the resin weariness or addition, if necessary, are more simply and quickly made. At the moment of prosthesis delivery, during installation, the screws are adjusted sequentially so that the prosthesis has passive fitting, a radiograph is taken to evaluate the bone level of each implant and the adjustment of the components [4]. After that, it is needed to confirm the existence of adequate space for cleaning, followed by a correct training and implementation of hygiene measures to ensure good soft tissue health at the long term [3, 6, 7].

Conclusion The prosthesis Brånemark protocol is a viable and effective alternative in edentulous patients, providing stability to the prosthesis, masticatory efficiency, and aesthetic. The analysis and planning of each case are necessary to treatment success.

References 1. Adell R, Lekholm U, Rockler B, Brånemark P-I. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10(6):387-416.

322 – RSBO. 2015 Jul-Sep;12(3):316-22 Poluha� et al. – Prosthetic rehabilitation using association of total and implant-supported total denture (Branemark protocol) – case report

2. Arita CA. Prótese sobre implantes no segmento posterior. Implant News. 2006;3(4):336-43. 3. Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. A retrospective analysis of 800 Brånemark system implants following the All-on-Four™ protocol. J Prosthodont. 2014;23(2):83-8. 4. Darcymar MR, Zardo CM, Souza Neto J. Odontologia estética e a prótese fixa dentogengival. São Paulo: Artes Médicas; 2003.

9. Guichet DL, Caputo AA, Choi H, Sorensen JA. Passivity of fit marginal opening in screw - or cement - retained implants fixed partial denture designs. Int J Maxillo Fac Implants. 2000;15(2):239-46. 10. Lindquist LW, Carlsson GE, Glantz PO. Rehabilitaion of the edentulous mandible with a tissue-integrated fixed prosthesis: a sixyear longitudinal study. Quintessence Int. 1987;18(2):89-96.

5. Dinato JC, Nunes LS. Tratamento protético sobre implante no desdentado total na atualidade. Implant News. 2006;3(5):452-67.

11. Lindquist LW, Rockler B, Carlson GE. Bone resorption around fixtures in edentulous patients treated with mandibular fixed tissue-integrated prostheses. J Prosthet Dent. 1988;59(1):59-63.

6. Ferrigno N, Lauretti M, Fanalli S, Grippaudo G. A long-term follow-up study of nonsubmerged ITIimplants in the treatment of totally edentulous jaws. Part I: ten-year life table analysis of a prospective multicenter study with 1.286 implants. Clin Oral Implants Res. 2002;13(3):260-73.

12. Minoretti R, Triaca A, Saulacic N. Unconventional implants for distal cantilever fixed full-arch prostheses: a long-term evaluation of four cases. Int J Periodontics Restorative Dent. 2012;32(2): 59-67.

7. Friberg B, Jemt T. Rehabilitation of edentulous mandibles by means of osseointegrated implants: a 5-year follow-up study on one or two-stage surgery, number of implants, implant surfaces, and age at surgery. Clin Implant Dent Relat Res. 2015;17(3):413-24. 8. Greco GD, Jansen WC, Landre JJ, Seraidarian PI. Biomechanical analysis of the stresses generated by different disocclusion patterns in an implantsupported mandibular complete denture. J Appl Oral Sci. 2009;17(5):515-20.

13. Misch CE. Prótese sobre implantes. São Paulo: Santos; 2007. p. 252-64. 14. Rasmusson L, Roos J, Bystedt H. A 10year follow-up study of titanium dioxide-blasted implants. Clinical Implant Dentistry and Related Research. 2005;7(1):36-42. 15. Telles D, Coelho AB, Lourenço EV. Próteses fixas sobre implantes. São Paulo; 2014. 16. Telles D, Hollweg H, Castellucci L. Prótese total convencional e sobre implantes. São Paulo: Santos; 2003.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):323-9

Case Report Article

Bleaching and enamel microabrasion in the smile esthetics: a case report Thais de Paula Faccio Alves1 Ana Flávia Simões Barbosa1 Thaís Fantinato Trindade1 Carolina de Andrade Lima Chaves1 Walter Raucci Neto1 Vivian Colucci1 Corresponding author: Vivian Colucci Universidade de Ribeirão Preto Avenida Costábile Romano, n. 2.201 – Ribeirânia CEP 14096-000 – Ribeirão Preto – SP – Brasil E-mail: vi.colucci@gmail.com 1

Department of Dentistry, University of Ribeirão Preto – Ribeirão Preto – SP – Brazil.

Received for publication: June 23, 2015. Accepted for publication: August 7, 2015.

Keywords: dental aesthetic; dental bleaching; enamel microabrasion.

Abstract Introduction: The color change of teeth is frequent in the dental office and has important role in smile harmony. Objective: To discuss through case report the dental bleaching technique associated with enamel microabrasion to remove localized white spots on the maxillary incisors and canines. Case report: Patient, female, aged 18 years, attended the Clinic of the University of Ribeirão Preto complaining about the negative aesthetics of her smile due to the presence of white spots on teeth #13, #12, #11, #21, #22 and #23. After detailed anamnesis and clinical examination, the spots were diagnosed as enamel demineralization caused by cariogenic challenge occurred during the use of orthodontic brackets. Dental bleaching technique with 38% hydrogen peroxide was applied followed by enamel microabrasion with 6.6% hydrochloric acid and silicon carbide paste. After absolute isolation, 1 mm thick paste was applied on enamel stain with the aid of resin composite polishing abrasive rubber. Each application was followed by copious washing and analysis of the stain removal with wet enamel surface. In total, six applications of 10 seconds each were used. Finally, enamel polishing was executed with felt discs and diamond paste, and topical application of fluoride. Conclusion: It was concluded that bleaching associated with enamel microabrasion technique is a safe, simple, and effective option for solving the esthetics of teeth with white spots.

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Introduction Denta l caries is a multifactoria l chronic disease caused by acids produced by bacterial metabolism that diffuse through and dissolve the dental tissues [14]. Initially, bacteria colonize the enamel acquired pellicle and ferment available carbohydrates, leading to the formation of organic acids, such as lactic, formic, acetic, and propionic acid [15], which promotes pH reduction of the oral cavity. The drop in pH makes the oral environment unsaturated regarding the tooth, which results in loss of dental tissue ions to the environment. With the concentration of ions in the oral environment, pH increases returning the ions from oral fluid to dental tissues [15]. The imbalance between de and remineralization processes, with a predominance of demineralizing episodes, over time, leads to the emergence of incipient lesions in enamel, the white spot lesions [31]. Some clinical situations, the use of fixed orthodontic appliances favors the development of caries, since they create biofilm stagnation areas and limits the natural defense mechanisms of selfcleaning, such as the friction of the muscles at the dental surface and the action of saliva [23]. Thus, white spot lesions are frequently observed in the dental clinic in patients with this appliance type, especially in the area around the brackets and under orthodontic bands, because of the difficulty of cleaning. Even after the removal of the appliance and remineralization of enamel surface, the white spot lesions are still visible clinically [17, 33], adversely interfering with the smile aesthetics and taking patients seeking dental therapy more frequently, to remove surface staining of the teeth for aesthetic reasons. Attempting to recover the smile aesthetics, some procedures have been suggested. Small stains and defects of the enamel surface, regardless of etiology, can often be removed with local action of acid and/or abrasive materials. The enamel microabrasion is a conservative technique that removes only a small layer of enamel surface by the action of abrasive agents [22, 29] effectively, safely, and permanently [22]. Enamel microabrasion is indicated for the aesthetic treatment of white spots due to fluorosis, remineralized postorthodontic treatment demineralization white spot, localized hypoplasia resulting from dental trauma or infection, and idiopathic hypoplasia where discoloration is limited to the most superficial layer of enamel [22].

Because of the wear promoted on the enamel surface by microabrasion, the teeth may have a darkest staining due to the reflection of the dentin color [29]. Consequently, many times this technique is associated with tooth whitening with excellent cosmetic results [18, 28, 29]. Thus, this study aimed to discuss through a case report the esthetics recovering by dental bleaching associated with enamel microabrasion technique.

Case report A female, aged 18 years, attended the clinic of the Dentistry Course at the University of Ribeirão Preto (Unaerp) with complaint of lack of aesthetic in anterior teeth, which had a bilateral, white, and opaque spots (figure 1).

Figure 1 – Frontal view of the occlusion

The first appointment consisted of a careful anamnesis seeking to identify the factors that led the patient to have the enamel changes, followed by a thorough clinical examination of the spots. The clinical aspect, added to the clinical history, led to the diagnosis of enamel demineralization caused by cariogenic challenge occurred during the use of orthodontic brackets. An evaluation of the initial color was performed with the aid of Vita Classic®, scale and the recorded shade was A2 (figure 2).

Figure 2 – Initial color assessment with Vita Classic scale

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A further examination was carried out, by focusing the LED light from a light-curing unit (Ultraled, Dabi Atlante, Brazil) on the palatal surface to observe by transillumination and predict the caries lesion depth (figure 3). The cervical third was the most affected by the spots, however they were superficial.

After the first appointment, the color was assessed again, and the new color was shade A1 (figure 6).

Figure 3 – LED light application on the palatal surface

The proposed treatment planning was in-office bleaching associated with enamel microabrasion because it is a more conservative treatment with good results. Initially, for tooth whitening, with the aid of a lip retractor, the gingival barrier (Opal Dan®, Ultradent Products Inc., USA) was applied (figure 4).

Figure 6 – Final color after tooth whitening

The enamel microabrasion was proposed because it is a more conservative treatment with good results, performed 15 days after the bleaching appointment. Initially, the gingival tissue was protected with rubber dam in the area comprising the teeth that would be treated (figure 7). The patient’s eyes were protected with glasses and a previous prophylaxis with pumice and water was carried out.

Figure 4 – Gingival barrier application

The 38% hydrogen peroxide gel (OpalescenceBoost PF®, Ultradent Products Inc., USA) was applied on the teeth previously isolated (figure 5) at 3 applications of 15 minutes. Figure 7 – Rubber dam

Figure 5 – Whitening gel after application

Subsequently, the paste for the chemicalmechanical abrasion containing 6.6% hydrochloric acid (HCl) a nd pa r t icles of si l icon ca rbide (Opalustre®, UltradentProducts Inc., USA) was applied onto the white spots. To assist in the removal of stains, the superficial wear was performed with abrasive rubber for resin composite polishing associated with the paste. Five applications were executed per tooth (figure 8).

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At the end of each period, the teeth were copiously washed with water and a new assessment was performed, keeping the tooth wet. After the microabrasion procedure, which was completed in a single clinical appointment, tooth polishing was executed with felt disc and diamond paste (Polimax, TDV, Brazil) (figure 11). Then, topical neutral fluoride (Flugel, DFL, Brazil) was applied for 5 minutes (figure 12). Figure 8 – Paste application with abrasive rubber

Soon after, the application of the paste was made using a wooden spatula rubbing the area with a circular motion for 10 seconds on each tooth in areas hard to reach (figure 9). Two 10-second applications were performed on each tooth. Figure 11 – Tooth polishing with diamond paste and felt disc

Figure 9 – Paste application by wooden spatula

Finally, rubber cups (OpalCups®, Ultradent Products Inc., USA) at low speed (figure 10) were used. We performed five more applications of the paste abraded with circular movements under slight pressure for 10 seconds on each tooth.

Figure 10 – Paste applied with rubber cup

Figura 12 – Fluoride topical application

Figures 13 and 14 show the final aspect after tooth whitening and enamel microabrasion procedures.

Figure 13 – Transillumination after the procedures

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Figure 14 – Final clinical aspects

Discussion The white spot lesions in dental enamel have varied etiolog y, which may be of extrinsic or intrinsic origin. Changes in enamel translucency and/or texture may occur by numerous factors, such as hypoplasia, hypomineralization, fluorosis, pigmentation by drugs, and demineralization by caries [22]. For each one of these cases, different clinical behaviors may be necessary. Thus, the correct differential diagnosis is essential for treatment success. Enamel demineralization is an extremely common side effect of the orthodontic treatment with fixed appliances [23]. The enamel structure with respect to its shape and organization is changed due to the contact with acids originating from human bacterial metabolism [10]. Over time, this process continues by increasing the volume of intercrystalline spaces that are now occupied by air. The difference between the refractive indices of light through the air (n = 1) and the enamel (n = 1.62) makes the white spot lesions as opaque white to the human eye [10]. Once the causal factor was removed and conditions balanced between episodes of de and remineralization, the process can be stopped and the white spot lesions become inactive [31]. However, the whitish aspect, although smooth and shiny, may still remain clinically visible [21], interfering with the smile esthetics. Surface stains and enamel irregularities often lead patients to seek intervention to improve the smile and, in these cases, several treatments are possible. The enamel microabrasion is one of the most suitable resources for these cases [22], because it is considered a safe and effective technique [29].

Moreover, the microabrasion can be combined with tooth bleaching still favoring esthetics [28-30]. In this case report, aiming at reducing the contrast between the white spot lesions and healthy tooth surface [9, 24], the whitening of tooth surfaces with 35% hydrogen peroxide was indicated previously to the microabrasion. Although some studies indicate that tooth whitening should be performed after enamel microabrasion [28, 30], it was shown that permeability to hydrogen peroxide of the enamel subjected to microabrasion is greater [8]. Because the patient’s age and the possible damage to pulp by greater penetration of the bleaching agent, we opted to perform tooth whitening before microabrasion. Furthermore, tooth bleaching was carried only on the anterior teeth because the patient had numerous enamel cracks in premolars associated with sensitivity. Different procedures have been proposed for tooth whitening and at-home and in-office techniques are widely used in dental practice [6]. In this case report, because of the patient’s choice, we opted for in-office tooth whitening technique. Although the effectiveness of both is similar [5, 6], in-office technique has become popular because high-concentration hydrogen peroxide gel can be applied and results in faster tooth whitening [5], attracting the interest of patients. In this technique, significant whitening results can be seen after just one treatment session [5, 12], but it requires longer clinical time or several shorter appointments [32]. The longer clinical application time or the need for more appointments has been associated with dentinal sensitivity [19]. In this case report, three bleaching gel applications for 15 minutes were applied at one clinical appointment, but despite the longer clinical time, sensitivity did not occur. Different desensitizing agents such as potassium nitrate, amorphous calcium phosphate, and sodium fluoride [20] have been included in the composition of bleaching agents to minimize the side effects of sensitivity [5]. The bleaching agent employed in this case report is composed by 3% potassium nitrate and 1.1% f luoride ions, with neutral pH, which can directly influenced on the non-occurrence of sensitivity. A f t e r ble a c h i n g , m i c ro a br a s i on of t he remineralized white spot lesions was performed. The efficacy of microabrasion depends on the substrate's level of lesion [26], because the changes must show hard texture and affect the superficial layers of enamel for the technique to be most successful [3, 28]. To predict the depth of the spots, it has

328 – RSBO. 2015 Jul-Sep;12(3):323-9 Alves� et al. – Bleaching and enamel microabrasion in the smile esthetics: a case report

been suggested lighting through LED light [2]. The altered tissue allows greater light scattering, which makes its transmission rate lower than healthy tooth structures [27]. Therefore, the altered area appears darker after transillumination [27]. The darker the lesion, the greater is the lesion depth [2]. In general, the procedure consists of the clinical association between demineralization and surface abrasion of stained enamel to expose a subsurface layer without color change in a single appointment [26, 28]. Many products based on phosphoric acid or hydrochloric acid associated with abrasive agents has been proposed for microabrasion, and studies show the effectiveness of the technique regardless of the selected agent [1]. According to Bassir and Bagheri [4], hydrochloric acid-based products help to reduce the clinical time for effective removal of the stains. Thus, in the present study, we employed 6.6% hydrochloric acid and silicon carbide as abrasive paste. Furthermore, the use of its product was associated with an enamel wear thickness of 10%, which makes the procedure safer and more conservative [26]. The performance of sequential microabrasion procedures decreases the surface roughness [26]. Therefore, we decided to carry out six applications of six seconds each. The optical effects on dental tissue is changed after the microabrasion, since a prism-free and densely packed enamel layer due to abrasive remnants and smear layer impregnated in the micro pores created by the acid [11] is formed after treatment [13] and the modified refraction of light masks the subsurface spot [13]. Despite of the compression of the prisms, the surface roughness of the enamel increases after microabrasion [7, 26]. Thus, after microabrasion procedures, surface polishing is indicated. When microabrasion is performed with 6.6% hydrochloric acid and silicon carbide paste as abrasive, the application of diamond paste associated with felt discs is sufficient to restore the surface smoothness of treated enamel [7, 16, 26].

References

Conclusion

10. Consolaro A, Consolaro MFMO. Lesões cariosas incipientes e formação de cavidades durante o tratamento ortodôntico: É papel do ortodontista diagnosticar, prevenir e até tratar manchas brancas cariosas e não cariosas no esmalte? Rev Clín Ortodon Dental Press. 2006 Aug/Sep;5(4):104-11.

Ba sed i n t he ca se repor ted herei n, t he performance of tooth whitening associated with enamel microabrasion for treating white spot lesions is a safe and effective method to reach the smile esthetics.

1. Akin M, Basciftci FA. Can white spot lesions be treated effectively? Angle Orthod. 2012 Sep;82(5):770-5. 2. Alves M, Junqueira A, Rehder-Neto FC. Tratamento de manchas brancas: Diagnóstico e tecnologia associados. Rev APCD Estét. 2012;1(1):28-43. 3. Balan B, Madanda Uthaiah C, Narayanan S, Monnappa PM. Microabrasion: an effective method for improvement of esthetics in dentistry. Case Rep Dent. 2013;2013:951589. 4. Bassir MM, Bagheri G. Comparison between phosphoric acid and hydrochloric acid in microabrasion technique for the treatment of dental fluorosis. J Conserv Dent. 2013 Jan; 16(1):41-4. 5. Basting RT, Amaral FL, França FM, Flório FM. Clinical comparative study of the effectiveness of tooth sensitivity to 10% and 20% carbamide peroxide home-use and 35% and 38% hydrogen peroxide in-office bleaching materials containing desensitizing agents. Oper Dent. 2012;37(5): 464-73. 6. Bernardon JK, Sartori N, Ballarin A, Perdigão J, Lopes GC, Baratieri LN. Clinical performance of vital bleaching techniques. Oper Dent. 2010;35(1): 3-10. 7. Bertoldo C, Lima D, Frangoso L, Aambrosano G, Aguiar F, Lovadino J. Evaluation of the effect of different methods of microabrasion and polishing on surface roughness of dental enamel. Indian J Dent Res. 2014 May-Jun;25(3):290-3. 8. Briso AL, Lima AP, Gonçalves RS, Gallinari MO, dos Santos PH. Transenamel and transdentinal penetration of hydrogen peroxide applied to cracked or microabrasioned enamel. Oper Dent. 2014 Mar-Apr;39(2):166-73. 9. Castro KS, Ferreira AC, Duarte RM, Sampaio FC, Meireles SS. Acceptability, efficacy and safety of two treatment protocols for dental fluorosis: a randomized clinical trial. J Dent. 2014 Aug;42(8):938-44.

329 – RSBO. 2015 Jul-Sep;12(3):323-9 Alves� et al. – Bleaching and enamel microabrasion in the smile esthetics: a case report

11. Croll TP, Bullock GA. Enamel microabrasion for removal of smooth surface decalcifi cation lesions. J Clin Orthod. 1994 Jun;28(6):365-70. 12. de Silva Gottardi M, Brackett MG, Haywood VB. Number of in-office light-activated bleaching treatments needed to achieve patient satisfaction. Quintessence Int. 2006;37(2):115-20. 13. Donly KJ, O’Neill M, Croll TP. Enamel microabrasion: a microscopic evaluation of the “abrasion effect”. Quintessence Int. 1992;23(3): 175-9. 14. Featherstone JDB. Dental caries: a dynamic disease process. Aust Dent. 2008 Sep;53(3): 286-91. 15. Featherstone JDB. The science and practice of caries prevention. J Am Dent Assoc. 2000 Jul;131(7):887-9. 16. Fragoso LS, Lima DA, De Alexandre RS, Bertoldo CE, Aguiar FH, Lovadino JR. Evaluation of physical properties of enamel after microabrasion, polishing, and storage in artificial saliva. Biomed Mater. 2011 Jun;6(3):035001. 17. Kim Y, Son HH, Yi K, Kim HY, Ahn J, Chang J. The color change in artificial white spot lesions measured using a spectroradiometer. Clin Oral Investig. 2013 Jun;17(1):139-49. 18. Marson FC, Sensi LG, Araújo FO. Clareação dentária associada à microabrasão do esmalte para remoção de manchas brancas. Rev Dent Press Estet. 2007 Jan-Mar;4(1):89-96.

23. Pliska BT, Warner GA, Tantbirojn D, Larson BE. Treatment of white spot lesions with ACP paste and microabrasion. Angle Orthod. 2012 Sep;82(5):765-9. 24. Pontes DG, Correa KM, Cohen-Carneiro F. Re-establishing esthetics of fluorosis-stained teeth using enamel microabrasion and dental bleaching techniques. Eur J Esthet Dent. 2012 May;7(2): 130-7. 25. Rodrigues M, Mondelli RF, Oliveira GU, Franco EB, Baseggio W, Wang L. Minimal alterations on the enamel surface by micro-abrasion: in vitro roughness and wear assessments. J Appl Oral Sci. 2013;21(3):112-7. 26. Rodrigues MC, Mondelli RF, Oliveira GU, Franco EB, Bassegio W, Wang L. Minimal alterations on the enamel surface by micro-abrasion: in vitro roughness and wear assessments. J Appl Oral Sci. 2013 Mar-Apr;21(2):112-7. 27. Soares GG, Souza PR, Purger FPC, Vasconcellos AB, Ribeiro AA. Métodos de detecção de cárie. Rev Bras Odontol. 2012;69(1):84-9. 28. Sundfeld RH, Croll TP, Briso ALF, De Alexandre RS, Sundfeld D. Considerations about enamel microabrasion after 18 years. Am J Dent. 2007 Apr;20(2):67-72. 29. Sundfeld RH, Franco LM, Gonçalves RS, De Alexandre RS, Machao LS, Neto DS. Accomplishing esthetics using enamel microabrasion and bleaching – a case report. Oper Dent. 2014 MayJun;39(3):223-7.

19. Marson FC, Sensi LG, Vieira LC, Araújo E. Clinical evaluation of in-office dental bleaching treatments with and without the use of lightactivation sources. Oper Dent. 2008;33(1):15-22.

30. Sundfeld RH, Sundfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso AL. Microabrasion in tooth enamel discoloration defects: three cases with long-term follow-ups. J Appl Oral Sci. 2014 Jul-Aug;22(4):347-54.

20. Matis BA, Cochran MA, Eckert GJ, Matis JI. In vivo study of two carbamide peroxide gels with different desensitizing agents. Oper Dent. 2007;32(6):549-55.

31. Thystrup A, Bruun C, Holmen L. In vivo caries models – mechanisms for caries initiation and arrestment. Adv. Dent. Res. 1994 May-Jun; 8(2):144-57.

21. Nyvad B, Fejerskov O. Assessing the stage caries lesion activity on the basis of clinical and microbiological examination. Community Dent. Oral Epidemiol. 2006 May; 25(1):69-75.

32. Torres CR, Wiegand A, Sener B, Attin T. Influence of chemical activation of a 35% hydrogen peroxide bleaching gel on its penetration and efficacy – in vitro study. J Dent. 2010; 38(10): 838-46.

22. Pini NIP, Sundfeld-Neto D, Aguiar FHB, Sundfeld, RH, Martins JRM, Lovadino JR et al. Enamel microabrasion: an overview of clinical and scientific considerations. World J Clin Cases. 2015 Jun;3(1):34-41.

33. Zhao X, Gao X. Effect of resin infiltration treatment on the colour of white spot lesions. Hua Xi Kou Qiang Yi Xue Za Zhi. 2014 Jun;32(3): 306-9.

ISSN: Electronic version: 1984-5685 RSBO. 2015 Jul-Sep;12(3):330-3

Case Report Article

Oral rehabilitation in a patient with bipolar affective disorder: clinical case report Eduardo Rossetti1 Érico Kruchinski de Azevedo1 Bruna Eliza Zanini1 Vanessa Carriço Lemes2 João Armando Brancher2 Maria Fernanda Torres3 Andréa Paula Fregoneze4 Corresponding author: Andréa Paula Fregoneze Avenida Manoel Ribas, 750, apto 303 CEP 8051-020 – Curitiba – PR – Brasil E-mail: afregoneze@gmail.com 1 2 3 4

DDS – Curitiba – PR – Brazil. Positivo Univeristy – Curitiba – PR – Brazil. Federal University of Paraná – Curitiba – PR – Brazil. Pontifical Catholic University of Paraná – Curitiba – PR – Brazil.

Received for publication: June 19, 2015. Accepted for publication: July 21, 2015.

Abstract Keywords: Dentistry; people with special needs; bipolar affective disorder.

Objective: This study, through a literature review, aimed to present the key aspects found in Bipolar Affective Disorder (BAD), as well as present a case report of a patient who received dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR. Case report: Female patient, 30 years of age, leukoderma, diagnosed by medical and psychological exams as suffering from BAD and slight mental retardation. The most evident characteristics inherent to the primary illness included swings in mood and affection as well as bipolar or manic depressions. The special school where she studied and worked referred her to receive dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR. Her main complaint was the lack of upper front teeth and the esthetic. The treatment plan included adequacy of oral environment through basic periodontal therapy and production of removable partial dentures. Conclusion: People with BAD requires extra care with regard to behavioral management.

331 – RSBO. 2015 Jul-Sep;12(3):330-3 Rossetti� et al. – �� Oral rehabilitation in a patient with bipolar affective disorder: clinical case report

Introduction Bipolar disorder (BAD) is a changing in mood characterized by episodes of extreme excitement and depression, among which there is a latency period [13]. It affects between 1% and 2% of the general population, with an equal prevalence between males and females [4]. About 50% of patients with BAD report the occurrence of other cases in the family, especially among male monozygotic twins, where the prevalence may reach 80% [2]. BAD can be classified into disorder I, disorder II, dysthymia, cyclothymia, and bipolar disorder without specific cause. In disorder I, one or more manic or mixed episodes occur; in disorder II, one or more depressive episodes accompanied by at least one hypomanic episode occur. Dysthymia is a milder form of chronic depression, which can last up to two years and takes place between 6% and 8% of the adult population. Cyclothymia consists of a brief recurrent episode of hypomania and mild depression, symptoms ranging from depression to manic more quickly than other bipolar patients and cycles are short. Finally, the BAD without specific cause consists of partial syndromes such as recurrent hypomania without depression [12]. Although no age range of greater prevalence exists, the greatest onset of disease is between 15 and 24 years of life and if BAD is properly diagnosed and treated, may undergo remission for a period of five years [6]. The main medical findings are chronic fatigue, migraine, asthma, bronchitis, multiple chemical sensitiv it y, a nd hy pertension. They a re a lso predisposed to obesity, metabolic syndrome, type 2 diabetes, and cardiovascular/cerebrovascular diseases. Of course, these conditions are exacerbated if there is no primary and preventive health care [8]. Although drug therapy is the treatment of choice for patients with BAD, this is not enough by itself because the psychological rehabilitation is necessary; notwithstanding the drugs used have deleterious effects on oral health: marked developing of caries, xerostomia, alterations in taste, and bruxism [13]. In particular, the lithium carbonate used in these patients cause hypertrophy of the salivary glands, generalized stomatitis, ulcers on the mucosa, pain and myofascial dysfunction syndrome, xerostomia, and cervical caries lesion [9]. Because treating people with BAD includes a combination of psychoeducation, self-management,

pharmacotherapy, and health care, this study aimed to report a case of a patient diagnosed with BAD who received dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR.

Case report A female patient, 30 years old, leucoderma, diagnosed by medical and psychological tests as having BAD and discrete mental retardation was referred for dental care for by the school where she studied and worked. As the characteristics inherent to her condition were the mood swings, low selfesteem, and manic depressive disorders. Her main complaint was the lack of upper incisors, which, according to her, contributed to her mood changes (figure 1), but reported no pain symptoms.

Figure 1 – Initial photograph evidencing the loss of maxillary central incisors and maxillary left lateral incisor

Past medical history revealed the internment in a psychiatric hospital at the age of 12 for a period of three years and she was diagnosed with mild mental retardation. She used carbamazepine at a dose of 200 mg, for mood stabilization, but reported extreme difficulty to undergo previous dental procedures because of the impatience and the sudden change of mood. At clinical examination, the patient presented straight profile, lip sealing, and nasal breathing. At intraoral clinical examination, she showed significant loss of teeth (table I) and gingivitis.

332 – RSBO. 2015 Jul-Sep;12(3):330-3 Rossetti� et al. – �� Oral rehabilitation in a patient with bipolar affective disorder: clinical case report

Table I – Initial oral condition. The patient had DMFT index significantly higher than the mean value for the population at the same age range living in South of Brazil: 14 teeth were lost due to caries or periodontal disease; two teeth had caries (one requiring fixed prosthesis); eight filled teeth (three with dental amalgam and five with resin composite)

Tooth condition

Notation according to FDI and surface(s)

Lost by caries or periodontal disease (14)

18, 17, 16, 14, 11, 21, 22, 27, 28, 38, 37, 36, 35, 47

Dental amalgam restoration (3)

13 D, 24 OM, and 25 OD

Resin composite restoration (5)

26 MOB, 44 O, 45 O, 46 OV, and 48 OB

Caries (1)

12 ML

Need for fixed prosthesis (1)

Sound (8)

15, 34, 33, 32, 31, 41, 42, and 43

The treatment plan includes adequacy of the oral environment through basic periodontal therapy, oral hygiene instruction, endodontic treatment of the tooth 23, followed by restorative phase with multiple restorations, manufacture of metal core and post, provisional crown on a tooth 23, and maxillary and mandibular removable partial dentures (RPD) (figure 2). The patient was followed-up since RPD installation.

Figure 2 – Final photograph with RPD. The episodes of mood oscillation significantly decreased after RPD installation

Discussion According to the literature, the prognosis for the BAD is considered relatively favorable, although the results were not so encouraging [7]. People with BAD during childhood or early adolescence have a different course of the disease when compared to those developing BAD at adulthood, since adults have more frequent episodes of euphoria and depression [5].

In this study an adult patient, aged 30 years, diagnosed as having bipolar disorder, was treated at the clinic for patients with special needs of the Pontifical Catholic University of Paraná. During the dental treatment, the mood swings, which is characteristic of the disorder [4], was evident throughout the months and contributed to increase her anxiety. It is known that fear and anxiety are relatively common when a person is placed in front of a health professional, however significantly increase when the professional is a dentist [10], so in patients with BAD because of mood swings, extra care is required. The dentist accounts for identifying the factors causing anxiety and fear and implementing different strategies of management behavior by minimizing them [11]. In this case report, behavioral management was important, as she swung between euphoric states and depressive moments. The dental treatment itself was only started after trivial dialogues, which on one hand minimized the discomfort and the initial distrust regarding to the procedures, but on the other hand increased the period of treatment. Among the most common oral diseases in patients with psychiatric disorders are periodontal disease and caries due to low self-esteem, negativity, and apathy [1]. The final result is a significant increase in tooth extractions. In this case report, DMFT index was equal to 24 (D = 2, M = 14, F = 8), number much higher than the mean DMFT of adults aged 35 years living in southern Brazil [3]. Thus, the established treatment plan aimed at the adequacy of oral cavity with hygiene instructions, periodontal prophylaxis, and restorations, returning oral health. This was followed by endodontic treatment of the upper left canine tooth, which went smoothly, although with some episodes of further unrest by the patient.

333 – RSBO. 2015 Jul-Sep;12(3):330-3 Rossetti� et al. – �� Oral rehabilitation in a patient with bipolar affective disorder: clinical case report

At the final stage of restorative treatment, she opted by maxillary and mandibular RPD due to the difficulty of maintaining oral hygiene. RPD eliminates the need for additional niches, which further contribute to the accumulation of food residue. At the subsequent appointments, there was a distinct improvement in mood and selfesteem of the patient, important aspects from the psychotherapeutic point of view [6]. The patient was followed-up at every four months to monitor oral health.

Conclusion The treatment of people with BAD requires extra care regarding to the behavioral management. Longer appointments are needed to establish a greater connection between the dentist and the patient. Strategies should be developed to motivate the patient constantly.

References 1. Almomani F, Brown C, Williams KB. The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatr Rehabil J. 2006;29(4):274-81. 2. Belmaker RH. Medical progress bipolar disorder. N Engl J Med. 2004;351(5):476-86. 3. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2010. Resultados principais. Brasília: MS/Coordenação Nacional de Saúde Bucal. 51 p. [cited 2015 Mar 10]. Available from: URL:http://dab.saude.gov.br/CNSB/sbbrasil/ arquivos/projeto_sb2010_relatorio_final.pdf.

4. Clark DB. Dental care for the patient with bipolar disorder. J Can Dent Assoc. 2003;69(1):20-4. 5. Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA et al. Rapid, continuous cycling and psychiatric comorbidity in pediatric bipolar I disorder. Bipolar Disord. 2001;3(4):202-10. 6. Friedlander AH, Friedlander IK, Marder SR. Bipolar I disorder psychopathology, medical management and dental implications. J Am Dent Assoc. 2002;133(9):1209-17. 7. Huxley N, Baldessarini RJ. Disability and its treatment in bipolar disorder patients. Bipolar Disord. 2007;9(1-2):183-96. 8. McIntyre RS, Konarski JZ, Soczynska JK, Wilkins K, Panjwani G, Bouffard B et al. Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization. Psychiatr Serv. 2006;57(8):1140-4. 9. Nápole RCO, Cillo J, Haddad AS. Transtornos psiquiátricos em Odontologia. In: Haddad AS. Odontologia para pacientes com necessidades especiais. São Paulo: Santos; 2007. p. 241-61. 10. Nathan JE. Behavioral management strategies for young pediatric dental patients with disabilities. Journal of Dentistry for Children. 2001;68(2): 89-101. 11. Possobon RF, Carrascoza KC, Moraes ABA, Costa AL. O tratamento odontológico como gerador de ansiedade. Psicologia em Estudo. 2007;12(3):609-16. 12. Rosmus L, Cobban SJ. Bipolar affective disorder and the dental Hygienist. JCHD. 2007;41(2): 72-83. 13. Schulte PFJ, Brand HS. Bipolaire Stoornissen em mondgezondheid. Ned Tijdschr Tandheelkd. 2010;117(1):493-9.